Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0001F NOCOV DEF SYSMAN 01/01/2007 Y Description: HEART FAILURE COMPOSITE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0001U NOCOV DEF SYSMAN 02/01/2017 Y Description: RBC DNA HEA 35 AG 11 BLD GRP Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0002M NOCOV DEF SYSMAN 01/01/2013 Y Description: LIVER DIS 10 ASSAYS W/ASH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0002U NOCOV DEF SYSMAN 02/01/2017 Y Description: ONC CLRCT 3 UR METAB ALG PLP Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0003M NOCOV DEF SYSMAN 01/01/2013 Y Description: LIVER DIS 10 ASSAYS W/NASH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0003U NOCOV DEF SYSMAN 02/01/2017 Y Description: ONC OVAR 5 PRTN SER ALG SCOR Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0004M NOCOV DEF SYSMAN 07/01/2013 Y Description: SCOLIOSIS DNA ALYS Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0005F NOCOV DEF SYSMAN 01/01/2007 Y Description: OSTEOARTHRITIS COMPOSITE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0005U NOCOV DEF SYSMAN 05/01/2017 Y Description: ONCO PRST8 3 GENE UR ALG Category: Non Covered Services CMS Add: 05/01/2017 CMS Term: 0006M NOCOV DEF SYSMAN 07/01/2014 Y Description: ONC HEP GENE RISK CLASSIFIER Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0007M NOCOV DEF SYSMAN 07/01/2014 Y Description: ONC GASTRO 51 GENE NOMOGRAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0007U NOCOV DEF SYSMAN 08/01/2017 Y Description: RX TEST PRSMV UR W/DEF CONF Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0008U NOCOV DEF SYSMAN 08/01/2017 Y Description: HPYLORI DETCJ ABX RSTNC DNA Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0009U LAB L60 MAXFEE 07/01/2024 107 0 Description: ONC BRST CA ERBB2 AMP/NONAMP Category: Laboratory CMS Add: 08/01/2017 CMS Term: 0009U NOCOV DEF SYSMAN 08/01/2017 06/30/2024 Y 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 5 Description: ANESTH SALIVARY GLAND 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00102 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH REPAIR OF CLEFT LIP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00103 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH BLEPHAROPLASTY Category: Anesthesia CMS Add: 01/01/1994 CMS Term: 00104 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH ELECTROSHOCK Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0010U NOCOV DEF SYSMAN 08/01/2017 Y Description: NFCT DS STRN TYP WHL GEN SEQ Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0011M NOCOV DEF SYSMAN 01/01/2018 Y Description: ONC PRST8 CA MRNA 12 GEN ALG Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0011U NOCOV DEF SYSMAN 08/01/2017 Y Description: RX MNTR LC-MS/MS ORAL FLUID Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 00120 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH EAR SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00124 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH EAR EXAM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00126 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH TYMPANOTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0012F NOCOV DEF SYSMAN 01/01/2007 Y Description: CAP BACTERIAL ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0012M NOCOV DEF SYSMAN 04/01/2018 Y Description: ONC MRNA 5 GEN RSK URTHL CA Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0013M NOCOV DEF SYSMAN 04/01/2018 Y Description: ONC MRNA 5 GEN RECR URTHL CA Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00140 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH PROCEDURES ON EYE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00142 ANEST DEF ANESTH 02/01/2015 4 Description: ANESTH LENS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00144 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH CORNEAL TRANSPLANT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00145 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH VITREORETINAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00147 ANEST DEF ANESTH 02/01/2015 4 Description: ANESTH IRIDECTOMY Category: Anesthesia CMS Add: 01/01/1991 CMS Term: 00148 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH EYE EXAM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0014F NOCOV DEF SYSMAN 01/01/2008 Y Description: COMP PREOP ASSESS CAT SURG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0015F NOCOV DEF SYSMAN 01/01/2008 Y Description: MELAN FOLLOW-UP COMPLETE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0015M NOCOV DEF SYSMAN 10/01/2020 Y Description: ADRNL CORTCL TUM BCHM ASY 25 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 00160 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH NOSE/SINUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00162 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH NOSE/SINUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00164 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH BIOPSY OF NOSE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0016M NOCOV DEF SYSMAN 10/01/2020 Y Description: ONC BLADDER MRNA 219 GEN ALG Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0016U LAB L60 MAXFEE 07/01/2024 163.96 0 Description: ONC HMTLMF NEO RNA BCR/ABL1 Category: Laboratory CMS Add: 08/01/2017 CMS Term: 0016U NOCOV DEF SYSMAN 08/01/2017 06/30/2024 Y Description: ONC HMTLMF NEO RNA BCR/ABL1 Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 00170 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH PROCEDURE ON MOUTH Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00172 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH CLEFT PALATE REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00174 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH PHARYNGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00176 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH PHARYNGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0017M NOCOV DEF SYSMAN 01/01/2021 Y Description: ONC DLBCL MRNA 20 GENES ALG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0017U LAB L60 MAXFEE 07/01/2024 91.66 0 Description: ONC HMTLMF NEO JAK2 MUT DNA Category: Laboratory CMS Add: 08/01/2017 CMS Term: 0017U NOCOV DEF SYSMAN 08/01/2017 06/30/2024 Y Description: ONC HMTLMF NEO JAK2 MUT DNA Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0018M NOCOV DEF SYSMAN 10/01/2021 Y Description: TRNSPLJ RNL MEAS CD154+CLL Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0018U NOCOV DEF SYSMAN 10/01/2017 Y Description: ONC THYR 10 MICRORNA SEQ ALG Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 00190 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH FACE/SKULL BONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00192 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH FACIAL BONE SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0019M NOCOV DEF SYSMAN 10/01/2023 Y Description: CV DS PLASMA ALYS PRTN BMRK Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0019U NOCOV DEF SYSMAN 10/01/2017 Y Description: ONC RNA TISS PREDICT ALG Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 0020M NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC CNS ALYS 30000 DNA LOCI Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 00210 ANEST DEF ANESTH 10/16/2003 11 Description: ANESTH CRANIAL SURG NOS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00211 ANEST DEF ANESTH 01/01/2009 10 Description: ANESTH CRAN SURG HEMOTOMA Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 00212 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH SKULL DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00214 ANEST DEF ANESTH 10/16/2003 9 Description: ANESTH SKULL DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00215 ANEST DEF ANESTH 10/16/2003 9 Description: ANESTH SKULL REPAIR/FRACT Category: Anesthesia CMS Add: 01/01/1994 CMS Term: 00216 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTH HEAD VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00218 ANEST DEF ANESTH 10/16/2003 13 Description: ANESTH SPECIAL HEAD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0021U NOCOV DEF SYSMAN 10/01/2017 Y Description: ONC PRST8 DETCJ 8 AUTOANTB Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 00220 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH INTRCRN NERVE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00222 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH HEAD NERVE SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0022U NOCOV DEF SYSMAN 10/01/2017 Y Description: TGSAP NSM LUNG NEO DNA&RNA23 Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 0023U NOCOV DEF SYSMAN 10/01/2017 Y Description: ONC AML DNA DETCJ/NONDETCJ Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 0024U NOCOV DEF SYSMAN 01/01/2018 Y Description: GLYCA NUC MR SPECTRSC QUAN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0025U NOCOV DEF SYSMAN 01/01/2018 Y 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 0 Y Description: ONC THYR DNA&MRNA 112 GENES Category: Laboratory CMS Add: 01/01/2018 CMS Term: 0027U NOCOV DEF SYSMAN 01/01/2018 06/30/2024 Y Description: JAK2 GENE TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0027U LAB L60 MAXFEE 07/01/2024 121.91 0 Description: JAK2 GENE TRGT SEQ ALYS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 0029U NOCOV DEF SYSMAN 01/01/2018 06/30/2024 Y Description: RX METAB ADVRS TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0029U LAB L60 MAXFEE 07/01/2024 742.27 0 Y Description: RX METAB ADVRS TRGT SEQ ALYS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 00300 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH HEAD/NECK/PTRUNK Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0030U NOCOV DEF SYSMAN 01/01/2018 06/30/2024 Y Description: RX METAB WARF TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0030U LAB L60 MAXFEE 07/01/2024 134.13 0 Description: RX METAB WARF TRGT SEQ ALYS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 0031U NOCOV DEF SYSMAN 01/01/2018 Y Description: CYP1A2 GENE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00320 ANEST DEF ANESTH 09/26/2012 6 1-999Years Description: ANESTH NECK ORGAN 1YR/> Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00322 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH BIOPSY OF THYROID Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00326 ANEST DEF ANESTH 10/08/2020 7 0-364Days Description: ANESTH LARYNX/TRACH < 1 YR Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0032U NOCOV DEF SYSMAN 01/01/2018 Y Description: COMT GENE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0033U NOCOV DEF SYSMAN 01/01/2018 Y Description: HTR2A HTR2C GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0034U NOCOV DEF SYSMAN 01/01/2018 06/30/2024 Y Description: TPMT NUDT15 GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0034U LAB L60 MAXFEE 07/01/2024 466.17 0 Y Description: TPMT NUDT15 GENES Category: Laboratory CMS Add: 01/01/2018 CMS Term: 00350 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH NECK VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00352 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH NECK VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0035U NOCOV DEF SYSMAN 04/01/2018 Y Description: NEURO CSF PRION PRTN QUAL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0036U NOCOV DEF SYSMAN 04/01/2018 Y Description: XOME TUM & NML SPEC SEQ ALYS Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0037U NOCOV DEF SYSMAN 04/01/2018 06/30/2024 Y Description: TRGT GEN SEQ DNA 324 GENES Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0037U LAB L60 MAXFEE 07/01/2024 3500 0 Y Description: TRGT GEN SEQ DNA 324 GENES Category: Laboratory CMS Add: 04/01/2018 CMS Term: 0038U NOCOV DEF SYSMAN 04/01/2018 Y Description: VITAMIN D SRM MICROSAMP QUAN Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0039U NOCOV DEF SYSMAN 04/01/2018 Y Description: DNA ANTB 2STRAND HI AVIDITY Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00400 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH SKIN EXT/PER/ATRUNK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00402 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00404 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00406 ANEST DEF ANESTH 10/16/2003 13 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0040U NOCOV DEF SYSMAN 04/01/2018 06/30/2024 Y Description: BCR/ABL1 GENE MAJOR BP QUAN Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0040U LAB L60 MAXFEE 07/01/2024 409.9 0 Y Description: BCR/ABL1 GENE MAJOR BP QUAN Category: Laboratory CMS Add: 04/01/2018 CMS Term: 00410 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH CORRECT HEART RHYTHM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0041U NOCOV DEF SYSMAN 04/01/2018 Y Description: B BRGDRFERI ANTB 5 PRTN IGM Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0042T MEDSV DEF MAXFEE 01/01/2024 288.1 0 Y Description: CT PERFUSION W/CONTRAST CBF Category: Medical Services CMS Add: 01/01/2003 CMS Term: 0042U NOCOV DEF SYSMAN 04/01/2018 Y Description: B BRGDRFERI ANTB 12 PRTN IGG Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0043U NOCOV DEF SYSMAN 04/01/2018 Y Description: TBRF B GRP ANTB 4 PRTN IGM Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0044U NOCOV DEF SYSMAN 04/01/2018 Y Description: TBRF B GRP ANTB 4 PRTN IGG Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00450 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00454 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH COLLAR BONE BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0045U NOCOV DEF SYSMAN 07/01/2018 06/30/2024 Y Description: ONC BRST DUX CARC IS 12 GENE Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0045U LAB L60 MAXFEE 07/01/2024 3873 0 Y Description: ONC BRST DUX CARC IS 12 GENE Category: Laboratory CMS Add: 07/01/2018 CMS Term: 0046U NOCOV DEF SYSMAN 07/01/2018 Y Description: FLT3 GENE ITD VARIANTS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00470 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH REMOVAL OF RIB Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00472 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH CHEST WALL REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00474 ANEST DEF ANESTH 10/16/2003 13 Description: ANESTH SURGERY OF RIB Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0047U NOCOV DEF SYSMAN 07/01/2018 Y Description: ONC PRST8 MRNA 17 GENE ALG Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0048U NOCOV DEF SYSMAN 07/01/2018 Y Description: ONC SLD ORG NEO DNA 468 GENE Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0049U NOCOV DEF SYSMAN 07/01/2018 Y Description: NPM1 GENE ANALYSIS QUAN Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00500 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTH ESOPHAGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0050U NOCOV DEF SYSMAN 07/01/2018 Y Description: TRGT GEN SEQ DNA 194 GENES Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0051U NOCOV DEF SYSMAN 07/01/2018 Y Description: RX MNTR LC-MS/MS UR/BLD 31 Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00520 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH CHEST PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00522 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH CHEST LINING BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00524 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH CHEST DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00528 ANEST DEF ANESTH 10/16/2003 8 Description: ANES MEDIASCPY & DX THORSCPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00529 ANEST DEF ANESTH 01/01/2004 11 Description: ANES MEDSCPY&THORSCPY 1 LUNG Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 0052U NOCOV DEF SYSMAN 07/01/2018 Y Description: LPOPRTN BLD W/5 MAJ CLASSES Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00530 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH PACEMAKER INSERTION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00532 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH VASCULAR ACCESS Category: Anesthesia CMS Add: 01/01/1992 CMS Term: 00534 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH CARDIOVERTER/DEFIB Category: Anesthesia CMS Add: 01/01/1993 CMS Term: 00537 ANEST DEF ANESTH 01/01/2024 7 Description: ANESTH CARDIAC ELECTROPHYS Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00539 ANEST DEF ANESTH 10/15/2003 18 Description: ANESTH TRACH-BRONCH RECONST Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00540 ANEST DEF ANESTH 02/01/2015 12 Description: ANESTH CHEST SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00541 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTH ONE LUNG VENTILATION Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00542 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTHESIA REMOVAL PLEURA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00546 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTH LUNG CHEST WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00548 ANEST DEF ANESTH 10/16/2003 17 Description: ANESTH TRACHEA BRONCHI SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0054T NOCOV DEF SYSMAN 01/01/2008 Y Description: BONE SRGRY CMPTR FLUOR IMAGE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0054U NOCOV DEF SYSMAN 07/01/2018 Y Description: RX MNTR 14+ DRUGS & SBSTS Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00550 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH STERNAL DEBRIDEMENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0055T NOCOV DEF SYSMAN 01/01/2008 Y Description: BONE SRGRY CMPTR CT/MRI IMAG Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0055U NOCOV DEF SYSMAN 07/01/2018 Y Description: CARD HRT TRNSPL 96 DNA SEQ Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00560 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTH HEART SURG W/O PUMP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00561 ANEST DEF ANESTH 10/08/2020 25 0-364Days Description: ANESTH HEART SURG <1 YR Category: Anesthesia 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00562 ANEST DEF ANESTH 09/26/2012 20 1-999Years Description: ANESTH HRT SURG W/PMP AGE 1+ Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00563 ANEST DEF ANESTH 10/16/2003 25 Description: ANESTH HEART SURG W/ARREST Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00566 ANEST DEF ANESTH 10/16/2003 25 Description: ANESTH CABG W/O PUMP Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00567 ANEST DEF ANESTH 01/01/2009 18 Description: ANESTH CABG W/PUMP Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 00580 ANEST DEF ANESTH 10/16/2003 20 Description: ANESTH HEART/LUNG TRANSPLNT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0058U NOCOV DEF SYSMAN 07/01/2018 Y Description: ONC MERKEL CLL CARC SRM QUAN Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0059U NOCOV DEF SYSMAN 07/01/2018 Y Description: ONC MERKEL CLL CARC SRM +/- Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00600 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00604 ANEST DEF ANESTH 10/16/2003 13 Description: ANESTH SITTING PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0060U NOCOV DEF SYSMAN 07/01/2018 Y Description: TWN ZYG GEN SEQ ALYS CHRMS2 Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0061U NOCOV DEF SYSMAN 07/01/2018 Y Description: TC MEAS 5 BMRK SFDI M-S ALYS Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00620 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00625 ANEST DEF ANESTH 01/01/2007 13 Description: ANES SPINE TRANTHOR W/O VENT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 00626 ANEST DEF ANESTH 01/01/2007 15 Description: ANES SPINE TRANSTHOR W/VENT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 0062U NOCOV DEF SYSMAN 10/01/2018 Y Description: AI SLE IGG&IGM ALYS 80 BMRK Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00630 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH SPINE CORD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00632 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH REMOVAL OF NERVES Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00635 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH LUMBAR PUNCTURE Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0063U NOCOV DEF SYSMAN 10/01/2018 Y Description: NEURO AUTISM 32 AMINES ALG Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00640 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH SPINE MANIPULATION Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0064U NOCOV DEF SYSMAN 10/01/2018 Y Description: ANTB TP TOTAL&RPR IA QUAL Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0065U NOCOV DEF SYSMAN 10/01/2018 Y Description: SYFLS TST NONTREPONEMAL ANTB Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00670 ANEST DEF ANESTH 10/16/2003 13 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0067U NOCOV DEF SYSMAN 10/01/2018 Y Description: ONC BRST IMHCHEM PRFL 4 BMRK Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0068U NOCOV DEF SYSMAN 10/01/2018 Y Description: CANDIDA SPECIES PNL AMP PRB Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0069U NOCOV DEF SYSMAN 10/01/2018 Y Description: ONC CLRCT MICRORNA MIR-31-3P Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00700 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00702 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH FOR LIVER BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0070U LAB L60 MAXFEE 07/01/2024 676.37 0 Y Description: CYP2D6 GEN COM&SLCT RAR VRNT Category: Laboratory CMS Add: 10/01/2018 CMS Term: 0070U NOCOV DEF SYSMAN 10/01/2018 06/30/2024 Y Description: CYP2D6 GEN COM&SLCT RAR VRNT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0071T MEDSV DEF MAXFEE 01/01/2024 1774.53 0 Description: US LEIOMYOMATA ABLATE <200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0071U LAB L60 MAXFEE 07/01/2024 600 0 Y Description: CYP2D6 FULL GENE SEQUENCE Category: Laboratory 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0071U NOCOV DEF SYSMAN 10/01/2018 06/30/2024 Y Description: CYP2D6 FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0072T MEDSV DEF MAXFEE 01/01/2024 12/31/2024 610.62 0 Y Description: FCSD US ABLTJ LEIOMYOM>=200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0072T MEDSV DEF MAXFEE 01/01/2025 598.41 0 Y Description: FCSD US ABLTJ LEIOMYOM>=200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0072U LAB L60 MAXFEE 07/01/2024 450.91 0 Y Description: CYP2D6 GEN CYP2D6-2D7 HYBRID Category: Laboratory CMS Add: 10/01/2018 CMS Term: 0072U NOCOV DEF SYSMAN 10/01/2018 06/30/2024 Y Description: CYP2D6 GEN CYP2D6-2D7 HYBRID Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00730 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00731 ANEST DEF ANESTH 01/01/2018 5 Description: ANES UPR GI NDSC PX NOS Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00732 ANEST DEF ANESTH 01/01/2018 6 Description: ANES UPR GI NDSC PX ERCP Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 0073U LAB L60 MAXFEE 07/01/2024 450.91 0 Y Description: CYP2D6 GEN CYP2D7-2D6 HYBRID Category: Laboratory CMS Add: 10/01/2018 CMS Term: 0073U NOCOV DEF SYSMAN 10/01/2018 06/30/2024 Y Description: CYP2D6 GEN CYP2D7-2D6 HYBRID Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0074U LAB L60 MAXFEE 07/01/2024 450.91 0 Y Description: CYP2D6 NONDUPLICATED GENE Category: Laboratory CMS Add: 10/01/2018 CMS Term: 0074U NOCOV DEF SYSMAN 10/01/2018 06/30/2024 Y Description: CYP2D6 NONDUPLICATED GENE Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00750 ANEST DEF ANESTH 10/16/2003 4 Description: ANES HRNA RPR UPR ABD NOS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00752 ANEST DEF ANESTH 10/16/2003 6 Description: ANES HRNA RPR LMBR&VNT&/DEHS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00754 ANEST DEF ANESTH 10/16/2003 7 Description: ANES HRNA RPR OMPHALOCELE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00756 ANEST DEF ANESTH 10/16/2003 7 Description: ANES HRNA RPR DIPHRG HRNA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0075T NOCOV DEF SYSMAN 01/01/2005 Y Description: PERQ STENT/CHEST VERT ART Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0075U LAB L60 MAXFEE 07/01/2024 450.91 0 Y Description: CYP2D6 5' GENE DUP/MLT Category: Laboratory CMS Add: 10/01/2018 CMS Term: 0075U NOCOV DEF SYSMAN 10/01/2018 06/30/2024 Y Description: CYP2D6 5' GENE DUP/MLT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0076T NOCOV DEF SYSMAN 01/01/2005 Y Description: S&I STENT/CHEST VERT ART Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0076U LAB L60 MAXFEE 07/01/2024 450.91 0 Y Description: CYP2D6 3' GENE DUP/MLT Category: Laboratory CMS Add: 10/01/2018 CMS Term: 0076U NOCOV DEF SYSMAN 10/01/2018 06/30/2024 Y Description: CYP2D6 3' GENE DUP/MLT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00770 ANEST DEF ANESTH 10/16/2003 15 Description: ANES PX MAJ ABD BLOOD VESSEL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0077U NOCOV DEF SYSMAN 10/01/2018 Y Description: IG PARAPROTEIN QUAL BLD/UR Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0078U NOCOV DEF SYSMAN 10/01/2018 09/30/2024 Y Description: PAIN MGT OPI USE GNOTYP PNL Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 09/30/2024 00790 ANEST DEF ANESTH 10/16/2003 7 Description: ANES IPER UPR ABD NOS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00792 ANEST DEF ANESTH 10/16/2003 13 Description: ANES IPER UPR ABD PRTL HPTC Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00794 ANEST DEF ANESTH 10/16/2003 8 Description: ANES IPER UPR ABD PNCRTECT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00796 ANEST DEF ANESTH 10/16/2003 30 Description: ANES IPER UPR ABD LVR TRNSPL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00797 ANEST DEF ANESTH 02/01/2015 11 Description: ANES IPER UPR ABD GSTR PX MO Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0079U NOCOV DEF SYSMAN 10/01/2018 Y Description: CMPRTV DNA ALYS MLT SNPS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00800 ANEST DEF ANESTH 10/16/2003 4 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00802 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH FAT LAYER REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0080U NOCOV DEF SYSMAN 01/01/2019 Y 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 4 Description: ANES LWR INTST NDSC NOS Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00812 ANEST DEF ANESTH 01/01/2018 3 Description: ANES LWR INTST SCR COLSC Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00813 ANEST DEF ANESTH 01/01/2018 5 Description: ANES UPR LWR GI NDSC PX Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00820 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0082U NOCOV DEF SYSMAN 01/01/2019 Y Description: RX TEST DEF 90+ RX/SBSTS UR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 00830 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00832 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00834 ANEST DEF ANESTH 10/08/2020 5 0-364Days Description: ANESTH HERNIA REPAIR < 1 YR Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00836 ANEST DEF ANESTH 10/08/2020 6 0-6Months Description: ANESTH HERNIA REPAIR PREEMIE Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0083U NOCOV DEF SYSMAN 01/01/2019 Y Description: ONC RSPSE CHEMO CNTRST TOMOG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 00840 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH SURG LOWER ABDOMEN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00842 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH AMNIOCENTESIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00844 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00846 ANEST DEF ANESTH 10/16/2003 8 Y Description: ANESTH HYSTERECTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00848 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH PELVIC ORGAN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0084U NOCOV DEF SYSMAN 07/01/2019 Y Description: RBC DNA GNOTYP 10 BLD GROUPS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00851 ANEST DEF ANESTH 10/16/2003 6 Y Description: ANESTH TUBAL LIGATION Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 00860 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH SURGERY OF ABDOMEN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00862 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH KIDNEY/URETER SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00864 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH REMOVAL OF BLADDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00865 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1996 CMS Term: 00866 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH REMOVAL OF ADRENAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00868 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH KIDNEY TRANSPLANT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0086U NOCOV DEF SYSMAN 07/01/2019 Y Description: NFCT DS BACT&FNG ORG ID 6+ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00870 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH BLADDER STONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00872 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH KIDNEY STONE DESTRUCT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00873 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH KIDNEY STONE DESTRUCT Category: Anesthesia CMS Add: 01/01/1991 CMS Term: 0087U NOCOV DEF SYSMAN 07/01/2019 Y Description: CRD HRT TRNSPL MRNA 1283 GEN Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00880 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTH ABDOMEN VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00882 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH MAJOR VEIN LIGATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0088U NOCOV DEF SYSMAN 07/01/2019 Y Description: TRNSPLJ KDN ALGRFT REJ 1494 Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0089U NOCOV DEF SYSMAN 07/01/2019 Y Description: ONC MLNMA PRAME & LINC00518 Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00902 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH ANORECTAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00904 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH PERINEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00906 ANEST DEF ANESTH 10/16/2003 4 Description: ANES VULVECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00908 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0090U NOCOV DEF SYSMAN 07/01/2019 Y Description: ONC CUTAN MLNMA MRNA 23 GENE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00910 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH BLADDER SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00912 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH BLADDER TUMOR SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00914 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00916 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH BLEEDING CONTROL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00918 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH STONE REMOVAL Category: Anesthesia CMS Add: 01/01/1990 CMS Term: 0091U NOCOV DEF SYSMAN 07/01/2019 Y Description: ONC CLRCT SCR WHL BLD ALG Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00920 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH GENITALIA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00921 ANEST DEF ANESTH 10/15/2003 3 Y Description: ANESTH VASECTOMY Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00922 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH SPERM DUCT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00924 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH TESTIS EXPLORATION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00926 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH REMOVAL OF TESTIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00928 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH REMOVAL OF TESTIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0092U NOCOV DEF SYSMAN 07/01/2019 Y Description: ONC LNG 3 PRTN BMRK PLSM ALG Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00930 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH TESTIS SUSPENSION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00932 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH AMPUTATION OF PENIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00934 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH PENIS NODES REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00936 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH PENIS NODES REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00938 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH INSERT PENIS DEVICE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0093U NOCOV DEF SYSMAN 07/01/2019 Y Description: RX MNTR 65 COM DRUGS URINE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00940 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH VAGINAL PROCEDURES Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00942 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH SURG ON VAG/URETHRAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00944 ANEST DEF ANESTH 10/16/2003 6 Y Description: ANESTH VAGINAL HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00948 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH REPAIR OF CERVIX Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0094U NOCOV DEF SYSMAN 07/01/2019 06/30/2024 Y Description: GENOME RAPID SEQUENCE ALYS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0094U LAB L60 MAXFEE 07/01/2024 7582.2 0 Y Description: GENOME RAPID SEQUENCE ALYS Category: Laboratory 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00950 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH VAGINAL ENDOSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00952 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH HYSTEROSCOPE/GRAPH Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0095T NOCOV DEF SYSMAN 01/01/2006 Y Description: RMVL ARTIFIC DISC ADDL CRVCL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0095U NOCOV DEF SYSMAN 07/01/2019 Y Description: EE 2 PRTN BMRK ELISA EST Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0096U NOCOV DEF SYSMAN 07/01/2019 Y Description: HPV HI RISK TYPES MALE URINE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0098T NOCOV DEF SYSMAN 01/01/2006 Y Description: REV ARTIFIC DISC ADDL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0100T NOCOV DEF SYSMAN 01/01/2006 Y Description: PROSTH RETINA RECEIVE&GEN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0101T NOCOV DEF SYSMAN 01/01/2006 Y Description: ESW MUSCSKEL SYS NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0101U NOCOV DEF SYSMAN 07/01/2019 06/30/2024 Y Description: HERED COLON CA DO 15 GENES Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0101U LAB L60 MAXFEE 07/01/2024 1743.95 0 Y Description: HERED COLON CA DO 15 GENES Category: Laboratory CMS Add: 07/01/2019 CMS Term: 0102T NOCOV DEF SYSMAN 01/01/2006 Y Description: ESW PHY ANES LAT HMRL EPCNDL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0102U NOCOV DEF SYSMAN 07/01/2019 06/30/2024 Y Description: HERED BRST CA RLTD DO 17 GEN Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0102U LAB L60 MAXFEE 07/01/2024 1303.95 0 Y Description: HERED BRST CA RLTD DO 17 GEN Category: Laboratory CMS Add: 07/01/2019 CMS Term: 0103U NOCOV DEF SYSMAN 07/01/2019 06/30/2024 Y Description: HERED OVA CA PNL 24 GENES Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0103U LAB L60 MAXFEE 07/01/2024 1743.95 0 Y Description: HERED OVA CA PNL 24 GENES Category: Laboratory CMS Add: 07/01/2019 CMS Term: 0105U NOCOV DEF SYSMAN 10/01/2019 Y Description: NEPH CKD MULT ECLIA TUM NEC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0106T NOCOV DEF SYSMAN 01/01/2006 Y Description: TOUCH QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0106U NOCOV DEF SYSMAN 10/01/2019 Y Description: GSTR EMPTG 7 TIMED BRTH SPEC Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0107T NOCOV DEF SYSMAN 01/01/2006 Y Description: VIBRATE QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0107U NOCOV DEF SYSMAN 10/01/2019 Y Description: C DIFF TOX AG DETCJ IA STOOL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0108T NOCOV DEF SYSMAN 01/01/2006 Y Description: COOL QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0108U NOCOV DEF SYSMAN 10/01/2019 Y Description: GI BARRETT ESOPH 9 PRTN BMRK Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0109T NOCOV DEF SYSMAN 01/01/2006 Y Description: HEAT QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0109U NOCOV DEF SYSMAN 10/01/2019 Y Description: ID ASPERGILLUS DNA 4 SPECIES Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0110T NOCOV DEF SYSMAN 01/01/2006 Y Description: NOS QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0110U NOCOV DEF SYSMAN 10/01/2019 Y Description: RX MNTR 1+ORAL ONC RX&SBSTS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01112 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH BONE ASPIRATE/BX Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0111U LAB L60 MAXFEE 07/01/2024 682.29 0 Y Description: ONC COLON CA KRAS&NRAS ALYS Category: Laboratory CMS Add: 10/01/2019 CMS Term: 0111U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: ONC COLON CA KRAS&NRAS ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01120 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0112U NOCOV DEF SYSMAN 10/01/2019 Y Description: IADI 16S&18S RRNA GENES Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01130 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH BODY CAST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0113U NOCOV DEF SYSMAN 10/01/2019 Y Description: ONC PRST8 PCA3&TMPRSS2-ERG Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01140 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTH AMPUTATION AT PELVIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0114U NOCOV DEF SYSMAN 10/01/2019 Y Description: GI BARRETTS ESOPH VIM&CCNA1 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01150 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH PELVIC TUMOR SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0115U NOCOV DEF SYSMAN 10/01/2019 Y Description: RESPIR IADNA 18 VIRAL&2 BACT Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01160 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH PELVIS PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0116U NOCOV DEF SYSMAN 10/01/2019 Y Description: RX MNTR NZM IA 35+ORAL FLU Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01170 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01173 ANEST DEF ANESTH 01/01/2004 12 Description: ANESTH FX REPAIR PELVIS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 0117U NOCOV DEF SYSMAN 10/01/2019 Y Description: PAIN MGMT 11 ENDOGENOUS ANAL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0118U NOCOV DEF SYSMAN 10/01/2019 Y Description: TRNSPLJ DON-DRV CLL-FR DNA Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0119U NOCOV DEF SYSMAN 10/01/2019 Y Description: CRD CERAMIDES LIQ CHROM PLSM Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01200 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH HIP JOINT PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01202 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH ARTHROSCOPY OF HIP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0120U NOCOV DEF SYSMAN 10/01/2019 Y Description: ONC B CLL LYMPHM MRNA 58 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01210 ANEST DEF ANESTH 10/16/2003 6 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01212 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH HIP DISARTICULATION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01214 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH HIP ARTHROPLASTY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01215 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH REVISE HIP REPAIR Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0121U NOCOV DEF SYSMAN 10/01/2019 Y Description: SC DIS VCAM-1 WHOLE BLOOD Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01220 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH PROCEDURE ON FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0122U NOCOV DEF SYSMAN 10/01/2019 Y Description: SC DIS P-SELECTIN WHL BLOOD Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01230 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH SURGERY OF FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01232 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH AMPUTATION OF FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01234 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH RADICAL FEMUR SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0123U NOCOV DEF SYSMAN 10/01/2019 Y Description: MCHNL FRAGILITY RBC PRFLG Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01250 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH UPPER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01260 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH UPPER LEG VEINS SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01270 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH THIGH ARTERIES SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01272 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH FEMORAL ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01274 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH FEMORAL EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0129U LAB L60 MAXFEE 07/01/2024 1303.95 0 Y Description: HERED BRST CA RLTD DO PANEL Category: Laboratory 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0129U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: HERED BRST CA RLTD DO PANEL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0130U LAB L60 MAXFEE 07/01/2024 584.9 0 Y Description: HERED COLON CA DO MRNA PNL Category: Laboratory CMS Add: 10/01/2019 CMS Term: 0130U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: HERED COLON CA DO MRNA PNL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0131U LAB L60 MAXFEE 07/01/2024 710 0 Y Description: HERED BRST CA RLTD DO PNL 13 Category: Laboratory CMS Add: 10/01/2019 CMS Term: 0131U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: HERED BRST CA RLTD DO PNL 13 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01320 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0132U LAB L60 MAXFEE 07/01/2024 741.64 0 Y Description: HERED OVA CA RLTD DO PNL 17 Category: Laboratory CMS Add: 10/01/2019 CMS Term: 0132U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: HERED OVA CA RLTD DO PNL 17 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0133U NOCOV DEF SYSMAN 10/01/2019 Y Description: HERED PRST8 CA RLTD DO 11 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01340 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH KNEE AREA PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0134U LAB L60 MAXFEE 07/01/2024 748.39 0 Y Description: HERED PAN CA MRNA PNL 18 GEN Category: Laboratory CMS Add: 10/01/2019 CMS Term: 0134U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: HERED PAN CA MRNA PNL 18 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0135U LAB L60 MAXFEE 07/01/2024 700.56 0 Y Description: HERED GYN CA MRNA PNL 12 GEN Category: Laboratory CMS Add: 10/01/2019 CMS Term: 0135U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: HERED GYN CA MRNA PNL 12 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01360 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0136U LAB L60 MAXFEE 07/01/2024 407.43 0 Y Description: ATM MRNA SEQ ALYS Category: Laboratory 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0136U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: ATM MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0137U LAB L60 MAXFEE 07/01/2024 282.88 0 Y Description: PALB2 MRNA SEQ ALYS Category: Laboratory CMS Add: 10/01/2019 CMS Term: 0137U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: PALB2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01380 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH KNEE JOINT PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01382 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH DX KNEE ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0138U LAB L60 MAXFEE 07/01/2024 468.33 0 Y Description: BRCA1 BRCA2 MRNA SEQ ALYS Category: Laboratory CMS Add: 10/01/2019 CMS Term: 0138U NOCOV DEF SYSMAN 10/01/2019 06/30/2024 Y Description: BRCA1 BRCA2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01390 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH KNEE AREA PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01392 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01400 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH KNEE JOINT SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01402 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH KNEE ARTHROPLASTY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01404 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH AMPUTATION AT KNEE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0140U NOCOV DEF SYSMAN 01/01/2020 Y Description: NFCT DS FUNGI DNA 15 TRGT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0141U NOCOV DEF SYSMAN 01/01/2020 Y Description: NFCT DS BACT&FNG GRAM POS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01420 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH KNEE JOINT CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0142U NOCOV DEF SYSMAN 01/01/2020 Y Description: NFCT DS BACT&FNG GRAM NEG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01430 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH KNEE VEINS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01432 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH KNEE VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01440 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH KNEE ARTERIES SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01442 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH KNEE ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01444 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH KNEE ARTERY REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01462 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER LEG PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01464 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH ANKLE/FT ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01470 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01472 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH ACHILLES TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01474 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH LOWER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01480 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER LEG BONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01482 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH RADICAL LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01484 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH LOWER LEG REVISION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01486 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH ANKLE REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01490 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER LEG CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01500 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH LEG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01502 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH LWR LEG EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01520 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER LEG VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01522 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH LOWER LEG VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0152U NOCOV DEF SYSMAN 01/01/2020 Y Description: NFCT DS DNA UNTRGT NGNRJ SEQ Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0153U NOCOV DEF SYSMAN 01/01/2020 Y Description: ONC BREAST MRNA 101 GENES Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0154U NOCOV DEF SYSMAN 01/01/2020 Y Description: ONC URTHL CA RNA FGFR3 GENE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0155U NOCOV DEF SYSMAN 01/01/2020 Y Description: ONC BRST CA DNA PIK3CA GENE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0156U NOCOV DEF SYSMAN 01/01/2020 Y Description: COPY NUMBER SEQUENCE ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0157U NOCOV DEF SYSMAN 01/01/2020 Y Description: APC MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0158U NOCOV DEF SYSMAN 01/01/2020 06/30/2024 Y Description: MLH1 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0158U LAB L60 MAXFEE 07/01/2024 282.88 0 Y Description: MLH1 MRNA SEQ ALYS Category: Laboratory CMS Add: 01/01/2020 CMS Term: 0159U NOCOV DEF SYSMAN 01/01/2020 Y Description: MSH2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0160U NOCOV DEF SYSMAN 01/01/2020 Y Description: MSH6 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01610 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0161U NOCOV DEF SYSMAN 01/01/2020 Y Description: PMS2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01620 ANEST DEF ANESTH 10/16/2003 4 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01622 ANEST DEF ANESTH 10/16/2003 4 Description: ANES DX SHOULDER ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0162U NOCOV DEF SYSMAN 01/01/2020 Y Description: HERED COLON CA TRGT MRNA PNL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01630 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01634 ANEST DEF ANESTH 10/16/2003 9 Description: ANESTH SHOULDER JOINT AMPUT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01636 ANEST DEF ANESTH 10/16/2003 15 Description: ANESTH FOREQUARTER AMPUT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01638 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH SHOULDER REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0163U NOCOV DEF SYSMAN 04/01/2020 Y Description: ONC CLRCT SCR 3 PRTN ALG Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0164T NOCOV DEF SYSMAN 01/01/2007 Y Description: REMOVE LUMB ARTIF DISC ADDL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0164U NOCOV DEF SYSMAN 04/01/2020 Y Description: GI IBS IA ANTI-CDTB&VINCULIN Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01650 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH SHOULDER ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01652 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH SHOULDER VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01654 ANEST DEF ANESTH 10/16/2003 8 Description: ANESTH SHOULDER VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01656 ANEST DEF ANESTH 10/16/2003 10 Description: ANESTH ARM-LEG VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0165T NOCOV DEF SYSMAN 01/01/2007 Y Description: REVISE LUMB ARTIF DISC ADDL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0165U NOCOV DEF SYSMAN 04/01/2020 Y Description: PEANUT ALLG ASMT EPI Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0166U NOCOV DEF SYSMAN 04/01/2020 Y Description: LIVER DS 10 BIOCHEM ASY SRM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01670 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH SHOULDER VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0167U NOCOV DEF SYSMAN 04/01/2020 09/30/2024 Y Description: CHORNC GONADOTROPIN HCG IA Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 09/30/2024 01680 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH SHOULDER CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0169U NOCOV DEF SYSMAN 04/01/2020 06/30/2024 Y Description: NUDT15&TPMT GENE COM VRNT Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0169U LAB L60 MAXFEE 07/01/2024 466.17 0 Y Description: NUDT15&TPMT GENE COM VRNT Category: Laboratory CMS Add: 04/01/2020 CMS Term: 0170U NOCOV DEF SYSMAN 04/01/2020 Y Description: NEURO ASD RNA NEXT GEN SEQ Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01710 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH ELBOW AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01712 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH UPPR ARM TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01714 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH UPPR ARM TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01716 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH BICEPS TENDON REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0171U NOCOV DEF SYSMAN 04/01/2020 Y Description: TRGT GEN SEQ ALYS PNL DNA 23 Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0172U NOCOV DEF SYSMAN 07/01/2020 Y Description: ONC SLD TUM ALYS BRCA1 BRCA2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01730 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH UPPR ARM PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01732 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH DX ELBOW ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0173U NOCOV DEF SYSMAN 07/01/2020 Y Description: PSYC GEN ALYS PANEL 14 GENES Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01740 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH UPPER ARM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01742 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH HUMERUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01744 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH HUMERUS REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0174T NOCOV DEF SYSMAN 01/01/2007 Y Description: CAD CXR WITH INTERP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0174U NOCOV DEF SYSMAN 07/01/2020 Y Description: ONC SOLID TUMOR 30 PRTN TRGT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01756 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH RADICAL HUMERUS SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01758 ANEST DEF ANESTH 10/16/2003 5 Description: ANESTH HUMERAL LESION SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0175T NOCOV DEF SYSMAN 01/01/2007 Y Description: CAD CXR REMOTE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0175U NOCOV DEF SYSMAN 07/01/2020 Y Description: PSYC GEN ALYS PANEL 15 GENES Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01760 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH ELBOW REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0176U NOCOV DEF SYSMAN 07/01/2020 Y Description: CDTB&VINCULIN IGG ANTB IA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01770 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH UPPR ARM ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01772 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH UPPR ARM EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0177U NOCOV DEF SYSMAN 07/01/2020 Y Description: ONC BRST CA DNA PIK3CA 11 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01780 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH UPPER ARM VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01782 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH UPPR ARM VEIN REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0178U NOCOV DEF SYSMAN 07/01/2020 Y Description: PEANUT ALLG ASMT EPI CLIN RX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0179U NOCOV DEF SYSMAN 07/01/2020 Y Description: ONC NONSM CLL LNG CA ALYS 23 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0180U NOCOV DEF SYSMAN 07/01/2020 Y Description: ABO GNOTYP ABO 7 EXONS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01810 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER ARM SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0181U NOCOV DEF SYSMAN 07/01/2020 Y Description: CO GNOTYP AQP1 EXON 1 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01820 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER ARM PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01829 ANEST DEF ANESTH 10/15/2003 3 Description: ANESTH DX WRIST ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0182U NOCOV DEF SYSMAN 07/01/2020 Y Description: CROM GNOTYP CD55 EXONS 1-10 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01830 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER ARM SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01832 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH WRIST REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0183U NOCOV DEF SYSMAN 07/01/2020 Y Description: DI GNOTYP SLC4A1 EXON 19 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01840 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH LWR ARM ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01842 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH LWR ARM EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01844 ANEST DEF ANESTH 10/16/2003 6 Description: ANESTH VASCULAR SHUNT SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0184T NOCOV DEF SYSMAN 01/01/2008 Y Description: EXC RECTAL TUMOR ENDOSCOPIC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0184U NOCOV DEF SYSMAN 07/01/2020 Y Description: DO GNOTYP ART4 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01850 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER ARM VEIN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01852 ANEST DEF ANESTH 10/16/2003 4 Description: ANESTH LWR ARM VEIN REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0185U NOCOV DEF SYSMAN 07/01/2020 Y Description: FUT1 GNOTYP FUT1 EXON 4 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01860 ANEST DEF ANESTH 10/16/2003 3 Description: ANESTH LOWER ARM CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0186U NOCOV DEF SYSMAN 07/01/2020 Y Description: FUT2 GNOTYP FUT2 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0187U NOCOV DEF SYSMAN 07/01/2020 Y Description: FY GNOTYP ACKR1 EXONS 1-2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0188U NOCOV DEF SYSMAN 07/01/2020 Y Description: GE GNOTYP GYPC EXONS 1-4 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0189U NOCOV DEF SYSMAN 07/01/2020 Y Description: GYPA GNOTYP NTRNS 1 5 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0190U NOCOV DEF SYSMAN 07/01/2020 Y 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 5 Description: ANESTH DX ARTERIOGRAPHY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0191U NOCOV DEF SYSMAN 07/01/2020 Y Description: IN GNOTYP CD44 EXONS 2 3 6 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01920 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH CATHETERIZE HEART Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01922 ANEST DEF ANESTH 10/16/2003 7 Description: ANESTH CAT OR MRI SCAN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01924 ANEST DEF ANESTH 02/01/2015 5 Description: ANES THER INTERVEN RAD ARTRL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01925 ANEST DEF ANESTH 02/01/2015 7 Description: ANES THER INTERVEN RAD CARD Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01926 ANEST DEF ANESTH 02/01/2015 8 Description: ANES TX INTERV RAD HRT/CRAN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0192U NOCOV DEF SYSMAN 07/01/2020 Y Description: JK GNOTYP SLC14A1 EXON 9 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01930 ANEST DEF ANESTH 10/16/2003 5 Description: ANES THER INTERVEN RAD VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01931 ANEST DEF ANESTH 10/16/2003 7 Description: ANES THER INTERVEN RAD TIPS Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01932 ANEST DEF ANESTH 02/01/2015 6 Description: ANES TX INTERV RAD TH VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01933 ANEST DEF ANESTH 02/01/2015 7 Description: ANES TX INTERV RAD CRAN VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01937 ANEST DEF ANESTH 01/01/2022 4 Description: ANES DRG/ASPIR CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01938 ANEST DEF ANESTH 01/01/2022 4 Description: ANES DRG/ASPIR LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01939 ANEST DEF ANESTH 01/01/2022 4 Description: ANES NULYT AGT CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 0193U NOCOV DEF SYSMAN 07/01/2020 Y Description: JR GNOTYP ABCG2 EXONS 2-26 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01940 ANEST DEF ANESTH 01/01/2022 4 Description: ANES NULYT AGT LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01941 ANEST DEF ANESTH 01/01/2022 5 Description: ANES NEUROMD/NTRVRT CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01942 ANEST DEF ANESTH 01/01/2022 5 Description: ANES NEUROMD/NTRVRT LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 0194U NOCOV DEF SYSMAN 07/01/2020 Y Description: KEL GNOTYP KEL EXON 8 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01951 ANEST DEF ANESTH 10/16/2003 3 Description: ANES 2&3 BURN LESS 4% TBSA Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01952 ANEST DEF ANESTH 10/16/2003 5 Description: ANES 2&3 BURN 4-9% TBSA Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01953 ANEST DEF ANESTH 01/01/2024 1 Description: ANES 2&3 BURN EA ADD 9% TBSA Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01958 ANEST DEF ANESTH 01/01/2004 5 Description: ANES XTRNL CEPHALIC VERSION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0195U NOCOV DEF SYSMAN 07/01/2020 Y Description: KLF1 TARGETED SEQUENCING Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01960 ANEST DEF ANESTH 10/16/2003 5 Description: ANES VAGINAL DELIVERY ONLY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01961 ANEST DEF ANESTH 10/16/2003 7 Description: ANES CESAREAN DELIVERY ONLY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01962 ANEST DEF ANESTH 10/16/2003 8 Y Description: ANES URGENT HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01963 ANEST DEF ANESTH 02/01/2015 8 Y Description: ANES CESAREAN HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01965 ANEST DEF ANESTH 01/01/2006 4 Description: ANES INCOMPL/MISSED AB PX Category: Anesthesia CMS Add: 01/01/2006 CMS Term: 01966 ANEST DEF ANESTH 11/15/2014 4 Y Description: ANES INDUCED ABORTION PX Category: Anesthesia CMS Add: 01/01/2006 CMS Term: 01967 ANEST DEF ANESTH 10/16/2003 5 Description: NEURAXL LBR ANES VAG DLVR Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01968 ANEST DEF ANESTH 02/01/2015 2 Description: ANES/ANALG CS DLVR NEURAXIAL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01969 ANEST DEF ANESTH 10/16/2003 5 Y Description: ANES C HYST FLWG NEURAXIAL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0196U NOCOV DEF SYSMAN 07/01/2020 Y Description: LU GNOTYP BCAM EXON 3 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0197U NOCOV DEF SYSMAN 07/01/2020 Y Description: LW GNOTYP ICAM4 EXON 1 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0198T NOCOV DEF SYSMAN 01/01/2009 Y Description: OCULAR BLOOD FLOW MEASURE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0198U NOCOV DEF SYSMAN 07/01/2020 Y Description: RHD&RHCE GNTYP RHD1-10&RHCE5 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01990 ANEST DEF ANESTH 10/16/2003 7 Description: SUPPORT FOR ORGAN DONOR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01991 ANEST DEF ANESTH 10/15/2003 3 Description: ANESTH NERVE BLOCK/INJ Category: Anesthesia 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01992 ANEST DEF ANESTH 10/15/2003 5 Description: ANESTH N BLOCK/INJ PRONE Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 01996 ANEST DEF ANESTH 01/01/2024 3 Description: HOSP MANAGE CONT DRUG ADMIN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01999 ANEST DEF ANESTH 02/01/2015 0 Description: UNLISTED ANES PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0199U NOCOV DEF SYSMAN 07/01/2020 Y Description: SC GNOTYP ERMAP EXONS 4 12 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0200T NOCOV DEF SYSMAN 01/01/2010 Y Description: PERQ SACRAL AUGMT UNILAT INJ Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: 0200U NOCOV DEF SYSMAN 07/01/2020 Y Description: XK GNOTYP XK EXONS 1-3 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0201T NOCOV DEF SYSMAN 01/01/2010 Y Description: PERQ SACRAL AUGMT BILAT INJ Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: 0201U NOCOV DEF SYSMAN 07/01/2020 Y Description: YT GNOTYP ACHE EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0202T NOCOV DEF SYSMAN 01/01/2010 Y Description: POST VERT ARTHRPLST 1 LUMBAR Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: 0202U NOCOV DEF SYSMAN 05/20/2020 Y Description: NFCT DS 22 TRGT SARS-COV-2 Category: Non Covered Services CMS Add: 05/20/2020 CMS Term: 0203U NOCOV DEF SYSMAN 10/01/2020 Y Description: AI IBD MRNA XPRSN PRFL 17 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0204U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: ONC THYR MRNA XPRSN ALYS 593 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 06/30/2024 0205U NOCOV DEF SYSMAN 10/01/2020 Y Description: OPH AMD ALYS 3 GENE VARIANTS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0206U NOCOV DEF SYSMAN 10/01/2020 Y Description: NEURO ALZHEIMER CELL AGGREGJ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0207T NOCOV DEF SYSMAN 01/01/2010 Y Description: CLEAR EYELID GLAND W/HEAT Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0207U NOCOV DEF SYSMAN 10/01/2020 Y Description: NEURO ALZHEIMER QUAN IMAGING 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0208T NOCOV DEF SYSMAN 01/01/2010 Y Description: AUDIOMETRY AIR ONLY Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0209T NOCOV DEF SYSMAN 01/01/2010 Y Description: AUDIOMETRY AIR & BONE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0209U LAB L60 MAXFEE 07/01/2024 787.15 0 Y Description: CYTOG CONST ALYS INTERROG Category: Laboratory CMS Add: 10/01/2020 CMS Term: 0209U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: CYTOG CONST ALYS INTERROG Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0210T NOCOV DEF SYSMAN 01/01/2010 Y Description: SPEECH AUDIOMETRY THRESHOLD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0210U NOCOV DEF SYSMAN 10/01/2020 Y Description: SYPHILIS TST ANTB IA QUAN Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0211T NOCOV DEF SYSMAN 01/01/2010 Y Description: SPEECH AUDIOM THRESH & RECOG Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0211U NOCOV DEF SYSMAN 10/01/2020 Y Description: ONC PAN-TUM DNA&RNA GNRJ SEQ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0212T NOCOV DEF SYSMAN 01/01/2010 Y Description: COMPRE AUDIOMETRY EVALUATION Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0212U LAB L60 MAXFEE 07/01/2024 5475.2 0 Y Description: RARE DS GEN DNA ALYS PROBAND Category: Laboratory CMS Add: 10/01/2020 CMS Term: 0212U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: RARE DS GEN DNA ALYS PROBAND Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0213T NOCOV DEF SYSMAN 01/01/2010 Y 0-1 Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0213U LAB L60 MAXFEE 07/01/2024 2709.95 0 Y Description: RARE DS GEN DNA ALYS EA COMP Category: Laboratory CMS Add: 10/01/2020 CMS Term: 0213U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: RARE DS GEN DNA ALYS EA COMP Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0214T NOCOV DEF SYSMAN 01/01/2010 Y Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0214U LAB L60 MAXFEE 07/01/2024 5224.6 0 Y Description: RARE DS XOM DNA ALYS PROBAND Category: Laboratory 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0214U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: RARE DS XOM DNA ALYS PROBAND Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0215T NOCOV DEF SYSMAN 01/01/2010 Y Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0215U LAB L60 MAXFEE 07/01/2024 2574.65 0 Y Description: RARE DS XOM DNA ALYS EA COMP Category: Laboratory CMS Add: 10/01/2020 CMS Term: 0215U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: RARE DS XOM DNA ALYS EA COMP Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0216T NOCOV DEF SYSMAN 01/01/2010 Y 0-1 Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0216U LAB L60 MAXFEE 07/01/2024 1537.02 0 Y Description: NEURO INH ATAXIA DNA 12 COM Category: Laboratory CMS Add: 10/01/2020 CMS Term: 0216U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: NEURO INH ATAXIA DNA 12 COM Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0217T NOCOV DEF SYSMAN 01/01/2010 Y Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0217U LAB L60 MAXFEE 07/01/2024 2198.35 0 Y Description: NEURO INH ATAXIA DNA 51 GENE Category: Laboratory CMS Add: 10/01/2020 CMS Term: 0217U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: NEURO INH ATAXIA DNA 51 GENE Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0218T NOCOV DEF SYSMAN 01/01/2010 Y Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0218U LAB L60 MAXFEE 07/01/2024 2279 0 Y Description: NEURO MUSC DYS DMD SEQ ALYS Category: Laboratory CMS Add: 10/01/2020 CMS Term: 0218U NOCOV DEF SYSMAN 10/01/2020 06/30/2024 Y Description: NEURO MUSC DYS DMD SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0219T NOCOV DEF SYSMAN 01/01/2010 Y Description: PLMT POST FACET IMPLT CERV Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0219U NOCOV DEF SYSMAN 10/01/2020 Y Description: NFCT AGT HIV GNRJ SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0220T NOCOV DEF SYSMAN 01/01/2010 Y Description: PLMT POST FACET IMPLT THOR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0220U NOCOV DEF SYSMAN 10/01/2020 Y Description: ONC BRST CA AI ASSMT 12 FEAT Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0221T NOCOV DEF SYSMAN 01/01/2010 Y Description: PLMT POST FACET IMPLT LUMB Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0221U NOCOV DEF SYSMAN 10/01/2020 Y Description: ABO GNOTYP NEXT GNRJ SEQ ABO Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0222T NOCOV DEF SYSMAN 01/01/2010 Y Description: PLMT POST FACET IMPLT ADDL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0222U NOCOV DEF SYSMAN 10/01/2020 Y Description: RHD&RHCE GNTYP NEXT GNRJ SEQ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0223U NOCOV DEF SYSMAN 06/25/2020 Y Description: NFCT DS 22 TRGT SARS-COV-2 Category: Non Covered Services CMS Add: 06/25/2020 CMS Term: 0224U NOCOV DEF SYSMAN 06/25/2020 Y Description: ANTIBODY SARS-COV-2 TITER(S) Category: Non Covered Services CMS Add: 06/25/2020 CMS Term: 0225U NOCOV DEF SYSMAN 08/10/2020 Y Description: NFCT DS DNA&RNA 21 SARSCOV2 Category: Non Covered Services CMS Add: 08/10/2020 CMS Term: 0226U NOCOV DEF SYSMAN 08/10/2020 Y Description: SVNT SARSCOV2 ELISA PLSM SRM Category: Non Covered Services CMS Add: 08/10/2020 CMS Term: 0227U NOCOV DEF SYSMAN 01/01/2021 Y Description: RX ASY PRSMV 30+RX/METABLT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0228U NOCOV DEF SYSMAN 01/01/2021 Y Description: ONC PRST8 MA MOLEC PRFL ALG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0229U NOCOV DEF SYSMAN 01/01/2021 Y Description: BCAT1&IKZF1 PRMTR MTHYLN ALY Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0230U NOCOV DEF SYSMAN 01/01/2021 Y Description: AR FULL SEQUENCE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0231U NOCOV DEF SYSMAN 01/01/2021 06/30/2024 Y Description: CACNA1A FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0231U LAB L60 MAXFEE 07/01/2024 846.27 0 Y Description: CACNA1A FULL GENE ANALYSIS Category: Laboratory CMS Add: 01/01/2021 CMS Term: 0232T NOCOV DEF SYSMAN 07/01/2010 Y Description: NJX PLATELET PLASMA Category: Non Covered Services CMS Add: 07/01/2010 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0232U NOCOV DEF SYSMAN 01/01/2021 Y Description: CSTB FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0233U NOCOV DEF SYSMAN 01/01/2021 06/30/2024 Y Description: FXN GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0233U LAB L60 MAXFEE 07/01/2024 274.83 0 Y Description: FXN GENE ANALYSIS Category: Laboratory CMS Add: 01/01/2021 CMS Term: 0234T MEDSV DEF MAXFEE 01/01/2024 1879.23 0 Description: TRLUML PERIP ATHRC RENAL ART Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0234U NOCOV DEF SYSMAN 01/01/2021 Y Description: MECP2 FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0235T MEDSV DEF BILL40 01/01/2011 Description: TRLUML PERIP ATHRC VISCERAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0235U NOCOV DEF SYSMAN 01/01/2021 06/30/2024 Y Description: PTEN FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0235U LAB L60 MAXFEE 07/01/2024 600 0 Y Description: PTEN FULL GENE ANALYSIS Category: Laboratory CMS Add: 01/01/2021 CMS Term: 0236T MEDSV DEF MAXFEE 01/01/2024 1879.23 0 Description: TRLUML PERIP ATHRC ABD AORTA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0236U NOCOV DEF SYSMAN 01/01/2021 06/30/2024 Y Description: SMN1&SMN2 FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0236U LAB L60 MAXFEE 07/01/2024 602.7 0 Y Description: SMN1&SMN2 FULL GENE ANALYSIS Category: Laboratory CMS Add: 01/01/2021 CMS Term: 0237T MEDSV DEF MAXFEE 01/01/2024 1879.23 0 Description: TRLUML PERIP ATHRC BRCHIOCPH Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0237U NOCOV DEF SYSMAN 01/01/2021 06/30/2024 Y Description: CAR ION CHNLPTHY GEN SEQ PNL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0237U LAB L60 MAXFEE 07/01/2024 584.9 0 Y Description: CAR ION CHNLPTHY GEN SEQ PNL Category: Laboratory CMS Add: 01/01/2021 CMS Term: 0238T MEDSV DEF MAXFEE 01/01/2024 1879.23 0 Description: TRLUML PERIP ATHRC ILIAC ART Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0238U NOCOV DEF SYSMAN 01/01/2021 06/30/2024 Y Description: ONC LNCH SYN GEN DNA SEQ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0238U LAB L60 MAXFEE 07/01/2024 584.9 0 Y Description: ONC LNCH SYN GEN DNA SEQ ALY Category: Laboratory CMS Add: 01/01/2021 CMS Term: 0239U NOCOV DEF SYSMAN 01/01/2021 Y Description: TRGT GEN SEQ ALYS PNL 311+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0240U LAB DEF MAXFEE 10/01/2024 142.63 0 Description: NFCT DS VIR RESP RNA 3 TRGT Category: Laboratory CMS Add: 10/06/2020 CMS Term: 0241U LAB DEF MAXFEE 10/01/2024 142.63 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 0 Y Description: TRGT GEN SEQ ALYS PNL 55-74 Category: Laboratory CMS Add: 04/01/2021 CMS Term: 0243U NOCOV DEF SYSMAN 04/01/2021 Y Description: OB PE BIOCHEM ASSAY PGF ALG Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0244U NOCOV DEF SYSMAN 04/01/2021 Y Description: ONC SOLID ORGN DNA 257 GENES Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0245U NOCOV DEF SYSMAN 04/01/2021 Y Description: ONC THYR MUT ALYS 10 GEN&37 Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0246U NOCOV DEF SYSMAN 04/01/2021 Y Description: RBC DNA GNOTYP 16 BLD GROUPS Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0247U NOCOV DEF SYSMAN 04/01/2021 Y Description: OB PRTRM BRTH IBP4 SHBG MEAS Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0248U NOCOV DEF SYSMAN 07/01/2021 Y Description: ONC SPHRD CELL CUL 12 RX PNL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0249U NOCOV DEF SYSMAN 07/01/2021 Y Description: ONC BRST ALYS 32 PHSPRTN ALG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0250U NOCOV DEF SYSMAN 07/01/2021 Y Description: ONC SLD ORG NEO DNA 505 GENE Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0251U NOCOV DEF SYSMAN 07/01/2021 Y Description: HEPCIDIN-25 ELISA SERUM/PLSM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0252U NOCOV DEF SYSMAN 07/01/2021 Y Description: FTL ANEUPLOIDY STR ALYS DNA Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0253T NOCOV DEF SYSMAN 01/01/2011 Y Description: INSERT AQUEOUS DRAIN DEVICE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0253U NOCOV DEF SYSMAN 07/01/2021 Y Description: RPRDTVE MED RNA GEN PRFL 238 Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0254U NOCOV DEF SYSMAN 07/01/2021 Y Description: REPRDTVE MED ALYS 24 CHRMSM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0255U NOCOV DEF SYSMAN 10/01/2021 Y Description: ANDROLOGY INFERTILITY ASSMT Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0256U NOCOV DEF SYSMAN 10/01/2021 Y Description: TMA/TMAO PRFL MS/MS UR ALG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0257U NOCOV DEF SYSMAN 10/01/2021 Y Description: VLCAD LEUK NZM ACTV WHL BLD Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0258U NOCOV DEF SYSMAN 10/01/2021 Y Description: AI PSOR MRNA 50-100 GEN ALG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0259U NOCOV DEF SYSMAN 10/01/2021 Y Description: NEPH CKD NUC MRS MEAS GFR Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0260U NOCOV DEF SYSMAN 10/01/2021 Y Description: RARE DS ID OPT GENOME MAPG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0261U NOCOV DEF SYSMAN 10/01/2021 Y Description: ONC CLRCT CA IMG ALYS W/AI Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0262U NOCOV DEF SYSMAN 10/01/2021 Y Description: ONC SLD TUM RT-PCR 7 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0263T NOCOV DEF SYSMAN 06/02/2017 Y Description: IM B1 MRW CEL THER CMPL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0263U NOCOV DEF SYSMAN 10/01/2021 Y Description: NEURO ASD MEAS 16 C METBLT Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0264T NOCOV DEF SYSMAN 06/02/2017 Y Description: IM B1 MRW CEL THER XCL HRVST Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0264U NOCOV DEF SYSMAN 10/01/2021 Y Description: RARE DS ID OPT GENOME MAPG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0265T NOCOV DEF SYSMAN 06/02/2017 Y Description: IM B1 MRW CEL THER HRVST ONL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0265U LAB L60 MAXFEE 07/01/2024 5475.8 0 Y Description: RAR DO WHL GN&MTCDRL DNA ALS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0265U NOCOV DEF SYSMAN 10/01/2021 06/30/2024 Y Description: RAR DO WHL GN&MTCDRL DNA ALS Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0266T NOCOV DEF SYSMAN 06/02/2017 Y Description: IMPLT/RPL CRTD SNS DEV TOTAL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0266U NOCOV DEF SYSMAN 10/01/2021 Y Description: UNXPL CNST HRTBL DO GN XPRSN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0267T NOCOV DEF SYSMAN 06/02/2017 Y Description: IMPLT/RPL CRTD SNS DEV LEAD Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0267U LAB L60 MAXFEE 07/01/2024 6739.33 0 Y Description: RARE DO ID OPT GEN MAPG&SEQ Category: Laboratory CMS Add: 10/01/2021 CMS Term: 0267U NOCOV DEF SYSMAN 10/01/2021 06/30/2024 Y Description: RARE DO ID OPT GEN MAPG&SEQ Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0268T NOCOV DEF SYSMAN 06/02/2017 Y Description: IMPLT/RPL CRTD SNS DEV GEN Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0268U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM AHUS GEN SEQ ALYS 15 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0269T NOCOV DEF SYSMAN 06/02/2017 Y Description: REV/REMVL CRTD SNS DEV TOTAL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0269U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM AUT DM CGEN TRMBCTPNA 22 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0270T NOCOV DEF SYSMAN 07/01/2011 Y Description: REV/REMVL CRTD SNS DEV LEAD Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0270U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM CGEN COAGJ DO 20 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0271T NOCOV DEF SYSMAN 06/02/2017 Y Description: REV/REMVL CRTD SNS DEV GEN Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0271U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM CGEN NEUTROPENIA 24 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0272T NOCOV DEF SYSMAN 06/02/2017 Y Description: INTERROGATE CRTD SNS DEV Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0272U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM GENETIC BLD DO 60 GENES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0273T NOCOV DEF SYSMAN 06/02/2017 Y Description: INTERROGATE CRTD SNS W/PGRMG Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0273U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM GEN HYPRFIBRNLYSIS 8 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0274T NOCOV DEF SYSMAN 06/02/2017 Y Description: PERQ LAMOT/LAM CRV/THRC Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0274U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM GEN PLTLT DO 62 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0275T NOCOV DEF SYSMAN 06/02/2017 Y Description: PERQ LAMOT/LAM LUMBAR Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0275U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM HEPRN NDUC TRMBCTPNA SRM Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0276U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM INH THROMBOCYTOPENIA 42 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0277U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM GEN PLTLT FUNCJ DO 40 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0278T NOCOV DEF SYSMAN 01/01/2012 Y Description: TEMPR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0278U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM GEN THROMBOSIS 14 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0279U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM VW FACTOR&CLGN III BNDG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0280U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM VW FACTOR&CLGN IV BNDG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0281U NOCOV DEF SYSMAN 10/01/2021 Y Description: HEM VWD PROPEPTIDE AG LVL Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0282U NOCOV DEF SYSMAN 10/01/2021 Y Description: RBC DNA GNTYP 12 BLD GRP GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0283U NOCOV DEF SYSMAN 10/01/2021 Y Description: VW FACTOR TYPE 2B EVAL PLSM Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0284U NOCOV DEF SYSMAN 10/01/2021 Y Description: VW FACTOR TYPE 2N EVAL PLSM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0285U NOCOV DEF SYSMAN 01/01/2022 Y Description: ONC RSPS RADJ CLL FR DNA TOX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0286U NOCOV DEF SYSMAN 01/01/2022 Y Description: CEP72 NUDT15&TPMT GENE ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0287U LAB L60 MAXFEE 01/20/2023 3600 0 Y Description: ONC THYR DNA&MRNA 112 GENES Category: Laboratory CMS Add: 01/01/2022 CMS Term: 0288U NOCOV DEF SYSMAN 01/01/2022 Y Description: ONC LUNG MRNA QUAN PCR 11&3 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0289U NOCOV DEF SYSMAN 01/01/2022 Y Description: NEURO ALZHEIMER MRNA 24 GEN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0290U NOCOV DEF SYSMAN 01/01/2022 Y Description: PAIN MGMT MRNA GEN XPRSN 36 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0291U NOCOV DEF SYSMAN 01/01/2022 Y Description: PSYC MOOD DO MRNA 144 GENES Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0292U NOCOV DEF SYSMAN 01/01/2022 Y Description: PSYC STRS DO MRNA 72 GENES Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0293U NOCOV DEF SYSMAN 01/01/2022 Y Description: PSYC SUICIDAL IDEA MRNA 54 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0294U NOCOV DEF SYSMAN 01/01/2022 Y Description: LNGVTY&MRTLTY RSK MRNA 18GEN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0295U NOCOV DEF SYSMAN 01/01/2022 Y Description: ONC BRST DUX CARC 7 PROTEINS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0296U NOCOV DEF SYSMAN 01/01/2022 Y Description: ONC ORL&/OROP CA 20 MLC FEAT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0297U NOCOV DEF SYSMAN 01/01/2022 Y Description: ONC PAN TUM WHL GEN SEQ DNA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0298U NOCOV DEF SYSMAN 01/01/2022 Y Description: ONC PAN TUM WHL TRNS SEQ RNA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0299U NOCOV DEF SYSMAN 01/01/2022 Y Description: ONC PAN TUM WHL GEN OPT MAPG Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0300U NOCOV DEF SYSMAN 01/01/2022 Y Description: ONC PAN TUM WHL GEN SEQ&OPT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0301U NOCOV DEF SYSMAN 01/01/2022 Y Description: IADNA BARTONELLA DDPCR Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0302U NOCOV DEF SYSMAN 01/01/2022 Y Description: IADNA BRTNLA DDPCR FLWG LIQ Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0303U NOCOV DEF SYSMAN 01/01/2022 Y Description: HEM RBC ADS WHL BLD HYPOXIC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0304U NOCOV DEF SYSMAN 01/01/2022 Y Description: HEM RBC ADS WHL BLD NORMOXIC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0305U NOCOV DEF SYSMAN 01/01/2022 Y Description: HEM RBC FNCLTY&DFRM SHR STRS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0306U NOCOV DEF SYSMAN 04/01/2022 Y Description: ONC MRD NXT-GNRJ ALYS 1ST Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0307U NOCOV DEF SYSMAN 04/01/2022 Y Description: ONC MRD NXT-GNRJ ALYS SBSQ Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0308T NOCOV DEF SYSMAN 01/01/2012 Y Description: INSJ OCULAR TELESCOPE PROSTH Category: Non Covered Services CMS Add: 07/01/2012 CMS Term: 0308U NOCOV DEF SYSMAN 04/01/2022 Y Description: CRD CAD ALYS 3 PRTN 3 PARAM Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0309U NOCOV DEF SYSMAN 04/01/2022 Y Description: CRD CV DS ALY 4 PRTN PLM ALG Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0310U NOCOV DEF SYSMAN 04/01/2022 Y Description: PED VSCLTS KD ALYS 3 BMRKS Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0311U NOCOV DEF SYSMAN 04/01/2022 Y Description: NFCT DS BCT QUAN ANTMCRB SC Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0312U NOCOV DEF SYSMAN 04/01/2022 Y Description: AI DS SLE ALYS 8 IGG AUTOANT Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0313U NOCOV DEF SYSMAN 04/01/2022 Y Description: ONC PNCRS DNA&MRNA SEQ 74 Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0314U NOCOV DEF SYSMAN 04/01/2022 Y Description: ONC CUTAN MLNMA MRNA 35 GENE Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0315U NOCOV DEF SYSMAN 04/01/2022 Y Description: ONC CUTAN SQ CLL CA MRNA 40 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0316U NOCOV DEF SYSMAN 04/01/2022 Y Description: B BRGDRFERI LYME DS OSPA EVL Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0317U NOCOV DEF SYSMAN 04/01/2022 Y Description: ONC LUNG CA 4-PRB FISH ASSAY Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0318U NOCOV DEF SYSMAN 04/01/2022 Y Description: PED WHL GEN MTHYLTN ALYS 50+ Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0319U NOCOV DEF SYSMAN 04/01/2022 Y Description: NEPH RNA PRETRNSPL PERPH BLD Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0320U NOCOV DEF SYSMAN 04/01/2022 Y Description: NEPH RNA PSTTRNSPL PERPH BLD Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0321U NOCOV DEF SYSMAN 04/01/2022 Y Description: IADNA GU PTHGN 20BCT&FNG ORG Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0322U NOCOV DEF SYSMAN 04/01/2022 Y Description: NEURO ASD MEAS 14 ACYL CARN Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0323U NOCOV DEF SYSMAN 07/01/2022 Y Description: IADNA CNS PTHGN NEXT GEN SEQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0326U LAB DEF BILL90 07/24/2023 Y Description: TRGT GEN SEQ ALYS PNL 83+ Category: Laboratory CMS Add: 07/01/2022 CMS Term: 0327U NOCOV DEF SYSMAN 07/01/2022 06/30/2024 Y Description: FTL ANEUPLOIDY TRSMY DNA SEQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0327U LAB L60 MAXFEE 07/01/2024 795 0 Y Description: FTL ANEUPLOIDY TRSMY DNA SEQ Category: Laboratory CMS Add: 07/01/2022 CMS Term: 0328U NOCOV DEF SYSMAN 07/01/2022 Y Description: DRUG ASSAY 120+ RX&METABLT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0329T NOCOV DEF SYSMAN 07/01/2013 Y Description: MNTR IO PRESS 24HRS/> UNI/BI Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0329U NOCOV DEF SYSMAN 07/01/2022 Y Description: ONC NEO XOME&TRNS SEQ ALYS Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0330T NOCOV DEF SYSMAN 07/01/2013 Y Description: TEAR FILM IMG UNI/BI W/I&R Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0330U NOCOV DEF SYSMAN 07/01/2022 Y Description: IADNA VAG PTHGN PANEL 27 ORG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0331T NOCOV DEF SYSMAN 07/01/2013 Y Description: HEART SYMP IMAGE PLNR Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0331U NOCOV DEF SYSMAN 07/01/2022 Y Description: ONC HL NEO OPT GEN MAPPING Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0332T NOCOV DEF SYSMAN 07/01/2013 Y Description: HEART SYMP IMAGE PLNR SPECT Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0332U NOCOV DEF SYSMAN 10/01/2022 Y Description: ONC PAN TUM GEN PRFLG 8 DNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0333T NOCOV DEF SYSMAN 07/01/2013 Y Description: VISUAL EP SCR ACUITY AUTO Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0333U NOCOV DEF SYSMAN 10/01/2022 Y Description: ONC LVR SURVEILANC HCC CFDNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0334U NOCOV DEF SYSMAN 10/01/2022 Y Description: ONC SLD ORGN TGSA DNA 84/+ Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0335T NOCOV DEF SYSMAN 01/01/2014 Y Description: INSJ SINUS TARSI IMPLANT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0335U LAB L60 MAXFEE 07/01/2024 5224.6 0 Y Description: RARE DS WHL GEN SEQ FETA Category: Laboratory CMS Add: 10/01/2022 CMS Term: 0335U NOCOV DEF SYSMAN 10/01/2022 06/30/2024 Y Description: RARE DS WHL GEN SEQ FETA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0336U LAB L60 MAXFEE 07/01/2024 2574.65 0 Y Description: RARE DS WHL GEN SEQ BLD/SLV Category: Laboratory CMS Add: 10/01/2022 CMS Term: 0336U NOCOV DEF SYSMAN 10/01/2022 06/30/2024 Y Description: RARE DS WHL GEN SEQ BLD/SLV Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0337U NOCOV DEF SYSMAN 10/01/2022 Y Description: ONC PLSM CELL DO&MYELOMA ID Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0338T NOCOV DEF SYSMAN 01/01/2014 Y Description: TRNSCTH RENAL SYMP DENRV UNL Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0338U NOCOV DEF SYSMAN 10/01/2022 Y Description: ONC SLD TUM CRCG TUM CL SLCT Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0339T NOCOV DEF SYSMAN 01/01/2014 Y Description: TRNSCTH RENAL SYMP DENRV BIL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0339U NOCOV DEF SYSMAN 10/01/2022 Y Description: ONC PRST8 MRNA HOXC6 & DLX1 Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0340U NOCOV DEF SYSMAN 10/01/2022 10/31/2024 Y Description: ONC PAN CA ALYS MRD PLASMA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0340U LAB L60 MAXFEE 11/01/2024 3590 0 Y Description: ONC PAN CA ALYS MRD PLASMA Category: Laboratory CMS Add: 10/01/2022 CMS Term: 0341U NOCOV DEF SYSMAN 10/01/2022 Y Description: FTL ANEUP DNA SEQ CMPR ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0342T NOCOV DEF SYSMAN 01/01/2014 Y Description: THXP APHERESIS W/HDL DELIP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0342U NOCOV DEF SYSMAN 10/01/2022 Y Description: ONC PNCRTC CA MULT IA ECLIA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0343U NOCOV DEF SYSMAN 10/01/2022 Y Description: ONC PRST8 XOM ALY 442 SNCRNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0344U NOCOV DEF SYSMAN 10/01/2022 Y Description: HEP NAFLD SEMIQ EVL 28 LIPID Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0345T NOCOV DEF SYSMAN 01/01/2014 Y Description: TRANSCATH MTRAL VLVE REPAIR Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0345U NOCOV DEF SYSMAN 10/01/2022 10/31/2024 Y Description: PSYC GENOM ALYS PNL 15 GEN Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0345U LAB L60 MAXFEE 11/01/2024 1336.09 0 Y Description: PSYC GENOM ALYS PNL 15 GEN Category: Laboratory CMS Add: 10/01/2022 CMS Term: 0346U NOCOV DEF SYSMAN 10/01/2022 12/31/2024 Y Description: BETA AMYL AB40&AB42 LC-MS/MS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 12/31/2024 0347T NOCOV DEF SYSMAN 07/01/2014 Y Description: INS BONE DEVICE FOR RSA Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0347U NOCOV DEF SYSMAN 10/01/2022 Y Description: RX METAB/PCX DNA 16 GEN ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0348T NOCOV DEF SYSMAN 07/01/2014 Y Description: RSA SPINE EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0348U NOCOV DEF SYSMAN 10/01/2022 Y Description: RX METAB/PCX DNA 25 GEN ALYS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0349T NOCOV DEF SYSMAN 07/01/2014 Y Description: RSA UPPER EXTR EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0349U NOCOV DEF SYSMAN 10/01/2022 Y Description: RX METAB/PCX DNA 27GEN RX IA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0350T NOCOV DEF SYSMAN 07/01/2014 Y Description: RSA LOWER EXTR EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0350U NOCOV DEF SYSMAN 10/01/2022 Y Description: RX METAB/PCX DNA 27 GEN ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0351T NOCOV DEF SYSMAN 07/01/2014 Y Description: INTRAOP OCT BRST/NODE SPEC Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0351U NOCOV DEF SYSMAN 10/01/2022 Y Description: NFCT DS BCT/VIRAL TRAIL IP10 Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0352T NOCOV DEF SYSMAN 07/01/2014 Y Description: OCT BRST/NODE I&R PER SPEC Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0352U NOCOV DEF SYSMAN 10/01/2022 12/31/2024 Y Description: NFCT DS BV&VAGINITIS AMP PRB Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 12/31/2024 0353T NOCOV DEF SYSMAN 07/01/2014 Y Description: INTRAOP OCT BREAST CAVITY Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0353U NOCOV DEF SYSMAN 10/01/2022 06/30/2024 Y Description: IADNA CHLMYD&GONORR AMP PRB Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 06/30/2024 0354T NOCOV DEF SYSMAN 07/01/2014 Y Description: OCT BREAST SURG CAVITY I&R Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0354U NOCOV DEF SYSMAN 10/01/2022 03/31/2024 Y 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 01/01/2023 Y Description: APOL1 RISK VARIANTS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0356U NOCOV DEF SYSMAN 01/01/2023 Y Description: ONC OROP/ANAL 17 DNA DDPCR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0358T NOCOV DEF SYSMAN 07/01/2014 Y Description: BIA WHOLE BODY Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0358U NOCOV DEF SYSMAN 01/01/2023 Y Description: NEURO ALYS B-AMYL 1-42&1-40 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0359U NOCOV DEF SYSMAN 01/01/2023 Y Description: ONC PRST8 CA ALYS ALL PSA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0360U NOCOV DEF SYSMAN 01/01/2023 Y Description: ONC LUNG ELISA 7 AUTOANT ALG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0361U NOCOV DEF SYSMAN 01/01/2023 Y Description: NEURFLMNT LT CHN DIG IA QUAN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0362T U1 MENTL DEF MAXFEE 04/01/2025 28.54 0 Y Description: BHV ID SUPRT ASSMT EA 15 MIN Category: Mental Health CMS Add: 07/01/2014 CMS Term: 0362U NOCOV DEF SYSMAN 01/01/2023 Y Description: ONC PAP THYR CA RNA 82&10 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0363U NOCOV DEF SYSMAN 01/01/2023 Y Description: ONC URTHL MRNA 5 GEN ALG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0364U NOCOV DEF SYSMAN 04/01/2023 Y Description: ONC HL NEO GEN SEQ ALYS ALG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0365U NOCOV DEF SYSMAN 04/01/2023 Y Description: ONC BLDR 10 UR HRBR URTHL CA Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0366U NOCOV DEF SYSMAN 04/01/2023 Y Description: ONC BLDR 10 PRB RECR BLDR CA Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0367U NOCOV DEF SYSMAN 04/01/2023 Y Description: ONC BLDR 10 FLWG TRURL RESCJ Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0368U NOCOV DEF SYSMAN 04/01/2023 Y Description: ONC CLRCT CA MUT&MTHYLTN MRK Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0369U NOCOV DEF SYSMAN 04/01/2023 Y Description: IADNA GI PTHGN 31 ORG&21 ARG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0370U NOCOV DEF SYSMAN 04/01/2023 Y Description: IADNA SURG WND PTHGN 34&21 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0371U NOCOV DEF SYSMAN 04/01/2023 Y Description: IADNA GU PTHGN SEMIQ DNA16&1 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0372U NOCOV DEF SYSMAN 04/01/2023 Y Description: NFCT DS GU PTHGN ARG DETCJ Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0373T U1 MENTL DEF MAXFEE 04/01/2025 28.54 0 Y Description: ADAPT BHV TX EA 15 MIN Category: Mental Health 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0373U NOCOV DEF SYSMAN 04/01/2023 Y Description: IADNA RSP TR NFCT 17 8 13&16 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0374U NOCOV DEF SYSMAN 04/01/2023 Y Description: IADNA GU PTHGN 21 ORG&21ARG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0375U NOCOV DEF SYSMAN 04/01/2023 Y Description: ONC OVRN BCHM ASY 7 PRTN ALG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0376U NOCOV DEF SYSMAN 04/01/2023 Y Description: ONC PRST8 CA IMG ALYS 128 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0377U NOCOV DEF SYSMAN 04/01/2023 Y Description: CV DS QUAN ADVSRM/PLSM LPRTN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0378T NOCOV DEF SYSMAN 01/01/2015 Y Description: VISUAL FIELD ASSMNT REV/RPRT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 0378U NOCOV DEF SYSMAN 04/01/2023 Y Description: RFC1 REPEAT XPNSJ VRNT ALYS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0379T NOCOV DEF SYSMAN 01/01/2015 Y Description: VIS FIELD ASSMNT TECH SUPPT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 0379U NOCOV DEF SYSMAN 04/01/2023 Y Description: TGSAP SL OR NEO DNA523&RNA55 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0380U NOCOV DEF SYSMAN 04/01/2023 12/31/2024 Y Description: RX METB ADVRS TRGT SQ ALY 20 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 12/31/2024 0381U NOCOV DEF SYSMAN 04/01/2023 Y Description: MAPLE SYRUP UR DS MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0382U NOCOV DEF SYSMAN 04/01/2023 Y Description: HYPRPHENYLALNINMIA MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0383U NOCOV DEF SYSMAN 04/01/2023 Y Description: TYROSINEMIA TYP I MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0384U NOCOV DEF SYSMAN 04/01/2023 Y Description: NEPH CKD RSK HI STG KDN DS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0385U NOCOV DEF SYSMAN 04/01/2023 Y Description: NEPH CKD ALG RSK DBTC KDN DS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0387U NOCOV DEF SYSMAN 07/01/2023 Y Description: ONC MLNMA AMBRA1&AMLO 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0388U NOCOV DEF SYSMAN 07/01/2023 Y Description: ONC NONSM CLL LNG CA 37 GEN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0389U NOCOV DEF SYSMAN 07/01/2023 Y Description: PED FBRL KD IFI27&MCEMP1 RNA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0390U NOCOV DEF SYSMAN 07/01/2023 Y Description: OB PE KDR ENG&RBP4 IA ALG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0391U NOCOV DEF SYSMAN 07/01/2023 Y Description: ONC SLD TUM DNA&RNA 437 GEN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0392U NOCOV DEF SYSMAN 07/01/2023 Y Description: RX METAB GENRX IA 16 GENES Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0393U NOCOV DEF SYSMAN 07/01/2023 Y Description: NEU PRKSN MSFL A-SYNCLN PRTN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0394T NOCOV DEF SYSMAN 01/01/2016 Y Description: HDR ELCTRNC SKN SURF BRCHYTX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0394U NOCOV DEF SYSMAN 07/01/2023 Y Description: PFAS 16 PFAS COMPND LC MS/MS Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0395T NOCOV DEF SYSMAN 01/01/2016 Y Description: HDR ELCTR NTRST/NTRCV BRCHTX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0395U NOCOV DEF SYSMAN 07/01/2023 Y Description: ONC LNG MULTIOMICS PLSM ALG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0396U NOCOV DEF SYSMAN 07/01/2023 09/30/2024 Y Description: OB PREIMPLTJ TST 300000 DNA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 09/30/2024 0397T NOCOV DEF SYSMAN 01/01/2016 Y Description: ERCP W/OPTICAL ENDOMICROSCPY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0398T MEDSV PRF MAXFEE 01/01/2024 12/31/2024 1349.13 0 Y Description: MRGFUS STRTCTC LES ABLTJ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 12/31/2024 0398U NOCOV DEF SYSMAN 07/01/2023 Y Description: GI BARET ESPH DNA MTHYLN ALY Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0399U NOCOV DEF SYSMAN 07/01/2023 Y Description: NEURO CERE FOLATE DEFNCY SRM Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0400U NOCOV DEF SYSMAN 07/01/2023 Y Description: OB XPND CAR SCR 145 GENES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0401U NOCOV DEF SYSMAN 07/01/2023 Y Description: CRD C HRT DS 9 GEN 12 VRNTS Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0402T NOCOV DEF SYSMAN 01/01/2016 Y Description: COLGN CRS-LINK CRN&PACHYMTRY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0402U NOCOV DEF SYSMAN 10/01/2023 Y Description: NFCT AGT STI MULT AMP PRB TQ Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0403T NOCOV DEF SYSMAN 01/01/2016 Y Description: DIABETES PREV STANDARD CURR Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0403U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC PRST8 MRNA 18 GEN 1ST UR Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0404U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC BRST SEMIQ MEAS THYM KN Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0405U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC PNCRTC 59 MTHLTN BLK MRK Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0406U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC LUNG FLOW CYTMTRY 5 MRK Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0407U NOCOV DEF SYSMAN 10/01/2023 Y Description: NEPH DBTC CKD MULT ECLIA ALG Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0408T NOCOV DEF SYSMAN 01/01/2016 Y Description: INSJ/RPLC CARDIAC MODULJ SYS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0408U NOCOV DEF SYSMAN 10/01/2023 Y Description: IAAD BLK AC WV BSNSR SARSCV2 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0409T NOCOV DEF SYSMAN 01/01/2016 Y Description: INSJ/RPLC CAR MODULJ PLS GN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0409U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC SLD TUM DNA 80 & RNA 36 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0410T NOCOV DEF SYSMAN 01/01/2016 Y Description: INSJ/RPLC CAR MODULJ ATR ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0410U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC PNCRTC DNA WHL GN SEQ 5- Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0411T NOCOV DEF SYSMAN 01/01/2016 Y Description: INSJ/RPLC CAR MODULJ VNT ELT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0411U NOCOV DEF SYSMAN 10/01/2023 10/31/2024 Y Description: PSYC GENOM ALYS PNL 15 GEN Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0411U LAB L60 MAXFEE 11/01/2024 1336.09 0 Y Description: PSYC GENOM ALYS PNL 15 GEN Category: Laboratory CMS Add: 10/01/2023 CMS Term: 0412T NOCOV DEF SYSMAN 01/01/2016 Y Description: RMVL CARDIAC MODULJ PLS GEN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0412U NOCOV DEF SYSMAN 10/01/2023 Y Description: BETA AMYLOID AB42/40 IMPRCIP Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0413T NOCOV DEF SYSMAN 01/01/2016 Y Description: RMVL CAR MODULJ TRANVNS ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0413U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC HL NEO OPT GEN MAPG DNA Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0414T NOCOV DEF SYSMAN 01/01/2016 Y Description: RMVL & RPL CAR MODULJ PLS GN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0414U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC LNG AUG ALG ALY WHL SLD8 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0415T NOCOV DEF SYSMAN 01/01/2016 Y Description: REPOS CAR MODULJ TRANVNS ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0415U NOCOV DEF SYSMAN 10/01/2023 Y Description: CV DS ACS BLD ALG 5 YR SCORE Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0416T NOCOV DEF SYSMAN 01/01/2016 Y Description: RELOC SKIN POCKET PLS GEN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0416U NOCOV DEF SYSMAN 10/01/2023 03/31/2024 Y 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 01/01/2016 Y Description: PRGRMG EVAL CARDIAC MODULJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0417U NOCOV DEF SYSMAN 10/01/2023 Y Description: RARE DS ALYS 335 NUC GENES Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0418T NOCOV DEF SYSMAN 01/01/2016 Y Description: INTERRO EVAL CARDIAC MODULJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0418U NOCOV DEF SYSMAN 10/01/2023 Y Description: ONC BRST AUG ALG ALY WHL SL8 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0419T NOCOV DEF SYSMAN 01/01/2016 Y Description: DSTRJ NEUROFIBROMA XTNSV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0419U NOCOV DEF SYSMAN 10/01/2023 Y Description: NRPSYC GEN SEQ VRNT ALY 13 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0420T NOCOV DEF SYSMAN 01/01/2016 Y Description: DSTRJ NEUROFIBROMA XTNSV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0420U NOCOV DEF SYSMAN 01/01/2024 Y Description: ONC URTHL MRNA XPRSN 6 SNP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0421T NOCOV DEF SYSMAN 01/01/2016 Y Description: WATERJET PROSTATE ABLTJ CMPL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0421U NOCOV DEF SYSMAN 01/01/2024 Y Description: ONC CLRCT SCR SGL AMP 8 RNA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0422T NOCOV DEF SYSMAN 01/01/2016 Y Description: TACTILE BREAST IMG UNI/BI Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0422U NOCOV DEF SYSMAN 01/01/2024 Y Description: ONC PAN SOLID TUM ALYS DNA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0423U NOCOV DEF SYSMAN 01/01/2024 Y Description: PSYC GENOMIC ALYS PNL 26 GEN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0424U NOCOV DEF SYSMAN 01/01/2024 Y Description: ONC PRST8 XOM ALYS 53 SNCRNA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0425U NOCOV DEF SYSMAN 01/01/2024 Y Description: GENOM RPD SEQ ALYS EA CMPRTR Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0426U NOCOV DEF SYSMAN 01/01/2024 Y Description: GENOME ULTRA-RAPID SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0427U NOCOV DEF SYSMAN 01/01/2024 Y Description: MONOCYTE DSTRBJ WDTH WHL BLD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0428U NOCOV DEF SYSMAN 01/01/2024 12/31/2024 Y Description: ONC BRST CTDNA ALYS 56/> GEN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 12/31/2024 0429U NOCOV DEF SYSMAN 01/01/2024 Y Description: HPV OROP SWAB 14 HI-RISK TYP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0430U NOCOV DEF SYSMAN 01/01/2024 Y Description: GI MALABS AAT CALPRO PNCRTC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0431U NOCOV DEF SYSMAN 01/01/2024 Y Description: GLY RCPTR ALPHA1 IGG SRM/CSF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0432U NOCOV DEF SYSMAN 01/01/2024 Y Description: KLHL11 ANTB SR/CSF ASY QUAL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0433U NOCOV DEF SYSMAN 01/01/2024 Y Description: ONC PRST8 5 DNA REG MRK PCR Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0434U NOCOV DEF SYSMAN 01/01/2024 Y Description: RX METAB ADVRS VRNT ALYS 25 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0435U NOCOV DEF SYSMAN 01/01/2024 Y Description: ONC CHEMO RX CYTOX CSC 14 RX Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0436U NOCOV DEF SYSMAN 01/01/2024 Y Description: ONC LNG PLSM ALYS 388 PRTN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0437T NOCOV DEF SYSMAN 01/01/2017 Y Description: IMPLTJ SYNTH RNFCMT ABDL WAL Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0437U NOCOV DEF SYSMAN 01/01/2024 Y Description: PSYC ANXIETY DO MRNA 15 BMRK Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0438U NOCOV DEF SYSMAN 01/01/2024 Y Description: RX METAB ADVRS VRNT ALYS 33 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0439T NOCOV DEF SYSMAN 01/01/2017 Y Description: MYOCRD CONTRAST PRFUJ ECHO Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0439U NOCOV DEF SYSMAN 04/01/2024 Y Description: CRD CHD DNA ALYS 5 SNP 3 DNA Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0440T NOCOV DEF SYSMAN 01/01/2017 Y Description: ABLTJ PERC UXTR/PERPH NRV Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0440U NOCOV DEF SYSMAN 04/01/2024 Y Description: CRD CHD DNA ALYS 10 SNP 6DNA Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0441T NOCOV DEF SYSMAN 01/01/2017 Y Description: ABLTJ PERC LXTR/PERPH NRV Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0441U NOCOV DEF SYSMAN 04/01/2024 Y Description: NFCT DS BCT FNGL/VIRAL SEMIQ Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0442T NOCOV DEF SYSMAN 01/01/2017 Y Description: ABLTJ PERC PLEX/TRNCL NRV 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0442U NOCOV DEF SYSMAN 04/01/2024 Y Description: NFCT DS RESPIR NFCTJ MXA&CRP Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0443T NOCOV DEF SYSMAN 01/01/2017 Y Description: R-T SPCTRL ALYS PRST8 TISS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0443U NOCOV DEF SYSMAN 04/01/2024 Y Description: NEURFLMNT LT CHN ULTRSENS IA Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0444T NOCOV DEF SYSMAN 01/01/2017 Y Description: 1ST PLMT DRUG ELUT OC INS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0444U NOCOV DEF SYSMAN 04/01/2024 Y Description: ONC SLD ORGN NEO TGSAP 361 Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0445T NOCOV DEF SYSMAN 01/01/2017 Y Description: SBSQT PLMT DRUG ELUT OC INS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0445U NOCOV DEF SYSMAN 04/01/2024 Y Description: ABETA42 & PTAU181 ECLIA CSF Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0446T NOCOV DEF SYSMAN 01/01/2017 Y Description: INSJ IMPLTBL GLUCOSE SENSOR Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0446U NOCOV DEF SYSMAN 04/01/2024 Y Description: AI DS SLE ALYS 10 CYTOKINE Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0447T NOCOV DEF SYSMAN 01/01/2017 Y Description: RMVL IMPLTBL GLUCOSE SENSOR Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0447U NOCOV DEF SYSMAN 04/01/2024 Y Description: AI DS SLE ALYS 11 CYTOKINE Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0448T NOCOV DEF SYSMAN 01/01/2017 Y Description: REMVL INSJ IMPLTBL GLUC SENS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0448U NOCOV DEF SYSMAN 04/01/2024 12/31/2024 Y Description: ONC LNG&CLN CA DNA QUAL NGS Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 12/31/2024 0449T NOCOV DEF SYSMAN 01/01/2017 Y Description: INSJ AQUEOUS DRAIN DEV 1ST Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0449U NOCOV DEF SYSMAN 04/01/2024 Y Description: CAR SCR SEV INH COND 5 GENES Category: Non Covered Services CMS Add: 04/01/2024 CMS Term: 0450T NOCOV DEF SYSMAN 01/01/2017 Y Description: INSJ AQUEOUS DRAIN DEV EACH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0450U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC MM LC-MS/MS MONOC P-PRTN Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0451U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC MM LC-MS/MS PEP ION QUAN Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0452U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC BLDR MTHYL PENK LTE-QMSP Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0453U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC CLRCT CA CFDNA QPCR ASY Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0454U NOCOV DEF SYSMAN 07/01/2024 Y Description: RARE DS ID OPT GENOME MAPG Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0455U NOCOV DEF SYSMAN 07/01/2024 Y Description: NFCT AGT STI MULT AMP PRB UR Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0456U NOCOV DEF SYSMAN 07/01/2024 12/31/2024 Y Description: AI RA NGS 19 GENES ANTI-CCP Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 12/31/2024 0457U NOCOV DEF SYSMAN 07/01/2024 Y Description: PFAS 9 CMPND LCMS/MS PLS/SR Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0458U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC BRST CA S100 A8&A9 ELISA Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0459U NOCOV DEF SYSMAN 07/01/2024 Y Description: ABETA42 & TTAU ECLIA CSF Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0460U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC WHL BLD/BUCC RTPCR 24GEN Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0461U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC RXGENOM ALYS RTPCR 24GEN Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0462U NOCOV DEF SYSMAN 07/01/2024 Y Description: MELATONIN LVL TST SLP STD7/9 Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0463U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC CRVX MRNA GENXPRSN 14BMK Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0464T NOCOV DEF SYSMAN 01/01/2017 Y Description: VISUAL EP TEST FOR GLAUCOMA Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0464U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC CLRCT SCR QRTSA DNA MRK Category: Non Covered Services CMS Add: 07/01/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0465U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC URTHL CARC DNA QMSP 2GEN Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0466U NOCOV DEF SYSMAN 07/01/2024 Y Description: CRD CAD DNA GWAS 564856 SNP Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0467U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC BLDR DNA NGS 60GEN&ANEUP Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0468U NOCOV DEF SYSMAN 07/01/2024 Y Description: HEP NASH MIR34A5P A2M YKL40 Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0469T NOCOV DEF SYSMAN 07/01/2017 Y Description: RTA POLARIZE SCAN OC SCR BI Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 0469U NOCOV DEF SYSMAN 07/01/2024 Y Description: RARE DS WHL GEN SEQ FTL SAMP Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0470U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC OROP DETCJ MRD 8 DNA HPV Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0471U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC CLRC CA 35 VRN KRAS&NRAS Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0472T NOCOV DEF SYSMAN 07/01/2017 Y Description: PRGRMG IO RTA ELTRD RA Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 0472U NOCOV DEF SYSMAN 07/01/2024 Y Description: CA VI PSP&SP1 ANTB SJOGREN Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0473T NOCOV DEF SYSMAN 07/01/2017 Y Description: REPRGRMG IO RTA ELTRD RA Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 0473U NOCOV DEF SYSMAN 07/01/2024 Y Description: ONC SLD TUM BLD/SLV 648 GENE Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0474T MEDSV PRF MAXFEE 01/01/2024 630.32 0 Description: INSJ AQUEOUS DRG DEV IO RSVR Category: Medical Services CMS Add: 07/01/2017 CMS Term: 0474U NOCOV DEF SYSMAN 07/01/2024 Y Description: HERED PAN CA GSAP 88GENE NGS Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0475U NOCOV DEF SYSMAN 07/01/2024 Y Description: HERED PRST8 CA GSAP 23 GENES Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0476U NOCOV DEF SYSMAN 10/01/2024 Y Description: RX METAB PSYC 14GEN&CYP2D6 Category: Non Covered Services CMS Add: 10/01/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0477U NOCOV DEF SYSMAN 10/01/2024 Y Description: RX METAB PSY 14&CYP2D6 GN-RX Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0478U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC NSCLC DNA&RNA DPCR 9GENS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0479T NOCOV DEF SYSMAN 01/01/2018 Y Description: FXJL ABL LSR 1ST 100 SQ CM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0479U NOCOV DEF SYSMAN 10/01/2024 Y Description: TAU PHOSPHORYLATED PTAU217 Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0480T NOCOV DEF SYSMAN 01/01/2018 Y Description: FXJL ABL LSR EA ADDL 100SQCM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0480U NOCOV DEF SYSMAN 10/01/2024 Y Description: NFCT DS CSF METAG NGS ALYS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0481T NOCOV DEF SYSMAN 01/01/2018 Y Description: NJX AUTOL WBC CONCENTRATE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0481U NOCOV DEF SYSMAN 10/01/2024 Y Description: IDH1 IDH2&TERT PROMOTER NGS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0482U NOCOV DEF SYSMAN 10/01/2024 Y Description: OB PE BIOCHEM ASY SFLT1&PLGF Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0483T NOCOV DEF SYSMAN 01/01/2018 Y Description: TMVI PERCUTANEOUS APPROACH Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0483U NOCOV DEF SYSMAN 10/01/2024 Y Description: NFCT DS NG GYRA S91F PT MUT Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0484T NOCOV DEF SYSMAN 01/01/2018 Y Description: TMVI TRANSTHORACIC EXPOSURE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0484U NOCOV DEF SYSMAN 10/01/2024 Y Description: NFCT DS MGEN 23S RRNA PT MUT Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0485T NOCOV DEF SYSMAN 01/01/2018 Y Description: OCT MID EAR I&R UNILATERAL Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0485U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC SOL TUM CFDNA&RNA NGS GM Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0486T NOCOV DEF SYSMAN 01/01/2018 Y Description: OCT MID EAR I&R BILATERAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0486U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC PAN SOL TUM NGS CFCTDNA Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0487U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC SOL TUM CFCDNA TGSAP 84 Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0488T NOCOV DEF SYSMAN 01/01/2018 Y Description: DIABETES PREV ONLINE/ELEC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0488U NOCOV DEF SYSMAN 10/01/2024 Y Description: OB FETAL AG NIPT CFDNA ALYS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0489T MEDSV DEF BILL90 01/01/2018 Y Description: REGN CELL TX SCLDR HANDS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0489U NOCOV DEF SYSMAN 10/01/2024 Y Description: OB SGNIPT CFDNA SEQ ALYS 1+ Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0490T MEDSV DEF BILL90 01/01/2018 Y Description: REGN CELL TX SCLDR H MLT INJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0490U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC CUTAN/UVEAL MLNMA CD146 Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0491U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC SOL TUM CTC SLCT ER PRTN Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0492U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC SOL TUM CTC SLCTN PD-L1 Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0493U NOCOV DEF SYSMAN 10/01/2024 Y Description: TRNSPL MED QUAN DD-CFDNA NGS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0494T MEDSV DEF BILL90 01/01/2018 Y Description: PREP & CANNULJ CDVR DON LUNG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0494U NOCOV DEF SYSMAN 10/01/2024 Y Description: RBC AG FTL RHD GENE ALYS NGS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0495T MEDSV DEF BILL90 01/01/2018 Y Description: MNTR CDVR DON LNG 1ST 2 HRS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0495U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC PRST8 ALYS CRCG PLSM PRT Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0496T MEDSV DEF BILL90 01/01/2018 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0496U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC CLRCT CFDNA 8/7 GENES Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0497U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC PRST8 MRNA RT-PCR 6GENES Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0498U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC CLRCT NGS MUT DETC 43GEN Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0499U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC CLRCT&LNG DNA NGS 8GENES Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0500F NOCOV DEF SYSMAN 01/01/2005 Y Description: INITIAL PRENATAL CARE VISIT Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0500T MEDSV DEF BILL90 01/01/2018 12/31/2024 Description: HPV 5+ HI RISK HPV TYPES Category: Medical Services CMS Add: 01/01/2018 CMS Term: 12/31/2024 0500U NOCOV DEF SYSMAN 10/01/2024 Y Description: AUTOINFLAM DS VEXAS SYND DNA Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0501F NOCOV DEF SYSMAN 01/01/2005 Y Description: PRENATAL FLOW SHEET Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0501U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC CLRC BLD QUAN MEAS CFDNA Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0502F NOCOV DEF SYSMAN 01/01/2005 Y Description: SUBSEQUENT PRENATAL CARE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0502U NOCOV DEF SYSMAN 10/01/2024 Y Description: HPV E6/E7 MRK HI-RSK TYP CRV Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0503F NOCOV DEF SYSMAN 01/01/2005 Y Description: POSTPARTUM CARE VISIT Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0503U NOCOV DEF SYSMAN 10/01/2024 Y Description: NEURO ALZ DS BAMYL&TAU PRTN Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0504U NOCOV DEF SYSMAN 10/01/2024 Y Description: NFCT DS UTI ID 17 PATH ORGS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0505F NOCOV DEF SYSMAN 01/01/2007 Y Description: HEMODIALYSIS PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0505T NOCOV DEF SYSMAN 07/01/2018 Y Description: EV FEMPOP ARTL REVSC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0505U NOCOV DEF SYSMAN 10/01/2024 Y Description: NFCT DS VAG INFCTJ ID 32ORGS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0506T NOCOV DEF SYSMAN 07/01/2018 Y Description: MAC PGMT OPT DNS MEAS HFP Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0506U NOCOV DEF SYSMAN 10/01/2024 Y Description: GI BARRETTS ESOPHGL CELL 89 Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0507F NOCOV DEF SYSMAN 01/01/2007 Y Description: PERITON DIALYSIS PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0507T NOCOV DEF SYSMAN 07/01/2018 Y Description: NEAR IFR 2IMG MIBMN GLND I&R Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0507U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC OVR DNA WHOLE GEN W/5HMC Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0508U NOCOV DEF SYSMAN 10/01/2024 Y Description: TRNSPLJ MED DD-CFDNA 40 SNPS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0509F NOCOV DEF SYSMAN 01/01/2008 Y Description: URINE INCON PLAN DOCD Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 0509T NOCOV DEF SYSMAN 01/01/2019 Y Description: PATTERN ERG W/I&R Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0509U NOCOV DEF SYSMAN 10/01/2024 Y Description: TRNSPLJ MED DD-CFDNA<12 SNPS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0510T NOCOV DEF SYSMAN 01/01/2019 Y Description: RMVL SINUS TARSI IMPLANT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0510U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC PNCRTC CA ALG ALYS 16GEN Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0511T NOCOV DEF SYSMAN 01/01/2019 Y Description: RMVL&RINSJ SINUS TARSI IMPLT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0511U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC SOL TUM 3DMICROENVIR 36+ Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0512T NOCOV DEF SYSMAN 01/01/2019 Y Description: ESW INTEG WND HLG 1ST WND Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0512U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC PRST8 ALYS DGTZ IMG MSI Category: Non Covered Services CMS Add: 10/01/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0513F NOCOV DEF SYSMAN 01/01/2008 Y Description: ELEV BP PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0513T NOCOV DEF SYSMAN 01/01/2019 Y Description: ESW INTEG WND HLG EA ADDL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0513U NOCOV DEF SYSMAN 10/01/2024 Y Description: ONC PRST8 ALG ALYS MSI&HRD Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0514F NOCOV DEF SYSMAN 01/01/2008 Y Description: CARE PLAN HGB DOCD ESA PT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0514U NOCOV DEF SYSMAN 10/01/2024 Y Description: GI IBD IA QUAN DETER ADL LVL Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0515T NOCOV DEF SYSMAN 01/01/2019 Y Description: INSJ WCS LV COMPL SYS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0515U NOCOV DEF SYSMAN 10/01/2024 Y Description: GI IBD IA QUAN DETER IFX LVL Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0516F NOCOV DEF SYSMAN 01/01/2008 Y Description: ANEMIA PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0516T NOCOV DEF SYSMAN 01/01/2019 Y Description: INSJ WCS LV ELTRD ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0516U NOCOV DEF SYSMAN 10/01/2024 Y Description: RX METAB RXGENOMIC GNOTYP 40 Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0517F NOCOV DEF SYSMAN 01/01/2008 Y Description: GLAUCOMA PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0517T NOCOV DEF SYSMAN 01/01/2019 Y Description: INSJ WCS LV BOTH COMPNT PG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0517U NOCOV DEF SYSMAN 10/01/2024 Y Description: THER RX MNTR 80+ PSYACTIV RX Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0518F NOCOV DEF SYSMAN 01/01/2008 Y Description: FALL PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0518T NOCOV DEF SYSMAN 01/01/2019 Y Description: RMVL PG WCS LV BATTERY ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0518U NOCOV DEF SYSMAN 10/01/2024 Y Description: THER RX MNTR 90+ PN&MTL HLTH Category: Non Covered Services CMS Add: 10/01/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0519F NOCOV DEF SYSMAN 01/01/2008 Y Description: PLAND CHEMO DOCD B/4 TXMNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0519T NOCOV DEF SYSMAN 01/01/2019 Y Description: RMV&RPLCMT PG WCS LV BOTH Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0519U NOCOV DEF SYSMAN 10/01/2024 Y Description: THER RX MNTR MEDS P/D/A 110+ Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0520F NOCOV DEF SYSMAN 01/01/2008 Y Description: RAD DOS LIMTS B/4 3D RAD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0520T NOCOV DEF SYSMAN 01/01/2019 Y Description: RMV&RPLCMT PG WCS LV BATTERY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0520U NOCOV DEF SYSMAN 10/01/2024 Y Description: THER RX MNTR 200+ RX/SBSTS Category: Non Covered Services CMS Add: 10/01/2024 CMS Term: 0521F NOCOV DEF SYSMAN 01/01/2008 Y Description: PLAN OF CARE 4 PAIN DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0521T NOCOV DEF SYSMAN 01/01/2019 Y Description: INTERROG DEV EVAL WCS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0521U NOCOV DEF SYSMAN 01/01/2025 Y Description: RF IGA&IGM CCP ANTB SR-A IA Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0522T NOCOV DEF SYSMAN 01/01/2019 Y Description: PRGRMG DEV EVAL WCS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0522U NOCOV DEF SYSMAN 01/01/2025 Y Description: CA VI PSP&SP1 ANTB CL SEMIQL Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0523T NOCOV DEF SYSMAN 01/01/2019 Y Description: NTRAPX C FFR W/3D FUNCJL MAP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0523U NOCOV DEF SYSMAN 01/01/2025 Y Description: ONC SOLTUM DNA NGS SNV 22GEN Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0524T NOCOV DEF SYSMAN 01/01/2019 Y Description: EV CATH DIR CHEM ABLTJ W/IMG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0524U NOCOV DEF SYSMAN 01/01/2025 Y Description: OB PE SFLT-1/PLGF IA SRM/PLS Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0525F NOCOV DEF SYSMAN 01/01/2009 Y Description: INITIAL VISIT FOR EPISODE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0525T NOCOV DEF SYSMAN 01/01/2019 Y Description: INSJ/RPLCMT COMPL IIMS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0525U NOCOV DEF SYSMAN 01/01/2025 Y Description: ONC SPHRD CELL CUL 11-RX PNL Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0526F NOCOV DEF SYSMAN 01/01/2009 Y Description: SUBS VISIT FOR EPISODE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 0526T NOCOV DEF SYSMAN 01/01/2019 Y Description: INSJ/RPLCMT IIMS ELTRD ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0526U NOCOV DEF SYSMAN 01/01/2025 Y Description: NEFRO RNL TRNSPL QUAN CXCL10 Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0527T NOCOV DEF SYSMAN 01/01/2019 Y Description: INSJ/RPLCMT IIMS IMPLT MNTR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0527U NOCOV DEF SYSMAN 01/01/2025 Y Description: HSV 1&2 VZV AMP PRB TQ PTHGN Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0528F NOCOV DEF SYSMAN 01/01/2009 Y Description: RCMND FLW-UP 10 YRS DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0528T NOCOV DEF SYSMAN 01/01/2019 Y Description: PRGRMG DEV EVAL IIMS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0528U NOCOV DEF SYSMAN 01/01/2025 Y Description: LRT IAD 18BCT/8VIR&7ARG RNA Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0529F NOCOV DEF SYSMAN 01/01/2009 Y Description: INTRVL 3/>YR PTS CLNSCP DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0529T NOCOV DEF SYSMAN 01/01/2019 Y Description: INTERROG DEV EVAL IIMS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0529U NOCOV DEF SYSMAN 01/01/2025 Y Description: HEM VTE SNP F2&F5 GEN LEIDEN Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0530T NOCOV DEF SYSMAN 01/01/2019 Y Description: REMOVAL COMPLETE IIMS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0530U NOCOV DEF SYSMAN 01/01/2025 Y Description: ONC PAN-SOL TUM CTDNA 77 GEN Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0531T NOCOV DEF SYSMAN 01/01/2019 Y Description: REMOVAL IIMS ELECTRODE ONLY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0532T NOCOV DEF SYSMAN 01/01/2019 Y Description: REMOVAL IIMS IMPLT MNTR ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0535F NOCOV DEF SYSMAN 01/01/2009 Y Description: DYSPNEA MNGMNT PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0540F NOCOV DEF SYSMAN 01/01/2009 Y Description: GLUCO MNGMNT PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0540T MEDSV DEF BILL90 01/01/2019 12/31/2024 Y Description: CAR-T CLL ADMN AUTOLOGOUS Category: Medical Services CMS Add: 01/01/2019 CMS Term: 12/31/2024 0541T NOCOV DEF SYSMAN 01/01/2019 Y Description: MYOCARDIAL IMAGING MCG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0542T NOCOV DEF SYSMAN 01/01/2019 Y Description: MYOCARDIAL IMAGING MCG I&R Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0543T NOCOV DEF SYSMAN 07/01/2019 Y Description: TA MV RPR W/ARTIF CHORD TEND Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0544T NOCOV DEF SYSMAN 07/01/2019 Y Description: TCAT MV ANNULUS RCNSTJ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0545F NOCOV DEF SYSMAN 01/01/2010 Y Description: FOLLOW UP CARE PLAN MDD DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0545T NOCOV DEF SYSMAN 07/01/2019 Y Description: TCAT TV ANNULUS RCNSTJ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0546T NOCOV DEF SYSMAN 07/01/2019 Y Description: RF SPECTRSC NTRAOP MRGN ASMT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0547T NOCOV DEF SYSMAN 07/01/2019 Y Description: B1 MATRL QUAL TST MCRIND TIB Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0552T NOCOV DEF SYSMAN 07/01/2019 Y Description: LOW-LEVEL LASER THERAPY Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0553T NOCOV DEF SYSMAN 07/01/2019 12/31/2024 Y Description: PERQ TCAT ILIAC ANAST IMPLT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 12/31/2024 0554T MEDSV DEF BILL90 07/01/2019 Description: B1 STR & FX RSK ANALYSIS Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0555F NOCOV DEF SYSMAN 01/01/2012 Y Description: SYMPTOM MGMNT PLAN CARE DOCD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0555T MEDSV DEF BILL90 07/01/2019 Description: B1 STR&FX RSK TRANSMIS DATA Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0556F NOCOV DEF SYSMAN 01/01/2012 Y Description: PLAN CARE LIPID CONTROL DOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0556T MEDSV DEF BILL90 07/01/2019 Description: B1 STR & FX RSK ASSESSMENT Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0557F NOCOV DEF SYSMAN 01/01/2012 Y Description: PLAN CAREMNG ANGNL SYMPTDOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0557T MEDSV DEF BILL90 07/01/2019 Description: B1 STR & FX RSK I&R Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0558T NOCOV DEF SYSMAN 07/01/2019 Y Description: CT SCAN F/BIOMCHN CT ALYS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0559T NOCOV DEF SYSMAN 07/01/2019 Y Description: ANTMC MDL 3D PRINT 1ST CMPNT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0560T NOCOV DEF SYSMAN 07/01/2019 Y Description: ANTMC MDL 3D PRINT EA ADDL Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0561T NOCOV DEF SYSMAN 07/01/2019 Y Description: ANTMC GUIDE 3D PRINT 1ST GD Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0562T NOCOV DEF SYSMAN 07/01/2019 Y Description: ANTMC GUIDE 3D PRINT EA ADDL Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0563T NOCOV DEF SYSMAN 01/01/2020 Y Description: EVAC MEIBOMIAN GLND HEAT BI Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0564T NOCOV DEF SYSMAN 01/01/2020 12/31/2024 Y Description: ONC CHEMO RX CYTOTOX CSC 14 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 12/31/2024 0565T NOCOV DEF SYSMAN 01/01/2020 Y Description: AUTOL CELL IMPLT ADPS HRVG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0566T NOCOV DEF SYSMAN 01/01/2020 Y Description: AUTOL CELL IMPLT ADPS NJX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0567T MEDSV DEF BILL90 01/01/2020 12/31/2025 21-999Years Description: PERM FLP TUBE OCCLS W/IMPLT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 12/31/2024 0568T NOCOV DEF SYSMAN 01/01/2020 12/31/2024 Y Description: INTRO MIX SALINE&AIR F/SSG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 12/31/2024 *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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0569T NOCOV DEF SYSMAN 01/01/2020 Y Description: TTVR PERQ APPR 1ST PROSTH Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0570T NOCOV DEF SYSMAN 01/01/2020 Y Description: TTVR PERQ EA ADDL PROSTH Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0571T MEDSV DEF BILL90 01/01/2020 Y Description: INSJ/RPLCMT ICDS SS ELTRD Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0572T MEDSV DEF BILL90 01/01/2020 Y Description: INSERTION SS DFB ELECTRODE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0573T MEDSV DEF BILL90 01/01/2020 Y Description: REMOVAL SS DFB ELECTRODE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0574T MEDSV DEF BILL90 01/01/2020 Y Description: REPOS PREV SS IMPL DFB ELTRD Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0575F NOCOV DEF SYSMAN 01/01/2012 Y 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 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 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 Y Description: EPHYS EVAL ICDS SS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0578T MEDSV DEF BILL90 01/01/2020 Y Description: REM INTERROG DEV ICDS PHYS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0579T MEDSV DEF BILL90 01/01/2020 Y Description: REM INTERROG DEV ICDS TECH Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0580F NOCOV DEF SYSMAN 01/01/2013 Y Description: MULTIDISCIPLINARY CARE PLAN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0580T MEDSV DEF BILL90 01/01/2020 Description: RMVL SS IMPL DFB PG ONLY Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0581F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT TRNSFRD FROM ANESTH TO CC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0581T NOCOV DEF SYSMAN 01/01/2020 Y Description: ABLTJ MAL BRST TUM PERQ CRTX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0582F NOCOV DEF SYSMAN 01/01/2013 Y Description: NO TRNSFR FROM ANESTH TO CC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0582T MEDSV DEF BILL90 01/01/2020 Description: TRURL ABLTJ MAL PRST8 TISS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0583F NOCOV DEF SYSMAN 01/01/2013 Y Description: TRANSFER CARE CHECKLIST USED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0583T MEDSV DEF BILL90 01/01/2020 Y Description: TMPST AUTO TUBE DLVR SYS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0584F NOCOV DEF SYSMAN 01/01/2013 Y Description: NO TRANSFERCARE CHKLIST USED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0584T NOCOV DEF SYSMAN 01/01/2020 Y Description: PERQ ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0585T NOCOV DEF SYSMAN 01/01/2020 Y Description: LAPS ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0586T NOCOV DEF SYSMAN 01/01/2020 Y Description: OPEN ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0587T MEDSV DEF BILL90 01/01/2020 Y Description: PERQ IMPLTJ/RPLCMT ISDNS PTN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0588T MEDSV DEF BILL90 01/01/2020 Y Description: REVISION/REMOVAL ISDNS PTN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0589T MEDSV DEF BILL90 01/01/2020 Y Description: ELEC ALYS SMPL PRGRMG IINS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0590T MEDSV DEF BILL90 01/01/2020 Y Description: ELEC ALYS CPLX PRGRMG IINS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0591T NOCOV DEF SYSMAN 01/01/2020 Y Description: HLTH&WB COACHING INDIV 1ST Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0592T NOCOV DEF SYSMAN 01/01/2020 Y Description: HLTH&WB COACHING INDIV F-UP Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0593T NOCOV DEF SYSMAN 01/01/2020 Y Description: HLTH&WB COACHING GROUP Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0594T MEDSV DEF BILL90 07/01/2020 Y Description: OSTEOT HUM XTRNL LNGTH DEV Category: Medical 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0596T NOCOV DEF SYSMAN 07/01/2020 Y Description: TEMP FML IU VLV-PMP 1ST INSJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0597T NOCOV DEF SYSMAN 07/01/2020 Y Description: TEMP FML IU VALVE-PMP RPLCMT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0598T NOCOV DEF SYSMAN 07/01/2020 Y Description: NCNTC R-T FLUOR WND IMG 1ST Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0599T NOCOV DEF SYSMAN 07/01/2020 Y Description: NCNTC R-T FLUOR WND IMG EA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0600T NOCOV DEF SYSMAN 07/01/2020 Y Description: IRE ABLTJ 1+TUM ORGAN PERQ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0601T NOCOV DEF SYSMAN 07/01/2020 Y Description: IRE ABLTJ 1+TUMORS OPEN Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0602T NOCOV DEF SYSMAN 07/01/2020 Y Description: TRANSDERMAL GFR MEASUREMENTS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0603T NOCOV DEF SYSMAN 07/01/2020 Y Description: TRANSDERMAL GFR MONITORING Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0604T NOCOV DEF SYSMAN 07/01/2020 Y Description: REM OCT RTA DEV SETUP&EDUCAJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0605T NOCOV DEF SYSMAN 07/01/2020 Y Description: REM OCT RTA TECHL SPRT MIN 8 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0606T NOCOV DEF SYSMAN 07/01/2020 Y Description: REM OCT RTA PHYS/QHP EA 30D Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0607T MEDSV DEF BILL90 07/01/2020 Description: REM MNTR PULM FLU MNTR SETUP Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0608T MEDSV DEF BILL90 07/01/2020 Description: REM MNTR PULM FLU MNTR ALYS Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0609T NOCOV DEF SYSMAN 07/01/2020 Y Description: MRS DISC PAIN ACQUISJ DATA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0610T NOCOV DEF SYSMAN 07/01/2020 Y Description: MRS DISC PAIN TRANSMIS DATA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0611T NOCOV DEF SYSMAN 07/01/2020 Y Description: MRS DISC PAIN ALG ALYS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0612T NOCOV DEF SYSMAN 07/01/2020 Y Description: MRS DISCOGENIC PAIN I&R Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0613T NOCOV DEF SYSMAN 07/01/2020 Y Description: PERQ TCAT INTRATRL SEPTL SHT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0614T MEDSV DEF BILL90 07/01/2020 Description: RMVL&RPLCMT SS IMPL DFB PG Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0615T MEDSV DEF MAXFEE 01/01/2024 12/31/2024 111.95 0 Description: AUTO ALYS BINOCULAR EYE MVMT Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0615T MEDSV PRF MAXFEE 01/01/2025 107.43 0 Description: AUTO ALYS BINOCULAR EYE MVMT Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0616T NOCOV DEF SYSMAN 07/01/2020 12/31/2024 Y Description: INSERTION OF IRIS PROSTHESIS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 12/31/2024 0617T NOCOV DEF SYSMAN 07/01/2020 12/31/2024 Y Description: INSJ IRIS PROSTH W/RMVL&INSJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 12/31/2024 0618T NOCOV DEF SYSMAN 07/01/2020 12/31/2024 Y Description: INSJ IRIS PROSTH SEC IO LENS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 12/31/2024 0619T MEDSV DEF BILL90 07/01/2020 Description: CYSTO W/PRST8 COMMISSUROTOMY Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0620T NOCOV DEF SYSMAN 01/01/2021 Y Description: EVASC VEN ARTLZ TIBL/PRNL VN Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0621T NOCOV DEF SYSMAN 01/01/2021 Y Description: TRABECULOSTOMY INTERNO LASER Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0622T NOCOV DEF SYSMAN 01/01/2021 Y Description: TRABECULOSTOMY INT LSR W/SCP Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0623T NOCOV DEF SYSMAN 01/01/2021 Y Description: AUTO QUANTIFICATION C PLAQUE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0624T NOCOV DEF SYSMAN 01/01/2021 Y Description: AUTO QUAN C PLAQ DATA PREP Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0625T NOCOV DEF SYSMAN 01/01/2021 Y Description: AUTO QUAN C PLAQ CPTR ALYS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0626T NOCOV DEF SYSMAN 01/01/2021 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0627T NOCOV DEF SYSMAN 01/01/2021 Y Description: PERQ NJX ALGC FLUOR LMBR 1ST Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0628T NOCOV DEF SYSMAN 01/01/2021 Y Description: PERQ NJX ALGC FLUOR LMBR EA Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0629T NOCOV DEF SYSMAN 01/01/2021 Y Description: PERQ NJX ALGC CT LMBR 1ST Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0630T NOCOV DEF SYSMAN 01/01/2021 Y Description: PERQ NJX ALGC CT LMBR EA Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0631T NOCOV DEF SYSMAN 01/01/2021 Y Description: TC VIS LIT HYPERSPECTRAL IMG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0632T NOCOV DEF SYSMAN 01/01/2021 Y Description: PERQ TCAT US ABLTJ NRV P-ART Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0633T NOCOV DEF SYSMAN 01/01/2021 Y Description: CT BREAST W/3D UNI C- Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0634T NOCOV DEF SYSMAN 01/01/2021 Y Description: CT BREAST W/3D UNI C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0635T NOCOV DEF SYSMAN 01/01/2021 Y Description: CT BREAST W/3D UNI C-/C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0636T NOCOV DEF SYSMAN 01/01/2021 Y Description: CT BREAST W/3D BI C- Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0637T NOCOV DEF SYSMAN 01/01/2021 Y Description: CT BREAST W/3D BI C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0638T NOCOV DEF SYSMAN 01/01/2021 Y Description: CT BREAST W/3D BI C-/C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0639T NOCOV DEF SYSMAN 01/01/2021 Y Description: WRLS SKN SNR ANISOTROPY MEAS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0640T NOCOV DEF SYSMAN 07/01/2021 Y Description: NCNTC IFR SPCTRSC O/T PAD 1 Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0643T NOCOV DEF SYSMAN 07/01/2021 Y Description: TCAT L VENTR RSTRJ DEV IMPLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0644T NOCOV DEF SYSMAN 07/01/2021 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0645T NOCOV DEF SYSMAN 07/01/2021 Y Description: TCAT IMPLTJ C SINS RDCTJ DEV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0646T NOCOV DEF SYSMAN 07/01/2021 Y Description: TTVI/RPLCMT W/PRSTC VLV PERQ Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0647T NOCOV DEF SYSMAN 07/01/2021 Y Description: INSJ GTUBE PERQ MAG GASTRPXY Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0648T NOCOV DEF SYSMAN 07/01/2021 Y Description: QUAN MR TIS WO MRI 1ORGN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0649T NOCOV DEF SYSMAN 07/01/2021 Y Description: QUAN MR TISS W/MRI 1ORGN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0650T NOCOV DEF SYSMAN 07/01/2021 Y Description: PRGRMG DEV EVAL SCRMS REMOTE Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0651T NOCOV DEF SYSMAN 07/01/2021 Y Description: MAG CTRLD CAPSULE ENDOSCOPY Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0652T NOCOV DEF SYSMAN 07/01/2021 Y Description: EGD FLX TRANSNASAL DX BR/WA Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0653T NOCOV DEF SYSMAN 07/01/2021 Y Description: EGD FLX TRANSNASAL BX 1/MLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0654T NOCOV DEF SYSMAN 07/01/2021 Y Description: EGD FLX TRANSNASAL TUBE/CATH Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0655T MEDSV DEF BILL90 07/01/2021 Y Description: TPRNL FOCAL ABLTJ MAL PRST8 Category: Medical Services CMS Add: 07/01/2021 CMS Term: 0656T NOCOV DEF SYSMAN 07/01/2021 Y Description: ANT LMBR VRT BDY TETH <7 SEG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0657T NOCOV DEF SYSMAN 07/01/2021 Y Description: ANT LMBR VRT BDY TETH 8+ SEG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0658T NOCOV DEF SYSMAN 07/01/2021 Y Description: ELEC IMPD SPECTRSC 1+SKN LES Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0659T NOCOV DEF SYSMAN 07/01/2021 Y Description: TCAT INTRA-C NFS SUPERSAT O2 Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0660T NOCOV DEF SYSMAN 07/01/2021 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0661T NOCOV DEF SYSMAN 07/01/2021 Y Description: RMVL&RIMPLTJ ANT SGM IMPLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0662T NOCOV DEF SYSMAN 07/01/2021 Y Description: SCALP COOL 1ST MEAS&CALBRJ Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0663T NOCOV DEF SYSMAN 07/01/2021 Y Description: SCALP COOL PLMT MNTR RMVL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0664T NOCOV DEF SYSMAN 07/01/2021 Y Description: DON HYSTERECTOMY OPEN CDVR Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0665T NOCOV DEF SYSMAN 07/01/2021 Y Description: DON HYSTERECTOMY OPEN LIV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0666T NOCOV DEF SYSMAN 07/01/2021 Y Description: DON HYSTERECTOMY LAPS LIV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0667T NOCOV DEF SYSMAN 07/01/2021 Y Description: DON HYSTERECTOMY RCP UTER Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0668T NOCOV DEF SYSMAN 07/01/2021 Y Description: BKBENCH PREP DON UTER ALGRFT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0669T NOCOV DEF SYSMAN 07/01/2021 Y Description: BKBENCH RCNSTJ DON UTER VEN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0670T NOCOV DEF SYSMAN 07/01/2021 Y Description: BKBENCH RCNSTJ DON UTER ARTL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0671T MEDSV DEF MAXFEE 01/01/2024 12/31/2024 958.93 0 Description: INSJ ANT SGM AQ DRG DEV 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0671T MEDSV DEF MAXFEE 01/01/2025 630.32 0 Description: INSJ ANT SGM AQ DRG DEV 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0672T NOCOV DEF SYSMAN 01/01/2022 Y Description: NDOVAG CRYG RF REMDL TISS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0673T MEDSV DEF BILL90 01/01/2022 Y Description: ABLTJ B9 THYR NDUL PERQ LASR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0674T MEDSV DEF BILL90 01/01/2022 Description: LAPS INSJ NW/RPCMT PRM ISDSS Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0675T MEDSV DEF BILL90 01/01/2022 Description: LAPS INSJ NW/RPCMT ISDSS 1LD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0676T MEDSV DEF BILL90 01/01/2022 Description: LAPS INSJ NW/RPCMT ISDSS EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0677T MEDSV DEF BILL90 01/01/2022 Description: LAPS REPOS LEAD ISDSS 1ST LD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0678T NOCOV DEF SYSMAN 01/01/2022 Y Description: LAPS REPOS LEAD ISDSS EA ADD Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0679T NOCOV DEF SYSMAN 01/01/2022 Y Description: LAPS RMVL LEAD ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0680T NOCOV DEF SYSMAN 01/01/2022 Y Description: INSJ/RPLCMT PG ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0681T NOCOV DEF SYSMAN 01/01/2022 Y Description: RLCJ PULSE GEN ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0682T NOCOV DEF SYSMAN 01/01/2022 Y Description: REMOVAL PULSE GEN ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0683T NOCOV DEF SYSMAN 01/01/2022 Y Description: PRGRMG DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0684T NOCOV DEF SYSMAN 01/01/2022 Y Description: PERI-PX DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0685T NOCOV DEF SYSMAN 01/01/2022 Y Description: INTERROG DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0686T NOCOV DEF SYSMAN 01/01/2022 Y Description: HISTOTRIPSY MAL HEPATCEL TIS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0687T NOCOV DEF SYSMAN 01/01/2022 Y Description: TX AMBLYOPIA DEV SETUP 1ST Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0688T NOCOV DEF SYSMAN 01/01/2022 Y Description: TX AMBLYOPIA ASSMT W/REPORT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0689T NOCOV DEF SYSMAN 01/01/2022 Y Description: QUAN US TIS CHARAC W/O DX US Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0690T NOCOV DEF SYSMAN 01/01/2022 Y Description: QUAN US TIS CHARAC W/DX US Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0691T NOCOV DEF SYSMAN 01/01/2022 Y Description: AUTO ALYS XST CT STD VRT FX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0692T NOCOV DEF SYSMAN 01/01/2022 Y Description: THERAPEUTIC ULTRAFILTRATION Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0693T NOCOV DEF SYSMAN 01/01/2022 Y Description: COMPRE FUL BDY 3D MTN ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0694T NOCOV DEF SYSMAN 01/01/2022 Y Description: 3D VOL IMG&RCNSTJ BRST/AX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0695T NOCOV DEF SYSMAN 01/01/2022 Y Description: BDY SRF MPG PM/CVDFB TM IMPL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0696T NOCOV DEF SYSMAN 01/01/2022 Y Description: BDY SURF MAPG PM/CVDFB F/UP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0697T NOCOV DEF SYSMAN 01/01/2022 Y Description: QUAN MR TIS WO MRI MLT ORGN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0698T NOCOV DEF SYSMAN 01/01/2022 Y Description: QUAN MR TISS W/MRI MLT ORGN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0699T MEDSV DEF BILL90 01/01/2022 Description: NJX PST CHMBR EYE MEDICATION Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0700T NOCOV DEF SYSMAN 01/01/2022 Y Description: MOLEC FLUOR IMG SUS NEV 1ST Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0701T NOCOV DEF SYSMAN 01/01/2022 Y Description: MOLEC FLUOR IMG SUS NEV EA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0704T NOCOV DEF SYSMAN 01/01/2022 Y Description: REM TX AMBLYOPIA SETUP&EDU Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0705T NOCOV DEF SYSMAN 01/01/2022 Y Description: REM TX AMBLYOPIA TECH SPRT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0706T NOCOV DEF SYSMAN 01/01/2022 Y Description: REM TX AMBLYOPIA I&R PHY/QHP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0707T NOCOV DEF SYSMAN 01/01/2022 Y Description: NJX B1 SUB MTRL SBCHDRL DFCT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0708T NOCOV DEF SYSMAN 01/01/2022 Y Description: ID CA IMMNTX PREP & 1ST NJX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0709T NOCOV DEF SYSMAN 01/01/2022 Y Description: ID CA IMMNTX EACH ADDL NJX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0710T NOCOV DEF SYSMAN 01/01/2022 Y Description: N-INVAS ARTL PLAQ ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0711T NOCOV DEF SYSMAN 01/01/2022 Y Description: N-NVS ARTL PLAQ ALYS DAT PRP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0712T NOCOV DEF SYSMAN 01/01/2022 Y Description: N-NVS ARTL PLAQ ALYS QUAN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0713T NOCOV DEF SYSMAN 01/01/2022 Y Description: N-NVS ARTL PLAQ ALYS RVW I&R Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0714T NOCOV DEF SYSMAN 07/01/2022 Y Description: TPLA B9 PRST8 HYPRPLSA<50ML Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0716T NOCOV DEF SYSMAN 07/01/2022 Y Description: CAR ACOUS WAVFRM REC CAD RSK Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0717T NOCOV DEF SYSMAN 07/01/2022 Y Description: ADRC THER PRTL RC TEAR Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0718T NOCOV DEF SYSMAN 07/01/2022 Y Description: ADRC THER PRTL RC TEAR NJX Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0719T NOCOV DEF SYSMAN 07/01/2022 Y Description: PST VRT JT RPLCMT LMBR 1 SGM Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0720T NOCOV DEF SYSMAN 07/01/2022 Y Description: PRQ ELC NRV STIM CN WO IMPLT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0721T NOCOV DEF SYSMAN 07/01/2022 Y Description: QUAN CT TISS CHARAC W/O CT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0722T NOCOV DEF SYSMAN 07/01/2022 Y Description: QUAN CT TISS CHARAC W/CT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0723T NOCOV DEF SYSMAN 07/01/2022 Y Description: QMRCP W/O DX MRI SM ANAT SES Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0724T NOCOV DEF SYSMAN 07/01/2022 Y Description: QMRCP W/DX MRI SAME ANATOMY Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0725T NOCOV DEF SYSMAN 07/01/2022 Y Description: VESTIBULAR DEV IMPLTJ UNI Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0726T NOCOV DEF SYSMAN 07/01/2022 Y Description: RMVL IMPLT VSTIBULAR DEV UNI 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0727T NOCOV DEF SYSMAN 07/01/2022 Y Description: RMVL&RPLCMT IMPLT VSTBLR DEV Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0728T NOCOV DEF SYSMAN 07/01/2022 Y Description: DX ALYS VSTBLR IMPLT UNI 1ST Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0729T NOCOV DEF SYSMAN 07/01/2022 Y Description: DX ALYS VSTBLR IMPLT UNI SBQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0730T MEDSV DEF BILL90 07/01/2022 Description: TRABECULOTOMY LSR W/OCT GDN Category: Medical Services CMS Add: 07/01/2022 CMS Term: 0731T NOCOV DEF SYSMAN 07/01/2022 Y Description: AUGMNT AI-BASED FCL PHNT A/R Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0732T NOCOV DEF SYSMAN 07/01/2022 Y Description: IMMNTX ADMN ELECTROPORATN IM Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0733T NOCOV DEF SYSMAN 07/01/2022 Y Description: REM R-T MTN NREHAB THER SPLY Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0734T NOCOV DEF SYSMAN 07/01/2022 Y Description: REM R-T MTN NREHAB TX MGMT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0735T NOCOV DEF SYSMAN 07/01/2022 Y Description: PREP TUM CAV IORT PRIM CRNOT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0736T NOCOV DEF SYSMAN 07/01/2022 Y Description: COLONIC LAVAGE 35+L WATER Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0737T NOCOV DEF SYSMAN 07/01/2022 Y Description: XENOGRAFT IMPLTJ ARTCLR SURF Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0738T NOCOV DEF SYSMAN 01/01/2023 Y Description: TX PLN MAG FLD ABLTJ PRST8 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0739T NOCOV DEF SYSMAN 01/01/2023 Y Description: ABLTJ MAL PRST8 MAG FLD NDCT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0740T NOCOV DEF SYSMAN 01/01/2023 Y Description: REM AUTON ALG NSLN CAL SETUP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0741T NOCOV DEF SYSMAN 01/01/2023 Y Description: REM AUTON ALG NSLN DATA COLL Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0742T RADIO DEF BILL90 01/01/2023 Description: AQMBF SPECT XERS/STRS & REST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0743T RADIO DEF BILL90 01/01/2023 Description: B1 STR & FX RSK VRT FX ASSMT Category: Radiology CMS Add: 01/01/2023 CMS Term: 0744T NOCOV DEF SYSMAN 01/01/2023 Y Description: INSJ BIOPROSTC VLV FEM VN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0745T MEDSV DEF BILL90 01/01/2023 Description: CAR ABLT RAD ARR N-INVAS LOC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 0746T MEDSV DEF BILL90 01/01/2023 Description: CAR ABLT RAD ARR CNV LOC MAP Category: Medical Services CMS Add: 01/01/2023 CMS Term: 0747T NOCOV DEF SYSMAN 01/01/2023 Y Description: CAR ABLT RAD ARRHYT DLVR RAD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0748T NOCOV DEF SYSMAN 01/01/2023 Y Description: NJX STM CL PRDCT ANL SFT TIS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0749T RADIO DEF BILL90 01/01/2023 Description: B1 STR&FX RSK ASSMT DXR-BMD Category: Radiology CMS Add: 01/01/2023 CMS Term: 0750T RADIO DEF BILL90 01/01/2023 Description: B1 STR&FX RSK ASMT DXRBMD1VW Category: Radiology CMS Add: 01/01/2023 CMS Term: 0751T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SLD LEVEL II Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0752T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SLD LVL III Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0753T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SLD LEVEL IV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0754T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SLD LEVEL V Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0755T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SLD LEVEL VI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0756T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SLD SPC GRPI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0757T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SL SPC GRPII Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0758T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SL SPC HCHEM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0759T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SL SP GRPIII Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0760T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SL IMM 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0761T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SL IMM EA 1 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0762T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP SL IMM EA M Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0763T NOCOV DEF SYSMAN 01/01/2023 Y Description: DGTZ GLS MCRSCP MPHMTRC ALYS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0764T NOCOV DEF SYSMAN 01/01/2023 Y Description: ASSTV ALG ECG RSK ASMT CNCRT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0765T NOCOV DEF SYSMAN 01/01/2023 Y Description: ASSTV ALG ECG RSK ASMT PREV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0766T NOCOV DEF SYSMAN 01/01/2023 Y Description: TC MAG STIMJ PN 1ST NERVE Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0767T NOCOV DEF SYSMAN 01/01/2023 Y Description: TC MAG STIMJ PN EA ADDL NRV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0770T NOCOV DEF SYSMAN 01/01/2023 Y Description: VR TECHNOLOGY ASSIST THERAPY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0771T NOCOV DEF SYSMAN 01/01/2023 Y Description: VR PX DISSOC SVC SM PHY 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0772T NOCOV DEF SYSMAN 01/01/2023 Y Description: VR PX DISSOC SVC SM PHY EA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0773T NOCOV DEF SYSMAN 01/01/2023 Y Description: VR PX DISSOC SVC OTH PHY 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0774T NOCOV DEF SYSMAN 01/01/2023 Y Description: VR PX DISSOC SVC OTH PHY EA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0776T NOCOV DEF SYSMAN 01/01/2023 Y Description: THER INDCTJ NTRABRN HYPTHRM Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0777T MEDSV DEF BILL90 01/01/2023 Description: R-T PRS SENSING EDRL GDN SYS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0778T NOCOV DEF SYSMAN 01/01/2023 Y Description: SMMG CNCRNT APPL IMU SNR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0779T NOCOV DEF SYSMAN 01/01/2023 Y Description: GI MYOELECTRICAL ACTV STUDY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0780T NOCOV DEF SYSMAN 01/01/2023 Y Description: INSTLJ FECAL MICROBIOTA SSP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0781T NOCOV DEF SYSMAN 01/01/2023 Y Description: BRNCHSC RF DSTRJ PULM NRV BI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0782T NOCOV DEF SYSMAN 01/01/2023 Y Description: BRNCHSC RF DSTRJ PLM NRV UNI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0783T NOCOV DEF SYSMAN 01/01/2023 Y Description: TC AURICULR NEUROSTIMULATION Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0784T NOCOV DEF SYSMAN 01/01/2024 Y Description: INS/RPLMT ELTRD RA SPI NSTIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0785T NOCOV DEF SYSMAN 01/01/2024 Y Description: REVJ/RMVL NEA SPI W/NSTIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0786T NOCOV DEF SYSMAN 01/01/2024 Y Description: INSJ/RPLCMT PRQ RA SAC NSTIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0787T NOCOV DEF SYSMAN 01/01/2024 Y Description: REVJ/RMVL NEA SAC W/NSTIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0788T NOCOV DEF SYSMAN 01/01/2024 Y Description: ELEC ALY SMP IINS SP/SAC NRV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0789T NOCOV DEF SYSMAN 01/01/2024 Y Description: ELEC ALY CPX IINS SP/SAC NRV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0790T NOCOV DEF SYSMAN 01/01/2024 Y Description: REVJ RPLCMT/RMVL VRT TETHRG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0791T NOCOV DEF SYSMAN 07/01/2023 Y Description: MOTR COG VR GAIT TRAIN EA 15 Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0792T NOCOV DEF SYSMAN 07/01/2023 Y Description: APPL SLVR DIAMN FLUORIDE 38% Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0793T NOCOV DEF SYSMAN 07/01/2023 Y Description: PRQ TCAT THRM ABLT NRV P-ART 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0794T NOCOV DEF SYSMAN 07/01/2023 Y Description: PT SPEC ALG RX-ONC TX OPTION Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0795T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT INS 2CHMBR LDLS PM CMPL Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0796T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT INS 2CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0797T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT INS 2CHMBR LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0798T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT RMV 2CHMBR LDLS PM CMPL Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0799T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT RMVL 2CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0800T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT RMVL 2CHMBR LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0801T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT RMV&RPL 2CHMBR LDLS PM Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0802T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT RMV&RPL2CHMB LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0803T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT RMV&RPL2CHMB LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0804T NOCOV DEF SYSMAN 07/01/2023 Y Description: PRGRMG EVL LDLS PM 2CHMBR IP Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0805T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT S&IVC PRSTC VL IMPL PRQ Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0806T NOCOV DEF SYSMAN 07/01/2023 Y Description: TCAT S&IVC PRSTC VL IMPL OPN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0807T NOCOV DEF SYSMAN 07/01/2023 Y Description: PULM TISS VNTJ ALYS PREV CT Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0808T NOCOV DEF SYSMAN 07/01/2023 Y Description: PULM TISS VNTJ ALYS W/CT Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0810T NOCOV DEF SYSMAN 07/01/2023 Y Description: SUBRTA NJX RX AGT W/VTRC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0811T NOCOV DEF SYSMAN 01/01/2024 Y Description: REM MLT DAY UROFLOW SETUP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0812T NOCOV DEF SYSMAN 01/01/2024 Y Description: REM MLT DAY UROFLOW DEV SPLY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0813T NOCOV DEF SYSMAN 01/01/2024 Y Description: EGD VOL ADJMT BARIATRIC BALO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0814T NOCOV DEF SYSMAN 01/01/2024 Y Description: PRQ NJX BIOD OSTEO MATRL FEM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0815T NOCOV DEF SYSMAN 01/01/2024 Y Description: US REMS B1 DNS HIPS PLVS/SPI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0816T NOCOV DEF SYSMAN 01/01/2024 Y Description: OPN INSJ/RPLCMT INS PTN SUBQ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0817T NOCOV DEF SYSMAN 01/01/2024 Y Description: OPN INSJ/RPLCMT INS PTN SUBF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0818T NOCOV DEF SYSMAN 01/01/2024 Y Description: REVJ/RMVL INS PTN SUBQ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0819T NOCOV DEF SYSMAN 01/01/2024 Y Description: REVJ/RMVL INS PTN SUBF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0820T NOCOV DEF SYSMAN 01/01/2024 Y Description: MNTR PSYCHDLC MED 1STPHY/QHP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0821T NOCOV DEF SYSMAN 01/01/2024 Y Description: MNTR PSYCHDLC MED 2NDPHY/QHP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0822T NOCOV DEF SYSMAN 01/01/2024 Y Description: MNTR PSYCHDLC MED CLN STAFF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0823T NOCOV DEF SYSMAN 01/01/2024 Y Description: TCAT INS 1CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0824T NOCOV DEF SYSMAN 01/01/2024 Y Description: TCAT RMV 1CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0825T NOCOV DEF SYSMAN 01/01/2024 Y Description: TCAT RMV&RPL1CHMB LDLS PM RA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0826T NOCOV DEF SYSMAN 01/01/2024 Y Description: PRGRMG EVL LDLS PM 1CHMBR IP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0827T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CYTP SMEARS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0828T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CYTP SMPL FL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0829T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CYTP CONCTRJ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0830T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CYTP SLCTV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0831T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CYTP C/V Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0832T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CYTP OTH SCR Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0833T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CYTP OTH PRP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0834T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CYTP OTH XTN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0835T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP FNA 1ST EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0836T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP FNA EA ADDL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0837T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP FNA I&R Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0838T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CSLT SLD ELS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0839T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CSLT MAT PRP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0840T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CSLT COMPRE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0841T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP PTH CSLT 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0842T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP PTH CSLT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0843T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CSLT CYT 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0844T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP CSLT CYT EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0845T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP IMFLUOR 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0846T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP IMFLUOR EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0847T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP XM ARCH TISS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0848T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP ISH 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0849T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP ISH EA ADL 1 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0850T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP ISH EA MULT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0851T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP MPHMTRC 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0852T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP MPHMTRC EA 1 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0853T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP MPHMTRC EA M Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0854T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP BLD SMR PRPH Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0855T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP B1 MAROW SMR Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0856T NOCOV DEF SYSMAN 01/01/2024 Y Description: DGTZ GLS MCRSCP ELECTRON MIC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0857T NOCOV DEF SYSMAN 01/01/2024 Y Description: OPTO-ACOUSTIC IMG BREAST UNI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0858T NOCOV DEF SYSMAN 01/01/2024 Y Description: EXT TRNSCRANL MAG STIMJ MEAS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0859T NOCOV DEF SYSMAN 01/01/2024 Y Description: NCNTC IFR SPCTRSC O/T PAD EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0860T NOCOV DEF SYSMAN 01/01/2024 Y Description: NCNTC IFR SPCTRSC SCR PAD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0861T NOCOV DEF SYSMAN 01/01/2024 Y Description: RMVL PG WCS LV BOTH COMPNT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0862T NOCOV DEF SYSMAN 01/01/2024 Y Description: RLCJ PG WCS LV BATTERY ONLY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0863T NOCOV DEF SYSMAN 01/01/2024 Y Description: RLCJ PG WCS LV TRNSMTR ONLY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0864T NOCOV DEF SYSMAN 01/01/2024 Y Description: LOW NTSTY ESWT CORPUS CVRNSM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0865T NOCOV DEF SYSMAN 01/01/2024 Y Description: QUAN MRI ALYS BRN W/O DX MRI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0866T NOCOV DEF SYSMAN 01/01/2024 Y Description: QUAN MRI ALYS BRN W/DX MRI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0867T NOCOV DEF SYSMAN 07/01/2024 Y Description: TPLA B9 PRST8 HYPRPLSA>=50ML Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0868T NOCOV DEF SYSMAN 07/01/2024 Y Description: HI-RES GASTRIC EP MAPPING Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0869T NOCOV DEF SYSMAN 07/01/2024 Y Description: NJX B1 SUB MTRL HW FIXJ AUG Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0870T NOCOV DEF SYSMAN 07/01/2024 Y Description: IMP SUBQ PRTL ASCTS PMP SYS Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0871T NOCOV DEF SYSMAN 07/01/2024 Y Description: RPLCMT SUBQ PRTL ASCITES PMP Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0872T NOCOV DEF SYSMAN 07/01/2024 Y Description: RPLCMT NDWLLG BLDR&PRTL CATH Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0873T NOCOV DEF SYSMAN 07/01/2024 Y Description: REVJ SUBQ PRTL ASCT PMP SYS Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0874T NOCOV DEF SYSMAN 07/01/2024 Y Description: RMVL PERTL ASCITES PMP SYS Category: Non Covered Services CMS Add: 07/01/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0875T NOCOV DEF SYSMAN 07/01/2024 Y Description: PRGRM SUBQ PRTL ASCT PMP SYS Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0876T NOCOV DEF SYSMAN 07/01/2024 Y Description: DUPLEX SCAN HEMO FSTL LMTD Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0877T NOCOV DEF SYSMAN 07/01/2024 Y Description: AUGMNT ALYS CH CT ILD W/O CT Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0878T NOCOV DEF SYSMAN 07/01/2024 Y Description: AUGMNT ALYS CH CT ILD W/CT Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0879T NOCOV DEF SYSMAN 07/01/2024 Y Description: AUGMNT ALYS CH CT ILD PREP Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0880T NOCOV DEF SYSMAN 07/01/2024 Y Description: AUGMNT ALYS CH CT ILD I&R Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0881T NOCOV DEF SYSMAN 07/01/2024 Y Description: CRYOTHERAPY ORAL CAVITY Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0882T NOCOV DEF SYSMAN 07/01/2024 Y Description: INTRAOP THER ESTIM PN UE 1ST Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0883T NOCOV DEF SYSMAN 07/01/2024 Y Description: INTRAOP THER ESTIM PN UE EA Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0884T NOCOV DEF SYSMAN 07/01/2024 Y Description: ESPHGSC FLX 1ST TNDSC DILAT Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0885T NOCOV DEF SYSMAN 07/01/2024 Y Description: COLSC FLX 1ST TNDSC DILAT Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0886T NOCOV DEF SYSMAN 07/01/2024 Y Description: SGMDSC FLX 1ST TNDSC DILAT Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0887T NOCOV DEF SYSMAN 07/01/2024 Y Description: END-TIDAL CTRL INHALED ANES Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0888T NOCOV DEF SYSMAN 07/01/2024 Y Description: HISTOTRIPSY MAL RENAL TISSUE Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0889T NOCOV DEF SYSMAN 07/01/2024 Y Description: PRSNLZ TRGT DVL ARHFCMRIGTBS Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0890T NOCOV DEF SYSMAN 07/01/2024 Y Description: ARHFCMRIGTBS 1ST TX DAY Category: Non Covered Services CMS Add: 07/01/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0891T NOCOV DEF SYSMAN 07/01/2024 Y Description: ARHFCMRIGTBS SBSQ TX DAY Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0892T NOCOV DEF SYSMAN 07/01/2024 Y Description: ARHFCMRIGTBS SBSQ PER TX DAY Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0893T NOCOV DEF SYSMAN 07/01/2024 Y Description: N-INVAS ASSMT BLD OXYGNATION Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0894T NOCOV DEF SYSMAN 07/01/2024 Y Description: CANNULATION LIVER ALLOGRAFT Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0895T NOCOV DEF SYSMAN 07/01/2024 Y Description: CONNJ LVR ALGRFT PRFU DEV 1 Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0896T NOCOV DEF SYSMAN 07/01/2024 Y Description: CONNJ LVR ALGRFT PRFU DEV EA Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0897T NOCOV DEF SYSMAN 07/01/2024 Y Description: N-INVAS AUGMNT ARRHYT ALYS Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0898T NOCOV DEF SYSMAN 07/01/2024 Y Description: N-INVAS PRST8 CANCER EST MAP Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0899T NOCOV DEF SYSMAN 07/01/2024 Y Description: N-INVAS DETER AQMBF AUG CMR Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0900T NOCOV DEF SYSMAN 07/01/2024 Y Description: N-INVAS EST AQMBF ASSTV CMR Category: Non Covered Services CMS Add: 07/01/2024 CMS Term: 0901T NOCOV DEF SYSMAN 01/01/2025 Y Description: PLMT BONE MARROW SMPLG PORT Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0902T NOCOV DEF SYSMAN 01/01/2025 Y Description: QTC NTRVL AUGMNT ALG ALY ECG Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0903T NOCOV DEF SYSMAN 01/01/2025 Y Description: ECG ALG 12 LEAD REDUCED I&R Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0904T NOCOV DEF SYSMAN 01/01/2025 Y Description: ECG ALG 12 LD RDCD TRCG ONLY Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0905T NOCOV DEF SYSMAN 01/01/2025 Y Description: ECG ALG 12 LD RDCD I&R ONLY Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0906T NOCOV DEF SYSMAN 01/01/2025 Y Description: COMS THER 1ST APPL<=50 SQ CM Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0907T NOCOV DEF SYSMAN 01/01/2025 Y Description: COMS THER EA ADDL<=50 SQ CM Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0908T MEDSV DEF BILL90 01/01/2025 Y Description: OPN IMP INT NSTM SYS VGS NRV Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0909T MEDSV DEF BILL90 01/01/2025 Y Description: RPLCMT INT NSTIM SYS VGS NRV Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0910T MEDSV DEF BILL90 01/01/2025 Y Description: RMVL INT NSTIM SYS VAGUS NRV Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0911T MEDSV DEF BILL90 01/01/2025 Y Description: ELEC ALY NSTM SYS VGS NRV WO Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0912T MEDSV DEF BILL90 01/01/2025 Y Description: ELEC ALYS NSTIM SYS VGS SMPL Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0913T MEDSV DEF BILL90 01/01/2025 Y Description: PRQ TCAT THER RX NTRAC BALO1 Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0914T MEDSV DEF BILL90 01/01/2025 Y Description: PRQ TCAT THR RX NTRC BAL SEP Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0915T NOCOV DEF SYSMAN 01/01/2025 Y Description: INSJ PERM CCM-D SYS PG&ELTRD Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0916T NOCOV DEF SYSMAN 01/01/2025 Y Description: INSJ PERM CCM-D SYS PG ONLY Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0917T NOCOV DEF SYSMAN 01/01/2025 Y Description: INSJ PERM CCM-D SYS 1 LEAD Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0918T NOCOV DEF SYSMAN 01/01/2025 Y Description: INSJ PERM CCM-D SYS DUAL LD Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0919T NOCOV DEF SYSMAN 01/01/2025 Y Description: RMVL PERM CCM-D SYS PG ONLY Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0920T NOCOV DEF SYSMAN 01/01/2025 Y Description: RMVL PERM CCM-D SYS 1 PAC LD Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0921T NOCOV DEF SYSMAN 01/01/2025 Y Description: RMVL PERM CCM-D SYS 1 DFB LD Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0922T NOCOV DEF SYSMAN 01/01/2025 Y Description: RMVL PERM CCM-D SYS DUAL LD Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0923T NOCOV DEF SYSMAN 01/01/2025 Y Description: RMVL&RPLCMT PERM CCM-D PG Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0924T NOCOV DEF SYSMAN 01/01/2025 Y Description: RPOS PRV CCM-D TRNSVNS ELTRD Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0925T NOCOV DEF SYSMAN 01/01/2025 Y Description: RLCJ SKIN POCKET CCM-D PG Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0926T NOCOV DEF SYSMAN 01/01/2025 Y Description: PRGRMG DEV EVAL CCM-D IP Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0927T NOCOV DEF SYSMAN 01/01/2025 Y Description: INTERROG DEV EVAL CCM-D IP Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0928T NOCOV DEF SYSMAN 01/01/2025 Y Description: REM INTERROG DEV CCM-D PHYS Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0929T NOCOV DEF SYSMAN 01/01/2025 Y Description: REM INTERROG DEV CCM-D TECH Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0930T MEDSV DEF BILL90 01/01/2025 Y Description: EPHYS EVAL CCM-D LD 1ST IMPL Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0931T MEDSV DEF BILL90 01/01/2025 Y Description: EPHYS EVAL CCM-D LD SEPARATE Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0932T NOCOV DEF SYSMAN 01/01/2025 Y Description: N-INVS DET HRT FAIL AUG ECHO Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0933T NOCOV DEF SYSMAN 01/01/2025 Y Description: TCAT IMPL WRLS L ATR PRS SNR Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0934T NOCOV DEF SYSMAN 01/01/2025 Y Description: REM MNTR WRLS L ATR PRS SNR Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0935T NOCOV DEF SYSMAN 01/01/2025 Y Description: CYSTO W/RNL PEL SYMP DNRVTJ Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0936T MEDSV DEF BILL90 01/01/2025 Y Description: PHOTOBIOMODULATION THER RTA Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0937T NOCOV DEF SYSMAN 01/01/2025 Y Description: XTRNL ECG REC>15D<30D Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0938T NOCOV DEF SYSMAN 01/01/2025 Y Description: XTRNL ECG REC>15D<30D REC Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0939T NOCOV DEF SYSMAN 01/01/2025 Y Description: XTRNL ECG REC>15D<30D SCAN Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0940T NOCOV DEF SYSMAN 01/01/2025 Y Description: XTRNL ECG REC>15D<30D R&I Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0941T MEDSV DEF BILL90 01/01/2025 Y Description: CYSTO FLX INS&XPNS URTL SCAF Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0942T MEDSV DEF BILL90 01/01/2025 Y Description: CYSTO FLX RMV&RPLC URTL SCAF Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0943T MEDSV DEF BILL90 01/01/2025 Y Description: CYSTO FLX RMVL URTL SCAFFOLD Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0944T MEDSV DEF BILL90 01/01/2025 Y Description: 3D CNTR SIMULA TRGT LVR LES Category: Medical Services CMS Add: 01/01/2025 CMS Term: 0945T NOCOV DEF SYSMAN 01/01/2025 Y Description: INTRAOP ASSMT ABNL TUM TISS Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0946T NOCOV DEF SYSMAN 01/01/2025 Y Description: ORTHO IMPL MVMT ALYS PAIR CT Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 0947T MEDSV DEF BILL90 01/01/2025 Y Description: MRGFUS STRTCTC BL-BR DISRPJ Category: Medical Services CMS Add: 01/01/2025 CMS Term: 10004 MEDSV DEF RBRVS 01/01/2024 12/31/2024 47.71 Description: FNA BX W/O IMG GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10004 MEDSV DEF RBRVS 01/01/2025 47.58 Description: FNA BX W/O IMG GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 127.54 Description: FNA BX W/US GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10005 MEDSV DEF RBRVS 01/01/2025 123.11 Description: FNA BX W/US GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10006 MEDSV DEF RBRVS 01/01/2024 12/31/2024 56.8 Description: FNA BX W/US GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10006 MEDSV DEF RBRVS 01/01/2025 55.47 Description: FNA BX W/US GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10007 MEDSV DEF RBRVS 01/01/2024 12/31/2024 277.41 Description: FNA BX W/FLUOR GDN 1ST LES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 10007 MEDSV DEF RBRVS 01/01/2025 276.51 Description: FNA BX W/FLUOR GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10008 MEDSV DEF RBRVS 01/01/2024 12/31/2024 134.1 Description: FNA BX W/FLUOR GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10008 MEDSV DEF RBRVS 01/01/2025 128.57 Description: FNA BX W/FLUOR GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10009 MEDSV DEF RBRVS 01/01/2024 12/31/2024 407.05 Description: FNA BX W/CT GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10009 MEDSV DEF RBRVS 01/01/2025 388.76 Description: FNA BX W/CT GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 1000F NOCOV DEF SYSMAN 01/01/2005 Y Description: TOBACCO USE ASSESSED Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 10010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 223.21 Description: FNA BX W/CT GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10010 MEDSV DEF RBRVS 01/01/2025 214.05 Description: FNA BX W/CT GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10011 MEDSV DEF BILL20 01/01/2019 Description: FNA BX W/MR GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10012 MEDSV DEF BILL20 01/01/2019 Description: FNA BX W/MR GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10021 MEDSV DEF RBRVS 01/01/2024 12/31/2024 95.2 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 26 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 63.37 0 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 12/31/2024 15.73 0 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 MEDSV DEF RBRVS 01/01/2025 92.41 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 26 MEDSV DEF MAXFEE 01/01/2025 62.1 0 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 TC MEDSV DEF MAXFEE 01/01/2025 15.42 0 Description: FNA BX W/O IMG GDN 1ST LES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1002F NOCOV DEF SYSMAN 01/01/2005 Y Description: ASSESS ANGINAL SYMPTOM/LEVEL Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 10030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 606 Description: IMG GID FLU COLL DRG SFT TIS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 10030 MEDSV DEF RBRVS 01/01/2025 575.9 Description: IMG GID FLU COLL DRG SFT TIS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 10035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 346.06 0-1 Description: PLMT SFT TISS LOCLZJ DEV 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: 10035 MEDSV DEF RBRVS 01/01/2025 328.26 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 12/31/2024 286.65 Description: PLMT SFT TISS LOCLZJ DEV EA Category: Medical Services CMS Add: 01/01/2016 CMS Term: 10036 MEDSV DEF RBRVS 01/01/2025 267.92 Description: PLMT SFT TISS LOCLZJ DEV EA Category: Medical Services CMS Add: 01/01/2016 CMS Term: 1003F NOCOV DEF SYSMAN 01/01/2006 Y Description: LEVEL OF ACTIVITY ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10040 NOCOV DEF SYSMAN 01/01/1984 Y 0-1 Description: ACNE SURGERY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 1004F NOCOV DEF SYSMAN 01/01/2006 Y Description: CLIN SYMP VOL OVRLD ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 1005F NOCOV DEF SYSMAN 01/01/2006 Y Description: ASTHMA SYMPTOMS EVALUATE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 117.98 0-1 Description: I&D ABSCESS SIMPLE/SINGLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10060 MEDSV DEF RBRVS 01/01/2025 116.88 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 12/31/2024 199.61 0-1 Description: I&D ABSCESS COMP/MULTIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10061 MEDSV DEF RBRVS 01/01/2025 197.01 0-1 Description: I&D ABSCESS COMP/MULTIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1006F NOCOV DEF SYSMAN 01/01/2006 Y Description: OSTEOARTHRITIS ASSESS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1007F NOCOV DEF SYSMAN 01/01/2006 Y Description: ANTI-INFLM/ANLGSC OTC ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 234.88 Description: I&D PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10080 MEDSV DEF RBRVS 01/01/2025 227.89 Description: I&D PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10081 MEDSV DEF RBRVS 01/01/2024 12/31/2024 320.56 Description: I&D PILONIDAL CYST COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10081 MEDSV DEF RBRVS 01/01/2025 312.13 Description: I&D PILONIDAL CYST COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1008F NOCOV DEF SYSMAN 01/01/2006 Y Description: GI/RENAL RISK ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 1010F NOCOV DEF SYSMAN 01/01/2012 Y Description: SEVERITY ANGINA BY ACTVTY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1011F NOCOV DEF SYSMAN 01/01/2012 Y Description: ANGINA PRESENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 10120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 141.32 Description: INC&RMVL FB SUBQ TISS SMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10120 MEDSV DEF RBRVS 01/01/2025 139.54 Description: INC&RMVL FB SUBQ TISS SMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 247.46 Description: INC&RMVL FB SUBQ TISS COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10121 MEDSV DEF RBRVS 01/01/2025 241.89 Description: INC&RMVL FB SUBQ TISS COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1012F NOCOV DEF SYSMAN 01/01/2012 Y Description: ANGINA ABSENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 10140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.33 Description: I&D HMTMA SEROMA/FLUID COLLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10140 MEDSV DEF RBRVS 01/01/2025 155.6 Description: I&D HMTMA SEROMA/FLUID COLLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1015F NOCOV DEF SYSMAN 01/01/2007 Y Description: COPD SYMPTOMS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 10160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 121.66 Description: PNXR ASPIR ABSC HMTMA BULLA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10160 MEDSV DEF RBRVS 01/01/2025 118.95 Description: PNXR ASPIR ABSC HMTMA BULLA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 243.59 Description: I&D COMPLEX PO WOUND INFCTJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 10180 MEDSV DEF RBRVS 01/01/2025 237.68 Description: I&D COMPLEX PO WOUND INFCTJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 1018F NOCOV DEF SYSMAN 01/01/2007 Y Description: ASSESS DYSPNEA NOT PRESENT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1019F NOCOV DEF SYSMAN 01/01/2007 Y Description: ASSESS DYSPNEA PRESENT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1022F NOCOV DEF SYSMAN 01/01/2007 Y Description: PNEUMO IMM STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1026F NOCOV DEF SYSMAN 01/01/2007 Y Description: CO-MORBID CONDITION ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1030F NOCOV DEF SYSMAN 01/01/2007 Y Description: INFLUENZA IMM STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1031F NOCOV DEF SYSMAN 01/01/2012 Y Description: SMOKING & 2ND HAND ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1032F NOCOV DEF SYSMAN 01/01/2012 Y Description: SMOKER/EXPOSED 2ND HND SMOKE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1033F NOCOV DEF SYSMAN 01/01/2012 Y Description: TOBACCO NONSMOKER NOR 2NDHND Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1034F NOCOV DEF SYSMAN 01/01/2007 Y Description: CURRENT TOBACCO SMOKER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1035F NOCOV DEF SYSMAN 01/01/2007 Y Description: SMOKELESS TOBACCO USER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1036F NOCOV DEF SYSMAN 01/01/2007 Y Description: TOBACCO NON-USER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1038F NOCOV DEF SYSMAN 01/01/2007 Y Description: PERSISTENT ASTHMA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1039F NOCOV DEF SYSMAN 01/01/2007 Y Description: INTERMITTENT ASTHMA Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1040F NOCOV DEF SYSMAN 01/01/2007 Y Description: DSM-5 INFO MDD DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1050F NOCOV DEF SYSMAN 01/01/2007 Y Description: HISTORY OF MOLE CHANGES Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1052F NOCOV DEF SYSMAN 01/01/2012 Y Description: TYPE LOCATION ACTIVITYASSESS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1055F NOCOV DEF SYSMAN 01/01/2007 Y Description: VISUAL FUNCT STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1060F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC PERM/CONT/PAROX ATR FIB Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1061F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC LACK PERM&CONT&PAROX FIB Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1065F NOCOV DEF SYSMAN 01/01/2008 Y Description: ISCHM STROKE SYMP LT3 HRSB/4 Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1066F NOCOV DEF SYSMAN 01/01/2008 Y Description: ISCHM STROKE SX ONSET>=3HR Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1070F NOCOV DEF SYSMAN 01/01/2008 Y Description: ALARM SYMP ASSESSED-ABSENT Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1071F NOCOV DEF SYSMAN 01/01/2008 Y Description: ALARM SYMP ASSESSED-1+ PRSNT Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1090F NOCOV DEF SYSMAN 01/01/2008 Y Description: PRES/ABSN URINE INCON ASSESS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1091F NOCOV DEF SYSMAN 01/01/2008 Y Description: URINE INCON CHARACTERIZED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 11000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 54.63 0-1 Description: DBRDMT ECZ/INFECTED SKIN<10% Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11000 MEDSV DEF RBRVS 01/01/2025 54.56 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 12/31/2024 25.63 0-9 Description: DBRDMT ECZ/INFCT SKN EA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11001 MEDSV DEF RBRVS 01/01/2025 25.09 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 12/31/2024 521.07 Description: DBRDMT SKIN XTRNL GENT&PER Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11004 MEDSV DEF RBRVS 01/01/2025 506.22 Description: DBRDMT SKIN XTRNL GENT&PER Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.69 Description: DBRDMT SKIN ABDOMINAL WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11005 MEDSV DEF RBRVS 01/01/2025 680.3 Description: DBRDMT SKIN ABDOMINAL WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11006 MEDSV DEF RBRVS 01/01/2024 12/31/2024 638.37 Description: DBRDMT SKIN XTRNL GENT PER Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11006 MEDSV DEF RBRVS 01/01/2025 619.85 Description: DBRDMT SKIN XTRNL GENT PER Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11008 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.79 Description: RMV PRSTC MTRL/MESH ABD WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11008 MEDSV DEF RBRVS 01/01/2025 239.11 Description: RMV PRSTC MTRL/MESH ABD WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 1100F NOCOV DEF SYSMAN 01/01/2008 Y Description: PTFALLS ASSESS-DOCD GE2>/YR Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 11010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 421.55 Description: DEBRIDE SKIN AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11010 MEDSV DEF RBRVS 01/01/2025 405.87 Description: DEBRIDE SKIN AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11011 MEDSV DEF RBRVS 01/01/2024 12/31/2024 461.77 Description: DEBRIDE SKIN MUSC AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11011 MEDSV DEF RBRVS 01/01/2025 451.89 Description: DEBRIDE SKIN MUSC AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11012 MEDSV DEF RBRVS 01/01/2024 12/31/2024 604.9 Description: DEB SKIN BONE AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11012 MEDSV DEF RBRVS 01/01/2025 588.29 Description: DEB SKIN BONE AT FX SITE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1101F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 120.44 Description: DBRDMT SUBQ TIS 1ST 20SQCM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11042 MEDSV DEF RBRVS 01/01/2025 118.46 Description: DBRDMT SUBQ TIS 1ST 20SQCM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11043 MEDSV DEF RBRVS 01/01/2024 12/31/2024 216.17 Description: DBRDMT MUSC&/FSCA 1ST 20/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11043 MEDSV DEF RBRVS 01/01/2025 212.2 Description: DBRDMT MUSC&/FSCA 1ST 20/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11044 MEDSV DEF RBRVS 01/01/2024 12/31/2024 288.63 Description: DBRDMT BONE 1ST 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11044 MEDSV DEF RBRVS 01/01/2025 283.31 Description: DBRDMT BONE 1ST 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11045 MEDSV DEF RBRVS 01/01/2024 12/31/2024 37.06 Description: DBRDMT SUBQ TISS EACH ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11045 MEDSV DEF RBRVS 01/01/2025 36.36 Description: DBRDMT SUBQ TISS EACH ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11046 MEDSV DEF RBRVS 01/01/2024 12/31/2024 67.29 Description: DBRDMT MUSC&/FSCA EA ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11046 MEDSV DEF RBRVS 01/01/2025 66.03 Description: DBRDMT MUSC&/FSCA EA ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11047 MEDSV DEF RBRVS 01/01/2024 12/31/2024 111.39 Description: DBRDMT BONE EACH ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11047 MEDSV DEF RBRVS 01/01/2025 108.88 Description: DBRDMT BONE EACH ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11055 MEDSV DEF RBRVS 01/01/2024 12/31/2024 66.84 Description: PARING/CUTG B9 HYPRKER LES 1 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11055 MEDSV DEF RBRVS 01/01/2025 65.07 Description: PARING/CUTG B9 HYPRKER LES 1 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11056 MEDSV DEF RBRVS 01/01/2024 12/31/2024 77.17 Description: PARNG/CUTG B9 HYPRKR LES 2-4 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11056 MEDSV DEF RBRVS 01/01/2025 75.58 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 12/31/2024 84.41 Description: PARNG/CUTG B9 HYPRKR LES >4 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11057 MEDSV DEF RBRVS 01/01/2025 82.76 Description: PARNG/CUTG B9 HYPRKR LES >4 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 95.11 0-1 Description: TANGNTL BX SKIN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11102 MEDSV DEF RBRVS 01/01/2025 91.86 0-1 Description: TANGNTL BX SKIN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11103 MEDSV DEF RBRVS 01/01/2024 12/31/2024 47.17 Description: TANGNTL BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11103 MEDSV DEF RBRVS 01/01/2025 45.99 Description: TANGNTL BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11104 MEDSV DEF RBRVS 01/01/2024 12/31/2024 117.72 0-1 Description: PUNCH BX SKIN SINGLE LESION Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11104 MEDSV DEF RBRVS 01/01/2025 114.2 0-1 Description: PUNCH BX SKIN SINGLE LESION Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 55.42 Description: PUNCH BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11105 MEDSV DEF RBRVS 01/01/2025 54.33 Description: PUNCH BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11106 MEDSV DEF RBRVS 01/01/2024 12/31/2024 145.75 0-1 Description: INCAL BX SKN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11106 MEDSV DEF RBRVS 01/01/2025 141.71 0-1 Description: INCAL BX SKN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 66.97 Description: INCAL BX SKN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11107 MEDSV DEF RBRVS 01/01/2025 64.98 Description: INCAL BX SKN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 1110F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT LFT INPT FAC W/IN 60 DAYS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1111F NOCOV DEF SYSMAN 01/01/2008 Y Description: DSCHRG MED/CURRENT MED MERGE Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1116F NOCOV DEF SYSMAN 01/01/2008 Y Description: AURIC/PERI PAIN ASSESSED Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 1118F NOCOV DEF SYSMAN 01/01/2008 Y Description: GERD SYMPS ASSESSED 12 MONTH Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1119F NOCOV DEF SYSMAN 01/01/2008 Y Description: INIT EVAL FOR CONDITION Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 11200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 85.04 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 12/31/2024 17.26 Description: RMVL SKIN TAGS EA ADDL 10 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11201 MEDSV DEF RBRVS 01/01/2025 16.92 Description: RMVL SKIN TAGS EA ADDL 10 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1121F NOCOV DEF SYSMAN 01/01/2008 Y Description: SUBS EVAL FOR CONDITION Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1123F NOCOV DEF SYSMAN 01/01/2008 Y Description: ACP DISCUSS/DSCN MKR DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1124F NOCOV DEF SYSMAN 01/01/2008 Y Description: ACP DISCUSS-NO DSCNMKR DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1125F NOCOV DEF SYSMAN 01/01/2008 Y Description: AMNT PAIN NOTED PAIN PRSNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1126F NOCOV DEF SYSMAN 01/01/2008 Y Description: AMNT PAIN NOTED NONE PRSNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1127F NOCOV DEF SYSMAN 01/01/2010 Y Description: NEW EPISODE FOR CONDITION Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 1128F NOCOV DEF SYSMAN 01/01/2010 Y Description: SUBS EPISODE FOR CONDITION Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 11300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 94.93 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11300 MEDSV DEF RBRVS 01/01/2025 91.71 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11301 MEDSV DEF RBRVS 01/01/2024 12/31/2024 114.53 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11301 MEDSV DEF RBRVS 01/01/2025 111.06 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11302 MEDSV DEF RBRVS 01/01/2024 12/31/2024 129.04 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11302 MEDSV DEF RBRVS 01/01/2025 125.49 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11303 MEDSV DEF RBRVS 01/01/2024 12/31/2024 143.09 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11303 MEDSV DEF RBRVS 01/01/2025 138.86 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 99.55 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11305 MEDSV DEF RBRVS 01/01/2025 96.44 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11306 MEDSV DEF RBRVS 01/01/2024 12/31/2024 115.64 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11306 MEDSV DEF RBRVS 01/01/2025 112.26 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11307 MEDSV DEF RBRVS 01/01/2024 12/31/2024 131.2 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11307 MEDSV DEF RBRVS 01/01/2025 126.94 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11308 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138.77 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11308 MEDSV DEF RBRVS 01/01/2025 134.1 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 1130F NOCOV DEF SYSMAN 01/01/2009 Y Description: BK PAIN & FXN ASSESSED 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 109.29 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11310 MEDSV DEF RBRVS 01/01/2025 105.82 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11311 MEDSV DEF RBRVS 01/01/2024 12/31/2024 128.73 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11311 MEDSV DEF RBRVS 01/01/2025 125.17 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11312 MEDSV DEF RBRVS 01/01/2024 12/31/2024 146.81 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11312 MEDSV DEF RBRVS 01/01/2025 142.3 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11313 MEDSV DEF RBRVS 01/01/2024 12/31/2024 170.51 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11313 MEDSV DEF RBRVS 01/01/2025 165.81 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 1134F NOCOV DEF SYSMAN 01/01/2009 Y Description: EPSD BK PAIN FOR 6 WKS/< Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1135F NOCOV DEF SYSMAN 01/01/2009 Y Description: EPSD BK PAIN FOR >6 WKS Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1136F NOCOV DEF SYSMAN 01/01/2009 Y Description: EPSD BK PAIN FOR 12 WKS/< Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1137F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 119.8 Description: EXC TR-EXT B9+MARG 0.5 CM< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11400 MEDSV DEF RBRVS 01/01/2025 117.42 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 12/31/2024 146.3 Description: EXC TR-EXT B9+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11401 MEDSV DEF RBRVS 01/01/2025 143.18 Description: EXC TR-EXT B9+MARG 0.6-1 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11402 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 157.67 Description: EXC TR-EXT B9+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11403 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 181.37 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 12/31/2024 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 01/01/2025 204.77 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 12/31/2024 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 01/01/2025 290.28 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 12/31/2024 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 01/01/2025 116.53 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 12/31/2024 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 01/01/2025 146.84 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 12/31/2024 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 01/01/2025 164.61 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 12/31/2024 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 01/01/2025 188.58 Description: EXC H-F-NK-SP B9+MARG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11424 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 217.8 Description: EXC H-F-NK-SP B9+MARG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11426 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 300.01 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 12/31/2024 134.6 Description: EXC FACE-MM B9+MARG 0.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11440 MEDSV DEF RBRVS 01/01/2025 131.83 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 12/31/2024 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 01/01/2025 159.85 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 12/31/2024 181.3 Description: EXC FACE-MM B9+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11442 MEDSV DEF RBRVS 01/01/2025 177.4 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 12/31/2024 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 01/01/2025 209.11 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 12/31/2024 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 01/01/2025 259.68 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 12/31/2024 358.66 Description: EXC FACE-MM B9+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11446 MEDSV DEF RBRVS 01/01/2025 351.83 Description: EXC FACE-MM B9+MARG >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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 400.72 Description: EXC SKN HDRDNT AX SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11450 MEDSV DEF RBRVS 01/01/2025 389.5 Description: EXC SKN HDRDNT AX SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11451 MEDSV DEF RBRVS 01/01/2024 12/31/2024 490.33 Description: EXC SKN HDRDNT AX COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11451 MEDSV DEF RBRVS 01/01/2025 475.03 Description: EXC SKN HDRDNT AX COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11462 MEDSV DEF RBRVS 01/01/2024 12/31/2024 388.11 Description: EXC SKN HDRDNT ING SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11462 MEDSV DEF RBRVS 01/01/2025 378.93 Description: EXC SKN HDRDNT ING SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11463 MEDSV DEF RBRVS 01/01/2024 12/31/2024 497.41 Description: EXC SKN HDRDNT ING COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11463 MEDSV DEF RBRVS 01/01/2025 481.64 Description: EXC SKN HDRDNT ING COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11470 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 412.6 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 12/31/2024 504.5 Description: EXC SKN H/P/P/U COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11471 MEDSV DEF RBRVS 01/01/2025 496.1 Description: EXC SKN H/P/P/U COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1150F NOCOV DEF SYSMAN 01/01/2009 Y Description: DOC PT RSK DEATH W/IN 1YR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1151F NOCOV DEF SYSMAN 01/01/2009 Y Description: DOC NO PT RSK DEATH W/IN 1YR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1152F NOCOV DEF SYSMAN 01/01/2009 Y Description: DOC ADVNCD DIS COMFORT 1ST Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1153F NOCOV DEF SYSMAN 01/01/2009 Y Description: DOC ADVNCD DIS CMFRT NOT 1ST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1157F NOCOV DEF SYSMAN 01/01/2009 Y Description: ADVNC CARE PLAN IN RCRD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1158F NOCOV DEF SYSMAN 01/01/2009 Y Description: ADVNC CARE PLAN TLK DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1159F NOCOV DEF SYSMAN 01/01/2009 Y Description: MED LIST DOCD IN RCRD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 11600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 180.65 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 12/31/2024 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 01/01/2025 209.72 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 12/31/2024 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 01/01/2025 224.72 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 12/31/2024 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 01/01/2025 255.63 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 12/31/2024 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 01/01/2025 284.36 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 12/31/2024 416.55 Description: EXC TR-EXT MAL+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11606 MEDSV DEF RBRVS 01/01/2025 407.64 Description: EXC TR-EXT MAL+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1160F NOCOV DEF SYSMAN 01/01/2009 Y Description: RVW MEDS BY RX/DR IN RCRD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 186 Description: EXC H-F-NK-SP MAL+MARG 0.5/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11620 MEDSV DEF RBRVS 01/01/2025 181.43 Description: EXC H-F-NK-SP MAL+MARG 0.5/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11621 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 210.21 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 12/31/2024 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 01/01/2025 232.36 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 12/31/2024 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 01/01/2025 271.21 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 12/31/2024 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 01/01/2025 308.23 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 12/31/2024 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 01/01/2025 369.38 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 12/31/2024 190.4 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 01/01/2025 186.33 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 12/31/2024 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 01/01/2025 217.24 Description: EXC F/E/E/N/L MAL+MRG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11642 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 245.76 Description: EXC F/E/E/N/L MAL+MRG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11643 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 288.36 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 12/31/2024 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 01/01/2025 355.44 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 12/31/2024 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 01/01/2025 459.81 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 01/01/2009 Y Description: FXNL STATUS ASSESSED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 11719 MEDSV DEF RBRVS 01/01/2024 12/31/2024 13.33 Description: TRIM NAIL(S) ANY NUMBER Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11719 MEDSV DEF RBRVS 01/01/2025 13.27 Description: TRIM NAIL(S) ANY NUMBER Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 30.63 Description: DEBRIDE NAIL 1-5 Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11720 MEDSV DEF RBRVS 01/01/2025 30.28 Description: DEBRIDE NAIL 1-5 Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11721 MEDSV DEF RBRVS 01/01/2024 12/31/2024 41.79 Description: DEBRIDE NAIL 6 OR MORE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11721 MEDSV DEF RBRVS 01/01/2025 41.26 Description: DEBRIDE NAIL 6 OR MORE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 108.2 0-1 Description: REMOVAL OF NAIL PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11730 MEDSV DEF RBRVS 01/01/2025 105.85 0-1 Description: REMOVAL OF NAIL PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11732 MEDSV DEF RBRVS 01/01/2024 12/31/2024 31.43 0-10 Description: REMOVE NAIL PLATE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11732 MEDSV DEF RBRVS 01/01/2025 30.43 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 12/31/2024 53.31 Description: DRAIN BLOOD FROM UNDER NAIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11740 MEDSV DEF RBRVS 01/01/2025 53.05 Description: DRAIN BLOOD FROM UNDER NAIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 150.25 Description: REMOVAL OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11750 MEDSV DEF RBRVS 01/01/2025 148.3 Description: REMOVAL OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11755 MEDSV DEF RBRVS 01/01/2024 12/31/2024 115.59 Description: BIOPSY NAIL UNIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 11755 MEDSV DEF RBRVS 01/01/2025 112.56 Description: BIOPSY NAIL UNIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 1175F NOCOV DEF SYSMAN 01/01/2012 Y Description: FUNCTION STAT ASSESSED RVWD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 11760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 175.3 Description: REPAIR OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11760 MEDSV DEF RBRVS 01/01/2025 169.3 Description: REPAIR OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11762 MEDSV DEF RBRVS 01/01/2024 12/31/2024 270.4 Description: RECONSTRUCTION OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11762 MEDSV DEF RBRVS 01/01/2025 264.23 Description: RECONSTRUCTION OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11765 MEDSV DEF RBRVS 01/01/2024 12/31/2024 155.01 Description: EXCISION OF NAIL FOLD TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 11765 MEDSV DEF RBRVS 01/01/2025 152.64 Description: EXCISION OF NAIL FOLD TOE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 330.24 Description: REMOVE PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11770 MEDSV DEF RBRVS 01/01/2025 320.34 Description: REMOVE PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11771 MEDSV DEF RBRVS 01/01/2024 12/31/2024 582.68 Description: REMOVE PILONIDAL CYST EXTEN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11771 MEDSV DEF RBRVS 01/01/2025 569.13 Description: REMOVE PILONIDAL CYST EXTEN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11772 MEDSV DEF RBRVS 01/01/2024 12/31/2024 716.75 Description: REMOVE PILONIDAL CYST COMPL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11772 MEDSV DEF RBRVS 01/01/2025 697.54 Description: REMOVE PILONIDAL CYST COMPL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 1180F NOCOV DEF SYSMAN 01/01/2009 Y Description: THROMBOEMB RISK ASSESSED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1181F NOCOV DEF SYSMAN 01/01/2012 Y Description: NEUROPSYCHIA SYMPTS ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1182F NOCOV DEF SYSMAN 01/01/2012 Y Description: NEUROPSYCHI SYMPT 1+PRESENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1183F NOCOV DEF SYSMAN 01/01/2012 Y Description: NEUROPSYCHIATRIC SYMP ABSENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 11900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 53.47 0-1 Description: INJECT SKIN LESIONS 7 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11901 MEDSV DEF RBRVS 01/01/2025 64.6 0-1 Description: INJECT SKIN LESIONS >7 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.14 0-1 Description: CORRECT SKIN COLOR 6.0 CM/< Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11920 MEDSV DEF RBRVS 01/01/2025 182.17 0-1 Description: CORRECT SKIN COLOR 6.0 CM/< 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11921 MEDSV DEF RBRVS 01/01/2024 12/31/2024 207.8 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 01/01/2025 201.29 Y 0-1 Description: CORRECT SKN COLOR 6.1-20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11922 MEDSV DEF RBRVS 01/01/2024 12/31/2024 56.49 Y Description: CORRECT SKIN COLOR EA 20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11922 MEDSV DEF RBRVS 01/01/2025 55.51 Y Description: CORRECT SKIN COLOR EA 20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11950 NOCOV DEF SYSMAN 12/31/2000 Y 0-1 Description: TX CONTOUR DEFECTS 1 CC/< Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11951 NOCOV DEF SYSMAN 12/31/2000 Y 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 12/31/2000 Y 0-1 Description: TX CONTOUR DEFECTS 5.1-10CC Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11954 NOCOV DEF SYSMAN 12/31/2000 Y 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 12/31/2024 943.11 Description: INSERT TISSUE EXPANDER(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11960 MEDSV DEF RBRVS 01/01/2025 923.96 Description: INSERT TISSUE EXPANDER(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11970 MEDSV DEF RBRVS 01/01/2024 12/31/2024 522.35 Description: RPLCMT TISS XPNDR PERM IMPLT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11970 MEDSV DEF RBRVS 01/01/2025 510.96 Description: RPLCMT TISS XPNDR PERM IMPLT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11971 MEDSV DEF RBRVS 01/01/2024 12/31/2024 512.86 Description: RMVL TIS XPNDR WO INSJ IMPLT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 11971 MEDSV DEF RBRVS 01/01/2025 503.2 Description: RMVL TIS XPNDR WO INSJ IMPLT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 11976 MEDSV DEF RBRVS 01/01/2024 12/31/2024 135.06 Description: REMOVE CONTRACEPTIVE CAPSULE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 11976 MEDSV DEF RBRVS 01/01/2025 132.18 Description: REMOVE CONTRACEPTIVE CAPSULE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11980 MEDSV DEF RBRVS 01/01/2024 12/31/2024 87.86 Description: IMPLANT HORMONE PELLET(S) Category: Medical Services CMS Add: 01/01/2000 CMS Term: 11980 MEDSV DEF RBRVS 01/01/2025 86.1 Description: IMPLANT HORMONE PELLET(S) Category: Medical Services CMS Add: 01/01/2000 CMS Term: 11981 MEDSV DEF RBRVS 01/01/2024 12/31/2024 93.41 Description: INSERTION DRUG DLVR IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11981 MEDSV DEF RBRVS 01/01/2025 91.38 Description: INSERTION DRUG DLVR IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11982 MEDSV DEF RBRVS 01/01/2024 12/31/2024 104.38 Description: REMOVE DRUG IMPLANT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11982 MEDSV DEF RBRVS 01/01/2025 100.82 Description: REMOVE DRUG IMPLANT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11983 MEDSV DEF RBRVS 01/01/2024 12/31/2024 132.25 Description: REMOVE/INSERT DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11983 MEDSV DEF RBRVS 01/01/2025 128.93 Description: REMOVE/INSERT DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 12001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 85.6 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 12/31/2024 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 01/01/2025 103.62 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 12/31/2024 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 01/01/2025 120.59 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 12/31/2024 164.4 Description: RPR S/N/A/GEN/TRK12.6-20.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12005 MEDSV DEF RBRVS 01/01/2025 160.52 Description: RPR S/N/A/GEN/TRK12.6-20.0CM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12006 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 185.35 Description: RPR S/N/A/GEN/TRK20.1-30.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12007 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 210.14 Description: RPR S/N/AX/GEN/TRNK >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1200F NOCOV DEF SYSMAN 01/01/2010 Y Description: SEIZURE TYPE& FREQU DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12011 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 101.77 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 12/31/2024 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 01/01/2025 105.95 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 12/31/2024 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 01/01/2025 129.25 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 12/31/2024 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 01/01/2025 156.02 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 12/31/2024 204.3 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 01/01/2025 197.77 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 12/31/2024 140.92 Description: RPR FE/E/EN/L/M 20.1-30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12017 MEDSV DEF RBRVS 01/01/2025 137.12 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 12/31/2024 159.1 Description: RPR F/E/E/N/L/M >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12018 MEDSV DEF RBRVS 01/01/2025 154.59 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 12/31/2024 280.47 Description: TX SUPFC WND DEHSN SMPL CLSR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12020 MEDSV DEF RBRVS 01/01/2025 273.43 Description: TX SUPFC WND DEHSN SMPL CLSR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12021 MEDSV DEF RBRVS 01/01/2024 12/31/2024 165.5 Description: TX SUPFC WND DEHSN W/PACKING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12021 MEDSV DEF RBRVS 01/01/2025 161.91 Description: TX SUPFC WND DEHSN W/PACKING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12031 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 240.33 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 12/31/2024 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 01/01/2025 278.22 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 12/31/2024 313.3 Description: INTMD RPR S/TR/EXT 7.6-12.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12034 MEDSV DEF RBRVS 01/01/2025 305.88 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 12/31/2024 362.6 Description: INTMD RPR S/A/T/EXT 12.6-20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12035 MEDSV DEF RBRVS 01/01/2025 353.45 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 12/31/2024 401.36 Description: INTMD RPR S/A/T/EXT 20.1-30 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12036 MEDSV DEF RBRVS 01/01/2025 392.19 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 12/31/2024 449.33 Description: INTMD RPR S/TR/EXT >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12037 MEDSV DEF RBRVS 01/01/2025 440.19 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 12/31/2024 247.92 Description: INTMD RPR N-HF/GENIT 2.5CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12041 MEDSV DEF RBRVS 01/01/2025 241.05 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 12/31/2024 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 01/01/2025 284.08 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 12/31/2024 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 01/01/2025 349.2 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 12/31/2024 386.68 Description: INTMD RPR N-HF/GENIT12.6-20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12045 MEDSV DEF RBRVS 01/01/2025 375.27 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 12/31/2024 461.01 Description: INTMD RPR N-HF/GENIT20.1-30 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12046 MEDSV DEF RBRVS 01/01/2025 449.92 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 12/31/2024 504.91 Description: INTMD RPR N-HF/GENIT >30.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12047 MEDSV DEF RBRVS 01/01/2025 492.61 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 12/31/2024 266.24 Description: INTMD RPR FACE/MM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12051 MEDSV DEF RBRVS 01/01/2025 259.04 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 12/31/2024 296.76 Description: INTMD RPR FACE/MM 2.6-5.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12052 MEDSV DEF RBRVS 01/01/2025 288.83 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 12/31/2024 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 01/01/2025 332.35 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 12/31/2024 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 01/01/2025 348.99 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 12/31/2024 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 01/01/2025 456.68 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 12/31/2024 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 01/01/2025 525.43 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 12/31/2024 568.63 Description: INTMD RPR FACE/MM >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12057 MEDSV DEF RBRVS 01/01/2025 549.66 Description: INTMD RPR FACE/MM >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1205F NOCOV DEF SYSMAN 01/01/2010 Y Description: EPI ETIOL SYND RVWD AND DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 1220F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT SCREENED FOR DEPRESSION Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 13100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 320.32 Description: CMPLX RPR TRUNK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 13100 MEDSV DEF RBRVS 01/01/2025 311.07 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 12/31/2024 373.41 Description: CMPLX RPR TRUNK 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13101 MEDSV DEF RBRVS 01/01/2025 362.49 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 12/31/2024 108.98 Description: CMPLX RPR TRUNK ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13102 MEDSV DEF RBRVS 01/01/2025 105.67 Description: CMPLX RPR TRUNK ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 324.35 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 12/31/2024 400.1 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 01/01/2025 388.72 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 12/31/2024 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 01/01/2025 115.25 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 12/31/2024 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 01/01/2025 354.66 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 12/31/2024 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 01/01/2025 430.62 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 12/31/2024 157.9 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 13133 MEDSV DEF RBRVS 01/01/2025 153.6 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 12/31/2024 398.1 Description: CMPLX RPR E/N/E/L 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13151 MEDSV DEF RBRVS 01/01/2025 386.47 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 12/31/2024 467.1 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 01/01/2025 454.03 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 12/31/2024 173.5 Description: CMPLX RPR E/N/E/L ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13153 MEDSV DEF RBRVS 01/01/2025 168.04 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 12/31/2024 739.22 Description: SEC CLSR SURG WND/DEHSN XTN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 13160 MEDSV DEF RBRVS 01/01/2025 722.37 Description: SEC CLSR SURG WND/DEHSN XTN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 14000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 591.37 Description: TIS TRNFR TRUNK 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14000 MEDSV DEF RBRVS 01/01/2025 580.21 Description: TIS TRNFR TRUNK 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 752.7 Description: TIS TRNFR TRUNK 10.1-30SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14001 MEDSV DEF RBRVS 01/01/2025 737.87 Description: TIS TRNFR TRUNK 10.1-30SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1400F NOCOV DEF SYSMAN 01/01/2011 Y Description: PRKNS DIAG RVIEWED Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 14020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 644.65 Description: TIS TRNFR S/A/L 10 SQ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 14021 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 794.84 Description: TIS TRNFR S/A/L 10.1-30 SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 697.9 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 12/31/2024 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 01/01/2025 848.38 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 12/31/2024 720.4 Description: TIS TRNFR E/N/E/L 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14060 MEDSV DEF RBRVS 01/01/2025 706.47 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 12/31/2024 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 01/01/2025 915.33 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 12/31/2024 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 01/01/2025 986.87 Description: TIS TRNFR ANY 30.1-60 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14302 MEDSV DEF RBRVS 01/01/2024 12/31/2024 199.07 Description: TIS TRNFR ADDL 30 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14302 MEDSV DEF RBRVS 01/01/2025 193.01 Description: TIS TRNFR ADDL 30 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 637.44 Description: FILLETED FINGER/TOE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14350 MEDSV DEF RBRVS 01/01/2025 624.47 Description: FILLETED FINGER/TOE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1450F NOCOV DEF SYSMAN 01/01/2012 Y Description: SYMPTOMS IMPROVED/CONSIST Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1451F NOCOV DEF SYSMAN 01/01/2012 Y Description: SYMPT SHOW CLIN IMPORT DROP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1460F NOCOV DEF SYSMAN 01/01/2012 Y Description: QUAL CARD DIAG PRIOR 12 MONS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1461F NOCOV DEF SYSMAN 01/01/2012 Y Description: NO QUAL CARD DIAG PRIOR12MON Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1490F NOCOV DEF SYSMAN 01/01/2012 Y Description: DEM SEVERITY CLASSIFIED MILD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1491F NOCOV DEF SYSMAN 01/01/2012 Y Description: DEM SEVERITY CLASSIFIED MOD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1493F NOCOV DEF SYSMAN 01/01/2012 Y Description: DEM SEVERITY CLASS SEVERE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1494F NOCOV DEF SYSMAN 01/01/2012 Y Description: COGNIT ASSESSED AND REVIEWED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 15002 MEDSV DEF RBRVS 01/01/2024 12/31/2024 320.92 Description: WOUND PREP TRK/ARM/LEG Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15002 MEDSV DEF RBRVS 01/01/2025 310.84 Description: WOUND PREP TRK/ARM/LEG Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15003 MEDSV DEF RBRVS 01/01/2024 12/31/2024 63.97 Description: WOUND PREP ADDL 100 CM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15003 MEDSV DEF RBRVS 01/01/2025 62.26 Description: WOUND PREP ADDL 100 CM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15004 MEDSV DEF RBRVS 01/01/2024 12/31/2024 368.64 Description: WOUND PREP F/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15004 MEDSV DEF RBRVS 01/01/2025 357.86 Description: WOUND PREP F/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 104.43 Description: WND PREP F/N/HF/G ADDL CM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1500F NOCOV DEF SYSMAN 01/01/2013 Y Description: SYMPTOM&SIGN SYMM POLYNEURO Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15011 MEDSV DEF BILL20 01/01/2025 Description: HRV SKN CLL SSP AGRFT 1ST 25 Category: Medical Services CMS Add: 01/01/2025 CMS Term: 15012 MEDSV DEF BILL20 01/01/2025 Description: HRV SKN CLL SSP AGRFT EA ADD Category: Medical Services CMS Add: 01/01/2025 CMS Term: 15013 MEDSV DEF BILL20 01/01/2025 Description: PREPJ SKN CLL SSP AGRFT 1ST Category: Medical Services CMS Add: 01/01/2025 CMS Term: 15014 MEDSV DEF BILL20 01/01/2025 Description: PREPJ SKN CLL SSP AGRFT EA Category: Medical Services CMS Add: 01/01/2025 CMS Term: 15015 MEDSV DEF BILL20 01/01/2025 Description: APP SKN CL SSP AGRFT T/A/L 1 Category: Medical Services CMS Add: 01/01/2025 CMS Term: 15016 MEDSV DEF BILL20 01/01/2025 Description: APP SKN CL SSP AGRF T/A/L EA Category: Medical Services CMS Add: 01/01/2025 CMS Term: 15017 MEDSV DEF BILL20 01/01/2025 Description: APP SKN CLL SSP F/N/G/HF 1ST Category: Medical Services CMS Add: 01/01/2025 CMS Term: 15018 MEDSV DEF BILL20 01/01/2025 Description: APP SKN CLL SSP F/N/G/HF EA Category: Medical Services CMS Add: 01/01/2025 CMS Term: 1501F NOCOV DEF SYSMAN 01/01/2013 Y Description: NOT INITIAL EVAL FOR COND Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 1502F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT QUERIED PAIN FXN W/ INSTR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 1503F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT QUERIED SYMP RESP INSUFF Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 244.76 Description: HARVEST CULTURED SKIN GRAFT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15040 MEDSV DEF RBRVS 01/01/2025 236.22 Description: HARVEST CULTURED SKIN GRAFT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 1504F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT HAS RESP INSUFFICIENCY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 552.45 Description: PINCH GRAFT UP TO 2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15050 MEDSV DEF RBRVS 01/01/2025 533.23 Description: PINCH GRAFT UP TO 2 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1505F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT HAS NO RESP INSUFFICIENCY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 806.6 Description: SPLT AGRFT T/A/L 1ST 100SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15100 MEDSV DEF RBRVS 01/01/2025 786.54 Description: SPLT AGRFT T/A/L 1ST 100SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 172.44 Description: SPLT AGRFT T/A/L EA ADDL 100 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15101 MEDSV DEF RBRVS 01/01/2025 166.81 Description: SPLT AGRFT T/A/L EA ADDL 100 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 773.79 Description: EPIDRM AGRFT T/A/L 1ST 100 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15110 MEDSV DEF RBRVS 01/01/2025 754.84 Description: EPIDRM AGRFT T/A/L 1ST 100 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 103.25 Description: EPIDRM AGRFT T/A/L EA ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15111 MEDSV DEF RBRVS 01/01/2025 101.06 Description: EPIDRM AGRFT T/A/L EA ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 749.65 Description: EPDRM AGRFT F/S/N/H/F/G/M 1 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15115 MEDSV DEF RBRVS 01/01/2025 738.14 Description: EPDRM AGRFT F/S/N/H/F/G/M 1 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15116 MEDSV DEF RBRVS 01/01/2024 12/31/2024 141.73 Description: EPDRM AGRFT F/S/N/H/F/G/M EA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15116 MEDSV DEF RBRVS 01/01/2025 137.09 Description: EPDRM AGRFT F/S/N/H/F/G/M EA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 788.5 Description: SPLT AGRFT F/S/N/H/F/G/M 1ST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15120 MEDSV DEF RBRVS 01/01/2025 770.67 Description: SPLT AGRFT F/S/N/H/F/G/M 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 193.68 Description: SPLT AGRFT F/S/N/H/F/G/M EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15121 MEDSV DEF RBRVS 01/01/2025 186.56 Description: SPLT AGRFT F/S/N/H/F/G/M EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 671.89 Description: DRM AGRFT T/A/L 1ST 100 SQCM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15130 MEDSV DEF RBRVS 01/01/2025 653.26 Description: DRM AGRFT T/A/L 1ST 100 SQCM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15131 MEDSV DEF RBRVS 01/01/2024 12/31/2024 90.06 Description: DRM AGRFT T/A/L EA ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15131 MEDSV DEF RBRVS 01/01/2025 87.82 Description: DRM AGRFT T/A/L EA ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 822.2 Description: DRM AGRFT F/S/N/H/F/G/M 1ST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15135 MEDSV DEF RBRVS 01/01/2025 797.29 Description: DRM AGRFT F/S/N/H/F/G/M 1ST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15136 MEDSV DEF RBRVS 01/01/2024 12/31/2024 88.83 Description: DRM AGRFT F/S/N/H/F/G/M EA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15136 MEDSV DEF RBRVS 01/01/2025 86.61 Description: DRM AGRFT F/S/N/H/F/G/M EA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 647.3 Description: TIS CLTR SKN AGRFT T/A/L 1ST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15150 MEDSV DEF RBRVS 01/01/2025 630.43 Description: TIS CLTR SKN AGRFT T/A/L 1ST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 107.47 Description: TIS CLTR SKN AGRFT T/A/L ADD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15151 MEDSV DEF RBRVS 01/01/2025 104.68 Description: TIS CLTR SKN AGRFT T/A/L ADD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15152 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138 Description: TIS CLTR SKN AGRFT T/A/L EA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15152 MEDSV DEF RBRVS 01/01/2025 132.08 Description: TIS CLTR SKN AGRFT T/A/L EA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 740.29 Description: TIS CLTR AGRFT F/S/N/H/F/G 1 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15155 MEDSV DEF RBRVS 01/01/2025 719.92 Description: TIS CLTR AGRFT F/S/N/H/F/G 1 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15156 MEDSV DEF RBRVS 01/01/2024 12/31/2024 144.43 Description: TIS CLT AGRFT F/S/N/H/F/G AD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15156 MEDSV DEF RBRVS 01/01/2025 140.87 Description: TIS CLT AGRFT F/S/N/H/F/G AD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15157 MEDSV DEF RBRVS 01/01/2024 12/31/2024 160.97 Description: TIS CLT AGRFT F/S/N/H/F/G EA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15157 MEDSV DEF RBRVS 01/01/2025 156.65 Description: TIS CLT AGRFT F/S/N/H/F/G EA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 779.29 Y Description: FTH/GFT FR TRNK 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15200 MEDSV DEF RBRVS 01/01/2025 764.17 Y Description: FTH/GFT FR TRNK 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15201 MEDSV DEF RBRVS 01/01/2024 12/31/2024 130.87 Description: FTH/GFT FR TRNK EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15201 MEDSV DEF RBRVS 01/01/2025 126.29 Description: FTH/GFT FR TRNK EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 718.67 Description: FTH/GFT FR S/A/L 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15220 MEDSV DEF RBRVS 01/01/2025 704.35 Description: FTH/GFT FR S/A/L 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15221 MEDSV DEF RBRVS 01/01/2024 12/31/2024 121.03 Description: FTH/GFT FR S/A/L EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15221 MEDSV DEF RBRVS 01/01/2025 116.87 Description: FTH/GFT FR S/A/L EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 868.61 Description: FTH/GFT F/C/C/M/N/AX/G/H/F20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15240 MEDSV DEF RBRVS 01/01/2025 851.61 Description: FTH/GFT F/C/C/M/N/AX/G/H/F20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15241 MEDSV DEF RBRVS 01/01/2024 12/31/2024 161.55 Description: FTH/GFT F/C/C/M/N/A/G/H/F EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15241 MEDSV DEF RBRVS 01/01/2025 158.21 Description: FTH/GFT F/C/C/M/N/A/G/H/F EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 936.51 Description: FTH/GFT FR N/E/E/L 20 SQCM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15260 MEDSV DEF RBRVS 01/01/2025 918.56 Description: FTH/GFT FR N/E/E/L 20 SQCM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15261 MEDSV DEF RBRVS 01/01/2024 12/31/2024 192.31 Description: FTH/GFT FR N/E/E/L EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15261 MEDSV DEF RBRVS 01/01/2025 186.34 Description: FTH/GFT FR N/E/E/L EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15271 MEDSV DEF RBRVS 01/01/2024 12/31/2024 143.28 Description: SKIN SUB GRAFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15271 MEDSV DEF RBRVS 01/01/2025 140.46 Description: SKIN SUB GRAFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15272 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 22.47 Description: SKIN SUB GRAFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15273 MEDSV DEF RBRVS 01/01/2024 12/31/2024 288.67 Description: SKIN SUB GRFT T/ARM/LG CHILD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15273 MEDSV DEF RBRVS 01/01/2025 279.34 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 12/31/2024 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 01/01/2025 72.97 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 12/31/2024 149.04 Description: SKIN SUB GRAFT FACE/NK/HF/G Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15275 MEDSV DEF RBRVS 01/01/2025 145.96 Description: SKIN SUB GRAFT FACE/NK/HF/G 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15276 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 29.56 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 12/31/2024 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 01/01/2025 308.46 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 12/31/2024 88.5 Description: SKN SUB GRFT F/N/HF/G CH ADD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15278 MEDSV DEF RBRVS 01/01/2025 85.43 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 12/31/2024 843.08 Description: SKIN PEDICLE FLAP TRUNK Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15570 MEDSV DEF RBRVS 01/01/2025 821.19 Description: SKIN PEDICLE FLAP TRUNK Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15572 MEDSV DEF RBRVS 01/01/2024 12/31/2024 820.12 Description: SKIN PEDICLE FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15572 MEDSV DEF RBRVS 01/01/2025 802.39 Description: SKIN PEDICLE FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15574 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 808.6 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 12/31/2024 733.48 Description: PEDICLE E/N/E/L/NTRORAL Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15576 MEDSV DEF RBRVS 01/01/2025 716.64 Description: PEDICLE E/N/E/L/NTRORAL Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 315.01 Description: DELAY FLAP TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15600 MEDSV DEF RBRVS 01/01/2025 308.38 Description: DELAY FLAP TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 343.3 Description: DELAY FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15610 MEDSV DEF RBRVS 01/01/2025 335.71 Description: DELAY FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 409 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 12/31/2024 432.36 Description: DELAY FLAP EYE/NOS/EAR/LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15630 MEDSV DEF RBRVS 01/01/2025 424.16 Description: DELAY FLAP EYE/NOS/EAR/LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 503.79 Description: TRANSFER SKIN PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15650 MEDSV DEF RBRVS 01/01/2025 493.36 Description: TRANSFER SKIN PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1338.15 Description: MDFC FLAP W/PRSRV VASC PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 15730 MEDSV DEF RBRVS 01/01/2025 1300.37 Description: MDFC FLAP W/PRSRV VASC PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 15731 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1050.41 Description: FOREHEAD FLAP W/VASC PEDICLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15731 MEDSV DEF RBRVS 01/01/2025 1025.05 Description: FOREHEAD FLAP W/VASC PEDICLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15733 MEDSV DEF RBRVS 01/01/2024 12/31/2024 959.63 Description: MUSC MYOQ/FSCQ FLP H&N PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 15733 MEDSV DEF RBRVS 01/01/2025 934.78 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 12/31/2024 1380.12 Description: MUSCLE-SKIN GRAFT TRUNK Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15734 MEDSV DEF RBRVS 01/01/2025 1346.34 Description: MUSCLE-SKIN GRAFT TRUNK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15736 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1124.46 Description: MUSCLE-SKIN GRAFT ARM Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15736 MEDSV DEF RBRVS 01/01/2025 1099.78 Description: MUSCLE-SKIN GRAFT ARM Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15738 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1173.62 Description: MUSCLE-SKIN GRAFT LEG Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15738 MEDSV DEF RBRVS 01/01/2025 1142.9 Description: MUSCLE-SKIN GRAFT LEG Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 943.9 Description: ISLAND PEDICLE FLAP GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15740 MEDSV DEF RBRVS 01/01/2025 926.1 Description: ISLAND PEDICLE FLAP GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 856.6 Description: NEUROVASCULAR PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15750 MEDSV DEF RBRVS 01/01/2025 844.67 Description: NEUROVASCULAR PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15756 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2127.84 Description: FREE MYO/SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15756 MEDSV DEF RBRVS 01/01/2025 2066.63 Description: FREE MYO/SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15757 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2118.92 Description: FREE SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15757 MEDSV DEF RBRVS 01/01/2025 2056.73 Description: FREE SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15758 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2112.08 Description: FREE FASCIAL FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15758 MEDSV DEF RBRVS 01/01/2025 2048.64 Description: FREE FASCIAL FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 792.83 Description: COMPOSITE SKIN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15760 MEDSV DEF RBRVS 01/01/2025 774.82 Description: COMPOSITE SKIN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15769 MEDSV DEF RBRVS 01/01/2024 12/31/2024 445.77 Y Description: GRFG AUTOL SOFT TISS DIR EXC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15769 MEDSV DEF RBRVS 01/01/2025 436.18 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 12/31/2024 627.44 Description: DERMA-FAT-FASCIA GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15770 MEDSV DEF RBRVS 01/01/2025 615.3 Description: DERMA-FAT-FASCIA GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15771 MEDSV DEF RBRVS 01/01/2024 12/31/2024 563.54 Y Description: GRFG AUTOL FAT LIPO 50 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15771 MEDSV DEF RBRVS 01/01/2025 555.71 Y Description: GRFG AUTOL FAT LIPO 50 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15772 MEDSV DEF RBRVS 01/01/2024 12/31/2024 177.31 Y Description: GRFG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15772 MEDSV DEF RBRVS 01/01/2025 173.4 Y Description: GRFG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15773 MEDSV DEF RBRVS 01/01/2024 12/31/2024 555.73 Y Description: GRFG AUTOL FAT LIPO 25 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15773 MEDSV DEF RBRVS 01/01/2025 543.52 Y Description: GRFG AUTOL FAT LIPO 25 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15774 MEDSV DEF RBRVS 01/01/2024 12/31/2024 173.34 Y Description: GFRG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15774 MEDSV DEF RBRVS 01/01/2025 168.62 Y Description: GFRG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15775 NOCOV DEF SYSMAN 01/01/1996 Y Description: HAIR TRNSPL 1-15 PUNCH GRFTS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15776 NOCOV DEF SYSMAN 01/01/1900 Y Description: HAIR TRNSPL >15 PUNCH GRAFTS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15777 MEDSV DEF RBRVS 01/01/2024 12/31/2024 197.46 Description: ACELLULAR DERM MATRIX IMPLT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15777 MEDSV DEF RBRVS 01/01/2025 191.47 Description: ACELLULAR DERM MATRIX IMPLT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15778 MEDSV DEF RBRVS 01/01/2024 12/31/2024 351.38 Description: IMPL ABSRB MSH/PRSTH DLY CLS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15778 MEDSV DEF RBRVS 01/01/2025 341.71 Description: IMPL ABSRB MSH/PRSTH DLY CLS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 795 Y Description: DERMABRASION TOTAL FACE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15780 MEDSV DEF RBRVS 01/01/2025 778.98 Y Description: DERMABRASION TOTAL FACE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15781 MEDSV DEF RBRVS 01/01/2024 12/31/2024 503.27 Y Description: DERMABRASION SEGMENTAL FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15781 MEDSV DEF RBRVS 01/01/2025 488.77 Y Description: DERMABRASION SEGMENTAL FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15782 MEDSV DEF RBRVS 01/01/2024 12/31/2024 455.45 Y Description: DERMABRASION OTHER THAN FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15782 MEDSV DEF RBRVS 01/01/2025 446.74 Y Description: DERMABRASION OTHER THAN FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15783 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.02 Y Description: DERMABRASION SUPRFL ANY SITE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 15783 MEDSV DEF RBRVS 01/01/2025 414.81 Y Description: DERMABRASION SUPRFL ANY SITE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 15786 NOCOV DEF SYSMAN 01/01/2000 Y Description: ABRASION LESION SINGLE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15787 NOCOV DEF SYSMAN 12/31/2000 Y Description: ABRASION LESIONS ADD-ON Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15788 NOCOV DEF SYSMAN 01/01/1994 Y Description: CHEMICAL PEEL FACIAL EPIDRM Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15789 NOCOV DEF SYSMAN 01/01/1994 Y Description: CHEMICAL PEEL FACIAL DERMAL Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15792 NOCOV DEF SYSMAN 10/06/1994 Y Description: CHEM PEEL NONFACIAL EPIDRM Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15793 NOCOV DEF SYSMAN 10/06/1994 Y Description: CHEMICAL PEEL NONFACIAL DRM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15819 NOCOV DEF SYSMAN 10/06/1994 12/31/2024 Y Description: PLASTIC SURGERY NECK Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 12/31/2024 15820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 544.19 Y Description: BLEPHAROPLASTY LOWER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15820 MEDSV DEF RBRVS 01/01/2025 535.52 Y Description: BLEPHAROPLASTY LOWER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 581.69 Y Description: BLEPHARP LWR EYELID FAT PAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15821 MEDSV DEF RBRVS 01/01/2025 571.96 Y Description: BLEPHARP LWR EYELID FAT PAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15822 MEDSV DEF RBRVS 01/01/2024 12/31/2024 433.04 Y Description: BLEPHAROPLASTY UPPER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15822 MEDSV DEF RBRVS 01/01/2025 424.3 Y Description: BLEPHAROPLASTY UPPER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15823 MEDSV DEF RBRVS 01/01/2024 12/31/2024 583.7 Y Description: BLEPHARP UPR EYELID XCSV SKN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15823 MEDSV DEF RBRVS 01/01/2025 573.51 Y Description: BLEPHARP UPR EYELID XCSV SKN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15824 NOCOV DEF SYSMAN 01/01/1900 Y Description: RHYTIDECTOMY FOREHEAD Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15825 NOCOV DEF SYSMAN 01/01/1900 Y Description: RHYTDCT NCK PLTYSML TGHTG Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 15826 NOCOV DEF SYSMAN 01/01/1900 Y Description: RHYTIDECTOMY GLBLR FRN LINES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15828 NOCOV DEF SYSMAN 01/01/1900 Y Description: RHYTIDECTOMY CHEEK CHN & NCK Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15829 NOCOV DEF SYSMAN 01/01/1900 Y Description: RHYTIDECTOMY SMAS FLAP Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 15830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1084.12 Y Description: EXC EXCESSIVE SKIN ABDOMEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15830 MEDSV DEF RBRVS 01/01/2025 1057.73 Y Description: EXC EXCESSIVE SKIN ABDOMEN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15832 MEDSV DEF RBRVS 01/01/2024 12/31/2024 855.05 Y Description: EXC EXCESSIVE SKIN THIGH Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15832 MEDSV DEF RBRVS 01/01/2025 835.08 Y Description: EXC EXCESSIVE SKIN THIGH Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15833 MEDSV DEF RBRVS 01/01/2024 12/31/2024 814.95 Y Description: EXC EXCESSIVE SKIN LEG Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15833 MEDSV DEF RBRVS 01/01/2025 795.63 Y Description: EXC EXCESSIVE SKIN LEG Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15834 MEDSV DEF RBRVS 01/01/2024 12/31/2024 829.54 Y Description: EXC EXCESSIVE SKIN HIP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15834 MEDSV DEF RBRVS 01/01/2025 809.94 Y Description: EXC EXCESSIVE SKIN HIP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15835 MEDSV DEF RBRVS 01/01/2024 12/31/2024 864.53 Y Description: EXC EXCESSIVE SKIN BUTTOCK Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15835 MEDSV DEF RBRVS 01/01/2025 844 Y Description: EXC EXCESSIVE SKIN BUTTOCK Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15836 MEDSV DEF RBRVS 01/01/2024 12/31/2024 740.53 Y Description: EXC EXCESSIVE SKIN ARM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15836 MEDSV DEF RBRVS 01/01/2025 723.62 Y Description: EXC EXCESSIVE SKIN ARM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15837 MEDSV DEF RBRVS 01/01/2024 12/31/2024 806.97 Y Description: EXC EXCSV SKIN FOREARM/HAND Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15837 MEDSV DEF RBRVS 01/01/2025 788.52 Y Description: EXC EXCSV SKIN FOREARM/HAND Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15838 MEDSV DEF RBRVS 01/01/2024 12/31/2024 603.78 Y Description: EXC EXCSV SUBMENTAL FAT PAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15838 MEDSV DEF RBRVS 01/01/2025 590.44 Y Description: EXC EXCSV SUBMENTAL FAT PAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15839 MEDSV DEF RBRVS 01/01/2024 12/31/2024 829.72 Y Description: EXC EXCESSIVE SKN OTHER AREA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15839 MEDSV DEF RBRVS 01/01/2025 811.62 Y Description: EXC EXCESSIVE SKN OTHER AREA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 946.16 Description: NERVE PALSY FASCIAL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15840 MEDSV DEF RBRVS 01/01/2025 922.26 Description: NERVE PALSY FASCIAL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15841 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1649.27 Description: NERVE PALSY MUSCLE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15841 MEDSV DEF RBRVS 01/01/2025 1606.53 Description: NERVE PALSY MUSCLE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15842 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2497.78 Description: NERVE PALSY MICROSURG GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15842 MEDSV DEF RBRVS 01/01/2025 2429.48 Description: NERVE PALSY MICROSURG GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 985.22 Description: SKIN AND MUSCLE REPAIR FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15845 MEDSV DEF RBRVS 01/01/2025 962.93 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 Y Description: EXC SKIN ABD ADD-ON Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15851 MEDSV DEF RBRVS 01/01/2024 12/31/2024 53.72 Description: REMOVAL SUTR/STAPLE REQ ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15851 MEDSV DEF RBRVS 01/01/2025 52.42 Description: REMOVAL SUTR/STAPLE REQ ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15852 MEDSV DEF RBRVS 01/01/2024 12/31/2024 42.38 Description: DRESSING CHANGE NOT FOR BURN Category: Medical Services CMS Add: 01/01/1989 CMS Term: 15852 MEDSV DEF RBRVS 01/01/2025 40.35 Description: DRESSING CHANGE NOT FOR BURN Category: Medical Services CMS Add: 01/01/1989 CMS Term: 15853 MEDSV DEF RBRVS 01/01/2024 12/31/2024 10.35 Description: REMOVAL SUTR/STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15853 MEDSV DEF RBRVS 01/01/2025 10.42 Description: REMOVAL SUTR/STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15854 MEDSV DEF RBRVS 01/01/2024 12/31/2024 14.52 Description: REMOVAL SUTR&STAPL XREQ ANES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15854 MEDSV DEF RBRVS 01/01/2025 14.21 Description: REMOVAL SUTR&STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 98.12 Description: TEST FOR BLOOD FLOW IN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15860 MEDSV DEF RBRVS 01/01/2025 95.09 Description: TEST FOR BLOOD FLOW IN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15876 NOCOV DEF SYSMAN 12/01/1993 Y Description: SUCTION LIPECTOMY HEAD&NECK Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15877 NOCOV DEF SYSMAN 01/01/2007 Y Description: SUCTION LIPECTOMY TRUNK Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15878 NOCOV DEF SYSMAN 12/01/1993 Y Description: SUCTION LIPECTOMY UPR EXTREM Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15879 NOCOV DEF SYSMAN 01/01/1997 Y Description: SUCTION LIPECTOMY LWR EXTREM Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 592.22 Description: EXC COCCYGL PR ULC PRIM SUTR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15920 MEDSV DEF RBRVS 01/01/2025 569.25 Description: EXC COCCYGL PR ULC PRIM SUTR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15922 MEDSV DEF RBRVS 01/01/2024 12/31/2024 741.97 Description: EXC COCCYGL PR ULC FLAP CLSR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15922 MEDSV DEF RBRVS 01/01/2025 724.35 Description: EXC COCCYGL PR ULC FLAP CLSR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15931 MEDSV DEF RBRVS 01/01/2024 12/31/2024 648.89 Description: EXC SACRAL PR ULC PRIM SUTR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15931 MEDSV DEF RBRVS 01/01/2025 633.2 Description: EXC SACRAL PR ULC PRIM SUTR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15933 MEDSV DEF RBRVS 01/01/2024 12/31/2024 803.45 Description: EXC SAC PR ULC PRIM STR OSTC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15933 MEDSV DEF RBRVS 01/01/2025 786.73 Description: EXC SAC PR ULC PRIM STR OSTC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15934 MEDSV DEF RBRVS 01/01/2024 12/31/2024 876.81 Description: EXC SACRAL PR ULC SKN FLAP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15934 MEDSV DEF RBRVS 01/01/2025 892.97 Description: EXC SACRAL PR ULC SKN FLAP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15935 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1074.08 Description: EXC SAC PR ULC SKN FLP OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15935 MEDSV DEF RBRVS 01/01/2025 1047.31 Description: EXC SAC PR ULC SKN FLP OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15936 MEDSV DEF RBRVS 01/01/2024 12/31/2024 832.89 Description: EXC SAC PR ULC PREP MUS FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15936 MEDSV DEF RBRVS 01/01/2025 808.12 Description: EXC SAC PR ULC PREP MUS FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15937 MEDSV DEF RBRVS 01/01/2024 12/31/2024 966.96 Description: EXC SAC PR ULC PREP MUS OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15937 MEDSV DEF RBRVS 01/01/2025 935.16 Description: EXC SAC PR ULC PREP MUS OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15940 MEDSV DEF RBRVS 01/01/2024 12/31/2024 655.17 Description: EXC ISCHIAL PR ULC PRIM SUTR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15940 MEDSV DEF RBRVS 01/01/2025 639.75 Description: EXC ISCHIAL PR ULC PRIM SUTR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15941 MEDSV DEF RBRVS 01/01/2024 12/31/2024 868.11 Description: EXC ISCH PR ULC PRM SUT OSTC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15941 MEDSV DEF RBRVS 01/01/2025 840.72 Description: EXC ISCH PR ULC PRM SUT OSTC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15944 MEDSV DEF RBRVS 01/01/2024 12/31/2024 869.29 Description: EXC ISCH PR ULC SKN FLP CLSR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15944 MEDSV DEF RBRVS 01/01/2025 847.95 Description: EXC ISCH PR ULC SKN FLP CLSR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15945 MEDSV DEF RBRVS 01/01/2024 12/31/2024 948.25 Description: EXC ISCH PR ULC SKN FLP OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15945 MEDSV DEF RBRVS 01/01/2025 925.61 Description: EXC ISCH PR ULC SKN FLP OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15946 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1496.68 Description: EXC ISCH PR ULC PREP MUS FLP Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15946 MEDSV DEF RBRVS 01/01/2025 1452.03 Description: EXC ISCH PR ULC PREP MUS FLP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15950 MEDSV DEF RBRVS 01/01/2024 12/31/2024 592.74 Description: EXC TRCHNTR PR ULC PRIM SUTR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15950 MEDSV DEF RBRVS 01/01/2025 579.14 Description: EXC TRCHNTR PR ULC PRIM SUTR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15951 MEDSV DEF RBRVS 01/01/2024 12/31/2024 836.48 Description: EXC TRCHNTR PR ULC OSTC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15951 MEDSV DEF RBRVS 01/01/2025 816.2 Description: EXC TRCHNTR PR ULC OSTC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15952 MEDSV DEF RBRVS 01/01/2024 12/31/2024 852.21 Description: EXC TRCHNTR PR ULC FLP CLSR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15952 MEDSV DEF RBRVS 01/01/2025 831.6 Description: EXC TRCHNTR PR ULC FLP CLSR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15953 MEDSV DEF RBRVS 01/01/2024 12/31/2024 938.58 Description: EXC TRCHNTR PR ULC FLP OSTC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15953 MEDSV DEF RBRVS 01/01/2025 915.76 Description: EXC TRCHNTR PR ULC FLP OSTC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15956 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1077.87 Description: EXC TRCHNTR PR ULC PREP FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15956 MEDSV DEF RBRVS 01/01/2025 1068.12 Description: EXC TRCHNTR PR ULC PREP FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15958 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1093.91 Description: EXC TRCHNTR PR ULC PREP OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15958 MEDSV DEF RBRVS 01/01/2025 1061.27 Description: EXC TRCHNTR PR ULC PREP OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX EXC PRESSURE ULC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 73.16 Description: INITIAL TREATMENT OF BURN(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16000 MEDSV DEF RBRVS 01/01/2025 72.73 Description: INITIAL TREATMENT OF BURN(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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 16020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 79.4 Description: DRESS/DEBRID P-THICK BURN S Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16020 MEDSV DEF RBRVS 01/01/2025 78.29 Description: DRESS/DEBRID P-THICK BURN S Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 145.74 Description: DRESS/DEBRID P-THICK BURN M Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16025 MEDSV DEF RBRVS 01/01/2025 143.4 Description: DRESS/DEBRID P-THICK BURN M Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 182.19 Description: DRESS/DEBRID P-THICK BURN L Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16030 MEDSV DEF RBRVS 01/01/2025 178.63 Description: DRESS/DEBRID P-THICK BURN L Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 181.12 Description: INCISION OF BURN SCAB INITI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16035 MEDSV DEF RBRVS 01/01/2025 176.98 Description: INCISION OF BURN SCAB INITI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16036 MEDSV DEF RBRVS 01/01/2024 12/31/2024 75.58 Description: ESCHAROTOMY ADDL INCISION Category: Medical Services CMS Add: 01/01/2001 CMS Term: 16036 MEDSV DEF RBRVS 01/01/2025 73.07 Description: ESCHAROTOMY ADDL INCISION Category: Medical Services CMS Add: 01/01/2001 CMS Term: 17000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 63 0-1 Description: DESTRUCT PREMALG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17000 MEDSV DEF RBRVS 01/01/2025 62.29 0-1 Description: DESTRUCT PREMALG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17003 MEDSV DEF RBRVS 01/01/2024 12/31/2024 6.29 Description: DESTRUCT PREMALG LES 2-14 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17003 MEDSV DEF RBRVS 01/01/2025 6.14 Description: DESTRUCT PREMALG LES 2-14 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17004 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.14 Description: DESTROY PREMAL LESIONS 15/> Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17004 MEDSV DEF RBRVS 01/01/2025 153.51 Description: DESTROY PREMAL LESIONS 15/> 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17106 MEDSV DEF RBRVS 01/01/2024 12/31/2024 322.28 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17106 MEDSV DEF RBRVS 01/01/2025 317.25 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 417.98 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17107 MEDSV DEF RBRVS 01/01/2025 411.92 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17108 MEDSV DEF RBRVS 01/01/2024 12/31/2024 591.89 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17108 MEDSV DEF RBRVS 01/01/2025 583.14 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 106.35 0-1 Description: DESTRUCT B9 LESION 1-14 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17110 MEDSV DEF RBRVS 01/01/2025 104.34 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 12/31/2024 124.32 Description: DESTRUCT LESION 15 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17111 MEDSV DEF RBRVS 01/01/2025 122.11 Description: DESTRUCT LESION 15 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 81.52 Description: CHEM CAUT OF GRANLTJ TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17250 MEDSV DEF RBRVS 01/01/2025 79.23 Description: CHEM CAUT OF GRANLTJ TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 94.03 Description: DSTRJ MAL LES T/A/L 0.5 CM/< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17260 MEDSV DEF RBRVS 01/01/2025 91.89 Description: DSTRJ MAL LES T/A/L 0.5 CM/< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17261 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138.97 Description: DSTRJ MAL LES T/A/L .6-1.0CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17261 MEDSV DEF RBRVS 01/01/2025 136.51 Description: DSTRJ MAL LES T/A/L .6-1.0CM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17262 MEDSV DEF RBRVS 01/01/2024 12/31/2024 167.73 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 01/01/2025 164.15 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 01/01/2024 12/31/2024 181.49 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 01/01/2025 177.69 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 01/01/2024 12/31/2024 194.45 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 01/01/2025 190.46 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 01/01/2024 12/31/2024 221.77 Description: DSTRJ MAL LES T/A/L >4.0 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17266 MEDSV DEF RBRVS 01/01/2025 216.58 Description: DSTRJ MAL LES T/A/L >4.0 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 140.54 Description: DSTR MAL LES S/N/H/F/G .5 /< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17270 MEDSV DEF RBRVS 01/01/2025 137.81 Description: DSTR MAL LES S/N/H/F/G .5 /< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17271 MEDSV DEF RBRVS 01/01/2024 12/31/2024 156.49 Description: DSTR MAL LES S/N/H/F/G 0.6-1 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17271 MEDSV DEF RBRVS 01/01/2025 153.2 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 01/01/2024 12/31/2024 177.41 Description: DSTR MAL LES S/N/H/F/G 1.1-2 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17272 MEDSV DEF RBRVS 01/01/2025 173.71 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 01/01/2024 12/31/2024 196.65 Description: DSTR MAL LES S/N/H/F/G 2.1-3 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17273 MEDSV DEF RBRVS 01/01/2025 192.72 Description: DSTR MAL LES S/N/H/F/G 2.1-3 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17274 MEDSV DEF RBRVS 01/01/2024 12/31/2024 230.57 Description: DSTR MAL LES S/N/H/F/G 3.1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17274 MEDSV DEF RBRVS 01/01/2025 225.38 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 01/01/2024 12/31/2024 267.65 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 01/01/2025 261.42 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 01/01/2024 12/31/2024 131.57 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 01/01/2025 129.56 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 01/01/2024 12/31/2024 169.24 Description: DSTR MAL LS F/E/E/N/L/M .6-1 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17281 MEDSV DEF RBRVS 01/01/2025 165.73 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 01/01/2024 12/31/2024 193.53 Description: DSTR MAL LS F/E/E/N/L/M1.1-2 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17282 MEDSV DEF RBRVS 01/01/2025 189.37 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 01/01/2024 12/31/2024 228.87 Description: DSTR MAL LS F/E/E/N/L/M2.1-3 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17283 MEDSV DEF RBRVS 01/01/2025 224.01 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 01/01/2024 12/31/2024 260.24 Description: DSTR MAL LS F/E/E/N/L/M3.1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17284 MEDSV DEF RBRVS 01/01/2025 254.49 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 01/01/2024 12/31/2024 333.33 Description: DSTR MAL LS F/E/E/N/L/M>4.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17286 MEDSV DEF RBRVS 01/01/2025 326.85 Description: DSTR MAL LS F/E/E/N/L/M>4.0 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17311 MEDSV DEF RBRVS 01/01/2024 12/31/2024 636.4 Description: MOHS 1 STAGE H/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17311 MEDSV DEF RBRVS 01/01/2025 624.07 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 12/31/2024 385.73 Description: MOHS ADDL STAGE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17312 MEDSV DEF RBRVS 01/01/2025 378.08 Description: MOHS ADDL STAGE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17313 MEDSV DEF RBRVS 01/01/2024 12/31/2024 597.22 Description: MOHS 1 STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17313 MEDSV DEF RBRVS 01/01/2025 586.16 Description: MOHS 1 STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17314 MEDSV DEF RBRVS 01/01/2024 12/31/2024 369.69 Description: MOHS ADDL STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17314 MEDSV DEF RBRVS 01/01/2025 362.2 Description: MOHS ADDL STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17315 MEDSV DEF RBRVS 01/01/2024 12/31/2024 74 Description: MOHS SURG ADDL BLOCK Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17315 MEDSV DEF RBRVS 01/01/2025 73.39 Description: MOHS SURG ADDL BLOCK Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17340 NOCOV DEF SYSMAN 12/31/2000 Y Description: CRYOTHERAPY FOR ACNE Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: 17360 NOCOV DEF SYSMAN 12/31/2000 Y Description: CHEMICAL EXFOLIATION ACNE Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: 17380 NOCOV DEF SYSMAN 12/01/1993 Y Description: ELECTROLYSIS EPILATION EA 30 Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 17999 MEDSV DEF BILL20 09/01/2021 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 12/31/2024 95.37 Description: PUNCTURE ASPIR CYST BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19000 MEDSV DEF RBRVS 01/01/2025 91.44 Description: PUNCTURE ASPIR CYST BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 24.76 Description: PUNCTURE ASPIR CYST BRST EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19001 MEDSV DEF RBRVS 01/01/2025 24.21 Description: PUNCTURE ASPIR CYST BRST EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 435.85 Description: MASTOTOMY EXPL DRG ABSC DP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19020 MEDSV DEF RBRVS 01/01/2025 424.57 Description: MASTOTOMY EXPL DRG ABSC DP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 155.22 Description: NJX PX ONLY MAM DUCTO/GLCTO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19030 MEDSV DEF RBRVS 01/01/2025 149.99 Description: NJX PX ONLY MAM DUCTO/GLCTO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19081 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.52 Description: BX BREAST 1ST LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19081 MEDSV DEF RBRVS 01/01/2025 452 Description: BX BREAST 1ST LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19082 MEDSV DEF RBRVS 01/01/2024 12/31/2024 365.67 Description: BX BREAST ADD LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19082 MEDSV DEF RBRVS 01/01/2025 346.25 Description: BX BREAST ADD LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19083 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.39 Description: BX BREAST 1ST LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19083 MEDSV DEF RBRVS 01/01/2025 450.01 Description: BX BREAST 1ST LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19084 MEDSV DEF RBRVS 01/01/2024 12/31/2024 360.27 Description: BX BREAST ADD LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19084 MEDSV DEF RBRVS 01/01/2025 340.7 Description: BX BREAST ADD LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19085 MEDSV DEF RBRVS 01/01/2024 12/31/2024 726.01 Description: BX BREAST 1ST LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19085 MEDSV DEF RBRVS 01/01/2025 688.99 Description: BX BREAST 1ST LESION MR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19086 MEDSV DEF RBRVS 01/01/2024 12/31/2024 562.67 Description: BX BREAST ADD LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19086 MEDSV DEF RBRVS 01/01/2025 531.29 Description: BX BREAST ADD LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 139.55 Description: BX BREAST PERCUT W/O IMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19100 MEDSV DEF RBRVS 01/01/2025 134.06 Description: BX BREAST PERCUT W/O IMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 304.92 Description: BIOPSY OF BREAST OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19101 MEDSV DEF RBRVS 01/01/2025 295.22 Description: BIOPSY OF BREAST OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19105 NOCOV DEF SYSMAN 01/01/2007 Y Description: CRYOSURG ABLATE FA EACH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 19110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 450.33 Description: NIPPLE EXPLORATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19110 MEDSV DEF RBRVS 01/01/2025 439.12 Description: NIPPLE EXPLORATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 426.26 Description: EXCISE BREAST DUCT FISTULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19112 MEDSV DEF RBRVS 01/01/2025 416.26 Description: EXCISE BREAST DUCT FISTULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 478.48 Description: REMOVAL OF BREAST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19120 MEDSV DEF RBRVS 01/01/2025 468.98 Description: REMOVAL OF BREAST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 526.64 0-2 Description: EXCISION BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19125 MEDSV DEF RBRVS 01/01/2025 516.1 0-2 Description: EXCISION BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19126 MEDSV DEF RBRVS 01/01/2024 12/31/2024 144.84 Description: EXCISION ADDL BREAST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19126 MEDSV DEF RBRVS 01/01/2025 140.9 Description: EXCISION ADDL BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19281 MEDSV DEF RBRVS 01/01/2024 12/31/2024 227.5 Description: PERQ DEVICE BREAST 1ST IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19281 MEDSV DEF RBRVS 01/01/2025 220.2 Description: PERQ DEVICE BREAST 1ST IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19282 MEDSV DEF RBRVS 01/01/2024 12/31/2024 160.83 Description: PERQ DEVICE BREAST EA IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19282 MEDSV DEF RBRVS 01/01/2025 155.24 Description: PERQ DEVICE BREAST EA IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19283 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.11 Description: PERQ DEV BREAST 1ST STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19283 MEDSV DEF RBRVS 01/01/2025 235.47 Description: PERQ DEV BREAST 1ST STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19284 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.83 Description: PERQ DEV BREAST ADD STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19284 MEDSV DEF RBRVS 01/01/2025 171.55 Description: PERQ DEV BREAST ADD STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 349.15 Description: PERQ DEV BREAST 1ST US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19285 MEDSV DEF RBRVS 01/01/2025 331.28 Description: PERQ DEV BREAST 1ST US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19286 MEDSV DEF RBRVS 01/01/2024 12/31/2024 285.72 Description: PERQ DEV BREAST ADD US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19286 MEDSV DEF RBRVS 01/01/2025 269.88 Description: PERQ DEV BREAST ADD US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19287 MEDSV DEF RBRVS 01/01/2024 12/31/2024 602.11 Description: PERQ DEV BREAST 1ST MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19287 MEDSV DEF RBRVS 01/01/2025 571.4 Description: PERQ DEV BREAST 1ST MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19288 MEDSV DEF RBRVS 01/01/2024 12/31/2024 465 Description: PERQ DEV BREAST ADD MR GUIDE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19288 MEDSV DEF RBRVS 01/01/2025 439.15 Description: PERQ DEV BREAST ADD MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19294 MEDSV DEF RBRVS 01/01/2024 12/31/2024 148.46 Description: PREPJ TUM CAV IORT PRTL MAST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 19294 MEDSV DEF RBRVS 01/01/2025 144.56 Description: PREPJ TUM CAV IORT PRTL MAST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 19296 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3462.93 Description: PLACE PO BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19296 MEDSV DEF RBRVS 01/01/2025 3249.38 Description: PLACE PO BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19297 MEDSV DEF RBRVS 01/01/2024 12/31/2024 85.42 Description: PLACE BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19297 MEDSV DEF RBRVS 01/01/2025 82.61 Description: PLACE BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19298 MEDSV DEF RBRVS 01/01/2024 12/31/2024 825.22 Description: PLACE BREAST RAD TUBE/CATHS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19298 MEDSV DEF RBRVS 01/01/2025 794.7 Description: PLACE BREAST RAD TUBE/CATHS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 539.79 Y Description: MASTECTOMY FOR GYNECOMASTIA Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19300 MEDSV DEF RBRVS 01/01/2025 521.43 Y Description: MASTECTOMY FOR GYNECOMASTIA Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19301 MEDSV DEF RBRVS 01/01/2024 12/31/2024 604.85 Y Description: PARTIAL MASTECTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19301 MEDSV DEF RBRVS 01/01/2025 590.93 Y Description: PARTIAL MASTECTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19302 MEDSV DEF RBRVS 01/01/2024 12/31/2024 830.14 Description: P-MASTECTOMY W/LN REMOVAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19302 MEDSV DEF RBRVS 01/01/2025 811.08 Description: P-MASTECTOMY W/LN REMOVAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19303 MEDSV DEF RBRVS 01/01/2024 12/31/2024 876.4 Y 0-2 Description: MAST SIMPLE COMPLETE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19303 MEDSV DEF RBRVS 01/01/2025 856.26 Y 0-2 Description: MAST SIMPLE COMPLETE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1054.18 0-2 Description: MAST RADICAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19305 MEDSV DEF RBRVS 01/01/2025 1027.12 0-2 Description: MAST RADICAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19306 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1116.87 0-2 Description: MAST RAD URBAN TYPE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19306 MEDSV DEF RBRVS 01/01/2025 1090.62 0-2 Description: MAST RAD URBAN TYPE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19307 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1080.1 0-2 Description: MAST MOD RAD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19307 MEDSV DEF RBRVS 01/01/2025 1054.1 0-2 Description: MAST MOD RAD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19316 MEDSV DEF RBRVS 01/01/2024 12/31/2024 734.4 Y Description: MASTOPEXY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19316 MEDSV DEF RBRVS 01/01/2025 717.47 Y Description: MASTOPEXY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19318 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1014.4 Y Description: BREAST REDUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19318 MEDSV DEF RBRVS 01/01/2025 989.16 Y Description: BREAST REDUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 571.89 Y Description: BREAST AUGMENTATION W/IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19325 MEDSV DEF RBRVS 01/01/2025 559.46 Y Description: BREAST AUGMENTATION W/IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19328 MEDSV DEF RBRVS 01/01/2024 12/31/2024 515.13 Description: RMVL INTACT BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19328 MEDSV DEF RBRVS 01/01/2025 503.16 Description: RMVL INTACT BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 601.06 Description: RMVL RUPTURED BREAST IMPLANT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19330 MEDSV DEF RBRVS 01/01/2025 586.02 Description: RMVL RUPTURED BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 704.69 Y Description: INSJ BREAST IMPLT SM D MAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19340 MEDSV DEF RBRVS 01/01/2025 687.74 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 12/31/2024 707.56 Y Description: INSJ/RPLCMT BRST IMPLT SEP D Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19342 MEDSV DEF RBRVS 01/01/2025 691.12 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 12/31/2024 773.19 Y Description: NIPPLE/AREOLA RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19350 MEDSV DEF RBRVS 01/01/2025 755.21 Y Description: NIPPLE/AREOLA RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19355 NOCOV DEF SYSMAN 10/06/1994 Y Description: CORRECT INVERTED NIPPLE(S) Category: Non Covered Services CMS Add: 01/01/1988 CMS Term: 19357 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1075.83 Description: TISS XPNDR PLMT BRST RCNSTJ Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19357 MEDSV DEF RBRVS 01/01/2025 1051.92 Description: TISS XPNDR PLMT BRST RCNSTJ Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19361 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1444.41 Description: BRST RCNSTJ LATSMS DRSI FLAP Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19361 MEDSV DEF RBRVS 01/01/2025 1406.55 Description: BRST RCNSTJ LATSMS DRSI FLAP Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19364 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2518.67 Description: BRST RCNSTJ FREE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19364 MEDSV DEF RBRVS 01/01/2025 2446.34 Description: BRST RCNSTJ FREE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19367 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1641.47 Description: BRST RCNSTJ 1 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19367 MEDSV DEF RBRVS 01/01/2025 1597.39 Description: BRST RCNSTJ 1 PDCL TRAM FLAP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19368 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2010.72 Description: BRST RCNSTJ 1PDCL TRAM ANAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19368 MEDSV DEF RBRVS 01/01/2025 1953.49 Description: BRST RCNSTJ 1PDCL TRAM ANAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19369 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1868.31 Description: BRST RCNSTJ 2 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19369 MEDSV DEF RBRVS 01/01/2025 1815.47 Description: BRST RCNSTJ 2 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 624.11 Description: REVJ PERI-IMPLT CAPSULE BRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19370 MEDSV DEF RBRVS 01/01/2025 610.3 Description: REVJ PERI-IMPLT CAPSULE BRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19371 MEDSV DEF RBRVS 01/01/2024 12/31/2024 662.32 Description: PERI-IMPLT CAPSLC BRST COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19371 MEDSV DEF RBRVS 01/01/2025 645.85 Description: PERI-IMPLT CAPSLC BRST COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 750.47 Description: REVJ RECONSTRUCTED BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19380 MEDSV DEF RBRVS 01/01/2025 732.69 Description: REVJ RECONSTRUCTED BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19396 NOCOV DEF SYSMAN 12/31/2000 Y Description: DESIGN CUSTOM BREAST IMPLANT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 19499 MEDSV DEF BILL20 10/15/2020 Y Description: UNLISTED PROCEDURE BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2000F NOCOV DEF SYSMAN 01/01/2005 Y Description: BLOOD PRESSURE MEASURE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 2001F NOCOV DEF SYSMAN 01/01/2006 Y Description: WEIGHT RECORD Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 2002F NOCOV DEF SYSMAN 01/01/2006 Y Description: CLIN SIGN VOL OVRLD ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 2004F NOCOV DEF SYSMAN 01/01/2006 Y Description: INITIAL EXAM INVOLVED JOINTS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 551.64 Description: EXPL PENTRG WOUND NECK Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20100 MEDSV DEF RBRVS 01/01/2025 538.01 Description: EXPL PENTRG WOUND NECK Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 539.71 Description: EXPL PENTRG WOUND CHEST Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20101 MEDSV DEF RBRVS 01/01/2025 517.15 Description: EXPL PENTRG WOUND CHEST Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 564.27 Description: EXPL PENTRG WND ABD/FLNK/BK Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20102 MEDSV DEF RBRVS 01/01/2025 551.48 Description: EXPL PENTRG WND ABD/FLNK/BK Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20103 MEDSV DEF RBRVS 01/01/2024 12/31/2024 524.89 Description: EXPL PENTRG WOUND EXTREMITY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20103 MEDSV DEF RBRVS 01/01/2025 510.93 Description: EXPL PENTRG WOUND EXTREMITY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 2010F NOCOV DEF SYSMAN 01/01/2007 Y Description: VITAL SIGNS RECORDED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2014F NOCOV DEF SYSMAN 01/01/2007 Y Description: MENTAL STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 928.43 Description: EXCISION EPIPHYSEAL BAR Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20150 MEDSV DEF RBRVS 01/01/2025 908.33 Description: EXCISION EPIPHYSEAL BAR Category: Medical Services CMS Add: 01/01/1997 CMS Term: 2015F NOCOV DEF SYSMAN 01/01/2012 Y Description: ASTHMA IMPAIRMENT ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 2016F NOCOV DEF SYSMAN 01/01/2012 Y Description: ASTHMA RISK ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 2018F NOCOV DEF SYSMAN 01/01/2007 Y Description: HYDRATION STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2019F NOCOV DEF SYSMAN 01/01/2007 Y Description: DILATED MACUL EXAM DONE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 201.76 Description: MUSCLE BIOPSY SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20200 MEDSV DEF RBRVS 01/01/2025 194.67 Description: MUSCLE BIOPSY SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 280.26 Description: DEEP MUSCLE BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20205 MEDSV DEF RBRVS 01/01/2025 272.8 Description: DEEP MUSCLE BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20206 MEDSV DEF RBRVS 01/01/2024 12/31/2024 209.58 Description: BIOPSY MUSCLE PERQ NEEDLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20206 MEDSV DEF RBRVS 01/01/2025 198.84 Description: BIOPSY MUSCLE PERQ NEEDLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2020F NOCOV DEF SYSMAN 01/01/2007 Y Description: DILATED FUNDUS EVAL DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2021F NOCOV DEF SYSMAN 01/01/2007 Y Description: DILAT MACULAR EXAM DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 221.34 Description: BONE BIOPSY TROCAR/NDL SUPFC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20220 MEDSV DEF RBRVS 01/01/2025 211.14 Description: BONE BIOPSY TROCAR/NDL SUPFC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 362.11 Description: BONE BIOPSY TROCAR/NDL DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20225 MEDSV DEF RBRVS 01/01/2025 344.43 Description: BONE BIOPSY TROCAR/NDL DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2022F NOCOV DEF SYSMAN 01/01/2007 Y Description: DILAT RTA XM EVC RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2023F NOCOV DEF SYSMAN 10/01/2019 Y 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 12/31/2024 131.39 Description: BONE BIOPSY OPEN SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20240 MEDSV DEF RBRVS 01/01/2025 128.57 Description: BONE BIOPSY OPEN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20245 MEDSV DEF RBRVS 01/01/2024 12/31/2024 318.69 Description: BONE BIOPSY OPEN DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20245 MEDSV DEF RBRVS 01/01/2025 309.75 Description: BONE BIOPSY OPEN DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2024F NOCOV DEF SYSMAN 01/01/2007 Y 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 12/31/2024 355.81 Description: BIOPSY VRT BDY OPEN THORACIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20250 MEDSV DEF RBRVS 01/01/2025 349.67 Description: BIOPSY VRT BDY OPEN THORACIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20251 MEDSV DEF RBRVS 01/01/2024 12/31/2024 385.18 Description: BIOPSY VRT BDY OPEN LMBR/CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20251 MEDSV DEF RBRVS 01/01/2025 375.07 Description: BIOPSY VRT BDY OPEN LMBR/CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2025F NOCOV DEF SYSMAN 10/01/2019 Y Description: 7 FLD RTA PHOTO W/O RTNOPTHY Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 2026F NOCOV DEF SYSMAN 01/01/2007 Y Description: EYE IMG VALID EVC RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2027F NOCOV DEF SYSMAN 01/01/2007 Y Description: OPTIC NERVE HEAD EVAL DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2028F NOCOV DEF SYSMAN 01/01/2007 Y Description: FOOT EXAM PERFORMED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2029F NOCOV DEF SYSMAN 01/01/2007 Y Description: COMPLETE PHYS SKIN EXAM DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2030F NOCOV DEF SYSMAN 01/01/2007 Y Description: H2O STAT DOCD NORMAL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2031F NOCOV DEF SYSMAN 01/01/2007 Y Description: H2O STAT DOCD DEHYDRATED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2033F NOCOV DEF SYSMAN 10/01/2019 Y Description: EYE IMG VALID W/O RTNOPTHY Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 2035F NOCOV DEF SYSMAN 01/01/2008 Y Description: TYMP MEMB MOTION EXAMD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 2040F NOCOV DEF SYSMAN 01/01/2009 Y Description: BK PN XM ON INIT VISIT DATE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 2044F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 116.19 Description: INJECTION OF SINUS TRACT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20500 MEDSV DEF RBRVS 01/01/2025 113.73 Description: INJECTION OF SINUS TRACT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 134.93 Description: INJECT SINUS TRACT FOR X-RAY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20501 MEDSV DEF RBRVS 01/01/2025 128.64 Description: INJECT SINUS TRACT FOR X-RAY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 2050F NOCOV DEF SYSMAN 01/01/2009 Y Description: WOUND CHAR SIZE ETC DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 20520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 202.71 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20520 MEDSV DEF RBRVS 01/01/2025 199.35 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 433.58 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20525 MEDSV DEF RBRVS 01/01/2025 420.75 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20526 ANEST DEF RBRVS 01/01/2024 12/31/2024 76.12 Description: THER INJECTION CARP TUNNEL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20526 ANEST DEF RBRVS 01/01/2025 74.84 Description: THER INJECTION CARP TUNNEL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20527 MEDSV DEF RBRVS 01/01/2024 12/31/2024 81.4 Description: INJ DUPUYTREN CORD W/ENZYME Category: Medical Services CMS Add: 01/01/2012 CMS Term: 20527 MEDSV DEF RBRVS 01/01/2025 79.54 Description: INJ DUPUYTREN CORD W/ENZYME Category: Medical Services CMS Add: 01/01/2012 CMS Term: 20550 ANEST DEF RBRVS 01/01/2024 12/31/2024 54.19 Description: INJ TENDON SHEATH/LIGAMENT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20550 ANEST DEF RBRVS 01/01/2025 53.02 Description: INJ TENDON SHEATH/LIGAMENT Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 20551 MEDSV DEF RBRVS 01/01/2024 12/31/2024 54.19 Description: INJ TENDON ORIGIN/INSERTION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 20551 MEDSV DEF RBRVS 01/01/2025 52.86 Description: INJ TENDON ORIGIN/INSERTION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 20552 ANEST DEF RBRVS 01/01/2024 12/31/2024 49.59 Description: INJ TRIGGER POINT 1/2 MUSCL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20552 ANEST DEF RBRVS 01/01/2025 48.24 Description: INJ TRIGGER POINT 1/2 MUSCL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20553 ANEST DEF RBRVS 01/01/2024 12/31/2024 57.28 Description: INJECT TRIGGER POINTS 3/> Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20553 ANEST DEF RBRVS 01/01/2025 55.57 Description: INJECT TRIGGER POINTS 3/> Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 318.47 Description: PLACE NDL MUSC/TIS FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20555 MEDSV DEF RBRVS 01/01/2025 310.5 Description: PLACE NDL MUSC/TIS FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20560 NOCOV DEF SYSMAN 01/01/2020 Y 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 01/01/2020 Y Description: NDL INSJ W/O NJX 3+ MUSC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 20600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 49.59 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20600 MEDSV DEF RBRVS 01/01/2025 49.31 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 12/31/2024 77.15 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20604 MEDSV DEF RBRVS 01/01/2025 76.02 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 51.51 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20605 MEDSV DEF RBRVS 01/01/2025 50.56 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 12/31/2024 83.67 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20606 MEDSV DEF RBRVS 01/01/2025 82.51 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 2060F NOCOV DEF SYSMAN 01/01/2010 Y 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 12/31/2024 60.19 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20610 MEDSV DEF RBRVS 01/01/2025 59.33 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 12/31/2024 93.11 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20611 MEDSV DEF RBRVS 01/01/2025 90.93 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20612 MEDSV DEF RBRVS 01/01/2024 12/31/2024 59.91 Description: ASPIRATE/INJ GANGLION CYST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 20612 MEDSV DEF RBRVS 01/01/2025 59.53 Description: ASPIRATE/INJ GANGLION CYST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 20615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 237.22 Description: TREATMENT OF BONE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20615 MEDSV DEF RBRVS 01/01/2025 232.93 Description: TREATMENT OF BONE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 211.63 Description: INSERT AND REMOVE BONE PIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20650 MEDSV DEF RBRVS 01/01/2025 212.16 Description: INSERT AND REMOVE BONE PIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 215.89 Description: APPLY REM FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20660 MEDSV DEF RBRVS 01/01/2025 209.27 Description: APPLY REM FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20661 MEDSV DEF RBRVS 01/01/2024 12/31/2024 472.1 Description: APPLICATION HALO CRANIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20661 MEDSV DEF RBRVS 01/01/2025 471.67 Description: APPLICATION HALO CRANIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20662 MEDSV DEF RBRVS 01/01/2024 12/31/2024 485.63 Description: APPLICATION HALO PELVIC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20662 MEDSV DEF RBRVS 01/01/2025 478.18 Description: APPLICATION HALO PELVIC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20663 MEDSV DEF RBRVS 01/01/2024 12/31/2024 447.64 Description: APPLICATION HALO FEMORAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20663 MEDSV DEF RBRVS 01/01/2025 441.59 Description: APPLICATION HALO FEMORAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20664 MEDSV DEF RBRVS 01/01/2024 12/31/2024 798.79 Description: APPL HALO CRANIAL 6+PINS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 20664 MEDSV DEF RBRVS 01/01/2025 787.96 Description: APPL HALO CRANIAL 6+PINS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 20665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 111.14 Description: RMVL TONGS/HALO ANTHR INDIV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20665 MEDSV DEF RBRVS 01/01/2025 109.07 Description: RMVL TONGS/HALO ANTHR INDIV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 333.58 Description: REMOVAL IMPLANT SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20670 MEDSV DEF RBRVS 01/01/2025 323.14 Description: REMOVAL IMPLANT SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 560.75 Description: REMOVAL OF IMPLANT DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20680 MEDSV DEF RBRVS 01/01/2025 546.8 Description: REMOVAL OF IMPLANT DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20690 MEDSV DEF RBRVS 01/01/2024 12/31/2024 554.09 Description: APPL UNIPLN UNI EXT FIXJ SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20690 MEDSV DEF RBRVS 01/01/2025 542.44 Description: APPL UNIPLN UNI EXT FIXJ SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20692 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1045.6 Description: APPL MLTPLN UNI EXT FIXJ SYS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20692 MEDSV DEF RBRVS 01/01/2025 1029.53 Description: APPL MLTPLN UNI EXT FIXJ SYS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20693 MEDSV DEF RBRVS 01/01/2024 12/31/2024 414.68 Description: ADJMT/REVJ EXT FIXJ SYS ANES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20693 MEDSV DEF RBRVS 01/01/2025 410.86 Description: ADJMT/REVJ EXT FIXJ SYS ANES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20694 MEDSV DEF RBRVS 01/01/2024 12/31/2024 402.24 Description: RMVL EXT FIXJ SYS UNDER ANES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20694 MEDSV DEF RBRVS 01/01/2025 395.26 Description: RMVL EXT FIXJ SYS UNDER ANES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20696 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1090.22 Description: APP MLTPLN UNI XTRNL FIX 1ST Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20696 MEDSV DEF RBRVS 01/01/2025 1060.58 Description: APP MLTPLN UNI XTRNL FIX 1ST Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20697 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1694.24 Description: APP MLTPLN UNI XTRNL FIX XCH Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20697 MEDSV DEF RBRVS 01/01/2025 1602.67 Description: APP MLTPLN UNI XTRNL FIX XCH Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 78.02 Description: MNL PREP&INSJ DP RX DLVR DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20700 MEDSV DEF RBRVS 01/01/2025 75.76 Description: MNL PREP&INSJ DP RX DLVR DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20701 MEDSV DEF RBRVS 01/01/2024 12/31/2024 59.43 Description: RMVL DEEP RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20701 MEDSV DEF RBRVS 01/01/2025 57.4 Description: RMVL DEEP RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 130.89 Description: MNL PREP&INSJ IMED RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20702 MEDSV DEF RBRVS 01/01/2025 127.38 Description: MNL PREP&INSJ IMED RX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20703 MEDSV DEF RBRVS 01/01/2024 12/31/2024 94.41 Description: RMVL IMED RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20703 MEDSV DEF RBRVS 01/01/2025 92.89 Description: RMVL IMED RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20704 MEDSV DEF RBRVS 01/01/2024 12/31/2024 135.2 Description: MNL PREP&INSJ I-ARTIC RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20704 MEDSV DEF RBRVS 01/01/2025 133.85 Description: MNL PREP&INSJ I-ARTIC RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 114.35 Description: RMVL I-ARTIC RX DELIVERY DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20705 MEDSV DEF RBRVS 01/01/2025 110.74 Description: RMVL I-ARTIC RX DELIVERY DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20802 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2525.03 Description: REPLANTATION ARM COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20802 MEDSV DEF RBRVS 01/01/2025 2464.28 Description: REPLANTATION ARM COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2998.97 Description: REPLANT FOREARM COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20805 MEDSV DEF RBRVS 01/01/2025 2924.69 Description: REPLANT FOREARM COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20808 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3616.57 Description: REPLANTATION HAND COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20808 MEDSV DEF RBRVS 01/01/2025 3525.54 Description: REPLANTATION HAND COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20816 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1890.84 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20816 MEDSV DEF RBRVS 01/01/2025 1844.92 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20822 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1634.14 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20822 MEDSV DEF RBRVS 01/01/2025 1596.57 Description: REPLANTATION DIGIT COMPLETE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20824 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1894.23 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20824 MEDSV DEF RBRVS 01/01/2025 1848.54 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20827 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1677.95 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20827 MEDSV DEF RBRVS 01/01/2025 1638.8 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20838 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2563.66 Description: REPLANTATION FOOT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20838 MEDSV DEF RBRVS 01/01/2025 2501.06 Description: REPLANTATION FOOT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 364.25 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20900 MEDSV DEF RBRVS 01/01/2025 349.51 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20902 MEDSV DEF RBRVS 01/01/2024 12/31/2024 254.69 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20902 MEDSV DEF RBRVS 01/01/2025 247.7 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20910 MEDSV DEF RBRVS 01/01/2024 12/31/2024 443.13 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20910 MEDSV DEF RBRVS 01/01/2025 436.79 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20912 MEDSV DEF RBRVS 01/01/2024 12/31/2024 452.26 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20912 MEDSV DEF RBRVS 01/01/2025 443.35 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 376.33 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20920 MEDSV DEF RBRVS 01/01/2025 368.83 Description: REMOVAL OF FASCIA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20922 MEDSV DEF RBRVS 01/01/2024 12/31/2024 562.9 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20922 MEDSV DEF RBRVS 01/01/2025 557.68 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20924 MEDSV DEF RBRVS 01/01/2024 12/31/2024 470.89 Description: REMOVAL OF TENDON FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20924 MEDSV DEF RBRVS 01/01/2025 461.83 Description: REMOVAL OF TENDON FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20930 NOCOV DEF SYSMAN 08/01/2012 Y Description: SP BONE ALGRFT MORSEL ADD-ON Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 20931 MEDSV DEF RBRVS 01/01/2024 12/31/2024 98.46 Description: SP BONE ALGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20931 MEDSV DEF RBRVS 01/01/2025 95.81 Description: SP BONE ALGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20932 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.28 Description: OSTEOART ALGRFT W/SURF & B1 Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20932 MEDSV DEF RBRVS 01/01/2025 671.9 Description: OSTEOART ALGRFT W/SURF & B1 Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20933 MEDSV DEF RBRVS 01/01/2024 12/31/2024 634.81 Description: HEMICRT INTRCLRY ALGRFT PRTL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20933 MEDSV DEF RBRVS 01/01/2025 616.31 Description: HEMICRT INTRCLRY ALGRFT PRTL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20934 MEDSV DEF RBRVS 01/01/2024 12/31/2024 690.94 Description: INTERCALARY ALGRFT COMPL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20934 MEDSV DEF RBRVS 01/01/2025 671.27 Description: INTERCALARY ALGRFT COMPL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20936 NOCOV DEF SYSMAN 08/01/2012 Y Description: SP BONE AGRFT LOCAL ADD-ON Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 20937 MEDSV DEF RBRVS 01/01/2024 12/31/2024 150.32 Description: SP BONE AGRFT MORSEL ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20937 MEDSV DEF RBRVS 01/01/2025 146.03 Description: SP BONE AGRFT MORSEL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20938 MEDSV DEF RBRVS 01/01/2024 12/31/2024 163.45 Description: SP BONE AGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20938 MEDSV DEF RBRVS 01/01/2025 159.43 Description: SP BONE AGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20939 MEDSV DEF RBRVS 01/01/2024 12/31/2024 63 Description: BONE MARROW ASPIR BONE GRFG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 20939 MEDSV DEF RBRVS 01/01/2025 60.89 Description: BONE MARROW ASPIR BONE GRFG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 20950 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.36 Description: FLUID PRESSURE MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20950 MEDSV DEF RBRVS 01/01/2025 240.38 Description: FLUID PRESSURE MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20955 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2295.73 Description: FIBULA BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20955 MEDSV DEF RBRVS 01/01/2025 2215.41 Description: FIBULA BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20956 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2429.12 Description: ILIAC BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20956 MEDSV DEF RBRVS 01/01/2025 2369.33 Description: ILIAC BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20957 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2529.94 Description: MT BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20957 MEDSV DEF RBRVS 01/01/2025 2468.78 Description: MT BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20962 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2456.72 Description: OTHER BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20962 MEDSV DEF RBRVS 01/01/2025 2403.38 Description: OTHER BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20969 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2537.47 Description: BONE/SKIN GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20969 MEDSV DEF RBRVS 01/01/2025 2466.89 Description: BONE/SKIN GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20970 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2619.19 Description: BONE/SKIN GRAFT ILIAC CREST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20970 MEDSV DEF RBRVS 01/01/2025 2555.64 Description: BONE/SKIN GRAFT ILIAC CREST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20972 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2611.71 Description: BONE/SKIN GRAFT METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20972 MEDSV DEF RBRVS 01/01/2025 2548.06 Description: BONE/SKIN GRAFT METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20973 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2758.4 Description: BONE/SKIN GRAFT GREAT TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20973 MEDSV DEF RBRVS 01/01/2025 2690.67 Description: BONE/SKIN GRAFT GREAT TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20974 MEDSV DEF RBRVS 01/01/2024 12/31/2024 75.92 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20974 MEDSV DEF RBRVS 01/01/2025 75.68 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20975 MEDSV DEF RBRVS 01/01/2024 12/31/2024 159.39 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20975 MEDSV DEF RBRVS 01/01/2025 156.62 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20979 NOCOV DEF SYSMAN 01/01/2000 Y Description: US BONE STIMULATION Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: 20982 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3280.33 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 20982 MEDSV DEF RBRVS 01/01/2025 3109.34 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 20983 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 4782.98 0 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20983 MEDSV DEF RBRVS 01/01/2025 4527.69 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20985 MEDSV DEF RBRVS 01/01/2024 12/31/2024 132.75 Description: CPTR-ASST DIR MS PX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20985 MEDSV DEF RBRVS 01/01/2025 128.91 Description: CPTR-ASST DIR MS PX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX MUSCSKEL GENERAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 21010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 701.78 Y Description: INCISION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21010 MEDSV DEF RBRVS 01/01/2025 682.26 Y Description: INCISION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21011 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.78 Description: EXC FACE LES SC <2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21011 MEDSV DEF RBRVS 01/01/2025 341.49 Description: EXC FACE LES SC <2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21012 MEDSV DEF RBRVS 01/01/2024 12/31/2024 315.01 Description: EXC FACE LES SBQ 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21012 MEDSV DEF RBRVS 01/01/2025 309 Description: EXC FACE LES SBQ 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21013 MEDSV DEF RBRVS 01/01/2024 12/31/2024 501.04 Description: EXC FACE TUM DEEP < 2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21013 MEDSV DEF RBRVS 01/01/2025 487.98 Description: EXC FACE TUM DEEP < 2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21014 MEDSV DEF RBRVS 01/01/2024 12/31/2024 486.37 Description: EXC FACE TUM DEEP 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21014 MEDSV DEF RBRVS 01/01/2025 475.29 Description: EXC FACE TUM DEEP 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 651.6 Description: RESECT FACE/SCALP TUM < 2 CM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21015 MEDSV DEF RBRVS 01/01/2025 636.85 Description: RESECT FACE/SCALP TUM < 2 CM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21016 MEDSV DEF RBRVS 01/01/2024 12/31/2024 935.9 Description: RESECT FACE/SCALP TUM 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21016 MEDSV DEF RBRVS 01/01/2025 912.38 Description: RESECT FACE/SCALP TUM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 744.21 Description: EXCISION OF BONE LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21025 MEDSV DEF RBRVS 01/01/2025 730.06 Description: EXCISION OF BONE LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21026 MEDSV DEF RBRVS 01/01/2024 12/31/2024 501.94 Description: EXCISION OF FACIAL BONE(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21026 MEDSV DEF RBRVS 01/01/2025 492.78 Description: EXCISION OF FACIAL BONE(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21029 MEDSV DEF RBRVS 01/01/2024 12/31/2024 719.8 Description: CONTOUR OF FACE BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21029 MEDSV DEF RBRVS 01/01/2025 705.7 Description: CONTOUR OF FACE BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 432.65 Description: EXCISE MAX/ZYGOMA B9 TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21030 MEDSV DEF RBRVS 01/01/2025 421.39 Description: EXCISE MAX/ZYGOMA B9 TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21031 MEDSV DEF RBRVS 01/01/2024 12/31/2024 359.64 Description: REMOVE EXOSTOSIS MANDIBLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21031 MEDSV DEF RBRVS 01/01/2025 351.35 Description: REMOVE EXOSTOSIS MANDIBLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21032 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.03 Description: REMOVE EXOSTOSIS MAXILLA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21032 MEDSV DEF RBRVS 01/01/2025 341.65 Description: REMOVE EXOSTOSIS MAXILLA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21034 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1217.85 Description: EXCISE MAX/ZYGOMA MAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21034 MEDSV DEF RBRVS 01/01/2025 1187.18 Description: EXCISE MAX/ZYGOMA MAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 438.22 Description: EXCISE MANDIBLE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21040 MEDSV DEF RBRVS 01/01/2025 425.62 Description: EXCISE MANDIBLE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21044 MEDSV DEF RBRVS 01/01/2024 12/31/2024 809.68 Description: REMOVAL OF JAW BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21044 MEDSV DEF RBRVS 01/01/2025 790.23 Description: REMOVAL OF JAW BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21045 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1126.43 Description: EXTENSIVE JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21045 MEDSV DEF RBRVS 01/01/2025 1096.13 Description: EXTENSIVE JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21046 MEDSV DEF RBRVS 01/01/2024 12/31/2024 933.49 Description: REMOVE MANDIBLE CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21046 MEDSV DEF RBRVS 01/01/2025 907.84 Description: REMOVE MANDIBLE CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21047 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1146.07 Description: EXCISE LWR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21047 MEDSV DEF RBRVS 01/01/2025 1111.69 Description: EXCISE LWR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21048 MEDSV DEF RBRVS 01/01/2024 12/31/2024 939.99 Description: REMOVE MAXILLA CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21048 MEDSV DEF RBRVS 01/01/2025 916.39 Description: REMOVE MAXILLA CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21049 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1084.7 Description: EXCIS UPPR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21049 MEDSV DEF RBRVS 01/01/2025 1056.15 Description: EXCIS UPPR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 816.05 Description: REMOVAL OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21050 MEDSV DEF RBRVS 01/01/2025 793.3 Description: REMOVAL OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 740.77 Description: REMOVE JAW JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21060 MEDSV DEF RBRVS 01/01/2025 719.47 Description: REMOVE JAW JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 574.61 Description: REMOVE CORONOID PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21070 MEDSV DEF RBRVS 01/01/2025 561.44 Description: REMOVE CORONOID PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21073 MEDSV DEF RBRVS 01/01/2024 12/31/2024 352.55 Description: MNPJ OF TMJ W/ANESTH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 21073 MEDSV DEF RBRVS 01/01/2025 348.91 Description: MNPJ OF TMJ W/ANESTH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 21076 MEDSV DEF RBRVS 01/01/2024 12/31/2024 813.98 Description: IMPRES&PREP SURG OBT PROSTH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21076 MEDSV DEF RBRVS 01/01/2025 798.63 Description: IMPRES&PREP SURG OBT PROSTH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21077 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1997.69 Description: IMPRES&PREP ORBITAL PROSTH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21077 MEDSV DEF RBRVS 01/01/2025 1955.59 Description: IMPRES&PREP ORBITAL PROSTH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21079 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1366.03 Description: IMPRES&PREP INTRM OBT PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21079 MEDSV DEF RBRVS 01/01/2025 1340.55 Description: IMPRES&PREP INTRM OBT PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1570.1 Description: IMPRES&PREP DEF OBT PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21080 MEDSV DEF RBRVS 01/01/2025 1528.92 Description: IMPRES&PREP DEF OBT PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21081 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1447.51 Description: IMPRES&PREP MNDBL RES PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21081 MEDSV DEF RBRVS 01/01/2025 1413.85 Description: IMPRES&PREP MNDBL RES PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21082 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1336.2 Description: IMPRES&PREP PALTL AUG PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21082 MEDSV DEF RBRVS 01/01/2025 1320.38 Description: IMPRES&PREP PALTL AUG PROSTH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21083 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1275.02 Description: IMPRES&PREP PALTL LFT PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21083 MEDSV DEF RBRVS 01/01/2025 1254.2 Description: IMPRES&PREP PALTL LFT PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21084 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1455.92 Description: IMPRES&PREP SP AID PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21084 MEDSV DEF RBRVS 01/01/2025 1431.41 Description: IMPRES&PREP SP AID PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21085 MEDSV DEF RBRVS 01/01/2024 12/31/2024 635.86 Description: IMPRES&PREP ORAL SURG SPLINT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21085 MEDSV DEF RBRVS 01/01/2025 626.57 Description: IMPRES&PREP ORAL SURG SPLINT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21086 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1485.71 Description: IMPRES&PREP AURICULAR PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21086 MEDSV DEF RBRVS 01/01/2025 1452.21 Description: IMPRES&PREP AURICULAR PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21087 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1485.71 Description: IMPRES&PREP NASAL PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21087 MEDSV DEF RBRVS 01/01/2025 1452.21 Description: IMPRES&PREP NASAL PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21088 MEDSV DEF BILL20 01/01/2014 Description: IMPRES&PREP FACIAL PROSTH Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21089 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED MAXLFCL PROSTH PX Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 581.66 Description: MAXILLOFACIAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21100 MEDSV DEF RBRVS 01/01/2025 566.88 Description: MAXILLOFACIAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 810.91 Y Description: INTERDENTAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21110 MEDSV DEF RBRVS 01/01/2025 783.05 Y Description: INTERDENTAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21116 MEDSV DEF RBRVS 01/01/2024 12/31/2024 202.54 Description: INJECTION JAW JOINT X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21116 MEDSV DEF RBRVS 01/01/2025 192.93 Description: INJECTION JAW JOINT X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 618.13 Y Description: GENIOPLASTY AUGMENTATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21120 MEDSV DEF RBRVS 01/01/2025 601.42 Y Description: GENIOPLASTY AUGMENTATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 597.01 Y Description: GENIOP SLDG OSTEOT 1 Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21121 MEDSV DEF RBRVS 01/01/2025 582.83 Y Description: GENIOP SLDG OSTEOT 1 Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21122 MEDSV DEF RBRVS 01/01/2024 12/31/2024 697.21 Y Description: GENIOP SLDG OSTEOT 2/> Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21122 MEDSV DEF RBRVS 01/01/2025 678.79 Y Description: GENIOP SLDG OSTEOT 2/> Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21123 MEDSV DEF RBRVS 01/01/2024 12/31/2024 800.4 Y Description: GENIOP SLDG AUGMENTATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21123 MEDSV DEF RBRVS 01/01/2025 775.29 Y Description: GENIOP SLDG AUGMENTATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2454.93 Y Description: AUGMENTATION MNDBLR PROSTC Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21125 MEDSV DEF RBRVS 01/01/2025 2351.25 Y Description: AUGMENTATION MNDBLR PROSTC Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21127 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3746.7 Y Description: AUGMENTATION MNDBLR B1 GRF Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21127 MEDSV DEF RBRVS 01/01/2025 3634.3 Y Description: AUGMENTATION MNDBLR B1 GRF Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21137 MEDSV DEF RBRVS 01/01/2024 12/31/2024 698.62 Y Description: RDCTJ FOREHEAD CNTRG ONLY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21137 MEDSV DEF RBRVS 01/01/2025 681.85 Y Description: RDCTJ FOREHEAD CNTRG ONLY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21138 MEDSV DEF RBRVS 01/01/2024 12/31/2024 850.1 Y Description: RDCTJ FOREHEAD CNTRG&PROSTC Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21138 MEDSV DEF RBRVS 01/01/2025 828.89 Y Description: RDCTJ FOREHEAD CNTRG&PROSTC Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21139 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1013.51 Y Description: RDCTJ FOREHEAD CNTRG&SETBACK Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21139 MEDSV DEF RBRVS 01/01/2025 985.94 Y Description: RDCTJ FOREHEAD CNTRG&SETBACK Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21141 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1257.97 Description: LEFORT I-1 PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21141 MEDSV DEF RBRVS 01/01/2025 1221.28 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 12/31/2024 1291.33 Description: LEFORT I-2 PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21142 MEDSV DEF RBRVS 01/01/2025 1253.35 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 12/31/2024 1330.59 Description: LEFORT I-3/> PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21143 MEDSV DEF RBRVS 01/01/2025 1291.91 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 12/31/2024 1463.77 Description: LEFORT I-1 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21145 MEDSV DEF RBRVS 01/01/2025 1419.97 Description: LEFORT I-1 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21146 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1528.21 Description: LEFORT I-2 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21146 MEDSV DEF RBRVS 01/01/2025 1482.66 Description: LEFORT I-2 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21147 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1609.26 Description: LEFORT I-3/> PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21147 MEDSV DEF RBRVS 01/01/2025 1559.93 Description: LEFORT I-3/> 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1542.33 Description: LEFORT II ANTERIOR INTRUSION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21150 MEDSV DEF RBRVS 01/01/2025 1499.38 Description: LEFORT II ANTERIOR INTRUSION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1697.56 Description: LEFORT II W/BONE GRAFTS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21151 MEDSV DEF RBRVS 01/01/2025 1649.9 Description: LEFORT II W/BONE GRAFTS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21154 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1826.71 Description: LEFORT III W/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21154 MEDSV DEF RBRVS 01/01/2025 1775.96 Description: LEFORT III W/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2026.01 Description: LEFORT III W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21155 MEDSV DEF RBRVS 01/01/2025 1969.56 Description: LEFORT III W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21159 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2427.58 Description: LEFORT III W/FHDW/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21159 MEDSV DEF RBRVS 01/01/2025 2358.71 Description: LEFORT III W/FHDW/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2632.97 Description: LEFORT III W/FHD W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21160 MEDSV DEF RBRVS 01/01/2025 2557.75 Description: LEFORT III W/FHD W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21172 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1889.45 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21172 MEDSV DEF RBRVS 01/01/2025 1846.63 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21175 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2049.33 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21175 MEDSV DEF RBRVS 01/01/2025 1989.85 Description: RECONSTRUCT ORBIT/FOREHEAD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21179 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1410.35 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21179 MEDSV DEF RBRVS 01/01/2025 1371.24 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1574.97 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21180 MEDSV DEF RBRVS 01/01/2025 1530.69 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21181 MEDSV DEF RBRVS 01/01/2024 12/31/2024 689.79 Description: CONTOUR CRANIAL BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21181 MEDSV DEF RBRVS 01/01/2025 672.45 Description: CONTOUR CRANIAL BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21182 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1959.82 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21182 MEDSV DEF RBRVS 01/01/2025 1904.64 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21183 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2131.83 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21183 MEDSV DEF RBRVS 01/01/2025 2071.26 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21184 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2292.4 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21184 MEDSV DEF RBRVS 01/01/2025 2227.54 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21188 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1492.21 Description: RECONSTRUCTION OF MIDFACE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21188 MEDSV DEF RBRVS 01/01/2025 1445.66 Description: RECONSTRUCTION OF MIDFACE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21193 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1162.99 Description: RECONST LWR JAW W/O GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21193 MEDSV DEF RBRVS 01/01/2025 1128.63 Description: RECONST LWR JAW W/O 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21194 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1345.17 Description: RECONST LWR JAW W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21194 MEDSV DEF RBRVS 01/01/2025 1304.49 Description: RECONST LWR JAW W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21195 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1265.66 Description: RECONST LWR JAW W/O FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21195 MEDSV DEF RBRVS 01/01/2025 1226.4 Description: RECONST LWR JAW W/O FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21196 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1352.45 Y Description: RECONST LWR JAW W/FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21196 MEDSV DEF RBRVS 01/01/2025 1310.49 Y Description: RECONST LWR JAW W/FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21198 MEDSV DEF RBRVS 01/01/2024 12/31/2024 962.29 Description: RECONSTR LWR JAW SEGMENT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21198 MEDSV DEF RBRVS 01/01/2025 924.82 Description: RECONSTR LWR JAW SEGMENT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21199 MEDSV DEF RBRVS 01/01/2024 12/31/2024 961.49 Y Y Description: RECONSTR LWR JAW W/ADVANCE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 21199 MEDSV DEF RBRVS 01/01/2025 933.18 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 12/31/2024 918.44 Y Description: RECONSTRUCT UPPER JAW BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21206 MEDSV DEF RBRVS 01/01/2025 893.3 Y Description: RECONSTRUCT UPPER JAW BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21208 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1542.61 Y Description: AUGMENTATION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21208 MEDSV DEF RBRVS 01/01/2025 1491.11 Y Description: AUGMENTATION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21209 MEDSV DEF RBRVS 01/01/2024 12/31/2024 770.63 Y Description: REDUCTION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21209 MEDSV DEF RBRVS 01/01/2025 728.73 Y Description: REDUCTION OF FACIAL BONES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1655.81 Y Description: FACE BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21210 MEDSV DEF RBRVS 01/01/2025 1602.47 Y Description: FACE BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3826.33 Y Description: LOWER JAW BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21215 MEDSV DEF RBRVS 01/01/2025 3684.14 Y Description: LOWER JAW BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.26 Y Description: RIB CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21230 MEDSV DEF RBRVS 01/01/2025 681.61 Y Description: RIB CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 689.19 Y Description: EAR CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21235 MEDSV DEF RBRVS 01/01/2025 675.72 Y Description: EAR CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 993.61 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21240 MEDSV DEF RBRVS 01/01/2025 962.23 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21242 MEDSV DEF RBRVS 01/01/2024 12/31/2024 955.06 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21242 MEDSV DEF RBRVS 01/01/2025 928.91 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21243 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1581.51 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21243 MEDSV DEF RBRVS 01/01/2025 1537.75 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21244 MEDSV DEF RBRVS 01/01/2024 12/31/2024 947.06 Y Description: RECONSTRUCTION OF LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21244 MEDSV DEF RBRVS 01/01/2025 921.23 Y Description: RECONSTRUCTION OF LOWER JAW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21245 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1156.58 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21245 MEDSV DEF RBRVS 01/01/2025 1117.94 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21246 MEDSV DEF RBRVS 01/01/2024 12/31/2024 802.49 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21246 MEDSV DEF RBRVS 01/01/2025 779.59 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21247 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1491.95 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21247 MEDSV DEF RBRVS 01/01/2025 1448.12 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21248 MEDSV DEF RBRVS 01/01/2024 12/31/2024 924.76 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21248 MEDSV DEF RBRVS 01/01/2025 902.85 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21249 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1255.44 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21249 MEDSV DEF RBRVS 01/01/2025 1224.99 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21255 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1261.5 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21255 MEDSV DEF RBRVS 01/01/2025 1223.18 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21256 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1150.67 Description: RECONSTRUCTION OF ORBIT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21256 MEDSV DEF RBRVS 01/01/2025 1122.59 Description: RECONSTRUCTION OF ORBIT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1272.13 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21260 MEDSV DEF RBRVS 01/01/2025 1235.85 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21261 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2251.44 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21261 MEDSV DEF RBRVS 01/01/2025 2186.86 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21263 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2082.85 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21263 MEDSV DEF RBRVS 01/01/2025 2023.57 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21267 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1487.87 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21267 MEDSV DEF RBRVS 01/01/2025 1445.2 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21268 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1865.67 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21268 MEDSV DEF RBRVS 01/01/2025 1813.23 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 944.19 Y Description: AUGMENTATION CHEEK BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21270 MEDSV DEF RBRVS 01/01/2025 924.43 Y Description: AUGMENTATION CHEEK BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 784.87 Description: REVISION ORBITOFACIAL BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21275 MEDSV DEF RBRVS 01/01/2025 764.91 Description: REVISION ORBITOFACIAL BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 550.51 Description: MEDIAL CANTHOPEXY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21280 MEDSV DEF RBRVS 01/01/2025 541.99 Description: MEDIAL CANTHOPEXY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21282 MEDSV DEF RBRVS 01/01/2024 12/31/2024 372.72 Description: LATERAL CANTHOPEXY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21282 MEDSV DEF RBRVS 01/01/2025 367.42 Description: LATERAL CANTHOPEXY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21295 MEDSV DEF RBRVS 01/01/2024 12/31/2024 184.5 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21295 MEDSV DEF RBRVS 01/01/2025 182.43 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21296 MEDSV DEF RBRVS 01/01/2024 12/31/2024 383.62 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21296 MEDSV DEF RBRVS 01/01/2025 375.34 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21299 MEDSV DEF BILL20 10/15/2020 Y Y Description: UNLISTED CRANFCL&MAXLFCL PX Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21315 MEDSV DEF RBRVS 01/01/2024 12/31/2024 141.16 Description: CLSD TX NSL FX MNPJ WO STBLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21315 MEDSV DEF RBRVS 01/01/2025 139.04 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 12/31/2024 203.91 Description: CLSD TX NSL FX W/MNPJ&STABLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21320 MEDSV DEF RBRVS 01/01/2025 197.47 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 12/31/2024 418.49 Description: OPEN TX NOSE FX UNCOMPLICATD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21325 MEDSV DEF RBRVS 01/01/2025 408.15 Description: OPEN TX NOSE FX UNCOMPLICATD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 503.3 Description: OPEN TX NOSE FX W/SKELE FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21330 MEDSV DEF RBRVS 01/01/2025 490.5 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 12/31/2024 672.2 Description: OPEN TX NOSE & SEPTAL FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21335 MEDSV DEF RBRVS 01/01/2025 656.89 Description: OPEN TX NOSE & SEPTAL FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21336 MEDSV DEF RBRVS 01/01/2024 12/31/2024 597.73 Description: OPEN TX SEPTAL FX W/WO STABJ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21336 MEDSV DEF RBRVS 01/01/2025 583.68 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 12/31/2024 392.28 Description: CLOSED TX SEPTAL&NOSE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21337 MEDSV DEF RBRVS 01/01/2025 382.22 Description: CLOSED TX SEPTAL&NOSE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21338 MEDSV DEF RBRVS 01/01/2024 12/31/2024 631.53 Description: OPEN NASOETHMOID FX W/O FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21338 MEDSV DEF RBRVS 01/01/2025 614 Description: OPEN NASOETHMOID FX W/O FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21339 MEDSV DEF RBRVS 01/01/2024 12/31/2024 714.24 Description: OPEN NASOETHMOID FX W/ FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21339 MEDSV DEF RBRVS 01/01/2025 693.81 Description: OPEN NASOETHMOID FX W/ FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 708.57 Description: PERQ TX NASOETHMOID FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21340 MEDSV DEF RBRVS 01/01/2025 691.97 Description: PERQ TX NASOETHMOID FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21343 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1022.99 Description: OPEN TX DPRSD FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21343 MEDSV DEF RBRVS 01/01/2025 995.7 Description: OPEN TX DPRSD FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21344 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1311.5 Description: OPEN TX COMPL FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21344 MEDSV DEF RBRVS 01/01/2025 1273.17 Description: OPEN TX COMPL FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 754.88 Description: CLOSED TX NOSE/JAW FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21345 MEDSV DEF RBRVS 01/01/2025 738.78 Description: CLOSED TX NOSE/JAW FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21346 MEDSV DEF RBRVS 01/01/2024 12/31/2024 963.59 Description: OPN TX NASOMAX FX W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21346 MEDSV DEF RBRVS 01/01/2025 933.09 Description: OPN TX NASOMAX FX W/FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21347 MEDSV DEF RBRVS 01/01/2024 12/31/2024 977.63 Description: OPN TX NASOMAX FX MULTPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21347 MEDSV DEF RBRVS 01/01/2025 948.16 Description: OPN TX NASOMAX FX MULTPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21348 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1028.77 Description: OPN TX NASOMAX FX W/GRAFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21348 MEDSV DEF RBRVS 01/01/2025 1002.58 Description: OPN TX NASOMAX FX W/GRAFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21355 MEDSV DEF RBRVS 01/01/2024 12/31/2024 421.51 Description: PERQ TX MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21355 MEDSV DEF RBRVS 01/01/2025 412.49 Description: PERQ TX MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21356 MEDSV DEF RBRVS 01/01/2024 12/31/2024 508.46 Description: OPN TX DPRSD ZYGOMATIC ARCH Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21356 MEDSV DEF RBRVS 01/01/2025 497.29 Description: OPN TX DPRSD ZYGOMATIC ARCH Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 493.76 Description: OPN TX DPRSD MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21360 MEDSV DEF RBRVS 01/01/2025 484.12 Description: OPN TX DPRSD MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1014.74 Description: OPN TX COMPLX MALAR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21365 MEDSV DEF RBRVS 01/01/2025 985.51 Description: OPN TX COMPLX MALAR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21366 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1184.96 Description: OPN TX COMPLX MALAR W/GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21366 MEDSV DEF RBRVS 01/01/2025 1153.96 Description: OPN TX COMPLX MALAR W/GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21385 MEDSV DEF RBRVS 01/01/2024 12/31/2024 682.62 Description: OPN TX ORBIT FX TRANSANTRAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21385 MEDSV DEF RBRVS 01/01/2025 665.25 Description: OPN TX ORBIT FX TRANSANTRAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21386 MEDSV DEF RBRVS 01/01/2024 12/31/2024 643.72 Description: OPN TX ORBIT FX PERIORBITAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21386 MEDSV DEF RBRVS 01/01/2025 628.72 Description: OPN TX ORBIT FX PERIORBITAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21387 MEDSV DEF RBRVS 01/01/2024 12/31/2024 712.55 Description: OPN TX ORBIT FX COMBINED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21387 MEDSV DEF RBRVS 01/01/2025 694.18 Description: OPN TX ORBIT FX COMBINED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 753.4 Description: OPN TX ORBIT PERIORBTL IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21390 MEDSV DEF RBRVS 01/01/2025 735.72 Description: OPN TX ORBIT PERIORBTL IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21395 MEDSV DEF RBRVS 01/01/2024 12/31/2024 937.18 Description: OPN TX ORBIT PERIORBT W/GRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21395 MEDSV DEF RBRVS 01/01/2025 911.41 Description: OPN TX ORBIT PERIORBT W/GRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 200.42 Description: CLOSED TX ORBIT W/O MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21400 MEDSV DEF RBRVS 01/01/2025 199.83 Description: CLOSED TX ORBIT W/O MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21401 MEDSV DEF RBRVS 01/01/2024 12/31/2024 475.53 Description: CLOSED TX ORBIT W/MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21401 MEDSV DEF RBRVS 01/01/2025 464.3 Description: CLOSED TX ORBIT W/MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21406 MEDSV DEF RBRVS 01/01/2024 12/31/2024 543.74 Description: OPN TX ORBIT FX W/O IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21406 MEDSV DEF RBRVS 01/01/2025 531.6 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 12/31/2024 607.56 Description: OPN TX ORBIT FX W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21407 MEDSV DEF RBRVS 01/01/2025 589.71 Description: OPN TX ORBIT FX W/IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21408 MEDSV DEF RBRVS 01/01/2024 12/31/2024 839.63 Description: OPN TX ORBIT FX W/BONE GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21408 MEDSV DEF RBRVS 01/01/2025 817.77 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 12/31/2024 606.01 Description: CLTX PALATAL/MAX FX WIRE FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21421 MEDSV DEF RBRVS 01/01/2025 591.7 Description: CLTX PALATAL/MAX FX WIRE FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21422 MEDSV DEF RBRVS 01/01/2024 12/31/2024 590.97 Description: OPTX PALATAL/MAX FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21422 MEDSV DEF RBRVS 01/01/2025 571.05 Description: OPTX PALATAL/MAX FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21423 MEDSV DEF RBRVS 01/01/2024 12/31/2024 742.51 Description: OPTX PALATAL/MAX FX COMP Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21423 MEDSV DEF RBRVS 01/01/2025 722 Description: OPTX PALATAL/MAX FX COMP Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21431 MEDSV DEF RBRVS 01/01/2024 12/31/2024 654.71 Description: CLTX CRANIOFACIAL SEPARATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21431 MEDSV DEF RBRVS 01/01/2025 636.35 Description: CLTX CRANIOFACIAL SEPARATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21432 MEDSV DEF RBRVS 01/01/2024 12/31/2024 666.84 Description: OPTX CRANFCL SEP W/WIRING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21432 MEDSV DEF RBRVS 01/01/2025 645.88 Description: OPTX CRANFCL SEP W/WIRING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21433 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1607.77 Description: OPTX CRANFCL SEP COMP MLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21433 MEDSV DEF RBRVS 01/01/2025 1563.41 Description: OPTX CRANFCL SEP COMP MLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1306.24 Description: OPTX CRNFC SEP COMP INT&/XTR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21435 MEDSV DEF RBRVS 01/01/2025 1272.86 Description: OPTX CRNFC SEP COMP INT&/XTR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21436 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1888.3 Description: OPTX CRNFCL SEP COMP MLT INT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21436 MEDSV DEF RBRVS 01/01/2025 1838.41 Description: OPTX CRNFCL SEP COMP MLT INT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 644.25 Description: CLTX MNDBLR/MAX ALV RIDGE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21440 MEDSV DEF RBRVS 01/01/2025 692.57 Description: CLTX MNDBLR/MAX ALV RIDGE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 739.07 Description: OPTX MNDBLR/MAX ALV RIDGE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21445 MEDSV DEF RBRVS 01/01/2025 709.99 Description: OPTX MNDBLR/MAX ALV RIDGE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 555.53 Description: CLTX MNDBLR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21450 MEDSV DEF RBRVS 01/01/2025 539.29 Description: CLTX MNDBLR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21451 MEDSV DEF RBRVS 01/01/2024 12/31/2024 723.11 Description: CLTX MNDBLR FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21451 MEDSV DEF RBRVS 01/01/2025 702.59 Description: CLTX MNDBLR FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21452 MEDSV DEF RBRVS 01/01/2024 12/31/2024 697.22 Description: PERQ TX MNDBLR FX XTRNL FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21452 MEDSV DEF RBRVS 01/01/2025 665.67 Description: PERQ TX MNDBLR FX XTRNL FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21453 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1024.08 Description: CLTX MNDBLR FX NTRDNTL FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21453 MEDSV DEF RBRVS 01/01/2025 994.78 Description: CLTX MNDBLR FX NTRDNTL FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21454 MEDSV DEF RBRVS 01/01/2024 12/31/2024 461.18 Description: OPTX MNDBLR FX XTRNL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21454 MEDSV DEF RBRVS 01/01/2025 452.74 Description: OPTX MNDBLR FX XTRNL FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21461 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1713.68 Description: OPTX MNDBLR FX WO NTRDNTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21461 MEDSV DEF RBRVS 01/01/2025 1666.08 Description: OPTX MNDBLR FX WO NTRDNTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21462 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1855.83 Description: OPTX MNDBLR FX W/NTRDNTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21462 MEDSV DEF RBRVS 01/01/2025 1777.26 Description: OPTX MNDBLR FX W/NTRDNTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21465 MEDSV DEF RBRVS 01/01/2024 12/31/2024 753.82 Description: OPTX MNDBLR CNDYLR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21465 MEDSV DEF RBRVS 01/01/2025 737.93 Description: OPTX MNDBLR CNDYLR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21470 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1088.28 Description: OPTX COMPLICATED MNDBLR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21470 MEDSV DEF RBRVS 01/01/2025 1066.79 Description: OPTX COMPLICATED MNDBLR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21480 MEDSV DEF RBRVS 01/01/2024 12/31/2024 132.2 Description: CLTX TMPRMAND DISLC 1ST/SBSQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21480 MEDSV DEF RBRVS 01/01/2025 128.15 Description: CLTX TMPRMAND DISLC 1ST/SBSQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21485 MEDSV DEF RBRVS 01/01/2024 12/31/2024 909.81 Description: CLTX TMPRMAND DISLC COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21485 MEDSV DEF RBRVS 01/01/2025 872.68 Description: CLTX TMPRMAND DISLC COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21490 MEDSV DEF RBRVS 01/01/2024 12/31/2024 742.64 Description: OPTX TMPRMAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21490 MEDSV DEF RBRVS 01/01/2025 727.37 Description: OPTX TMPRMAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21497 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665.67 Description: INTERDENTAL WIRG OTH/THN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21497 MEDSV DEF RBRVS 01/01/2025 646.49 Description: INTERDENTAL WIRG OTH/THN FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21499 MEDSV DEF BILL20 10/15/2020 Y Description: UNLISTED MUSCSKEL PX HEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 21501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.45 Description: I&D DP ABSC/HMTMA SFT TS NCK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21501 MEDSV DEF RBRVS 01/01/2025 444.04 Description: I&D DP ABSC/HMTMA SFT TS NCK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 465.27 Description: I&D DP ABS/HMTM NCK RIB OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21502 MEDSV DEF RBRVS 01/01/2025 455.02 Description: I&D DP ABS/HMTM NCK RIB OSTC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 415.15 Description: INC DEEP OPNG B1 CRTX THORAX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21510 MEDSV DEF RBRVS 01/01/2025 406.94 Description: INC DEEP OPNG B1 CRTX THORAX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 250.14 Description: BIOPSY OF NECK/CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21550 MEDSV DEF RBRVS 01/01/2025 243.68 Description: BIOPSY OF NECK/CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 412.62 Description: EXC NECK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21552 MEDSV DEF RBRVS 01/01/2025 404.35 Description: EXC NECK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 676.16 Description: EXC NECK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21554 MEDSV DEF RBRVS 01/01/2025 661.43 Description: EXC NECK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 404.68 Description: EXC NECK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21555 MEDSV DEF RBRVS 01/01/2025 394.62 Description: EXC NECK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.25 Description: EXC NECK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21556 MEDSV DEF RBRVS 01/01/2025 482.35 Description: EXC NECK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21557 MEDSV DEF RBRVS 01/01/2024 12/31/2024 881.57 Description: RESECT NECK THORAX TUMOR<5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21557 MEDSV DEF RBRVS 01/01/2025 864.2 Description: RESECT NECK THORAX TUMOR<5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21558 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1237.06 Description: RESECT NECK TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21558 MEDSV DEF RBRVS 01/01/2025 1203.88 Description: RESECT NECK TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 522.3 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21600 MEDSV DEF RBRVS 01/01/2025 513.17 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1041.88 Description: EXC CHEST WALL TUMOR W/RIBS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21601 MEDSV DEF RBRVS 01/01/2025 1021.8 Description: EXC CHEST WALL TUMOR W/RIBS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21602 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1406.37 Description: EXC CH WAL TUM W/O LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21602 MEDSV DEF RBRVS 01/01/2025 1364.97 Description: EXC CH WAL TUM W/O LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21603 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1531.79 Description: EXC CH WAL TUM W/LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21603 MEDSV DEF RBRVS 01/01/2025 1493.99 Description: EXC CH WAL TUM W/LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1025.84 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21610 MEDSV DEF RBRVS 01/01/2025 1059.02 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 566.3 Description: REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21615 MEDSV DEF RBRVS 01/01/2025 552.98 Description: REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21616 MEDSV DEF RBRVS 01/01/2024 12/31/2024 645.24 Description: REMOVAL OF RIB AND NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21616 MEDSV DEF RBRVS 01/01/2025 630.85 Description: REMOVAL OF RIB AND NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 463.44 Description: PARTIAL REMOVAL OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21620 MEDSV DEF RBRVS 01/01/2025 451.66 Description: PARTIAL REMOVAL OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21627 MEDSV DEF RBRVS 01/01/2024 12/31/2024 502.37 Description: STERNAL DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 21627 MEDSV DEF RBRVS 01/01/2025 493.81 Description: STERNAL DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 21630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1219.96 Description: RADICAL RESECTION STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21630 MEDSV DEF RBRVS 01/01/2025 1188.59 Description: RADICAL RESECTION STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21632 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1101.61 Description: EXTENSIVE STERNUM SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12/31/2024 21632 MEDSV DEF RBRVS 01/01/2025 1075.86 Description: EXTENSIVE STERNUM SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12/31/2024 21685 MEDSV DEF RBRVS 01/01/2024 12/31/2024 924.19 Description: HYOID MYOTOMY & SUSPENSION Category: Medical Services CMS Add: 01/01/2004 CMS Term: 21685 MEDSV DEF RBRVS 01/01/2025 900.69 Description: HYOID MYOTOMY & SUSPENSION Category: Medical Services CMS Add: 01/01/2004 CMS Term: 21700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 322.28 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21700 MEDSV DEF RBRVS 01/01/2025 314.57 Description: REVISION OF NECK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 480.84 Description: REVISION OF NECK MUSCLE/RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21705 MEDSV DEF RBRVS 01/01/2025 468.65 Description: REVISION OF NECK MUSCLE/RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 480.72 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21720 MEDSV DEF RBRVS 01/01/2025 474.08 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 505.62 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21725 MEDSV DEF RBRVS 01/01/2025 496.39 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 928.82 Description: RECONSTRUCTION OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21740 MEDSV DEF RBRVS 01/01/2025 906.29 Description: RECONSTRUCTION OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21742 MEDSV DEF MAXFEE 01/01/2024 750.06 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 944.4 0 Description: REPAIR STERNUM/NUSS W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 615.43 Description: REPAIR OF STERNUM SEPARATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 21750 MEDSV DEF RBRVS 01/01/2025 599.88 Description: REPAIR OF STERNUM SEPARATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 21811 MEDSV DEF RBRVS 01/01/2024 12/31/2024 537.88 Description: OPTX OF RIB FX W/FIXJ SCOPE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21811 MEDSV DEF RBRVS 01/01/2025 523.8 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 12/31/2024 652.16 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21812 MEDSV DEF RBRVS 01/01/2025 632.34 Description: TREATMENT OF RIB FRACTURE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21813 MEDSV DEF RBRVS 01/01/2024 12/31/2024 887.23 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21813 MEDSV DEF RBRVS 01/01/2025 861.85 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 141.81 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21820 MEDSV DEF RBRVS 01/01/2025 140.31 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 505.55 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21825 MEDSV DEF RBRVS 01/01/2025 497.35 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21899 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX NECK/THORAX Category: Medical Services CMS Add: 01/01/1982 CMS Term: 21920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 240.26 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21920 MEDSV DEF RBRVS 01/01/2025 234.34 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21925 MEDSV DEF RBRVS 01/01/2024 12/31/2024 458.85 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21925 MEDSV DEF RBRVS 01/01/2025 449.95 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 467.25 Description: EXC BACK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21930 MEDSV DEF RBRVS 01/01/2025 456.96 Description: EXC BACK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21931 MEDSV DEF RBRVS 01/01/2024 12/31/2024 432.7 Description: EXC BACK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21931 MEDSV DEF RBRVS 01/01/2025 424.01 Description: EXC BACK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21932 MEDSV DEF RBRVS 01/01/2024 12/31/2024 613.48 Description: EXC BACK TUM DEEP < 5 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21932 MEDSV DEF RBRVS 01/01/2025 598.32 Description: EXC BACK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21933 MEDSV DEF RBRVS 01/01/2024 12/31/2024 679.69 Description: EXC BACK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21933 MEDSV DEF RBRVS 01/01/2025 663.87 Description: EXC BACK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21935 MEDSV DEF RBRVS 01/01/2024 12/31/2024 936.86 Description: RESECT BACK TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21935 MEDSV DEF RBRVS 01/01/2025 916.17 Description: RESECT BACK TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21936 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1294.59 Description: RESECT BACK TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21936 MEDSV DEF RBRVS 01/01/2025 1265.47 Description: RESECT BACK TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 867.73 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 12/31/2024 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 01/01/2025 851.44 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 12/31/2024 788.54 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22100 MEDSV DEF RBRVS 01/01/2025 837.45 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 794.64 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22101 MEDSV DEF RBRVS 01/01/2025 786.33 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 721.18 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22102 MEDSV DEF RBRVS 01/01/2025 701.77 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22103 MEDSV DEF RBRVS 01/01/2024 12/31/2024 122.44 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22103 MEDSV DEF RBRVS 01/01/2025 118.74 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 962.29 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22110 MEDSV DEF RBRVS 01/01/2025 944.17 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1019.41 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22112 MEDSV DEF RBRVS 01/01/2025 1003.15 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22114 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1019.41 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22114 MEDSV DEF RBRVS 01/01/2025 1003.15 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22116 MEDSV DEF RBRVS 01/01/2024 12/31/2024 125.58 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22116 MEDSV DEF RBRVS 01/01/2025 122.29 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22206 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2209.96 Description: INCIS SPINE 3 COLUMN THORAC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22206 MEDSV DEF RBRVS 01/01/2025 2161.85 Description: INCIS SPINE 3 COLUMN THORAC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22207 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2172.97 Description: INCIS SPINE 3 COLUMN LUMBAR Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22207 MEDSV DEF RBRVS 01/01/2025 2124.7 Description: INCIS SPINE 3 COLUMN LUMBAR Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22208 MEDSV DEF RBRVS 01/01/2024 12/31/2024 524.01 Description: INCIS SPINE 3 COLUMN ADL SEG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22208 MEDSV DEF RBRVS 01/01/2025 511.13 Description: INCIS SPINE 3 COLUMN ADL SEG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1619.29 Description: INCIS 1 VERTEBRAL SEG CERV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22210 MEDSV DEF RBRVS 01/01/2025 1588.45 Description: INCIS 1 VERTEBRAL SEG CERV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22212 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1377.48 Description: INCIS 1 VERTEBRAL SEG THORAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22212 MEDSV DEF RBRVS 01/01/2025 1350.92 Description: INCIS 1 VERTEBRAL SEG THORAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22214 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1377.59 Description: INCIS 1 VERTEBRAL SEG LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22214 MEDSV DEF RBRVS 01/01/2025 1350.59 Description: INCIS 1 VERTEBRAL SEG LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22216 MEDSV DEF RBRVS 01/01/2024 12/31/2024 325.42 Description: INCIS ADDL SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22216 MEDSV DEF RBRVS 01/01/2025 316.57 Description: INCIS ADDL SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1473.11 Description: OSTEOT DSC ANT 1 VRT SGM CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22220 MEDSV DEF RBRVS 01/01/2025 1443.43 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 12/31/2024 1573.54 Description: OSTEOT DSC ANT 1VRT SGM THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22222 MEDSV DEF RBRVS 01/01/2025 1545.41 Description: OSTEOT DSC ANT 1VRT SGM THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22224 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1452.64 Description: OSTEOT DSC ANT 1VRT SGM LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22224 MEDSV DEF RBRVS 01/01/2025 1423 Description: OSTEOT DSC ANT 1VRT SGM LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22226 MEDSV DEF RBRVS 01/01/2024 12/31/2024 323.19 Description: OSTEOT DSC ANT 1VRT SGM EA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22226 MEDSV DEF RBRVS 01/01/2025 314.54 Description: OSTEOT DSC ANT 1VRT SGM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 289.82 Description: CLOSED TX VERT FX W/O MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22310 MEDSV DEF RBRVS 01/01/2025 285.51 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 12/31/2024 820.5 Description: CLOSED TX VERT FX W/MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22315 MEDSV DEF RBRVS 01/01/2025 816.77 Description: CLOSED TX VERT FX W/MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22318 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1477.44 Description: TREAT ODONTOID FX W/O GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22318 MEDSV DEF RBRVS 01/01/2025 1450 Description: TREAT ODONTOID FX W/O GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22319 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1633.37 0-1 Description: TREAT ODONTOID FX W/GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22319 MEDSV DEF RBRVS 01/01/2025 1601.08 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 12/31/2024 1334.36 Description: TREAT SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22325 MEDSV DEF RBRVS 01/01/2025 1310.35 Description: TREAT SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22326 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1362.39 Description: TREAT NECK SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22326 MEDSV DEF RBRVS 01/01/2025 1334.78 Description: TREAT NECK SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22327 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1388.6 Description: TREAT THORAX SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22327 MEDSV DEF RBRVS 01/01/2025 1362.98 Description: TREAT THORAX SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22328 MEDSV DEF RBRVS 01/01/2024 12/31/2024 251.22 Description: TREAT EACH ADD SPINE FX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22328 MEDSV DEF RBRVS 01/01/2025 243.63 Description: TREAT EACH ADD SPINE FX Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.26 Description: MANIPULATION OF SPINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22505 MEDSV DEF RBRVS 01/01/2025 117.13 Description: MANIPULATION OF SPINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1702.57 Description: PERQ CERVICOTHORACIC INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22510 MEDSV DEF RBRVS 01/01/2025 1616.18 Description: PERQ CERVICOTHORACIC INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22511 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1693.53 Description: PERQ LUMBOSACRAL INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22511 MEDSV DEF RBRVS 01/01/2025 1613.75 Description: PERQ LUMBOSACRAL INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 683.18 Description: VERTEBROPLASTY ADDL INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22512 MEDSV DEF RBRVS 01/01/2025 653.83 Description: VERTEBROPLASTY ADDL INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22513 MEDSV DEF RBRVS 01/01/2024 12/31/2024 5367.56 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22513 MEDSV DEF RBRVS 01/01/2025 5079.77 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22514 MEDSV DEF RBRVS 01/01/2024 12/31/2024 5341.41 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22514 MEDSV DEF RBRVS 01/01/2025 5057.6 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22515 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2756.58 0 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22515 MEDSV DEF RBRVS 01/01/2025 2601.16 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22526 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1859.8 Description: IDET SINGLE LEVEL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22526 MEDSV DEF RBRVS 01/01/2025 1775.34 Description: IDET SINGLE LEVEL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22527 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1527.89 Description: IDET 1 OR MORE LEVELS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22527 MEDSV DEF RBRVS 01/01/2025 1455.45 Description: IDET 1 OR MORE LEVELS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22532 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1623.24 Description: ARTHRD LAT XTRCVTRY TQ THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22532 MEDSV DEF RBRVS 01/01/2025 1585.13 Description: ARTHRD LAT XTRCVTRY TQ THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22533 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1514.64 Description: ARTHRD LAT XTRCVTRY TQ LMBR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22533 MEDSV DEF RBRVS 01/01/2025 1484.94 Description: ARTHRD LAT XTRCVTRY TQ LMBR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22534 MEDSV DEF RBRVS 01/01/2024 12/31/2024 322.99 Description: ARTHRD LAT XTRCVTRY TQ EA AD Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22534 MEDSV DEF RBRVS 01/01/2025 314.69 Description: ARTHRD LAT XTRCVTRY TQ EA AD Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22548 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1751.26 Description: ARTHRD ANT TORAL/XORAL C1-C2 Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22548 MEDSV DEF RBRVS 01/01/2025 1717 Description: ARTHRD ANT TORAL/XORAL C1-C2 Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22551 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1533.73 Description: ARTHRD ANT NTRBDY CERVICAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22551 MEDSV DEF RBRVS 01/01/2025 1499.45 Description: ARTHRD ANT NTRBDY CERVICAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 353.15 Description: ARTHRD ANT NTRBD CERVICAL EA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22552 MEDSV DEF RBRVS 01/01/2025 343.88 Description: ARTHRD ANT NTRBD CERVICAL EA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1141.92 Description: ARTHRD ANT NTRBD MIN DSC CRV 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22554 MEDSV DEF RBRVS 01/01/2025 1118.68 Description: ARTHRD ANT NTRBD MIN DSC CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1515.62 Description: ARTHRD ANT NTRBD MIN DSC THC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22556 MEDSV DEF RBRVS 01/01/2025 1492.25 Description: ARTHRD ANT NTRBD MIN DSC THC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22558 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1389.96 Description: ARTHRD ANT NTRBD MIN DSC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22558 MEDSV DEF RBRVS 01/01/2025 1357.06 Description: ARTHRD ANT NTRBD MIN DSC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22585 MEDSV DEF RBRVS 01/01/2024 12/31/2024 291.99 Description: ARTHRD ANT NTRBD MIN DSC EA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22585 MEDSV DEF RBRVS 01/01/2025 283.46 Description: ARTHRD ANT NTRBD MIN DSC EA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22586 NOCOV DEF SYSMAN 01/01/2013 Y 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 12/31/2024 1429.02 Description: ARTHRD PST TQ CRANIOCERVICAL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22590 MEDSV DEF RBRVS 01/01/2025 1401.21 Description: ARTHRD PST TQ CRANIOCERVICAL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22595 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1364.66 Description: ARTHRD PST TQ ATLAS-AXIS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22595 MEDSV DEF RBRVS 01/01/2025 1340.48 Description: ARTHRD PST TQ ATLAS-AXIS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1176.73 Description: ARTHRD PST TQ 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22600 MEDSV DEF RBRVS 01/01/2025 1155.42 Description: ARTHRD PST TQ 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1160.55 Description: ARTHRD PST TQ 1NTRSPC THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22610 MEDSV DEF RBRVS 01/01/2025 1139.13 Description: ARTHRD PST TQ 1NTRSPC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22612 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1440.6 Description: ARTHRD PST TQ 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22612 MEDSV DEF RBRVS 01/01/2025 1406.44 Description: ARTHRD PST TQ 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22614 MEDSV DEF RBRVS 01/01/2024 12/31/2024 349.04 Description: ARTHRD PST TQ 1NTRSPC EA ADD Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22614 MEDSV DEF RBRVS 01/01/2025 339.88 Description: ARTHRD PST TQ 1NTRSPC EA ADD Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1401.93 Description: ARTHRD PST TQ 1NTRSPC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22630 MEDSV DEF RBRVS 01/01/2025 1373.94 Description: ARTHRD PST TQ 1NTRSPC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22632 MEDSV DEF RBRVS 01/01/2024 12/31/2024 284.72 Description: ARTHRD PST TQ 1NTRSPC LM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22632 MEDSV DEF RBRVS 01/01/2025 277.43 Description: ARTHRD PST TQ 1NTRSPC LM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22633 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1634.91 Description: ARTHRD CMBN 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22633 MEDSV DEF RBRVS 01/01/2025 1598.64 Description: ARTHRD CMBN 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22634 MEDSV DEF RBRVS 01/01/2024 12/31/2024 432.23 Description: ARTHRD CMBN 1NTRSPC EA ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22634 MEDSV DEF RBRVS 01/01/2025 420.87 Description: ARTHRD CMBN 1NTRSPC EA ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1246.05 Description: ARTHRD PST DFRM<6 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22800 MEDSV DEF RBRVS 01/01/2025 1219.97 Description: ARTHRD PST DFRM<6 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22802 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1924.57 Description: ARTHRD PST DFRM 7-12 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22802 MEDSV DEF RBRVS 01/01/2025 1880.98 Description: ARTHRD PST DFRM 7-12 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22804 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2212.23 Description: ARTHRD PST DFRM 13+ VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22804 MEDSV DEF RBRVS 01/01/2025 2159.06 Description: ARTHRD PST DFRM 13+ VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22808 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1654.47 Description: ARTHRD ANT DFRM 2-3 VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22808 MEDSV DEF RBRVS 01/01/2025 1618.98 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 12/31/2024 1850.36 Description: ARTHRD ANT DFRM 4-7 VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22810 MEDSV DEF RBRVS 01/01/2025 1805.65 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 12/31/2024 2027.73 Description: ARTHRD ANT DFRM 8+ VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22812 MEDSV DEF RBRVS 01/01/2025 1979.02 Description: ARTHRD ANT DFRM 8+ VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22818 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1979.35 Description: KYPHECTOMY 1-2 SEGMENTS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22818 MEDSV DEF RBRVS 01/01/2025 1930.63 Description: KYPHECTOMY 1-2 SEGMENTS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22819 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2279.28 Description: KYPHECTOMY 3 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22819 MEDSV DEF RBRVS 01/01/2025 2222.4 Description: KYPHECTOMY 3 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 749.9 Description: EXPLORATION OF SPINAL FUSION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22830 MEDSV DEF RBRVS 01/01/2025 735.65 Description: EXPLORATION OF SPINAL FUSION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22836 NOCOV DEF SYSMAN 01/01/2024 Y Description: ANT THRC VRT BODY TETHRG <7 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 22837 NOCOV DEF SYSMAN 01/01/2024 Y Description: ANT THRC VRT BODY TETHRG 8+ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22838 NOCOV DEF SYSMAN 01/01/2024 Y 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 12/31/2024 678.06 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22840 MEDSV DEF RBRVS 01/01/2025 659.18 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22841 NOCOV DEF SYSMAN 08/01/2012 Y Description: INSERT SPINE FIXATION DEVICE Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 22842 MEDSV DEF RBRVS 01/01/2024 12/31/2024 681.65 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22842 MEDSV DEF RBRVS 01/01/2025 663.34 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22843 MEDSV DEF RBRVS 01/01/2024 12/31/2024 729.56 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22843 MEDSV DEF RBRVS 01/01/2025 710.2 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22844 MEDSV DEF RBRVS 01/01/2024 12/31/2024 886.23 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22844 MEDSV DEF RBRVS 01/01/2025 860.91 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 648.22 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22845 MEDSV DEF RBRVS 01/01/2025 630.71 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22846 MEDSV DEF RBRVS 01/01/2024 12/31/2024 674.11 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22846 MEDSV DEF RBRVS 01/01/2025 656.03 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22847 MEDSV DEF RBRVS 01/01/2024 12/31/2024 732.28 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22847 MEDSV DEF RBRVS 01/01/2025 711.11 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22848 MEDSV DEF RBRVS 01/01/2024 12/31/2024 323.11 Description: INSERT PELV FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22848 MEDSV DEF RBRVS 01/01/2025 314.64 Description: INSERT PELV FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22849 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1186.01 Description: REINSERT SPINAL FIXATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 22849 MEDSV DEF RBRVS 01/01/2025 1159.67 Description: REINSERT SPINAL FIXATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 22850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 671.02 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22850 MEDSV DEF RBRVS 01/01/2025 658.24 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22852 MEDSV DEF RBRVS 01/01/2024 12/31/2024 646.26 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22852 MEDSV DEF RBRVS 01/01/2025 634.8 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22853 MEDSV DEF RBRVS 01/01/2024 12/31/2024 230.55 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22853 MEDSV DEF RBRVS 01/01/2025 224.14 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22854 MEDSV DEF RBRVS 01/01/2024 12/31/2024 298.84 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22854 MEDSV DEF RBRVS 01/01/2025 290.67 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22855 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1006.48 Description: REMOVAL ANTERIOR INSTRMJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22855 MEDSV DEF RBRVS 01/01/2025 984.53 Description: REMOVAL ANTERIOR INSTRMJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22856 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1469.68 Y Description: TOT DISC ARTHRP 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/2009 CMS Term: 22856 MEDSV DEF RBRVS 01/01/2025 1436.76 Y Description: TOT DISC ARTHRP 1NTRSPC CRV 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22857 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1628.99 Y Description: TOT DISC ARTHRP 1NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22857 MEDSV DEF RBRVS 01/01/2025 1571.58 Y Description: TOT DISC ARTHRP 1NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22858 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.91 Description: TOT DISC ARTHRP 2ND LVL CRV Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22858 MEDSV DEF RBRVS 01/01/2025 441.28 Description: TOT DISC ARTHRP 2ND LVL CRV Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22859 MEDSV DEF RBRVS 01/01/2024 12/31/2024 297.85 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22859 MEDSV DEF RBRVS 01/01/2025 289.84 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22860 MEDSV DEF BILL20 01/01/2023 12/31/2024 Y Description: TOT DISC ARTHRP 2NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2023 CMS Term: 22860 MEDSV DEF RBRVS 01/01/2025 316.86 Y Description: TOT DISC ARTHRP 2NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2023 CMS Term: 22861 NOCOV DEF SYSMAN 01/01/2009 Y Description: REV RPLCM ARTHRP 1NTRSPC CRV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 22862 NOCOV DEF SYSMAN 01/01/2007 Y Description: REV RPLCM RTHRP 1NTRSPC LMBR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 22864 NOCOV DEF SYSMAN 01/01/2009 Y Description: RMVL TOT ARTHRP 1NTRSPC CRV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 22865 NOCOV DEF SYSMAN 01/01/2007 Y Description: RMVL TOT ARTHRP 1NTRSPC LMBR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 22867 MEDSV DEF RBRVS 01/01/2024 12/31/2024 974.82 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22867 MEDSV DEF RBRVS 01/01/2025 951.19 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22868 MEDSV DEF RBRVS 01/01/2024 12/31/2024 217.28 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22868 MEDSV DEF RBRVS 01/01/2025 210.64 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22869 MEDSV DEF RBRVS 01/01/2024 12/31/2024 408 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22869 MEDSV DEF RBRVS 01/01/2025 400.71 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 12/31/2024 111.55 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22870 MEDSV DEF RBRVS 01/01/2025 108.05 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22899 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PROCEDURE SPINE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 22900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 521.38 Description: EXC ABDL TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22900 MEDSV DEF RBRVS 01/01/2025 511.11 Description: EXC ABDL TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22901 MEDSV DEF RBRVS 01/01/2024 12/31/2024 612.13 Description: EXC ABDL TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22901 MEDSV DEF RBRVS 01/01/2025 599.67 Description: EXC ABDL TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22902 MEDSV DEF RBRVS 01/01/2024 12/31/2024 437.25 Description: EXC ABD LES SC < 3 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22902 MEDSV DEF RBRVS 01/01/2025 427.24 Description: EXC ABD LES SC < 3 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22903 MEDSV DEF RBRVS 01/01/2024 12/31/2024 405.4 Description: EXC ABD LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22903 MEDSV DEF RBRVS 01/01/2025 397.04 Description: EXC ABD LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22904 MEDSV DEF RBRVS 01/01/2024 12/31/2024 963.54 Description: RADICAL RESECT ABD TUMOR<5CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22904 MEDSV DEF RBRVS 01/01/2025 940.47 Description: RADICAL RESECT ABD TUMOR<5CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1216.84 Description: RAD RESECT ABD TUMOR 5 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22905 MEDSV DEF RBRVS 01/01/2025 1189.11 Description: RAD RESECT ABD TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22999 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX ABDOMEN MUSCSKEL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 23000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 513.97 Description: REMOVAL OF CALCIUM DEPOSITS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23000 MEDSV DEF RBRVS 01/01/2025 503.73 Description: REMOVAL OF CALCIUM DEPOSITS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 643.94 Description: RELEASE SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23020 MEDSV DEF RBRVS 01/01/2025 631 Description: RELEASE SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.24 Description: DRAIN SHOULDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23030 MEDSV DEF RBRVS 01/01/2025 399.17 Description: DRAIN SHOULDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23031 MEDSV DEF RBRVS 01/01/2024 12/31/2024 404.25 Description: DRAIN SHOULDER BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23031 MEDSV DEF RBRVS 01/01/2025 392.65 Description: DRAIN SHOULDER BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 635.77 Description: DRAIN SHOULDER BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23035 MEDSV DEF RBRVS 01/01/2025 619 Description: DRAIN SHOULDER BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 669.4 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23040 MEDSV DEF RBRVS 01/01/2025 655.45 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23044 MEDSV DEF RBRVS 01/01/2024 12/31/2024 530.06 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23044 MEDSV DEF RBRVS 01/01/2025 516.67 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 210.6 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23065 MEDSV DEF RBRVS 01/01/2025 206.46 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23066 MEDSV DEF RBRVS 01/01/2024 12/31/2024 526.62 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23066 MEDSV DEF RBRVS 01/01/2025 521.46 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23071 MEDSV DEF RBRVS 01/01/2024 12/31/2024 388.08 Description: EXC SHOULDER LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23071 MEDSV DEF RBRVS 01/01/2025 380.57 Description: EXC SHOULDER LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23073 MEDSV DEF RBRVS 01/01/2024 12/31/2024 643.9 Description: EXC SHOULDER TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23073 MEDSV DEF RBRVS 01/01/2025 630.4 Description: EXC SHOULDER TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23075 MEDSV DEF RBRVS 01/01/2024 12/31/2024 480.05 Description: EXC SHOULDER LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23075 MEDSV DEF RBRVS 01/01/2025 467.79 Description: EXC SHOULDER LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23076 MEDSV DEF RBRVS 01/01/2024 12/31/2024 504.07 Description: EXC SHOULDER TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23076 MEDSV DEF RBRVS 01/01/2025 493.9 Description: EXC SHOULDER TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23077 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1034.47 Description: RESECT SHOULDER TUMOR < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 23077 MEDSV DEF RBRVS 01/01/2025 1012.69 Description: RESECT SHOULDER TUMOR < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 23078 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1317.09 Description: RESECT SHOULDER TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23078 MEDSV DEF RBRVS 01/01/2025 1289.05 Description: RESECT SHOULDER TUMOR 5 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 474.41 Description: BIOPSY OF SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23100 MEDSV DEF RBRVS 01/01/2025 466.37 Description: BIOPSY OF SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 428.28 Description: SHOULDER JOINT SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23101 MEDSV DEF RBRVS 01/01/2025 421.61 Description: SHOULDER JOINT SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 597.03 Description: REMOVE SHOULDER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23105 MEDSV DEF RBRVS 01/01/2025 587.87 Description: REMOVE SHOULDER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23106 MEDSV DEF RBRVS 01/01/2024 12/31/2024 470.64 Description: INCISION OF COLLARBONE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23106 MEDSV DEF RBRVS 01/01/2025 462.86 Description: INCISION OF COLLARBONE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 617.85 Description: EXPLORE TREAT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 23107 MEDSV DEF RBRVS 01/01/2025 608.85 Description: EXPLORE TREAT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 23120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 549.31 Description: CLAVICULECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23120 MEDSV DEF RBRVS 01/01/2025 540.69 Description: CLAVICULECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 661.98 Description: CLAVICULECTOMY TOTAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23125 MEDSV DEF RBRVS 01/01/2025 649.02 Description: CLAVICULECTOMY TOTAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 577.99 Description: ACROMP/ACROMIONECTOMY PRTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23130 MEDSV DEF RBRVS 01/01/2025 567.39 Description: ACROMP/ACROMIONECTOMY PRTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 519.45 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23140 MEDSV DEF RBRVS 01/01/2025 510.24 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 649.19 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23145 MEDSV DEF RBRVS 01/01/2025 636.42 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23146 MEDSV DEF RBRVS 01/01/2024 12/31/2024 582.67 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23146 MEDSV DEF RBRVS 01/01/2025 572.47 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 622.94 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23150 MEDSV DEF RBRVS 01/01/2025 610.94 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 743.16 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23155 MEDSV DEF RBRVS 01/01/2025 727.94 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23156 MEDSV DEF RBRVS 01/01/2024 12/31/2024 633.77 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23156 MEDSV DEF RBRVS 01/01/2025 621.45 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23170 MEDSV DEF RBRVS 01/01/2024 12/31/2024 527.91 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23170 MEDSV DEF RBRVS 01/01/2025 518.94 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23172 MEDSV DEF RBRVS 01/01/2024 12/31/2024 533.63 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23172 MEDSV DEF RBRVS 01/01/2025 524.04 Description: REMOVE SHOULDER BLADE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23174 MEDSV DEF RBRVS 01/01/2024 12/31/2024 712.36 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23174 MEDSV DEF RBRVS 01/01/2025 699.48 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 613.98 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23180 MEDSV DEF RBRVS 01/01/2025 603.34 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23182 MEDSV DEF RBRVS 01/01/2024 12/31/2024 627.4 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23182 MEDSV DEF RBRVS 01/01/2025 615.86 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23184 MEDSV DEF RBRVS 01/01/2024 12/31/2024 690.72 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23184 MEDSV DEF RBRVS 01/01/2025 677.77 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23190 MEDSV DEF RBRVS 01/01/2024 12/31/2024 538 Description: PARTIAL REMOVAL OF SCAPULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23190 MEDSV DEF RBRVS 01/01/2025 528.09 Description: PARTIAL REMOVAL OF SCAPULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23195 MEDSV DEF RBRVS 01/01/2024 12/31/2024 693.35 Description: REMOVAL OF HEAD OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23195 MEDSV DEF RBRVS 01/01/2025 683.35 Description: REMOVAL OF HEAD OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1389.25 Description: RESECT CLAVICLE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23200 MEDSV DEF RBRVS 01/01/2025 1357.28 Description: RESECT CLAVICLE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1628.48 Description: RESECT SCAPULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23210 MEDSV DEF RBRVS 01/01/2025 1590.06 Description: RESECT SCAPULA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1784.69 Description: RESECT PROX HUMERUS TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23220 MEDSV DEF RBRVS 01/01/2025 1741.07 Description: RESECT PROX HUMERUS TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 280.88 Description: REMOVE SHOULDER FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23330 MEDSV DEF RBRVS 01/01/2025 274 Description: REMOVE SHOULDER FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23333 MEDSV DEF RBRVS 01/01/2024 12/31/2024 442.13 Description: REMOVE SHOULDER FB DEEP Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23333 MEDSV DEF RBRVS 01/01/2025 435.18 Description: REMOVE SHOULDER FB DEEP Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23334 MEDSV DEF RBRVS 01/01/2024 12/31/2024 981.61 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23334 MEDSV DEF RBRVS 01/01/2025 962.13 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1173.1 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23335 MEDSV DEF RBRVS 01/01/2025 1147.08 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 154.66 Description: INJECTION FOR SHOULDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23350 MEDSV DEF RBRVS 01/01/2025 147.55 Description: INJECTION FOR SHOULDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23395 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1187.86 Description: MUSCLE TRANSFER SHOULDER/ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23395 MEDSV DEF RBRVS 01/01/2025 1164.29 Description: MUSCLE TRANSFER SHOULDER/ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23397 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1055.29 Description: MUSCLE TRANSFERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23397 MEDSV DEF RBRVS 01/01/2025 1033.2 Description: MUSCLE TRANSFERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 903.14 Description: FIXATION OF SHOULDER BLADE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23400 MEDSV DEF RBRVS 01/01/2025 883.44 Description: FIXATION OF SHOULDER BLADE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 576.9 Description: INCISION OF TENDON & MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23405 MEDSV DEF RBRVS 01/01/2025 564.49 Description: INCISION OF TENDON & MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23406 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.13 Description: INCISE TENDON(S) & MUSCLE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23406 MEDSV DEF RBRVS 01/01/2025 672.19 Description: INCISE TENDON(S) & MUSCLE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 763.32 Description: REPAIR ROTATOR CUFF ACUTE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23410 MEDSV DEF RBRVS 01/01/2025 746.99 Description: REPAIR ROTATOR CUFF ACUTE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23412 MEDSV DEF RBRVS 01/01/2024 12/31/2024 792.65 Description: REPAIR ROTATOR CUFF CHRONIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23412 MEDSV DEF RBRVS 01/01/2025 776.24 Description: REPAIR ROTATOR CUFF CHRONIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 651.27 Description: RELEASE OF SHOULDER LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23415 MEDSV DEF RBRVS 01/01/2025 638.66 Description: RELEASE OF SHOULDER LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 905.01 Description: REPAIR OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23420 MEDSV DEF RBRVS 01/01/2025 886.6 Description: REPAIR OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 694.16 Description: REPAIR BICEPS TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23430 MEDSV DEF RBRVS 01/01/2025 680.42 Description: REPAIR BICEPS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 704 Description: REMOVE/TRANSPLANT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23440 MEDSV DEF RBRVS 01/01/2025 690.66 Description: REMOVE/TRANSPLANT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 877.59 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23450 MEDSV DEF RBRVS 01/01/2025 858.52 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23455 MEDSV DEF RBRVS 01/01/2024 12/31/2024 918.66 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23455 MEDSV DEF RBRVS 01/01/2025 895.78 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1010.53 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23460 MEDSV DEF RBRVS 01/01/2025 988.38 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23462 MEDSV DEF RBRVS 01/01/2024 12/31/2024 988.92 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23462 MEDSV DEF RBRVS 01/01/2025 966.98 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23465 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1036.12 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23465 MEDSV DEF RBRVS 01/01/2025 1013.23 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23466 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1040.52 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 23466 MEDSV DEF RBRVS 01/01/2025 1019.98 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 23470 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1109.86 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23470 MEDSV DEF RBRVS 01/01/2025 1084.76 Description: RECONSTRUCT SHOULDER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23472 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1336.84 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23472 MEDSV DEF RBRVS 01/01/2025 1305.01 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23473 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1488.16 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23473 MEDSV DEF RBRVS 01/01/2025 1451.33 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23474 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1606.11 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23474 MEDSV DEF RBRVS 01/01/2025 1566.02 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23480 MEDSV DEF RBRVS 01/01/2024 12/31/2024 762.9 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23480 MEDSV DEF RBRVS 01/01/2025 746.99 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23485 MEDSV DEF RBRVS 01/01/2024 12/31/2024 885.62 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23485 MEDSV DEF RBRVS 01/01/2025 866.3 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23490 MEDSV DEF RBRVS 01/01/2024 12/31/2024 800.04 Description: REINFORCE CLAVICLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23490 MEDSV DEF RBRVS 01/01/2025 783.25 Description: REINFORCE CLAVICLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23491 MEDSV DEF RBRVS 01/01/2024 12/31/2024 942.28 Description: REINFORCE SHOULDER BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23491 MEDSV DEF RBRVS 01/01/2025 922.09 Description: REINFORCE SHOULDER BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 213.18 Description: CLTX CLAVICULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23500 MEDSV DEF RBRVS 01/01/2025 211.28 Description: CLTX CLAVICULAR FX W/O 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 340.98 Description: CLTX CLAVICULAR FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23505 MEDSV DEF RBRVS 01/01/2025 338.1 Description: CLTX CLAVICULAR FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 672.45 Description: OPTX CLAVICULAR FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23515 MEDSV DEF RBRVS 01/01/2025 659.2 Description: OPTX CLAVICULAR FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 229.47 Description: CLTX STRNCLAV DISLC W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23520 MEDSV DEF RBRVS 01/01/2025 227.36 Description: CLTX STRNCLAV DISLC W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 376.36 Description: CLTX STRNCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23525 MEDSV DEF RBRVS 01/01/2025 373.18 Description: CLTX STRNCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 538.8 Description: OPTX STRNCLAV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23530 MEDSV DEF RBRVS 01/01/2025 528.41 Description: OPTX STRNCLAV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23532 MEDSV DEF RBRVS 01/01/2024 12/31/2024 585.52 Description: OPTX STRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23532 MEDSV DEF RBRVS 01/01/2025 574.6 Description: OPTX STRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 228.46 Description: CLTX ACROMCLAV DISLC WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23540 MEDSV DEF RBRVS 01/01/2025 225.43 Description: CLTX ACROMCLAV DISLC WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 341.76 Description: CLTX ACROMCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23545 MEDSV DEF RBRVS 01/01/2025 339.32 Description: CLTX ACROMCLAV DISLC W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 536.16 Description: OPTX ACROMCLV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23550 MEDSV DEF RBRVS 01/01/2025 525.2 Description: OPTX ACROMCLV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 606.08 Description: OPTX ACRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23552 MEDSV DEF RBRVS 01/01/2025 595.52 Description: OPTX ACRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 223.82 Description: CLTX SCAPULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23570 MEDSV DEF RBRVS 01/01/2025 221.8 Description: CLTX SCAPULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 389.02 Description: CLTX SCAP FX W/MNPJ +-TRACTJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23575 MEDSV DEF RBRVS 01/01/2025 384.95 Description: CLTX SCAP FX W/MNPJ +-TRACTJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23585 MEDSV DEF RBRVS 01/01/2024 12/31/2024 907.28 Description: OPTX SCAPULAR FX W/INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23585 MEDSV DEF RBRVS 01/01/2025 886.89 Description: OPTX SCAPULAR FX W/INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 317.53 Description: CLTX PROX HUMRL FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23600 MEDSV DEF RBRVS 01/01/2025 314.71 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 12/31/2024 445.19 Description: CLTX PRX HMRL FX MNPJ+-TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23605 MEDSV DEF RBRVS 01/01/2025 439.28 Description: CLTX PRX HMRL FX MNPJ+-TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 821.59 Description: OPTX PROX HUMRL FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23615 MEDSV DEF RBRVS 01/01/2025 804.87 Description: OPTX PROX HUMRL FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23616 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1144.33 Description: OPTX PRX HMRL FX FIX RPR RPL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 23616 MEDSV DEF RBRVS 01/01/2025 1119.19 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 12/31/2024 258.7 Description: CLTX GR HMRL TBRS FX WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23620 MEDSV DEF RBRVS 01/01/2025 256.28 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 12/31/2024 368.54 Description: CLTX GR HMRL TBRS FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23625 MEDSV DEF RBRVS 01/01/2025 362.1 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 12/31/2024 727.7 Description: OPTX GR HMRL TBRS FX INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23630 MEDSV DEF RBRVS 01/01/2025 713.98 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 12/31/2024 315.2 Description: CLTX SHO DSLC W/MNPJ WO ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23650 MEDSV DEF RBRVS 01/01/2025 313.15 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 12/31/2024 384.49 Description: CLTX SHO DSLC W/MNPJ W/ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23655 MEDSV DEF RBRVS 01/01/2025 378.67 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 12/31/2024 549.07 Description: OPTX ACUTE SHOULDER DISLC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23660 MEDSV DEF RBRVS 01/01/2025 537.33 Description: OPTX ACUTE SHOULDER DISLC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 411.51 Description: CLTX SHO DSLC FX GR HMRL TBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23665 MEDSV DEF RBRVS 01/01/2025 407.7 Description: CLTX SHO DSLC FX GR HMRL TBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 810.39 Description: OPTX SHO DISLC FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23670 MEDSV DEF RBRVS 01/01/2025 794.87 Description: OPTX SHO DISLC FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23675 MEDSV DEF RBRVS 01/01/2024 12/31/2024 520.6 Description: CLTX SHO DISLC NECK FX MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23675 MEDSV DEF RBRVS 01/01/2025 516.06 Description: CLTX SHO DISLC NECK FX MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 863.65 Description: OPTX SHO DISLC NECK FX FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23680 MEDSV DEF RBRVS 01/01/2025 839.26 Description: OPTX SHO DISLC NECK FX FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 182.81 Description: MNPJ ANES SHO JT FIXJ APRATS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23700 MEDSV DEF RBRVS 01/01/2025 179.34 Description: MNPJ ANES SHO JT FIXJ APRATS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 952.45 Description: ARTHRODESIS GLENOHUMERAL JT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23800 MEDSV DEF RBRVS 01/01/2025 932.13 Description: ARTHRODESIS GLENOHUMERAL JT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23802 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1187.59 Description: ARTHRD GLENOHUMERAL JT W/GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23802 MEDSV DEF RBRVS 01/01/2025 1162.54 Description: ARTHRD GLENOHUMERAL JT W/GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1279.73 Description: INTERTHORACOSCPLR AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23900 MEDSV DEF RBRVS 01/01/2025 1250.3 Description: INTERTHORACOSCPLR AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1039.76 Description: DISARTICULATION SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23920 MEDSV DEF RBRVS 01/01/2025 1018.03 Description: DISARTICULATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23921 MEDSV DEF RBRVS 01/01/2024 12/31/2024 440.94 Description: DISARTICULATION SHO SEC CLSR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23921 MEDSV DEF RBRVS 01/01/2025 434.29 Description: DISARTICULATION SHO SEC CLSR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23929 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PROCEDURE SHOULDER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 23930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 325.88 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 12/31/2024 283.78 Description: I&D UPR A/E BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23931 MEDSV DEF RBRVS 01/01/2025 276.23 Description: I&D UPR A/E BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23935 MEDSV DEF RBRVS 01/01/2024 12/31/2024 481.41 Description: INC DP OPN B1 CRTX HUM/ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23935 MEDSV DEF RBRVS 01/01/2025 473.32 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 12/31/2024 448.39 Description: ARTHRT ELBW EXPL DRG/RMVL FB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24000 MEDSV DEF RBRVS 01/01/2025 440.96 Description: ARTHRT ELBW EXPL DRG/RMVL FB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24006 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665.17 Description: ARTHRT ELBW CAPSL EXC RLS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24006 MEDSV DEF RBRVS 01/01/2025 654.02 Description: ARTHRT ELBW CAPSL EXC RLS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 242.17 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24065 MEDSV DEF RBRVS 01/01/2025 236.95 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24066 MEDSV DEF RBRVS 01/01/2024 12/31/2024 581.2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24066 MEDSV DEF RBRVS 01/01/2025 570.22 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24071 MEDSV DEF RBRVS 01/01/2024 12/31/2024 374.91 Description: EXC ARM/ELBOW LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24071 MEDSV DEF RBRVS 01/01/2025 368.04 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 12/31/2024 640.93 Description: EX ARM/ELBOW TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24073 MEDSV DEF RBRVS 01/01/2025 627.21 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 12/31/2024 497.28 Description: EXC ARM/ELBOW LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24075 MEDSV DEF RBRVS 01/01/2025 481.6 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 12/31/2024 509.28 Description: EX ARM/ELBOW TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24076 MEDSV DEF RBRVS 01/01/2025 499.11 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 12/31/2024 952.05 Description: RAD RESCJ TUM TISS A/E <5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 24077 MEDSV DEF RBRVS 01/01/2025 924.64 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 12/31/2024 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 01/01/2025 1190.1 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 12/31/2024 393.83 Description: ARTHRT ELBW SYNOVIAL BX ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24100 MEDSV DEF RBRVS 01/01/2025 388.14 Description: ARTHRT ELBW SYNOVIAL BX ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.45 Description: ARTHRT ELBW JT EXPL BX RMVL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24101 MEDSV DEF RBRVS 01/01/2025 464.02 Description: ARTHRT ELBW JT EXPL BX RMVL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 576.69 Description: ARTHRT ELBOW W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24102 MEDSV DEF RBRVS 01/01/2025 566.98 Description: ARTHRT ELBOW W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 338.82 Description: EXCISION OLECRANON BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24105 MEDSV DEF RBRVS 01/01/2025 334.64 Description: EXCISION OLECRANON BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 552.39 Description: EXC/CURTG B1 CST/B9 TUM HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24110 MEDSV DEF RBRVS 01/01/2025 542.57 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 12/31/2024 687.41 Description: EXC/CRTG B1 CST/TUM HUM AGRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24115 MEDSV DEF RBRVS 01/01/2025 673.71 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 12/31/2024 799.49 Description: EXC/CRTG B1 CST/TUM HUM ALGR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24116 MEDSV DEF RBRVS 01/01/2025 782.69 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 12/31/2024 499.62 Description: EXC/CRTG B1 CST/B9 TUM RDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24120 MEDSV DEF RBRVS 01/01/2025 490.5 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 12/31/2024 582.08 Description: EXC/CRTG B1 CST/TUM RDS AGRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24125 MEDSV DEF RBRVS 01/01/2025 571.57 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 12/31/2024 607.67 Description: EXC/CRTG B1 CST/TUM RDS ALGR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24126 MEDSV DEF RBRVS 01/01/2025 596.27 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 12/31/2024 481.4 Description: EXCISION RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24130 MEDSV DEF RBRVS 01/01/2025 471.27 Description: EXCISION RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24134 MEDSV DEF RBRVS 01/01/2024 12/31/2024 696.68 Description: SEQUESTRECTOMY SHFT/DSTL HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24134 MEDSV DEF RBRVS 01/01/2025 682.74 Description: SEQUESTRECTOMY SHFT/DSTL HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24136 MEDSV DEF RBRVS 01/01/2024 12/31/2024 590.93 Description: SEQUESTRECTOMY RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24136 MEDSV DEF RBRVS 01/01/2025 579.81 Description: SEQUESTRECTOMY RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24138 MEDSV DEF RBRVS 01/01/2024 12/31/2024 642.8 Description: SEQUESTRECTOMY OLECRN PROCES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24138 MEDSV DEF RBRVS 01/01/2025 631.41 Description: SEQUESTRECTOMY OLECRN PROCES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 656.74 Description: PARTIAL EXC BONE HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24140 MEDSV DEF RBRVS 01/01/2025 643.42 Description: PARTIAL EXC BONE HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 555.73 Description: PRTL EXC BONE RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24145 MEDSV DEF RBRVS 01/01/2025 545.46 Description: PRTL EXC BONE RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24147 MEDSV DEF RBRVS 01/01/2024 12/31/2024 588.98 Description: PRTL EXC BONE OLECRN PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24147 MEDSV DEF RBRVS 01/01/2025 577.48 Description: PRTL EXC BONE OLECRN PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24149 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1097.81 Description: RADICAL RESECTION OF ELBOW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24149 MEDSV DEF RBRVS 01/01/2025 1075.98 Description: RADICAL RESECTION OF ELBOW Category: Medical Services CMS Add: 01/01/1997 CMS Term: 24150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1424.95 Description: RAD RESCJ TUM DSTL/SHFT HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24150 MEDSV DEF RBRVS 01/01/2025 1392.39 Description: RAD RESCJ TUM DSTL/SHFT HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24152 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1240.68 Description: RAD RESECTION TUM RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24152 MEDSV DEF RBRVS 01/01/2025 1213.45 Description: RAD RESECTION TUM RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 791.95 Description: RESECTION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24155 MEDSV DEF RBRVS 01/01/2025 775.06 Description: RESECTION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1164.05 Description: RMVL PROSTHHUMRL&ULNAR CMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24160 MEDSV DEF RBRVS 01/01/2025 1136.24 Description: RMVL PROSTHHUMRL&ULNAR CMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24164 MEDSV DEF RBRVS 01/01/2024 12/31/2024 675 Description: REMOVAL PROSTH RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24164 MEDSV DEF RBRVS 01/01/2025 661.76 Description: REMOVAL PROSTH RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 201.85 Description: RMVL FB UPPER ARM/ELBW SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24200 MEDSV DEF RBRVS 01/01/2025 200.67 Description: RMVL FB UPPER ARM/ELBW SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24201 MEDSV DEF RBRVS 01/01/2024 12/31/2024 512 Description: RMVL FB UPPER ARM/ELBW DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24201 MEDSV DEF RBRVS 01/01/2025 561.77 Description: RMVL FB UPPER ARM/ELBW DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 180.01 Description: INJECTION PX FOR ELBOW ARTHG Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24220 MEDSV DEF RBRVS 01/01/2025 172.66 Description: INJECTION PX FOR ELBOW ARTHG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 411.22 Description: MNPJ ELBOW UNDER ANES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24300 MEDSV DEF RBRVS 01/01/2025 409.87 Description: MNPJ ELBOW UNDER ANES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24301 MEDSV DEF RBRVS 01/01/2024 12/31/2024 701.5 Description: MUSC/TDN TRANSFER UPR A/E 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24301 MEDSV DEF RBRVS 01/01/2025 685.4 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 12/31/2024 543.16 Description: TENDON LNGTH UPR A/E EA TDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24305 MEDSV DEF RBRVS 01/01/2025 533.68 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 12/31/2024 446.33 Description: TNOT OPN ELBW TO SHO EA TDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24310 MEDSV DEF RBRVS 01/01/2025 437.27 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 12/31/2024 726.49 Description: TENOPLASTY ELBOW TO SHO 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24320 MEDSV DEF RBRVS 01/01/2025 711.64 Description: TENOPLASTY ELBOW TO SHO 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 669.71 Description: FLEXOR-PLASTY ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24330 MEDSV DEF RBRVS 01/01/2025 656.36 Description: FLEXOR-PLASTY ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24331 MEDSV DEF RBRVS 01/01/2024 12/31/2024 730.93 Description: FLEXOR-PLASTY ELBW W/ADVMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24331 MEDSV DEF RBRVS 01/01/2025 716.11 Description: FLEXOR-PLASTY ELBW W/ADVMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24332 MEDSV DEF RBRVS 01/01/2024 12/31/2024 575.35 0-2 Description: TENOLYSIS TRICEPS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24332 MEDSV DEF RBRVS 01/01/2025 565.36 0-2 Description: TENOLYSIS TRICEPS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 562.95 Description: TENODESIS BICEPS TDN AT ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24340 MEDSV DEF RBRVS 01/01/2025 549.97 Description: TENODESIS BICEPS TDN AT ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24341 MEDSV DEF RBRVS 01/01/2024 12/31/2024 698.64 Description: RPR TDN/MUSC UPR A/E EACH Category: Medical Services CMS Add: 01/01/1997 CMS Term: 24341 MEDSV DEF RBRVS 01/01/2025 688.52 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 12/31/2024 722.25 Description: REPAIR OF RUPTURED TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24342 MEDSV DEF RBRVS 01/01/2025 707.17 Description: REPAIR OF RUPTURED TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24343 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 656.23 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 12/31/2024 1016.64 0-2 Description: RECONSTRUCT ELBOW LAT LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24344 MEDSV DEF RBRVS 01/01/2025 1004.84 0-2 Description: RECONSTRUCT ELBOW LAT LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 653.07 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 12/31/2024 1025.28 0-2 Description: RECONSTRUCT ELBOW MED LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24346 MEDSV DEF RBRVS 01/01/2025 1004.84 0-2 Description: RECONSTRUCT ELBOW MED LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24357 MEDSV DEF RBRVS 01/01/2024 12/31/2024 396.41 Description: REPAIR ELBOW PERC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24357 MEDSV DEF RBRVS 01/01/2025 387.9 Description: REPAIR ELBOW PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24358 MEDSV DEF RBRVS 01/01/2024 12/31/2024 496.34 Description: REPAIR ELBOW W/DEB OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24358 MEDSV DEF RBRVS 01/01/2025 488.54 Description: REPAIR ELBOW W/DEB OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24359 MEDSV DEF RBRVS 01/01/2024 12/31/2024 620.17 Description: REPAIR ELBOW DEB/ATTCH OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24359 MEDSV DEF RBRVS 01/01/2025 608.94 Description: REPAIR ELBOW DEB/ATTCH OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 839 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24360 MEDSV DEF RBRVS 01/01/2025 821.48 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24361 MEDSV DEF RBRVS 01/01/2024 12/31/2024 934.92 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24361 MEDSV DEF RBRVS 01/01/2025 914.64 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24362 MEDSV DEF RBRVS 01/01/2024 12/31/2024 983.65 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24362 MEDSV DEF RBRVS 01/01/2025 961.97 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24363 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1340.59 Description: REPLACE ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24363 MEDSV DEF RBRVS 01/01/2025 1310.54 Description: REPLACE ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 598.41 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24365 MEDSV DEF RBRVS 01/01/2025 586.91 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24366 MEDSV DEF RBRVS 01/01/2024 12/31/2024 635.86 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24366 MEDSV DEF RBRVS 01/01/2025 622.94 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1423.85 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24370 MEDSV DEF RBRVS 01/01/2025 1388.95 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24371 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1633.71 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24371 MEDSV DEF RBRVS 01/01/2025 1594.59 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 770.56 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24400 MEDSV DEF RBRVS 01/01/2025 754.7 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 981.13 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24410 MEDSV DEF RBRVS 01/01/2025 960.33 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 990.98 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24420 MEDSV DEF RBRVS 01/01/2025 967.14 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 979.82 Description: REPAIR OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24430 MEDSV DEF RBRVS 01/01/2025 958.53 Description: REPAIR OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1002.31 Description: REPAIR HUMERUS WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24435 MEDSV DEF RBRVS 01/01/2025 983.21 Description: REPAIR HUMERUS WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24470 MEDSV DEF RBRVS 01/01/2024 12/31/2024 627.48 Description: REVISION OF ELBOW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24470 MEDSV DEF RBRVS 01/01/2025 615.82 Description: REVISION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24495 MEDSV DEF RBRVS 01/01/2024 12/31/2024 865.41 Description: DECOMPRESSION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24495 MEDSV DEF RBRVS 01/01/2025 838.87 Description: DECOMPRESSION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24498 MEDSV DEF RBRVS 01/01/2024 12/31/2024 805.66 Description: REINFORCE HUMERUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 24498 MEDSV DEF RBRVS 01/01/2025 789.15 Description: REINFORCE HUMERUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 24500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 344.75 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24500 MEDSV DEF RBRVS 01/01/2025 342.4 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 476.94 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24505 MEDSV DEF RBRVS 01/01/2025 471.58 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 819.8 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24515 MEDSV DEF RBRVS 01/01/2025 802.72 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24516 MEDSV DEF RBRVS 01/01/2024 12/31/2024 799.03 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24516 MEDSV DEF RBRVS 01/01/2025 781.64 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 364.77 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24530 MEDSV DEF RBRVS 01/01/2025 361.12 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 585.3 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24535 MEDSV DEF RBRVS 01/01/2025 579.33 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24538 MEDSV DEF RBRVS 01/01/2024 12/31/2024 737.87 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24538 MEDSV DEF RBRVS 01/01/2025 722.12 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 861.91 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24545 MEDSV DEF RBRVS 01/01/2025 845.22 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24546 MEDSV DEF RBRVS 01/01/2024 12/31/2024 962.54 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24546 MEDSV DEF RBRVS 01/01/2025 942.5 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 317.77 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24560 MEDSV DEF RBRVS 01/01/2025 314.05 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24565 MEDSV DEF RBRVS 01/01/2024 12/31/2024 511.68 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24565 MEDSV DEF RBRVS 01/01/2025 505.25 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24566 MEDSV DEF RBRVS 01/01/2024 12/31/2024 673.27 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24566 MEDSV DEF RBRVS 01/01/2025 661.31 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 683.76 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24575 MEDSV DEF RBRVS 01/01/2025 671.63 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24576 MEDSV DEF RBRVS 01/01/2024 12/31/2024 334.85 Description: TREAT HUMERUS FRACTURE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24576 MEDSV DEF RBRVS 01/01/2025 332.99 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24577 MEDSV DEF RBRVS 01/01/2024 12/31/2024 525.82 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24577 MEDSV DEF RBRVS 01/01/2025 518.99 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24579 MEDSV DEF RBRVS 01/01/2024 12/31/2024 777.97 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24579 MEDSV DEF RBRVS 01/01/2025 762.66 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24582 MEDSV DEF RBRVS 01/01/2024 12/31/2024 762.03 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24582 MEDSV DEF RBRVS 01/01/2025 748.63 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24586 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1008.34 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24586 MEDSV DEF RBRVS 01/01/2025 986.23 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24587 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1008.89 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24587 MEDSV DEF RBRVS 01/01/2025 986.79 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 358.75 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24600 MEDSV DEF RBRVS 01/01/2025 353.78 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 449.95 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24605 MEDSV DEF RBRVS 01/01/2025 442.81 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 666.55 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24615 MEDSV DEF RBRVS 01/01/2025 652.49 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 551.4 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24620 MEDSV DEF RBRVS 01/01/2025 543.12 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 632.14 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24635 MEDSV DEF RBRVS 01/01/2025 619.8 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 98.92 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24640 MEDSV DEF RBRVS 01/01/2025 97.31 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 252.07 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24650 MEDSV DEF RBRVS 01/01/2025 250.34 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24655 MEDSV DEF RBRVS 01/01/2024 12/31/2024 424.97 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24655 MEDSV DEF RBRVS 01/01/2025 422.68 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 614.99 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24665 MEDSV DEF RBRVS 01/01/2025 604.1 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24666 MEDSV DEF RBRVS 01/01/2024 12/31/2024 683.93 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24666 MEDSV DEF RBRVS 01/01/2025 670.08 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 279.05 Description: TREAT ULNAR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24670 MEDSV DEF RBRVS 01/01/2025 276.73 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24675 MEDSV DEF RBRVS 01/01/2024 12/31/2024 436.82 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24675 MEDSV DEF RBRVS 01/01/2025 431 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24685 MEDSV DEF RBRVS 01/01/2024 12/31/2024 611.18 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24685 MEDSV DEF RBRVS 01/01/2025 600.38 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 775.75 Description: FUSION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24800 MEDSV DEF RBRVS 01/01/2025 760.53 Description: FUSION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24802 MEDSV DEF RBRVS 01/01/2024 12/31/2024 930.32 Description: FUSION/GRAFT OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24802 MEDSV DEF RBRVS 01/01/2025 910.17 Description: FUSION/GRAFT OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 685.76 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24900 MEDSV DEF RBRVS 01/01/2025 673.75 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 682.97 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24920 MEDSV DEF RBRVS 01/01/2025 668.9 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24925 MEDSV DEF RBRVS 01/01/2024 12/31/2024 532.68 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24925 MEDSV DEF RBRVS 01/01/2025 522.95 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 719.74 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24930 MEDSV DEF RBRVS 01/01/2025 704.92 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24931 MEDSV DEF RBRVS 01/01/2024 12/31/2024 863.65 Description: AMPUTATE UPPER ARM & IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24931 MEDSV DEF RBRVS 01/01/2025 844.84 Description: AMPUTATE UPPER ARM & IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24935 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1135.53 Description: REVISION OF AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24935 MEDSV DEF RBRVS 01/01/2025 1108.29 Description: REVISION OF AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24940 MEDSV PRF MAXFEE 01/01/2024 1764.79 0 Description: REVISION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX HUMERUS/ELBOW Category: Medical Services CMS Add: 01/01/1982 CMS Term: 25000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 326.03 Description: INCISION OF TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25000 MEDSV DEF RBRVS 01/01/2025 321.77 Description: INCISION OF TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 326.62 0-2 Description: INCISE FLEXOR CARPI RADIALIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25001 MEDSV DEF RBRVS 01/01/2025 323.32 0-2 Description: INCISE FLEXOR CARPI RADIALIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 697.11 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25020 MEDSV DEF RBRVS 01/01/2025 675.15 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25023 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1218.96 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25023 MEDSV DEF RBRVS 01/01/2025 1189.44 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25024 MEDSV DEF RBRVS 01/01/2024 12/31/2024 721.43 0-2 Description: DECOMPRESS FOREARM 2 SPACES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25024 MEDSV DEF RBRVS 01/01/2025 711.71 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1136.05 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25025 MEDSV DEF RBRVS 01/01/2025 1111.12 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25028 MEDSV DEF RBRVS 01/01/2024 12/31/2024 648.89 Description: DRAINAGE OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25028 MEDSV DEF RBRVS 01/01/2025 632.16 Description: DRAINAGE OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25031 MEDSV DEF RBRVS 01/01/2024 12/31/2024 346.05 Description: DRAINAGE OF FOREARM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25031 MEDSV DEF RBRVS 01/01/2025 340.95 Description: DRAINAGE OF FOREARM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 549.3 Description: TREAT FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25035 MEDSV DEF RBRVS 01/01/2025 541.26 Description: TREAT FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 524.12 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25040 MEDSV DEF RBRVS 01/01/2025 513.31 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 239.58 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25065 MEDSV DEF RBRVS 01/01/2025 234.29 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25066 MEDSV DEF RBRVS 01/01/2024 12/31/2024 344.98 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25066 MEDSV DEF RBRVS 01/01/2025 339.72 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25071 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.43 Description: EXC FOREARM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25071 MEDSV DEF RBRVS 01/01/2025 386.68 Description: EXC FOREARM LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25073 MEDSV DEF RBRVS 01/01/2024 12/31/2024 500.19 Description: EXC FOREARM TUM DEEP 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25073 MEDSV DEF RBRVS 01/01/2025 490.18 Description: EXC FOREARM TUM DEEP 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25075 MEDSV DEF RBRVS 01/01/2024 12/31/2024 485.26 Description: EXC FOREARM LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25075 MEDSV DEF RBRVS 01/01/2025 471.29 Description: EXC FOREARM LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25076 MEDSV DEF RBRVS 01/01/2024 12/31/2024 486.09 Description: EXC FOREARM TUM DEEP < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25076 MEDSV DEF RBRVS 01/01/2025 476.68 Description: EXC FOREARM TUM DEEP < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25077 MEDSV DEF RBRVS 01/01/2024 12/31/2024 820.88 Description: RESECT FOREARM/WRIST TUM<3CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 25077 MEDSV DEF RBRVS 01/01/2025 769.11 Description: RESECT FOREARM/WRIST TUM<3CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 25078 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1074.51 Description: RESECT FORARM/WRIST TUM 3CM> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25078 MEDSV DEF RBRVS 01/01/2025 1049.86 Description: RESECT FORARM/WRIST TUM 3CM> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25085 MEDSV DEF RBRVS 01/01/2024 12/31/2024 421.64 Description: INCISION OF WRIST CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25085 MEDSV DEF RBRVS 01/01/2025 415.11 Description: INCISION OF WRIST CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 329.08 Description: BIOPSY OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25100 MEDSV DEF RBRVS 01/01/2025 324.29 Description: BIOPSY OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 380.84 Description: EXPLORE/TREAT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25101 MEDSV DEF RBRVS 01/01/2025 376.12 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 458.66 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25105 MEDSV DEF RBRVS 01/01/2025 450.12 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 579.52 Description: REMOVE WRIST JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25107 MEDSV DEF RBRVS 01/01/2025 570.26 Description: REMOVE WRIST JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25109 MEDSV DEF RBRVS 01/01/2024 12/31/2024 503.68 Description: EXCISE TENDON FOREARM/WRIST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25109 MEDSV DEF RBRVS 01/01/2025 494.54 Description: EXCISE TENDON FOREARM/WRIST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 327.1 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25110 MEDSV DEF RBRVS 01/01/2025 321.13 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 306.21 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25111 MEDSV DEF RBRVS 01/01/2025 302.39 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 367.52 Description: REREMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25112 MEDSV DEF RBRVS 01/01/2025 362.54 Description: REREMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 708.05 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25115 MEDSV DEF RBRVS 01/01/2025 694.77 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25116 MEDSV DEF RBRVS 01/01/2024 12/31/2024 566.74 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25116 MEDSV DEF RBRVS 01/01/2025 557.67 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25118 MEDSV DEF RBRVS 01/01/2024 12/31/2024 360.83 Description: EXCISE WRIST TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25118 MEDSV DEF RBRVS 01/01/2025 355.6 Description: EXCISE WRIST TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25119 MEDSV DEF RBRVS 01/01/2024 12/31/2024 471.05 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25119 MEDSV DEF RBRVS 01/01/2025 462.78 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 471.64 Description: REMOVAL OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25120 MEDSV DEF RBRVS 01/01/2025 463.33 Description: REMOVAL OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 557.15 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25125 MEDSV DEF RBRVS 01/01/2025 547.35 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25126 MEDSV DEF RBRVS 01/01/2024 12/31/2024 560.92 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25126 MEDSV DEF RBRVS 01/01/2025 551.16 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 425.14 Description: REMOVAL OF WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25130 MEDSV DEF RBRVS 01/01/2025 418.01 Description: REMOVAL OF WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 524.86 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25135 MEDSV DEF RBRVS 01/01/2025 516.62 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25136 MEDSV DEF RBRVS 01/01/2024 12/31/2024 466.97 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25136 MEDSV DEF RBRVS 01/01/2025 458.96 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 488.44 Description: REMOVE FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25145 MEDSV DEF RBRVS 01/01/2025 480.13 Description: REMOVE FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 532.09 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25150 MEDSV DEF RBRVS 01/01/2025 521.3 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 548.31 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25151 MEDSV DEF RBRVS 01/01/2025 537.92 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25170 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1354.95 Description: RESECT RADIUS/ULNAR TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25170 MEDSV DEF RBRVS 01/01/2025 1323.78 Description: RESECT RADIUS/ULNAR TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 463.9 Description: REMOVAL OF WRIST BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25210 MEDSV DEF RBRVS 01/01/2025 455.97 Description: REMOVAL OF WRIST BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 581.08 Description: REMOVAL OF WRIST BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25215 MEDSV DEF RBRVS 01/01/2025 570.25 Description: REMOVAL OF WRIST BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 407.67 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25230 MEDSV DEF RBRVS 01/01/2025 400.95 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 404.71 Description: PARTIAL REMOVAL OF 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25240 MEDSV DEF RBRVS 01/01/2025 398.38 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25246 MEDSV DEF RBRVS 01/01/2024 12/31/2024 185.68 Description: INJECTION FOR WRIST X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25246 MEDSV DEF RBRVS 01/01/2025 177.87 Description: INJECTION FOR WRIST X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25248 MEDSV DEF RBRVS 01/01/2024 12/31/2024 389.33 Description: REMOVE FOREARM FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25248 MEDSV DEF RBRVS 01/01/2025 390.33 Description: REMOVE FOREARM FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 499.81 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25250 MEDSV DEF RBRVS 01/01/2025 491.31 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25251 MEDSV DEF RBRVS 01/01/2024 12/31/2024 671.03 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25251 MEDSV DEF RBRVS 01/01/2025 657.8 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25259 MEDSV DEF RBRVS 01/01/2024 12/31/2024 407.37 Description: MANIPULATE WRIST W/ANESTHES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25259 MEDSV DEF RBRVS 01/01/2025 403.07 Description: MANIPULATE WRIST W/ANESTHES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 595.61 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25260 MEDSV DEF RBRVS 01/01/2025 584.19 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25263 MEDSV DEF RBRVS 01/01/2024 12/31/2024 593.19 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25263 MEDSV DEF RBRVS 01/01/2025 582.47 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 701.76 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25265 MEDSV DEF RBRVS 01/01/2025 689.06 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 464.83 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25270 MEDSV DEF RBRVS 01/01/2025 456.27 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25272 MEDSV DEF RBRVS 01/01/2024 12/31/2024 524.21 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25272 MEDSV DEF RBRVS 01/01/2025 514.71 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25274 MEDSV DEF RBRVS 01/01/2024 12/31/2024 624.45 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25274 MEDSV DEF RBRVS 01/01/2025 611.18 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 629.65 Description: REPAIR FOREARM TENDON SHEATH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25275 MEDSV DEF RBRVS 01/01/2025 617.62 Description: REPAIR FOREARM TENDON SHEATH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 531.31 Description: REVISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25280 MEDSV DEF RBRVS 01/01/2025 521.73 Description: REVISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.32 Description: INCISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25290 MEDSV DEF RBRVS 01/01/2025 403.68 Description: INCISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25295 MEDSV DEF RBRVS 01/01/2024 12/31/2024 495.43 Description: RELEASE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25295 MEDSV DEF RBRVS 01/01/2025 486.26 Description: RELEASE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 645.05 Description: FUSION OF TENDONS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25300 MEDSV DEF RBRVS 01/01/2025 632.67 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25301 MEDSV DEF RBRVS 01/01/2024 12/31/2024 603.02 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25301 MEDSV DEF RBRVS 01/01/2025 591.85 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 582.89 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25310 MEDSV DEF RBRVS 01/01/2025 572.2 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25312 MEDSV DEF RBRVS 01/01/2024 12/31/2024 671.26 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25312 MEDSV DEF RBRVS 01/01/2025 657.68 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25315 MEDSV DEF RBRVS 01/01/2024 12/31/2024 716.97 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25315 MEDSV DEF RBRVS 01/01/2025 702.41 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25316 MEDSV DEF RBRVS 01/01/2024 12/31/2024 851.46 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25316 MEDSV DEF RBRVS 01/01/2025 833.73 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 922.62 Description: REPAIR/REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25320 MEDSV DEF RBRVS 01/01/2025 907.57 Description: REPAIR/REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25332 MEDSV DEF RBRVS 01/01/2024 12/31/2024 789.03 Description: REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25332 MEDSV DEF RBRVS 01/01/2025 773.2 Description: REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 877.4 Description: CENTRALIZATION WRIST ON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25335 MEDSV DEF RBRVS 01/01/2025 858.45 Description: CENTRALIZATION WRIST ON ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25337 MEDSV DEF RBRVS 01/01/2024 12/31/2024 829.73 Description: RECONSTRUCT ULNA/RADIOULNAR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25337 MEDSV DEF RBRVS 01/01/2025 814.22 Description: RECONSTRUCT ULNA/RADIOULNAR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 632.22 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25350 MEDSV DEF RBRVS 01/01/2025 619.31 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25355 MEDSV DEF RBRVS 01/01/2024 12/31/2024 712.62 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25355 MEDSV DEF RBRVS 01/01/2025 698.67 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 614.01 Description: REVISION OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25360 MEDSV DEF RBRVS 01/01/2025 602.42 Description: REVISION OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 852.42 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25365 MEDSV DEF RBRVS 01/01/2025 834.36 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 940.59 Description: REVISE RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25370 MEDSV DEF RBRVS 01/01/2025 920.59 Description: REVISE RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25375 MEDSV DEF RBRVS 01/01/2024 12/31/2024 885.92 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25375 MEDSV DEF RBRVS 01/01/2025 866.88 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 718.77 Description: SHORTEN RADIUS OR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25390 MEDSV DEF RBRVS 01/01/2025 703.52 Description: SHORTEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25391 MEDSV DEF RBRVS 01/01/2024 12/31/2024 924.64 Description: LENGTHEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25391 MEDSV DEF RBRVS 01/01/2025 904.48 Description: LENGTHEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25392 MEDSV DEF RBRVS 01/01/2024 12/31/2024 940.71 Description: SHORTEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25392 MEDSV DEF RBRVS 01/01/2025 920.08 Description: SHORTEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25393 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1046.04 Description: LENGTHEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25393 MEDSV DEF RBRVS 01/01/2025 1022.7 Description: LENGTHEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25394 MEDSV DEF RBRVS 01/01/2024 12/31/2024 730.3 0-2 Description: REPAIR CARPAL BONE SHORTEN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25394 MEDSV DEF RBRVS 01/01/2025 716.14 0-2 Description: REPAIR CARPAL BONE SHORTEN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 749.34 Description: REPAIR RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25400 MEDSV DEF RBRVS 01/01/2025 732.75 Description: REPAIR RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 964.17 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25405 MEDSV DEF RBRVS 01/01/2025 943.14 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 899.05 Description: REPAIR RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25415 MEDSV DEF RBRVS 01/01/2025 879.62 Description: REPAIR RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1079.65 Description: REPAIR/GRAFT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25420 MEDSV DEF RBRVS 01/01/2025 1056.45 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 894.94 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25425 MEDSV DEF RBRVS 01/01/2025 875.64 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25426 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1040.14 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25426 MEDSV DEF RBRVS 01/01/2025 1017.11 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 682.58 Description: VASC GRAFT INTO CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25430 MEDSV DEF RBRVS 01/01/2025 670.03 Description: VASC GRAFT INTO CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25431 MEDSV DEF RBRVS 01/01/2024 12/31/2024 733.68 0-2 Description: REPAIR NONUNION CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25431 MEDSV DEF RBRVS 01/01/2025 719.12 0-2 Description: REPAIR NONUNION CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 718.23 Description: REPAIR NONU SCPHD CARPL B1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25440 MEDSV DEF RBRVS 01/01/2025 703.63 Description: REPAIR NONU SCPHD CARPL B1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25441 MEDSV DEF RBRVS 01/01/2024 12/31/2024 871.98 Description: ARTHRP W/PROSTC DSTL RDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25441 MEDSV DEF RBRVS 01/01/2025 853.04 Description: ARTHRP W/PROSTC DSTL RDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25442 MEDSV DEF RBRVS 01/01/2024 12/31/2024 756.06 Description: ARTHRP W/PROSTC DSTL ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25442 MEDSV DEF RBRVS 01/01/2025 740.28 Description: ARTHRP W/PROSTC DSTL ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25443 MEDSV DEF RBRVS 01/01/2024 12/31/2024 731.87 Description: ARTHRP PROSTC DSTL SCPH CRPL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25443 MEDSV DEF RBRVS 01/01/2025 717.59 Description: ARTHRP PROSTC DSTL SCPH CRPL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25444 MEDSV DEF RBRVS 01/01/2024 12/31/2024 772.3 Description: ARTHRP W/PROSTC LUNATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25444 MEDSV DEF RBRVS 01/01/2025 752.27 Description: ARTHRP W/PROSTC LUNATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 674.38 Description: ARTHRP W/PROSTC TRAPEZIUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25445 MEDSV DEF RBRVS 01/01/2025 660.26 Description: ARTHRP W/PROSTC TRAPEZIUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25446 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1089.86 Description: ARTHRP W/PROSTC DST RDS&CRPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25446 MEDSV DEF RBRVS 01/01/2025 1065.68 Description: ARTHRP W/PROSTC DST RDS&CRPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25447 MEDSV DEF RBRVS 01/01/2024 12/31/2024 777.57 Description: ARTHRP NTRCRP/CRP/MTCR NTRPS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25447 MEDSV DEF RBRVS 01/01/2025 762.67 Description: ARTHRP NTRCRP/CRP/MTCR NTRPS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25448 MEDSV DEF RBRVS 01/01/2025 817.72 Y Description: ARTHRP NTRCRPL/CRP/MTCRP SSP Category: Medical Services CMS Add: 01/01/2025 CMS Term: 25449 MEDSV DEF RBRVS 01/01/2024 12/31/2024 961.62 Description: REVJ ARTHRP WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25449 MEDSV DEF RBRVS 01/01/2025 940.93 Description: REVJ ARTHRP WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 577.67 Description: EPIPHYSL ARRST DSTL RDS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25450 MEDSV DEF RBRVS 01/01/2025 567.12 Description: EPIPHYSL ARRST DSTL RDS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25455 MEDSV DEF RBRVS 01/01/2024 12/31/2024 681.65 Description: EPIPHYSL ARRST DSTL RDS&ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25455 MEDSV DEF RBRVS 01/01/2025 668.52 Description: EPIPHYSL ARRST DSTL RDS&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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25490 MEDSV DEF RBRVS 01/01/2024 12/31/2024 670.6 Description: PROPHYLACTIC TX RADIUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25490 MEDSV DEF RBRVS 01/01/2025 657.56 Description: PROPHYLACTIC TX RADIUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25491 MEDSV DEF RBRVS 01/01/2024 12/31/2024 688.9 Description: PROPHYLACTIC TX ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25491 MEDSV DEF RBRVS 01/01/2025 675.45 Description: PROPHYLACTIC TX ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25492 MEDSV DEF RBRVS 01/01/2024 12/31/2024 842.67 Description: PROPHYLACTIC TX RADIUS&ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25492 MEDSV DEF RBRVS 01/01/2025 825.38 Description: PROPHYLACTIC TX RADIUS&ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 271.65 Description: CLTX RDL SHFT FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25500 MEDSV DEF RBRVS 01/01/2025 269.99 Description: CLTX RDL SHFT FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 481.13 Description: CLTX RDL SHFT FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25505 MEDSV DEF RBRVS 01/01/2025 475.96 Description: CLTX RDL SHFT FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 626.71 Description: OPTX RADIAL SHAFT FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25515 MEDSV DEF RBRVS 01/01/2025 616.17 Description: OPTX RADIAL SHAFT FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 544.97 Description: CLTX RDL SHFT FX&DISLC Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25520 MEDSV DEF RBRVS 01/01/2025 536.92 Description: CLTX RDL SHFT FX&DISLC Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 738.57 Description: OPTX RDL SHFT FX&CLTX RAD/UL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25525 MEDSV DEF RBRVS 01/01/2025 723.87 Description: OPTX RDL SHFT FX&CLTX RAD/UL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25526 MEDSV DEF RBRVS 01/01/2024 12/31/2024 889.29 Description: OPTX RDL SHFT FX&DSTL RAD/UL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25526 MEDSV DEF RBRVS 01/01/2025 871.83 Description: OPTX RDL SHFT FX&DSTL RAD/UL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 252.31 Description: CLTX ULNAR SHFT FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25530 MEDSV DEF RBRVS 01/01/2025 251.35 Description: CLTX ULNAR SHFT FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 469.41 Description: CLTX ULNAR SHFT FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25535 MEDSV DEF RBRVS 01/01/2025 463.31 Description: CLTX ULNAR SHFT FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 585.59 Description: OPTX ULNAR SHFT FX INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25545 MEDSV DEF RBRVS 01/01/2025 575.19 Description: OPTX ULNAR SHFT FX INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 277.03 Description: CLTX RDL&ULN SHFT FX WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25560 MEDSV DEF RBRVS 01/01/2025 274.95 Description: CLTX RDL&ULN SHFT FX WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25565 MEDSV DEF RBRVS 01/01/2024 12/31/2024 493.22 Description: CLTX RDL&ULN SHFT FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25565 MEDSV DEF RBRVS 01/01/2025 484.9 Description: CLTX RDL&ULN SHFT FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25574 MEDSV DEF RBRVS 01/01/2024 12/31/2024 632.28 Description: OPTX RDL&ULN SHFT FX RDS/ULN Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25574 MEDSV DEF RBRVS 01/01/2025 619.81 Description: OPTX RDL&ULN SHFT FX RDS/ULN Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 842.24 Description: OPTX RDL&ULN SHFT FX RDS&ULN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25575 MEDSV DEF RBRVS 01/01/2025 825.81 Description: OPTX RDL&ULN SHFT FX RDS&ULN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 323.01 Description: CLTX DST RDL FX/EPHYS SEP WO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25600 MEDSV DEF RBRVS 01/01/2025 320.6 Description: CLTX DST RDL FX/EPHYS SEP WO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 511.3 Description: CLTX DST RDL FX/EPHYS SEP W/ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25605 MEDSV DEF RBRVS 01/01/2025 503.94 Description: CLTX DST RDL FX/EPHYS SEP W/ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 625.5 Description: PERQ SKEL FIXJ DSTL RDL FX Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25606 MEDSV DEF RBRVS 01/01/2025 615.48 Description: PERQ SKEL FIXJ DSTL RDL FX Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25607 MEDSV DEF RBRVS 01/01/2024 12/31/2024 692.09 Description: OPTX DST RD XARTC FX/EPI SEP Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25607 MEDSV DEF RBRVS 01/01/2025 679.96 Description: OPTX DST RD XARTC FX/EPI SEP Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25608 MEDSV DEF RBRVS 01/01/2024 12/31/2024 772.77 Description: OPTX DST RD XART FX/EPI SEP2 Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25608 MEDSV DEF RBRVS 01/01/2025 758.78 Description: OPTX DST RD XART FX/EPI SEP2 Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25609 MEDSV DEF RBRVS 01/01/2024 12/31/2024 980.42 Description: OPTX DST RD XART FX/EP SEP3+ Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25609 MEDSV DEF RBRVS 01/01/2025 961.22 Description: OPTX DST RD XART FX/EP SEP3+ Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25622 MEDSV DEF RBRVS 01/01/2024 12/31/2024 293.86 Description: CLTX CARPL SCPHD FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25622 MEDSV DEF RBRVS 01/01/2025 291.48 Description: CLTX CARPL SCPHD FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25624 MEDSV DEF RBRVS 01/01/2024 12/31/2024 465.12 Description: CLTX CARPL SCPHD FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25624 MEDSV DEF RBRVS 01/01/2025 460.53 Description: CLTX CARPL SCPHD FX W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25628 MEDSV DEF RBRVS 01/01/2024 12/31/2024 673.39 Description: OPTX CARPL SCPHD FX INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25628 MEDSV DEF RBRVS 01/01/2025 660.26 Description: OPTX CARPL SCPHD FX INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 291.99 Description: CLTX CARPL FX W/O MNPJ EA B1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25630 MEDSV DEF RBRVS 01/01/2025 288.96 Description: CLTX CARPL FX W/O MNPJ EA B1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 441.3 Description: CLTX CARPL FX W/MNPJ EA B1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25635 MEDSV DEF RBRVS 01/01/2025 437 Description: CLTX CARPL FX W/MNPJ EA B1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25645 MEDSV DEF RBRVS 01/01/2024 12/31/2024 535.21 Description: OPTX CRPL FX OTH/THN SCPH EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25645 MEDSV DEF RBRVS 01/01/2025 525.08 Description: OPTX CRPL FX OTH/THN SCPH EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 315.48 Description: CLTX ULNAR STYLOID FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25650 MEDSV DEF RBRVS 01/01/2025 311.4 Description: CLTX ULNAR STYLOID FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25651 MEDSV DEF RBRVS 01/01/2024 12/31/2024 460.83 Description: PERQ SKEL FIX ULNAR STYLD FX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25651 MEDSV DEF RBRVS 01/01/2025 454.73 Description: PERQ SKEL FIX ULNAR STYLD FX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25652 MEDSV DEF RBRVS 01/01/2024 12/31/2024 583.95 Description: OPTX ULNAR STYLOID FRACTURE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25652 MEDSV DEF RBRVS 01/01/2025 573.26 Description: OPTX ULNAR STYLOID FRACTURE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 423.8 Description: CLTX RDCRPL/NTRCRPL DISLC 1+ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25660 MEDSV DEF RBRVS 01/01/2025 418.39 Description: CLTX RDCRPL/NTRCRPL DISLC 1+ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 569.54 Description: OPTX RDCRPL/NTRCRPL DISLC 1+ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25670 MEDSV DEF RBRVS 01/01/2025 558.24 Description: OPTX RDCRPL/NTRCRPL DISLC 1+ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25671 MEDSV DEF RBRVS 01/01/2024 12/31/2024 498.97 Description: PERQ SKEL FIX RAD/ULN DISLC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25671 MEDSV DEF RBRVS 01/01/2025 494.4 Description: PERQ SKEL FIX RAD/ULN DISLC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25675 MEDSV DEF RBRVS 01/01/2024 12/31/2024 433.08 Description: CLTX DSTL RAD/ULN DISLC MNPJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25675 MEDSV DEF RBRVS 01/01/2025 427.96 Description: CLTX DSTL RAD/ULN DISLC MNPJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25676 MEDSV DEF RBRVS 01/01/2024 12/31/2024 590.98 Description: OPTX RAD/ULN DISLC AQT/CHRNC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25676 MEDSV DEF RBRVS 01/01/2025 580.63 Description: OPTX RAD/ULN DISLC AQT/CHRNC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 499.05 Description: CLTX TRNS-SCPHPRLNR FX MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25680 MEDSV DEF RBRVS 01/01/2025 491.81 Description: CLTX TRNS-SCPHPRLNR FX MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25685 MEDSV DEF RBRVS 01/01/2024 12/31/2024 685.47 Description: OPTX TRNS-SCPHPRLNR FX DISLC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25685 MEDSV DEF RBRVS 01/01/2025 671.96 Description: OPTX TRNS-SCPHPRLNR FX DISLC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25690 MEDSV DEF RBRVS 01/01/2024 12/31/2024 463.17 Description: CLTX LUNATE DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25690 MEDSV DEF RBRVS 01/01/2025 456.93 Description: CLTX LUNATE DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25695 MEDSV DEF RBRVS 01/01/2024 12/31/2024 592.82 Description: OPTX LUNATE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25695 MEDSV DEF RBRVS 01/01/2025 581.48 Description: OPTX LUNATE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 684.85 Description: ARTHRD WRIST COMPLETE WO GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25800 MEDSV DEF RBRVS 01/01/2025 669.66 Description: ARTHRD WRIST COMPLETE WO GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 788.96 Description: ARTHRD WRIST W/SLIDING GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25805 MEDSV DEF RBRVS 01/01/2025 772.87 Description: ARTHRD WRIST W/SLIDING GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 809.45 Description: ARTHRD WRST ILIAC/OTH AGRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25810 MEDSV DEF RBRVS 01/01/2025 793.39 Description: ARTHRD WRST ILIAC/OTH AGRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 609.62 Description: ARTHRD WRIST LMTD W/O B1 GRF Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25820 MEDSV DEF RBRVS 01/01/2025 595.8 Description: ARTHRD WRIST LMTD W/O B1 GRF Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 743.67 Description: ARTHRD WRIST WITH AUTOGRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25825 MEDSV DEF RBRVS 01/01/2025 727.5 Description: ARTHRD WRIST WITH AUTOGRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 949.92 Description: ARTHRD DST RAD/UL JT SGM RSC Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25830 MEDSV DEF RBRVS 01/01/2025 938.27 Description: ARTHRD DST RAD/UL JT SGM RSC Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 668.48 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25900 MEDSV DEF RBRVS 01/01/2025 656.41 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 654.26 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25905 MEDSV DEF RBRVS 01/01/2025 641.48 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25907 MEDSV DEF RBRVS 01/01/2024 12/31/2024 574.36 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25907 MEDSV DEF RBRVS 01/01/2025 564.04 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25909 MEDSV DEF RBRVS 01/01/2024 12/31/2024 639.65 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25909 MEDSV DEF RBRVS 01/01/2025 626.52 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25915 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1079.78 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25915 MEDSV DEF RBRVS 01/01/2025 1055.48 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 682.44 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25920 MEDSV DEF RBRVS 01/01/2025 667.11 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25922 MEDSV DEF RBRVS 01/01/2024 12/31/2024 605.09 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25922 MEDSV DEF RBRVS 01/01/2025 591.98 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25924 MEDSV DEF RBRVS 01/01/2024 12/31/2024 666.77 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25924 MEDSV DEF RBRVS 01/01/2025 651.73 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25927 MEDSV DEF RBRVS 01/01/2024 12/31/2024 809.36 Description: AMPUTATION OF HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25927 MEDSV DEF RBRVS 01/01/2025 786.84 Description: AMPUTATION OF HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25929 MEDSV DEF RBRVS 01/01/2024 12/31/2024 559.78 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25929 MEDSV DEF RBRVS 01/01/2025 549.72 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25931 MEDSV DEF RBRVS 01/01/2024 12/31/2024 749.4 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25931 MEDSV DEF RBRVS 01/01/2025 728.89 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25999 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX FOREARM/WRIST Category: Medical Services CMS Add: 01/01/1982 CMS Term: 26010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 322.79 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26010 MEDSV DEF RBRVS 01/01/2025 312.97 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26011 MEDSV DEF RBRVS 01/01/2024 12/31/2024 451.11 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26011 MEDSV DEF RBRVS 01/01/2025 432.48 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 521.9 Description: DRAIN HAND TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26020 MEDSV DEF RBRVS 01/01/2025 512.26 Description: DRAIN HAND TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.82 Description: DRAINAGE OF PALM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26025 MEDSV DEF RBRVS 01/01/2025 386.16 Description: DRAINAGE OF PALM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 460.93 Description: DRAINAGE OF PALM BURSAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26030 MEDSV DEF RBRVS 01/01/2025 452.71 Description: DRAINAGE OF PALM BURSAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26034 MEDSV DEF RBRVS 01/01/2024 12/31/2024 517.08 Description: TREAT HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26034 MEDSV DEF RBRVS 01/01/2025 508.51 Description: TREAT HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 801.57 Description: DECOMPRESS FINGERS/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26035 MEDSV DEF RBRVS 01/01/2025 786.54 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26037 MEDSV DEF RBRVS 01/01/2024 12/31/2024 525.6 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26037 MEDSV DEF RBRVS 01/01/2025 515.46 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 298.58 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26040 MEDSV DEF RBRVS 01/01/2025 294.33 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26045 MEDSV DEF RBRVS 01/01/2024 12/31/2024 443.88 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26045 MEDSV DEF RBRVS 01/01/2025 436.52 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26055 MEDSV DEF RBRVS 01/01/2024 12/31/2024 554.02 Description: INCISE FINGER TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26055 MEDSV DEF RBRVS 01/01/2025 537.19 Description: INCISE FINGER TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 241.54 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26060 MEDSV DEF RBRVS 01/01/2025 238.02 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 304.89 Description: EXPLORE/TREAT HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26070 MEDSV DEF RBRVS 01/01/2025 300.41 Description: EXPLORE/TREAT HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26075 MEDSV DEF RBRVS 01/01/2024 12/31/2024 319.44 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26075 MEDSV DEF RBRVS 01/01/2025 314.28 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 375.53 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26080 MEDSV DEF RBRVS 01/01/2025 370.29 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 319.56 Description: BIOPSY HAND JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26100 MEDSV DEF RBRVS 01/01/2025 315.21 Description: BIOPSY HAND JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 321.85 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26105 MEDSV DEF RBRVS 01/01/2025 317.13 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 307.35 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26110 MEDSV DEF RBRVS 01/01/2025 302.41 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 389.02 Description: EXC HAND LES SC 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26111 MEDSV DEF RBRVS 01/01/2025 382.54 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 12/31/2024 512.45 Description: EXC HAND TUM DEEP 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26113 MEDSV DEF RBRVS 01/01/2025 503.51 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 12/31/2024 515.47 Description: EXC HAND LES SC < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26115 MEDSV DEF RBRVS 01/01/2025 502.05 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 12/31/2024 492.55 Description: EXC HAND TUM DEEP < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26116 MEDSV DEF RBRVS 01/01/2025 483.74 Description: EXC HAND TUM DEEP < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26117 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.7 Description: RAD RESECT HAND TUMOR < 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26117 MEDSV DEF RBRVS 01/01/2025 680.86 Description: RAD RESECT HAND TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26118 MEDSV DEF RBRVS 01/01/2024 12/31/2024 979.66 Description: RAD RESECT HAND TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26118 MEDSV DEF RBRVS 01/01/2025 952.94 Description: RAD RESECT HAND TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 562.51 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26121 MEDSV DEF RBRVS 01/01/2025 551.95 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26123 MEDSV DEF RBRVS 01/01/2024 12/31/2024 783.85 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26123 MEDSV DEF RBRVS 01/01/2025 769.51 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 247.82 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26125 MEDSV DEF RBRVS 01/01/2025 240.82 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 440.39 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26130 MEDSV DEF RBRVS 01/01/2025 433.18 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 520.64 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26135 MEDSV DEF RBRVS 01/01/2025 510.46 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 477.55 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26140 MEDSV DEF RBRVS 01/01/2025 469.83 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 484.98 Description: TENDON EXCISION PALM/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26145 MEDSV DEF RBRVS 01/01/2025 476.58 Description: TENDON EXCISION PALM/FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 577.69 Description: REMOVE TENDON SHEATH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26160 MEDSV DEF RBRVS 01/01/2025 560.92 Description: REMOVE TENDON SHEATH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26170 MEDSV DEF RBRVS 01/01/2024 12/31/2024 384.93 Description: REMOVAL OF PALM TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26170 MEDSV DEF RBRVS 01/01/2025 378.56 Description: REMOVAL OF PALM TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 423.81 Description: REMOVAL OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26180 MEDSV DEF RBRVS 01/01/2025 417.04 Description: REMOVAL OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26185 MEDSV DEF RBRVS 01/01/2024 12/31/2024 522.03 Description: REMOVE FINGER BONE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26185 MEDSV DEF RBRVS 01/01/2025 514.64 Description: REMOVE FINGER BONE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 424.62 Description: REMOVE HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26200 MEDSV DEF RBRVS 01/01/2025 416.81 Description: REMOVE HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 565.84 Description: REMOVE/GRAFT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26205 MEDSV DEF RBRVS 01/01/2025 555.15 Description: REMOVE/GRAFT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.18 Description: REMOVAL OF FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26210 MEDSV DEF RBRVS 01/01/2025 415.16 Description: REMOVAL OF FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 531.35 Description: REMOVE/GRAFT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26215 MEDSV DEF RBRVS 01/01/2025 521.36 Description: REMOVE/GRAFT FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 470.1 Description: PARTIAL REMOVAL OF HAND BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26230 MEDSV DEF RBRVS 01/01/2025 461.14 Description: PARTIAL REMOVAL OF HAND BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 463.01 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26235 MEDSV DEF RBRVS 01/01/2025 455.17 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26236 MEDSV DEF RBRVS 01/01/2024 12/31/2024 414.45 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26236 MEDSV DEF RBRVS 01/01/2025 408.46 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 987 Description: EXTENSIVE HAND SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26250 MEDSV DEF RBRVS 01/01/2025 966.8 Description: EXTENSIVE HAND SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 740.56 Description: RESECT PROX FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26260 MEDSV DEF RBRVS 01/01/2025 725.73 Description: RESECT PROX FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26262 MEDSV DEF RBRVS 01/01/2024 12/31/2024 588.12 Description: RESECT DISTAL FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26262 MEDSV DEF RBRVS 01/01/2025 577.86 Description: RESECT DISTAL FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 329.45 Description: REMOVAL OF IMPLANT FROM HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26320 MEDSV DEF RBRVS 01/01/2025 323.84 Description: REMOVAL OF IMPLANT FROM HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 334.63 Description: MANIPULATE FINGER W/ANESTH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26340 MEDSV DEF RBRVS 01/01/2025 333.31 Description: MANIPULATE FINGER W/ANESTH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 26341 MEDSV DEF RBRVS 01/01/2024 12/31/2024 109.68 Description: MANIPULAT PALM CORD POST INJ Category: Medical Services CMS Add: 01/01/2012 CMS Term: 26341 MEDSV DEF RBRVS 01/01/2025 107.37 Description: MANIPULAT PALM CORD POST INJ Category: Medical Services CMS Add: 01/01/2012 CMS Term: 26350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 703.75 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26350 MEDSV DEF RBRVS 01/01/2025 684.61 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26352 MEDSV DEF RBRVS 01/01/2024 12/31/2024 785.07 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26352 MEDSV DEF RBRVS 01/01/2025 761.38 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26356 MEDSV DEF RBRVS 01/01/2024 12/31/2024 746.05 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26356 MEDSV DEF RBRVS 01/01/2025 730.91 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26357 MEDSV DEF RBRVS 01/01/2024 12/31/2024 831.9 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26357 MEDSV DEF RBRVS 01/01/2025 815.42 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26358 MEDSV DEF RBRVS 01/01/2024 12/31/2024 916.26 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26358 MEDSV DEF RBRVS 01/01/2025 897.96 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 739.51 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26370 MEDSV DEF RBRVS 01/01/2025 717.21 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26372 MEDSV DEF RBRVS 01/01/2024 12/31/2024 859.42 Description: REPAIR/GRAFT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26372 MEDSV DEF RBRVS 01/01/2025 834.92 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26373 MEDSV DEF RBRVS 01/01/2024 12/31/2024 827.74 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26373 MEDSV DEF RBRVS 01/01/2025 803.85 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 823.56 Description: REVISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26390 MEDSV DEF RBRVS 01/01/2025 800.45 Description: REVISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26392 MEDSV DEF RBRVS 01/01/2024 12/31/2024 938.82 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26392 MEDSV DEF RBRVS 01/01/2025 912.34 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 568.03 Description: REPAIR HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26410 MEDSV DEF RBRVS 01/01/2025 551.8 Description: REPAIR HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26412 MEDSV DEF RBRVS 01/01/2024 12/31/2024 676.35 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26412 MEDSV DEF RBRVS 01/01/2025 655.74 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 799.66 Description: EXCISION HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26415 MEDSV DEF RBRVS 01/01/2025 776.51 Description: EXCISION HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26416 MEDSV DEF RBRVS 01/01/2024 12/31/2024 864.09 Description: GRAFT HAND OR FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26416 MEDSV DEF RBRVS 01/01/2025 839.9 Description: GRAFT HAND OR FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26418 MEDSV DEF RBRVS 01/01/2024 12/31/2024 589.46 Description: REPAIR FINGER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26418 MEDSV DEF RBRVS 01/01/2025 573.93 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.33 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26420 MEDSV DEF RBRVS 01/01/2025 680.53 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26426 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.65 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26426 MEDSV DEF RBRVS 01/01/2025 465.27 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26428 MEDSV DEF RBRVS 01/01/2024 12/31/2024 749.4 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26428 MEDSV DEF RBRVS 01/01/2025 728.21 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26432 MEDSV DEF RBRVS 01/01/2024 12/31/2024 514.56 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26432 MEDSV DEF RBRVS 01/01/2025 499.71 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26433 MEDSV DEF RBRVS 01/01/2024 12/31/2024 541.11 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26433 MEDSV DEF RBRVS 01/01/2025 524.88 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26434 MEDSV DEF RBRVS 01/01/2024 12/31/2024 655.04 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26434 MEDSV DEF RBRVS 01/01/2025 636.96 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26437 MEDSV DEF RBRVS 01/01/2024 12/31/2024 629.44 Description: REALIGNMENT OF TENDONS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26437 MEDSV DEF RBRVS 01/01/2025 611.85 Description: REALIGNMENT OF TENDONS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 614.78 Description: RELEASE PALM/FINGER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26440 MEDSV DEF RBRVS 01/01/2025 596.46 Description: RELEASE PALM/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26442 MEDSV DEF RBRVS 01/01/2024 12/31/2024 931.24 Description: RELEASE PALM & FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26442 MEDSV DEF RBRVS 01/01/2025 906.53 Description: RELEASE PALM & FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 573.35 Description: RELEASE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26445 MEDSV DEF RBRVS 01/01/2025 554.38 Description: RELEASE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26449 MEDSV DEF RBRVS 01/01/2024 12/31/2024 655.33 Description: RELEASE FOREARM/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26449 MEDSV DEF RBRVS 01/01/2025 644.83 Description: RELEASE FOREARM/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 439.31 Description: INCISION OF PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26450 MEDSV DEF RBRVS 01/01/2025 427.17 Description: INCISION OF PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26455 MEDSV DEF RBRVS 01/01/2024 12/31/2024 436.75 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26455 MEDSV DEF RBRVS 01/01/2025 424.38 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 424.75 Description: INCISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26460 MEDSV DEF RBRVS 01/01/2025 415.88 Description: INCISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26471 MEDSV DEF RBRVS 01/01/2024 12/31/2024 623.26 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26471 MEDSV DEF RBRVS 01/01/2025 605.72 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26474 MEDSV DEF RBRVS 01/01/2024 12/31/2024 614.35 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26474 MEDSV DEF RBRVS 01/01/2025 597.44 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26476 MEDSV DEF RBRVS 01/01/2024 12/31/2024 606.49 Description: TENDON LENGTHENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26476 MEDSV DEF RBRVS 01/01/2025 590.27 Description: TENDON LENGTHENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26477 MEDSV DEF RBRVS 01/01/2024 12/31/2024 591.05 Description: TENDON SHORTENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26477 MEDSV DEF RBRVS 01/01/2025 577.88 Description: TENDON SHORTENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26478 MEDSV DEF RBRVS 01/01/2024 12/31/2024 626.29 Description: LENGTHENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26478 MEDSV DEF RBRVS 01/01/2025 603.79 Description: LENGTHENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26479 MEDSV DEF RBRVS 01/01/2024 12/31/2024 636.19 Description: SHORTENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26479 MEDSV DEF RBRVS 01/01/2025 619.11 Description: SHORTENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26480 MEDSV DEF RBRVS 01/01/2024 12/31/2024 740.63 Y Description: TRANSPLANT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26480 MEDSV DEF RBRVS 01/01/2025 719.8 Y Description: TRANSPLANT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26483 MEDSV DEF RBRVS 01/01/2024 12/31/2024 819.69 Y Description: TRANSPLANT/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26483 MEDSV DEF RBRVS 01/01/2025 797.45 Y Description: TRANSPLANT/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26485 MEDSV DEF RBRVS 01/01/2024 12/31/2024 787.43 Y Description: TRANSPLANT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26485 MEDSV DEF RBRVS 01/01/2025 765.52 Y Description: TRANSPLANT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26489 MEDSV DEF RBRVS 01/01/2024 12/31/2024 905.17 Y Description: TRANSPLANT/GRAFT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26489 MEDSV DEF RBRVS 01/01/2025 879.05 Y Description: TRANSPLANT/GRAFT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26490 MEDSV DEF RBRVS 01/01/2024 12/31/2024 787.9 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26490 MEDSV DEF RBRVS 01/01/2025 766.33 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26492 MEDSV DEF RBRVS 01/01/2024 12/31/2024 870.23 Description: TENDON TRANSFER WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26492 MEDSV DEF RBRVS 01/01/2025 846.84 Description: TENDON TRANSFER WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26494 MEDSV DEF RBRVS 01/01/2024 12/31/2024 791.02 Description: HAND TENDON/MUSCLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26494 MEDSV DEF RBRVS 01/01/2025 769.52 Description: HAND TENDON/MUSCLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26496 MEDSV DEF RBRVS 01/01/2024 12/31/2024 850.89 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26496 MEDSV DEF RBRVS 01/01/2025 827.51 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26497 MEDSV DEF RBRVS 01/01/2024 12/31/2024 849.91 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26497 MEDSV DEF RBRVS 01/01/2025 826.4 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26498 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1102.4 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26498 MEDSV DEF RBRVS 01/01/2025 1072.3 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26499 MEDSV DEF RBRVS 01/01/2024 12/31/2024 818.57 Y Description: REVISION OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26499 MEDSV DEF RBRVS 01/01/2025 795.65 Y Description: REVISION OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 625.39 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26500 MEDSV DEF RBRVS 01/01/2025 630.11 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 710.53 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26502 MEDSV DEF RBRVS 01/01/2025 691.29 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26508 MEDSV DEF RBRVS 01/01/2024 12/31/2024 638.66 Description: RELEASE THUMB CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26508 MEDSV DEF RBRVS 01/01/2025 621.85 Description: RELEASE THUMB CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 606.61 Description: THUMB TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26510 MEDSV DEF RBRVS 01/01/2025 587.86 Description: THUMB TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26516 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.89 Description: FUSION OF KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26516 MEDSV DEF RBRVS 01/01/2025 681.41 Description: FUSION OF KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26517 MEDSV DEF RBRVS 01/01/2024 12/31/2024 813.66 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26517 MEDSV DEF RBRVS 01/01/2025 791.18 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26518 MEDSV DEF RBRVS 01/01/2024 12/31/2024 823.83 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26518 MEDSV DEF RBRVS 01/01/2025 801.06 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 644.46 Description: RELEASE KNUCKLE CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26520 MEDSV DEF RBRVS 01/01/2025 624.93 Description: RELEASE KNUCKLE CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 647.04 Description: RELEASE FINGER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26525 MEDSV DEF RBRVS 01/01/2025 628.34 Description: RELEASE FINGER CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 507.19 Description: REVISE KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26530 MEDSV DEF RBRVS 01/01/2025 500.57 Description: REVISE KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26531 MEDSV DEF RBRVS 01/01/2024 12/31/2024 592.62 Description: REVISE KNUCKLE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26531 MEDSV DEF RBRVS 01/01/2025 581.54 Description: REVISE KNUCKLE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 412.87 Description: REVISE FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26535 MEDSV DEF RBRVS 01/01/2025 406.15 Description: REVISE FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26536 MEDSV DEF RBRVS 01/01/2024 12/31/2024 706.85 Description: REVISE/IMPLANT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26536 MEDSV DEF RBRVS 01/01/2025 687.19 Description: REVISE/IMPLANT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 660.2 Description: REPAIR HAND JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26540 MEDSV DEF RBRVS 01/01/2025 641.42 Description: REPAIR HAND JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26541 MEDSV DEF RBRVS 01/01/2024 12/31/2024 784.46 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26541 MEDSV DEF RBRVS 01/01/2025 765.13 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26542 MEDSV DEF RBRVS 01/01/2024 12/31/2024 680.59 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26542 MEDSV DEF RBRVS 01/01/2025 662.57 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.13 Description: RECONSTRUCT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26545 MEDSV DEF RBRVS 01/01/2025 674.18 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26546 MEDSV DEF RBRVS 01/01/2024 12/31/2024 975.1 Description: REPAIR NONUNION HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26546 MEDSV DEF RBRVS 01/01/2025 949.92 Description: REPAIR NONUNION HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26548 MEDSV DEF RBRVS 01/01/2024 12/31/2024 753.44 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26548 MEDSV DEF RBRVS 01/01/2025 732.59 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1538.81 Description: POLLICIZATION DIGIT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26550 MEDSV DEF RBRVS 01/01/2025 1495.18 Description: POLLICIZATION DIGIT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26551 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3046.37 Description: GREAT TOE-HAND TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26551 MEDSV DEF RBRVS 01/01/2025 2963.71 Description: GREAT TOE-HAND TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26553 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3026.26 Description: SINGLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26553 MEDSV DEF RBRVS 01/01/2025 2943.85 Description: SINGLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3520.87 Description: DOUBLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26554 MEDSV DEF RBRVS 01/01/2025 3425.24 Description: DOUBLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1294.81 Description: POSITIONAL CHANGE OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26555 MEDSV DEF RBRVS 01/01/2025 1258.08 Description: POSITIONAL CHANGE OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3147.15 Description: TOE JOINT TRANSFER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26556 MEDSV DEF RBRVS 01/01/2025 3063.16 Description: TOE JOINT TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 599.31 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26560 MEDSV DEF RBRVS 01/01/2025 582.58 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26561 MEDSV DEF RBRVS 01/01/2024 12/31/2024 920.81 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26561 MEDSV DEF RBRVS 01/01/2025 895.69 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26562 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1283.98 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26562 MEDSV DEF RBRVS 01/01/2025 1251.86 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26565 MEDSV DEF RBRVS 01/01/2024 12/31/2024 672.92 Description: CORRECT METACARPAL FLAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26565 MEDSV DEF RBRVS 01/01/2025 651.76 Description: CORRECT METACARPAL FLAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26567 MEDSV DEF RBRVS 01/01/2024 12/31/2024 678.41 Description: CORRECT FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26567 MEDSV DEF RBRVS 01/01/2025 659.53 Description: CORRECT FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26568 MEDSV DEF RBRVS 01/01/2024 12/31/2024 873.84 Description: LENGTHEN METACARPAL/FINGER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26568 MEDSV DEF RBRVS 01/01/2025 848.45 Description: LENGTHEN METACARPAL/FINGER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1435.33 Description: REPAIR CLEFT HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26580 MEDSV DEF RBRVS 01/01/2025 1398.62 Description: REPAIR CLEFT HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26587 MEDSV DEF RBRVS 01/01/2024 12/31/2024 969.48 Description: RECONSTRUCT EXTRA FINGER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26587 MEDSV DEF RBRVS 01/01/2025 949.61 Description: RECONSTRUCT EXTRA FINGER Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26590 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1335.17 Description: REPAIR FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26590 MEDSV DEF RBRVS 01/01/2025 1298.62 Description: REPAIR FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26591 MEDSV DEF RBRVS 01/01/2024 12/31/2024 460.41 Description: REPAIR MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26591 MEDSV DEF RBRVS 01/01/2025 449.9 Description: REPAIR MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26593 MEDSV DEF RBRVS 01/01/2024 12/31/2024 608.59 Description: RELEASE MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26593 MEDSV DEF RBRVS 01/01/2025 591.8 Description: RELEASE MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26596 MEDSV DEF RBRVS 01/01/2024 12/31/2024 766.77 Description: EXCISION CONSTRICTING TISSUE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26596 MEDSV DEF RBRVS 01/01/2025 747.27 Description: EXCISION CONSTRICTING TISSUE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 287.4 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26600 MEDSV DEF RBRVS 01/01/2025 285.39 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 314.84 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26605 MEDSV DEF RBRVS 01/01/2025 311.46 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26607 MEDSV DEF RBRVS 01/01/2024 12/31/2024 478.63 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26607 MEDSV DEF RBRVS 01/01/2025 467.9 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26608 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.96 Description: TREAT METACARPAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26608 MEDSV DEF RBRVS 01/01/2025 446.6 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 26615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 539.91 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26615 MEDSV DEF RBRVS 01/01/2025 530.99 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26641 MEDSV DEF RBRVS 01/01/2024 12/31/2024 397.65 Description: TREAT THUMB DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26641 MEDSV DEF RBRVS 01/01/2025 393.43 Description: TREAT THUMB DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26645 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.65 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26645 MEDSV DEF RBRVS 01/01/2025 405.97 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.85 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26650 MEDSV DEF RBRVS 01/01/2025 446.5 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 589.76 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26665 MEDSV DEF RBRVS 01/01/2025 579.26 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.72 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26670 MEDSV DEF RBRVS 01/01/2025 330.25 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26675 MEDSV DEF RBRVS 01/01/2024 12/31/2024 437.99 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26675 MEDSV DEF RBRVS 01/01/2025 432.62 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26676 MEDSV DEF RBRVS 01/01/2024 12/31/2024 481.08 Description: PIN HAND DISLOCATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26676 MEDSV DEF RBRVS 01/01/2025 473.06 Description: PIN HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26685 MEDSV DEF RBRVS 01/01/2024 12/31/2024 540.05 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26685 MEDSV DEF RBRVS 01/01/2025 533.46 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26686 MEDSV DEF RBRVS 01/01/2024 12/31/2024 582.18 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26686 MEDSV DEF RBRVS 01/01/2025 571.04 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 324 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26700 MEDSV DEF RBRVS 01/01/2025 320.13 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 415.28 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26705 MEDSV DEF RBRVS 01/01/2025 410.26 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26706 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.57 Description: PIN KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26706 MEDSV DEF RBRVS 01/01/2025 416.42 Description: PIN KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 538.39 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26715 MEDSV DEF RBRVS 01/01/2025 529.08 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 192 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26720 MEDSV DEF RBRVS 01/01/2025 191.19 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 325.98 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26725 MEDSV DEF RBRVS 01/01/2025 322.35 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26727 MEDSV DEF RBRVS 01/01/2024 12/31/2024 447.51 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26727 MEDSV DEF RBRVS 01/01/2025 440.5 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26735 MEDSV DEF RBRVS 01/01/2024 12/31/2024 557.98 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26735 MEDSV DEF RBRVS 01/01/2025 548.55 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 222.43 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26740 MEDSV DEF RBRVS 01/01/2025 221.3 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26742 MEDSV DEF RBRVS 01/01/2024 12/31/2024 356.29 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26742 MEDSV DEF RBRVS 01/01/2025 350.74 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26746 MEDSV DEF RBRVS 01/01/2024 12/31/2024 694.64 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26746 MEDSV DEF RBRVS 01/01/2025 680.7 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.62 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26750 MEDSV DEF RBRVS 01/01/2025 178.62 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26755 MEDSV DEF RBRVS 01/01/2024 12/31/2024 305.29 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26755 MEDSV DEF RBRVS 01/01/2025 301.3 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26756 MEDSV DEF RBRVS 01/01/2024 12/31/2024 401.35 Description: PIN FINGER FRACTURE EACH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26756 MEDSV DEF RBRVS 01/01/2025 394.6 Description: PIN FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26765 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.13 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26765 MEDSV DEF RBRVS 01/01/2025 466.14 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 274.46 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26770 MEDSV DEF RBRVS 01/01/2025 273.3 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26775 MEDSV DEF RBRVS 01/01/2024 12/31/2024 376.37 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26775 MEDSV DEF RBRVS 01/01/2025 372.52 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26776 MEDSV DEF RBRVS 01/01/2024 12/31/2024 424.41 Description: PIN FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26776 MEDSV DEF RBRVS 01/01/2025 417.75 Description: PIN FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26785 MEDSV DEF RBRVS 01/01/2024 12/31/2024 514.97 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26785 MEDSV DEF RBRVS 01/01/2025 505.72 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 779.71 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26820 MEDSV DEF RBRVS 01/01/2025 758.52 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26841 MEDSV DEF RBRVS 01/01/2024 12/31/2024 727.25 Description: FUSION OF THUMB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26841 MEDSV DEF RBRVS 01/01/2025 710.35 Description: FUSION OF THUMB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26842 MEDSV DEF RBRVS 01/01/2024 12/31/2024 782 Description: THUMB FUSION WITH GRAFT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26842 MEDSV DEF RBRVS 01/01/2025 760.6 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26843 MEDSV DEF RBRVS 01/01/2024 12/31/2024 735.46 Description: FUSION OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26843 MEDSV DEF RBRVS 01/01/2025 715.5 Description: FUSION OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26844 MEDSV DEF RBRVS 01/01/2024 12/31/2024 808.08 Description: FUSION/GRAFT OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26844 MEDSV DEF RBRVS 01/01/2025 786.08 Description: FUSION/GRAFT OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 692.62 Description: FUSION OF KNUCKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26850 MEDSV DEF RBRVS 01/01/2025 673.51 Description: FUSION OF KNUCKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26852 MEDSV DEF RBRVS 01/01/2024 12/31/2024 784.73 Description: FUSION OF KNUCKLE WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26852 MEDSV DEF RBRVS 01/01/2025 764.1 Description: FUSION OF KNUCKLE WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 578.26 Description: FUSION OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26860 MEDSV DEF RBRVS 01/01/2025 562.81 Description: FUSION OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26861 MEDSV DEF RBRVS 01/01/2024 12/31/2024 93.28 Description: FUSION OF FINGER JNT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26861 MEDSV DEF RBRVS 01/01/2025 91.2 Description: FUSION OF FINGER JNT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26862 MEDSV DEF RBRVS 01/01/2024 12/31/2024 721.86 Description: FUSION/GRAFT OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26862 MEDSV DEF RBRVS 01/01/2025 703.18 Description: FUSION/GRAFT OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26863 MEDSV DEF RBRVS 01/01/2024 12/31/2024 209.93 Description: FUSE/GRAFT ADDED 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26863 MEDSV DEF RBRVS 01/01/2025 203.43 Description: FUSE/GRAFT ADDED JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26910 MEDSV DEF RBRVS 01/01/2024 12/31/2024 717.69 Description: AMPUTATE METACARPAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26910 MEDSV DEF RBRVS 01/01/2025 697.05 Description: AMPUTATE METACARPAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26951 MEDSV DEF RBRVS 01/01/2024 12/31/2024 659.86 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26951 MEDSV DEF RBRVS 01/01/2025 644.32 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26952 MEDSV DEF RBRVS 01/01/2024 12/31/2024 645.17 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26952 MEDSV DEF RBRVS 01/01/2025 626.91 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26989 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX HANDS/FINGERS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 26990 MEDSV DEF RBRVS 01/01/2024 12/31/2024 634.31 Description: DRAINAGE OF PELVIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26990 MEDSV DEF RBRVS 01/01/2025 620.45 Description: DRAINAGE OF PELVIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26991 MEDSV DEF RBRVS 01/01/2024 12/31/2024 662.67 Description: DRAINAGE OF PELVIS BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26991 MEDSV DEF RBRVS 01/01/2025 644.15 Description: DRAINAGE OF PELVIS BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26992 MEDSV DEF RBRVS 01/01/2024 12/31/2024 935.72 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26992 MEDSV DEF RBRVS 01/01/2025 918.31 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 373.65 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27000 MEDSV DEF RBRVS 01/01/2025 364.57 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 505 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27001 MEDSV DEF RBRVS 01/01/2025 494.43 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27003 MEDSV DEF RBRVS 01/01/2024 12/31/2024 559.75 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27003 MEDSV DEF RBRVS 01/01/2025 549.69 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 667.29 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27005 MEDSV DEF RBRVS 01/01/2025 657.66 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27006 MEDSV DEF RBRVS 01/01/2024 12/31/2024 668.25 Description: INCISION OF HIP TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27006 MEDSV DEF RBRVS 01/01/2025 658.18 Description: INCISION OF HIP TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 855.57 Description: INCISION OF HIP/THIGH FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27025 MEDSV DEF RBRVS 01/01/2025 844.24 Description: INCISION OF HIP/THIGH FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27027 MEDSV DEF RBRVS 01/01/2024 12/31/2024 827.85 Description: BUTTOCK FASCIOTOMY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27027 MEDSV DEF RBRVS 01/01/2025 803.02 Description: BUTTOCK FASCIOTOMY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 868.62 Description: DRAINAGE OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27030 MEDSV DEF RBRVS 01/01/2025 849.32 Description: DRAINAGE OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27033 MEDSV DEF RBRVS 01/01/2024 12/31/2024 901.24 Description: EXPLORATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27033 MEDSV DEF RBRVS 01/01/2025 881.35 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1073.44 Description: DENERVATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27035 MEDSV DEF RBRVS 01/01/2025 1054.2 Description: DENERVATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27036 MEDSV DEF RBRVS 01/01/2024 12/31/2024 943.63 Description: EXCISION OF HIP JOINT/MUSCLE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 27036 MEDSV DEF RBRVS 01/01/2025 925.12 Description: EXCISION OF HIP JOINT/MUSCLE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 27040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 317.65 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27040 MEDSV DEF RBRVS 01/01/2025 308.82 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27041 MEDSV DEF RBRVS 01/01/2024 12/31/2024 661.01 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27041 MEDSV DEF RBRVS 01/01/2025 645.12 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27043 MEDSV DEF RBRVS 01/01/2024 12/31/2024 432.7 Description: EXC HIP PELVIS LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27043 MEDSV DEF RBRVS 01/01/2025 423.57 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 12/31/2024 680.34 Description: EXC HIP/PELV TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27045 MEDSV DEF RBRVS 01/01/2025 663.38 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 12/31/2024 459.23 Description: EXC HIP/PELVIS LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27047 MEDSV DEF RBRVS 01/01/2025 449.44 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 12/31/2024 565.62 Description: EXC HIP/PELV TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27048 MEDSV DEF RBRVS 01/01/2025 554.62 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27049 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1229.11 Description: RESECT HIP/PELV TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27049 MEDSV DEF RBRVS 01/01/2025 1286.06 Description: RESECT HIP/PELV TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 379.98 Description: BIOPSY OF SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27050 MEDSV DEF RBRVS 01/01/2025 374.86 Description: BIOPSY OF SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27052 MEDSV DEF RBRVS 01/01/2024 12/31/2024 540.46 Description: BIOPSY OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27052 MEDSV DEF RBRVS 01/01/2025 531.73 Description: BIOPSY OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27054 MEDSV DEF RBRVS 01/01/2024 12/31/2024 642.73 Description: REMOVAL OF HIP JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27054 MEDSV DEF RBRVS 01/01/2025 629.41 Description: REMOVAL OF HIP JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27057 MEDSV DEF RBRVS 01/01/2024 12/31/2024 934.19 Description: BUTTOCK FASCIOTOMY W/DBRDMT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27057 MEDSV DEF RBRVS 01/01/2025 912.54 Description: BUTTOCK FASCIOTOMY W/DBRDMT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27059 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1665.72 Description: RESECT HIP/PELV TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27059 MEDSV DEF RBRVS 01/01/2025 1625.09 Description: RESECT HIP/PELV TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 436.17 Description: REMOVAL OF ISCHIAL BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27060 MEDSV DEF RBRVS 01/01/2025 428.95 Description: REMOVAL OF ISCHIAL BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27062 MEDSV DEF RBRVS 01/01/2024 12/31/2024 425.74 Description: REMOVE FEMUR LESION/BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27062 MEDSV DEF RBRVS 01/01/2025 417.73 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 492.97 Description: REMOVE HIP BONE LES SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27065 MEDSV DEF RBRVS 01/01/2025 480.72 Description: REMOVE HIP BONE LES SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27066 MEDSV DEF RBRVS 01/01/2024 12/31/2024 762.77 Description: REMOVE HIP BONE LES DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27066 MEDSV DEF RBRVS 01/01/2025 743.77 Description: REMOVE HIP BONE LES DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27067 MEDSV DEF RBRVS 01/01/2024 12/31/2024 960.76 Description: REMOVE/GRAFT HIP BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27067 MEDSV DEF RBRVS 01/01/2025 940.4 Description: REMOVE/GRAFT HIP BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 825.39 Description: PART REMOVE HIP BONE SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27070 MEDSV DEF RBRVS 01/01/2025 805.23 Description: PART REMOVE HIP BONE SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27071 MEDSV DEF RBRVS 01/01/2024 12/31/2024 907.41 Description: PART REMOVAL HIP BONE DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27071 MEDSV DEF RBRVS 01/01/2025 883.21 Description: PART REMOVAL HIP BONE DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27075 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1916.69 Description: RESECT HIP TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27075 MEDSV DEF RBRVS 01/01/2025 1870.07 Description: RESECT HIP TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27076 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2315.4 Description: RESECT HIP TUM INCL ACETABUL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27076 MEDSV DEF RBRVS 01/01/2025 2257.11 Description: RESECT HIP TUM INCL ACETABUL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27077 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2581.19 Description: RESECT HIP TUM W/INNOM BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27077 MEDSV DEF RBRVS 01/01/2025 2515.55 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27078 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1889.94 Description: RSECT HIP TUM INCL FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27078 MEDSV DEF RBRVS 01/01/2025 1844.26 Description: RSECT HIP TUM INCL FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.04 Description: REMOVAL OF TAIL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27080 MEDSV DEF RBRVS 01/01/2025 461.04 Description: REMOVAL OF TAIL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27086 MEDSV DEF RBRVS 01/01/2024 12/31/2024 290.37 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27086 MEDSV DEF RBRVS 01/01/2025 282.97 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27087 MEDSV DEF RBRVS 01/01/2024 12/31/2024 568.84 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27087 MEDSV DEF RBRVS 01/01/2025 557.31 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27090 MEDSV DEF RBRVS 01/01/2024 12/31/2024 773.08 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27090 MEDSV DEF RBRVS 01/01/2025 754.62 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27091 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1469.73 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27091 MEDSV DEF RBRVS 01/01/2025 1434.8 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27093 MEDSV DEF RBRVS 01/01/2024 12/31/2024 219.67 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27093 MEDSV DEF RBRVS 01/01/2025 209.49 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27095 MEDSV DEF RBRVS 01/01/2024 12/31/2024 292.7 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27095 MEDSV DEF RBRVS 01/01/2025 277.22 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27096 MEDSV DEF RBRVS 01/01/2024 12/31/2024 152.74 Description: INJECT SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 27096 MEDSV DEF RBRVS 01/01/2025 150.61 Description: INJECT SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 27097 MEDSV DEF RBRVS 01/01/2024 12/31/2024 637.36 Description: REVISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27097 MEDSV DEF RBRVS 01/01/2025 624.44 Description: REVISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27098 MEDSV DEF RBRVS 01/01/2024 12/31/2024 648.63 Description: TRANSFER TENDON TO PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27098 MEDSV DEF RBRVS 01/01/2025 635.9 Description: TRANSFER TENDON TO PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 772.8 Description: TRANSFER OF ABDOMINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27100 MEDSV DEF RBRVS 01/01/2025 757.04 Description: TRANSFER OF ABDOMINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 809.38 Description: TRANSFER OF SPINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27105 MEDSV DEF RBRVS 01/01/2025 792.89 Description: TRANSFER OF SPINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 901.12 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27110 MEDSV DEF RBRVS 01/01/2025 881.96 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 839.08 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27111 MEDSV DEF RBRVS 01/01/2025 821.89 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1200.84 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27120 MEDSV DEF RBRVS 01/01/2025 1173.7 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27122 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1021.25 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27122 MEDSV DEF RBRVS 01/01/2025 999.22 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1047.2 Description: PARTIAL HIP REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27125 MEDSV DEF RBRVS 01/01/2025 1024.09 Description: PARTIAL HIP REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1186.05 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27130 MEDSV DEF RBRVS 01/01/2025 1158.64 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27132 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1540.94 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27132 MEDSV DEF RBRVS 01/01/2025 1504.4 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27134 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1753.74 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27134 MEDSV DEF RBRVS 01/01/2025 1710.09 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27137 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1350.93 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27137 MEDSV DEF RBRVS 01/01/2025 1319.22 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27138 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1403.31 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27138 MEDSV DEF RBRVS 01/01/2025 1369.93 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 832.08 Y Description: TRANSPLANT FEMUR RIDGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27140 MEDSV DEF RBRVS 01/01/2025 814.83 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27146 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1171.62 Description: INCISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27146 MEDSV DEF RBRVS 01/01/2025 1156.35 Description: INCISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27147 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1349.87 Description: REVISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27147 MEDSV DEF RBRVS 01/01/2025 1319.48 Description: REVISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1458.99 Description: INCISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27151 MEDSV DEF RBRVS 01/01/2025 1424.82 Description: INCISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27156 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1571.21 Description: REVISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27156 MEDSV DEF RBRVS 01/01/2025 1533.96 Description: REVISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27158 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1292.14 Description: REVISION OF PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27158 MEDSV DEF RBRVS 01/01/2025 1262.64 Description: REVISION OF PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27161 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1128.64 Description: INCISION OF NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27161 MEDSV DEF RBRVS 01/01/2025 1103.75 Description: INCISION OF NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27165 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1271.4 Description: INCISION/FIXATION OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27165 MEDSV DEF RBRVS 01/01/2025 1240.18 Description: INCISION/FIXATION OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27170 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1082.87 Description: REPAIR/GRAFT FEMUR HEAD/NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27170 MEDSV DEF RBRVS 01/01/2025 1056.2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27175 MEDSV DEF RBRVS 01/01/2024 12/31/2024 620.11 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27175 MEDSV DEF RBRVS 01/01/2025 607.69 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27176 MEDSV DEF RBRVS 01/01/2024 12/31/2024 856.46 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27176 MEDSV DEF RBRVS 01/01/2025 838.31 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27177 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1033.61 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27177 MEDSV DEF RBRVS 01/01/2025 1011.15 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27178 MEDSV DEF RBRVS 01/01/2024 12/31/2024 856.46 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27178 MEDSV DEF RBRVS 01/01/2025 838.31 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27179 MEDSV DEF RBRVS 01/01/2024 12/31/2024 908.08 Description: REVISE HEAD/NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27179 MEDSV DEF RBRVS 01/01/2025 888.24 Description: REVISE HEAD/NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27181 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1037.13 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27181 MEDSV DEF RBRVS 01/01/2025 1015.33 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27185 MEDSV DEF RBRVS 01/01/2024 12/31/2024 669.71 Description: REVISION OF FEMUR EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27185 MEDSV DEF RBRVS 01/01/2025 656.36 Description: REVISION OF FEMUR EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27187 MEDSV DEF RBRVS 01/01/2024 12/31/2024 924.01 Description: REINFORCE HIP BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27187 MEDSV DEF RBRVS 01/01/2025 904.48 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27197 MEDSV DEF RBRVS 01/01/2024 12/31/2024 124.28 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27197 MEDSV DEF RBRVS 01/01/2025 121.44 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27198 MEDSV DEF RBRVS 01/01/2024 12/31/2024 293.49 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27198 MEDSV DEF RBRVS 01/01/2025 286.35 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 176.91 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27200 MEDSV DEF RBRVS 01/01/2025 177.89 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27202 MEDSV DEF RBRVS 01/01/2024 12/31/2024 491.65 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27202 MEDSV DEF RBRVS 01/01/2025 482.08 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 572.77 Description: TREAT PELVIC FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27215 MEDSV DEF RBRVS 01/01/2025 559.65 Description: TREAT PELVIC FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27216 MEDSV DEF RBRVS 01/01/2024 12/31/2024 846.96 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27216 MEDSV DEF RBRVS 01/01/2025 827.44 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27217 MEDSV DEF RBRVS 01/01/2024 12/31/2024 795.95 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27217 MEDSV DEF RBRVS 01/01/2025 777.81 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27218 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1093.44 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27218 MEDSV DEF RBRVS 01/01/2025 1066.97 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 391.94 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27220 MEDSV DEF RBRVS 01/01/2025 384.17 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27222 MEDSV DEF RBRVS 01/01/2024 12/31/2024 914.4 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27222 MEDSV DEF RBRVS 01/01/2025 889.81 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27226 MEDSV DEF RBRVS 01/01/2024 12/31/2024 977.49 Description: TREAT HIP WALL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27226 MEDSV DEF RBRVS 01/01/2025 958.11 Description: TREAT HIP WALL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27227 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1521.54 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27227 MEDSV DEF RBRVS 01/01/2025 1487.03 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27228 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1730.09 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27228 MEDSV DEF RBRVS 01/01/2025 1688.2 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 457.73 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27230 MEDSV DEF RBRVS 01/01/2025 450.68 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27232 MEDSV DEF RBRVS 01/01/2024 12/31/2024 673.93 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27232 MEDSV DEF RBRVS 01/01/2025 658.71 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 841.08 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27235 MEDSV DEF RBRVS 01/01/2025 823.54 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27236 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1103.65 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27236 MEDSV DEF RBRVS 01/01/2025 1080.01 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27238 MEDSV DEF RBRVS 01/01/2024 12/31/2024 438.87 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27238 MEDSV DEF RBRVS 01/01/2025 432.09 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 887.65 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27240 MEDSV DEF RBRVS 01/01/2025 865.14 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27244 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1135.1 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27244 MEDSV DEF RBRVS 01/01/2025 1110.24 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27245 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1134.31 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27245 MEDSV DEF RBRVS 01/01/2025 1109.01 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27246 MEDSV DEF RBRVS 01/01/2024 12/31/2024 367.75 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27246 MEDSV DEF RBRVS 01/01/2025 361.66 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27248 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.95 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27248 MEDSV DEF RBRVS 01/01/2025 676.4 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 165.78 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27250 MEDSV DEF RBRVS 01/01/2025 160.57 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27252 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.17 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27252 MEDSV DEF RBRVS 01/01/2025 681.15 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27253 MEDSV DEF RBRVS 01/01/2024 12/31/2024 872.1 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27253 MEDSV DEF RBRVS 01/01/2025 852.16 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27254 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1175.78 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27254 MEDSV DEF RBRVS 01/01/2025 1149.01 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27256 MEDSV DEF RBRVS 01/01/2024 12/31/2024 292.27 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27256 MEDSV DEF RBRVS 01/01/2025 288.2 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27257 MEDSV DEF RBRVS 01/01/2024 12/31/2024 334.3 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27257 MEDSV DEF RBRVS 01/01/2025 327.25 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27258 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1029.41 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27258 MEDSV DEF RBRVS 01/01/2025 1006.87 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27259 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1424.32 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27259 MEDSV DEF RBRVS 01/01/2025 1391.99 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 391.28 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 27265 MEDSV DEF RBRVS 01/01/2025 386.95 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27266 MEDSV DEF RBRVS 01/01/2024 12/31/2024 546.06 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 27266 MEDSV DEF RBRVS 01/01/2025 534.2 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 27267 MEDSV DEF RBRVS 01/01/2024 12/31/2024 413.98 Description: CLTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27267 MEDSV DEF RBRVS 01/01/2025 408.46 Description: CLTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27268 MEDSV DEF RBRVS 01/01/2024 12/31/2024 509.26 Description: CLTX THIGH FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27268 MEDSV DEF RBRVS 01/01/2025 499.98 Description: CLTX THIGH FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27269 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1146.14 Description: OPTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27269 MEDSV DEF RBRVS 01/01/2025 1118.68 Description: OPTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 171.52 Description: MANIPULATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27275 MEDSV DEF RBRVS 01/01/2025 169 Description: MANIPULATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27278 MEDSV DEF BILL20 01/01/2024 12/31/2024 Description: ARTHRD SI JT PRQ WO TFXJ DEV Category: Medical Services CMS Add: 01/01/2024 CMS Term: 27278 MEDSV DEF RBRVS 01/01/2025 11013.84 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 12/31/2024 752.02 Description: ARTHRD SI JT PERQ/MIN NVAS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 27279 MEDSV DEF RBRVS 01/01/2025 725.6 Description: ARTHRD SI JT PERQ/MIN NVAS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 27280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1236.35 Description: ARTHR SI JT OPN B1GRF INSTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27280 MEDSV DEF RBRVS 01/01/2025 1207.53 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27282 MEDSV DEF RBRVS 01/01/2024 12/31/2024 799.54 Description: ARTHRODESIS SYMPHYSIS PUBIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27282 MEDSV DEF RBRVS 01/01/2025 783.01 Description: ARTHRODESIS SYMPHYSIS PUBIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27284 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1477.69 Description: ARTHRODESIS HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27284 MEDSV DEF RBRVS 01/01/2025 1442.19 Description: ARTHRODESIS HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27286 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1515.09 Description: ARTHRD HIP JT SBTRCHC OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27286 MEDSV DEF RBRVS 01/01/2025 1479.16 Description: ARTHRD HIP JT SBTRCHC OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1499.24 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27290 MEDSV DEF RBRVS 01/01/2025 1464.04 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27295 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1161.41 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27295 MEDSV DEF RBRVS 01/01/2025 1136.67 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27299 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX PELVIS/HIP JOINT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 27301 MEDSV DEF RBRVS 01/01/2024 12/31/2024 627.21 Description: DRAIN THIGH/KNEE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27301 MEDSV DEF RBRVS 01/01/2025 613.05 Description: DRAIN THIGH/KNEE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27303 MEDSV DEF RBRVS 01/01/2024 12/31/2024 593.68 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27303 MEDSV DEF RBRVS 01/01/2025 586.33 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27305 MEDSV DEF RBRVS 01/01/2025 444.25 Description: INCISE THIGH TENDON & FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27306 MEDSV DEF RBRVS 01/01/2024 12/31/2024 319.16 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27306 MEDSV DEF RBRVS 01/01/2025 321.49 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27307 MEDSV DEF RBRVS 01/01/2024 12/31/2024 389.01 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27307 MEDSV DEF RBRVS 01/01/2025 381.58 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 682.7 Description: EXPLORATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27310 MEDSV DEF RBRVS 01/01/2025 669.29 Description: EXPLORATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27323 MEDSV DEF RBRVS 01/01/2024 12/31/2024 256.38 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27323 MEDSV DEF RBRVS 01/01/2025 250.92 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27324 MEDSV DEF RBRVS 01/01/2024 12/31/2024 381.62 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27324 MEDSV DEF RBRVS 01/01/2025 375.16 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 528.19 Description: NEURECTOMY HAMSTRING Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27325 MEDSV DEF RBRVS 01/01/2025 518.45 Description: NEURECTOMY HAMSTRING Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27326 MEDSV DEF RBRVS 01/01/2024 12/31/2024 489.31 Description: NEURECTOMY POPLITEAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27326 MEDSV DEF RBRVS 01/01/2025 480.84 Description: NEURECTOMY POPLITEAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27327 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27327 MEDSV DEF RBRVS 01/01/2025 454.44 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 12/31/2024 577.63 Description: EXC THIGH/KNEE TUM DEEP <5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27328 MEDSV DEF RBRVS 01/01/2025 566.07 Description: EXC THIGH/KNEE TUM DEEP <5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27329 MEDSV DEF RBRVS 01/01/2024 12/31/2024 958.55 Description: RESECT THIGH/KNEE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27329 MEDSV DEF RBRVS 01/01/2025 936.15 Description: RESECT THIGH/KNEE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 395.96 Description: BIOPSY KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27330 MEDSV DEF RBRVS 01/01/2025 390.21 Description: BIOPSY KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27331 MEDSV DEF RBRVS 01/01/2024 12/31/2024 446.82 Description: EXPLORE/TREAT KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27331 MEDSV DEF RBRVS 01/01/2025 438.85 Description: EXPLORE/TREAT KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27332 MEDSV DEF RBRVS 01/01/2024 12/31/2024 602.84 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27332 MEDSV DEF RBRVS 01/01/2025 591.9 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27333 MEDSV DEF RBRVS 01/01/2024 12/31/2024 550.91 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27333 MEDSV DEF RBRVS 01/01/2025 541.29 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27334 MEDSV DEF RBRVS 01/01/2024 12/31/2024 640.96 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27334 MEDSV DEF RBRVS 01/01/2025 627.99 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27335 MEDSV DEF RBRVS 01/01/2025 699.32 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27337 MEDSV DEF RBRVS 01/01/2024 12/31/2024 387.46 Description: EXC THIGH/KNEE LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27337 MEDSV DEF RBRVS 01/01/2025 379.97 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 12/31/2024 695.37 Description: EXC THIGH/KNEE TUM DEP 5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27339 MEDSV DEF RBRVS 01/01/2025 682.96 Description: EXC THIGH/KNEE TUM DEP 5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 351.79 Description: REMOVAL OF KNEECAP BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27340 MEDSV DEF RBRVS 01/01/2025 347.14 Description: REMOVAL OF KNEECAP BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 455.06 Description: REMOVAL OF KNEE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27345 MEDSV DEF RBRVS 01/01/2025 447.93 Description: REMOVAL OF KNEE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27347 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.12 Description: REMOVE KNEE CYST Category: Medical Services CMS Add: 01/01/1999 CMS Term: 27347 MEDSV DEF RBRVS 01/01/2025 485.28 Description: REMOVE KNEE CYST Category: Medical Services CMS Add: 01/01/1999 CMS Term: 27350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 611.34 Description: REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27350 MEDSV DEF RBRVS 01/01/2025 599.82 Description: REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27355 MEDSV DEF RBRVS 01/01/2024 12/31/2024 568.21 Description: REMOVE FEMUR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27355 MEDSV DEF RBRVS 01/01/2025 556.99 Description: REMOVE FEMUR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27356 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27356 MEDSV DEF RBRVS 01/01/2025 676.19 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27357 MEDSV DEF RBRVS 01/01/2024 12/31/2024 762.32 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27357 MEDSV DEF RBRVS 01/01/2025 746.26 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27358 MEDSV DEF RBRVS 01/01/2024 12/31/2024 251.52 Description: REMOVE FEMUR LESION/FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27358 MEDSV DEF RBRVS 01/01/2025 244.11 Description: REMOVE FEMUR LESION/FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 842.12 Description: PARTIAL REMOVAL LEG BONE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27360 MEDSV DEF RBRVS 01/01/2025 822.54 Description: PARTIAL REMOVAL LEG BONE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27364 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1438.02 Description: RESECT THIGH/KNEE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27364 MEDSV DEF RBRVS 01/01/2025 1402.88 Description: RESECT THIGH/KNEE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1888.88 Description: RESECT FEMUR/KNEE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27365 MEDSV DEF RBRVS 01/01/2025 1843.23 Description: RESECT FEMUR/KNEE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27369 MEDSV DEF RBRVS 01/01/2024 12/31/2024 174.03 Description: NJX CNTRST KNE ARTHG/CT/MRI Category: Medical Services CMS Add: 01/01/2019 CMS Term: 27369 MEDSV DEF RBRVS 01/01/2025 166.42 Description: NJX CNTRST KNE ARTHG/CT/MRI Category: Medical Services CMS Add: 01/01/2019 CMS Term: 27372 MEDSV DEF RBRVS 01/01/2024 12/31/2024 549.25 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27372 MEDSV DEF RBRVS 01/01/2025 532.69 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27380 MEDSV DEF RBRVS 01/01/2025 570.73 Description: REPAIR OF KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27381 MEDSV DEF RBRVS 01/01/2024 12/31/2024 765.8 Description: REPAIR/GRAFT KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27381 MEDSV DEF RBRVS 01/01/2025 748.47 Description: REPAIR/GRAFT KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27385 MEDSV DEF RBRVS 01/01/2024 12/31/2024 568.82 Description: REPAIR OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27385 MEDSV DEF RBRVS 01/01/2025 557.38 Description: REPAIR OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27386 MEDSV DEF RBRVS 01/01/2024 12/31/2024 798.44 Description: REPAIR/GRAFT OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27386 MEDSV DEF RBRVS 01/01/2025 781.46 Description: REPAIR/GRAFT OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 421.83 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27390 MEDSV DEF RBRVS 01/01/2025 415.36 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27391 MEDSV DEF RBRVS 01/01/2024 12/31/2024 542.38 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27391 MEDSV DEF RBRVS 01/01/2025 531.6 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27392 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665.04 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27392 MEDSV DEF RBRVS 01/01/2025 652.31 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27393 MEDSV DEF RBRVS 01/01/2024 12/31/2024 470.5 Description: LENGTHENING OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27393 MEDSV DEF RBRVS 01/01/2025 461.33 Description: LENGTHENING OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27394 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27394 MEDSV DEF RBRVS 01/01/2025 599.89 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27395 MEDSV DEF RBRVS 01/01/2024 12/31/2024 820.2 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27395 MEDSV DEF RBRVS 01/01/2025 803.55 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27396 MEDSV DEF RBRVS 01/01/2024 12/31/2024 577.49 Y Description: TRANSPLANT OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27396 MEDSV DEF RBRVS 01/01/2025 566.77 Y Description: TRANSPLANT OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27397 MEDSV DEF RBRVS 01/01/2024 12/31/2024 849.77 Y Description: TRANSPLANTS OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27397 MEDSV DEF RBRVS 01/01/2025 833.53 Y Description: TRANSPLANTS OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 648.97 Description: REVISE THIGH MUSCLES/TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27400 MEDSV DEF RBRVS 01/01/2025 636.39 Description: REVISE THIGH MUSCLES/TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27403 MEDSV DEF RBRVS 01/01/2024 12/31/2024 601.8 Description: REPAIR OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27403 MEDSV DEF RBRVS 01/01/2025 590.97 Description: REPAIR OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 630.86 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27405 MEDSV DEF RBRVS 01/01/2025 619.37 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27407 MEDSV DEF RBRVS 01/01/2024 12/31/2024 742.03 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27407 MEDSV DEF RBRVS 01/01/2025 727.31 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27409 MEDSV DEF RBRVS 01/01/2024 12/31/2024 898 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27409 MEDSV DEF RBRVS 01/01/2025 878.77 Description: REPAIR OF KNEE LIGAMENTS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27412 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1521.14 Description: AUTOCHONDROCYTE IMPLANT KNEE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27412 MEDSV DEF RBRVS 01/01/2025 1486.59 Description: AUTOCHONDROCYTE IMPLANT KNEE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1269.28 Description: OSTEOCHONDRAL KNEE ALLOGRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27415 MEDSV DEF RBRVS 01/01/2025 1241.86 Description: OSTEOCHONDRAL KNEE ALLOGRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27416 MEDSV DEF RBRVS 01/01/2024 12/31/2024 909.3 Description: OSTEOCHONDRAL KNEE AUTOGRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27416 MEDSV DEF RBRVS 01/01/2025 889.66 Description: OSTEOCHONDRAL KNEE AUTOGRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27418 MEDSV DEF RBRVS 01/01/2024 12/31/2024 772.6 Description: REPAIR DEGENERATED KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27418 MEDSV DEF RBRVS 01/01/2025 751.07 Description: REPAIR DEGENERATED KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 695.41 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27420 MEDSV DEF RBRVS 01/01/2025 684.81 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27422 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.69 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27422 MEDSV DEF RBRVS 01/01/2025 677.69 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27424 MEDSV DEF RBRVS 01/01/2024 12/31/2024 697.68 Description: REVISION/REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27424 MEDSV DEF RBRVS 01/01/2025 683.69 Description: REVISION/REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 426 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27425 MEDSV DEF RBRVS 01/01/2025 419.34 Description: LAT RETINACULAR RELEASE OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27427 MEDSV DEF RBRVS 01/01/2024 12/31/2024 662.85 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27427 MEDSV DEF RBRVS 01/01/2025 648.27 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27428 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1036.16 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27428 MEDSV DEF RBRVS 01/01/2025 1015.49 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27429 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1167.37 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27429 MEDSV DEF RBRVS 01/01/2025 1144.45 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.55 Description: REVISION OF THIGH MUSCLES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27430 MEDSV DEF RBRVS 01/01/2025 678.18 Description: REVISION OF THIGH MUSCLES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 754.78 Description: INCISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27435 MEDSV DEF RBRVS 01/01/2025 737.03 Description: INCISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27437 MEDSV DEF RBRVS 01/01/2024 12/31/2024 616.97 Description: REVISE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27437 MEDSV DEF RBRVS 01/01/2025 605.4 Description: REVISE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27438 MEDSV DEF RBRVS 01/01/2024 12/31/2024 781.56 Description: REVISE KNEECAP WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27438 MEDSV DEF RBRVS 01/01/2025 765.73 Description: REVISE KNEECAP WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27440 MEDSV DEF RBRVS 01/01/2025 727.21 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27441 MEDSV DEF RBRVS 01/01/2024 12/31/2024 766.29 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27441 MEDSV DEF RBRVS 01/01/2025 750.31 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27442 MEDSV DEF RBRVS 01/01/2024 12/31/2024 809.8 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27442 MEDSV DEF RBRVS 01/01/2025 790.43 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27443 MEDSV DEF RBRVS 01/01/2024 12/31/2024 759.08 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27443 MEDSV DEF RBRVS 01/01/2025 743.93 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1159.47 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27445 MEDSV DEF RBRVS 01/01/2025 1133.6 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27446 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1061.09 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27446 MEDSV DEF RBRVS 01/01/2025 1037.8 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27447 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1184.96 Description: TOTAL KNEE ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27447 MEDSV DEF RBRVS 01/01/2025 1157.11 Description: TOTAL KNEE ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27448 MEDSV DEF RBRVS 01/01/2024 12/31/2024 769.72 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27448 MEDSV DEF RBRVS 01/01/2025 753.8 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27450 MEDSV DEF RBRVS 01/01/2025 916.78 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27454 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1196.28 Description: REALIGNMENT OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27454 MEDSV DEF RBRVS 01/01/2025 1169.41 Description: REALIGNMENT OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27455 MEDSV DEF RBRVS 01/01/2024 12/31/2024 892.73 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27455 MEDSV DEF RBRVS 01/01/2025 872.7 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27457 MEDSV DEF RBRVS 01/01/2024 12/31/2024 890.52 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27457 MEDSV DEF RBRVS 01/01/2025 857.52 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27465 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1153.89 Description: SHORTENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27465 MEDSV DEF RBRVS 01/01/2025 1127.41 Description: SHORTENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27466 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1096.63 Description: LENGTHENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27466 MEDSV DEF RBRVS 01/01/2025 1072.65 Description: LENGTHENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27468 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1239.39 Description: SHORTEN/LENGTHEN THIGHS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27468 MEDSV DEF RBRVS 01/01/2025 1211.13 Description: SHORTEN/LENGTHEN THIGHS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27470 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1093.09 Description: REPAIR OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27470 MEDSV DEF RBRVS 01/01/2025 1069.85 Description: REPAIR OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27472 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27472 MEDSV DEF RBRVS 01/01/2025 1143.87 Description: REPAIR/GRAFT OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27475 MEDSV DEF RBRVS 01/01/2024 12/31/2024 618.84 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27475 MEDSV DEF RBRVS 01/01/2025 607.07 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27477 MEDSV DEF RBRVS 01/01/2024 12/31/2024 683.31 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27477 MEDSV DEF RBRVS 01/01/2025 669.53 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27479 MEDSV DEF RBRVS 01/01/2024 12/31/2024 852.58 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27479 MEDSV DEF RBRVS 01/01/2025 834.42 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27485 MEDSV DEF RBRVS 01/01/2024 12/31/2024 626.89 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27485 MEDSV DEF RBRVS 01/01/2025 614.25 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27486 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1296.7 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27486 MEDSV DEF RBRVS 01/01/2025 1267.21 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27487 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1615.79 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27487 MEDSV DEF RBRVS 01/01/2025 1577.7 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27488 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1110.59 Description: REMOVAL OF KNEE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27488 MEDSV DEF RBRVS 01/01/2025 1086.48 Description: REMOVAL OF KNEE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27495 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27495 MEDSV DEF RBRVS 01/01/2025 1023.08 Description: REINFORCE THIGH Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27496 MEDSV DEF RBRVS 01/01/2024 12/31/2024 513.11 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27496 MEDSV DEF RBRVS 01/01/2025 505.08 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27497 MEDSV DEF RBRVS 01/01/2024 12/31/2024 541.93 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27497 MEDSV DEF RBRVS 01/01/2025 531.83 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27498 MEDSV DEF RBRVS 01/01/2024 12/31/2024 613.2 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27498 MEDSV DEF RBRVS 01/01/2025 601.96 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27499 MEDSV DEF RBRVS 01/01/2024 12/31/2024 654.69 Y Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27499 MEDSV DEF RBRVS 01/01/2025 641.95 Y Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 492.16 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27500 MEDSV DEF RBRVS 01/01/2025 482.79 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 474.72 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27501 MEDSV DEF RBRVS 01/01/2025 465.07 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 702.75 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27502 MEDSV DEF RBRVS 01/01/2025 685.38 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27503 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27503 MEDSV DEF RBRVS 01/01/2025 728.73 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27506 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1237.59 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27506 MEDSV DEF RBRVS 01/01/2025 1210.53 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27507 MEDSV DEF RBRVS 01/01/2024 12/31/2024 895.93 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27507 MEDSV DEF RBRVS 01/01/2025 875.12 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27508 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.45 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27508 MEDSV DEF RBRVS 01/01/2025 487.03 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27509 MEDSV DEF RBRVS 01/01/2024 12/31/2024 632.84 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27509 MEDSV DEF RBRVS 01/01/2025 618.33 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 635.78 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27510 MEDSV DEF RBRVS 01/01/2025 622.87 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27511 MEDSV DEF RBRVS 01/01/2024 12/31/2024 921.53 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27511 MEDSV DEF RBRVS 01/01/2025 899.64 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27513 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1141.26 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27513 MEDSV DEF RBRVS 01/01/2025 1112.54 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27514 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27514 MEDSV DEF RBRVS 01/01/2025 872.72 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27516 MEDSV DEF RBRVS 01/01/2024 12/31/2024 488.55 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27516 MEDSV DEF RBRVS 01/01/2025 482.39 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27517 MEDSV DEF RBRVS 01/01/2024 12/31/2024 644.45 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27517 MEDSV DEF RBRVS 01/01/2025 632.34 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27519 MEDSV DEF RBRVS 01/01/2024 12/31/2024 824.77 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27519 MEDSV DEF RBRVS 01/01/2025 805.38 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 310.09 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27520 MEDSV DEF RBRVS 01/01/2025 307.42 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27524 MEDSV DEF RBRVS 01/01/2024 12/31/2024 701.76 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27524 MEDSV DEF RBRVS 01/01/2025 687.35 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 293.12 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27530 MEDSV DEF RBRVS 01/01/2025 290.66 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27532 MEDSV DEF RBRVS 01/01/2024 12/31/2024 582.07 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27532 MEDSV DEF RBRVS 01/01/2025 573.13 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27535 MEDSV DEF RBRVS 01/01/2025 811.38 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27536 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1098.5 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27536 MEDSV DEF RBRVS 01/01/2025 1075.35 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27538 MEDSV DEF RBRVS 01/01/2024 12/31/2024 457.47 Description: TREAT KNEE FRACTURE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27538 MEDSV DEF RBRVS 01/01/2025 450.67 Description: TREAT KNEE FRACTURE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 758.12 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27540 MEDSV DEF RBRVS 01/01/2025 741.34 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 485.75 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27550 MEDSV DEF RBRVS 01/01/2025 475.28 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 592.23 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27552 MEDSV DEF RBRVS 01/01/2025 582.99 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 811.65 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27556 MEDSV DEF RBRVS 01/01/2025 792.64 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27557 MEDSV DEF RBRVS 01/01/2024 12/31/2024 965.55 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27557 MEDSV DEF RBRVS 01/01/2025 942.41 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27558 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27558 MEDSV DEF RBRVS 01/01/2025 1070.83 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 355.38 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27560 MEDSV DEF RBRVS 01/01/2025 350.78 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27562 MEDSV DEF RBRVS 01/01/2024 12/31/2024 460.6 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27562 MEDSV DEF RBRVS 01/01/2025 453.54 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27566 MEDSV DEF RBRVS 01/01/2024 12/31/2024 828.62 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27566 MEDSV DEF RBRVS 01/01/2025 811.77 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 143.01 Description: FIXATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27570 MEDSV DEF RBRVS 01/01/2025 141.17 Description: FIXATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1365.33 Description: FUSION OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27580 MEDSV DEF RBRVS 01/01/2025 1334.96 Description: FUSION OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27590 MEDSV DEF RBRVS 01/01/2024 12/31/2024 713.56 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27590 MEDSV DEF RBRVS 01/01/2025 695.27 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27591 MEDSV DEF RBRVS 01/01/2024 12/31/2024 894.25 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27591 MEDSV DEF RBRVS 01/01/2025 874.42 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27592 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27592 MEDSV DEF RBRVS 01/01/2025 596.47 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27594 MEDSV DEF RBRVS 01/01/2024 12/31/2024 461.92 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27594 MEDSV DEF RBRVS 01/01/2025 453.93 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27596 MEDSV DEF RBRVS 01/01/2024 12/31/2024 653.33 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27596 MEDSV DEF RBRVS 01/01/2025 634.87 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27598 MEDSV DEF RBRVS 01/01/2024 12/31/2024 636.59 Description: AMPUTATE LOWER LEG AT KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27598 MEDSV DEF RBRVS 01/01/2025 618.39 Description: AMPUTATE LOWER LEG AT KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27599 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX FEMUR/KNEE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 27600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 372 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27600 MEDSV DEF RBRVS 01/01/2025 361.75 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.62 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27601 MEDSV DEF RBRVS 01/01/2025 403.13 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27602 MEDSV DEF RBRVS 01/01/2024 12/31/2024 436.14 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27602 MEDSV DEF RBRVS 01/01/2025 424.47 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27603 MEDSV DEF RBRVS 01/01/2024 12/31/2024 492.91 Description: DRAIN LOWER LEG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27603 MEDSV DEF RBRVS 01/01/2025 477.98 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27604 MEDSV DEF RBRVS 01/01/2024 12/31/2024 421.34 Description: DRAIN LOWER LEG BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27604 MEDSV DEF RBRVS 01/01/2025 411.24 Description: DRAIN LOWER LEG BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 309.21 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27605 MEDSV DEF RBRVS 01/01/2025 301.89 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 253.52 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27606 MEDSV DEF RBRVS 01/01/2025 247.41 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27607 MEDSV DEF RBRVS 01/01/2024 12/31/2024 559.14 Description: TREAT LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27607 MEDSV DEF RBRVS 01/01/2025 548.23 Description: TREAT LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 603.08 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27610 MEDSV DEF RBRVS 01/01/2025 591.12 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27612 MEDSV DEF RBRVS 01/01/2024 12/31/2024 531.97 Description: EXPLORATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27612 MEDSV DEF RBRVS 01/01/2025 527.33 Description: EXPLORATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27613 MEDSV DEF RBRVS 01/01/2024 12/31/2024 235.65 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27613 MEDSV DEF RBRVS 01/01/2025 232.35 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27614 MEDSV DEF RBRVS 01/01/2024 12/31/2024 550.2 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27614 MEDSV DEF RBRVS 01/01/2025 538.91 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 946.52 Description: RESECT LEG/ANKLE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27615 MEDSV DEF RBRVS 01/01/2025 913.79 Description: RESECT LEG/ANKLE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27616 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1167.79 Description: RESECT LEG/ANKLE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27616 MEDSV DEF RBRVS 01/01/2025 1132.8 Description: RESECT LEG/ANKLE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27618 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.82 Description: EXC LEG/ANKLE TUM < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27618 MEDSV DEF RBRVS 01/01/2025 442.73 Description: EXC LEG/ANKLE TUM < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27619 MEDSV DEF RBRVS 01/01/2024 12/31/2024 437.9 Description: EXC LEG/ANKLE TUM DEEP <5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27619 MEDSV DEF RBRVS 01/01/2025 432.04 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 12/31/2024 417.54 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27620 MEDSV DEF RBRVS 01/01/2025 414.05 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27625 MEDSV DEF RBRVS 01/01/2024 12/31/2024 537.2 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27625 MEDSV DEF RBRVS 01/01/2025 528.5 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27626 MEDSV DEF RBRVS 01/01/2024 12/31/2024 572.9 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27626 MEDSV DEF RBRVS 01/01/2025 569.62 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 501.1 Description: REMOVAL OF TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27630 MEDSV DEF RBRVS 01/01/2025 493.35 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27632 MEDSV DEF RBRVS 01/01/2024 12/31/2024 380.15 Description: EXC LEG/ANKLE LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27632 MEDSV DEF RBRVS 01/01/2025 371.55 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 12/31/2024 628.28 Description: EXC LEG/ANKLE TUM DEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27634 MEDSV DEF RBRVS 01/01/2025 611.61 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 12/31/2024 542.37 Description: REMOVE LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27635 MEDSV DEF RBRVS 01/01/2025 531.84 Description: REMOVE LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27637 MEDSV DEF RBRVS 01/01/2024 12/31/2024 690.55 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27637 MEDSV DEF RBRVS 01/01/2025 683.14 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27638 MEDSV DEF RBRVS 01/01/2024 12/31/2024 698.72 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27638 MEDSV DEF RBRVS 01/01/2025 679.86 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 775.24 Description: PARTIAL REMOVAL OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27640 MEDSV DEF RBRVS 01/01/2025 759.08 Description: PARTIAL REMOVAL OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27641 MEDSV DEF RBRVS 01/01/2024 12/31/2024 610.94 Description: PARTIAL REMOVAL OF FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27641 MEDSV DEF RBRVS 01/01/2025 598.94 Description: PARTIAL REMOVAL OF FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27645 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1628.48 Description: RESECT TIBIA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27645 MEDSV DEF RBRVS 01/01/2025 1590.06 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27646 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1415.83 Description: RESECT FIBULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27646 MEDSV DEF RBRVS 01/01/2025 1383.25 Description: RESECT FIBULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27647 MEDSV DEF RBRVS 01/01/2024 12/31/2024 947.52 Description: RESECT TALUS/CALCANEUS TUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27647 MEDSV DEF RBRVS 01/01/2025 927.91 Description: RESECT TALUS/CALCANEUS TUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27648 MEDSV DEF RBRVS 01/01/2024 12/31/2024 200.86 Description: INJECTION FOR ANKLE X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27648 MEDSV DEF RBRVS 01/01/2025 191.55 Description: INJECTION FOR ANKLE X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 617.56 Description: REPAIR ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27650 MEDSV DEF RBRVS 01/01/2025 605.05 Description: REPAIR ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27652 MEDSV DEF RBRVS 01/01/2024 12/31/2024 625.64 Description: REPAIR/GRAFT ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27652 MEDSV DEF RBRVS 01/01/2025 621.11 Description: REPAIR/GRAFT ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27654 MEDSV DEF RBRVS 01/01/2024 12/31/2024 670.88 Description: REPAIR OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27654 MEDSV DEF RBRVS 01/01/2025 659.25 Description: REPAIR OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27656 MEDSV DEF RBRVS 01/01/2024 12/31/2024 503.48 Description: REPAIR LEG FASCIA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27656 MEDSV DEF RBRVS 01/01/2025 483.34 Description: REPAIR LEG FASCIA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27658 MEDSV DEF RBRVS 01/01/2024 12/31/2024 347.64 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27658 MEDSV DEF RBRVS 01/01/2025 341.97 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27659 MEDSV DEF RBRVS 01/01/2024 12/31/2024 443.41 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27659 MEDSV DEF RBRVS 01/01/2025 437.63 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27664 MEDSV DEF RBRVS 01/01/2024 12/31/2024 341.22 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27664 MEDSV DEF RBRVS 01/01/2025 334.79 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 395.23 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27665 MEDSV DEF RBRVS 01/01/2025 391.4 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27675 MEDSV DEF RBRVS 01/01/2024 12/31/2024 468.31 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27675 MEDSV DEF RBRVS 01/01/2025 458.25 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27676 MEDSV DEF RBRVS 01/01/2024 12/31/2024 567.96 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27676 MEDSV DEF RBRVS 01/01/2025 559.92 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.08 Description: RELEASE OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27680 MEDSV DEF RBRVS 01/01/2025 388.86 Description: RELEASE OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27681 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.8 Description: RELEASE OF LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27681 MEDSV DEF RBRVS 01/01/2025 467.54 Description: RELEASE OF LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27685 MEDSV DEF RBRVS 01/01/2024 12/31/2024 615.04 Description: REVISION OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27685 MEDSV DEF RBRVS 01/01/2025 602.45 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27686 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.91 Description: REVISE LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27686 MEDSV DEF RBRVS 01/01/2025 490.5 Description: REVISE LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27687 MEDSV DEF RBRVS 01/01/2024 12/31/2024 426.66 Description: REVISION OF CALF TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27687 MEDSV DEF RBRVS 01/01/2025 419.7 Description: REVISION OF CALF TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27690 MEDSV DEF RBRVS 01/01/2024 12/31/2024 599.34 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27690 MEDSV DEF RBRVS 01/01/2025 588.41 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27691 MEDSV DEF RBRVS 01/01/2024 12/31/2024 695.27 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27691 MEDSV DEF RBRVS 01/01/2025 681.63 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27692 MEDSV DEF RBRVS 01/01/2024 12/31/2024 92.89 Description: REVISE ADDITIONAL LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27692 MEDSV DEF RBRVS 01/01/2025 91.53 Description: REVISE ADDITIONAL LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27695 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.93 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27695 MEDSV DEF RBRVS 01/01/2025 448.46 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27696 MEDSV DEF RBRVS 01/01/2024 12/31/2024 517.46 Description: REPAIR OF ANKLE LIGAMENTS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27696 MEDSV DEF RBRVS 01/01/2025 507.49 Description: REPAIR OF ANKLE LIGAMENTS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27698 MEDSV DEF RBRVS 01/01/2024 12/31/2024 600.01 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27698 MEDSV DEF RBRVS 01/01/2025 586.2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 576.23 Description: REVISION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27700 MEDSV DEF RBRVS 01/01/2025 649.67 Description: REVISION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 894.76 Description: RECONSTRUCT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27702 MEDSV DEF RBRVS 01/01/2025 875.78 Description: RECONSTRUCT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27703 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1032.97 Description: RECONSTRUCTION ANKLE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27703 MEDSV DEF RBRVS 01/01/2025 1009.23 Description: RECONSTRUCTION ANKLE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27704 MEDSV DEF RBRVS 01/01/2024 12/31/2024 531.35 Description: REMOVAL OF ANKLE IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27704 MEDSV DEF RBRVS 01/01/2025 520.36 Description: REMOVAL OF ANKLE IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 703.19 Description: OSTEOTOMY TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27705 MEDSV DEF RBRVS 01/01/2025 684.72 Description: OSTEOTOMY TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27707 MEDSV DEF RBRVS 01/01/2024 12/31/2024 380.03 Description: OSTEOTOMY FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27707 MEDSV DEF RBRVS 01/01/2025 373.97 Description: OSTEOTOMY FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27709 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1053.81 Description: OSTEOTOMY TIBIA & FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27709 MEDSV DEF RBRVS 01/01/2025 1039.32 Description: OSTEOTOMY TIBIA & FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27712 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1020.56 Description: OSTEOT MLT RELIGNMT IMED ROD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27712 MEDSV DEF RBRVS 01/01/2025 999.53 Description: OSTEOT MLT RELIGNMT IMED ROD Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 993.47 Description: OSTPL TIBFIB LNGTH/SHRT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27715 MEDSV DEF RBRVS 01/01/2025 971.82 Description: OSTPL TIBFIB LNGTH/SHRT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 812.16 Description: REPAIR OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27720 MEDSV DEF RBRVS 01/01/2025 794.85 Description: REPAIR OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27722 MEDSV DEF RBRVS 01/01/2024 12/31/2024 831.03 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27722 MEDSV DEF RBRVS 01/01/2025 814.38 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27724 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1159.97 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27724 MEDSV DEF RBRVS 01/01/2025 1132.32 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1125.27 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27725 MEDSV DEF RBRVS 01/01/2025 1102.44 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27726 MEDSV DEF RBRVS 01/01/2024 12/31/2024 889.83 Description: REPAIR FIBULA NONUNION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27726 MEDSV DEF RBRVS 01/01/2025 868.4 Description: REPAIR FIBULA NONUNION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27727 MEDSV DEF RBRVS 01/01/2024 12/31/2024 963.45 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27727 MEDSV DEF RBRVS 01/01/2025 942.69 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 549.52 Description: REPAIR OF TIBIA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27730 MEDSV DEF RBRVS 01/01/2025 539.73 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27732 MEDSV DEF RBRVS 01/01/2024 12/31/2024 425.47 Description: REPAIR OF FIBULA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27732 MEDSV DEF RBRVS 01/01/2025 418.48 Description: REPAIR OF FIBULA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27734 MEDSV DEF RBRVS 01/01/2024 12/31/2024 613.89 Description: REPAIR LOWER LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27734 MEDSV DEF RBRVS 01/01/2025 602.27 Description: REPAIR LOWER LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 660.04 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27740 MEDSV DEF RBRVS 01/01/2025 647.27 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27742 MEDSV DEF RBRVS 01/01/2024 12/31/2024 723.45 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27742 MEDSV DEF RBRVS 01/01/2025 709.36 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27745 MEDSV DEF RBRVS 01/01/2024 12/31/2024 703.2 Description: REINFORCE TIBIA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27745 MEDSV DEF RBRVS 01/01/2025 680.49 Description: REINFORCE TIBIA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 330.57 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27750 MEDSV DEF RBRVS 01/01/2025 327.49 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27752 MEDSV DEF RBRVS 01/01/2024 12/31/2024 505.35 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27752 MEDSV DEF RBRVS 01/01/2025 497.2 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27756 MEDSV DEF RBRVS 01/01/2024 12/31/2024 540.06 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27756 MEDSV DEF RBRVS 01/01/2025 531.28 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27758 MEDSV DEF RBRVS 01/01/2024 12/31/2024 832.85 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27758 MEDSV DEF RBRVS 01/01/2025 815.66 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27759 MEDSV DEF RBRVS 01/01/2024 12/31/2024 924.54 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27759 MEDSV DEF RBRVS 01/01/2025 904.47 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 316.44 Description: CLTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27760 MEDSV DEF RBRVS 01/01/2025 314.93 Description: CLTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27762 MEDSV DEF RBRVS 01/01/2024 12/31/2024 457.73 Description: CLTX MED ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27762 MEDSV DEF RBRVS 01/01/2025 455.79 Description: CLTX MED ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27766 MEDSV DEF RBRVS 01/01/2024 12/31/2024 567.49 Description: OPTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27766 MEDSV DEF RBRVS 01/01/2025 554.93 Description: OPTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27767 MEDSV DEF RBRVS 01/01/2024 12/31/2024 277.64 Description: CLTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27767 MEDSV DEF RBRVS 01/01/2025 273.7 Description: CLTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27768 MEDSV DEF RBRVS 01/01/2024 12/31/2024 421.99 Description: CLTX POST ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27768 MEDSV DEF RBRVS 01/01/2025 416.71 Description: CLTX POST ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27769 MEDSV DEF RBRVS 01/01/2024 12/31/2024 677.53 Description: OPTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27769 MEDSV DEF RBRVS 01/01/2025 663.26 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 294.76 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27780 MEDSV DEF RBRVS 01/01/2025 292.04 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27781 MEDSV DEF RBRVS 01/01/2024 12/31/2024 415.31 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27781 MEDSV DEF RBRVS 01/01/2025 410.35 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27784 MEDSV DEF RBRVS 01/01/2024 12/31/2024 662.64 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27784 MEDSV DEF RBRVS 01/01/2025 654.59 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27786 MEDSV DEF RBRVS 01/01/2024 12/31/2024 298.73 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27786 MEDSV DEF RBRVS 01/01/2025 295.85 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27788 MEDSV DEF RBRVS 01/01/2024 12/31/2024 403.71 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27788 MEDSV DEF RBRVS 01/01/2025 398.25 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27792 MEDSV DEF RBRVS 01/01/2024 12/31/2024 603.2 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27792 MEDSV DEF RBRVS 01/01/2025 591.5 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27808 MEDSV DEF RBRVS 01/01/2024 12/31/2024 319.15 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27808 MEDSV DEF RBRVS 01/01/2025 317.18 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 448.94 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27810 MEDSV DEF RBRVS 01/01/2025 443.45 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27814 MEDSV DEF RBRVS 01/01/2024 12/31/2024 712.99 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27814 MEDSV DEF RBRVS 01/01/2025 698.04 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27816 MEDSV DEF RBRVS 01/01/2024 12/31/2024 314.34 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27816 MEDSV DEF RBRVS 01/01/2025 312.77 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27818 MEDSV DEF RBRVS 01/01/2024 12/31/2024 465.69 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27818 MEDSV DEF RBRVS 01/01/2025 460 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27822 MEDSV DEF RBRVS 01/01/2024 12/31/2024 816.23 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27822 MEDSV DEF RBRVS 01/01/2025 797.44 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27823 MEDSV DEF RBRVS 01/01/2024 12/31/2024 917.76 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27823 MEDSV DEF RBRVS 01/01/2025 897.23 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27824 MEDSV DEF RBRVS 01/01/2024 12/31/2024 302.42 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27824 MEDSV DEF RBRVS 01/01/2025 297.1 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 514.05 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27825 MEDSV DEF RBRVS 01/01/2025 506 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27826 MEDSV DEF RBRVS 01/01/2024 12/31/2024 798.41 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27826 MEDSV DEF RBRVS 01/01/2025 781.05 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27827 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1043.33 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27827 MEDSV DEF RBRVS 01/01/2025 1019.42 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27828 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1233.67 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27828 MEDSV DEF RBRVS 01/01/2025 1204.39 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27829 MEDSV DEF RBRVS 01/01/2024 12/31/2024 661.69 Description: TREAT LOWER LEG JOINT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27829 MEDSV DEF RBRVS 01/01/2025 647.49 Description: TREAT LOWER LEG JOINT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 369.8 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27830 MEDSV DEF RBRVS 01/01/2025 365.33 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27831 MEDSV DEF RBRVS 01/01/2024 12/31/2024 385.19 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27831 MEDSV DEF RBRVS 01/01/2025 379.96 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27832 MEDSV DEF RBRVS 01/01/2024 12/31/2024 705.63 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27832 MEDSV DEF RBRVS 01/01/2025 692.71 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 365.25 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27840 MEDSV DEF RBRVS 01/01/2025 360.58 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27842 MEDSV DEF RBRVS 01/01/2024 12/31/2024 461.43 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27842 MEDSV DEF RBRVS 01/01/2025 454.93 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27846 MEDSV DEF RBRVS 01/01/2024 12/31/2024 671.7 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27846 MEDSV DEF RBRVS 01/01/2025 664.38 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27848 MEDSV DEF RBRVS 01/01/2024 12/31/2024 733.18 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27848 MEDSV DEF RBRVS 01/01/2025 721.61 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 154.38 Description: FIXATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27860 MEDSV DEF RBRVS 01/01/2025 150.82 Description: FIXATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27870 MEDSV DEF RBRVS 01/01/2024 12/31/2024 941.02 Description: FUSION OF ANKLE JOINT OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27870 MEDSV DEF RBRVS 01/01/2025 919.7 Description: FUSION OF ANKLE JOINT OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27871 MEDSV DEF RBRVS 01/01/2024 12/31/2024 644.9 Description: FUSION OF TIBIOFIBULAR JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27871 MEDSV DEF RBRVS 01/01/2025 631.57 Description: FUSION OF TIBIOFIBULAR JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 819.41 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27880 MEDSV DEF RBRVS 01/01/2025 797.19 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27881 MEDSV DEF RBRVS 01/01/2024 12/31/2024 780.6 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27881 MEDSV DEF RBRVS 01/01/2025 751 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27882 MEDSV DEF RBRVS 01/01/2024 12/31/2024 538.27 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27882 MEDSV DEF RBRVS 01/01/2025 525.16 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27884 MEDSV DEF RBRVS 01/01/2024 12/31/2024 529.56 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27884 MEDSV DEF RBRVS 01/01/2025 518.19 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27886 MEDSV DEF RBRVS 01/01/2024 12/31/2024 593.13 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27886 MEDSV DEF RBRVS 01/01/2025 580.05 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27888 MEDSV DEF RBRVS 01/01/2024 12/31/2024 594.25 Description: AMPUTATION OF FOOT AT ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27888 MEDSV DEF RBRVS 01/01/2025 506.42 Description: AMPUTATION OF FOOT AT ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27889 MEDSV DEF RBRVS 01/01/2024 12/31/2024 583.15 Description: ANKLE DISARTICULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27889 MEDSV DEF RBRVS 01/01/2025 573.59 Description: ANKLE DISARTICULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27892 MEDSV DEF RBRVS 01/01/2024 12/31/2024 496.54 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27892 MEDSV DEF RBRVS 01/01/2025 486.77 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27893 MEDSV DEF RBRVS 01/01/2024 12/31/2024 573 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27893 MEDSV DEF RBRVS 01/01/2025 562.92 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27894 MEDSV DEF RBRVS 01/01/2024 12/31/2024 751.79 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27894 MEDSV DEF RBRVS 01/01/2025 733.26 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27899 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX LEG/ANKLE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 28001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28001 MEDSV DEF RBRVS 01/01/2025 157.55 Description: DRAINAGE OF BURSA OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28002 MEDSV DEF RBRVS 01/01/2024 12/31/2024 231.62 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28002 MEDSV DEF RBRVS 01/01/2025 225.75 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28003 MEDSV DEF RBRVS 01/01/2024 12/31/2024 357.45 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28003 MEDSV DEF RBRVS 01/01/2025 346.78 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 540.59 Description: TREAT FOOT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28005 MEDSV DEF RBRVS 01/01/2025 531.27 Description: TREAT FOOT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28008 MEDSV DEF RBRVS 01/01/2024 12/31/2024 401.39 Description: INCISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28008 MEDSV DEF RBRVS 01/01/2025 393.2 Description: INCISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 220.13 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28010 MEDSV DEF RBRVS 01/01/2025 218.06 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28011 MEDSV DEF RBRVS 01/01/2024 12/31/2024 296.71 Description: INCISION OF TOE TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28011 MEDSV DEF RBRVS 01/01/2025 293.67 Description: INCISION OF TOE TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 510.7 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28020 MEDSV DEF RBRVS 01/01/2025 495.36 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28022 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28022 MEDSV DEF RBRVS 01/01/2025 446.24 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28024 MEDSV DEF RBRVS 01/01/2024 12/31/2024 428.83 Description: EXPLORATION OF TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28024 MEDSV DEF RBRVS 01/01/2025 424 Description: EXPLORATION OF TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 493.63 Description: DECOMPRESSION OF TIBIA NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28035 MEDSV DEF RBRVS 01/01/2025 483.32 Description: DECOMPRESSION OF TIBIA NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28039 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 437.74 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 12/31/2024 424.3 Description: EXC FOOT/TOE TUM DEP 1.5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28041 MEDSV DEF RBRVS 01/01/2025 417.54 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 12/31/2024 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 01/01/2025 352.02 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 12/31/2024 450.99 Description: EXC FOOT/TOE TUM DEEP <1.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28045 MEDSV DEF RBRVS 01/01/2025 441.82 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 12/31/2024 669.73 Description: RESECT FOOT/TOE TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 28046 MEDSV DEF RBRVS 01/01/2025 648.07 Description: RESECT FOOT/TOE TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 28047 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28047 MEDSV DEF RBRVS 01/01/2025 945.74 Description: RESECT FOOT/TOE TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 389.02 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28050 MEDSV DEF RBRVS 01/01/2025 382.98 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28052 MEDSV DEF RBRVS 01/01/2024 12/31/2024 364.07 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28052 MEDSV DEF RBRVS 01/01/2025 358.71 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28054 MEDSV DEF RBRVS 01/01/2024 12/31/2024 342.35 Description: BIOPSY OF TOE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28054 MEDSV DEF RBRVS 01/01/2025 337.04 Description: BIOPSY OF TOE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28055 MEDSV DEF RBRVS 01/01/2024 12/31/2024 363.27 Description: NEURECTOMY FOOT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 28055 MEDSV DEF RBRVS 01/01/2025 361.96 Description: NEURECTOMY FOOT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 28060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 483.12 Description: PARTIAL REMOVAL FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28060 MEDSV DEF RBRVS 01/01/2025 475.55 Description: PARTIAL REMOVAL FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28062 MEDSV DEF RBRVS 01/01/2024 12/31/2024 540.14 Description: REMOVAL OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28062 MEDSV DEF RBRVS 01/01/2025 531.55 Description: REMOVAL OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.52 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28070 MEDSV DEF RBRVS 01/01/2025 465.45 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28072 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28072 MEDSV DEF RBRVS 01/01/2025 449.63 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 496.74 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28080 MEDSV DEF RBRVS 01/01/2025 489.37 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28086 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.85 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28086 MEDSV DEF RBRVS 01/01/2025 478.9 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28088 MEDSV DEF RBRVS 01/01/2024 12/31/2024 428.14 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28088 MEDSV DEF RBRVS 01/01/2025 424.45 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28090 MEDSV DEF RBRVS 01/01/2024 12/31/2024 434.49 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28090 MEDSV DEF RBRVS 01/01/2025 427.56 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28092 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.06 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28092 MEDSV DEF RBRVS 01/01/2025 387.49 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 570.89 Description: REMOVAL OF ANKLE/HEEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28100 MEDSV DEF RBRVS 01/01/2025 558.66 Description: REMOVAL OF ANKLE/HEEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 570.13 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28102 MEDSV DEF RBRVS 01/01/2025 559.95 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28103 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28103 MEDSV DEF RBRVS 01/01/2025 362.52 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28104 MEDSV DEF RBRVS 01/01/2024 12/31/2024 488.43 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28104 MEDSV DEF RBRVS 01/01/2025 480.96 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28106 MEDSV DEF RBRVS 01/01/2024 12/31/2024 403.8 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28106 MEDSV DEF RBRVS 01/01/2025 398.42 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.54 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28107 MEDSV DEF RBRVS 01/01/2025 467.39 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28108 MEDSV DEF RBRVS 01/01/2024 12/31/2024 405.59 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28108 MEDSV DEF RBRVS 01/01/2025 398.64 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 428.08 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28110 MEDSV DEF RBRVS 01/01/2025 424.13 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 445.76 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28111 MEDSV DEF RBRVS 01/01/2025 435.92 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 450.05 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28112 MEDSV DEF RBRVS 01/01/2025 441.52 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28113 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28113 MEDSV DEF RBRVS 01/01/2025 537.3 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28114 MEDSV DEF RBRVS 01/01/2024 12/31/2024 994.27 Description: REMOVAL OF METATARSAL HEADS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28114 MEDSV DEF RBRVS 01/01/2025 975.22 Description: REMOVAL OF METATARSAL HEADS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28116 MEDSV DEF RBRVS 01/01/2024 12/31/2024 730.17 Description: REVISION OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28116 MEDSV DEF RBRVS 01/01/2025 704.88 Description: REVISION OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28118 MEDSV DEF RBRVS 01/01/2024 12/31/2024 561.26 Description: REMOVAL OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28118 MEDSV DEF RBRVS 01/01/2025 553.38 Description: REMOVAL OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28119 MEDSV DEF RBRVS 01/01/2024 12/31/2024 489.78 Description: REMOVAL OF HEEL SPUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28119 MEDSV DEF RBRVS 01/01/2025 483.35 Description: REMOVAL OF HEEL SPUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 626.36 Description: PART REMOVAL OF ANKLE/HEEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28120 MEDSV DEF RBRVS 01/01/2025 613.26 Description: PART REMOVAL OF ANKLE/HEEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28122 MEDSV DEF RBRVS 01/01/2024 12/31/2024 552.78 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28122 MEDSV DEF RBRVS 01/01/2025 544.2 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28124 MEDSV DEF RBRVS 01/01/2024 12/31/2024 444.79 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28124 MEDSV DEF RBRVS 01/01/2025 439.26 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28126 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28126 MEDSV DEF RBRVS 01/01/2025 358.47 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 571.34 Description: REMOVAL OF ANKLE BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28130 MEDSV DEF RBRVS 01/01/2025 572.09 Description: REMOVAL OF ANKLE BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 532.59 Description: REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28140 MEDSV DEF RBRVS 01/01/2025 519.97 Description: REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 390.58 Description: REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28150 MEDSV DEF RBRVS 01/01/2025 383.98 Description: REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28153 MEDSV DEF RBRVS 01/01/2024 12/31/2024 378.29 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28153 MEDSV DEF RBRVS 01/01/2025 371.51 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 380.85 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28160 MEDSV DEF RBRVS 01/01/2025 374.75 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28171 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1023.5 Description: RESECT TARSAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28171 MEDSV DEF RBRVS 01/01/2025 1001.15 Description: RESECT TARSAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28173 MEDSV DEF RBRVS 01/01/2024 12/31/2024 689.42 Description: RESECT METATARSAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28173 MEDSV DEF RBRVS 01/01/2025 676.49 Description: RESECT METATARSAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28175 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28175 MEDSV DEF RBRVS 01/01/2025 438.62 Description: RESECT PHALANX OF TOE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28190 MEDSV DEF RBRVS 01/01/2024 12/31/2024 225.22 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28190 MEDSV DEF RBRVS 01/01/2025 220.24 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28192 MEDSV DEF RBRVS 01/01/2024 12/31/2024 428.69 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28192 MEDSV DEF RBRVS 01/01/2025 421.19 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28193 MEDSV DEF RBRVS 01/01/2024 12/31/2024 488.45 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28193 MEDSV DEF RBRVS 01/01/2025 478.9 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 461.05 Description: REPAIR OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28200 MEDSV DEF RBRVS 01/01/2025 452.4 Description: REPAIR OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28202 MEDSV DEF RBRVS 01/01/2024 12/31/2024 562.62 Description: REPAIR/GRAFT OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28202 MEDSV DEF RBRVS 01/01/2025 549.19 Description: REPAIR/GRAFT OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28208 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.73 Description: REPAIR OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28208 MEDSV DEF RBRVS 01/01/2025 443.66 Description: REPAIR OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 556.86 Description: REPAIR/GRAFT OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28210 MEDSV DEF RBRVS 01/01/2025 544.07 Description: REPAIR/GRAFT OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28220 MEDSV DEF RBRVS 01/01/2025 414.26 Description: RELEASE OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28222 MEDSV DEF RBRVS 01/01/2024 12/31/2024 493.17 Description: RELEASE OF FOOT TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28222 MEDSV DEF RBRVS 01/01/2025 493.43 Description: RELEASE OF FOOT TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 385.21 Description: RELEASE OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28225 MEDSV DEF RBRVS 01/01/2025 378.59 Description: RELEASE OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28226 MEDSV DEF RBRVS 01/01/2024 12/31/2024 573.17 Description: RELEASE OF FOOT TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28226 MEDSV DEF RBRVS 01/01/2025 560.19 Description: RELEASE OF FOOT TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 405.18 Description: INCISION OF FOOT TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28230 MEDSV DEF RBRVS 01/01/2025 396.69 Description: INCISION OF FOOT TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28232 MEDSV DEF RBRVS 01/01/2024 12/31/2024 351.91 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28232 MEDSV DEF RBRVS 01/01/2025 346.14 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28234 MEDSV DEF RBRVS 01/01/2024 12/31/2024 381.21 Description: INCISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28234 MEDSV DEF RBRVS 01/01/2025 375.83 Description: INCISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28238 MEDSV DEF RBRVS 01/01/2024 12/31/2024 631.06 Description: REVISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28238 MEDSV DEF RBRVS 01/01/2025 616.24 Description: REVISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 414.2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28240 MEDSV DEF RBRVS 01/01/2025 406.68 Description: RELEASE OF BIG TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 547.03 Description: REVISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28250 MEDSV DEF RBRVS 01/01/2025 537.97 Description: REVISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 670.81 Description: RELEASE OF MIDFOOT JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28260 MEDSV DEF RBRVS 01/01/2025 666.85 Description: RELEASE OF MIDFOOT JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28261 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1113.44 Description: REVISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28261 MEDSV DEF RBRVS 01/01/2025 979.13 Description: REVISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28262 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1298.02 Description: REVISION OF FOOT AND ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28262 MEDSV DEF RBRVS 01/01/2025 1248.48 Description: REVISION OF FOOT AND ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28264 MEDSV DEF RBRVS 01/01/2024 12/31/2024 818.15 Description: RELEASE OF MIDFOOT JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28264 MEDSV DEF RBRVS 01/01/2025 796.69 Description: RELEASE OF MIDFOOT JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.03 Description: RELEASE OF FOOT CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28270 MEDSV DEF RBRVS 01/01/2025 446.66 Description: RELEASE OF FOOT CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28272 MEDSV DEF RBRVS 01/01/2024 12/31/2024 357.78 Description: RELEASE OF TOE JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28272 MEDSV DEF RBRVS 01/01/2025 352.02 Description: RELEASE OF TOE JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28280 MEDSV DEF RBRVS 01/01/2025 463.43 Description: FUSION OF TOES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 502.32 Description: REPAIR OF HAMMERTOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28285 MEDSV DEF RBRVS 01/01/2025 495.9 Description: REPAIR OF HAMMERTOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28286 MEDSV DEF RBRVS 01/01/2024 12/31/2024 412.36 Description: REPAIR OF HAMMERTOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28286 MEDSV DEF RBRVS 01/01/2025 407.81 Description: REPAIR OF HAMMERTOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28288 MEDSV DEF RBRVS 01/01/2024 12/31/2024 563 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28288 MEDSV DEF RBRVS 01/01/2025 553.88 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28289 MEDSV DEF RBRVS 01/01/2024 12/31/2024 642.31 Description: CORRJ HALUX RIGDUS W/O IMPLT Category: Medical Services CMS Add: 01/01/1999 CMS Term: 28289 MEDSV DEF RBRVS 01/01/2025 630.51 Description: CORRJ HALUX RIGDUS W/O IMPLT Category: Medical Services CMS Add: 01/01/1999 CMS Term: 28291 MEDSV DEF RBRVS 01/01/2024 12/31/2024 653.04 Description: CORRJ HALUX RIGDUS W/IMPLT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 28291 MEDSV DEF RBRVS 01/01/2025 633.9 Description: CORRJ HALUX RIGDUS W/IMPLT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 28292 MEDSV DEF RBRVS 01/01/2024 12/31/2024 650.53 Description: COR HLX VLGS RSC PRX PHLX BS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28292 MEDSV DEF RBRVS 01/01/2025 643.01 Description: COR HLX VLGS RSC PRX PHLX BS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28295 MEDSV DEF RBRVS 01/01/2024 12/31/2024 996.47 Description: COR HLX VLGS PRX MTAR OSTEOT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 28295 MEDSV DEF RBRVS 01/01/2025 953.47 Description: COR HLX VLGS PRX MTAR OSTEOT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 28296 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28296 MEDSV DEF RBRVS 01/01/2025 810.7 Description: COR HLX VLGS DSTL MTAR OSTEO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28297 MEDSV DEF RBRVS 01/01/2024 12/31/2024 958.75 Description: COR HLX VLGS JT ARTHRD Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28297 MEDSV DEF RBRVS 01/01/2025 933.49 Description: COR HLX VLGS JT ARTHRD Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28298 MEDSV DEF RBRVS 01/01/2024 12/31/2024 776.3 Description: COR HLX VLGS PRX PHLX OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28298 MEDSV DEF RBRVS 01/01/2025 763.51 Description: COR HLX VLGS PRX PHLX OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28299 MEDSV DEF RBRVS 01/01/2024 12/31/2024 940.63 Y Description: COR HLX VLGS DOUBLE OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28299 MEDSV DEF RBRVS 01/01/2025 925.15 Y Description: COR HLX VLGS DOUBLE OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 608.89 Description: INCISION OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28300 MEDSV DEF RBRVS 01/01/2025 597.27 Description: INCISION OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28302 MEDSV DEF RBRVS 01/01/2024 12/31/2024 666.93 Description: INCISION OF ANKLE BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28302 MEDSV DEF RBRVS 01/01/2025 653.66 Description: INCISION OF ANKLE BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28304 MEDSV DEF RBRVS 01/01/2024 12/31/2024 774.03 Description: INCISION OF MIDFOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28304 MEDSV DEF RBRVS 01/01/2025 756.32 Description: INCISION OF MIDFOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 630.6 Description: INCISE/GRAFT MIDFOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28305 MEDSV DEF RBRVS 01/01/2025 622.21 Description: INCISE/GRAFT MIDFOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28306 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28306 MEDSV DEF RBRVS 01/01/2025 558.03 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28307 MEDSV DEF RBRVS 01/01/2024 12/31/2024 728.65 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28307 MEDSV DEF RBRVS 01/01/2025 711.73 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28308 MEDSV DEF RBRVS 01/01/2024 12/31/2024 531.12 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28308 MEDSV DEF RBRVS 01/01/2025 523.38 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28309 MEDSV DEF RBRVS 01/01/2024 12/31/2024 841.54 Description: INCISION OF METATARSALS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28309 MEDSV DEF RBRVS 01/01/2025 829.94 Description: INCISION OF METATARSALS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 507.12 Description: REVISION OF BIG TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28310 MEDSV DEF RBRVS 01/01/2025 501.24 Description: REVISION OF BIG TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28312 MEDSV DEF RBRVS 01/01/2024 12/31/2024 496.74 Description: REVISION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28312 MEDSV DEF RBRVS 01/01/2025 497.32 Description: REVISION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28313 MEDSV DEF RBRVS 01/01/2024 12/31/2024 492.31 Description: REPAIR DEFORMITY OF TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28313 MEDSV DEF RBRVS 01/01/2025 482.86 Description: REPAIR DEFORMITY OF TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28315 MEDSV DEF RBRVS 01/01/2024 12/31/2024 448.08 Description: REMOVAL OF SESAMOID BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28315 MEDSV DEF RBRVS 01/01/2025 438.7 Description: REMOVAL OF SESAMOID BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28320 MEDSV DEF RBRVS 01/01/2025 567.42 Description: REPAIR OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28322 MEDSV DEF RBRVS 01/01/2024 12/31/2024 733.83 Description: REPAIR OF METATARSALS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28322 MEDSV DEF RBRVS 01/01/2025 718.25 Description: REPAIR OF METATARSALS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 531.77 Description: RESECT ENLARGED TOE TISSUE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28340 MEDSV DEF RBRVS 01/01/2025 524.08 Description: RESECT ENLARGED TOE TISSUE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28341 MEDSV DEF RBRVS 01/01/2024 12/31/2024 618.08 Description: RESECT ENLARGED TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28341 MEDSV DEF RBRVS 01/01/2025 608.65 Description: RESECT ENLARGED TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28344 MEDSV DEF RBRVS 01/01/2024 12/31/2024 391.83 Description: REPAIR EXTRA TOE(S) Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28344 MEDSV DEF RBRVS 01/01/2025 386.02 Description: REPAIR EXTRA TOE(S) Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 480.2 Description: REPAIR WEBBED TOE(S) Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28345 MEDSV DEF RBRVS 01/01/2025 473.31 Description: REPAIR WEBBED TOE(S) Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1020.2 Description: RECONSTRUCT CLEFT FOOT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28360 MEDSV DEF RBRVS 01/01/2025 998.6 Description: RECONSTRUCT CLEFT FOOT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 234.73 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28400 MEDSV DEF RBRVS 01/01/2025 233.21 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28405 MEDSV DEF RBRVS 01/01/2025 420.75 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28406 MEDSV DEF RBRVS 01/01/2024 12/31/2024 528.87 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28406 MEDSV DEF RBRVS 01/01/2025 542.97 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1051.27 Description: TREAT HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28415 MEDSV DEF RBRVS 01/01/2025 1025.54 Description: TREAT HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1204.19 Description: TREAT/GRAFT HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28420 MEDSV DEF RBRVS 01/01/2025 1176.54 Description: TREAT/GRAFT HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 227.81 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28430 MEDSV DEF RBRVS 01/01/2025 225.74 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 349.81 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28435 MEDSV DEF RBRVS 01/01/2025 346.08 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28436 MEDSV DEF RBRVS 01/01/2024 12/31/2024 465.84 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28436 MEDSV DEF RBRVS 01/01/2025 457.87 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 969.7 Description: TREAT ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28445 MEDSV DEF RBRVS 01/01/2025 958.5 Description: TREAT ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28446 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28446 MEDSV DEF RBRVS 01/01/2025 1109.29 Description: OSTEOCHONDRAL TALUS AUTOGRFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 28450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 200.02 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28450 MEDSV DEF RBRVS 01/01/2025 199.37 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28455 MEDSV DEF RBRVS 01/01/2024 12/31/2024 278.75 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28455 MEDSV DEF RBRVS 01/01/2025 241.39 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28456 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.9 Description: TREAT MIDFOOT FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28456 MEDSV DEF RBRVS 01/01/2025 343.17 Description: TREAT MIDFOOT FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28465 MEDSV DEF RBRVS 01/01/2024 12/31/2024 597.22 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28465 MEDSV DEF RBRVS 01/01/2025 591.98 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28470 MEDSV DEF RBRVS 01/01/2024 12/31/2024 206.81 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28470 MEDSV DEF RBRVS 01/01/2025 205.42 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28475 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.63 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28475 MEDSV DEF RBRVS 01/01/2025 245.12 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28476 MEDSV DEF RBRVS 01/01/2024 12/31/2024 366.39 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28476 MEDSV DEF RBRVS 01/01/2025 359.08 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28485 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28485 MEDSV DEF RBRVS 01/01/2025 522.44 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28490 MEDSV DEF RBRVS 01/01/2024 12/31/2024 134.07 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28490 MEDSV DEF RBRVS 01/01/2025 133.54 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28495 MEDSV DEF RBRVS 01/01/2024 12/31/2024 168.96 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28495 MEDSV DEF RBRVS 01/01/2025 169.43 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28496 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.96 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28496 MEDSV DEF RBRVS 01/01/2025 460.18 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 610.2 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28505 MEDSV DEF RBRVS 01/01/2025 598.47 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 114.76 Description: TREATMENT OF TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28510 MEDSV DEF RBRVS 01/01/2025 114.5 Description: TREATMENT OF TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 155.48 Description: TREATMENT OF TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28515 MEDSV DEF RBRVS 01/01/2025 155.52 Description: TREATMENT OF TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 530.32 Description: TREAT TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28525 MEDSV DEF RBRVS 01/01/2025 522.85 Description: TREAT TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28530 MEDSV DEF RBRVS 01/01/2025 110.41 Description: TREAT SESAMOID BONE FRACTURE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28531 MEDSV DEF RBRVS 01/01/2024 12/31/2024 307.17 Description: TREAT SESAMOID BONE FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28531 MEDSV DEF RBRVS 01/01/2025 303.19 Description: TREAT SESAMOID BONE FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 185.78 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28540 MEDSV DEF RBRVS 01/01/2025 185.81 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 292.36 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28545 MEDSV DEF RBRVS 01/01/2025 289.79 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28546 MEDSV DEF RBRVS 01/01/2024 12/31/2024 546.78 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28546 MEDSV DEF RBRVS 01/01/2025 535.61 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 808.83 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28555 MEDSV DEF RBRVS 01/01/2025 788.32 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 222.41 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28570 MEDSV DEF RBRVS 01/01/2025 221.4 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 357.22 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28575 MEDSV DEF RBRVS 01/01/2025 353.65 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28576 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28576 MEDSV DEF RBRVS 01/01/2025 359.23 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28585 MEDSV DEF RBRVS 01/01/2024 12/31/2024 829.68 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28585 MEDSV DEF RBRVS 01/01/2025 826.52 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 207.24 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28600 MEDSV DEF RBRVS 01/01/2025 177.07 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 323.06 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28605 MEDSV DEF RBRVS 01/01/2025 320.46 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 361.81 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28606 MEDSV DEF RBRVS 01/01/2025 362.55 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 773.71 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28615 MEDSV DEF RBRVS 01/01/2025 760.98 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 144.99 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28630 MEDSV DEF RBRVS 01/01/2025 143.41 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 165.82 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28635 MEDSV DEF RBRVS 01/01/2025 159.29 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28636 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28636 MEDSV DEF RBRVS 01/01/2025 323 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28645 MEDSV DEF RBRVS 01/01/2024 12/31/2024 607.53 Description: REPAIR TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28645 MEDSV DEF RBRVS 01/01/2025 599.63 Description: REPAIR TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 116.69 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28660 MEDSV DEF RBRVS 01/01/2025 116.37 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 140.97 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28665 MEDSV DEF RBRVS 01/01/2025 141.49 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28666 MEDSV DEF RBRVS 01/01/2024 12/31/2024 167.76 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28666 MEDSV DEF RBRVS 01/01/2025 163.8 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28675 MEDSV DEF RBRVS 01/01/2024 12/31/2024 538.06 Description: REPAIR OF TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28675 MEDSV DEF RBRVS 01/01/2025 528.63 Description: REPAIR OF TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1140.73 Description: ARTHRODESIS PANTALAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28705 MEDSV DEF RBRVS 01/01/2025 1116.15 Description: ARTHRODESIS PANTALAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 876.58 Description: ARTHRODESIS TRIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28715 MEDSV DEF RBRVS 01/01/2025 858.46 Description: ARTHRODESIS TRIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 726.69 Description: ARTHRODESIS SUBTALAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28725 MEDSV DEF RBRVS 01/01/2025 713.61 Description: ARTHRODESIS SUBTALAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 682.08 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28730 MEDSV DEF RBRVS 01/01/2025 666.5 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28735 MEDSV DEF RBRVS 01/01/2024 12/31/2024 731.26 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28735 MEDSV DEF RBRVS 01/01/2025 713.55 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28737 MEDSV DEF RBRVS 01/01/2024 12/31/2024 645.72 Description: REVISION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28737 MEDSV DEF RBRVS 01/01/2025 637.24 Description: REVISION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 772.23 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28740 MEDSV DEF RBRVS 01/01/2025 755.48 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 729.99 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28750 MEDSV DEF RBRVS 01/01/2025 712.95 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28755 MEDSV DEF RBRVS 01/01/2024 12/31/2024 470.59 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28755 MEDSV DEF RBRVS 01/01/2025 461.99 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 712.15 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28760 MEDSV DEF RBRVS 01/01/2025 708.43 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28800 MEDSV DEF RBRVS 01/01/2025 487.7 Description: AMPUTATION OF MIDFOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 663.61 Description: AMPUTATION THRU METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28805 MEDSV DEF RBRVS 01/01/2025 648.84 Description: AMPUTATION THRU METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 394.22 Description: AMPUTATION TOE & METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28810 MEDSV DEF RBRVS 01/01/2025 387.42 Description: AMPUTATION TOE & METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 278.83 Description: AMPUTATION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28820 MEDSV DEF RBRVS 01/01/2025 271.49 Description: AMPUTATION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 273.25 Description: PARTIAL AMPUTATION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28825 MEDSV DEF RBRVS 01/01/2025 267.15 Description: PARTIAL AMPUTATION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28890 NOCOV DEF SYSMAN 01/01/2006 Y Description: HI ENRGY ESWT PLANTAR FASCIA Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 28899 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX FOOT/TOES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 29000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 323.66 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29000 MEDSV DEF RBRVS 01/01/2025 326.8 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 255 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29010 MEDSV DEF RBRVS 01/01/2025 256.47 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29015 MEDSV DEF RBRVS 01/01/2025 274.48 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 239.58 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29035 MEDSV DEF RBRVS 01/01/2025 241.65 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 273.4 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29040 MEDSV DEF RBRVS 01/01/2025 274.87 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29044 MEDSV DEF RBRVS 01/01/2024 12/31/2024 268.31 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29044 MEDSV DEF RBRVS 01/01/2025 269.77 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29046 MEDSV DEF RBRVS 01/01/2024 12/31/2024 293.61 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29046 MEDSV DEF RBRVS 01/01/2025 294.71 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29049 MEDSV DEF RBRVS 01/01/2024 12/31/2024 92.64 Description: APPLICATION OF FIGURE EIGHT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29049 MEDSV DEF RBRVS 01/01/2025 92.38 Description: APPLICATION OF FIGURE EIGHT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29055 MEDSV DEF RBRVS 01/01/2024 12/31/2024 208.12 Description: APPLICATION OF SHOULDER CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29055 MEDSV DEF RBRVS 01/01/2025 208.77 Description: APPLICATION OF SHOULDER CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29058 MEDSV DEF RBRVS 01/01/2024 12/31/2024 114.95 Description: APPLICATION OF SHOULDER CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29058 MEDSV DEF RBRVS 01/01/2025 114.05 Description: APPLICATION OF SHOULDER CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29065 MEDSV DEF RBRVS 01/01/2025 89.76 Description: APPLICATION OF LONG ARM CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29075 MEDSV DEF RBRVS 01/01/2024 12/31/2024 81.62 Description: APPLICATION OF FOREARM CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29075 MEDSV DEF RBRVS 01/01/2025 81.03 Description: APPLICATION OF FOREARM CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29085 MEDSV DEF RBRVS 01/01/2024 12/31/2024 89.64 Description: APPLY HAND/WRIST CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29085 MEDSV DEF RBRVS 01/01/2025 88.99 Description: APPLY HAND/WRIST CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29086 MEDSV DEF RBRVS 01/01/2024 12/31/2024 71.84 Description: APPLY FINGER CAST Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29086 MEDSV DEF RBRVS 01/01/2025 71.83 Description: APPLY FINGER CAST Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 77.08 Description: APPLY LONG ARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29105 MEDSV DEF RBRVS 01/01/2025 76.44 Description: APPLY LONG ARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 61.77 Description: APPLY FOREARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29125 MEDSV DEF RBRVS 01/01/2025 61.88 Description: APPLY FOREARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29126 MEDSV DEF RBRVS 01/01/2024 12/31/2024 72.5 Description: APPLY FOREARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29126 MEDSV DEF RBRVS 01/01/2025 72.76 Description: APPLY FOREARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 38.93 Description: APPLICATION OF FINGER SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29130 MEDSV DEF RBRVS 01/01/2025 38.63 Description: APPLICATION OF FINGER SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29131 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29131 MEDSV DEF RBRVS 01/01/2025 49.93 Description: APPLICATION OF FINGER SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 30.83 Description: STRAPPING THORAX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29200 MEDSV DEF RBRVS 01/01/2025 29.69 Description: STRAPPING THORAX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 28.66 Description: STRAPPING OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29240 MEDSV DEF RBRVS 01/01/2025 27.58 Description: STRAPPING OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 27.75 Description: STRAPPING OF ELBOW OR WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29260 MEDSV DEF RBRVS 01/01/2025 26.83 Description: STRAPPING OF ELBOW OR WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 28.06 Description: STRAPPING OF HAND OR FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29280 MEDSV DEF RBRVS 01/01/2025 27.45 Description: STRAPPING OF HAND OR FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 230.67 Description: APPLICATION OF HIP CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29305 MEDSV DEF RBRVS 01/01/2025 230.88 Description: APPLICATION OF HIP CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 254.58 Description: APPLICATION OF HIP CASTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29325 MEDSV DEF RBRVS 01/01/2025 254.91 Description: APPLICATION OF HIP CASTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 126.19 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29345 MEDSV DEF RBRVS 01/01/2025 124.54 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29355 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29355 MEDSV DEF RBRVS 01/01/2025 130.34 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29358 MEDSV DEF RBRVS 01/01/2024 12/31/2024 149.44 Description: APPLY LONG LEG CAST BRACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29358 MEDSV DEF RBRVS 01/01/2025 149.71 Description: APPLY LONG LEG CAST BRACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 115.31 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29365 MEDSV DEF RBRVS 01/01/2025 114.91 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 74.73 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29405 MEDSV DEF RBRVS 01/01/2025 74.45 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 70.4 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29425 MEDSV DEF RBRVS 01/01/2025 70.05 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 107.42 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29435 MEDSV DEF RBRVS 01/01/2025 114.3 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 40.33 Description: ADDITION OF WALKER TO CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29440 MEDSV DEF RBRVS 01/01/2025 40.29 Description: ADDITION OF WALKER TO CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.49 Description: APPLY RIGID LEG CAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 29445 MEDSV DEF RBRVS 01/01/2025 118.82 Description: APPLY RIGID LEG CAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 29450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29450 MEDSV DEF RBRVS 01/01/2025 135.16 Description: APPLICATION OF LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 82.43 Description: APPLICATION LONG LEG SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29505 MEDSV DEF RBRVS 01/01/2025 83.07 Description: APPLICATION LONG LEG SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 66.95 Description: APPLICATION LOWER LEG SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29515 MEDSV DEF RBRVS 01/01/2025 67.01 Description: APPLICATION LOWER LEG SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 32.99 Description: STRAPPING OF HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29520 MEDSV DEF RBRVS 01/01/2025 32.11 Description: STRAPPING OF HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 28.36 Description: STRAPPING OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29530 MEDSV DEF RBRVS 01/01/2025 27.28 Description: STRAPPING OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 26.52 Description: STRAPPING OF ANKLE AND/OR FT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29540 MEDSV DEF RBRVS 01/01/2025 25.93 Description: STRAPPING OF ANKLE AND/OR FT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 18.06 Description: STRAPPING OF TOES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29550 MEDSV DEF RBRVS 01/01/2025 17.86 Description: STRAPPING OF TOES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 58.97 Description: STRAPPING UNNA BOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29580 MEDSV DEF RBRVS 01/01/2025 58.37 Description: STRAPPING UNNA BOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29581 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29581 MEDSV DEF RBRVS 01/01/2025 81.09 Description: APPLY MULTLAY COMPRS LWR LEG Category: Medical Services CMS Add: 01/01/2010 CMS Term: 29584 MEDSV DEF RBRVS 01/01/2024 12/31/2024 76.54 Description: APPL MULTLAY COMPRS ARM/HAND Category: Medical Services CMS Add: 01/01/2012 CMS Term: 29584 MEDSV DEF RBRVS 01/01/2025 73.21 Description: APPL MULTLAY COMPRS ARM/HAND Category: Medical Services CMS Add: 01/01/2012 CMS Term: 29700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 57.97 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29700 MEDSV DEF RBRVS 01/01/2025 58.9 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 58.56 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29705 MEDSV DEF RBRVS 01/01/2025 58.19 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 113.35 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29710 MEDSV DEF RBRVS 01/01/2025 112.47 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 79.63 Description: REPAIR OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29720 MEDSV DEF RBRVS 01/01/2025 79.74 Description: REPAIR OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 59.45 Description: WINDOWING OF CAST Category: Medical Services CMS Add: 01/01/1989 CMS Term: 29730 MEDSV DEF RBRVS 01/01/2025 59.83 Description: WINDOWING OF CAST Category: Medical Services CMS Add: 01/01/1989 CMS Term: 29740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 91.51 Description: WEDGING OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29740 MEDSV DEF RBRVS 01/01/2025 90.74 Description: WEDGING OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 99.2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29750 MEDSV DEF RBRVS 01/01/2025 97.76 Description: WEDGING OF CLUBFOOT CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29799 MEDSV DEF BILL20 10/15/2020 Y Description: UNLISTED PX CASTING/STRPG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.78 Y Description: JAW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 29800 MEDSV DEF RBRVS 01/01/2025 486.53 Y Description: JAW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 29804 MEDSV DEF RBRVS 01/01/2024 12/31/2024 563.55 Description: JAW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 29804 MEDSV DEF RBRVS 01/01/2025 548.99 Description: JAW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 29805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 438.64 Description: SHO ARTHRS DX +- SYNOVIAL BX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29805 MEDSV DEF RBRVS 01/01/2025 429.03 Description: SHO ARTHRS DX +- SYNOVIAL BX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29806 MEDSV DEF RBRVS 01/01/2024 12/31/2024 981.77 Description: SHO ARTHRS SRG CAPSULORRAPHY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29806 MEDSV DEF RBRVS 01/01/2025 962.14 Description: SHO ARTHRS SRG CAPSULORRAPHY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29807 MEDSV DEF RBRVS 01/01/2024 12/31/2024 960.54 Description: SHO ARTHRS SRG RPR SLAP LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29807 MEDSV DEF RBRVS 01/01/2025 939.59 Description: SHO ARTHRS SRG RPR SLAP LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29819 MEDSV DEF RBRVS 01/01/2024 12/31/2024 547.61 Description: SHO ARTHRS SRG RMVL LOOSE/FB Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29819 MEDSV DEF RBRVS 01/01/2025 537.36 Description: SHO ARTHRS SRG RMVL LOOSE/FB Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 498.37 Description: SHO ARTHRS SRG PRTL SYNVCT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29820 MEDSV DEF RBRVS 01/01/2025 488.51 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 553.95 Description: SHO ARTHRS SRG COMPL SYNVCT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29821 MEDSV DEF RBRVS 01/01/2025 542.16 Description: SHO ARTHRS SRG COMPL SYNVCT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29822 MEDSV DEF RBRVS 01/01/2024 12/31/2024 505.24 Description: SHO ARTHRS SRG LMTD DBRDMT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29822 MEDSV DEF RBRVS 01/01/2025 496.06 Description: SHO ARTHRS SRG LMTD DBRDMT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29823 MEDSV DEF RBRVS 01/01/2024 12/31/2024 553.29 Description: SHO ARTHRS SRG XTNSV DBRDMT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29823 MEDSV DEF RBRVS 01/01/2025 542.55 Description: SHO ARTHRS SRG XTNSV DBRDMT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29824 MEDSV DEF RBRVS 01/01/2024 12/31/2024 631.77 Description: SHO ARTHRS SRG DSTL CLAVICLC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29824 MEDSV DEF RBRVS 01/01/2025 619.22 Description: SHO ARTHRS SRG DSTL CLAVICLC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 547.61 Description: SHO ARTHRS SRG LSS&RESCJ ADS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29825 MEDSV DEF RBRVS 01/01/2025 536.44 Description: SHO ARTHRS SRG LSS&RESCJ ADS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29826 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.23 Description: SHO ARTHRS SRG DECOMPRESSION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 29826 MEDSV DEF RBRVS 01/01/2025 153.33 Description: SHO ARTHRS SRG DECOMPRESSION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 29827 MEDSV DEF RBRVS 01/01/2024 12/31/2024 991.97 Description: SHO ARTHRS SRG RT8TR CUF RPR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29827 MEDSV DEF RBRVS 01/01/2025 969.82 Description: SHO ARTHRS SRG RT8TR CUF RPR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29828 MEDSV DEF RBRVS 01/01/2024 12/31/2024 851.11 Description: SHO ARTHRS SRG BICP TENODSIS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29828 MEDSV DEF RBRVS 01/01/2025 833.12 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 426.22 Description: ELBOW ARTHROSCOPY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29830 MEDSV DEF RBRVS 01/01/2025 420.11 Description: ELBOW ARTHROSCOPY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29834 MEDSV DEF RBRVS 01/01/2024 12/31/2024 460.85 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29834 MEDSV DEF RBRVS 01/01/2025 451.06 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29835 MEDSV DEF RBRVS 01/01/2024 12/31/2024 475.57 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29835 MEDSV DEF RBRVS 01/01/2025 467.21 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29836 MEDSV DEF RBRVS 01/01/2024 12/31/2024 546.91 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29836 MEDSV DEF RBRVS 01/01/2025 534.92 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29837 MEDSV DEF RBRVS 01/01/2024 12/31/2024 493.42 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29837 MEDSV DEF RBRVS 01/01/2025 481.34 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29838 MEDSV DEF RBRVS 01/01/2024 12/31/2024 555.14 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29838 MEDSV DEF RBRVS 01/01/2025 545.29 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 424.07 Description: WRIST ARTHROSCOPY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29840 MEDSV DEF RBRVS 01/01/2025 415.2 Description: WRIST ARTHROSCOPY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29843 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.65 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29843 MEDSV DEF RBRVS 01/01/2025 447.07 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29844 MEDSV DEF RBRVS 01/01/2024 12/31/2024 468.68 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29844 MEDSV DEF RBRVS 01/01/2025 458.68 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 548.36 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29845 MEDSV DEF RBRVS 01/01/2025 537.98 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29846 MEDSV DEF RBRVS 01/01/2024 12/31/2024 489.94 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29846 MEDSV DEF RBRVS 01/01/2025 480.23 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29847 MEDSV DEF RBRVS 01/01/2024 12/31/2024 507.87 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29847 MEDSV DEF RBRVS 01/01/2025 498.43 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29848 MEDSV DEF RBRVS 01/01/2024 12/31/2024 479.58 Description: WRIST ENDOSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 29848 MEDSV DEF RBRVS 01/01/2025 472.1 Description: WRIST ENDOSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 29850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 581.57 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29850 MEDSV DEF RBRVS 01/01/2025 571.17 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29851 MEDSV DEF RBRVS 01/01/2024 12/31/2024 862.16 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29851 MEDSV DEF RBRVS 01/01/2025 844.35 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29855 MEDSV DEF RBRVS 01/01/2024 12/31/2024 726.74 Description: TIBIAL ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29855 MEDSV DEF RBRVS 01/01/2025 711.02 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29856 MEDSV DEF RBRVS 01/01/2024 12/31/2024 920.01 Description: TIBIAL ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29856 MEDSV DEF RBRVS 01/01/2025 900.55 Description: TIBIAL ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 601.95 Description: HIP ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29860 MEDSV DEF RBRVS 01/01/2025 599.33 Description: HIP ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29861 MEDSV DEF RBRVS 01/01/2024 12/31/2024 662.43 Description: HIP ARTHRO W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29861 MEDSV DEF RBRVS 01/01/2025 651.1 Description: HIP ARTHRO W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29862 MEDSV DEF RBRVS 01/01/2024 12/31/2024 755.95 Description: HIP ARTHR0 W/DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29862 MEDSV DEF RBRVS 01/01/2025 743.36 Description: HIP ARTHR0 W/DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29863 MEDSV DEF RBRVS 01/01/2024 12/31/2024 754.56 Description: HIP ARTHR0 W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29863 MEDSV DEF RBRVS 01/01/2025 742.9 Description: HIP ARTHR0 W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29866 MEDSV DEF RBRVS 01/01/2024 12/31/2024 976.03 Description: AUTGRFT IMPLNT KNEE W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29866 MEDSV DEF RBRVS 01/01/2025 956.41 Description: AUTGRFT IMPLNT KNEE W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29867 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1183.47 Description: ALLGRFT IMPLNT KNEE W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29867 MEDSV DEF RBRVS 01/01/2025 1158.68 Description: ALLGRFT IMPLNT KNEE W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29868 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1540.65 Description: MENISCAL TRNSPL KNEE W/SCPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29868 MEDSV DEF RBRVS 01/01/2025 1505.39 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29870 MEDSV DEF RBRVS 01/01/2024 12/31/2024 513.31 Description: KNEE ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29870 MEDSV DEF RBRVS 01/01/2025 505.71 Description: KNEE ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29871 MEDSV DEF RBRVS 01/01/2024 12/31/2024 481.34 Description: KNEE ARTHROSCOPY/DRAINAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29871 MEDSV DEF RBRVS 01/01/2025 472.36 Description: KNEE ARTHROSCOPY/DRAINAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29873 MEDSV DEF RBRVS 01/01/2024 12/31/2024 501.36 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29873 MEDSV DEF RBRVS 01/01/2025 494.23 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29874 MEDSV DEF RBRVS 01/01/2024 12/31/2024 500.32 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29874 MEDSV DEF RBRVS 01/01/2025 492.73 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29875 MEDSV DEF RBRVS 01/01/2024 12/31/2024 463.6 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29875 MEDSV DEF RBRVS 01/01/2025 455.25 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29876 MEDSV DEF RBRVS 01/01/2024 12/31/2024 607.81 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29876 MEDSV DEF RBRVS 01/01/2025 596.6 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29877 MEDSV DEF RBRVS 01/01/2024 12/31/2024 578.86 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29877 MEDSV DEF RBRVS 01/01/2025 567.74 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29879 MEDSV DEF RBRVS 01/01/2024 12/31/2024 615.92 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29879 MEDSV DEF RBRVS 01/01/2025 604.49 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 524.44 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29880 MEDSV DEF RBRVS 01/01/2025 514.55 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29881 MEDSV DEF RBRVS 01/01/2024 12/31/2024 505.24 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29881 MEDSV DEF RBRVS 01/01/2025 496.06 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29882 MEDSV DEF RBRVS 01/01/2024 12/31/2024 642.2 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29882 MEDSV DEF RBRVS 01/01/2025 628.88 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29883 MEDSV DEF RBRVS 01/01/2024 12/31/2024 783.67 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29883 MEDSV DEF RBRVS 01/01/2025 767.24 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29884 MEDSV DEF RBRVS 01/01/2024 12/31/2024 577.4 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29884 MEDSV DEF RBRVS 01/01/2025 566.78 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29885 MEDSV DEF RBRVS 01/01/2024 12/31/2024 703.44 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29885 MEDSV DEF RBRVS 01/01/2025 690.26 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29886 MEDSV DEF RBRVS 01/01/2024 12/31/2024 593.07 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29886 MEDSV DEF RBRVS 01/01/2025 582.47 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29887 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.66 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29887 MEDSV DEF RBRVS 01/01/2025 687.86 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29888 MEDSV DEF RBRVS 01/01/2024 12/31/2024 905.76 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29888 MEDSV DEF RBRVS 01/01/2025 885.08 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29889 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1134.23 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29889 MEDSV DEF RBRVS 01/01/2025 1111.2 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29891 MEDSV DEF RBRVS 01/01/2024 12/31/2024 627.53 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29891 MEDSV DEF RBRVS 01/01/2025 619.18 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29892 MEDSV DEF RBRVS 01/01/2024 12/31/2024 605.85 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29892 MEDSV DEF RBRVS 01/01/2025 594.33 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29893 MEDSV DEF RBRVS 01/01/2024 12/31/2024 622.79 Description: SCOPE PLANTAR FASCIOTOMY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29893 MEDSV DEF RBRVS 01/01/2025 612.82 Description: SCOPE PLANTAR FASCIOTOMY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29894 MEDSV DEF RBRVS 01/01/2024 12/31/2024 465.45 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29894 MEDSV DEF RBRVS 01/01/2025 463.51 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29895 MEDSV DEF RBRVS 01/01/2024 12/31/2024 436.44 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29895 MEDSV DEF RBRVS 01/01/2025 427.18 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29897 MEDSV DEF RBRVS 01/01/2024 12/31/2024 467.22 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29897 MEDSV DEF RBRVS 01/01/2025 455.41 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29898 MEDSV DEF RBRVS 01/01/2024 12/31/2024 526.85 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29898 MEDSV DEF RBRVS 01/01/2025 515.97 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29899 MEDSV DEF RBRVS 01/01/2024 12/31/2024 936.72 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29899 MEDSV DEF RBRVS 01/01/2025 915.37 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 471.56 Description: MCP JOINT ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29900 MEDSV DEF RBRVS 01/01/2025 464.6 Description: MCP JOINT ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29901 MEDSV DEF RBRVS 01/01/2024 12/31/2024 505.43 Description: MCP JOINT ARTHROSCOPY SURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29901 MEDSV DEF RBRVS 01/01/2025 497.32 Description: MCP JOINT ARTHROSCOPY SURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29902 MEDSV DEF RBRVS 01/01/2024 12/31/2024 535.48 Description: MCP JOINT ARTHROSCOPY SURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29902 MEDSV DEF RBRVS 01/01/2025 526.8 Description: MCP JOINT ARTHROSCOPY SURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29904 MEDSV DEF RBRVS 01/01/2024 12/31/2024 595.27 Description: SUBTALAR ARTHRO W/FB RMVL Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29904 MEDSV DEF RBRVS 01/01/2025 584.57 Description: SUBTALAR ARTHRO W/FB RMVL Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 488.45 Description: SUBTALAR ARTHRO W/EXC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29905 MEDSV DEF RBRVS 01/01/2025 481.55 Description: SUBTALAR ARTHRO W/EXC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29906 MEDSV DEF RBRVS 01/01/2024 12/31/2024 604.5 Description: SUBTALAR ARTHRO W/DEB Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29906 MEDSV DEF RBRVS 01/01/2025 600.65 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29907 MEDSV DEF RBRVS 01/01/2024 12/31/2024 814.61 Description: SUBTALAR ARTHRO W/FUSION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29907 MEDSV DEF RBRVS 01/01/2025 798.55 Description: SUBTALAR ARTHRO W/FUSION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29914 MEDSV DEF RBRVS 01/01/2024 12/31/2024 923.43 Description: HIP ARTHRO W/FEMOROPLASTY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29914 MEDSV DEF RBRVS 01/01/2025 902.22 Description: HIP ARTHRO W/FEMOROPLASTY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29915 MEDSV DEF RBRVS 01/01/2024 12/31/2024 944.1 Description: HIP ARTHRO ACETABULOPLASTY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29915 MEDSV DEF RBRVS 01/01/2025 924.13 Description: HIP ARTHRO ACETABULOPLASTY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29916 MEDSV DEF RBRVS 01/01/2024 12/31/2024 945.03 Description: HIP ARTHRO W/LABRAL REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29916 MEDSV DEF RBRVS 01/01/2025 920.63 Description: HIP ARTHRO W/LABRAL REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX ARTHROSCOPY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 30000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 251.89 Description: DRAINAGE OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30000 MEDSV DEF RBRVS 01/01/2025 241.85 Description: DRAINAGE OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 254.67 Description: DRAINAGE OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30020 MEDSV DEF RBRVS 01/01/2025 246.38 Description: DRAINAGE OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3006F NOCOV DEF SYSMAN 01/01/2007 Y Description: CXR DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3008F NOCOV DEF SYSMAN 01/01/2010 Y Description: BODY MASS INDEX DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 30100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30100 MEDSV DEF RBRVS 01/01/2025 128.55 Description: INTRANASAL BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 234.13 Description: REMOVAL OF NOSE POLYP(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30110 MEDSV DEF RBRVS 01/01/2025 227.89 Description: REMOVAL OF NOSE POLYP(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 442.16 Description: REMOVAL OF NOSE POLYP(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30115 MEDSV DEF RBRVS 01/01/2025 428.17 Description: REMOVAL OF NOSE POLYP(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30117 MEDSV DEF RBRVS 01/01/2024 12/31/2024 910.34 Description: REMOVAL OF INTRANASAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30117 MEDSV DEF RBRVS 01/01/2025 899.53 Description: REMOVAL OF INTRANASAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30118 MEDSV DEF RBRVS 01/01/2024 12/31/2024 751.22 Description: REMOVAL OF INTRANASAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30118 MEDSV DEF RBRVS 01/01/2025 650.62 Description: REMOVAL OF INTRANASAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3011F NOCOV DEF SYSMAN 01/01/2007 Y Description: LIPID PANEL DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 477.37 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30120 MEDSV DEF RBRVS 01/01/2025 467.99 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30124 MEDSV DEF RBRVS 01/01/2024 12/31/2024 287.47 Description: REMOVAL OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30124 MEDSV DEF RBRVS 01/01/2025 280.85 Description: REMOVAL OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 620.08 Description: REMOVAL OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30125 MEDSV DEF RBRVS 01/01/2025 601.26 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 394.36 Description: EXCISE INFERIOR TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30130 MEDSV DEF RBRVS 01/01/2025 382.25 Description: EXCISE INFERIOR TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 278.99 Description: RESECT INFERIOR TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30140 MEDSV DEF RBRVS 01/01/2025 270.5 Description: RESECT INFERIOR TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3014F NOCOV DEF SYSMAN 01/01/2007 Y Description: SCREEN MAMMO DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 758.65 Description: RHINECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30150 MEDSV DEF RBRVS 01/01/2025 732.18 Description: RHINECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3015F NOCOV DEF SYSMAN 01/01/2010 Y Description: CERV CANCER SCREEN DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 30160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 771.35 Description: RHINECTOMY TOTAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30160 MEDSV DEF RBRVS 01/01/2025 748.51 Description: RHINECTOMY TOTAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3016F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT SCRND UNHLTHY OH USE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3017F NOCOV DEF SYSMAN 01/01/2007 Y Description: COLORECTAL CA SCREEN DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3018F NOCOV DEF SYSMAN 01/01/2009 Y Description: PRE-PRXD RSK ET AL DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3019F NOCOV DEF SYSMAN 01/01/2012 Y Description: LVEF ASSESS PLANPOST DSCHRGE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 30200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 104.45 Description: INJECTION TREATMENT OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30200 MEDSV DEF RBRVS 01/01/2025 100.95 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3020F NOCOV DEF SYSMAN 01/01/2007 Y Description: LVF ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 141.67 Description: NASAL SINUS THERAPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30210 MEDSV DEF RBRVS 01/01/2025 138.71 Description: NASAL SINUS THERAPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3021F NOCOV DEF SYSMAN 01/01/2007 Y Description: LVEF MOD/SEVER DEPRS SYST Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 287.1 Description: INSERT NASAL SEPTAL BUTTON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30220 MEDSV DEF RBRVS 01/01/2025 277.31 Description: INSERT NASAL SEPTAL BUTTON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3022F NOCOV DEF SYSMAN 01/01/2007 Y Description: LVEF >=40% SYSTOLIC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3023F NOCOV DEF SYSMAN 01/01/2007 Y Description: SPIROM DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3025F NOCOV DEF SYSMAN 01/01/2007 Y Description: SPIROM FEV/FVC <70% W/COPD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3027F NOCOV DEF SYSMAN 01/01/2007 Y Description: SPIROM FEV/FVC>=70%/W/OCOPD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3028F NOCOV DEF SYSMAN 01/01/2007 Y Description: O2 SATURATION DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 197.43 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30300 MEDSV DEF RBRVS 01/01/2025 191.9 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 196.56 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30310 MEDSV DEF RBRVS 01/01/2025 191.18 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30320 MEDSV DEF RBRVS 01/01/2025 448.63 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3035F NOCOV DEF SYSMAN 01/01/2007 Y Description: O2 SATURATION<=88%/PAO<=55 Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3037F NOCOV DEF SYSMAN 01/01/2007 Y Description: O2 SATURATION >88%/PAO>55 HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3038F NOCOV DEF SYSMAN 01/01/2010 Y 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 12/31/2024 1154.67 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30400 MEDSV DEF RBRVS 01/01/2025 1117.22 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 3040F NOCOV DEF SYSMAN 01/01/2007 Y Description: FEV <40% PREDICTED VALUE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1327.35 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30410 MEDSV DEF RBRVS 01/01/2025 1284.8 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1372.81 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30420 MEDSV DEF RBRVS 01/01/2025 1329.72 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 3042F NOCOV DEF SYSMAN 01/01/2007 Y Description: FEV >=40% PREDICTED VALUE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1010.64 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30430 MEDSV DEF RBRVS 01/01/2025 977.46 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1257.31 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30435 MEDSV DEF RBRVS 01/01/2025 1216.9 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3044F NOCOV DEF SYSMAN 01/01/2007 Y Description: HG A1C LEVEL LT 7.0% Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1639.31 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30450 MEDSV DEF RBRVS 01/01/2025 1586.88 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 775.89 Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 30460 MEDSV DEF RBRVS 01/01/2025 752.41 Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 30462 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1491.22 Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 30462 MEDSV DEF RBRVS 01/01/2025 1444.55 Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 30465 MEDSV DEF RBRVS 01/01/2024 12/31/2024 971.07 Description: REPAIR NASAL STENOSIS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 30465 MEDSV DEF RBRVS 01/01/2025 941.42 Description: REPAIR NASAL STENOSIS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 30468 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2395.98 0 Description: RPR NSL VLV COLLAPSE W/IMPLT Category: Medical Services CMS Add: 01/01/2021 CMS Term: 30468 MEDSV DEF RBRVS 01/01/2025 2265.09 Description: RPR NSL VLV COLLAPSE W/IMPLT Category: Medical Services CMS Add: 01/01/2021 CMS Term: 30469 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2334.2 Description: RPR NSL VLV COLLAPSE W/RMDLG Category: Medical Services CMS Add: 01/01/2023 CMS Term: 30469 MEDSV DEF RBRVS 01/01/2025 2213.72 Description: RPR NSL VLV COLLAPSE W/RMDLG Category: Medical Services CMS Add: 01/01/2023 CMS Term: 3046F NOCOV DEF SYSMAN 01/01/2007 Y Description: HEMOGLOBIN A1C LEVEL >9.0% Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3048F NOCOV DEF SYSMAN 01/01/2007 Y Description: LDL-C <100 MG/DL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3049F NOCOV DEF SYSMAN 01/01/2007 Y Description: LDL-C 100-129 MG/DL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3050F NOCOV DEF SYSMAN 01/01/2007 Y Description: LDL-C >= 130 MG/DL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3051F NOCOV DEF SYSMAN 01/01/2020 Y Description: HG A1C>EQUAL 7.0%<8.0% Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 30520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 637.99 Description: REPAIR OF NASAL SEPTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30520 MEDSV DEF RBRVS 01/01/2025 619.81 Description: REPAIR OF NASAL SEPTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3052F NOCOV DEF SYSMAN 01/01/2020 Y Description: HG A1C>EQUAL 8.0%= 140 MM HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3078F NOCOV DEF SYSMAN 01/01/2007 Y Description: DIAST BP <80 MM HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3079F NOCOV DEF SYSMAN 01/01/2007 Y Description: DIAST BP 80-89 MM HG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30801 MEDSV DEF RBRVS 01/01/2024 12/31/2024 205.91 Description: ABLATE INF TURBINATE SUPERF Category: Medical Services CMS Add: 01/01/1992 CMS Term: 30801 MEDSV DEF RBRVS 01/01/2025 199.43 Description: ABLATE INF TURBINATE SUPERF Category: Medical Services CMS Add: 01/01/1992 CMS Term: 30802 MEDSV DEF RBRVS 01/01/2024 12/31/2024 262.23 Description: ABLATE INF TURBINATE SUBMUC Category: Medical Services CMS Add: 01/01/1992 CMS Term: 30802 MEDSV DEF RBRVS 01/01/2025 254.01 Description: ABLATE INF TURBINATE SUBMUC Category: Medical Services CMS Add: 01/01/1992 CMS Term: 3080F NOCOV DEF SYSMAN 01/01/2007 Y Description: DIAST BP >= 90 MM HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3082F NOCOV DEF SYSMAN 01/01/2007 Y Description: KT/V <1.2 Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3083F NOCOV DEF SYSMAN 01/01/2007 Y Description: KT/V =/> 1.2 & <1.7 Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3084F NOCOV DEF SYSMAN 01/01/2007 Y Description: KT/V >= 1.7 Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3085F NOCOV DEF SYSMAN 01/01/2007 Y Description: SUICIDE RISK ASSESSED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3088F NOCOV DEF SYSMAN 01/01/2007 Y Description: MDD MILD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3089F NOCOV DEF SYSMAN 01/01/2007 Y Description: MDD MODERATE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30901 MEDSV DEF RBRVS 01/01/2024 12/31/2024 147.15 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30901 MEDSV DEF RBRVS 01/01/2025 141.98 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30903 MEDSV DEF RBRVS 01/01/2024 12/31/2024 230.49 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30903 MEDSV DEF RBRVS 01/01/2025 221.2 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 329.24 Description: 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30905 MEDSV DEF RBRVS 01/01/2025 317.32 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30906 MEDSV DEF RBRVS 01/01/2024 12/31/2024 350 Description: REPEAT CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30906 MEDSV DEF RBRVS 01/01/2025 341.08 Description: REPEAT CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3090F NOCOV DEF SYSMAN 01/01/2007 Y Description: MDD SEVERE W/O PSYCH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30915 MEDSV DEF RBRVS 01/01/2024 12/31/2024 570.79 Description: LIGATION NASAL SINUS ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30915 MEDSV DEF RBRVS 01/01/2025 554.53 Description: LIGATION NASAL SINUS ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3091F NOCOV DEF SYSMAN 01/01/2007 Y Description: MDD SEVERE W/PSYCH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 825.72 Description: LIGATION UPPER JAW ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30920 MEDSV DEF RBRVS 01/01/2025 800.48 Description: LIGATION UPPER JAW ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3092F NOCOV DEF SYSMAN 01/01/2007 Y Description: MDD IN REMISSION Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 110.74 Description: THER FX NASAL INF TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30930 MEDSV DEF RBRVS 01/01/2025 109.01 Description: THER FX NASAL INF TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3093F NOCOV DEF SYSMAN 01/01/2007 Y Description: DOC NEW DIAG 1ST/ADDL MDD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3095F NOCOV DEF SYSMAN 01/01/2007 Y Description: CENTRAL DEXA RESULTS DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3096F NOCOV DEF SYSMAN 01/01/2007 Y Description: CENTRAL DEXA ORDERED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PROCEDURE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 174.15 Description: IRRIGATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31000 MEDSV DEF RBRVS 01/01/2025 170 Description: IRRIGATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31002 MEDSV DEF RBRVS 01/01/2024 12/31/2024 181.1 Description: IRRIGATION SPHENOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31002 MEDSV DEF RBRVS 01/01/2025 174.39 Description: IRRIGATION SPHENOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3100F NOCOV DEF SYSMAN 01/01/2008 Y Description: IMAGE TEST REF CAROT DIAM Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 411.44 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31020 MEDSV DEF RBRVS 01/01/2025 384.74 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 600.95 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31030 MEDSV DEF RBRVS 01/01/2025 588.77 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31032 MEDSV DEF RBRVS 01/01/2024 12/31/2024 563.33 Description: EXPLORE SINUS REMOVE POLYPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31032 MEDSV DEF RBRVS 01/01/2025 546.28 Description: EXPLORE SINUS REMOVE POLYPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 761.26 Description: EXPLORATION BEHIND UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31040 MEDSV DEF RBRVS 01/01/2025 739.05 Description: EXPLORATION BEHIND UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 489.48 Description: EXPLORATION SPHENOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31050 MEDSV DEF RBRVS 01/01/2025 474.73 Description: EXPLORATION SPHENOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31051 MEDSV DEF RBRVS 01/01/2024 12/31/2024 657.1 Description: SPHENOID SINUS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31051 MEDSV DEF RBRVS 01/01/2025 636.6 Description: SPHENOID SINUS SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 450.83 Description: EXPLORATION OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31070 MEDSV DEF RBRVS 01/01/2025 436.96 Description: EXPLORATION OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31075 MEDSV DEF RBRVS 01/01/2024 12/31/2024 783.44 Description: EXPLORATION OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31075 MEDSV DEF RBRVS 01/01/2025 759.6 Description: EXPLORATION OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1031.2 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31080 MEDSV DEF RBRVS 01/01/2025 999.32 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31081 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1104.71 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31081 MEDSV DEF RBRVS 01/01/2025 1070.82 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31084 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1143.02 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31084 MEDSV DEF RBRVS 01/01/2025 1108.33 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31085 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1178.54 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31085 MEDSV DEF RBRVS 01/01/2025 1142.01 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31086 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1113.42 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31086 MEDSV DEF RBRVS 01/01/2025 1079.12 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31087 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1059.44 Description: REMOVAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31087 MEDSV DEF RBRVS 01/01/2025 1027.76 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31090 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1047.47 Description: EXPLORATION OF SINUSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31090 MEDSV DEF RBRVS 01/01/2025 1015.37 Description: EXPLORATION OF SINUSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3110F NOCOV DEF SYSMAN 01/01/2008 Y Description: PRES/ABSN HMRHG/LESION DOCD Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3111F NOCOV DEF SYSMAN 01/01/2008 Y Description: CT/MRI BRAIN DONE W/IN 24HRS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3112F NOCOV DEF SYSMAN 01/01/2008 Y Description: CT/MRI BRAIN DONE 24 HRS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3115F NOCOV DEF SYSMAN 01/01/2012 Y Description: QUANT RESULTS ACTIVITY &SYMP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 3117F NOCOV DEF SYSMAN 01/01/2012 Y Description: HF ASSESSMENT TOOL COMPLETED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 3118F NOCOV DEF SYSMAN 01/01/2012 Y Description: NY HEART ASSOC CLASS DOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 3119F NOCOV DEF SYSMAN 01/01/2012 Y Description: NO EVAL ACTIVITY CLIN SYMP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 31200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 590.31 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31200 MEDSV DEF RBRVS 01/01/2025 577.28 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31201 MEDSV DEF RBRVS 01/01/2024 12/31/2024 751.49 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31201 MEDSV DEF RBRVS 01/01/2025 715.06 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 888.88 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31205 MEDSV DEF RBRVS 01/01/2025 868.43 Description: REMOVAL OF ETHMOID 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3120F NOCOV DEF SYSMAN 01/01/2008 Y Description: 12-LEAD ECG PERFORMED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1694.96 Description: REMOVAL OF UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31225 MEDSV DEF RBRVS 01/01/2025 1645.05 Description: REMOVAL OF UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1890.54 Description: REMOVAL OF UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31230 MEDSV DEF RBRVS 01/01/2025 1835.54 Description: REMOVAL OF UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31231 MEDSV DEF RBRVS 01/01/2024 12/31/2024 176.77 Description: NASAL ENDOSCOPY DX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31231 MEDSV DEF RBRVS 01/01/2025 170.49 Description: NASAL ENDOSCOPY DX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31233 MEDSV DEF RBRVS 01/01/2024 12/31/2024 257.76 Description: NSL/SINS NDSC DX MAX SINUSC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31233 MEDSV DEF RBRVS 01/01/2025 250.06 Description: NSL/SINS NDSC DX MAX SINUSC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 292.2 Description: NSL/SINS NDSC DX SPHN SINUSC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31235 MEDSV DEF RBRVS 01/01/2025 284.63 Description: NSL/SINS NDSC DX SPHN SINUSC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31237 MEDSV DEF RBRVS 01/01/2024 12/31/2024 240.7 Description: NSL/SINS NDSC SURG BX POLYPC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31237 MEDSV DEF RBRVS 01/01/2025 234.87 Description: NSL/SINS NDSC SURG BX POLYPC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31238 MEDSV DEF RBRVS 01/01/2024 12/31/2024 235.11 Description: NSL/SINS NDSC SRG NSL HEMRRG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31238 MEDSV DEF RBRVS 01/01/2025 228.61 Description: NSL/SINS NDSC SRG NSL HEMRRG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31239 MEDSV DEF RBRVS 01/01/2024 12/31/2024 571.23 Description: NSL/SINUS ENDOSCOPY SURG DCR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31239 MEDSV DEF RBRVS 01/01/2025 557.49 Description: NSL/SINUS ENDOSCOPY SURG DCR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 148.43 Description: NSL/SNS NDSC CNCH BULL RESCJ Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31240 MEDSV DEF RBRVS 01/01/2025 144.93 Description: NSL/SNS NDSC CNCH BULL RESCJ Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31241 MEDSV DEF RBRVS 01/01/2024 12/31/2024 415.24 Description: NSL/SNS NDSC LIG SPHNPTN ART Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31241 MEDSV DEF RBRVS 01/01/2025 403.88 Description: NSL/SNS NDSC LIG SPHNPTN ART Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31242 NOCOV DEF SYSMAN 01/01/2024 Y Description: NSL/SINUS NDSC RF ABLTJ PNN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 31243 NOCOV DEF SYSMAN 01/01/2024 Y Description: NSL/SINUS NDSC CRYOABLTJ PNN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 31253 MEDSV DEF RBRVS 01/01/2024 12/31/2024 467.29 Description: NSL/SINS NDSC TOTAL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31253 MEDSV DEF RBRVS 01/01/2025 453.47 Description: NSL/SINS NDSC TOTAL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31254 MEDSV DEF RBRVS 01/01/2024 12/31/2024 412.28 Description: NSL/SINS NDSC W/PRTL ETHMDCT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31254 MEDSV DEF RBRVS 01/01/2025 398.57 Description: NSL/SINS NDSC W/PRTL ETHMDCT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31255 MEDSV DEF RBRVS 01/01/2024 12/31/2024 302.21 Description: NSL/SINS NDSC W/TOT ETHMDCT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31255 MEDSV DEF RBRVS 01/01/2025 293.54 Description: NSL/SINS NDSC W/TOT ETHMDCT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31256 MEDSV DEF RBRVS 01/01/2024 12/31/2024 168.35 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31256 MEDSV DEF RBRVS 01/01/2025 163.77 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31257 MEDSV DEF RBRVS 01/01/2024 12/31/2024 416.48 Description: NSL/SINS NDSC TOT W/SPHENDT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31257 MEDSV DEF RBRVS 01/01/2025 404.47 Description: NSL/SINS NDSC TOT W/SPHENDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31259 MEDSV DEF RBRVS 01/01/2024 12/31/2024 440.66 Description: NSL/SINS NDSC SPHN TISS RMVL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31259 MEDSV DEF RBRVS 01/01/2025 427.63 Description: NSL/SINS NDSC SPHN TISS RMVL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31267 MEDSV DEF RBRVS 01/01/2024 12/31/2024 247.94 Description: ENDOSCOPY MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31267 MEDSV DEF RBRVS 01/01/2025 241.19 Description: ENDOSCOPY MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 3126F NOCOV DEF SYSMAN 01/01/2015 Y Description: ESOPH BX RPRT W/DYSPL INFO Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 31276 MEDSV DEF RBRVS 01/01/2024 12/31/2024 352.86 Description: NSL/SINS NDSC FRNT TISS RMVL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 31276 MEDSV DEF RBRVS 01/01/2025 343.32 Description: NSL/SINS NDSC FRNT TISS RMVL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 31287 MEDSV DEF RBRVS 01/01/2024 12/31/2024 188.4 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31287 MEDSV DEF RBRVS 01/01/2025 182.93 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31288 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.82 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31288 MEDSV DEF RBRVS 01/01/2025 212.61 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1072.85 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31290 MEDSV DEF RBRVS 01/01/2025 1040.46 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31291 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1135.34 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31291 MEDSV DEF RBRVS 01/01/2025 1106.47 Description: NASAL/SINUS ENDOSCOPY SURG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31292 MEDSV DEF RBRVS 01/01/2024 12/31/2024 933.02 Description: NSL/SINS NDSC MED/INF DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31292 MEDSV DEF RBRVS 01/01/2025 903.58 Description: NSL/SINS NDSC MED/INF DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31293 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1010.41 Description: NSL/SINS NDSC MED&INF DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31293 MEDSV DEF RBRVS 01/01/2025 980.86 Description: NSL/SINS NDSC MED&INF DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31294 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1154.15 Description: NSL/SINS NDSC SURG ON DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31294 MEDSV DEF RBRVS 01/01/2025 1120.05 Description: NSL/SINS NDSC SURG ON DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31295 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1570.63 0 Description: NSL/SINS NDSC SURG MAX SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31295 MEDSV DEF RBRVS 01/01/2025 1489.39 Description: NSL/SINS NDSC SURG MAX SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31296 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1594.57 0 Description: NSL/SINS NDSC SURG FRNT SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31296 MEDSV DEF RBRVS 01/01/2025 1512.34 Description: NSL/SINS NDSC SURG FRNT SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31297 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1557.17 0 Description: NSL/SINS NDSC SURG SPHN SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31297 MEDSV DEF RBRVS 01/01/2025 1476.17 Description: NSL/SINS NDSC SURG SPHN SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31298 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2955.88 0 Description: NSL/SINS NDSC SURG FRNT&SPHN Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31298 MEDSV DEF RBRVS 01/01/2025 2800.07 Description: NSL/SINS NDSC SURG FRNT&SPHN Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31299 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX ACCESSORY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1177.67 Description: REMOVAL OF LARYNX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31300 MEDSV DEF RBRVS 01/01/2025 1143.33 Description: REMOVAL OF LARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3130F NOCOV DEF SYSMAN 01/01/2008 Y Description: UPPER GI ENDOSCOPY PERFORMED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3132F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC REF UPPER GI ENDOSCOPY Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1929.9 Description: REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31360 MEDSV DEF RBRVS 01/01/2025 1874.53 Description: REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2381.76 Description: REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31365 MEDSV DEF RBRVS 01/01/2025 2312.3 Description: REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31367 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2043.51 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31367 MEDSV DEF RBRVS 01/01/2025 1981.89 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31368 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2259.45 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31368 MEDSV DEF RBRVS 01/01/2025 2190.66 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1918.11 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31370 MEDSV DEF RBRVS 01/01/2025 1859.62 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31375 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1823.15 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31375 MEDSV DEF RBRVS 01/01/2025 1768.07 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1797.67 Description: PARTIAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31380 MEDSV DEF RBRVS 01/01/2025 1743.64 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31382 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1968.6 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31382 MEDSV DEF RBRVS 01/01/2025 1908.94 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2629.37 Description: REMOVAL OF LARYNX & PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31390 MEDSV DEF RBRVS 01/01/2025 2550.7 Description: REMOVAL OF LARYNX & PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31395 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2759.96 Description: RECONSTRUCT LARYNX & PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31395 MEDSV DEF RBRVS 01/01/2025 2675.35 Description: RECONSTRUCT LARYNX & PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 952.96 Description: REVISION OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31400 MEDSV DEF RBRVS 01/01/2025 925.94 Description: REVISION OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3140F NOCOV DEF SYSMAN 01/01/2008 Y Description: UPPER GI ENDO SHOWS BARRTTS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3141F NOCOV DEF SYSMAN 01/01/2008 Y Description: UPPER GI ENDO NOT BARRTTS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 783.86 Description: EPIGLOTTIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31420 MEDSV DEF RBRVS 01/01/2025 762.77 Description: EPIGLOTTIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3142F NOCOV DEF SYSMAN 01/01/2008 Y Description: BARIUM SWALLOW TEST ORDERED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 131.43 Description: INSERT EMERGENCY AIRWAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31500 MEDSV DEF RBRVS 01/01/2025 127.4 Description: INSERT EMERGENCY AIRWAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 32.59 Description: CHANGE OF WINDPIPE AIRWAY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 31502 MEDSV DEF RBRVS 01/01/2025 31.77 Description: CHANGE OF WINDPIPE AIRWAY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 31505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 84.94 Description: DIAGNOSTIC LARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31505 MEDSV DEF RBRVS 01/01/2025 81.93 Description: DIAGNOSTIC LARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3150F NOCOV DEF SYSMAN 01/01/2008 Y Description: FORCEPS ESOPH BIOPSY DONE Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 202.77 Description: LARYNGOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31510 MEDSV DEF RBRVS 01/01/2025 197.28 Description: LARYNGOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31511 MEDSV DEF RBRVS 01/01/2024 12/31/2024 197.81 Description: REMOVE FOREIGN BODY LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31511 MEDSV DEF RBRVS 01/01/2025 192.65 Description: REMOVE FOREIGN BODY LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 203.55 Description: REMOVAL OF LARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31512 MEDSV DEF RBRVS 01/01/2025 198.44 Description: REMOVAL OF LARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31513 MEDSV DEF RBRVS 01/01/2024 12/31/2024 122.14 Description: INJECTION INTO VOCAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31513 MEDSV DEF RBRVS 01/01/2025 119.57 Description: INJECTION INTO VOCAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 201.78 Description: LARYNGOSCOPY FOR ASPIRATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31515 MEDSV DEF RBRVS 01/01/2025 194.38 Description: LARYNGOSCOPY FOR ASPIRATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 145.64 0-28Days Description: DX LARYNGOSCOPY NEWBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31520 MEDSV DEF RBRVS 01/01/2025 142.39 0-28Days Description: DX LARYNGOSCOPY NEWBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 234.93 Description: DX LARYNGOSCOPY EXCL NB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31525 MEDSV DEF RBRVS 01/01/2025 228.77 Description: DX LARYNGOSCOPY EXCL NB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31526 MEDSV DEF RBRVS 01/01/2024 12/31/2024 146.14 Description: DX LARYNGOSCOPY W/OPER SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31526 MEDSV DEF RBRVS 01/01/2025 142.72 Description: DX LARYNGOSCOPY W/OPER SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31527 MEDSV DEF RBRVS 01/01/2024 12/31/2024 181.81 Description: LARYNGOSCOPY FOR TREATMENT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31527 MEDSV DEF RBRVS 01/01/2025 177.03 Description: LARYNGOSCOPY FOR TREATMENT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31528 MEDSV DEF RBRVS 01/01/2024 12/31/2024 134.41 Description: LARYNGOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31528 MEDSV DEF RBRVS 01/01/2025 131.16 Description: LARYNGOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31529 MEDSV DEF RBRVS 01/01/2024 12/31/2024 149.87 Description: LARYNGOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31529 MEDSV DEF RBRVS 01/01/2025 146.48 Description: LARYNGOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 185.11 Description: LARYNGOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31530 MEDSV DEF RBRVS 01/01/2025 180.36 Description: LARYNGOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31531 MEDSV DEF RBRVS 01/01/2024 12/31/2024 197.44 Description: LARYNGOSCOPY W/FB & OP SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31531 MEDSV DEF RBRVS 01/01/2025 191.74 Description: LARYNGOSCOPY W/FB & OP SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 175.91 Description: LARYNGOSCOPY W/BIOPSY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31535 MEDSV DEF RBRVS 01/01/2025 171.76 Description: LARYNGOSCOPY W/BIOPSY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31536 MEDSV DEF RBRVS 01/01/2024 12/31/2024 196.12 Description: LARYNGOSCOPY W/BX & OP SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31536 MEDSV DEF RBRVS 01/01/2025 190.76 Description: LARYNGOSCOPY W/BX & OP SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 225.06 Description: LARYNGOSCOPY W/EXC OF TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31540 MEDSV DEF RBRVS 01/01/2025 218.7 Description: LARYNGOSCOPY W/EXC OF TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31541 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.44 Description: LARYNSCOP W/TUMR EXC + SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31541 MEDSV DEF RBRVS 01/01/2025 238.49 Description: LARYNSCOP W/TUMR EXC + SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 336.64 Description: REMOVE VC LESION W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31545 MEDSV DEF RBRVS 01/01/2025 327.77 Description: REMOVE VC LESION W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31546 MEDSV DEF RBRVS 01/01/2024 12/31/2024 510.45 Description: REMOVE VC LESION SCOPE/GRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31546 MEDSV DEF RBRVS 01/01/2025 496.49 Description: REMOVE VC LESION SCOPE/GRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31551 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1451.9 0-11Years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31551 MEDSV DEF RBRVS 01/01/2025 1411.41 0-11Years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1402.17 12-999Years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31552 MEDSV DEF RBRVS 01/01/2025 1362.68 12-999Years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31553 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1583.26 0-11Years Description: LARYNGOPLASTY LARYNGEAL STEN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31553 MEDSV DEF RBRVS 01/01/2025 1536.37 0-11Years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1584.19 12-999Years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31554 MEDSV DEF RBRVS 01/01/2025 1536.97 12-999Years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 3155F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 290.78 Description: LARYNGOSCOP W/ARYTENOIDECTOM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31560 MEDSV DEF RBRVS 01/01/2025 282.78 Description: LARYNGOSCOP W/ARYTENOIDECTOM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31561 MEDSV DEF RBRVS 01/01/2024 12/31/2024 317.92 Description: LARYNSCOP REMVE CART + SCOP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31561 MEDSV DEF RBRVS 01/01/2025 309.28 Description: LARYNSCOP REMVE CART + SCOP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 321.21 Description: LARYNGOSCOPE W/VC INJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31570 MEDSV DEF RBRVS 01/01/2025 313.3 Description: LARYNGOSCOPE W/VC INJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31571 MEDSV DEF RBRVS 01/01/2024 12/31/2024 231.65 Description: LARYNGOSCOP W/VC INJ + SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31571 MEDSV DEF RBRVS 01/01/2025 225.72 Description: LARYNGOSCOP W/VC INJ + SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31572 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.19 Description: LARGSC W/LASER DSTRJ LES Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31572 MEDSV DEF RBRVS 01/01/2025 475.82 Description: LARGSC W/LASER DSTRJ LES Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31573 MEDSV DEF RBRVS 01/01/2024 12/31/2024 269.81 Description: LARGSC W/THER INJECTION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31573 MEDSV DEF RBRVS 01/01/2025 262.34 Description: LARGSC W/THER INJECTION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31574 MEDSV DEF RBRVS 01/01/2024 12/31/2024 888.78 Description: LARGSC W/NJX AUGMENTATION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31574 MEDSV DEF RBRVS 01/01/2025 846.98 Description: LARGSC W/NJX AUGMENTATION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 121.16 Description: DIAGNOSTIC LARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31575 MEDSV DEF RBRVS 01/01/2025 117.54 Description: DIAGNOSTIC LARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31576 MEDSV DEF RBRVS 01/01/2024 12/31/2024 252.53 Description: LARYNGOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31576 MEDSV DEF RBRVS 01/01/2025 246.71 Description: LARYNGOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31577 MEDSV DEF RBRVS 01/01/2024 12/31/2024 259.36 Description: LARGSC W/RMVL FOREIGN BDY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31577 MEDSV DEF RBRVS 01/01/2025 249.34 Description: LARGSC W/RMVL FOREIGN BDY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31578 MEDSV DEF RBRVS 01/01/2024 12/31/2024 287.41 Description: LARGSC W/REMOVAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31578 MEDSV DEF RBRVS 01/01/2025 279.41 Description: LARGSC W/REMOVAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31579 MEDSV DEF RBRVS 01/01/2024 12/31/2024 186.28 Description: LARYNGOSCOPY TELESCOPIC Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31579 MEDSV DEF RBRVS 01/01/2025 180.86 Description: LARYNGOSCOPY TELESCOPIC Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1208.94 Description: LARYNGOPLASTY LARYNGEAL WEB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31580 MEDSV DEF RBRVS 01/01/2025 1173.06 Description: LARYNGOPLASTY LARYNGEAL WEB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31584 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1330.88 Description: LARYNGOPLASTY FX RDCTJ FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31584 MEDSV DEF RBRVS 01/01/2025 1289.7 Description: LARYNGOPLASTY FX RDCTJ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31587 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1136.62 Description: LARYNGOPLASTY CRICOID SPLIT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31587 MEDSV DEF RBRVS 01/01/2025 1105.55 Description: LARYNGOPLASTY CRICOID SPLIT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31590 MEDSV DEF RBRVS 01/01/2024 12/31/2024 869.52 Description: REINNERVATE LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31590 MEDSV DEF RBRVS 01/01/2025 846.06 Description: REINNERVATE LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31591 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1036.85 Description: LARYNGOPLASTY MEDIALIZATION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31591 MEDSV DEF RBRVS 01/01/2025 1008.03 Description: LARYNGOPLASTY MEDIALIZATION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31592 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1630.74 Description: CRICOTRACHEAL RESECTION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31592 MEDSV DEF RBRVS 01/01/2025 1584.07 Description: CRICOTRACHEAL RESECTION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31599 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PROCEDURE LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 280.8 Description: PLANNED TRACHEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31600 MEDSV DEF RBRVS 01/01/2025 272.57 Description: PLANNED TRACHEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 420.18 0-1Years Description: PLANNED TRACHEOSTOMY<2 YRS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31601 MEDSV DEF RBRVS 01/01/2025 408.4 0-1Years Description: PLANNED TRACHEOSTOMY<2 YRS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31603 MEDSV DEF RBRVS 01/01/2024 12/31/2024 295.43 Description: EMER TRACHEOSTOMY TTRACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31603 MEDSV DEF RBRVS 01/01/2025 286.41 Description: EMER TRACHEOSTOMY TTRACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 304.62 Description: EMER TRACHEOSTOMY CTHYR MEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31605 MEDSV DEF RBRVS 01/01/2025 294.01 Description: EMER TRACHEOSTOMY CTHYR MEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3160F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 900.7 Description: TRACHEOSTOMY FENEST SKIN FLP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31610 MEDSV DEF RBRVS 01/01/2025 874.1 Description: TRACHEOSTOMY FENEST SKIN FLP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31611 MEDSV DEF RBRVS 01/01/2024 12/31/2024 504.58 Description: CONSTJ TRACHESOPHGL FSTL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 31611 MEDSV DEF RBRVS 01/01/2025 491.83 Description: CONSTJ TRACHESOPHGL FSTL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 31612 MEDSV DEF RBRVS 01/01/2024 12/31/2024 87.29 Description: PERQ TRCHL PNXR TTRACH ASPIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31612 MEDSV DEF RBRVS 01/01/2025 84.85 Description: PERQ TRCHL PNXR TTRACH ASPIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31613 MEDSV DEF RBRVS 01/01/2024 12/31/2024 398.29 Description: TRACHEOSTOMA REVJ SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31613 MEDSV DEF RBRVS 01/01/2025 387.45 Description: TRACHEOSTOMA REVJ SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31614 MEDSV DEF RBRVS 01/01/2024 12/31/2024 671.63 Description: TRACHEOSTOMA REVJ COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31614 MEDSV DEF RBRVS 01/01/2025 651.64 Description: TRACHEOSTOMA REVJ COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 161.77 Description: TRCHEOBRNCHSC EST TRACHS INC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31615 MEDSV DEF RBRVS 01/01/2025 157.51 Description: TRCHEOBRNCHSC EST TRACHS INC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31622 MEDSV DEF RBRVS 01/01/2024 12/31/2024 231.48 Description: DX BRONCHOSCOPE/WASH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31622 MEDSV DEF RBRVS 01/01/2025 227.85 Description: DX BRONCHOSCOPE/WASH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31623 MEDSV DEF RBRVS 01/01/2024 12/31/2024 257.21 Description: DX BRONCHOSCOPE/BRUSH Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31623 MEDSV DEF RBRVS 01/01/2025 251.29 Description: DX BRONCHOSCOPE/BRUSH Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31624 MEDSV DEF RBRVS 01/01/2024 12/31/2024 238.86 Description: DX BRONCHOSCOPE/LAVAGE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31624 MEDSV DEF RBRVS 01/01/2025 233.94 Description: DX BRONCHOSCOPE/LAVAGE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31625 MEDSV DEF RBRVS 01/01/2024 12/31/2024 326.46 Description: BRONCHOSCOPY W/BIOPSY(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31625 MEDSV DEF RBRVS 01/01/2025 318.53 Description: BRONCHOSCOPY W/BIOPSY(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31626 MEDSV DEF RBRVS 01/01/2024 12/31/2024 734.78 Description: BRONCHOSCOPY W/MARKERS Category: Medical Services CMS Add: 01/01/2010 CMS Term: 31626 MEDSV DEF RBRVS 01/01/2025 711.06 Description: BRONCHOSCOPY W/MARKERS Category: Medical Services CMS Add: 01/01/2010 CMS Term: 31627 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1008.55 Description: NAVIGATIONAL BRONCHOSCOPY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 31627 MEDSV DEF RBRVS 01/01/2025 962.45 Description: NAVIGATIONAL BRONCHOSCOPY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 31628 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.94 Description: BRONCHOSCOPY/LUNG BX EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31628 MEDSV DEF RBRVS 01/01/2025 340.04 Description: BRONCHOSCOPY/LUNG BX EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31629 MEDSV DEF RBRVS 01/01/2024 12/31/2024 423.83 Description: BRONCHOSCOPY/NEEDLE BX EACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31629 MEDSV DEF RBRVS 01/01/2025 412.6 Description: BRONCHOSCOPY/NEEDLE BX EACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 183.75 Description: BRONCHOSCOPY DILATE/FX REPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31630 MEDSV DEF RBRVS 01/01/2025 178.86 Description: BRONCHOSCOPY DILATE/FX REPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31631 MEDSV DEF RBRVS 01/01/2024 12/31/2024 209.54 Description: BRONCHOSCOPY DILATE W/STENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31631 MEDSV DEF RBRVS 01/01/2025 203.86 Description: BRONCHOSCOPY DILATE W/STENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31632 MEDSV DEF RBRVS 01/01/2024 12/31/2024 60.9 0-4 Description: BRONCHOSCOPY/LUNG BX ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 31632 MEDSV DEF RBRVS 01/01/2025 59.61 0-4 Description: BRONCHOSCOPY/LUNG BX ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 31633 MEDSV DEF RBRVS 01/01/2024 12/31/2024 75.37 0-4 Description: BRONCHOSCOPY/NEEDLE BX ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 31633 MEDSV DEF RBRVS 01/01/2025 73.97 0-4 Description: BRONCHOSCOPY/NEEDLE BX ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 31634 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1407.71 0 Description: BRONCH W/BALLOON OCCLUSION Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31634 MEDSV DEF RBRVS 01/01/2025 1327.22 Description: BRONCH W/BALLOON OCCLUSION Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 273.58 Description: BRONCHOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31635 MEDSV DEF RBRVS 01/01/2025 268.06 Description: BRONCHOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31636 MEDSV DEF RBRVS 01/01/2024 12/31/2024 201.27 Description: BRONCHOSCOPY BRONCH STENTS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31636 MEDSV DEF RBRVS 01/01/2025 195.81 Description: BRONCHOSCOPY BRONCH STENTS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31637 MEDSV DEF RBRVS 01/01/2024 12/31/2024 71.71 Description: BRONCHOSCOPY STENT ADD-ON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31637 MEDSV DEF RBRVS 01/01/2025 68.91 Description: BRONCHOSCOPY STENT ADD-ON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31638 MEDSV DEF RBRVS 01/01/2024 12/31/2024 229.76 Description: BRONCHOSCOPY REVISE STENT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31638 MEDSV DEF RBRVS 01/01/2025 222.68 Description: BRONCHOSCOPY REVISE STENT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 231.15 Description: BRONCHOSCOPY W/TUMOR EXCISE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31640 MEDSV DEF RBRVS 01/01/2025 224.01 Description: BRONCHOSCOPY W/TUMOR EXCISE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31641 MEDSV DEF RBRVS 01/01/2024 12/31/2024 236.68 Description: BRONCHOSCOPY TREAT BLOCKAGE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31641 MEDSV DEF RBRVS 01/01/2025 229.85 Description: BRONCHOSCOPY TREAT BLOCKAGE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31643 MEDSV DEF RBRVS 01/01/2024 12/31/2024 159.04 Description: DIAG BRONCHOSCOPE/CATHETER Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31643 MEDSV DEF RBRVS 01/01/2025 154.79 Description: DIAG BRONCHOSCOPE/CATHETER Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31645 MEDSV DEF RBRVS 01/01/2024 12/31/2024 255.68 Description: BRNCHSC W/THER ASPIR 1ST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31645 MEDSV DEF RBRVS 01/01/2025 251.07 Description: BRNCHSC W/THER ASPIR 1ST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31646 MEDSV DEF RBRVS 01/01/2024 12/31/2024 132.04 Description: BRNCHSC W/THER ASPIR SBSQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31646 MEDSV DEF RBRVS 01/01/2025 129.13 Description: BRNCHSC W/THER ASPIR SBSQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31647 MEDSV DEF RBRVS 01/01/2024 12/31/2024 191.66 0-1 Description: BRONCHIAL VALVE INIT INSERT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31647 MEDSV DEF RBRVS 01/01/2025 186.6 0-1 Description: BRONCHIAL VALVE INIT INSERT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31648 MEDSV DEF RBRVS 01/01/2024 12/31/2024 183.34 0-1 Description: BRONCHIAL VALVE REMOV INIT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31648 MEDSV DEF RBRVS 01/01/2025 179.75 0-1 Description: BRONCHIAL VALVE REMOV INIT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31649 MEDSV DEF RBRVS 01/01/2024 12/31/2024 62.92 Description: BRONCHIAL VALVE REMOV ADDL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31649 MEDSV DEF RBRVS 01/01/2025 60.97 Description: BRONCHIAL VALVE REMOV ADDL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31651 MEDSV DEF RBRVS 01/01/2024 12/31/2024 71.41 Description: BRONCHIAL VALVE ADDL INSERT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31651 MEDSV DEF RBRVS 01/01/2025 68.91 Description: BRONCHIAL VALVE ADDL INSERT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31652 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 1125.44 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 12/31/2024 1218.48 0-1 Description: BRONCH EBUS SAMPLNG 3/> NODE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 31653 MEDSV DEF RBRVS 01/01/2025 1168.42 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 12/31/2024 112.97 Description: BRONCH EBUS IVNTJ PERPH LES Category: Medical Services CMS Add: 01/01/2016 CMS Term: 31654 MEDSV DEF RBRVS 01/01/2025 110.4 Description: BRONCH EBUS IVNTJ PERPH LES Category: Medical Services CMS Add: 01/01/2016 CMS Term: 31660 NOCOV DEF SYSMAN 01/01/2013 Y Description: BRONCH THERMOPLSTY 1 LOBE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 31661 NOCOV DEF SYSMAN 01/01/2013 Y Description: BRONCH THERMOPLSTY 2/> LOBES Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3170F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 269.23 Description: BRONCHIAL BRUSH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31717 MEDSV DEF RBRVS 01/01/2025 261.11 Description: BRONCHIAL BRUSH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 46.16 Description: CLEARANCE OF AIRWAYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31720 MEDSV DEF RBRVS 01/01/2025 44.73 Description: CLEARANCE OF AIRWAYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 74.39 Description: CLEARANCE OF AIRWAYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31725 MEDSV DEF RBRVS 01/01/2025 72.41 Description: CLEARANCE OF AIRWAYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31730 NOCOV DEF SYSMAN 10/06/1994 Y Description: INTRO WINDPIPE WIRE/TUBE Category: Non Covered Services CMS Add: 01/01/1993 CMS Term: 31750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1272.33 Description: TRACHEOPLASTY CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31750 MEDSV DEF RBRVS 01/01/2025 1232.37 Description: TRACHEOPLASTY CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31755 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1628.35 Description: TRACHPLSTY TRCHPHRYNGL FSTLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31755 MEDSV DEF RBRVS 01/01/2025 1578.96 Description: TRACHPLSTY TRCHPHRYNGL FSTLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1239.02 Description: TRACHEOPLASTY INTRATHORACIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31760 MEDSV DEF RBRVS 01/01/2025 1207.83 Description: TRACHEOPLASTY INTRATHORACIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31766 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1594.41 Description: CARINAL RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31766 MEDSV DEF RBRVS 01/01/2025 1551.72 Description: CARINAL RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1193.67 Description: REPAIR/GRAFT OF BRONCHUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31770 MEDSV DEF RBRVS 01/01/2025 1161.65 Description: REPAIR/GRAFT OF BRONCHUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31775 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1257.36 Description: RECONSTRUCT BRONCHUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31775 MEDSV DEF RBRVS 01/01/2025 1224.17 Description: RECONSTRUCT BRONCHUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1125.38 Description: RECONSTRUCT WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31780 MEDSV DEF RBRVS 01/01/2025 1095.7 Description: RECONSTRUCT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31781 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1349.64 Description: RECONSTRUCT WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31781 MEDSV DEF RBRVS 01/01/2025 1312.26 Description: RECONSTRUCT WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31785 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1008.53 Description: REMOVE WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31785 MEDSV DEF RBRVS 01/01/2025 981.24 Description: REMOVE WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31786 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1295.64 Description: REMOVE WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31786 MEDSV DEF RBRVS 01/01/2025 1261.46 Description: REMOVE WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 667.72 Description: REPAIR OF WINDPIPE INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31800 MEDSV DEF RBRVS 01/01/2025 646.33 Description: REPAIR OF WINDPIPE INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 739.22 Description: REPAIR OF WINDPIPE INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31805 MEDSV DEF RBRVS 01/01/2025 721.9 Description: REPAIR OF WINDPIPE INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 418.1 Description: CLOSURE OF WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31820 MEDSV DEF RBRVS 01/01/2025 407.61 Description: CLOSURE OF WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 578.01 Description: REPAIR OF WINDPIPE DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31825 MEDSV DEF RBRVS 01/01/2025 564.12 Description: REPAIR OF WINDPIPE DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 467.56 Description: REVISE WINDPIPE SCAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31830 MEDSV DEF RBRVS 01/01/2025 454.92 Description: REVISE WINDPIPE SCAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31899 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX TRACHEA BRONCHI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3200F NOCOV DEF SYSMAN 01/01/2008 Y Description: BARIUM SWALLOW TEST NOT REQ Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 32035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665.77 Description: THORACOSTOMY W/RIB RESECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32035 MEDSV DEF RBRVS 01/01/2025 650.82 Description: THORACOSTOMY W/RIB RESECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32036 MEDSV DEF RBRVS 01/01/2024 12/31/2024 718.19 Description: THORACOSTOMY W/FLAP DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32036 MEDSV DEF RBRVS 01/01/2025 701.85 Description: THORACOSTOMY W/FLAP DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32096 MEDSV DEF RBRVS 01/01/2024 12/31/2024 720.93 Description: OPEN WEDGE/BX LUNG INFILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32096 MEDSV DEF RBRVS 01/01/2025 703.58 Description: OPEN WEDGE/BX LUNG INFILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32097 MEDSV DEF RBRVS 01/01/2024 12/31/2024 722.93 Description: OPEN WEDGE/BX LUNG NODULE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32097 MEDSV DEF RBRVS 01/01/2025 704.79 Description: OPEN WEDGE/BX LUNG NODULE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32098 MEDSV DEF RBRVS 01/01/2024 12/31/2024 685.86 Description: OPEN BIOPSY OF LUNG PLEURA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32098 MEDSV DEF RBRVS 01/01/2025 667.13 Description: OPEN BIOPSY OF LUNG PLEURA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 730.48 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32100 MEDSV DEF RBRVS 01/01/2025 715 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3210F NOCOV DEF SYSMAN 01/01/2008 Y Description: GRP A STREP TEST PERFORMED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 32110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1329.68 Description: EXPLORE/REPAIR CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32110 MEDSV DEF RBRVS 01/01/2025 1300.77 Description: EXPLORE/REPAIR CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 788.41 Description: RE-EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32120 MEDSV DEF RBRVS 01/01/2025 769.95 Description: RE-EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32124 MEDSV DEF RBRVS 01/01/2024 12/31/2024 834.02 Description: EXPLORE CHEST FREE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32124 MEDSV DEF RBRVS 01/01/2025 814.43 Description: EXPLORE CHEST FREE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 892.9 Description: REMOVAL OF LUNG LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32140 MEDSV DEF RBRVS 01/01/2025 871.63 Description: REMOVAL OF LUNG LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32141 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1370.15 Description: REMOVE/TREAT LUNG LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32141 MEDSV DEF RBRVS 01/01/2025 1332.12 Description: REMOVE/TREAT LUNG LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 914.04 Description: REMOVAL OF LUNG LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32150 MEDSV DEF RBRVS 01/01/2025 897.21 Description: REMOVAL OF LUNG LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 905.98 Description: REMOVE LUNG FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32151 MEDSV DEF RBRVS 01/01/2025 884.33 Description: REMOVE LUNG FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3215F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 722.99 Description: OPEN CHEST HEART MASSAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32160 MEDSV DEF RBRVS 01/01/2025 706.37 Description: OPEN CHEST HEART MASSAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3216F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT IMMUNITY TO HEP B DOCD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 3218F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 1028.67 Description: DRAIN OPEN LUNG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32200 MEDSV DEF RBRVS 01/01/2025 1005.03 Description: DRAIN OPEN LUNG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3220F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 725.08 Description: TREAT CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32215 MEDSV DEF RBRVS 01/01/2025 708.5 Description: TREAT CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1441.65 Description: RELEASE OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32220 MEDSV DEF RBRVS 01/01/2025 1406.96 Description: RELEASE OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 900.24 Description: PARTIAL RELEASE OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32225 MEDSV DEF RBRVS 01/01/2025 876.18 Description: PARTIAL RELEASE OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3230F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 829.68 Description: REMOVAL OF CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32310 MEDSV DEF RBRVS 01/01/2025 808.97 Description: REMOVAL OF CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1448.05 Description: FREE/REMOVE CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32320 MEDSV DEF RBRVS 01/01/2025 1410.86 Description: FREE/REMOVE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 157.93 Description: NEEDLE BIOPSY CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32400 MEDSV DEF RBRVS 01/01/2025 154.08 Description: NEEDLE BIOPSY CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32408 MEDSV DEF RBRVS 01/01/2024 12/31/2024 805.65 Description: CORE NDL BX LNG/MED PERQ Category: Medical Services CMS Add: 01/01/2021 CMS Term: 32408 MEDSV DEF RBRVS 01/01/2025 763.73 Description: CORE NDL BX LNG/MED PERQ Category: Medical Services CMS Add: 01/01/2021 CMS Term: 32440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1410.64 Description: REMOVE LUNG PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32440 MEDSV DEF RBRVS 01/01/2025 1374.63 Description: REMOVE LUNG PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32442 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2733.58 Description: SLEEVE PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32442 MEDSV DEF RBRVS 01/01/2025 2656.02 Description: SLEEVE PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3163.08 Description: REMOVAL OF LUNG EXTRAPLEURAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 32445 MEDSV DEF RBRVS 01/01/2025 3077.2 Description: REMOVAL OF LUNG EXTRAPLEURAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 32480 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1331.88 Description: PARTIAL REMOVAL OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32480 MEDSV DEF RBRVS 01/01/2025 1296.74 Description: PARTIAL REMOVAL OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32482 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1423.16 Description: BILOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32482 MEDSV DEF RBRVS 01/01/2025 1385.74 Description: BILOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32484 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1288.53 Description: SEGMENTECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32484 MEDSV DEF RBRVS 01/01/2025 1254.64 Description: SEGMENTECTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32486 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2097.25 Description: SLEEVE LOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32486 MEDSV DEF RBRVS 01/01/2025 2038.58 Description: SLEEVE LOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32488 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2144.21 Description: COMPLETION PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32488 MEDSV DEF RBRVS 01/01/2025 2086.41 Description: COMPLETION PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32491 NOCOV DEF SYSMAN 01/01/1997 Y Description: LUNG VOLUME REDUCTION Category: Non Covered Services CMS Add: 01/01/1997 CMS Term: 32501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 216.91 Description: REPAIR BRONCHUS ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 32501 MEDSV DEF RBRVS 01/01/2025 210.77 Description: REPAIR BRONCHUS ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 32503 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1611.92 Description: RESECT APICAL LUNG TUMOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 32503 MEDSV DEF RBRVS 01/01/2025 1568.96 Description: RESECT APICAL LUNG TUMOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 32504 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1834.46 Description: RESECT APICAL LUNG TUM/CHEST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 32504 MEDSV DEF RBRVS 01/01/2025 1785.66 Description: RESECT APICAL LUNG TUM/CHEST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 32505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 840.42 Description: WEDGE RESECT OF LUNG INITIAL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32505 MEDSV DEF RBRVS 01/01/2025 818.97 Description: WEDGE RESECT OF LUNG INITIAL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32506 MEDSV DEF RBRVS 01/01/2024 12/31/2024 139.8 Description: WEDGE RESECT OF LUNG ADD-ON Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32506 MEDSV DEF RBRVS 01/01/2025 135.49 Description: WEDGE RESECT OF LUNG ADD-ON Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32507 MEDSV DEF RBRVS 01/01/2024 12/31/2024 139.8 Description: WEDGE RESECT OF LUNG DIAG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32507 MEDSV DEF RBRVS 01/01/2025 135.19 Description: WEDGE RESECT OF LUNG DIAG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3250F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 1554.72 Description: REMOVAL OF LUNG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32540 MEDSV DEF RBRVS 01/01/2025 1512.02 Description: REMOVAL OF LUNG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 737.34 Description: INSERT PLEURAL CATH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32550 MEDSV DEF RBRVS 01/01/2025 697.87 Description: INSERT PLEURAL CATH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32551 MEDSV DEF RBRVS 01/01/2024 12/31/2024 142.73 Description: INSERTION OF CHEST TUBE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32551 MEDSV DEF RBRVS 01/01/2025 138.75 Description: INSERTION OF CHEST TUBE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 170.25 Description: REMOVE LUNG CATHETER Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32552 MEDSV DEF RBRVS 01/01/2025 166.01 Description: REMOVE LUNG CATHETER Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32553 MEDSV DEF RBRVS 01/01/2024 12/31/2024 479.41 Description: INS MARK THOR FOR RT PERQ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32553 MEDSV DEF RBRVS 01/01/2025 457.98 Description: INS MARK THOR FOR RT PERQ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 219.56 0-3 Description: ASPIRATE PLEURA W/O IMAGING Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32554 MEDSV DEF RBRVS 01/01/2025 213.28 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 12/31/2024 296.86 0-3 Description: ASPIRATE PLEURA W/ IMAGING Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32555 MEDSV DEF RBRVS 01/01/2025 284.93 0-3 Description: ASPIRATE PLEURA W/ IMAGING 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 668.29 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 12/31/2024 624.56 0-3 Description: INSERT CATH PLEURA W/ IMAGE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32557 MEDSV DEF RBRVS 01/01/2025 595.26 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 12/31/2024 237.41 Description: TREAT PLEURODESIS W/AGENT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32560 MEDSV DEF RBRVS 01/01/2025 228.74 Description: TREAT PLEURODESIS W/AGENT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32561 MEDSV DEF RBRVS 01/01/2024 12/31/2024 88.12 Description: LYSE CHEST FIBRIN INIT DAY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32561 MEDSV DEF RBRVS 01/01/2025 87 Description: LYSE CHEST FIBRIN INIT DAY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32562 MEDSV DEF RBRVS 01/01/2024 12/31/2024 78.85 Description: LYSE CHEST FIBRIN SUBQ DAY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32562 MEDSV DEF RBRVS 01/01/2025 77.85 Description: LYSE CHEST FIBRIN SUBQ DAY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 276.6 Description: THORACOSCOPY DIAGNOSTIC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32601 MEDSV DEF RBRVS 01/01/2025 269.59 Description: THORACOSCOPY DIAGNOSTIC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32604 MEDSV DEF RBRVS 01/01/2024 12/31/2024 428.86 Description: THORACOSCOPY WBX SAC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32604 MEDSV DEF RBRVS 01/01/2025 417.33 Description: THORACOSCOPY WBX SAC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 413.44 Description: THORACOSCOPY W/BX MED SPACE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32606 MEDSV DEF RBRVS 01/01/2025 402.24 Description: THORACOSCOPY W/BX MED SPACE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32607 MEDSV DEF RBRVS 01/01/2024 12/31/2024 276.46 Description: THORACOSCOPY W/BX INFILTRATE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32607 MEDSV DEF RBRVS 01/01/2025 268.98 Description: THORACOSCOPY W/BX INFILTRATE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32608 MEDSV DEF RBRVS 01/01/2024 12/31/2024 339.36 Description: THORACOSCOPY W/BX NODULE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32608 MEDSV DEF RBRVS 01/01/2025 330.05 Description: THORACOSCOPY W/BX NODULE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32609 MEDSV DEF RBRVS 01/01/2024 12/31/2024 231.32 Description: THORACOSCOPY W/BX PLEURA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32609 MEDSV DEF RBRVS 01/01/2025 225.47 Description: THORACOSCOPY W/BX PLEURA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3260F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT CAT/PN CAT/HIST GRD DOCD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 32650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 604.51 Description: THORACOSCOPY W/PLEURODESIS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32650 MEDSV DEF RBRVS 01/01/2025 591.22 Description: THORACOSCOPY W/PLEURODESIS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32651 MEDSV DEF RBRVS 01/01/2024 12/31/2024 986.19 Description: THORACOSCOPY REMOVE CORTEX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32651 MEDSV DEF RBRVS 01/01/2025 961.64 Description: THORACOSCOPY REMOVE CORTEX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32652 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1495.23 Description: THORACOSCOPY REM TOTL CORTEX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32652 MEDSV DEF RBRVS 01/01/2025 1455.47 Description: THORACOSCOPY REM TOTL CORTEX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32653 MEDSV DEF RBRVS 01/01/2024 12/31/2024 955.47 Description: THORACOSCOPY REMOV FB/FIBRIN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32653 MEDSV DEF RBRVS 01/01/2025 931.9 Description: THORACOSCOPY REMOV FB/FIBRIN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32654 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1064.39 Description: THORACOSCOPY CONTRL BLEEDING 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32654 MEDSV DEF RBRVS 01/01/2025 1041.68 Description: THORACOSCOPY CONTRL BLEEDING Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32655 MEDSV DEF RBRVS 01/01/2024 12/31/2024 863.08 Description: THORACOSCOPY RESECT BULLAE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32655 MEDSV DEF RBRVS 01/01/2025 841.27 Description: THORACOSCOPY RESECT BULLAE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32656 MEDSV DEF RBRVS 01/01/2024 12/31/2024 725.73 Description: THORACOSCOPY W/PLEURECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32656 MEDSV DEF RBRVS 01/01/2025 707.98 Description: THORACOSCOPY W/PLEURECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32658 MEDSV DEF RBRVS 01/01/2024 12/31/2024 645.5 Description: THORACOSCOPY W/SAC FB REMOVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32658 MEDSV DEF RBRVS 01/01/2025 630.24 Description: THORACOSCOPY W/SAC FB REMOVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32659 MEDSV DEF RBRVS 01/01/2024 12/31/2024 663.03 Description: THORACOSCOPY W/SAC DRAINAGE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32659 MEDSV DEF RBRVS 01/01/2025 648.35 Description: THORACOSCOPY W/SAC DRAINAGE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3265F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 720.26 Description: THORACOSCOPY W/PERICARD EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32661 MEDSV DEF RBRVS 01/01/2025 702.94 Description: THORACOSCOPY W/PERICARD EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32662 MEDSV DEF RBRVS 01/01/2024 12/31/2024 806.08 Description: THORACOSCOPY W/MEDIAST EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32662 MEDSV DEF RBRVS 01/01/2025 786.43 Description: THORACOSCOPY W/MEDIAST EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32663 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1256.57 Description: THORACOSCOPY W/LOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32663 MEDSV DEF RBRVS 01/01/2025 1222.91 Description: THORACOSCOPY W/LOBECTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32664 MEDSV DEF RBRVS 01/01/2024 12/31/2024 764.33 Description: THORACOSCOPY W/ TH NRV EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32664 MEDSV DEF RBRVS 01/01/2025 745.85 Description: THORACOSCOPY W/ TH NRV EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1107.03 Description: THORACOSCOP W/ESOPH MUSC EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32665 MEDSV DEF RBRVS 01/01/2025 1077.93 Description: THORACOSCOP W/ESOPH MUSC EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32666 MEDSV DEF RBRVS 01/01/2024 12/31/2024 784.62 Description: THORACOSCOPY W/WEDGE RESECT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32666 MEDSV DEF RBRVS 01/01/2025 765.6 Description: THORACOSCOPY W/WEDGE RESECT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32667 MEDSV DEF RBRVS 01/01/2024 12/31/2024 139.8 Description: THORACOSCOPY W/W RESECT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32667 MEDSV DEF RBRVS 01/01/2025 135.65 Description: THORACOSCOPY W/W RESECT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32668 MEDSV DEF RBRVS 01/01/2024 12/31/2024 139.8 Description: THORACOSCOPY W/W RESECT DIAG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32668 MEDSV DEF RBRVS 01/01/2025 135.65 Description: THORACOSCOPY W/W RESECT DIAG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32669 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1206.12 Description: THORACOSCOPY REMOVE SEGMENT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32669 MEDSV DEF RBRVS 01/01/2025 1174.29 Description: THORACOSCOPY REMOVE SEGMENT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3266F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 1441.58 Description: THORACOSCOPY BILOBECTOMY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32670 MEDSV DEF RBRVS 01/01/2025 1399.1 Description: THORACOSCOPY BILOBECTOMY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32671 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1589.97 Description: THORACOSCOPY PNEUMONECTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32671 MEDSV DEF RBRVS 01/01/2025 1546.06 Description: THORACOSCOPY PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32672 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1359.3 Description: THORACOSCOPY FOR LVRS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32672 MEDSV DEF RBRVS 01/01/2025 1326.32 Description: THORACOSCOPY FOR LVRS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32673 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1092.47 Description: THORACOSCOPY W/THYMUS RESECT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32673 MEDSV DEF RBRVS 01/01/2025 1064.74 Description: THORACOSCOPY W/THYMUS RESECT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32674 MEDSV DEF RBRVS 01/01/2024 12/31/2024 191.51 Description: THORACOSCOPY LYMPH NODE EXC Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32674 MEDSV DEF RBRVS 01/01/2025 186.28 Description: THORACOSCOPY LYMPH NODE EXC Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3267F NOCOV DEF SYSMAN 01/01/2012 Y Description: PATH RPRT W/ PT PN CAT ET AL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 3268F NOCOV DEF SYSMAN 01/01/2008 Y Description: PSA/T/GLSC DOCD B/4 TXMNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3269F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 191.57 0-1 Description: THORAX STEREO RAD TARGETW/TX Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32701 MEDSV DEF RBRVS 01/01/2025 185.34 0-1 Description: THORAX STEREO RAD TARGETW/TX Category: Medical Services CMS Add: 01/01/2013 CMS Term: 3270F NOCOV DEF SYSMAN 01/01/2008 Y Description: NO BONE SCN B/4 TXMNT/AFTRDX Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3271F NOCOV DEF SYSMAN 01/01/2008 Y Description: LOW RISK PROSTATE CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3272F NOCOV DEF SYSMAN 01/01/2008 Y Description: MED RISK PROSTATE CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3273F NOCOV DEF SYSMAN 01/01/2008 Y Description: HIGH RISK PROSTATE CANCER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3274F NOCOV DEF SYSMAN 01/01/2008 Y Description: PROST CNCR RSK NOT LW/MD/HGH Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3278F NOCOV DEF SYSMAN 01/01/2008 Y Description: SERUM LVLS CA/IPTH/LPD ORD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3279F NOCOV DEF SYSMAN 01/01/2008 Y Description: HGB LVL >= 13 G/DL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 856.5 Description: REPAIR LUNG HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32800 MEDSV DEF RBRVS 01/01/2025 829.02 Description: REPAIR LUNG HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3280F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 813.22 Description: CLOSE CHEST AFTER DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32810 MEDSV DEF RBRVS 01/01/2025 794.33 Description: CLOSE CHEST AFTER DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32815 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2521.05 Description: CLOSE BRONCHIAL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32815 MEDSV DEF RBRVS 01/01/2025 2446.67 Description: CLOSE BRONCHIAL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3281F NOCOV DEF SYSMAN 01/01/2008 Y Description: HGB LVL <11 G/DL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1200.28 Description: RECONSTRUCT INJURED CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32820 MEDSV DEF RBRVS 01/01/2025 1171.05 Description: RECONSTRUCT INJURED CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3284F NOCOV DEF SYSMAN 01/01/2008 Y Description: IOP RED >=15% PRE-NTRV LVL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32850 NOCOV DEF SYSMAN 01/01/1994 Y Description: DONOR PNEUMONECTOMY Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 32851 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2933.27 Y Description: LUNG TRANSPLANT SINGLE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32851 MEDSV DEF RBRVS 01/01/2025 2853.17 Y Description: LUNG TRANSPLANT SINGLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32852 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3178.66 Y Description: LUNG TRANSPLANT WITH BYPASS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32852 MEDSV DEF RBRVS 01/01/2025 3081.84 Y Description: LUNG TRANSPLANT WITH BYPASS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32853 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4094.57 Y Description: LUNG TRANSPLANT DOUBLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32853 MEDSV DEF RBRVS 01/01/2025 3984.54 Y Description: LUNG TRANSPLANT DOUBLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32854 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4339.36 Y Description: LUNG TRANSPLANT WITH BYPASS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32854 MEDSV DEF RBRVS 01/01/2025 4219.11 Y Description: LUNG TRANSPLANT WITH BYPASS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32855 MEDSV DEF MAXFEE 01/01/2024 294.8 0 Y Description: PREPARE DONOR LUNG SINGLE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 32856 MEDSV DEF MAXFEE 01/01/2024 346.4 0 Y Description: PREPARE DONOR LUNG DOUBLE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 3285F NOCOV DEF SYSMAN 01/01/2008 Y Description: IOP DOWN <15% OF PRE-SVC LVL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3288F NOCOV DEF SYSMAN 01/01/2008 Y Description: FALL RISK ASSESSMENT DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1292.12 Description: REMOVAL OF RIB(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32900 MEDSV DEF RBRVS 01/01/2025 1192.59 Description: REMOVAL OF RIB(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1199.82 Description: REVISE & REPAIR CHEST WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32905 MEDSV DEF RBRVS 01/01/2025 1169.11 Description: REVISE & REPAIR CHEST WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32906 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1478.84 Description: REVISE & REPAIR CHEST WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32906 MEDSV DEF RBRVS 01/01/2025 1439.7 Description: REVISE & REPAIR CHEST WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3290F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT=D(RH)- AND UNSENSITIZED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3291F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT=D(RH)+ OR SENSITIZED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3292F NOCOV DEF SYSMAN 01/01/2008 Y Description: HIV TSTNG ASKED/DOCD/REVWD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3293F NOCOV DEF SYSMAN 01/01/2010 Y Description: ABO RH BLOOD TYPING DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 32940 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1109.66 Description: REVISION OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32940 MEDSV DEF RBRVS 01/01/2025 1081.18 Description: REVISION OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3294F NOCOV DEF SYSMAN 01/01/2010 Y Description: GRP B STREP SCREENING DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 32960 MEDSV DEF RBRVS 01/01/2024 12/31/2024 119.42 Description: THERAPEUTIC PNEUMOTHORAX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32960 MEDSV DEF RBRVS 01/01/2025 116.97 Description: THERAPEUTIC PNEUMOTHORAX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32994 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 4594.15 0 Description: ABLATE PULM TUMOR PERQ CRYBL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 32994 MEDSV DEF RBRVS 01/01/2025 4307.05 Description: ABLATE PULM TUMOR PERQ CRYBL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 32997 MEDSV DEF RBRVS 01/01/2024 12/31/2024 318.47 0-2 Description: TOTAL LUNG LAVAGE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 32997 MEDSV DEF RBRVS 01/01/2025 308.79 0-2 Description: TOTAL LUNG LAVAGE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 32998 NOCOV DEF SYSMAN 01/01/2007 Y Description: ABLATE PULM TUMOR PERQ RF Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 32999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX LUNGS & PLEURA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3300F NOCOV DEF SYSMAN 01/01/2008 Y Description: AJCC STAGE DOCD B/4 THXPY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 33016 MEDSV DEF RBRVS 01/01/2024 12/31/2024 211.16 Description: PERICARDIOCENTESIS W/IMAGING Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33016 MEDSV DEF RBRVS 01/01/2025 204.76 Description: PERICARDIOCENTESIS W/IMAGING Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33017 MEDSV DEF RBRVS 01/01/2024 12/31/2024 221.73 Description: PRCRD DRG 6YR+ W/O CGEN CAR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33017 MEDSV DEF RBRVS 01/01/2025 215.8 Description: PRCRD DRG 6YR+ W/O CGEN CAR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33018 MEDSV DEF RBRVS 01/01/2024 12/31/2024 259.27 Description: PRCRD DRG 0-5YR OR W/ANOMLY Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33018 MEDSV DEF RBRVS 01/01/2025 251.76 Description: PRCRD DRG 0-5YR OR W/ANOMLY Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33019 MEDSV DEF RBRVS 01/01/2024 12/31/2024 196.82 Description: PERQ PRCRD DRG INSJ CATH CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33019 MEDSV DEF RBRVS 01/01/2025 189.19 Description: PERQ PRCRD DRG INSJ CATH CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 3301F NOCOV DEF SYSMAN 01/01/2008 Y Description: CANCER STAGE DOCD METAST Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 33020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 744.16 Description: INCISION OF HEART SAC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33020 MEDSV DEF RBRVS 01/01/2025 724.2 Description: INCISION OF HEART SAC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 694.32 Description: INCISION OF HEART SAC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33025 MEDSV DEF RBRVS 01/01/2025 676.99 Description: INCISION OF HEART SAC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1794 Description: PARTIAL REMOVAL OF HEART SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33030 MEDSV DEF RBRVS 01/01/2025 1746.55 Description: PARTIAL REMOVAL OF HEART SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33031 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2218.16 Description: PARTIAL REMOVAL OF HEART SAC Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33031 MEDSV DEF RBRVS 01/01/2025 2155.87 Description: PARTIAL REMOVAL OF HEART SAC Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 906.38 Description: RESECT HEART SAC LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33050 MEDSV DEF RBRVS 01/01/2025 885.17 Description: RESECT HEART SAC LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1874.11 Description: EXC ICAR TUM RESC W/CARD BYP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33120 MEDSV DEF RBRVS 01/01/2025 1821.76 Description: EXC ICAR TUM RESC W/CARD BYP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1229.84 Description: RESCJ EXTERNAL CARDIAC TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33130 MEDSV DEF RBRVS 01/01/2025 1194.78 Description: RESCJ EXTERNAL CARDIAC TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1398.33 0-1 Description: HEART REVASCULARIZE (TMR) Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33140 MEDSV DEF RBRVS 01/01/2025 1356.39 0-1 Description: HEART REVASCULARIZE (TMR) Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33141 MEDSV DEF RBRVS 01/01/2024 12/31/2024 117.65 Description: HEART TMR W/OTHER PROCEDURE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 33141 MEDSV DEF RBRVS 01/01/2025 114.15 Description: HEART TMR W/OTHER PROCEDURE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 3315F NOCOV DEF SYSMAN 01/01/2008 Y Description: ER+ OR PR+ BREAST CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3316F NOCOV DEF SYSMAN 01/01/2008 Y Description: ER- OR PR- BREAST CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3317F NOCOV DEF SYSMAN 01/01/2008 Y Description: PATH RPT MALIG CANCER DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3318F NOCOV DEF SYSMAN 01/01/2008 Y Description: PATH RPT MALIG CANCER DOCD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3319F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 695.55 Description: INSERT EPICARD ELTRD OPEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33202 MEDSV DEF RBRVS 01/01/2025 676.99 Description: INSERT EPICARD ELTRD OPEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33203 MEDSV DEF RBRVS 01/01/2024 12/31/2024 727.69 Description: INSERT EPICARD ELTRD ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33203 MEDSV DEF RBRVS 01/01/2025 709.83 Description: INSERT EPICARD ELTRD ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33206 MEDSV DEF RBRVS 01/01/2024 12/31/2024 414.17 Description: INSERT HEART PM ATRIAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33206 MEDSV DEF RBRVS 01/01/2025 400.05 Description: INSERT HEART PM ATRIAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33207 MEDSV DEF RBRVS 01/01/2024 12/31/2024 434.48 Description: INSERT HEART PM VENTRICULAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33207 MEDSV DEF RBRVS 01/01/2025 419.97 Description: INSERT HEART PM VENTRICULAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33208 MEDSV DEF RBRVS 01/01/2024 12/31/2024 470.57 Description: INSRT HEART PM ATRIAL & VENT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33208 MEDSV DEF RBRVS 01/01/2025 454.54 Description: INSRT HEART PM ATRIAL & VENT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 3320F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 146.07 Description: INSERT ELECTRD/PM CATH SNGL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33210 MEDSV DEF RBRVS 01/01/2025 141.27 Description: INSERT ELECTRD/PM CATH SNGL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33211 MEDSV DEF RBRVS 01/01/2024 12/31/2024 151.91 Description: INSERT CARD ELECTRODES DUAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33211 MEDSV DEF RBRVS 01/01/2025 147.57 Description: INSERT CARD ELECTRODES DUAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33212 MEDSV DEF RBRVS 01/01/2024 12/31/2024 292 Description: INSERT PULSE GEN SNGL LEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33212 MEDSV DEF RBRVS 01/01/2025 284.66 Description: INSERT PULSE GEN SNGL LEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33213 MEDSV DEF RBRVS 01/01/2024 12/31/2024 305.66 Description: INSERT PULSE GEN DUAL LEADS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33213 MEDSV DEF RBRVS 01/01/2025 298.07 Description: INSERT PULSE GEN DUAL LEADS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33214 MEDSV DEF RBRVS 01/01/2024 12/31/2024 436.43 Description: UPGRADE OF PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33214 MEDSV DEF RBRVS 01/01/2025 421.65 Description: UPGRADE OF PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 281.84 Description: REPOSITION PACING-DEFIB LEAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33215 MEDSV DEF RBRVS 01/01/2025 273.24 Description: REPOSITION PACING-DEFIB LEAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33216 MEDSV DEF RBRVS 01/01/2024 12/31/2024 338.99 Description: INSERT 1 ELECTRODE PM-DEFIB Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33216 MEDSV DEF RBRVS 01/01/2025 327.67 Description: INSERT 1 ELECTRODE PM-DEFIB Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33217 MEDSV DEF RBRVS 01/01/2024 12/31/2024 335.65 Description: INSERT 2 ELECTRODE PM-DEFIB Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33217 MEDSV DEF RBRVS 01/01/2025 325.18 Description: INSERT 2 ELECTRODE PM-DEFIB Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33218 MEDSV DEF RBRVS 01/01/2024 12/31/2024 355.82 Description: REPAIR LEAD PACE-DEFIB ONE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33218 MEDSV DEF RBRVS 01/01/2025 343.77 Description: REPAIR LEAD PACE-DEFIB ONE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 3321F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 342.2 Description: REPAIR LEAD PACE-DEFIB DUAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33220 MEDSV DEF RBRVS 01/01/2025 335.55 Description: REPAIR LEAD PACE-DEFIB DUAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33221 MEDSV DEF RBRVS 01/01/2024 12/31/2024 327.33 Description: INSERT PULSE GEN MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33221 MEDSV DEF RBRVS 01/01/2025 315.1 Description: INSERT PULSE GEN MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33222 MEDSV DEF RBRVS 01/01/2024 12/31/2024 312.94 Description: RELOCATION POCKET PACEMAKER Category: Medical Services CMS Add: 01/01/1989 CMS Term: 33222 MEDSV DEF RBRVS 01/01/2025 303.7 Description: RELOCATION POCKET PACEMAKER Category: Medical Services CMS Add: 01/01/1989 CMS Term: 33223 MEDSV DEF RBRVS 01/01/2024 12/31/2024 372.93 Description: RELOCATE POCKET FOR DEFIB Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33223 MEDSV DEF RBRVS 01/01/2025 360.34 Description: RELOCATE POCKET FOR DEFIB Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33224 MEDSV DEF RBRVS 01/01/2024 12/31/2024 464.03 Description: INSERT PACING LEAD & CONNECT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33224 MEDSV DEF RBRVS 01/01/2025 446.31 Description: INSERT PACING LEAD & CONNECT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 419.34 Description: L VENTRIC PACING LEAD ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33225 MEDSV DEF RBRVS 01/01/2025 402.1 Description: L VENTRIC PACING LEAD ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33226 MEDSV DEF RBRVS 01/01/2024 12/31/2024 441.74 Description: REPOSITION L VENTRIC LEAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33226 MEDSV DEF RBRVS 01/01/2025 426.78 Description: REPOSITION L VENTRIC LEAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33227 MEDSV DEF RBRVS 01/01/2024 12/31/2024 308.49 Description: REMOVE&REPLACE PM GEN SINGL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33227 MEDSV DEF RBRVS 01/01/2025 298.9 Description: REMOVE&REPLACE PM GEN SINGL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33228 MEDSV DEF RBRVS 01/01/2024 12/31/2024 322.3 Description: REMV&REPLC PM GEN DUAL LEAD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33228 MEDSV DEF RBRVS 01/01/2025 312.16 Description: REMV&REPLC PM GEN DUAL LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33229 MEDSV DEF RBRVS 01/01/2024 12/31/2024 340.6 Description: REMV&REPLC PM GEN MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33229 MEDSV DEF RBRVS 01/01/2025 328.29 Description: REMV&REPLC PM GEN MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3322F NOCOV DEF SYSMAN 01/01/2009 Y Description: MELANOMAAJCC STAGE 0 OR IA Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.88 Description: INSRT PULSE GEN W/DUAL LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33230 MEDSV DEF RBRVS 01/01/2025 329.07 Description: INSRT PULSE GEN W/DUAL LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33231 MEDSV DEF RBRVS 01/01/2024 12/31/2024 363.78 Description: INSRT PULSE GEN W/MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33231 MEDSV DEF RBRVS 01/01/2025 353.18 Description: INSRT PULSE GEN W/MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33233 MEDSV DEF RBRVS 01/01/2024 12/31/2024 213.23 Description: REMOVAL OF PM GENERATOR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33233 MEDSV DEF RBRVS 01/01/2025 206.63 Description: REMOVAL OF PM GENERATOR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33234 MEDSV DEF RBRVS 01/01/2024 12/31/2024 440.52 Description: REMOVAL OF PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33234 MEDSV DEF RBRVS 01/01/2025 425.92 Description: REMOVAL OF PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 579.14 Description: REMOVAL PACEMAKER ELECTRODE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33235 MEDSV DEF RBRVS 01/01/2025 559.62 Description: REMOVAL PACEMAKER ELECTRODE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33236 MEDSV DEF RBRVS 01/01/2024 12/31/2024 710.04 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33236 MEDSV DEF RBRVS 01/01/2025 691.14 Description: REMOVE ELECTRODE/THORACOTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33237 MEDSV DEF RBRVS 01/01/2024 12/31/2024 761.09 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33237 MEDSV DEF RBRVS 01/01/2025 740.99 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33238 MEDSV DEF RBRVS 01/01/2024 12/31/2024 857.48 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33238 MEDSV DEF RBRVS 01/01/2025 837.83 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3323F NOCOV DEF SYSMAN 01/01/2010 Y 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 12/31/2024 332.62 Description: INSRT PULSE GEN W/SINGL LEAD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33240 MEDSV DEF RBRVS 01/01/2025 324.25 Description: INSRT PULSE GEN W/SINGL LEAD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33241 MEDSV DEF RBRVS 01/01/2024 12/31/2024 195.92 Description: REMOVE PULSE GENERATOR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33241 MEDSV DEF RBRVS 01/01/2025 190.06 Description: REMOVE PULSE GENERATOR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33243 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1238.28 Description: REMOVE ELTRD/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33243 MEDSV DEF RBRVS 01/01/2025 1206.3 Description: REMOVE ELTRD/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33244 MEDSV DEF RBRVS 01/01/2024 12/31/2024 785.63 Description: REMOVE ELCTRD TRANSVENOUSLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33244 MEDSV DEF RBRVS 01/01/2025 757.91 Description: REMOVE ELCTRD TRANSVENOUSLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33249 MEDSV DEF RBRVS 01/01/2024 12/31/2024 829.62 Description: INSJ/RPLCMT DEFIB W/LEAD(S) Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33249 MEDSV DEF RBRVS 01/01/2025 800.06 Description: INSJ/RPLCMT DEFIB W/LEAD(S) Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3324F NOCOV DEF SYSMAN 01/01/2010 Y Description: MRI CT SCAN ORD RVWD RQSTD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1309.4 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33250 MEDSV DEF RBRVS 01/01/2025 1271.83 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33251 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1461.11 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33251 MEDSV DEF RBRVS 01/01/2025 1422.65 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33254 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1221.74 Description: ABLATE ATRIA LMTD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33254 MEDSV DEF RBRVS 01/01/2025 1192.65 Description: ABLATE ATRIA LMTD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33255 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1461.18 Description: ABLATE ATRIA W/O BYPASS EXT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33255 MEDSV DEF RBRVS 01/01/2025 1419.13 Description: ABLATE ATRIA W/O BYPASS EXT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33256 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1731.03 Description: ABLATE ATRIA W/BYPASS EXTEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33256 MEDSV DEF RBRVS 01/01/2025 1679.71 Description: ABLATE ATRIA W/BYPASS EXTEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33257 MEDSV DEF RBRVS 01/01/2024 12/31/2024 525.4 Description: ABLATE ATRIA LMTD ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33257 MEDSV DEF RBRVS 01/01/2025 512.46 Description: ABLATE ATRIA LMTD ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33258 MEDSV DEF RBRVS 01/01/2024 12/31/2024 586.17 Description: ABLATE ATRIA X10SV ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33258 MEDSV DEF RBRVS 01/01/2025 570.19 Description: ABLATE ATRIA X10SV ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33259 MEDSV DEF RBRVS 01/01/2024 12/31/2024 763.01 Description: ABLATE ATRIA W/BYPASS ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33259 MEDSV DEF RBRVS 01/01/2025 744.6 Description: ABLATE ATRIA W/BYPASS ADD-ON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3325F NOCOV DEF SYSMAN 01/01/2008 Y Description: PREOP ASSES 4 CATARACT SURG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 33261 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1448.31 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33261 MEDSV DEF RBRVS 01/01/2025 1405.97 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33262 MEDSV DEF RBRVS 01/01/2024 12/31/2024 339.28 Description: RMVL& REPLC PULSE GEN 1 LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33262 MEDSV DEF RBRVS 01/01/2025 327.74 Description: RMVL& REPLC PULSE GEN 1 LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33263 MEDSV DEF RBRVS 01/01/2024 12/31/2024 352.32 Description: RMVL & RPLCMT DFB GEN 2 LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33263 MEDSV DEF RBRVS 01/01/2025 340.41 Description: RMVL & RPLCMT DFB GEN 2 LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33264 MEDSV DEF RBRVS 01/01/2024 12/31/2024 367.53 Description: RMVL & RPLCMT DFB GEN MLT LD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33264 MEDSV DEF RBRVS 01/01/2025 354.89 Description: RMVL & RPLCMT DFB GEN MLT LD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1224.52 Description: ABLATE ATRIA LMTD ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33265 MEDSV DEF RBRVS 01/01/2025 1192.03 Description: ABLATE ATRIA LMTD ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33266 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1654.03 Description: ABLATE ATRIA X10SV ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33266 MEDSV DEF RBRVS 01/01/2025 1606.79 Description: ABLATE ATRIA X10SV ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33267 MEDSV DEF RBRVS 01/01/2024 12/31/2024 939.78 Description: EXCL LAA OPEN ANY METHOD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33267 MEDSV DEF RBRVS 01/01/2025 914.72 Description: EXCL LAA OPEN ANY METHOD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33268 MEDSV DEF RBRVS 01/01/2024 12/31/2024 117.19 Description: EXCL LAA OPN OTH PX ANY METH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33268 MEDSV DEF RBRVS 01/01/2025 112.36 Description: EXCL LAA OPN OTH PX ANY METH Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33269 MEDSV DEF RBRVS 01/01/2024 12/31/2024 743.3 Description: EXCL LAA THRSCP ANY METHOD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33269 MEDSV DEF RBRVS 01/01/2025 726.84 Description: EXCL LAA THRSCP ANY METHOD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 510.83 Description: INS/REP SUBQ DEFIBRILLATOR Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33270 MEDSV DEF RBRVS 01/01/2025 491.9 Description: INS/REP SUBQ DEFIBRILLATOR Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33271 MEDSV DEF RBRVS 01/01/2024 12/31/2024 409.47 Description: INSJ SUBQ IMPLTBL DFB ELCTRD Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33271 MEDSV DEF RBRVS 01/01/2025 400 Description: INSJ SUBQ IMPLTBL DFB ELCTRD Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33272 MEDSV DEF RBRVS 01/01/2024 12/31/2024 315.21 Description: RMVL OF SUBQ DEFIBRILLATOR Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33272 MEDSV DEF RBRVS 01/01/2025 305.85 Description: RMVL OF SUBQ DEFIBRILLATOR Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33273 MEDSV DEF RBRVS 01/01/2024 12/31/2024 361.71 Description: REPOS PREV IMPLTBL SUBQ DFB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33273 MEDSV DEF RBRVS 01/01/2025 353.96 Description: REPOS PREV IMPLTBL SUBQ DFB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33274 MEDSV DEF RBRVS 01/01/2024 12/31/2024 435.72 Description: TCAT INSJ/RPL PERM LDLS PM Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33274 MEDSV DEF RBRVS 01/01/2025 419.67 Description: TCAT INSJ/RPL PERM LDLS PM Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.83 Description: TCAT RMVL PERM LDLS PM W/IMG Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33275 MEDSV DEF RBRVS 01/01/2025 442.69 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 12/31/2024 523.09 Y Description: INSJ PHRNC NRV STIM SYS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33276 MEDSV DEF RBRVS 01/01/2025 508.1 Y Description: INSJ PHRNC NRV STIM SYS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33277 MEDSV DEF RBRVS 01/01/2024 12/31/2024 273.28 Y Description: INSJ PHRNC NRV STIM TRANSVNS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33277 MEDSV DEF RBRVS 01/01/2025 265.28 Y Description: INSJ PHRNC NRV STIM TRANSVNS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33278 MEDSV DEF RBRVS 01/01/2024 12/31/2024 520.04 Description: RMVL PHRNC NRV STIM SYS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33278 MEDSV DEF RBRVS 01/01/2025 505.09 Description: RMVL PHRNC NRV STIM SYS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33279 MEDSV DEF RBRVS 01/01/2024 12/31/2024 314.62 Description: RMVL PHRNC NRV STIM TRANSVNS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33279 MEDSV DEF RBRVS 01/01/2025 305.41 Description: RMVL PHRNC NRV STIM TRANSVNS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 195.06 Description: RMVL PHRNC NRV STIM PG ONLY Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33280 MEDSV DEF RBRVS 01/01/2025 189.6 Description: RMVL PHRNC NRV STIM PG ONLY Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33281 MEDSV DEF RBRVS 01/01/2024 12/31/2024 340.07 Description: REPOSG PHRNC NRV STIM TRNSVN Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33281 MEDSV DEF RBRVS 01/01/2025 330.39 Description: REPOSG PHRNC NRV STIM TRNSVN Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4026.6 Description: INSJ SUBQ CAR RHYTHM MNTR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33285 MEDSV DEF RBRVS 01/01/2025 3752.74 Description: INSJ SUBQ CAR RHYTHM MNTR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33286 MEDSV DEF RBRVS 01/01/2024 12/31/2024 121.13 Description: RMVL SUBQ CAR RHYTHM MNTR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33286 MEDSV DEF RBRVS 01/01/2025 115.8 Description: RMVL SUBQ CAR RHYTHM MNTR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33287 MEDSV DEF RBRVS 01/01/2024 12/31/2024 350.88 Description: RMV&RPLCMT PHRNC NRV STIM PG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33287 MEDSV DEF RBRVS 01/01/2025 340.94 Description: RMV&RPLCMT PHRNC NRV STIM PG Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33288 MEDSV DEF RBRVS 01/01/2024 12/31/2024 462.25 Description: RMV&RPLCMT PHRNC NRV STIM LD Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33288 MEDSV DEF RBRVS 01/01/2025 448.96 Description: RMV&RPLCMT PHRNC NRV STIM LD Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33289 NOCOV DEF SYSMAN 01/01/2019 Y Description: TCAT IMPL WRLS P-ART PRS SNR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 3328F NOCOV DEF SYSMAN 01/01/2010 Y 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 12/31/2024 2182.98 Description: REPAIR OF HEART WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33300 MEDSV DEF RBRVS 01/01/2025 2126.97 Description: REPAIR OF HEART WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3658.27 Description: REPAIR OF HEART WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33305 MEDSV DEF RBRVS 01/01/2025 3559.3 Description: REPAIR OF HEART WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3330F NOCOV DEF SYSMAN 01/01/2009 Y Description: IMAGING STUDY ORDERED (BKP) Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1053.96 Description: EXPLORATORY HEART SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33310 MEDSV DEF RBRVS 01/01/2025 1024.13 Description: EXPLORATORY HEART SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33315 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1718.75 Description: EXPLORATORY HEART SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33315 MEDSV DEF RBRVS 01/01/2025 1671.78 Description: EXPLORATORY HEART SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3331F NOCOV DEF SYSMAN 01/01/2009 Y Description: BK IMAGING TST NOT ORDERED Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33320 MEDSV DEF RBRVS 01/01/2025 936.87 Description: REPAIR MAJOR BLOOD VESSEL(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33321 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1070.1 Description: REPAIR MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 33321 MEDSV DEF RBRVS 01/01/2025 1039.61 Description: REPAIR MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 33322 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1249.04 Description: REPAIR MAJOR BLOOD VESSEL(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33322 MEDSV DEF RBRVS 01/01/2025 1222.45 Description: REPAIR MAJOR BLOOD VESSEL(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1281.39 Description: INSERT MAJOR VESSEL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33330 MEDSV DEF RBRVS 01/01/2025 1244.64 Description: INSERT MAJOR VESSEL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1678.05 Description: INSERT MAJOR VESSEL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33335 MEDSV DEF RBRVS 01/01/2025 1627.94 Description: INSERT MAJOR VESSEL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 705.08 Description: PERQ CLSR TCAT L ATR APNDGE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33340 MEDSV DEF RBRVS 01/01/2025 679.65 Description: PERQ CLSR TCAT L ATR APNDGE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33361 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1082.48 Description: REPLACE AORTIC VALVE PERQ Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33361 MEDSV DEF RBRVS 01/01/2025 1051.74 Description: REPLACE AORTIC VALVE PERQ Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33362 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1180.43 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33362 MEDSV DEF RBRVS 01/01/2025 1145.88 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33363 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1222.27 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33363 MEDSV DEF RBRVS 01/01/2025 1188.76 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33364 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1223.04 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33364 MEDSV DEF RBRVS 01/01/2025 1184.31 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1276.88 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33365 MEDSV DEF RBRVS 01/01/2025 1239.46 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33366 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1407.13 Description: TRCATH REPLACE AORTIC VALVE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 33366 MEDSV DEF RBRVS 01/01/2025 1364.28 Description: TRCATH REPLACE AORTIC VALVE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 33367 MEDSV DEF RBRVS 01/01/2024 12/31/2024 546.36 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33367 MEDSV DEF RBRVS 01/01/2025 528.22 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33368 MEDSV DEF RBRVS 01/01/2024 12/31/2024 661.73 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33368 MEDSV DEF RBRVS 01/01/2025 640 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33369 MEDSV DEF RBRVS 01/01/2024 12/31/2024 873.59 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33369 MEDSV DEF RBRVS 01/01/2025 844.92 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.28 Description: TCAT PLMT&RMVL CEPD PERQ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33370 MEDSV DEF RBRVS 01/01/2025 115.97 Description: TCAT PLMT&RMVL CEPD PERQ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1729.02 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33390 MEDSV DEF RBRVS 01/01/2025 1676.62 Description: VALVULOPLASTY AORTIC VALVE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33391 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2049.2 Description: VALVULOPLASTY AORTIC VALVE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33391 MEDSV DEF RBRVS 01/01/2025 1986.12 Description: VALVULOPLASTY AORTIC VALVE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33404 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1571.22 Description: PREPARE HEART-AORTA CONDUIT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33404 MEDSV DEF RBRVS 01/01/2025 1525.75 Description: PREPARE HEART-AORTA CONDUIT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2036.35 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33405 MEDSV DEF RBRVS 01/01/2025 1979.08 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33406 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2579.69 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33406 MEDSV DEF RBRVS 01/01/2025 2508.24 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3340F NOCOV DEF SYSMAN 01/01/2009 Y Description: MAMMO ASSESS INC XRAY DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2278.65 0-1 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33410 MEDSV DEF RBRVS 01/01/2025 2212.44 0-1 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33411 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3004.25 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33411 MEDSV DEF RBRVS 01/01/2025 2917.04 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33412 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2818.34 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33412 MEDSV DEF RBRVS 01/01/2025 2730.76 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33413 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2888.08 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33413 MEDSV DEF RBRVS 01/01/2025 2799.42 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33414 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1922.31 Description: REPAIR OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33414 MEDSV DEF RBRVS 01/01/2025 1869.21 Description: REPAIR OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1818.64 Description: REVISION SUBVALVULAR TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33415 MEDSV DEF RBRVS 01/01/2025 1768.78 Description: REVISION SUBVALVULAR TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33416 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1816.13 Description: REVISE VENTRICLE MUSCLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33416 MEDSV DEF RBRVS 01/01/2025 1765.99 Description: REVISE VENTRICLE MUSCLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33417 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1498.69 Description: REPAIR OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33417 MEDSV DEF RBRVS 01/01/2025 1460.16 Description: REPAIR OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33418 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1612.85 Description: REPAIR TCAT MITRAL VALVE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33418 MEDSV DEF RBRVS 01/01/2025 1571.44 Description: REPAIR TCAT MITRAL VALVE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33419 MEDSV DEF RBRVS 01/01/2024 12/31/2024 379.17 Description: REPAIR TCAT MITRAL VALVE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33419 MEDSV DEF RBRVS 01/01/2025 368.11 Description: REPAIR TCAT MITRAL VALVE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 3341F NOCOV DEF SYSMAN 01/01/2009 Y Description: MAMMO ASSESS NEGATIVE DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33420 MEDSV DEF RBRVS 01/01/2025 1267.31 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33422 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1495.95 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33422 MEDSV DEF RBRVS 01/01/2025 1452.56 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2446.26 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33425 MEDSV DEF RBRVS 01/01/2025 2378.19 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33426 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2136.25 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33426 MEDSV DEF RBRVS 01/01/2025 2077.31 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33427 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2189.11 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33427 MEDSV DEF RBRVS 01/01/2025 2128.25 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 3342F NOCOV DEF SYSMAN 01/01/2009 Y Description: MAMMO ASSESS BENGN DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2512.73 Description: REPLACEMENT OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33430 MEDSV DEF RBRVS 01/01/2025 2442.27 Description: REPLACEMENT OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3343F NOCOV DEF SYSMAN 01/01/2009 Y Description: MAMMO PROBABLY BENGN DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3048.1 Description: RPLCMT A-VALVE TLCJ AUTOL PV Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33440 MEDSV DEF RBRVS 01/01/2025 2952.74 Description: RPLCMT A-VALVE TLCJ AUTOL PV Category: Medical Services CMS Add: 01/01/2019 CMS Term: 3344F NOCOV DEF SYSMAN 01/01/2009 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3345F NOCOV DEF SYSMAN 01/01/2009 Y Description: MAMMO ASSESS HGHLYMALIG DOC Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2150.25 Description: REVISION OF TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33460 MEDSV DEF RBRVS 01/01/2025 2084.22 Description: REVISION OF TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33463 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2765.87 Description: VALVULOPLASTY TRICUSPID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33463 MEDSV DEF RBRVS 01/01/2025 2683.49 Description: VALVULOPLASTY TRICUSPID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33464 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2187.58 Description: VALVULOPLASTY TRICUSPID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33464 MEDSV DEF RBRVS 01/01/2025 2127.38 Description: VALVULOPLASTY TRICUSPID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33465 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2468.65 Description: REPLACE TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33465 MEDSV DEF RBRVS 01/01/2025 2398.77 Description: REPLACE TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33468 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2192.99 Description: REVISION OF TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33468 MEDSV DEF RBRVS 01/01/2025 2130.95 Description: REVISION OF TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33471 MEDSV DEF RBRVS 12/31/2024 12/31/2024 1191.68 Description: VLVT PV CLSD HRT VIA P-ART Category: Medical Services CMS Add: 01/01/1987 CMS Term: 12/31/2024 33471 MEDSV DEF RBRVS 01/01/2025 1161.42 Description: VLVT PV CLSD HRT VIA P-ART Category: Medical Services CMS Add: 01/01/1987 CMS Term: 12/31/2024 33474 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1953.3 Description: REVISION OF PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33474 MEDSV DEF RBRVS 01/01/2025 1899.78 Description: REVISION OF PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33475 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2086.2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33475 MEDSV DEF RBRVS 01/01/2025 2026.62 Description: REPLACEMENT PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33476 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1369.84 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33476 MEDSV DEF RBRVS 01/01/2025 1335.12 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33477 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1211.01 Y Description: IMPLANT TCAT PULM VLV PERQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 33477 MEDSV DEF RBRVS 01/01/2025 1160.29 Y Description: IMPLANT TCAT PULM VLV PERQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 33478 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1415.06 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33478 MEDSV DEF RBRVS 01/01/2025 1378.53 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33496 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1496.76 Description: REPAIR PROSTH VALVE CLOT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 33496 MEDSV DEF RBRVS 01/01/2025 1453.02 Description: REPAIR PROSTH VALVE CLOT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 33500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1403.4 Description: REPAIR HEART VESSEL FISTULA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33500 MEDSV DEF RBRVS 01/01/2025 1362.39 Description: REPAIR HEART VESSEL FISTULA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1005 Description: REPAIR HEART VESSEL FISTULA Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33501 MEDSV DEF RBRVS 01/01/2025 976.88 Description: REPAIR HEART VESSEL FISTULA Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1150.79 Description: CORONARY ARTERY CORRECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33502 MEDSV DEF RBRVS 01/01/2025 1122.74 Description: CORONARY ARTERY CORRECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33503 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33503 MEDSV DEF RBRVS 01/01/2025 1167.42 Description: CORONARY ARTERY GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33504 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1319.08 Description: CORONARY ARTERY GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33504 MEDSV DEF RBRVS 01/01/2025 1285.88 Description: CORONARY ARTERY GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1842.23 Description: REPAIR ARTERY W/TUNNEL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33505 MEDSV DEF RBRVS 01/01/2025 1788.66 Description: REPAIR ARTERY W/TUNNEL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33506 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1835.99 Description: REPAIR ARTERY TRANSLOCATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33506 MEDSV DEF RBRVS 01/01/2025 1784.43 Description: REPAIR ARTERY TRANSLOCATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33507 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1541.38 Description: REPAIR ART INTRAMURAL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33507 MEDSV DEF RBRVS 01/01/2025 1498.59 Description: REPAIR ART INTRAMURAL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33508 MEDSV DEF RBRVS 01/01/2024 12/31/2024 14.41 Description: ENDOSCOPIC VEIN HARVEST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33508 MEDSV DEF RBRVS 01/01/2025 13.98 Description: ENDOSCOPIC VEIN HARVEST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33509 MEDSV DEF RBRVS 01/01/2024 12/31/2024 154.76 Description: NDSC HRV UXTR ART 1 SGM CAB Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33509 MEDSV DEF RBRVS 01/01/2025 149.69 Description: NDSC HRV UXTR ART 1 SGM CAB Category: Medical Services CMS Add: 01/01/2022 CMS Term: 3350F NOCOV DEF SYSMAN 01/01/2009 Y Description: MAMMO BX PROVEN MALIG DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1735.78 0-1 Description: CABG VEIN SINGLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33510 MEDSV DEF RBRVS 01/01/2025 1687.22 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33511 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1905.29 0-1 Description: CABG VEIN TWO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33511 MEDSV DEF RBRVS 01/01/2025 1852.38 0-1 Description: CABG VEIN TWO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2172.12 0-1 Description: CABG VEIN THREE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33512 MEDSV DEF RBRVS 01/01/2025 2109.11 0-1 Description: CABG VEIN THREE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33513 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2221.61 0-1 Description: CABG VEIN FOUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33513 MEDSV DEF RBRVS 01/01/2025 2153.79 0-1 Description: CABG VEIN FOUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33514 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2340.02 0-1 Description: CABG VEIN FIVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33514 MEDSV DEF RBRVS 01/01/2025 2269.17 0-1 Description: CABG VEIN FIVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33516 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2422.04 0-1 Description: CABG VEIN SIX OR MORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33516 MEDSV DEF RBRVS 01/01/2025 2348.49 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 12/31/2024 166.87 0-1 Description: CABG ARTERY-VEIN SINGLE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33517 MEDSV DEF RBRVS 01/01/2025 162.21 0-1 Description: CABG ARTERY-VEIN SINGLE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33518 MEDSV DEF RBRVS 01/01/2024 12/31/2024 367.2 0-1 Description: CABG ARTERY-VEIN TWO Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33518 MEDSV DEF RBRVS 01/01/2025 355.49 0-1 Description: CABG ARTERY-VEIN TWO Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33519 MEDSV DEF RBRVS 01/01/2024 12/31/2024 485.37 0-1 Description: CABG ARTERY-VEIN THREE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33519 MEDSV DEF RBRVS 01/01/2025 470.3 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3351F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 582 0-1 Description: CABG ARTERY-VEIN FOUR Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33521 MEDSV DEF RBRVS 01/01/2025 563.75 0-1 Description: CABG ARTERY-VEIN FOUR Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33522 MEDSV DEF RBRVS 01/01/2024 12/31/2024 653.61 0-1 Description: CABG ARTERY-VEIN FIVE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33522 MEDSV DEF RBRVS 01/01/2025 633.37 0-1 Description: CABG ARTERY-VEIN FIVE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33523 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 714.66 0-1 Description: CABG ART-VEIN SIX OR MORE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 3352F NOCOV DEF SYSMAN 01/01/2009 Y Description: NO SIG DEP SYMP BY DEP TOOL Category: Non Covered Services CMS Add: 07/01/2008 CMS Term: 33530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 468.63 Description: CORONARY ARTERY BYPASS/REOP Category: Medical Services CMS Add: 01/01/1991 CMS Term: 33530 MEDSV DEF RBRVS 01/01/2025 453.9 Description: CORONARY ARTERY BYPASS/REOP Category: Medical Services CMS Add: 01/01/1991 CMS Term: 33533 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1680.05 0-1 Description: CABG ARTERIAL SINGLE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33533 MEDSV DEF RBRVS 01/01/2025 1633.47 0-1 Description: CABG ARTERIAL SINGLE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33534 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1972.66 0-1 Description: CABG ARTERIAL TWO Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33534 MEDSV DEF RBRVS 01/01/2025 1917.92 0-1 Description: CABG ARTERIAL TWO Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2194.26 0-1 Description: CABG ARTERIAL THREE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33535 MEDSV DEF RBRVS 01/01/2025 2131.81 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33536 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2361.64 0-1 Description: CABG ARTERIAL FOUR OR MORE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33536 MEDSV DEF RBRVS 01/01/2025 2297.21 0-1 Description: CABG ARTERIAL FOUR OR MORE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 3353F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 2351.17 Description: REMOVAL OF HEART LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33542 MEDSV DEF RBRVS 01/01/2025 2283.42 Description: REMOVAL OF HEART LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2748.61 Description: REPAIR OF HEART DAMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33545 MEDSV DEF RBRVS 01/01/2025 2664.02 Description: REPAIR OF HEART DAMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33548 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2645.98 Description: RESTORE/REMODEL VENTRICLE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33548 MEDSV DEF RBRVS 01/01/2025 2565.92 Description: RESTORE/REMODEL VENTRICLE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 3354F NOCOV DEF SYSMAN 01/01/2009 Y Description: CLIN SIG DEP SYM BY DEP TOOL Category: Non Covered Services CMS Add: 07/01/2008 CMS Term: 33572 MEDSV DEF RBRVS 01/01/2024 12/31/2024 205.8 Description: OPEN CORONARY ENDARTERECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 33572 MEDSV DEF RBRVS 01/01/2025 199.67 Description: OPEN CORONARY ENDARTERECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 33600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1543.94 Description: CLOSURE OF VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33600 MEDSV DEF RBRVS 01/01/2025 1504.21 Description: CLOSURE OF VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33602 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1499.03 Description: CLOSURE OF VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33602 MEDSV DEF RBRVS 01/01/2025 1460.49 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1596.59 Description: ANASTOMOSIS/ARTERY-AORTA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33606 MEDSV DEF RBRVS 01/01/2025 1554.65 Description: ANASTOMOSIS/ARTERY-AORTA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33608 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1616.68 Description: REPAIR ANOMALY W/CONDUIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33608 MEDSV DEF RBRVS 01/01/2025 1574.48 Description: REPAIR ANOMALY W/CONDUIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1594.79 Description: REPAIR BY ENLARGEMENT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33610 MEDSV DEF RBRVS 01/01/2025 1552.93 Description: REPAIR BY ENLARGEMENT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33611 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1746.02 Description: REPAIR DOUBLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33611 MEDSV DEF RBRVS 01/01/2025 1697.84 Description: REPAIR DOUBLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33612 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1792.42 Description: REPAIR DOUBLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33612 MEDSV DEF RBRVS 01/01/2025 1743.17 Description: REPAIR DOUBLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1791.17 Description: REPAIR MODIFIED FONTAN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33615 MEDSV DEF RBRVS 01/01/2025 1743.1 Description: REPAIR MODIFIED FONTAN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33617 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1939.5 Description: REPAIR SINGLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33617 MEDSV DEF RBRVS 01/01/2025 1887.15 Description: REPAIR SINGLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33619 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2463.68 Description: REPAIR SINGLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33619 MEDSV DEF RBRVS 01/01/2025 2397.69 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1476.43 Description: APPLY R&L PULM ART BANDS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33620 MEDSV DEF RBRVS 01/01/2025 1435.73 Description: APPLY R&L PULM ART BANDS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33621 MEDSV DEF RBRVS 01/01/2024 12/31/2024 835.18 Description: TRANSTHOR CATH FOR STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33621 MEDSV DEF RBRVS 01/01/2025 813.86 Description: TRANSTHOR CATH FOR STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33622 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3065.11 Description: REDO COMPL CARDIAC ANOMALY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33622 MEDSV DEF RBRVS 01/01/2025 2976.81 Description: REDO COMPL CARDIAC ANOMALY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33641 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1468.14 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33641 MEDSV DEF RBRVS 01/01/2025 1428.85 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33645 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1551.26 Description: REVISION OF HEART VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33645 MEDSV DEF RBRVS 01/01/2025 1508.89 Description: REVISION OF HEART VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33647 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1626.89 Description: REPAIR HEART SEPTUM DEFECTS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33647 MEDSV DEF RBRVS 01/01/2025 1582.09 Description: REPAIR HEART SEPTUM DEFECTS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1572.53 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33660 MEDSV DEF RBRVS 01/01/2025 1529.81 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1712.55 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33665 MEDSV DEF RBRVS 01/01/2025 1665.53 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1762.51 Description: REPAIR OF HEART CHAMBERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33670 MEDSV DEF RBRVS 01/01/2025 1712.24 Description: REPAIR OF HEART CHAMBERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33675 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1764.2 Description: CLOSE MULT VSD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33675 MEDSV DEF RBRVS 01/01/2025 1715.49 Description: CLOSE MULT VSD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33676 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1811.08 Description: CLOSE MULT VSD W/RESECTION Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33676 MEDSV DEF RBRVS 01/01/2025 1760.82 Description: CLOSE MULT VSD W/RESECTION Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33677 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1880.35 Description: CL MULT VSD W/REM PUL BAND Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33677 MEDSV DEF RBRVS 01/01/2025 1828.19 Description: CL MULT VSD W/REM PUL BAND Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33681 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1656.74 Description: CLOSURE 1 VSD W/WO PATCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33681 MEDSV DEF RBRVS 01/01/2025 1613.63 Description: CLOSURE 1 VSD W/WO PATCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33684 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1690.66 Description: CLSR 1 VSD W/WO PATCH W/VLVT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33684 MEDSV DEF RBRVS 01/01/2025 1643.82 Description: CLSR 1 VSD W/WO PATCH W/VLVT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33688 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1684.14 Description: CLSR 1VSD W/WO PTCH RMVL BND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33688 MEDSV DEF RBRVS 01/01/2025 1636.12 Description: CLSR 1VSD W/WO PTCH RMVL BND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33690 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1082.94 Description: BANDING PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33690 MEDSV DEF RBRVS 01/01/2025 1056.61 Description: BANDING 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33692 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1748.63 Description: COMP RPR TOF WO PULM ATRESIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33692 MEDSV DEF RBRVS 01/01/2025 1698.99 Description: COMP RPR TOF WO PULM ATRESIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33694 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1746.02 Description: CMP RPR TOF WO PLM ATRS PTCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33694 MEDSV DEF RBRVS 01/01/2025 1697.84 Description: CMP RPR TOF WO PLM ATRS PTCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33697 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1839.12 Description: COMPL RPR TOF W/PULM ATRESIA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33697 MEDSV DEF RBRVS 01/01/2025 1788.03 Description: COMPL RPR TOF W/PULM ATRESIA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1390.18 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33702 MEDSV DEF RBRVS 01/01/2025 1353.87 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3370F NOCOV DEF SYSMAN 01/01/2009 Y Description: AJCC BRST CNCR STAGE 0 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1836.13 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33710 MEDSV DEF RBRVS 01/01/2025 1784.5 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1390.86 Description: REPAIR OF HEART DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33720 MEDSV DEF RBRVS 01/01/2025 1354.82 Description: REPAIR OF HEART DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33724 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1378.14 Description: REPAIR VENOUS ANOMALY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33724 MEDSV DEF RBRVS 01/01/2025 1341.04 Description: REPAIR VENOUS ANOMALY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33726 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33726 MEDSV DEF RBRVS 01/01/2025 1768.07 Description: REPAIR PUL VENOUS STENOSIS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 3372F NOCOV DEF SYSMAN 01/01/2009 Y Description: AJCC BRST CNCR STAGE 1 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1798.61 Description: REPAIR HEART-VEIN DEFECT(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33730 MEDSV DEF RBRVS 01/01/2025 1749.98 Description: REPAIR HEART-VEIN DEFECT(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33732 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1481.31 Description: REPAIR HEART-VEIN DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33732 MEDSV DEF RBRVS 01/01/2025 1443.44 Description: REPAIR HEART-VEIN DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33735 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1167.96 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33735 MEDSV DEF RBRVS 01/01/2025 1139.26 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33736 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1266.38 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33736 MEDSV DEF RBRVS 01/01/2025 1234.74 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33737 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1168.81 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12/31/2024 33737 MEDSV DEF RBRVS 01/01/2025 1139.39 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12/31/2024 33741 MEDSV DEF RBRVS 01/01/2024 12/31/2024 672.7 Description: TAS CONGENITAL CAR ANOMAL Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33741 MEDSV DEF RBRVS 01/01/2025 653.42 Description: TAS CONGENITAL CAR ANOMAL Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33745 MEDSV DEF RBRVS 01/01/2024 12/31/2024 960.88 Description: TIS CGEN CAR ANOMAL 1ST SHNT Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33745 MEDSV DEF RBRVS 01/01/2025 933.69 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33746 MEDSV DEF RBRVS 01/01/2024 12/31/2024 384.19 Description: TIS CGEN CAR ANOMAL EA ADDL Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33746 MEDSV DEF RBRVS 01/01/2025 373.29 Description: TIS CGEN CAR ANOMAL EA ADDL Category: Medical Services CMS Add: 01/01/2021 CMS Term: 3374F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 1134.84 Description: SHUNT SUBCLAVIAN TO PULM ART Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33750 MEDSV DEF RBRVS 01/01/2025 1104.29 Description: SHUNT SUBCLAVIAN TO PULM ART Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33755 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1186.52 Description: SHUNT AS-AORT TO PULM ART Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33755 MEDSV DEF RBRVS 01/01/2025 1157.26 Description: SHUNT AS-AORT TO PULM ART Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33762 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1152.25 Description: SHUNT DESC AORTA TO PULM ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33762 MEDSV DEF RBRVS 01/01/2025 1121.64 Description: SHUNT DESC AORTA TO PULM ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33764 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1186.52 Description: SHUNT CENTRAL W/PROSTC GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33764 MEDSV DEF RBRVS 01/01/2025 1157.26 Description: SHUNT CENTRAL W/PROSTC GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33766 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1197.63 Description: SHUNT SUPR V/C P-ART 1 LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33766 MEDSV DEF RBRVS 01/01/2025 1164.9 Description: SHUNT SUPR V/C P-ART 1 LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33767 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1277.36 Description: SHUNT SUPR V/C P-ART BTH LNG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33767 MEDSV DEF RBRVS 01/01/2025 1242.87 Description: SHUNT SUPR V/C P-ART BTH LNG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33768 MEDSV DEF RBRVS 01/01/2024 12/31/2024 371.01 Description: ANAST CAVOPULM SEC SUP V/C 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33768 MEDSV DEF RBRVS 01/01/2025 359.82 Description: ANAST CAVOPULM SEC SUP V/C Category: Medical Services CMS Add: 01/01/2006 CMS Term: 3376F NOCOV DEF SYSMAN 01/01/2009 Y Description: AJCC BRSTCNCR STAGE 2 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1892.66 Description: RPR TGA W/O SURG ENLGMNT VSD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33770 MEDSV DEF RBRVS 01/01/2025 1838.94 Description: RPR TGA W/O SURG ENLGMNT VSD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33771 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1945.63 Description: RPR TGA W/SURG ENLGMNT VSD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33771 MEDSV DEF RBRVS 01/01/2025 1888.99 Description: RPR TGA W/SURG ENLGMNT VSD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33774 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1617.14 Description: RPR TGA ATRIAL BAFFLE PX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33774 MEDSV DEF RBRVS 01/01/2025 1574.97 Description: RPR TGA ATRIAL BAFFLE PX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33775 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1664.52 Description: RPR TGA ATR BFL RMVL PLM BND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33775 MEDSV DEF RBRVS 01/01/2025 1620.09 Description: RPR TGA ATR BFL RMVL PLM BND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33776 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1759.47 Description: RPR TGA ATR BFL CLSR VSD Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33776 MEDSV DEF RBRVS 01/01/2025 1714.01 Description: RPR TGA ATR BFL CLSR VSD Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33777 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1695.73 Description: RPR TGA BFL RPR SBPULM OBSTR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33777 MEDSV DEF RBRVS 01/01/2025 1649.16 Description: RPR TGA BFL RPR SBPULM OBSTR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33778 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2105.31 Description: RPR TGA AORTIC PULM ART RCNS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33778 MEDSV DEF RBRVS 01/01/2025 2047.73 Description: RPR TGA AORTIC PULM ART RCNS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33779 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2077.2 Description: RPR TGA RCNSTJ RMVL PLM BND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33779 MEDSV DEF RBRVS 01/01/2025 2017.48 Description: RPR TGA RCNSTJ RMVL PLM BND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2116.68 Description: RPR TGA RCNSTJ CLSR VSD Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33780 MEDSV DEF RBRVS 01/01/2025 2056.45 Description: RPR TGA RCNSTJ CLSR VSD Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33781 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2065.41 Description: RPR TGA RCNSTJ RPR SBPL OBST Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33781 MEDSV DEF RBRVS 01/01/2025 2005.05 Description: RPR TGA RCNSTJ RPR SBPL OBST Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33782 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2883.18 Description: NIKAIDOH PROC Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33782 MEDSV DEF RBRVS 01/01/2025 2800.26 Description: NIKAIDOH PROC Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33783 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3115.32 Description: NIKAIDOH PROC W/OSTIA IMPLT Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33783 MEDSV DEF RBRVS 01/01/2025 3025.51 Description: NIKAIDOH PROC W/OSTIA IMPLT Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33786 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2037.69 Description: REPAIR ARTERIAL TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33786 MEDSV DEF RBRVS 01/01/2025 1979.94 Description: REPAIR ARTERIAL TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33788 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1375.77 Description: REVISION OF PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33788 MEDSV DEF RBRVS 01/01/2025 1338.36 Description: REVISION OF PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3378F NOCOV DEF SYSMAN 01/01/2009 Y Description: AJCC BRSTCNCR STAGE 3 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33800 MEDSV DEF RBRVS 01/01/2025 863.38 Description: AORTIC SUSPENSION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33802 MEDSV DEF RBRVS 01/01/2024 12/31/2024 978.43 Description: DIVISION ABERRANT VESSEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33802 MEDSV DEF RBRVS 01/01/2025 955.28 Description: DIVISION ABERRANT VESSEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33803 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1034.61 Description: DIV ABERRANT VSL W/REANAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33803 MEDSV DEF RBRVS 01/01/2025 1006.95 Description: DIV ABERRANT VSL W/REANAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3380F NOCOV DEF SYSMAN 01/01/2009 Y Description: AJCC BRSTCNCR STAGE 4 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33813 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1117.44 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 12/31/2024 33813 MEDSV DEF RBRVS 01/01/2025 1089.24 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 12/31/2024 33814 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1370.77 Description: OBLTRJ A-PULM SEP DEF W/BYP Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33814 MEDSV DEF RBRVS 01/01/2025 1336.03 Description: OBLTRJ A-PULM SEP DEF W/BYP Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 870.77 Description: REPAIR PDA BY LIGATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33820 MEDSV DEF RBRVS 01/01/2025 848.92 Description: REPAIR PDA BY LIGATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33822 MEDSV DEF RBRVS 01/01/2024 12/31/2024 917.84 0-17Years Description: REPAIR PDA DIV<18 YEARS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33822 MEDSV DEF RBRVS 01/01/2025 894.75 0-17Years Description: REPAIR PDA DIV<18 YEARS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33824 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1064.3 18-999Years Description: REPAIR PDA DIV 18 YRS&OLDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33824 MEDSV DEF RBRVS 01/01/2025 1037.83 18-999Years Description: REPAIR PDA DIV 18 YRS&OLDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3382F NOCOV DEF SYSMAN 01/01/2009 Y Description: AJCC CLN CNCR STAGE 0 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1116.45 Description: EXC COA W/DIRECT ANASTOMOSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33840 MEDSV DEF RBRVS 01/01/2025 1088.12 Description: EXC COA W/DIRECT ANASTOMOSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1201.76 Description: EXCISION COA W/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33845 MEDSV DEF RBRVS 01/01/2025 1172.06 Description: EXCISION COA W/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3384F NOCOV DEF SYSMAN 01/01/2009 Y Description: AJCC CLN CNCR STAGE 1 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33851 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1146.11 Description: EXC COA RPR L SUBCL ART/PRST Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33851 MEDSV DEF RBRVS 01/01/2025 1117.21 Description: EXC COA RPR L SUBCL ART/PRST Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33852 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1258.95 Description: RPR HYPOPL A-ARCH WO BYP Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33852 MEDSV DEF RBRVS 01/01/2025 1226.69 Description: RPR HYPOPL A-ARCH WO BYP Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33853 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1646 Description: RPR HYPOPL A-ARCH W/BYP Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33853 MEDSV DEF RBRVS 01/01/2025 1603.08 Description: RPR HYPOPL A-ARCH W/BYP Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33858 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3037.88 Description: AS-AORT GRF F/AORTIC DSJ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33858 MEDSV DEF RBRVS 01/01/2025 2946.69 Description: AS-AORT GRF F/AORTIC DSJ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33859 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2182.85 Description: AS-AORT GRF F/DS OTH/THN DSJ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33859 MEDSV DEF RBRVS 01/01/2025 2119.02 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33863 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2814.42 Description: ASCENDING AORTIC GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33863 MEDSV DEF RBRVS 01/01/2025 2731.75 Description: ASCENDING AORTIC GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33864 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2875.97 Description: ASCENDING AORTIC GRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33864 MEDSV DEF RBRVS 01/01/2025 2788.35 Description: ASCENDING AORTIC GRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33866 MEDSV DEF RBRVS 01/01/2024 12/31/2024 822.65 Description: AORTIC HEMIARCH GRAFT Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33866 MEDSV DEF RBRVS 01/01/2025 796.03 Description: AORTIC HEMIARCH GRAFT Category: Medical Services CMS Add: 01/01/2019 CMS Term: 3386F NOCOV DEF SYSMAN 01/01/2009 Y Description: AJCC CLN CNCR STAGE 2 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33871 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2913.5 Description: TRANSVRS A-ARCH GRF HYPTHRM Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33871 MEDSV DEF RBRVS 01/01/2025 2827.03 Description: TRANSVRS A-ARCH GRF HYPTHRM Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33875 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2454.22 Description: THORACIC AORTIC GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33875 MEDSV DEF RBRVS 01/01/2025 2385.77 Description: THORACIC AORTIC GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33877 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3216.93 Description: THORACOABDOMINAL GRAFT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 33877 MEDSV DEF RBRVS 01/01/2025 3124.75 Description: THORACOABDOMINAL GRAFT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 33880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1597.03 Description: ENDOVASC TAA REPR INCL SUBCL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33880 MEDSV DEF RBRVS 01/01/2025 1546.72 Description: ENDOVASC TAA REPR INCL SUBCL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33881 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33881 MEDSV DEF RBRVS 01/01/2025 1328.47 Description: ENDOVASC TAA REPR W/O SUBCL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33883 MEDSV DEF RBRVS 01/01/2024 12/31/2024 993.73 Description: INSERT ENDOVASC PROSTH TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33883 MEDSV DEF RBRVS 01/01/2025 965.2 Description: INSERT ENDOVASC PROSTH TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33884 MEDSV DEF RBRVS 01/01/2024 12/31/2024 349.73 Description: ENDOVASC PROSTH TAA ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33884 MEDSV DEF RBRVS 01/01/2025 339.54 Description: ENDOVASC PROSTH TAA ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33886 MEDSV DEF RBRVS 01/01/2024 12/31/2024 858.2 Description: ENDOVASC PROSTH DELAYED Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33886 MEDSV DEF RBRVS 01/01/2025 832.63 Description: ENDOVASC PROSTH DELAYED Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33889 MEDSV DEF RBRVS 01/01/2024 12/31/2024 705.79 Description: ARTERY TRANSPOSE/ENDOVAS TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33889 MEDSV DEF RBRVS 01/01/2025 685.44 Description: ARTERY TRANSPOSE/ENDOVAS TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 3388F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 853.06 Description: CAR-CAR BP GRFT/ENDOVAS TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33891 MEDSV DEF RBRVS 01/01/2025 827.7 Description: CAR-CAR BP GRFT/ENDOVAS TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33894 MEDSV DEF RBRVS 01/01/2024 12/31/2024 877.93 Description: EVASC ST RPR THRC/AA ACRS BR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33894 MEDSV DEF RBRVS 01/01/2025 853.04 Description: EVASC ST RPR THRC/AA ACRS BR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33895 MEDSV DEF RBRVS 01/01/2024 12/31/2024 698.48 Description: EVASC ST RPR THRC/AA X CRSG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33895 MEDSV DEF RBRVS 01/01/2025 678.9 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33897 MEDSV DEF RBRVS 01/01/2024 12/31/2024 519.51 Description: PERQ TRLUML ANGP NT/RECR COA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33897 MEDSV DEF RBRVS 01/01/2025 504.61 Description: PERQ TRLUML ANGP NT/RECR COA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 529.42 Description: PERQ P-ART REVSC 1 NM NT UNI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33900 MEDSV DEF RBRVS 01/01/2025 510.72 Description: PERQ P-ART REVSC 1 NM NT UNI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33901 MEDSV DEF RBRVS 01/01/2024 12/31/2024 695.93 Description: PERQ P-ART REVSC 1 NM NT BI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33901 MEDSV DEF RBRVS 01/01/2025 671.19 Description: PERQ P-ART REVSC 1 NM NT BI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33902 MEDSV DEF RBRVS 01/01/2024 12/31/2024 672.14 Description: PERQ P-ART REVSC 1 ABNOR UNI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33902 MEDSV DEF RBRVS 01/01/2025 648.1 Description: PERQ P-ART REVSC 1 ABNOR UNI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33903 MEDSV DEF RBRVS 01/01/2024 12/31/2024 792.22 Description: PERQ P-ART REVSC 1 ABNOR BI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33903 MEDSV DEF RBRVS 01/01/2025 763.83 Description: PERQ P-ART REVSC 1 ABNOR BI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33904 MEDSV DEF RBRVS 01/01/2024 12/31/2024 265.77 Description: PERQ P-ART REVSC EACH ADDL Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33904 MEDSV DEF RBRVS 01/01/2025 256.32 Description: PERQ P-ART REVSC EACH ADDL Category: Medical Services CMS Add: 01/01/2023 CMS Term: 3390F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 2364.5 Description: REMOVE LUNG ARTERY EMBOLI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33910 MEDSV DEF RBRVS 01/01/2025 2273.61 Description: REMOVE LUNG ARTERY EMBOLI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33915 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1236.78 Description: REMOVE LUNG ARTERY EMBOLI Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33915 MEDSV DEF RBRVS 01/01/2025 1199.17 Description: REMOVE LUNG ARTERY EMBOLI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33916 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3733.77 Description: SURGERY OF GREAT VESSEL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33916 MEDSV DEF RBRVS 01/01/2025 3622.64 Description: SURGERY OF GREAT VESSEL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33917 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1311.94 Description: REPAIR PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33917 MEDSV DEF RBRVS 01/01/2025 1278.8 Description: REPAIR PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1622.67 Description: REPAIR PULMONARY ATRESIA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33920 MEDSV DEF RBRVS 01/01/2025 1577.29 Description: REPAIR PULMONARY ATRESIA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33922 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1249.69 Description: TRANSECT PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33922 MEDSV DEF RBRVS 01/01/2025 1218.33 Description: TRANSECT PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33924 MEDSV DEF RBRVS 01/01/2024 12/31/2024 254.52 Description: REMOVE PULMONARY SHUNT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 33924 MEDSV DEF RBRVS 01/01/2025 246.49 Description: REMOVE PULMONARY SHUNT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 33925 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1537.06 Description: RPR PUL ART UNIFOCAL W/O CPB Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33925 MEDSV DEF RBRVS 01/01/2025 1494.09 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 12/31/2024 2159.45 Description: REPR PUL ART UNIFOCAL W/CPB Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33926 MEDSV DEF RBRVS 01/01/2025 2098.31 Description: REPR PUL ART UNIFOCAL W/CPB Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33927 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2272.57 Y Description: IMPLTJ TOT RPLCMT HRT SYS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33927 MEDSV DEF RBRVS 01/01/2025 2203.62 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 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 Y Description: RMVL RPLCMT HRT SYS F/TRNSPL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 33930 MEDSV DEF BILL20 01/01/2010 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 Y Description: PREPARE DONOR HEART/LUNG Category: Medical Services CMS Add: 01/01/2005 CMS Term: 33935 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4416.87 Y Description: TRANSPLANTATION HEART/LUNG Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33935 MEDSV DEF RBRVS 01/01/2025 4280.58 Y Description: TRANSPLANTATION HEART/LUNG Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33940 MEDSV PRF MAXFEE 01/01/2024 12/31/2024 3566.59 0 Description: REMOVAL OF DONOR HEART Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33940 MEDSV PRF MAXFEE 01/01/2025 3495.26 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 Y Description: PREPARE DONOR HEART Category: Medical Services CMS Add: 01/01/2005 CMS Term: 33945 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4359.16 Y Description: TRANSPLANTATION OF HEART Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33945 MEDSV DEF RBRVS 01/01/2025 4229.69 Y Description: TRANSPLANTATION OF HEART Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33946 MEDSV DEF RBRVS 01/01/2024 12/31/2024 279.16 Description: ECMO/ECLS INITIATION VENOUS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33946 MEDSV DEF RBRVS 01/01/2025 270.69 Description: ECMO/ECLS INITIATION VENOUS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33947 MEDSV DEF RBRVS 01/01/2024 12/31/2024 308.48 Description: ECMO/ECLS INITIATION ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33947 MEDSV DEF RBRVS 01/01/2025 299.44 Description: ECMO/ECLS INITIATION ARTERY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33948 MEDSV DEF RBRVS 01/01/2024 12/31/2024 217.46 Description: ECMO/ECLS DAILY MGMT-VENOUS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33948 MEDSV DEF RBRVS 01/01/2025 211.06 Description: ECMO/ECLS DAILY MGMT-VENOUS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33949 MEDSV DEF RBRVS 01/01/2024 12/31/2024 211.17 Description: ECMO/ECLS DAILY MGMT ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33949 MEDSV DEF RBRVS 01/01/2025 205.75 Description: ECMO/ECLS DAILY MGMT ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 3394F NOCOV DEF SYSMAN 01/01/2012 Y 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 12/31/2024 378.51 0-5Years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33951 MEDSV DEF RBRVS 01/01/2025 365.7 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 12/31/2024 383.41 6-999Years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33952 MEDSV DEF RBRVS 01/01/2025 371.86 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 12/31/2024 422.28 0-5Years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33953 MEDSV DEF RBRVS 01/01/2025 408.33 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 12/31/2024 425.24 6-999Years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33954 MEDSV DEF RBRVS 01/01/2025 412.46 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 12/31/2024 738.9 0-5Years Description: ECMO/ECLS INSJ CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33955 MEDSV DEF RBRVS 01/01/2025 714.9 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 12/31/2024 746.11 6-999Years Description: ECMO/ECLS INSJ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33956 MEDSV DEF RBRVS 01/01/2025 723.94 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 12/31/2024 164.69 0-5Years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33957 MEDSV DEF RBRVS 01/01/2025 159.34 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 12/31/2024 164.69 6-999Years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33958 MEDSV DEF RBRVS 01/01/2025 159.34 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 12/31/2024 208.63 0-5Years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33959 MEDSV DEF RBRVS 01/01/2025 202.59 0-5Years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 3395F NOCOV DEF SYSMAN 01/01/2012 Y Description: QUANT NONHER2 IHC BRST CX Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 33962 MEDSV DEF RBRVS 01/01/2024 12/31/2024 208.63 6-999Years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33962 MEDSV DEF RBRVS 01/01/2025 202.59 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 12/31/2024 417.15 0-5Years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33963 MEDSV DEF RBRVS 01/01/2025 403.51 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 12/31/2024 440.34 6-999Years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33964 MEDSV DEF RBRVS 01/01/2025 426.01 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 12/31/2024 164.69 0-5Years Description: ECMO/ECLS RMVL PERPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33965 MEDSV DEF RBRVS 01/01/2025 159.34 0-5Years Description: ECMO/ECLS RMVL PERPH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33966 MEDSV DEF RBRVS 01/01/2024 12/31/2024 211.94 6-999Years Description: ECMO/ECLS RMVL PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33966 MEDSV DEF RBRVS 01/01/2025 206.13 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 12/31/2024 231.4 Description: INSERT I-AORT PERCUT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33967 MEDSV DEF RBRVS 01/01/2025 225.02 Description: INSERT I-AORT PERCUT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33968 MEDSV DEF RBRVS 01/01/2024 12/31/2024 30.42 0-1 Description: REMOVE AORTIC ASSIST DEVICE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33968 MEDSV DEF RBRVS 01/01/2025 29.52 0-1 Description: REMOVE AORTIC ASSIST DEVICE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33969 MEDSV DEF RBRVS 01/01/2024 12/31/2024 243.43 0-5Years Description: ECMO/ECLS RMVL PERPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33969 MEDSV DEF RBRVS 01/01/2025 235.43 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 12/31/2024 317.08 Description: AORTIC CIRCULATION ASSIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33970 MEDSV DEF RBRVS 01/01/2025 306.88 Description: AORTIC CIRCULATION ASSIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33971 MEDSV DEF RBRVS 01/01/2024 12/31/2024 637.96 Description: AORTIC CIRCULATION ASSIST Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33971 MEDSV DEF RBRVS 01/01/2025 622.88 Description: AORTIC CIRCULATION ASSIST Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33973 MEDSV DEF RBRVS 01/01/2024 12/31/2024 448.55 Description: INSERT BALLOON DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33973 MEDSV DEF RBRVS 01/01/2025 433.32 Description: INSERT BALLOON DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33974 MEDSV DEF RBRVS 01/01/2024 12/31/2024 804.38 Description: REMOVE INTRA-AORTIC BALLOON Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33974 MEDSV DEF RBRVS 01/01/2025 782.89 Description: REMOVE INTRA-AORTIC BALLOON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33975 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1161.03 Description: IMPLANT VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33975 MEDSV DEF RBRVS 01/01/2025 1129.77 Description: IMPLANT VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33976 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1413.97 Description: IMPLANT VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33976 MEDSV DEF RBRVS 01/01/2025 1367.52 Description: IMPLANT VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33977 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1005.46 Description: REMOVE VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33977 MEDSV DEF RBRVS 01/01/2025 977.31 Description: REMOVE VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33978 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1190.02 Description: REMOVE VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33978 MEDSV DEF RBRVS 01/01/2025 1152.66 Description: REMOVE VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33979 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1736.34 Description: INSERT INTRACORPOREAL DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33979 MEDSV DEF RBRVS 01/01/2025 1683.61 Description: INSERT INTRACORPOREAL DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33980 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1590.64 Description: REMOVE INTRACORPOREAL DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33980 MEDSV DEF RBRVS 01/01/2025 1547.08 Description: REMOVE INTRACORPOREAL DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33981 MEDSV DEF RBRVS 01/01/2024 12/31/2024 740.8 Description: REPLACE VAD PUMP EXT Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33981 MEDSV DEF RBRVS 01/01/2025 716.1 Description: REPLACE VAD PUMP EXT Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33982 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1740.72 Description: REPLACE VAD INTRA W/O BP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33982 MEDSV DEF RBRVS 01/01/2025 1683.59 Description: REPLACE VAD INTRA W/O BP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33983 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2065.41 Description: REPLACE VAD INTRA W/BP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33983 MEDSV DEF RBRVS 01/01/2025 1981.14 Description: REPLACE VAD INTRA W/BP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33984 MEDSV DEF RBRVS 01/01/2024 12/31/2024 253.48 6-999Years Description: ECMO/ECLS RMVL PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33984 MEDSV DEF RBRVS 01/01/2025 245.78 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 12/31/2024 458.57 0-5Years Description: ECMO/ECLS RMVL CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33985 MEDSV DEF RBRVS 01/01/2025 443.07 0-5Years Description: ECMO/ECLS RMVL CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33986 MEDSV DEF RBRVS 01/01/2024 12/31/2024 467.9 6-999Years Description: ECMO/ECLS RMVL CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33986 MEDSV DEF RBRVS 01/01/2025 453.71 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 12/31/2024 185.51 Description: ARTERY EXPOS/GRAFT ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33987 MEDSV DEF RBRVS 01/01/2025 179.82 Description: ARTERY EXPOS/GRAFT ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33988 MEDSV DEF RBRVS 01/01/2024 12/31/2024 693.14 Description: INSERTION OF LEFT HEART VENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33988 MEDSV DEF RBRVS 01/01/2025 670.35 Description: INSERTION OF LEFT HEART VENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33989 MEDSV DEF RBRVS 01/01/2024 12/31/2024 440.34 Description: REMOVAL OF LEFT HEART VENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33989 MEDSV DEF RBRVS 01/01/2025 426.01 Description: REMOVAL OF LEFT HEART VENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33990 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 313.71 0-1 Description: INSJ PERQ VAD L HRT ARTERIAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33991 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 393.1 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 12/31/2024 167.9 0-1 Description: RMVL PERQ LEFT HEART VAD Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33992 MEDSV DEF RBRVS 01/01/2025 163.52 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 12/31/2024 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 01/01/2025 145.2 0-1 Description: REPOSG PERQ R/L HRT VAD Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33995 MEDSV DEF RBRVS 01/01/2024 12/31/2024 321.92 Description: INSJ PERQ VAD R HRT VENOUS Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33995 MEDSV DEF RBRVS 01/01/2025 309.58 Description: INSJ PERQ VAD R HRT VENOUS Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33997 MEDSV DEF RBRVS 01/01/2024 12/31/2024 141.92 Description: RMVL PERQ RIGHT HEART VAD Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33997 MEDSV DEF RBRVS 01/01/2025 140.14 Description: RMVL PERQ RIGHT HEART VAD Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX CARDIAC SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 814.52 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34001 MEDSV DEF RBRVS 01/01/2025 792.14 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34051 MEDSV DEF RBRVS 01/01/2024 12/31/2024 896.7 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34051 MEDSV DEF RBRVS 01/01/2025 871.87 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 533.75 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34101 MEDSV DEF RBRVS 01/01/2025 517.47 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 535.9 Description: REMOVAL OF ARM ARTERY CLOT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 34111 MEDSV DEF RBRVS 01/01/2025 516.86 Description: REMOVAL OF ARM ARTERY CLOT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 34151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1242.3 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34151 MEDSV DEF RBRVS 01/01/2025 1205 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34201 MEDSV DEF RBRVS 01/01/2024 12/31/2024 910.05 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34201 MEDSV DEF RBRVS 01/01/2025 884.23 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34203 MEDSV DEF RBRVS 01/01/2024 12/31/2024 844.86 Description: REMOVAL OF LEG ARTERY CLOT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 34203 MEDSV DEF RBRVS 01/01/2025 821.96 Description: REMOVAL OF LEG ARTERY CLOT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 34401 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1336.01 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34401 MEDSV DEF RBRVS 01/01/2025 1313.31 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34421 MEDSV DEF RBRVS 01/01/2024 12/31/2024 619.14 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34421 MEDSV DEF RBRVS 01/01/2025 602.98 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34451 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1276.81 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34451 MEDSV DEF RBRVS 01/01/2025 1241.5 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34471 MEDSV DEF RBRVS 01/01/2024 12/31/2024 960.77 Description: REMOVAL OF VEIN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34471 MEDSV DEF RBRVS 01/01/2025 934.61 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34490 MEDSV DEF RBRVS 01/01/2024 12/31/2024 583.4 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 34490 MEDSV DEF RBRVS 01/01/2025 499.9 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 34501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 797.35 Description: REPAIR VALVE FEMORAL VEIN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34501 MEDSV DEF RBRVS 01/01/2025 777.99 Description: REPAIR VALVE FEMORAL VEIN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1383.47 Description: RECONSTRUCT VENA CAVA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 34502 MEDSV DEF RBRVS 01/01/2025 1354.61 Description: RECONSTRUCT VENA CAVA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3450F NOCOV DEF SYSMAN 01/01/2009 Y Description: DYSPNEA SCRND NO-MILD DYSP Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 909.41 Description: TRANSPOSITION OF VEIN VALVE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34510 MEDSV DEF RBRVS 01/01/2025 884.82 Description: TRANSPOSITION OF VEIN VALVE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 3451F NOCOV DEF SYSMAN 01/01/2009 Y Description: DYSPNEA SCRND MOD-HIGH DYSP Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 881.64 Description: CROSS-OVER VEIN GRAFT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34520 MEDSV DEF RBRVS 01/01/2025 857.44 Description: CROSS-OVER VEIN GRAFT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 3452F NOCOV DEF SYSMAN 01/01/2009 Y Description: DYSPNEA NOT SCREENED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 839.38 Description: LEG VEIN FUSION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34530 MEDSV DEF RBRVS 01/01/2025 817.18 Description: LEG VEIN FUSION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3455F NOCOV DEF SYSMAN 01/01/2009 Y Description: TB SCR PFRMD&INTERPD 6 MO Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34701 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1103.79 Description: EVASC RPR A-AO NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34701 MEDSV DEF RBRVS 01/01/2025 1068.87 Description: EVASC RPR A-AO NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1644.64 Description: EVASC RPR A-AO NDGFT RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34702 MEDSV DEF RBRVS 01/01/2025 1593.46 Description: EVASC RPR A-AO NDGFT RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34703 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1225.46 Description: EVASC RPR A-UNILAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34703 MEDSV DEF RBRVS 01/01/2025 1186.65 Description: EVASC RPR A-UNILAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34704 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2039.76 Description: EVASC RPR A-UNILAC NDGFT RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34704 MEDSV DEF RBRVS 01/01/2025 1977.62 Description: EVASC RPR A-UNILAC NDGFT RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1360.3 Description: EVAC RPR A-BIILIAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34705 MEDSV DEF RBRVS 01/01/2025 1319.43 Description: EVAC RPR A-BIILIAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34706 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2024.39 Description: EVASC RPR A-BIILIAC RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34706 MEDSV DEF RBRVS 01/01/2025 1964.84 Description: EVASC RPR A-BIILIAC RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34707 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1040.46 Description: EVASC RPR ILIO-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34707 MEDSV DEF RBRVS 01/01/2025 1003.54 Description: EVASC RPR ILIO-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34708 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1613.81 Description: EVASC RPR ILIO-ILIAC RPT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34708 MEDSV DEF RBRVS 01/01/2025 1568.08 Description: EVASC RPR ILIO-ILIAC RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34709 MEDSV DEF RBRVS 01/01/2024 12/31/2024 286.73 Description: PLMT XTN PROSTH EVASC RPR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34709 MEDSV DEF RBRVS 01/01/2025 277.62 Description: PLMT XTN PROSTH EVASC RPR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 3470F NOCOV DEF SYSMAN 01/01/2009 Y Description: RA DISEASE ACTIVITY LOW Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 709.28 Description: DLYD PLMT XTN PROSTH 1ST VSL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34710 MEDSV DEF RBRVS 01/01/2025 689.8 Description: DLYD PLMT XTN PROSTH 1ST VSL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34711 MEDSV DEF RBRVS 01/01/2024 12/31/2024 261.67 Description: DLYD PLMT XTN PROSTH EA ADDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34711 MEDSV DEF RBRVS 01/01/2025 253.32 Description: DLYD PLMT XTN PROSTH EA ADDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34712 MEDSV DEF RBRVS 01/01/2024 12/31/2024 586.62 Description: TCAT DLVR ENHNCD FIXJ DEV Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34712 MEDSV DEF RBRVS 01/01/2025 569.38 Description: TCAT DLVR ENHNCD FIXJ DEV Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34713 MEDSV DEF RBRVS 01/01/2024 12/31/2024 109.65 Description: PERQ ACCESS & CLSR FEM ART Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34713 MEDSV DEF RBRVS 01/01/2025 106.18 Description: PERQ ACCESS & CLSR FEM ART Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34714 MEDSV DEF RBRVS 01/01/2024 12/31/2024 239.85 Description: OPN FEM ART EXPOS CNDT CRTJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34714 MEDSV DEF RBRVS 01/01/2025 232.83 Description: OPN FEM ART EXPOS CNDT CRTJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 265.87 Description: OPN AX/SUBCLA ART EXPOS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34715 MEDSV DEF RBRVS 01/01/2025 256.96 Description: OPN AX/SUBCLA ART EXPOS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34716 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.96 Description: OPN AX/SUBCLA ART EXPOS CNDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34716 MEDSV DEF RBRVS 01/01/2025 321.92 Description: OPN AX/SUBCLA ART EXPOS CNDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34717 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.74 Description: EVASC RPR A-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 34717 MEDSV DEF RBRVS 01/01/2025 381.26 Description: EVASC RPR A-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 34718 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1100.26 Description: EVASC RPR N/A A-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 34718 MEDSV DEF RBRVS 01/01/2025 1069.58 Description: EVASC RPR N/A A-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 3471F NOCOV DEF SYSMAN 01/01/2009 Y Description: RA DISEASE ACTIVITY MOD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3472F NOCOV DEF SYSMAN 01/01/2009 Y Description: RA DISEASE ACTIVITY HIGH Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3475F NOCOV DEF SYSMAN 01/01/2009 Y Description: DISEASE PROGN RA POOR DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3476F NOCOV DEF SYSMAN 01/01/2009 Y Description: DISEASE PROGN RA GOOD DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34808 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.78 Description: ENDOVAS ILIAC A DEVICE ADDON Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34808 MEDSV DEF RBRVS 01/01/2025 174.21 Description: ENDOVAS ILIAC A DEVICE ADDON Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34812 MEDSV DEF RBRVS 01/01/2024 12/31/2024 182.9 Description: OPN FEM ART EXPOS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34812 MEDSV DEF RBRVS 01/01/2025 177.25 Description: OPN FEM ART EXPOS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34813 MEDSV DEF RBRVS 01/01/2024 12/31/2024 209.38 Description: FEMORAL ENDOVAS GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34813 MEDSV DEF RBRVS 01/01/2025 202.01 Description: FEMORAL ENDOVAS GRAFT ADD-ON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 298.37 Description: OPN ILIAC ART EXPOS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34820 MEDSV DEF RBRVS 01/01/2025 289.59 Description: OPN ILIAC ART EXPOS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1566.09 Description: OPEN AORTIC TUBE PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34830 MEDSV DEF RBRVS 01/01/2025 1522.01 Description: OPEN AORTIC TUBE PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34831 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1712.82 Description: OPEN AORTOILIAC PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34831 MEDSV DEF RBRVS 01/01/2025 1664.98 Description: OPEN AORTOILIAC PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34832 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1683.18 Description: OPEN AORTOFEMOR PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34832 MEDSV DEF RBRVS 01/01/2025 1636 Description: OPEN AORTOFEMOR PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34833 MEDSV DEF RBRVS 01/01/2024 12/31/2024 347.74 Description: OPN ILAC ART EXPOS CNDT CRTJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 34833 MEDSV DEF RBRVS 01/01/2025 337.77 Description: OPN ILAC ART EXPOS CNDT CRTJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 34834 MEDSV DEF RBRVS 01/01/2024 12/31/2024 114.77 Description: OPN BRACH ART EXPOS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 34834 MEDSV DEF RBRVS 01/01/2025 111.14 Description: OPN BRACH ART EXPOS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 34839 NOCOV DEF SYSMAN 01/01/2015 Y 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 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 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 Y Description: ENDOVASC VISC AORTA 3 GRAFT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34844 MEDSV DEF MAXFEE 01/01/2024 1055.92 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 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 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 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 Y Description: VISC & INFRAREN ABD 4+ PROST Category: Medical Services CMS Add: 01/01/2014 CMS Term: 3490F NOCOV DEF SYSMAN 01/01/2009 Y Description: HISTORY AIDS-DEFINING COND Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3491F NOCOV DEF SYSMAN 01/01/2009 Y Description: HIV UNSURE BABY OF HIV+MOMS Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3492F NOCOV DEF SYSMAN 01/01/2009 Y Description: HISTORY CD4+ CELL COUNT <350 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3493F NOCOV DEF SYSMAN 01/01/2009 Y Description: NO HIST CD4+ CELL COUNT <350 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3494F NOCOV DEF SYSMAN 01/01/2009 Y Description: CD4+CELL COUNT <200CELLS/MM3 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3495F NOCOV DEF SYSMAN 01/01/2009 Y Description: CD4+CELL CNT 200-499 CELLS Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3496F NOCOV DEF SYSMAN 01/01/2009 Y Description: CD4+ CELL COUNT >= 500 CELLS Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3497F NOCOV DEF SYSMAN 01/01/2009 Y Description: CD4+ CELL PERCENTAGE <15% Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3498F NOCOV DEF SYSMAN 01/01/2009 Y Description: CD4+ CELL >=15% (HIV) Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 35001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1003.96 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35001 MEDSV DEF RBRVS 01/01/2025 972.33 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35002 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1013.1 Description: REPAIR ARTERY RUPTURE NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35002 MEDSV DEF RBRVS 01/01/2025 985.55 Description: REPAIR ARTERY RUPTURE NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 887.53 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35005 MEDSV DEF RBRVS 01/01/2025 863.49 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 3500F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 901.82 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35011 MEDSV DEF RBRVS 01/01/2025 876.96 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35013 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1134.05 Description: REPAIR ARTERY RUPTURE ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35013 MEDSV DEF RBRVS 01/01/2025 1100.63 Description: REPAIR ARTERY RUPTURE ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35021 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1135.06 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35021 MEDSV DEF RBRVS 01/01/2025 1102.06 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35022 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1297.04 Description: REPAIR ARTERY RUPTURE CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35022 MEDSV DEF RBRVS 01/01/2025 1259.51 Description: REPAIR ARTERY RUPTURE CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3502F NOCOV DEF SYSMAN 01/01/2009 Y Description: HIV RNA VRL LD SEGMT Category: Medical Services CMS Add: 01/01/1999 CMS Term: 35683 MEDSV DEF RBRVS 01/01/2025 351.36 Description: COMPOSITE BYP GRFT 3/> SEGMT Category: Medical Services CMS Add: 01/01/1999 CMS Term: 35685 MEDSV DEF RBRVS 01/01/2024 12/31/2024 175.52 Description: BYPASS GRAFT PATENCY/PATCH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 35685 MEDSV DEF RBRVS 01/01/2025 169.92 Description: BYPASS GRAFT PATENCY/PATCH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 35686 MEDSV DEF RBRVS 01/01/2024 12/31/2024 142.42 Description: BYPASS GRAFT/AV FIST PATENCY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 35686 MEDSV DEF RBRVS 01/01/2025 138.09 Description: BYPASS GRAFT/AV FIST PATENCY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 35691 MEDSV DEF RBRVS 01/01/2024 12/31/2024 842.76 Description: ART TRNSPOSJ VERTBRL CAROTID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35691 MEDSV DEF RBRVS 01/01/2025 819.71 Description: ART TRNSPOSJ VERTBRL CAROTID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35693 MEDSV DEF RBRVS 01/01/2024 12/31/2024 745.63 Description: ART TRNSPOSJ SUBCLAVIAN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35693 MEDSV DEF RBRVS 01/01/2025 727.51 Description: ART TRNSPOSJ SUBCLAVIAN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35694 MEDSV DEF RBRVS 01/01/2024 12/31/2024 879.78 Description: ART TRNSPOSJ SUBCLAV CAROTID 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35694 MEDSV DEF RBRVS 01/01/2025 855.91 Description: ART TRNSPOSJ SUBCLAV CAROTID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35695 MEDSV DEF RBRVS 01/01/2024 12/31/2024 913.14 Description: ART TRNSPOSJ CAROTID SUBCLAV Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35695 MEDSV DEF RBRVS 01/01/2025 888.09 Description: ART TRNSPOSJ CAROTID SUBCLAV Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35697 MEDSV DEF RBRVS 01/01/2024 12/31/2024 130.23 Description: REIMPLANT ARTERY EACH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 35697 MEDSV DEF RBRVS 01/01/2025 125.99 Description: REIMPLANT ARTERY EACH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 35700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 134.5 Description: REOPERATION BYPASS GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35700 MEDSV DEF RBRVS 01/01/2025 130.43 Description: REOPERATION BYPASS GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35701 MEDSV DEF RBRVS 01/01/2024 12/31/2024 406.89 Description: EXPL N/FLWD SURG NECK ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35701 MEDSV DEF RBRVS 01/01/2025 393.47 Description: EXPL N/FLWD SURG NECK ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 371.99 Description: EXPL N/FLWD SURG UXTR ART Category: Medical Services CMS Add: 01/01/2020 CMS Term: 35702 MEDSV DEF RBRVS 01/01/2025 359.59 Description: EXPL N/FLWD SURG UXTR ART Category: Medical Services CMS Add: 01/01/2020 CMS Term: 35703 MEDSV DEF RBRVS 01/01/2024 12/31/2024 374.78 Description: EXPL N/FLWD SURG LXTR ART Category: Medical Services CMS Add: 01/01/2020 CMS Term: 35703 MEDSV DEF RBRVS 01/01/2025 363.07 Description: EXPL N/FLWD SURG LXTR ART Category: Medical Services CMS Add: 01/01/2020 CMS Term: 3570F NOCOV DEF SYSMAN 01/01/2009 Y Description: RPRT BONE SCINT XREF W XRAY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3572F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT CONSID POSS RISK FX Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3573F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT NOT CONSID POSS RISK FX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 673.05 Description: EXPLORE NECK VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35800 MEDSV DEF RBRVS 01/01/2025 657.12 Description: EXPLORE NECK VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1806.5 Description: EXPLORE CHEST VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35820 MEDSV DEF RBRVS 01/01/2025 1755.71 Description: EXPLORE CHEST VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1100.77 Description: EXPLORE ABDOMINAL VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35840 MEDSV DEF RBRVS 01/01/2025 1073.76 Description: EXPLORE ABDOMINAL VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 752.73 Description: EXPLORE LIMB VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35860 MEDSV DEF RBRVS 01/01/2025 734.43 Description: EXPLORE LIMB VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35870 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1110.47 Description: REPAIR VESSEL GRAFT DEFECT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35870 MEDSV DEF RBRVS 01/01/2025 1079.64 Description: REPAIR VESSEL GRAFT DEFECT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35875 MEDSV DEF RBRVS 01/01/2024 12/31/2024 529.36 Description: REMOVAL OF CLOT IN GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35875 MEDSV DEF RBRVS 01/01/2025 513.86 Description: REMOVAL OF CLOT IN GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35876 MEDSV DEF RBRVS 01/01/2024 12/31/2024 840.53 Description: REMOVAL OF CLOT IN GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35876 MEDSV DEF RBRVS 01/01/2025 816.39 Description: REMOVAL OF CLOT IN GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35879 MEDSV DEF RBRVS 01/01/2024 12/31/2024 821.52 0-2 Description: REVISE GRAFT W/VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 35879 MEDSV DEF RBRVS 01/01/2025 797.2 0-2 Description: REVISE GRAFT W/VEIN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35881 MEDSV DEF RBRVS 01/01/2024 12/31/2024 912.1 0-2 Description: REVISE GRAFT W/VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 35881 MEDSV DEF RBRVS 01/01/2025 891.72 0-2 Description: REVISE GRAFT W/VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 35883 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1065.72 Description: REVJ FEM ANAST NONAUTOG GRF Category: Medical Services CMS Add: 01/01/2007 CMS Term: 35883 MEDSV DEF RBRVS 01/01/2025 1033.65 Description: REVJ FEM ANAST NONAUTOG GRF Category: Medical Services CMS Add: 01/01/2007 CMS Term: 35884 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1101.37 Description: REVJ FEM ANAST AUTOG VN GRF Category: Medical Services CMS Add: 01/01/2007 CMS Term: 35884 MEDSV DEF RBRVS 01/01/2025 1070.7 Description: REVJ FEM ANAST AUTOG VN GRF Category: Medical Services CMS Add: 01/01/2007 CMS Term: 35901 MEDSV DEF RBRVS 01/01/2024 12/31/2024 426.24 Description: EXCISION GRAFT NECK Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35901 MEDSV DEF RBRVS 01/01/2025 416.42 Description: EXCISION GRAFT NECK Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35903 MEDSV DEF RBRVS 01/01/2024 12/31/2024 506.91 Description: EXCISION GRAFT EXTREMITY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35903 MEDSV DEF RBRVS 01/01/2025 492.93 Description: EXCISION GRAFT EXTREMITY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1493.05 Description: EXCISION GRAFT THORAX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35905 MEDSV DEF RBRVS 01/01/2025 1451.18 Description: EXCISION GRAFT THORAX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35907 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1690.65 Description: EXCISION GRAFT ABDOMEN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35907 MEDSV DEF RBRVS 01/01/2025 1649.28 Description: EXCISION GRAFT ABDOMEN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 36000 NOCOV DEF SYSMAN 08/01/2012 Y Description: PLACE NEEDLE IN VEIN Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 36002 MEDSV DEF RBRVS 01/01/2024 12/31/2024 141.33 Description: PSEUDOANEURYSM INJECTION TRT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36002 MEDSV DEF RBRVS 01/01/2025 139.14 Description: PSEUDOANEURYSM INJECTION TRT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 36005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 238.37 Description: INJECTION EXT VENOGRAPHY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 36005 MEDSV DEF RBRVS 01/01/2025 225.96 Description: INJECTION EXT VENOGRAPHY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 36010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 503.85 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36010 MEDSV DEF RBRVS 01/01/2025 479.87 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36011 MEDSV DEF RBRVS 01/01/2024 12/31/2024 750.56 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36011 MEDSV DEF RBRVS 01/01/2025 710.65 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36012 MEDSV DEF RBRVS 01/01/2024 12/31/2024 777.95 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36012 MEDSV DEF RBRVS 01/01/2025 742.28 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36013 MEDSV DEF RBRVS 01/01/2024 12/31/2024 733.92 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36013 MEDSV DEF RBRVS 01/01/2025 695.5 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36014 MEDSV DEF RBRVS 01/01/2024 12/31/2024 732.89 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36014 MEDSV DEF RBRVS 01/01/2025 698.24 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 795.46 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36015 MEDSV DEF RBRVS 01/01/2025 751.69 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 522.15 Description: ESTABLISH ACCESS TO 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36100 MEDSV DEF RBRVS 01/01/2025 474.57 Description: ESTABLISH ACCESS TO ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.7 Description: INTRO NDL ICATH UPR/LXTR ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36140 MEDSV DEF RBRVS 01/01/2025 454.91 Description: INTRO NDL ICATH UPR/LXTR ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 524.77 Description: ESTABLISH ACCESS TO AORTA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36160 MEDSV DEF RBRVS 01/01/2025 492.92 Description: ESTABLISH ACCESS TO AORTA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 549.76 Description: PLACE CATHETER IN AORTA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36200 MEDSV DEF RBRVS 01/01/2025 525.77 Description: PLACE CATHETER IN AORTA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 964.1 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36215 MEDSV DEF RBRVS 01/01/2025 923.47 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36216 MEDSV DEF RBRVS 01/01/2024 12/31/2024 987.93 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36216 MEDSV DEF RBRVS 01/01/2025 947.64 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36217 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1652.19 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36217 MEDSV DEF RBRVS 01/01/2025 1609.44 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36218 MEDSV DEF RBRVS 01/01/2024 12/31/2024 192.88 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36218 MEDSV DEF RBRVS 01/01/2025 187.36 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36221 MEDSV DEF RBRVS 01/01/2024 12/31/2024 917.21 0-1 Description: PLACE CATH THORACIC AORTA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36221 MEDSV DEF RBRVS 01/01/2025 876.56 0-1 Description: PLACE CATH THORACIC AORTA Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36222 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1126.58 0-1 Description: PLACE CATH CAROTID/INOM ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36222 MEDSV DEF RBRVS 01/01/2025 1097.13 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 12/31/2024 1517.48 0-1 Description: PLACE CATH CAROTID/INOM ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36223 MEDSV DEF RBRVS 01/01/2025 1489.56 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 12/31/2024 1884.07 0-1 Description: PLACE CATH CAROTD ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36224 MEDSV DEF RBRVS 01/01/2025 1838.68 0-1 Description: PLACE CATH CAROTD ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1432.73 0-1 Description: PLACE CATH SUBCLAVIAN ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36225 MEDSV DEF RBRVS 01/01/2025 1414.53 0-1 Description: PLACE CATH SUBCLAVIAN ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36226 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1831.87 0-1 Description: PLACE CATH VERTEBRAL ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36226 MEDSV DEF RBRVS 01/01/2025 1791.72 0-1 Description: PLACE CATH VERTEBRAL ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36227 MEDSV DEF RBRVS 01/01/2024 12/31/2024 219.86 Description: PLACE CATH XTRNL CAROTID Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36227 MEDSV DEF RBRVS 01/01/2025 216.11 Description: PLACE CATH XTRNL CAROTID Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36228 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1161.77 Description: PLACE CATH INTRACRANIAL ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36228 MEDSV DEF RBRVS 01/01/2025 1154.02 Description: PLACE CATH INTRACRANIAL ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36245 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1157.1 Description: INS CATH ABD/L-EXT ART 1ST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36245 MEDSV DEF RBRVS 01/01/2025 1101.94 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 12/31/2024 773.99 Description: INS CATH ABD/L-EXT ART 2ND Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36246 MEDSV DEF RBRVS 01/01/2025 740.01 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 12/31/2024 1323.51 Description: INS CATH ABD/L-EXT ART 3RD Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36247 MEDSV DEF RBRVS 01/01/2025 1261.43 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 12/31/2024 109.63 Description: INS CATH ABD/L-EXT ART ADDL Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36248 MEDSV DEF RBRVS 01/01/2025 104.41 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 12/31/2024 1198.96 Description: INS CATH REN ART 1ST UNILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36251 MEDSV DEF RBRVS 01/01/2025 1141.95 Description: INS CATH REN ART 1ST UNILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36252 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1287.16 Description: INS CATH REN ART 1ST BILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36252 MEDSV DEF RBRVS 01/01/2025 1234.9 Description: INS CATH REN ART 1ST BILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36253 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1880.72 Description: INS CATH REN ART 2ND+ UNILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36253 MEDSV DEF RBRVS 01/01/2025 1787.88 Description: INS CATH REN ART 2ND+ UNILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36254 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1838.76 Description: INS CATH REN ART 2ND+ BILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36254 MEDSV DEF RBRVS 01/01/2025 1751.73 Description: INS CATH REN ART 2ND+ BILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 599.56 Description: INSERTION OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36260 MEDSV DEF RBRVS 01/01/2025 586.29 Description: INSERTION OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36261 MEDSV DEF RBRVS 01/01/2024 12/31/2024 376.78 Description: REVISION OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36261 MEDSV DEF RBRVS 01/01/2025 369.96 Description: REVISION OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36262 MEDSV DEF RBRVS 01/01/2024 12/31/2024 288.29 Description: REMOVAL OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36262 MEDSV DEF RBRVS 01/01/2025 283.2 Description: REMOVAL OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36299 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX VASCULAR NJX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 25.87 0-2Years Description: VNPNXR<3YRS PHY/QHP FEM/JUG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36400 MEDSV DEF RBRVS 01/01/2025 25.3 0-2Years Description: VNPNXR<3YRS PHY/QHP FEM/JUG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 22.25 0-2Years Description: VNPNXR<3YRS PHY/QHP SCALP VN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36405 MEDSV DEF RBRVS 01/01/2025 22.24 0-2Years Description: VNPNXR<3YRS PHY/QHP SCALP VN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36406 MEDSV DEF RBRVS 01/01/2024 12/31/2024 16.45 0-2Years Description: VNPNXR<3YRS PHY/QHP OTHER VN Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36406 MEDSV DEF RBRVS 01/01/2025 16.32 0-2Years Description: VNPNXR<3YRS PHY/QHP OTHER VN Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 16.3 3-999Years Description: VNPNXR 3YR/> PHY/QHP DX/THER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36410 MEDSV DEF RBRVS 01/01/2025 16.17 3-999Years Description: VNPNXR 3YR/> PHY/QHP DX/THER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36415 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 8.57 0 Description: COLL VENOUS BLD VENIPUNCTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36415 SE MRT DEF MAXFEE 01/01/2024 12/31/2024 8.57 0 Description: COLL VENOUS BLD VENIPUNCTURE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36415 MEDSV PRF MAXFEE 01/01/2025 8.83 0 Description: COLL VENOUS BLD VENIPUNCTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36415 SE MRT PRF MAXFEE 01/01/2025 8.83 0 Description: COLL VENOUS BLD VENIPUNCTURE Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 36416 MEDSV PRF MAXFEE 01/01/2024 12/31/2024 3.89 0 Description: COLLJ CAPILLARY BLOOD SPEC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36416 MEDSV PRF MAXFEE 01/01/2025 3.81 0 Description: COLLJ CAPILLARY BLOOD SPEC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 43.32 0-364Days Description: VENIPUNCTURE CUTDOWN < 1 YR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36420 MEDSV DEF RBRVS 01/01/2025 42 0-364Days Description: VENIPUNCTURE CUTDOWN < 1 YR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 36.93 1-999Years Description: VENIPUNCTURE CUTDOWN 1 YR/> Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36425 MEDSV DEF RBRVS 01/01/2025 35.69 1-999Years Description: VENIPUNCTURE CUTDOWN 1 YR/> Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 35.82 Description: TRANSFUSION BLD/BLD COMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36430 MEDSV DEF RBRVS 01/01/2025 37.91 Description: TRANSFUSION BLD/BLD COMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 47.76 0-2Years Description: BLD PUSH TFUJ 2 YR/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36440 MEDSV DEF RBRVS 01/01/2025 46.31 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 12/31/2024 161.51 0-28Days Description: BLD EXCHANGE TRUJ NEWBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36450 MEDSV DEF RBRVS 01/01/2025 157.36 0-28Days Description: BLD EXCHANGE TRUJ NEWBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36455 MEDSV DEF RBRVS 01/01/2024 12/31/2024 112.67 Description: BLD EXCHANGE TRUJ OTH THN NB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36455 MEDSV DEF RBRVS 01/01/2025 109.17 Description: BLD EXCHANGE TRUJ OTH THN NB Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36456 MEDSV DEF RBRVS 01/01/2024 12/31/2024 92.56 0-28Days Description: PRTL EXCHANGE TRANSFUSE NB Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36456 MEDSV DEF RBRVS 01/01/2025 89.75 0-28Days Description: PRTL EXCHANGE TRANSFUSE NB Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 319.41 Description: INTRAUTERINE TRANSFUSION FTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36460 MEDSV DEF RBRVS 01/01/2025 309.78 Description: INTRAUTERINE TRANSFUSION FTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36465 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1219.69 0 Description: NJX NONCMPND SCLRSNT 1 VEIN Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36465 MEDSV DEF RBRVS 01/01/2025 1153.29 Description: NJX NONCMPND SCLRSNT 1 VEIN Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36468 NOCOV DEF SYSMAN 01/01/1900 Y Description: NJX SCLRSNT SPIDER VEINS Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 36470 MEDSV DEF RBRVS 01/01/2024 12/31/2024 106.56 Description: NJX SCLRSNT 1 INCMPTNT VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36470 MEDSV DEF RBRVS 01/01/2025 104.23 Description: NJX SCLRSNT 1 INCMPTNT VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36471 MEDSV DEF RBRVS 01/01/2024 12/31/2024 184.85 Description: NJX SCLRSNT MLT INCMPTNT VN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36471 MEDSV DEF RBRVS 01/01/2025 180.38 Description: NJX SCLRSNT MLT INCMPTNT VN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36474 MEDSV DEF RBRVS 01/01/2024 12/31/2024 238.27 Description: ENDOVENOUS MCHNCHEM ADD-ON Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36474 MEDSV DEF RBRVS 01/01/2025 225.12 Description: ENDOVENOUS MCHNCHEM ADD-ON Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36475 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1001.97 Description: ENDOVENOUS RF 1ST VEIN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36475 MEDSV DEF RBRVS 01/01/2025 954.41 Description: ENDOVENOUS RF 1ST VEIN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36476 MEDSV DEF RBRVS 01/01/2024 12/31/2024 262.43 Description: ENDOVENOUS RF VEIN ADD-ON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36476 MEDSV DEF RBRVS 01/01/2025 250.84 Description: ENDOVENOUS RF VEIN ADD-ON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36478 MEDSV DEF RBRVS 01/01/2024 12/31/2024 910.1 Description: ENDOVENOUS LASER 1ST VEIN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36478 MEDSV DEF RBRVS 01/01/2025 872.25 Description: ENDOVENOUS LASER 1ST VEIN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36479 MEDSV DEF RBRVS 01/01/2024 12/31/2024 277.24 Description: ENDOVENOUS LASER VEIN ADDON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36479 MEDSV DEF RBRVS 01/01/2025 270.01 Description: ENDOVENOUS LASER VEIN ADDON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36481 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1630.09 Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36481 MEDSV DEF RBRVS 01/01/2025 1539.05 Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36482 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1555.65 Description: ENDOVEN THER CHEM ADHES 1ST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36482 MEDSV DEF RBRVS 01/01/2025 1486.11 Description: ENDOVEN THER CHEM ADHES 1ST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36483 MEDSV DEF RBRVS 01/01/2024 12/31/2024 125.46 Description: ENDOVEN THER CHEM ADHES SBSQ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36483 MEDSV DEF RBRVS 01/01/2025 122.37 Description: ENDOVEN THER CHEM ADHES SBSQ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 164.91 Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36500 MEDSV DEF RBRVS 01/01/2025 160.29 Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3650F NOCOV DEF SYSMAN 01/01/2010 Y Description: EEG ORDERED RVWD REQSTD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 36510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 80.83 0-28Days Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36510 MEDSV DEF RBRVS 01/01/2025 79.53 0-28Days Description: INSERTION OF CATHETER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36511 MEDSV DEF RBRVS 01/01/2024 12/31/2024 103.66 Description: APHERESIS WBC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36511 MEDSV DEF RBRVS 01/01/2025 102.27 Description: APHERESIS WBC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 100.89 Description: APHERESIS RBC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36512 MEDSV DEF RBRVS 01/01/2025 97.58 Description: APHERESIS RBC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36513 MEDSV DEF RBRVS 01/01/2024 12/31/2024 99.54 Description: APHERESIS PLATELETS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36513 MEDSV DEF RBRVS 01/01/2025 96.88 Description: APHERESIS PLATELETS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36514 MEDSV DEF RBRVS 01/01/2024 12/31/2024 523.88 Description: APHERESIS PLASMA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36514 MEDSV DEF RBRVS 01/01/2025 604.47 Description: APHERESIS PLASMA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36516 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1630.58 Description: APHERESIS IMMUNOADS SLCTV Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36516 MEDSV DEF RBRVS 01/01/2025 1607.48 Description: APHERESIS IMMUNOADS SLCTV Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36522 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1259.35 Description: PHOTOPHERESIS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 36522 MEDSV DEF RBRVS 01/01/2025 1207.64 Description: PHOTOPHERESIS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 36555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 178.66 0-4Years Description: INSERT NON-TUNNEL CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36555 MEDSV DEF RBRVS 01/01/2025 171.7 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 12/31/2024 199.91 5-999Years Description: INSERT NON-TUNNEL CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36556 MEDSV DEF RBRVS 01/01/2025 192.89 5-999Years Description: INSERT NON-TUNNEL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36557 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1077.98 0-4Years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36557 MEDSV DEF RBRVS 01/01/2025 1025.29 0-4Years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36558 MEDSV DEF RBRVS 01/01/2024 12/31/2024 777.87 5-999Years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36558 MEDSV DEF RBRVS 01/01/2025 736.19 5-999Years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1148.96 0-4Years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36560 MEDSV DEF RBRVS 01/01/2025 1093.07 0-4Years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36561 MEDSV DEF RBRVS 01/01/2024 12/31/2024 919.22 5-999Years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36561 MEDSV DEF RBRVS 01/01/2025 868.72 5-999Years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36563 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1048.17 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36563 MEDSV DEF RBRVS 01/01/2025 973.14 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36565 MEDSV DEF RBRVS 01/01/2024 12/31/2024 763.98 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36565 MEDSV DEF RBRVS 01/01/2025 736.26 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36566 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3966.29 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36566 MEDSV DEF RBRVS 01/01/2025 3742.71 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36568 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 83.33 0-4Years Description: INSJ PICC <5 YR W/O IMAGING 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36569 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 84.93 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 12/31/2024 1356.38 0-4Years Description: INSERT PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36570 MEDSV DEF RBRVS 01/01/2025 1287.65 0-4Years Description: INSERT PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36571 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1175.86 5-999Years Description: INSERT PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36571 MEDSV DEF RBRVS 01/01/2025 1112.45 5-999Years Description: INSERT PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36572 MEDSV DEF RBRVS 01/01/2024 12/31/2024 351.08 0-4Years Description: INSJ PICC RS&I <5 YR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 36572 MEDSV DEF RBRVS 01/01/2025 334.05 0-4Years Description: INSJ PICC RS&I <5 YR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 36573 MEDSV DEF RBRVS 01/01/2024 12/31/2024 359.96 5-999Years Description: INSJ PICC RS&I 5 YR+ Category: Medical Services CMS Add: 01/01/2019 CMS Term: 36573 MEDSV DEF RBRVS 01/01/2025 341.85 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 12/31/2024 135.28 Description: REPAIR TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36575 MEDSV DEF RBRVS 01/01/2025 129.92 Description: REPAIR TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36576 MEDSV DEF RBRVS 01/01/2024 12/31/2024 321.34 Description: REPAIR TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36576 MEDSV DEF RBRVS 01/01/2025 308.02 Description: REPAIR TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36578 MEDSV DEF RBRVS 01/01/2024 12/31/2024 402.57 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36578 MEDSV DEF RBRVS 01/01/2025 383.58 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 177.87 Description: REPLACE CVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36580 MEDSV DEF RBRVS 01/01/2025 169.37 Description: REPLACE CVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36581 MEDSV DEF RBRVS 01/01/2024 12/31/2024 727.92 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36581 MEDSV DEF RBRVS 01/01/2025 690.27 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36582 MEDSV DEF RBRVS 01/01/2024 12/31/2024 821.65 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36582 MEDSV DEF RBRVS 01/01/2025 776.93 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36583 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1069.36 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36583 MEDSV DEF RBRVS 01/01/2025 1016.95 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36584 MEDSV DEF RBRVS 01/01/2024 12/31/2024 305.62 Description: COMPL RPLCMT PICC RS&I Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36584 MEDSV DEF RBRVS 01/01/2025 290.27 Description: COMPL RPLCMT PICC RS&I Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36585 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1079.89 Description: REPLACE PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36585 MEDSV DEF RBRVS 01/01/2025 1014.43 Description: REPLACE PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36589 MEDSV DEF RBRVS 01/01/2024 12/31/2024 154.05 Description: REMOVAL TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36589 MEDSV DEF RBRVS 01/01/2025 149.19 Description: REMOVAL TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36590 MEDSV DEF RBRVS 01/01/2024 12/31/2024 207.28 Description: REMOVAL TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36590 MEDSV DEF RBRVS 01/01/2025 200.65 Description: REMOVAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36591 MEDSV DEF RBRVS 01/01/2024 12/31/2024 24.55 Description: DRAW BLOOD OFF VENOUS DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36591 MEDSV DEF RBRVS 01/01/2025 24.91 Description: DRAW BLOOD OFF VENOUS DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36592 MEDSV DEF RBRVS 01/01/2024 12/31/2024 26.71 Description: COLLECT BLOOD FROM PICC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36592 MEDSV DEF RBRVS 01/01/2025 27.03 Description: COLLECT BLOOD FROM PICC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36593 MEDSV DEF RBRVS 01/01/2024 12/31/2024 30.27 0-2 Description: DECLOT VASCULAR DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36593 MEDSV DEF RBRVS 01/01/2025 31.11 0-2 Description: DECLOT VASCULAR DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36595 MEDSV DEF RBRVS 01/01/2024 12/31/2024 555.06 Description: MECH REMOV TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36595 MEDSV DEF RBRVS 01/01/2025 530.88 Description: MECH REMOV TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36596 MEDSV DEF RBRVS 01/01/2024 12/31/2024 106.36 Description: MECH REMOV TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36596 MEDSV DEF RBRVS 01/01/2025 104.2 Description: MECH REMOV TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36597 MEDSV DEF RBRVS 01/01/2024 12/31/2024 104.56 Description: REPOSITION VENOUS CATHETER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36597 MEDSV DEF RBRVS 01/01/2025 100.27 Description: REPOSITION VENOUS CATHETER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36598 MEDSV DEF RBRVS 01/01/2024 12/31/2024 113.26 Description: INJ W/FLUOR EVAL CV DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 36598 MEDSV DEF RBRVS 01/01/2025 108.06 Description: INJ W/FLUOR EVAL CV DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 36600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 25.98 Description: WITHDRAWAL OF ARTERIAL BLOOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36600 MEDSV DEF RBRVS 01/01/2025 25.29 Description: WITHDRAWAL OF ARTERIAL BLOOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 41.98 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36620 MEDSV DEF RBRVS 01/01/2025 40.51 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36625 MEDSV DEF RBRVS 01/01/2024 12/31/2024 97.2 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36625 MEDSV DEF RBRVS 01/01/2025 94.26 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 110.02 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36640 MEDSV DEF RBRVS 01/01/2025 108.74 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 64.8 0-28Days Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36660 MEDSV DEF RBRVS 01/01/2025 62.83 0-28Days Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 54.7 Description: INSERT NEEDLE BONE CAVITY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 36680 MEDSV DEF RBRVS 01/01/2025 53.35 Description: INSERT NEEDLE BONE CAVITY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 36800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 112.64 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36800 MEDSV DEF RBRVS 01/01/2025 109.53 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 196.51 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36810 MEDSV DEF RBRVS 01/01/2025 191.12 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36815 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.86 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36815 MEDSV DEF RBRVS 01/01/2025 117.39 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36818 MEDSV DEF RBRVS 01/01/2024 12/31/2024 616.48 Description: AV FUSE UPPR ARM CEPHALIC Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36818 MEDSV DEF RBRVS 01/01/2025 599.65 Description: AV FUSE UPPR ARM CEPHALIC Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36819 MEDSV DEF RBRVS 01/01/2024 12/31/2024 652.23 Description: AV FUSE UPPR ARM BASILIC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 36819 MEDSV DEF RBRVS 01/01/2025 634.16 Description: AV FUSE UPPR ARM BASILIC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 36820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 647.32 Description: AV FUSION/FOREARM VEIN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 36820 MEDSV DEF RBRVS 01/01/2025 631.42 Description: AV FUSION/FOREARM VEIN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 36821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 591.15 Description: AV FUSION DIRECT ANY SITE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36821 MEDSV DEF RBRVS 01/01/2025 573.85 Description: AV FUSION DIRECT ANY SITE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36823 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1275.86 Description: INSERTION OF CANNULA(S) Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36823 MEDSV DEF RBRVS 01/01/2025 1244.24 Description: INSERTION OF CANNULA(S) Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 709.36 Description: ARTERY-VEIN AUTOGRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36825 MEDSV DEF RBRVS 01/01/2025 689.71 Description: ARTERY-VEIN AUTOGRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 595.88 Description: ARTERY-VEIN NONAUTOGRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36830 MEDSV DEF RBRVS 01/01/2025 579.35 Description: ARTERY-VEIN NONAUTOGRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36831 MEDSV DEF RBRVS 01/01/2024 12/31/2024 550.95 Description: OPEN THROMBECT AV FISTULA Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36831 MEDSV DEF RBRVS 01/01/2025 536.68 Description: OPEN THROMBECT AV FISTULA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36832 MEDSV DEF RBRVS 01/01/2024 12/31/2024 676.03 Description: AV FISTULA REVISION OPEN Category: Medical Services CMS Add: 01/01/1990 CMS Term: 36832 MEDSV DEF RBRVS 01/01/2025 657.81 Description: AV FISTULA REVISION OPEN Category: Medical Services CMS Add: 01/01/1990 CMS Term: 36833 MEDSV DEF RBRVS 01/01/2024 12/31/2024 721.67 Description: AV FISTULA REVISION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36833 MEDSV DEF RBRVS 01/01/2025 701.33 Description: AV FISTULA REVISION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36835 MEDSV DEF RBRVS 01/01/2024 12/31/2024 438.13 Description: INSERTION THOMAS SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36835 MEDSV DEF RBRVS 01/01/2025 427.89 Description: INSERTION THOMAS SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36836 MEDSV DEF RBRVS 01/01/2024 12/31/2024 6495.28 Description: PRQ AV FSTL CRTJ UXTR 1 ACS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 36836 MEDSV DEF RBRVS 01/01/2025 7265.27 Description: PRQ AV FSTL CRTJ UXTR 1 ACS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 36837 MEDSV DEF RBRVS 01/01/2024 12/31/2024 9240.36 Description: PRQ AV FSTL CRT UXTR SEP ACS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 36837 MEDSV DEF RBRVS 01/01/2025 8646.99 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 12/31/2024 1017.11 Description: DIST REVAS LIGATION HEMO Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36838 MEDSV DEF RBRVS 01/01/2025 986.48 Description: DIST REVAS LIGATION HEMO Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 214.01 Description: EXTERNAL CANNULA DECLOTTING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36860 MEDSV DEF RBRVS 01/01/2025 208.26 Description: EXTERNAL CANNULA DECLOTTING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36861 MEDSV DEF RBRVS 01/01/2024 12/31/2024 124.88 Description: CANNULA DECLOTTING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36861 MEDSV DEF RBRVS 01/01/2025 120.76 Description: CANNULA DECLOTTING 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36901 MEDSV DEF RBRVS 01/01/2024 12/31/2024 657.69 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36901 MEDSV DEF RBRVS 01/01/2025 628.94 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36902 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1125.62 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36902 MEDSV DEF RBRVS 01/01/2025 1074.69 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36903 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 3987.18 0 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36903 MEDSV DEF RBRVS 01/01/2025 3760.56 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36904 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1689.15 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36904 MEDSV DEF RBRVS 01/01/2025 1608.04 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2127.96 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36905 MEDSV DEF RBRVS 01/01/2025 2023.45 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36906 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 5058.86 0 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36906 MEDSV DEF RBRVS 01/01/2025 4789.24 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36907 MEDSV DEF RBRVS 01/01/2024 12/31/2024 550.82 Description: BALO ANGIOP CTR DIALYSIS SEG Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36907 MEDSV DEF RBRVS 01/01/2025 524.42 Description: BALO ANGIOP CTR DIALYSIS SEG Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36908 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1320.19 0 Description: STENT PLMT CTR DIALYSIS SEG Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36908 MEDSV DEF RBRVS 01/01/2025 1254.49 Description: STENT PLMT CTR DIALYSIS SEG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36909 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1783.17 0 Description: DIALYSIS CIRCUIT EMBOLJ Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36909 MEDSV DEF RBRVS 01/01/2025 1677.7 Description: DIALYSIS CIRCUIT EMBOLJ Category: Medical Services CMS Add: 01/01/2017 CMS Term: 3700F NOCOV DEF SYSMAN 01/01/2011 Y Description: PSYCH DISORDERS ASSESSED Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 37140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2102.87 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37140 MEDSV DEF RBRVS 01/01/2025 2046.53 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1951.62 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 37145 MEDSV DEF RBRVS 01/01/2025 1899.23 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 37160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2004.2 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 37160 MEDSV DEF RBRVS 01/01/2025 1950.74 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 37180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1925.96 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37180 MEDSV DEF RBRVS 01/01/2025 1875.06 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37181 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2102.87 Description: SPLICE SPLEEN/KIDNEY VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37181 MEDSV DEF RBRVS 01/01/2025 2046.53 Description: SPLICE SPLEEN/KIDNEY VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37182 MEDSV DEF RBRVS 01/01/2024 12/31/2024 759.11 Description: INSERT HEPATIC SHUNT (TIPS) Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37182 MEDSV DEF RBRVS 01/01/2025 731.55 Description: INSERT HEPATIC SHUNT (TIPS) Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37183 MEDSV DEF RBRVS 01/01/2024 12/31/2024 5476.5 Description: REVISION TIPS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37183 MEDSV DEF RBRVS 01/01/2025 5146.38 Description: REVISION TIPS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37184 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1591.74 Description: PRIM ART M-THRMBC 1ST VSL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37184 MEDSV DEF RBRVS 01/01/2025 1516.07 Description: PRIM ART M-THRMBC 1ST VSL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37185 MEDSV DEF RBRVS 01/01/2024 12/31/2024 438.35 Description: PRIM ART M-THRMBC SBSQ VSL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37185 MEDSV DEF RBRVS 01/01/2025 420.52 Description: PRIM ART M-THRMBC SBSQ VSL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37186 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1103.07 Description: SEC ART THROMBECTOMY ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37186 MEDSV DEF RBRVS 01/01/2025 1049.64 Description: SEC ART THROMBECTOMY ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37187 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1589.59 Description: VENOUS MECH THROMBECTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37187 MEDSV DEF RBRVS 01/01/2025 1501.24 Description: VENOUS MECH THROMBECTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37188 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1370.93 Description: VEN MECHNL THRMBC REPEAT TX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37188 MEDSV DEF RBRVS 01/01/2025 1284.66 Description: VEN MECHNL THRMBC REPEAT TX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37191 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1898.56 Description: INS ENDOVAS VENA CAVA FILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37191 MEDSV DEF RBRVS 01/01/2025 1789.63 Description: INS ENDOVAS VENA CAVA FILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37192 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1182.69 Description: REDO ENDOVAS VENA CAVA FILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37192 MEDSV DEF RBRVS 01/01/2025 1131.56 Description: REDO ENDOVAS VENA CAVA FILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37193 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1400.78 Description: REM ENDOVAS VENA CAVA FILTER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37193 MEDSV DEF RBRVS 01/01/2025 1331.33 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 Description: THROMBOLYTIC THERAPY STROKE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 37197 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1451.75 0-2 Description: REMOVE INTRVAS FOREIGN BODY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37197 MEDSV DEF RBRVS 01/01/2025 1387.91 0-2 Description: REMOVE INTRVAS FOREIGN BODY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 199.87 Description: TRANSCATHETER BIOPSY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 37200 MEDSV DEF RBRVS 01/01/2025 192.98 Description: TRANSCATHETER BIOPSY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 3720F NOCOV DEF SYSMAN 01/01/2011 Y Description: COGNIT IMPAIRMENT ASSESSED Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 37211 MEDSV DEF RBRVS 01/01/2024 12/31/2024 349.83 0-1 Description: THROMBOLYTIC ART THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37211 MEDSV DEF RBRVS 01/01/2025 339.3 0-1 Description: THROMBOLYTIC ART THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37212 MEDSV DEF RBRVS 01/01/2024 12/31/2024 307.31 0-1 Description: THROMBOLYTIC VENOUS THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37212 MEDSV DEF RBRVS 01/01/2025 297.28 0-1 Description: THROMBOLYTIC VENOUS THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37213 MEDSV DEF RBRVS 01/01/2024 12/31/2024 210.11 0-1 Description: THROMBLYTIC ART/VEN THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37213 MEDSV DEF RBRVS 01/01/2025 203.42 0-1 Description: THROMBLYTIC ART/VEN THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37214 MEDSV DEF RBRVS 01/01/2024 12/31/2024 111.06 0-1 Description: CESSJ THERAPY CATH REMOVAL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37214 MEDSV DEF RBRVS 01/01/2025 107.1 0-1 Description: CESSJ THERAPY CATH REMOVAL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 883.66 Description: TRANSCATH STENT CCA W/EPS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37215 MEDSV DEF RBRVS 01/01/2025 856.52 Description: TRANSCATH STENT CCA W/EPS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 37216 NOCOV DEF SYSMAN 01/01/2005 Y 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 12/31/2024 964.48 Description: STENT PLACEMT RETRO CAROTID Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37217 MEDSV DEF RBRVS 01/01/2025 934.2 Description: STENT PLACEMT RETRO CAROTID Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37218 MEDSV DEF RBRVS 01/01/2024 12/31/2024 738.58 Description: STENT PLACEMT ANTE CAROTID Category: Medical Services CMS Add: 01/01/2015 CMS Term: 37218 MEDSV DEF RBRVS 01/01/2025 720.5 Description: STENT PLACEMT ANTE CAROTID Category: Medical Services CMS Add: 01/01/2015 CMS Term: 37220 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2330.43 0 Description: ILIAC REVASC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37220 MEDSV DEF RBRVS 01/01/2025 2218.78 Description: ILIAC REVASC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37221 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2867.12 0 Description: ILIAC REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37221 MEDSV DEF RBRVS 01/01/2025 2722.77 Description: ILIAC REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37222 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 569.93 0 Description: ILIAC REVASC ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37222 MEDSV DEF RBRVS 01/01/2025 546.79 Description: ILIAC REVASC ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37223 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1184.24 0 Description: ILIAC REVASC W/STENT ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37223 MEDSV DEF RBRVS 01/01/2025 1122.62 Description: ILIAC REVASC W/STENT ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37224 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2718.87 0 Description: FEM/POPL REVAS W/TLA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37224 MEDSV DEF RBRVS 01/01/2025 2578.75 Description: FEM/POPL REVAS W/TLA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37225 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 8158.99 0 Description: FEM/POPL REVAS W/ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37225 MEDSV DEF RBRVS 01/01/2025 7743.48 Description: FEM/POPL REVAS W/ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37226 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 7591.83 0 Description: FEM/POPL REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37226 MEDSV DEF RBRVS 01/01/2025 7171.43 Description: FEM/POPL REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37227 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 10450.12 0 Description: FEM/POPL REVASC STNT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37227 MEDSV DEF RBRVS 01/01/2025 9888.8 Description: FEM/POPL REVASC STNT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37228 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 3861.53 0 Description: TIB/PER REVASC W/TLA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37228 MEDSV DEF RBRVS 01/01/2025 3656.37 Description: TIB/PER REVASC W/TLA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37229 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 8293.17 0 Description: TIB/PER REVASC W/ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37229 MEDSV DEF RBRVS 01/01/2025 7880.69 Description: TIB/PER REVASC W/ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37230 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 8302.23 0 Description: TIB/PER REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37230 MEDSV DEF RBRVS 01/01/2025 7890.3 Description: TIB/PER REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37231 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 10974.34 0 Description: TIB/PER REVASC STENT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37231 MEDSV DEF RBRVS 01/01/2025 10426.7 Description: TIB/PER REVASC STENT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37232 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 762.29 0 Description: TIB/PER REVASC ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37232 MEDSV DEF RBRVS 01/01/2025 727.27 Description: TIB/PER REVASC ADD-ON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37233 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 968.79 0 Description: TIBPER REVASC W/ATHER ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37233 MEDSV DEF RBRVS 01/01/2025 934.91 Description: TIBPER REVASC W/ATHER ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37234 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 3381.22 0 Description: REVSC OPN/PRQ TIB/PERO STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37234 MEDSV DEF RBRVS 01/01/2025 3217.85 Description: REVSC OPN/PRQ TIB/PERO STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37235 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 3695.12 0 Description: TIB/PER REVASC STNT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37235 MEDSV DEF RBRVS 01/01/2025 3502.31 Description: TIB/PER REVASC STNT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37236 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2555.99 Description: OPEN/PERQ PLACE STENT 1ST Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37236 MEDSV DEF RBRVS 01/01/2025 2431.06 Description: OPEN/PERQ PLACE STENT 1ST Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37237 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1201.19 Description: OPEN/PERQ PLACE STENT EA ADD Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37237 MEDSV DEF RBRVS 01/01/2025 1142.53 Description: OPEN/PERQ PLACE STENT EA ADD Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37238 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3213.53 Description: OPEN/PERQ PLACE STENT SAME Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37238 MEDSV DEF RBRVS 01/01/2025 3056.22 Description: OPEN/PERQ PLACE STENT SAME Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37239 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1595.5 Description: OPEN/PERQ PLACE STENT EA ADD Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37239 MEDSV DEF RBRVS 01/01/2025 1527.07 Description: OPEN/PERQ PLACE STENT EA ADD Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37241 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4354.63 Description: VASC EMBOLIZE/OCCLUDE VENOUS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37241 MEDSV DEF RBRVS 01/01/2025 4099.49 Description: VASC EMBOLIZE/OCCLUDE VENOUS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37242 MEDSV DEF RBRVS 01/01/2024 12/31/2024 6644.87 Description: VASC EMBOLIZE/OCCLUDE ARTERY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37242 MEDSV DEF RBRVS 01/01/2025 6262.92 Description: VASC EMBOLIZE/OCCLUDE ARTERY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37243 MEDSV DEF RBRVS 01/01/2024 12/31/2024 8079.39 Description: VASC EMBOLIZE/OCCLUDE ORGAN Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37243 MEDSV DEF RBRVS 01/01/2025 7598.26 Description: VASC EMBOLIZE/OCCLUDE ORGAN Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37244 MEDSV DEF RBRVS 01/01/2024 12/31/2024 6171.45 Description: VASC EMBOLIZE/OCCLUDE BLEED Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37244 MEDSV DEF RBRVS 01/01/2025 5808.65 Description: VASC EMBOLIZE/OCCLUDE BLEED Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37246 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1692.08 Description: TRLUML BALO ANGIOP 1ST ART Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37246 MEDSV DEF RBRVS 01/01/2025 1609.17 Description: TRLUML BALO ANGIOP 1ST ART Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37247 MEDSV DEF RBRVS 01/01/2024 12/31/2024 523.64 Description: TRLUML BALO ANGIOP ADDL ART Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37247 MEDSV DEF RBRVS 01/01/2025 522.71 Description: TRLUML BALO ANGIOP ADDL ART Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37248 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1267.24 Description: TRLUML BALO ANGIOP 1ST VEIN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37248 MEDSV DEF RBRVS 01/01/2025 1202.97 Description: TRLUML BALO ANGIOP 1ST VEIN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37249 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.77 Description: TRLUML BALO ANGIOP ADDL VEIN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37249 MEDSV DEF RBRVS 01/01/2025 392.78 Description: TRLUML BALO ANGIOP ADDL VEIN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37252 MEDSV DEF RBRVS 01/01/2024 12/31/2024 887.19 Description: INTRVASC US NONCORONARY 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: 37252 MEDSV DEF RBRVS 01/01/2025 840.38 Description: INTRVASC US NONCORONARY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37253 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.56 Description: INTRVASC US NONCORONARY ADDL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 37253 MEDSV DEF RBRVS 01/01/2025 154.39 Description: INTRVASC US NONCORONARY ADDL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 3725F NOCOV DEF SYSMAN 01/01/2012 Y Description: SCREEN DEPRESSION PERFORMED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 37500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 563.58 Description: ENDOSCOPY LIGATE PERF VEINS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37500 MEDSV DEF RBRVS 01/01/2025 549.08 Description: ENDOSCOPY LIGATE PERF VEINS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37501 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED VASC ENDOSCOPY PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 3750F NOCOV DEF SYSMAN 01/01/2012 Y Description: PTNOTRCVNGSTEROID>=10MG/DAY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 3751F NOCOV DEF SYSMAN 01/01/2013 Y Description: ELECTRODIAG POLYNEURO 6 MN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3752F NOCOV DEF SYSMAN 01/01/2013 Y Description: NO ELECTRODIAG POLYNEURO 6MN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3753F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT HAS SYMP&SIGNS NEUROPATHY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3754F NOCOV DEF SYSMAN 01/01/2013 Y Description: SCREENING TESTS DM DONE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3755F NOCOV DEF SYSMAN 01/01/2013 Y Description: COG&BEHAV IMPRMNT SCRNG DONE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 37565 MEDSV DEF RBRVS 01/01/2024 12/31/2024 667.59 Description: LIGATION INT JUGULAR VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37565 MEDSV DEF RBRVS 01/01/2025 651.89 Description: LIGATION INT JUGULAR VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3756F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT W/PSEUDOBULB AFFECT/ALS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3757F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT W/O PSEUDOBULBAFFECT/ALS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3758F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT REF PULM FX TEST/PEAKFLOW Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3759F NOCOV DEF SYSMAN 01/01/2013 Y 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 12/31/2024 690.22 Description: LIGATION XTRNL CAROTID ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37600 MEDSV DEF RBRVS 01/01/2025 675.99 Description: LIGATION XTRNL CAROTID ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 658.31 Description: LIGATION INT/COM CAROTID ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37605 MEDSV DEF RBRVS 01/01/2025 640.96 Description: LIGATION INT/COM CAROTID ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 656.24 Description: LIG INT/COM CAROTID ART OCCL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37606 MEDSV DEF RBRVS 01/01/2025 645.64 Description: LIG INT/COM CAROTID ART OCCL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37607 MEDSV DEF RBRVS 01/01/2024 12/31/2024 337.32 Description: LIG/BANDING ANGIOACS AV FSTL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 37607 MEDSV DEF RBRVS 01/01/2025 328.7 Description: LIG/BANDING ANGIOACS AV FSTL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 37609 MEDSV DEF RBRVS 01/01/2024 12/31/2024 289.48 Description: LIGATION/BX TEMPORAL ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37609 MEDSV DEF RBRVS 01/01/2025 280.31 Description: LIGATION/BX TEMPORAL ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3760F NOCOV DEF SYSMAN 01/01/2013 Y 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 12/31/2024 474.66 Description: LIGATION MAJOR ARTERY NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37615 MEDSV DEF RBRVS 01/01/2025 464.32 Description: LIGATION MAJOR ARTERY NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37616 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1001.12 Description: LIGATION MAJOR ARTERY CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37616 MEDSV DEF RBRVS 01/01/2025 993.57 Description: LIGATION MAJOR ARTERY CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37617 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1194.39 Description: LIGATION MAJOR ARTERY ABD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37617 MEDSV DEF RBRVS 01/01/2025 1169.26 Description: LIGATION MAJOR ARTERY ABD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37618 MEDSV DEF RBRVS 01/01/2024 12/31/2024 354.98 Description: LIGATION MAJOR ARTERY XTR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37618 MEDSV DEF RBRVS 01/01/2025 348.93 Description: LIGATION MAJOR ARTERY XTR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37619 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1564.62 Description: LIGATION OF INF VENA CAVA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37619 MEDSV DEF RBRVS 01/01/2025 1521.11 Description: LIGATION OF INF VENA CAVA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3761F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT W/O DYSPHAG/WT LOSS/NUTR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3762F NOCOV DEF SYSMAN 01/01/2013 Y Description: PATIENT IS DYSARTHRIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3763F NOCOV DEF SYSMAN 01/01/2013 Y Description: PATIENT IS NOT DYSARTHRIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 37650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 411.17 Description: LIGATION OF FEMORAL VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37650 MEDSV DEF RBRVS 01/01/2025 400.87 Description: LIGATION OF FEMORAL VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1193.36 Description: LIGATION COMMON ILIAC VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37660 MEDSV DEF RBRVS 01/01/2025 1161.99 Description: LIGATION COMMON ILIAC VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 221.58 Description: LIGATION&DIV LONG SAPH VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37700 MEDSV DEF RBRVS 01/01/2025 215.34 Description: LIGATION&DIV LONG SAPH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37718 MEDSV DEF RBRVS 01/01/2024 12/31/2024 352.51 Description: LIG DIV&STRPG SHORT SAPH VN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37718 MEDSV DEF RBRVS 01/01/2025 343.53 Description: LIG DIV&STRPG SHORT SAPH VN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37722 MEDSV DEF RBRVS 01/01/2024 12/31/2024 417.84 Description: LIG DIV&STRPG LONG SAPH VEIN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37722 MEDSV DEF RBRVS 01/01/2025 403.29 Description: LIG DIV&STRPG LONG SAPH VEIN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37735 MEDSV DEF RBRVS 01/01/2024 12/31/2024 520.69 Description: LIG&DIV&COMPL STRPG SAPH VN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37735 MEDSV DEF RBRVS 01/01/2025 507.43 Description: LIG&DIV&COMPL STRPG SAPH VN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3775F NOCOV DEF SYSMAN 04/01/2014 Y Description: ADENOMA DETECTED SCREENING Category: Non Covered Services CMS Add: 04/01/2014 CMS Term: 37760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 515.69 Description: LIG PRFRATR VN RADICAL 1 LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37760 MEDSV DEF RBRVS 01/01/2025 502.42 Description: LIG PRFRATR VN RADICAL 1 LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37761 MEDSV DEF RBRVS 01/01/2024 12/31/2024 487.4 Description: LIGATE LEG VEINS OPEN Category: Medical Services CMS Add: 01/01/2010 CMS Term: 37761 MEDSV DEF RBRVS 01/01/2025 471.58 Description: LIGATE LEG VEINS OPEN Category: Medical Services CMS Add: 01/01/2010 CMS Term: 37765 MEDSV DEF RBRVS 01/01/2024 12/31/2024 389.65 Description: STAB PHLEB VEINS XTR 10-20 Category: Medical Services CMS Add: 01/01/2004 CMS Term: 37765 MEDSV DEF RBRVS 01/01/2025 375.55 Description: STAB PHLEB VEINS XTR 10-20 Category: Medical Services CMS Add: 01/01/2004 CMS Term: 37766 MEDSV DEF RBRVS 01/01/2024 12/31/2024 457.47 Description: PHLEB VEINS - EXTREM 20+ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 37766 MEDSV DEF RBRVS 01/01/2025 441.61 Description: PHLEB VEINS - EXTREM 20+ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 3776F NOCOV DEF SYSMAN 04/01/2014 Y Description: ADENOMA NOT DETECT SCREENING Category: Non Covered Services CMS Add: 04/01/2014 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 212.06 Description: REVISION OF LEG VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37780 MEDSV DEF RBRVS 01/01/2025 207.65 Description: REVISION OF LEG VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37785 MEDSV DEF RBRVS 01/01/2024 12/31/2024 320.86 Description: LIGATE/DIVIDE/EXCISE VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37785 MEDSV DEF RBRVS 01/01/2025 311.64 Description: LIGATE/DIVIDE/EXCISE VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37788 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1175.07 Description: REVASCULARIZATION PENIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 37788 MEDSV DEF RBRVS 01/01/2025 1151.22 Description: REVASCULARIZATION PENIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 37790 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.03 Description: PENILE VENOUS OCCLUSION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 37790 MEDSV DEF RBRVS 01/01/2025 445.61 Description: PENILE VENOUS OCCLUSION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 37799 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX VASCULAR SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1050.35 Description: REMOVAL OF SPLEEN TOTAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38100 MEDSV DEF RBRVS 01/01/2025 1022.73 Description: REMOVAL OF SPLEEN TOTAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1058.88 Description: REMOVAL OF SPLEEN PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38101 MEDSV DEF RBRVS 01/01/2025 1031.29 Description: REMOVAL OF SPLEEN PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 238.06 Description: REMOVAL OF SPLEEN TOTAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38102 MEDSV DEF RBRVS 01/01/2025 231.53 Description: REMOVAL OF SPLEEN TOTAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1173.89 Description: REPAIR OF RUPTURED SPLEEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38115 MEDSV DEF RBRVS 01/01/2025 1143.24 Description: REPAIR OF RUPTURED SPLEEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 966.02 Description: LAPAROSCOPY SPLENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38120 MEDSV DEF RBRVS 01/01/2025 943.47 Description: LAPAROSCOPY SPLENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38129 MEDSV DEF BILL20 01/01/2014 0-1 Description: UNLISTED LAPS PX SPLEEN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 122.8 Description: INJECTION FOR SPLEEN X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38200 MEDSV DEF RBRVS 01/01/2025 118.63 Description: INJECTION FOR SPLEEN X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38204 NOCOV DEF SYSMAN 08/01/2012 Y Description: BL DONOR SEARCH MANAGEMENT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 79.61 Y Description: HARVEST ALLOGENEIC STEM CELL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38205 MEDSV DEF RBRVS 01/01/2025 77.57 Y Description: HARVEST ALLOGENEIC STEM CELL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38206 MEDSV DEF RBRVS 01/01/2024 12/31/2024 78.99 Y Description: HARVEST AUTO STEM CELLS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38206 MEDSV DEF RBRVS 01/01/2025 76.06 Y Description: HARVEST AUTO STEM CELLS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38207 NOCOV DEF SYSMAN 01/01/2003 Y Description: CRYOPRESERVE STEM CELLS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38208 NOCOV DEF SYSMAN 01/01/2003 Y Description: THAW PRESERVED STEM CELLS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38209 NOCOV DEF SYSMAN 01/01/2003 Y Description: WASH HARVEST STEM CELLS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38210 NOCOV DEF SYSMAN 01/01/2003 Y Description: T-CELL DEPLETION OF HARVEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38211 NOCOV DEF SYSMAN 01/01/2003 Y Description: TUMOR CELL DEPLETE OF HARVST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38212 NOCOV DEF SYSMAN 01/01/2003 Y Description: RBC DEPLETION OF HARVEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38213 NOCOV DEF SYSMAN 01/01/2003 Y Description: PLATELET DEPLETE OF HARVEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38214 NOCOV DEF SYSMAN 01/01/2003 Y Description: VOLUME DEPLETE OF HARVEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38215 NOCOV DEF SYSMAN 01/01/2003 Y Description: HARVEST STEM CELL CONCENTRTE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 145.38 Description: DX BONE MARROW ASPIRATIONS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 38220 MEDSV DEF RBRVS 01/01/2025 144.13 Description: DX BONE MARROW ASPIRATIONS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 38221 MEDSV DEF RBRVS 01/01/2024 12/31/2024 151.18 Description: DX BONE MARROW BIOPSIES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 38221 MEDSV DEF RBRVS 01/01/2025 149.17 Description: DX BONE MARROW BIOPSIES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 38222 MEDSV DEF RBRVS 01/01/2024 12/31/2024 164.03 Description: DX BONE MARROW BX & ASPIR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 38222 MEDSV DEF RBRVS 01/01/2025 160.76 Description: DX BONE MARROW BX & ASPIR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 38225 MEDSV DEF RBRVS 01/01/2025 89.64 Y Description: CAR-T HRV BLD-DRV T LYMPHCYT Category: Medical Services CMS Add: 01/01/2025 CMS Term: 38226 MEDSV DEF RBRVS 01/01/2025 36.34 Y Description: CAR-T PREP T LYMPHCYT F/TRNS Category: Medical Services CMS Add: 01/01/2025 CMS Term: 38227 MEDSV DEF RBRVS 01/01/2025 36.67 Y Description: CAR-T RECEIPT&PREPJ ADMN Category: Medical Services CMS Add: 01/01/2025 CMS Term: 38228 MEDSV DEF RBRVS 01/01/2025 266.25 Y Description: CAR-T ADMN AUTOLOGOUS Category: Medical Services CMS Add: 01/01/2025 CMS Term: 38230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 185.91 Y Description: BONE MARROW HARVEST ALLOGEN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38230 MEDSV DEF RBRVS 01/01/2025 180.84 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38232 MEDSV DEF RBRVS 01/01/2024 12/31/2024 178.99 Y Description: BONE MARROW HARVEST AUTOLOG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 38232 MEDSV DEF RBRVS 01/01/2025 171.01 Y Description: BONE MARROW HARVEST AUTOLOG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 38240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 226.48 Y Description: TRANSPLT ALLO HCT/DONOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38240 MEDSV DEF RBRVS 01/01/2025 222.66 Y Description: TRANSPLT ALLO HCT/DONOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38241 MEDSV DEF RBRVS 01/01/2024 12/31/2024 167.39 Y Description: TRANSPLT AUTOL HCT/DONOR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 38241 MEDSV DEF RBRVS 01/01/2025 164.51 Y Description: TRANSPLT AUTOL HCT/DONOR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 38242 MEDSV DEF RBRVS 01/01/2024 12/31/2024 118.52 Y Description: TRANSPLT ALLO LYMPHOCYTES Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38242 MEDSV DEF RBRVS 01/01/2025 116.3 Y Description: TRANSPLT ALLO LYMPHOCYTES Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38243 MEDSV DEF RBRVS 01/01/2024 12/31/2024 116.11 Y 0-1 Description: TRANSPLJ HEMATOPOIETIC BOOST Category: Medical Services CMS Add: 01/01/2013 CMS Term: 38243 MEDSV DEF RBRVS 01/01/2025 114.23 Y 0-1 Description: TRANSPLJ HEMATOPOIETIC BOOST Category: Medical Services CMS Add: 01/01/2013 CMS Term: 38300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 313.6 Description: DRAINAGE LYMPH NODE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38300 MEDSV DEF RBRVS 01/01/2025 305.08 Description: DRAINAGE LYMPH NODE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.6 Description: DRAINAGE LYMPH NODE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38305 MEDSV DEF RBRVS 01/01/2025 445.3 Description: DRAINAGE LYMPH NODE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38308 MEDSV DEF RBRVS 01/01/2024 12/31/2024 428.29 Description: INCISION OF LYMPH CHANNELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38308 MEDSV DEF RBRVS 01/01/2025 422.91 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 533.37 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38380 MEDSV DEF RBRVS 01/01/2025 527.53 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38381 MEDSV DEF RBRVS 01/01/2024 12/31/2024 728.25 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38381 MEDSV DEF RBRVS 01/01/2025 711.2 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38382 MEDSV DEF RBRVS 01/01/2024 12/31/2024 621.13 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38382 MEDSV DEF RBRVS 01/01/2025 606.65 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 311.32 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38500 MEDSV DEF RBRVS 01/01/2025 303.23 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 165.9 Description: NEEDLE BIOPSY LYMPH NODES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38505 MEDSV DEF RBRVS 01/01/2025 159.06 Description: NEEDLE BIOPSY LYMPH NODES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 492.27 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38510 MEDSV DEF RBRVS 01/01/2025 479.08 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 432.9 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38520 MEDSV DEF RBRVS 01/01/2025 422.76 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 404.31 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38525 MEDSV DEF RBRVS 01/01/2025 396.12 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 521.6 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38530 MEDSV DEF RBRVS 01/01/2025 511.75 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38531 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.95 Description: OPEN BX/EXC INGUINOFEM NODES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 38531 MEDSV DEF RBRVS 01/01/2025 402.2 Description: OPEN BX/EXC INGUINOFEM NODES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 38542 MEDSV DEF RBRVS 01/01/2024 12/31/2024 488.7 Description: EXPLORE DEEP NODE(S) NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38542 MEDSV DEF RBRVS 01/01/2025 477.72 Description: EXPLORE DEEP NODE(S) NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 479.35 Description: REMOVAL NECK/ARMPIT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38550 MEDSV DEF RBRVS 01/01/2025 470.03 Description: REMOVAL NECK/ARMPIT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 937.63 Description: REMOVAL NECK/ARMPIT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38555 MEDSV DEF RBRVS 01/01/2025 915.62 Description: REMOVAL NECK/ARMPIT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38562 MEDSV DEF RBRVS 01/01/2024 12/31/2024 655.28 Description: REMOVAL PELVIC LYMPH NODES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 38562 MEDSV DEF RBRVS 01/01/2025 642.36 Description: REMOVAL PELVIC LYMPH NODES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 38564 MEDSV DEF RBRVS 01/01/2024 12/31/2024 645.33 Description: REMOVAL ABDOMEN LYMPH NODES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 38564 MEDSV DEF RBRVS 01/01/2025 629.67 Description: REMOVAL ABDOMEN LYMPH NODES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 38570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 478.06 0-1 Description: LAPAROSCOPY LYMPH NODE BIOP Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38570 MEDSV DEF RBRVS 01/01/2025 469.22 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38571 MEDSV DEF RBRVS 01/01/2024 12/31/2024 617.9 0-1 Description: LAPAROSCOPY LYMPHADENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38571 MEDSV DEF RBRVS 01/01/2025 605.19 0-1 Description: LAPAROSCOPY LYMPHADENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38572 MEDSV DEF RBRVS 01/01/2024 12/31/2024 842.21 0-1 Description: LAPAROSCOPY LYMPHADENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38572 MEDSV DEF RBRVS 01/01/2025 817.36 0-1 Description: LAPAROSCOPY LYMPHADENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38573 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1090.7 Description: LAPS PELVIC LYMPHADEC Category: Medical Services CMS Add: 01/01/2018 CMS Term: 38573 MEDSV DEF RBRVS 01/01/2025 1068.6 Description: LAPS PELVIC LYMPHADEC Category: Medical Services CMS Add: 01/01/2018 CMS Term: 38589 MEDSV DEF BILL20 01/01/2014 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 12/31/2024 758.24 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38700 MEDSV DEF RBRVS 01/01/2025 738.1 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1249.59 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38720 MEDSV DEF RBRVS 01/01/2025 1221.23 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38724 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1359.34 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38724 MEDSV DEF RBRVS 01/01/2025 1324.09 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 642.62 Description: REMOVE ARMPIT LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38740 MEDSV DEF RBRVS 01/01/2025 629.01 Description: REMOVE ARMPIT LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38745 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38745 MEDSV DEF RBRVS 01/01/2025 789.29 Description: REMOVE ARMPIT LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38746 MEDSV DEF RBRVS 01/01/2024 12/31/2024 191.35 Description: REMOVE THORACIC LYMPH NODES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38746 MEDSV DEF RBRVS 01/01/2025 185.97 Description: REMOVE THORACIC LYMPH NODES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38747 MEDSV DEF RBRVS 01/01/2024 12/31/2024 240.83 Description: REMOVE ABDOMINAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38747 MEDSV DEF RBRVS 01/01/2025 234.54 Description: REMOVE ABDOMINAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 771.05 Description: REMOVE GROIN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38760 MEDSV DEF RBRVS 01/01/2025 754.18 Description: REMOVE GROIN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38765 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1205.01 Description: REMOVE GROIN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38765 MEDSV DEF RBRVS 01/01/2025 1175.1 Description: REMOVE GROIN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 748.88 Description: REMOVE PELVIS LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38770 MEDSV DEF RBRVS 01/01/2025 735.43 Description: REMOVE PELVIS LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 963.66 Description: REMOVE ABDOMEN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38780 MEDSV DEF RBRVS 01/01/2025 949.48 Description: REMOVE ABDOMEN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38790 MEDSV DEF RBRVS 01/01/2024 12/31/2024 75.95 Description: INJECT FOR LYMPHATIC X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38790 MEDSV DEF RBRVS 01/01/2025 74.1 Description: INJECT FOR LYMPHATIC X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38792 MEDSV DEF RBRVS 01/01/2024 12/31/2024 77.03 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38792 MEDSV DEF RBRVS 01/01/2025 75.09 Description: RA TRACER ID OF SENTINL NODE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 38794 MEDSV DEF RBRVS 01/01/2024 12/31/2024 262.32 Description: ACCESS THORACIC LYMPH DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38794 MEDSV DEF RBRVS 01/01/2025 257.03 Description: ACCESS THORACIC LYMPH DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 124.31 Description: IO MAP OF SENT LYMPH NODE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 38900 MEDSV DEF RBRVS 01/01/2025 121.42 Description: IO MAP OF SENT LYMPH NODE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 38999 MEDSV DEF BILL20 10/15/2020 Y Description: UNLISTD PX HEMIC/LYMPHTC SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 442.02 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39000 MEDSV DEF RBRVS 01/01/2025 452.39 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 713.71 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39010 MEDSV DEF RBRVS 01/01/2025 696.75 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 784.03 Description: RESECT MEDIASTINAL CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39200 MEDSV DEF RBRVS 01/01/2025 764.22 Description: RESECT MEDIASTINAL CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1030.56 Description: RESECT MEDIASTINAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39220 MEDSV DEF RBRVS 01/01/2025 1003.68 Description: RESECT MEDIASTINAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39401 MEDSV DEF RBRVS 01/01/2024 12/31/2024 277.19 Description: MEDIASTINOSCPY W/MEDSTNL BX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 39401 MEDSV DEF RBRVS 01/01/2025 270.47 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 39402 MEDSV DEF RBRVS 01/01/2024 12/31/2024 361.66 Description: MEDIASTINOSCPY W/LMPH NOD BX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 39402 MEDSV DEF RBRVS 01/01/2025 352.29 Description: MEDIASTINOSCPY W/LMPH NOD BX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 39499 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX MEDIASTINUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 774.56 Description: REPAIR DIAPHRAGM LACERATION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 39501 MEDSV DEF RBRVS 01/01/2025 759.13 Description: REPAIR DIAPHRAGM LACERATION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 39503 MEDSV DEF RBRVS 01/01/2024 12/31/2024 5207.54 0-28Days Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39503 MEDSV DEF RBRVS 01/01/2025 5055.04 0-28Days Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 786.84 Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39540 MEDSV DEF RBRVS 01/01/2025 769.85 Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39541 MEDSV DEF RBRVS 01/01/2024 12/31/2024 848.79 Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39541 MEDSV DEF RBRVS 01/01/2025 826.55 Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 811.39 Description: REVISION OF DIAPHRAGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39545 MEDSV DEF RBRVS 01/01/2025 791.13 Description: REVISION OF DIAPHRAGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 733.88 0-1 Description: RESECT DIAPHRAGM SIMPLE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 39560 MEDSV DEF RBRVS 01/01/2025 717.79 0-1 Description: RESECT DIAPHRAGM SIMPLE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 39561 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 39561 MEDSV DEF RBRVS 01/01/2025 1114.26 0-1 Description: RESECT DIAPHRAGM COMPLEX Category: Medical Services CMS Add: 01/01/2000 CMS Term: 39599 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX DIAPHRAGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4000F NOCOV DEF SYSMAN 01/01/2005 Y Description: TOBACCO USE TXMNT COUNSELING Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 4001F NOCOV DEF SYSMAN 01/01/2005 Y Description: TOBACCO USE TXMNT PHARMACOL Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 4003F NOCOV DEF SYSMAN 01/01/2006 Y Description: PT ED WRITE/ORAL PTS W/ HF Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4004F NOCOV DEF SYSMAN 01/01/2010 Y Description: PT TOBACCO SCREEN RCVD TLK Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 4005F NOCOV DEF SYSMAN 01/01/2007 Y Description: PHARM THX FOR OP RXD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4008F NOCOV DEF SYSMAN 01/01/2012 Y Description: BETA-BLOCKER THERAPY RXD/TKN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4010F NOCOV DEF SYSMAN 01/01/2012 Y Description: ACE/ARB THERAPY RXD/TAKEN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4011F NOCOV DEF SYSMAN 01/01/2005 Y Description: ORAL ANTIPLATELET THERAPY RX Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 4012F NOCOV DEF SYSMAN 01/01/2006 Y Description: WARFARIN THERAPY RX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4013F NOCOV DEF SYSMAN 01/01/2012 Y Description: STATIN THERAPY/CURRENTLY TKN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4014F NOCOV DEF SYSMAN 01/01/2006 Y Description: WRITTEN DISCHARGE INSTR PRVD Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4015F NOCOV DEF SYSMAN 01/01/2006 Y Description: PERSIST ASTHMA MEDICINE CTRL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4016F NOCOV DEF SYSMAN 01/01/2006 Y Description: ANTI-INFLM/ANLGSC AGENT RX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4017F NOCOV DEF SYSMAN 01/01/2006 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4018F NOCOV DEF SYSMAN 01/01/2006 Y Description: THERAPY EXERCISE JOINT RX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4019F NOCOV DEF SYSMAN 01/01/2007 Y Description: DOC RECPT COUNSL VIT D/CALC+ Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4025F NOCOV DEF SYSMAN 01/01/2007 Y Description: INHALED BRONCHODILATOR RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4030F NOCOV DEF SYSMAN 01/01/2007 Y Description: OXYGEN THERAPY RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4033F NOCOV DEF SYSMAN 01/01/2007 Y Description: PULMONARY REHAB REC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4035F NOCOV DEF SYSMAN 01/01/2007 Y Description: INFLUENZA IMM REC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4037F NOCOV DEF SYSMAN 01/01/2007 Y Description: INFLUENZA IMM ORDER/ADMIN Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4040F NOCOV DEF SYSMAN 01/01/2007 Y Description: PNEUMOC VAC/ADMIN/RCVD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4041F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC ORDER CEFAZOLIN/CEFUROX Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4042F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC ANTIBIO NOT GIVEN Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4043F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC ORDER GIVEN STOP ANTIBIO Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4044F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC ORDER GIVEN VTE PROPHYLX Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4045F NOCOV DEF SYSMAN 01/01/2007 Y Description: EMPIRIC ANTIBIOTIC RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4046F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC ANTIBIO GIVEN B/4 SURG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4047F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC ANTIBIO GIVEN B/4 SURG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4048F NOCOV DEF SYSMAN 01/01/2008 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40490 MEDSV DEF RBRVS 01/01/2024 12/31/2024 115.51 Description: BIOPSY OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40490 MEDSV DEF RBRVS 01/01/2025 112.36 Description: BIOPSY OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4049F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC ORDER GIVEN STOP ANTIBIO Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 40500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 495.46 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40500 MEDSV DEF RBRVS 01/01/2025 486.02 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4050F NOCOV DEF SYSMAN 01/01/2007 Y Description: HT CARE PLAN DOC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 40510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 459.67 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40510 MEDSV DEF RBRVS 01/01/2025 449.09 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4051F NOCOV DEF SYSMAN 01/01/2007 Y Description: REFERRED FOR AN AV FISTULA Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 40520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 474.29 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40520 MEDSV DEF RBRVS 01/01/2025 460.52 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 516.47 Description: RECONSTRUCT LIP WITH FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40525 MEDSV DEF RBRVS 01/01/2025 505.69 Description: RECONSTRUCT LIP WITH FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40527 MEDSV DEF RBRVS 01/01/2024 12/31/2024 591.15 Description: RECONSTRUCT LIP WITH FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40527 MEDSV DEF RBRVS 01/01/2025 577.96 Description: RECONSTRUCT LIP WITH FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4052F NOCOV DEF SYSMAN 01/01/2007 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 524.64 Description: PARTIAL REMOVAL OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40530 MEDSV DEF RBRVS 01/01/2025 510.12 Description: PARTIAL REMOVAL OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4053F NOCOV DEF SYSMAN 01/01/2007 Y Description: HEMODIALYSIS VIA AV GRAFT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4054F NOCOV DEF SYSMAN 01/01/2007 Y Description: HEMODIALYSIS VIA CATHETER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4055F NOCOV DEF SYSMAN 01/01/2007 Y Description: PT RCVNG PERITON DIALYSIS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4056F NOCOV DEF SYSMAN 01/01/2007 Y Description: APPROP ORAL REHYD RECOMMD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4058F NOCOV DEF SYSMAN 01/01/2007 Y Description: PED GASTRO ED GIVEN CAREGVR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4060F NOCOV DEF SYSMAN 01/01/2007 Y Description: PSYCH SVCS PROVIDED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4062F NOCOV DEF SYSMAN 01/01/2007 Y Description: PT REFERRAL PSYCH DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4063F NOCOV DEF SYSMAN 01/01/2010 Y Description: ANTIDEPRES RXTHXPY NOT RXD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 4064F NOCOV DEF SYSMAN 01/01/2007 Y Description: ANTIDEPRESSANT RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 40650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 448.56 Description: RPR LIP FTH VERMILION ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40650 MEDSV DEF RBRVS 01/01/2025 439.24 Description: RPR LIP FTH VERMILION ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40652 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40654 MEDSV DEF RBRVS 01/01/2025 537.26 Description: RPR LIP FTH>1HALF VER HT/CPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4065F NOCOV DEF SYSMAN 01/01/2007 Y Description: ANTIPSYCHOTIC RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4066F NOCOV DEF SYSMAN 01/01/2007 Y Description: ECT PROVIDED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4067F NOCOV DEF SYSMAN 01/01/2007 Y Description: PT REFERRAL FOR ECT DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4069F NOCOV DEF SYSMAN 01/01/2012 Y Description: VTE PROPHYLAXIS RCVD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 40700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 935.52 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40700 MEDSV DEF RBRVS 01/01/2025 913.16 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40701 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1104.41 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40701 MEDSV DEF RBRVS 01/01/2025 1076.45 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 927.65 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40702 MEDSV DEF RBRVS 01/01/2025 904.98 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4070F NOCOV DEF SYSMAN 01/01/2008 Y Description: DVT PROPHYLX RECVD DAY 2 Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 40720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 952.69 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40720 MEDSV DEF RBRVS 01/01/2025 928.67 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4073F NOCOV DEF SYSMAN 01/01/2008 Y Description: ORAL ANTIPLAT THX RX DISCHRG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4075F NOCOV DEF SYSMAN 01/01/2008 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40761 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1001.11 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40761 MEDSV DEF RBRVS 01/01/2025 974.86 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4077F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC T-PA ADMIN CONSIDERED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 40799 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PROCEDURE LIPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4079F NOCOV DEF SYSMAN 01/01/2008 Y Description: DOC REHAB SVCS CONSIDERED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 40800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 189.63 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40800 MEDSV DEF RBRVS 01/01/2025 184.84 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40801 MEDSV DEF RBRVS 01/01/2024 12/31/2024 272.67 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40801 MEDSV DEF RBRVS 01/01/2025 267.62 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40804 MEDSV DEF RBRVS 01/01/2024 12/31/2024 175.21 Description: REMOVAL FOREIGN BODY MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40804 MEDSV DEF RBRVS 01/01/2025 173.26 Description: REMOVAL FOREIGN BODY MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 267.6 Description: REMOVAL FOREIGN BODY MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40805 MEDSV DEF RBRVS 01/01/2025 261.53 Description: REMOVAL FOREIGN BODY MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40806 MEDSV DEF RBRVS 01/01/2024 12/31/2024 92.65 Y Description: INCISION OF LIP FOLD Category: Medical Services CMS Add: 01/01/1985 CMS Term: 40806 MEDSV DEF RBRVS 01/01/2025 90.65 Y Description: INCISION OF LIP FOLD Category: Medical Services CMS Add: 01/01/1985 CMS Term: 40808 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40808 MEDSV DEF RBRVS 01/01/2025 154.79 Description: BIOPSY OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 203.65 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40810 MEDSV DEF RBRVS 01/01/2025 198.18 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40812 MEDSV DEF RBRVS 01/01/2024 12/31/2024 264.79 Description: EXCISE/REPAIR MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40812 MEDSV DEF RBRVS 01/01/2025 253.82 Description: EXCISE/REPAIR MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40814 MEDSV DEF RBRVS 01/01/2024 12/31/2024 351.69 Description: EXCISE/REPAIR MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40814 MEDSV DEF RBRVS 01/01/2025 340.49 Description: EXCISE/REPAIR MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40816 MEDSV DEF RBRVS 01/01/2024 12/31/2024 378.1 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40816 MEDSV DEF RBRVS 01/01/2025 370.02 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40818 MEDSV DEF RBRVS 01/01/2024 12/31/2024 344.64 Description: EXCISE ORAL MUCOSA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40818 MEDSV DEF RBRVS 01/01/2025 332.5 Description: EXCISE ORAL MUCOSA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40819 MEDSV DEF RBRVS 01/01/2024 12/31/2024 253.3 Y Description: EXCISE LIP OR CHEEK FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40819 MEDSV DEF RBRVS 01/01/2025 248.12 Y Description: EXCISE LIP OR CHEEK FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 242.46 Description: TREATMENT OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40820 MEDSV DEF RBRVS 01/01/2025 236.6 Description: TREATMENT OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40830 MEDSV DEF RBRVS 01/01/2025 204.82 Description: REPAIR MOUTH LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40831 MEDSV DEF RBRVS 01/01/2024 12/31/2024 279.15 Description: REPAIR MOUTH LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40831 MEDSV DEF RBRVS 01/01/2025 269.6 Description: REPAIR MOUTH LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 811.87 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40840 MEDSV DEF RBRVS 01/01/2025 790.39 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40842 MEDSV DEF RBRVS 01/01/2024 12/31/2024 868.54 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40842 MEDSV DEF RBRVS 01/01/2025 846.32 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40843 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1118.74 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40843 MEDSV DEF RBRVS 01/01/2025 1089.06 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40844 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1402.82 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40844 MEDSV DEF RBRVS 01/01/2025 1366.93 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1391.19 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40845 MEDSV DEF RBRVS 01/01/2025 1354.3 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4084F NOCOV DEF SYSMAN 01/01/2008 Y Description: ASPIRIN RECVD W/IN 24 HRS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4086F NOCOV DEF SYSMAN 01/01/2012 Y Description: ASPIRIN/CLOPIDOGREL RXD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 40899 MEDSV DEF BILL20 10/15/2020 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4090F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT RCVNG EPO THXPY Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4095F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT NOT RCVNG EPO THXPY Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 41000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138.48 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41000 MEDSV DEF RBRVS 01/01/2025 133.23 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 224.64 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41005 MEDSV DEF RBRVS 01/01/2025 208.15 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41006 MEDSV DEF RBRVS 01/01/2024 12/31/2024 320.55 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41006 MEDSV DEF RBRVS 01/01/2025 311 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41007 MEDSV DEF RBRVS 01/01/2024 12/31/2024 308.99 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41007 MEDSV DEF RBRVS 01/01/2025 301.71 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41008 MEDSV DEF RBRVS 01/01/2024 12/31/2024 367.88 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41008 MEDSV DEF RBRVS 01/01/2025 359.67 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41009 MEDSV DEF RBRVS 01/01/2024 12/31/2024 397.81 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41009 MEDSV DEF RBRVS 01/01/2025 388.1 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4100F NOCOV DEF SYSMAN 01/01/2008 Y Description: BIPHOS THXPY VEIN ORD/RECVD Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 41010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 204.28 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41010 MEDSV DEF RBRVS 01/01/2025 197.39 Y Description: INCISION OF TONGUE FOLD Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 375.44 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41015 MEDSV DEF RBRVS 01/01/2025 366.68 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41016 MEDSV DEF RBRVS 01/01/2024 12/31/2024 439.57 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41016 MEDSV DEF RBRVS 01/01/2025 426.03 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41017 MEDSV DEF RBRVS 01/01/2024 12/31/2024 439.57 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41017 MEDSV DEF RBRVS 01/01/2025 426.02 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41018 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.93 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41018 MEDSV DEF RBRVS 01/01/2025 480.38 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41019 MEDSV DEF RBRVS 01/01/2024 12/31/2024 464.1 Description: PLACE NEEDLES H&N FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 41019 MEDSV DEF RBRVS 01/01/2025 451.99 Description: PLACE NEEDLES H&N FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 41100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 176.21 Description: BIOPSY OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41100 MEDSV DEF RBRVS 01/01/2025 171.48 Description: BIOPSY OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 176.36 Description: BIOPSY OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41105 MEDSV DEF RBRVS 01/01/2025 172.21 Description: BIOPSY OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41108 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41108 MEDSV DEF RBRVS 01/01/2025 153.73 Description: BIOPSY OF FLOOR OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4110F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 216.32 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41110 MEDSV DEF RBRVS 01/01/2025 210.05 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 319.18 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41112 MEDSV DEF RBRVS 01/01/2025 310.32 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41113 MEDSV DEF RBRVS 01/01/2024 12/31/2024 342.66 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41113 MEDSV DEF RBRVS 01/01/2025 331.59 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41114 MEDSV DEF RBRVS 01/01/2024 12/31/2024 584.04 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41114 MEDSV DEF RBRVS 01/01/2025 569.67 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.21 Y Description: EXCISION OF TONGUE FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41115 MEDSV DEF RBRVS 01/01/2025 238.59 Y Description: EXCISION OF TONGUE FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41116 MEDSV DEF RBRVS 01/01/2024 12/31/2024 314.69 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41116 MEDSV DEF RBRVS 01/01/2025 305.28 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 993.97 Description: PARTIAL REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41120 MEDSV DEF RBRVS 01/01/2025 962.16 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1228.73 Description: PARTIAL REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41130 MEDSV DEF RBRVS 01/01/2025 1190.47 Description: PARTIAL REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2025.92 Description: TONGUE AND NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41135 MEDSV DEF RBRVS 01/01/2025 1964.48 Description: TONGUE AND NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2041.71 Description: REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41140 MEDSV DEF RBRVS 01/01/2025 1978.41 Description: REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2572.52 Description: TONGUE REMOVAL NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41145 MEDSV DEF RBRVS 01/01/2025 2491.38 Description: TONGUE REMOVAL NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2055.05 Description: TONGUE MOUTH JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41150 MEDSV DEF RBRVS 01/01/2025 1992.73 Description: TONGUE MOUTH JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41153 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2230.38 Description: TONGUE MOUTH NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41153 MEDSV DEF RBRVS 01/01/2025 2168.42 Description: TONGUE MOUTH NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2797.88 Description: TONGUE JAW & NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41155 MEDSV DEF RBRVS 01/01/2025 2705.01 Description: TONGUE JAW & NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4115F NOCOV DEF SYSMAN 01/01/2008 Y Description: BETA BLCKR ADMIN W/IN 24 HRS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4120F NOCOV DEF SYSMAN 01/01/2008 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4124F NOCOV DEF SYSMAN 01/01/2008 Y Description: ANTIBIOT NOT RXD/GIVEN Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 41250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 265.94 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41250 MEDSV DEF RBRVS 01/01/2025 257.09 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41251 MEDSV DEF RBRVS 01/01/2024 12/31/2024 294.58 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41251 MEDSV DEF RBRVS 01/01/2025 283.61 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41252 MEDSV DEF RBRVS 01/01/2024 12/31/2024 308.11 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41252 MEDSV DEF RBRVS 01/01/2025 297.03 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4130F NOCOV DEF SYSMAN 01/01/2008 Y Description: TOPICAL PREP RX AOE Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4131F NOCOV DEF SYSMAN 01/01/2008 Y Description: SYST ANTIMICROBIAL THX RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4132F NOCOV DEF SYSMAN 01/01/2008 Y Description: NO SYST ANTIMICROBIAL THX RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4133F NOCOV DEF SYSMAN 01/01/2008 Y Description: ANTIHIST/DECONG RX/RECOM Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4134F NOCOV DEF SYSMAN 01/01/2008 Y Description: NO ANTIHIST/DECONG RX/RECOM Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4135F NOCOV DEF SYSMAN 01/01/2008 Y Description: SYSTEMIC CORTICOSTEROIDS RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4136F NOCOV DEF SYSMAN 01/01/2008 Y Description: SYST CORTICOSTEROIDS NOT RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4140F NOCOV DEF SYSMAN 01/01/2012 Y Description: INHALED CORTICOSTEROIDS RXD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4142F NOCOV DEF SYSMAN 01/01/2012 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4144F NOCOV DEF SYSMAN 01/01/2012 Y Description: ALT LONG-TERM CNTRL MED RXD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4145F NOCOV DEF SYSMAN 01/01/2012 Y Description: 2+ ANTI-HYPRTNSV AGENTS TKN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4148F NOCOV DEF SYSMAN 01/01/2009 Y Description: HEP A VAC INJXN ADMIN/RECVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4149F NOCOV DEF SYSMAN 01/01/2009 Y Description: HEP B VAC INJXN ADMIN/RECVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4150F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT RECVNG ANTIVIR TXMNT HEPC Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 41510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 427.06 Description: TONGUE TO LIP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41510 MEDSV DEF RBRVS 01/01/2025 414.51 Description: TONGUE TO LIP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 626.56 Description: TONGUE SUSPENSION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 41512 MEDSV DEF RBRVS 01/01/2025 607.33 Description: TONGUE SUSPENSION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 4151F NOCOV DEF SYSMAN 07/01/2016 Y 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 12/31/2024 344.68 Description: RECONSTRUCTION TONGUE FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41520 MEDSV DEF RBRVS 01/01/2025 335.41 Description: RECONSTRUCTION TONGUE FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 861.52 Description: TONGUE BASE VOL REDUCTION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 41530 MEDSV DEF RBRVS 01/01/2025 826.87 Description: TONGUE BASE VOL REDUCTION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 4153F NOCOV DEF SYSMAN 01/01/2008 Y Description: COMBO PEGINTF/RIB RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4155F NOCOV DEF SYSMAN 01/01/2008 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4157F NOCOV DEF SYSMAN 01/01/2008 Y Description: HEP B VAC SERIES PREV RECVD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4158F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT EDU RE ALCOH DRNKNG DONE Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 41599 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX TONGUE FLR MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4159F NOCOV DEF SYSMAN 01/01/2008 Y Description: CONTRCP TALK B/4 ANTIV TXMNT Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4163F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT COUNS 4 TXMNT OPT PROST Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4164F NOCOV DEF SYSMAN 01/01/2008 Y Description: ADJV HRMNL THXPY RXD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4165F NOCOV DEF SYSMAN 01/01/2008 Y Description: 3D-CRT/IMRT RECEIVED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4167F NOCOV DEF SYSMAN 01/01/2008 Y Description: HD BED TILTED 1ST DAY VENT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4168F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT CARE ICU&VENT W/IN 24HRS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4169F NOCOV DEF SYSMAN 01/01/2008 Y Description: NO PT CARE ICU/VENT IN 24HRS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4171F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT RCVNG ESA THXPY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4172F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT NOT RCVNG ESA THXPY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4174F NOCOV DEF SYSMAN 01/01/2008 Y Description: COUNS POTENT GLAUC IMPCT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4175F NOCOV DEF SYSMAN 01/01/2008 Y Description: VIS 20/40/> W/IN 90 DAYS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4176F NOCOV DEF SYSMAN 01/01/2008 Y Description: TALK RE UV LIGHT PT/CRGVR Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4177F NOCOV DEF SYSMAN 01/01/2008 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4178F NOCOV DEF SYSMAN 01/01/2008 Y Description: ANTID GLBLN RCVD W/IN 26WKS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4179F NOCOV DEF SYSMAN 01/01/2008 Y Description: TAMOXIFEN/AI PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 271.94 Description: DRAINAGE OF GUM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41800 MEDSV DEF RBRVS 01/01/2025 264.56 Description: DRAINAGE OF GUM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 291.55 Description: REMOVAL FOREIGN BODY GUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41805 MEDSV DEF RBRVS 01/01/2025 279.77 Description: REMOVAL FOREIGN BODY GUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41806 MEDSV DEF RBRVS 01/01/2024 12/31/2024 386.3 Description: REMOVAL FOREIGN BODY JAWBONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41806 MEDSV DEF RBRVS 01/01/2025 372.5 Description: REMOVAL FOREIGN BODY JAWBONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4180F NOCOV DEF SYSMAN 01/01/2008 Y Description: ADJV THXPYRXD/RCVD COLON CA Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4181F NOCOV DEF SYSMAN 01/01/2008 Y Description: CONFORMAL RADN THXPY RCVD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41820 MEDSV PRF MAXFEE 01/01/2024 12/31/2024 10.65 0 Description: EXCISION GUM EACH QUADRANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41820 MEDSV PRF MAXFEE 01/01/2025 10.44 0 Description: EXCISION GUM EACH QUADRANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41821 MEDSV DEF BILL20 01/01/2014 Description: EXCISION OF GUM FLAP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41822 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.4 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41822 MEDSV DEF RBRVS 01/01/2025 322.29 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41823 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41823 MEDSV DEF RBRVS 01/01/2025 481.75 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 207.03 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41825 MEDSV DEF RBRVS 01/01/2025 201.77 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41826 MEDSV DEF RBRVS 01/01/2024 12/31/2024 284.81 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41826 MEDSV DEF RBRVS 01/01/2025 273.22 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41827 MEDSV DEF RBRVS 01/01/2024 12/31/2024 405.44 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41827 MEDSV DEF RBRVS 01/01/2025 395.94 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41828 MEDSV DEF RBRVS 01/01/2024 12/31/2024 329.05 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41828 MEDSV DEF RBRVS 01/01/2025 320.48 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 4182F NOCOV DEF SYSMAN 01/01/2008 Y Description: NO CONFORMAL RADN THXPY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 438.39 Description: REMOVAL OF GUM TISSUE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41830 MEDSV DEF RBRVS 01/01/2025 425.78 Description: REMOVAL OF GUM TISSUE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41850 MEDSV DEF BILL20 01/01/2014 Description: TREATMENT OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 4185F NOCOV DEF SYSMAN 01/01/2008 Y Description: CONTINUOUS PPI OR H2RA RCVD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4186F NOCOV DEF SYSMAN 01/01/2008 Y Description: NO CONT PPI OR H2RA RCVD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41870 MEDSV DEF BILL20 01/01/2014 Description: PERIODONTAL MUCOSAL GRAFTING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41872 MEDSV DEF RBRVS 01/01/2024 12/31/2024 439.01 Description: GINGIVOPLASTY EACH QUADRANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41872 MEDSV DEF RBRVS 01/01/2025 428.82 Description: GINGIVOPLASTY EACH QUADRANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41874 MEDSV DEF RBRVS 01/01/2024 12/31/2024 357.76 Description: ALVEOLOPLASTY EACH QUADRANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41874 MEDSV DEF RBRVS 01/01/2025 351.23 Description: ALVEOLOPLASTY EACH QUADRANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4187F NOCOV DEF SYSMAN 01/01/2008 Y Description: ANTI RHEUM DRUGTHXPYRXD/GVN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4188F NOCOV DEF SYSMAN 01/01/2008 Y Description: APPROP ACE/ARB TSTNG DONE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41899 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX DENTALVLR STRUX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4189F NOCOV DEF SYSMAN 01/01/2008 Y Description: APPROP DIGOXIN TSTNG DONE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4190F NOCOV DEF SYSMAN 01/01/2008 Y Description: APPROP DIURETIC TSTNG DONE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4191F NOCOV DEF SYSMAN 01/01/2008 Y Description: APPROP ANTICONVULS TSTNG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4192F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT NOT RCVNG GLUCOCO THXPY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4193F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT RCV <10MG DAILY PREDNISO Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4194F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT RCV >=10MG DAILY PREDNISO Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4195F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT RCVNG ANTI-RHEUM THXPY RA Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4196F NOCOV DEF SYSMAN 01/01/2009 Y Description: PTNOT RCVNG ANTI-RHM THXPYRA Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 151.4 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42000 MEDSV DEF RBRVS 01/01/2025 147.27 Description: DRAINAGE MOUTH ROOF LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4200F NOCOV DEF SYSMAN 01/01/2008 Y Description: EXTERNAL BEAM TO PROST ONLY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4201F NOCOV DEF SYSMAN 01/01/2008 Y Description: EXTRNL BEAM OTHER THAN PROST Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 137.89 Description: BIOPSY ROOF OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42100 MEDSV DEF RBRVS 01/01/2025 134.04 Description: BIOPSY ROOF OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42104 MEDSV DEF RBRVS 01/01/2024 12/31/2024 204.36 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42104 MEDSV DEF RBRVS 01/01/2025 199.07 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42106 MEDSV DEF RBRVS 01/01/2024 12/31/2024 239.26 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42106 MEDSV DEF RBRVS 01/01/2025 229.69 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 426.71 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42107 MEDSV DEF RBRVS 01/01/2025 407.69 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4210F NOCOV DEF SYSMAN 01/01/2008 Y Description: ACE/ARB THXPY FOR MOS/> Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 942.48 Description: REMOVE PALATE/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42120 MEDSV DEF RBRVS 01/01/2025 913.5 Description: REMOVE PALATE/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 292.86 Description: EXCISION OF UVULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42140 MEDSV DEF RBRVS 01/01/2025 284.09 Description: EXCISION OF UVULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 647.83 Description: REPAIR PALATE PHARYNX/UVULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: 42145 MEDSV DEF RBRVS 01/01/2025 632.03 Description: REPAIR PALATE PHARYNX/UVULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: 42160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.29 Description: TREATMENT MOUTH ROOF LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42160 MEDSV DEF RBRVS 01/01/2025 207.19 Description: TREATMENT MOUTH ROOF LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 241.01 Description: REPAIR LAC PALATE<2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42180 MEDSV DEF RBRVS 01/01/2025 233.68 Description: REPAIR LAC PALATE<2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42182 MEDSV DEF RBRVS 01/01/2024 12/31/2024 311.64 Description: REPAIR PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42182 MEDSV DEF RBRVS 01/01/2025 302.56 Description: REPAIR PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 862.16 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42200 MEDSV DEF RBRVS 01/01/2025 839.44 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 896.72 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42205 MEDSV DEF RBRVS 01/01/2025 872.69 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4220F NOCOV DEF SYSMAN 01/01/2008 Y Description: DIGOXIN THXPY FOR 6 MOS/> Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1000.89 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42210 MEDSV DEF RBRVS 01/01/2025 974.19 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 654.09 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42215 MEDSV DEF RBRVS 01/01/2025 637.73 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 4221F NOCOV DEF SYSMAN 01/01/2008 Y Description: DIURETIC THXPY FOR 6 MOS/> Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 538.77 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42220 MEDSV DEF RBRVS 01/01/2025 525.92 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 916.16 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42225 MEDSV DEF RBRVS 01/01/2025 889.35 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42226 MEDSV DEF RBRVS 01/01/2024 12/31/2024 851.82 Description: LENGTHENING OF PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42226 MEDSV DEF RBRVS 01/01/2025 827.97 Description: LENGTHENING OF PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42227 MEDSV DEF RBRVS 01/01/2024 12/31/2024 793.76 Description: LENGTHENING OF PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42227 MEDSV DEF RBRVS 01/01/2025 771.67 Description: LENGTHENING OF PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 697.74 Description: REPAIR PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42235 MEDSV DEF RBRVS 01/01/2025 678.93 Description: REPAIR PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 810.82 Description: REPAIR NOSE TO LIP FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42260 MEDSV DEF RBRVS 01/01/2025 790.49 Description: REPAIR NOSE TO LIP FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 167.44 Description: PREPARATION PALATE MOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42280 MEDSV DEF RBRVS 01/01/2025 161.78 Description: PREPARATION PALATE MOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42281 MEDSV DEF RBRVS 01/01/2024 12/31/2024 212.16 Description: INSERTION PALATE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42281 MEDSV DEF RBRVS 01/01/2025 205.68 Description: INSERTION PALATE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42299 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX PALATE UVULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 203.28 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42300 MEDSV DEF RBRVS 01/01/2025 197.45 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 399.15 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42305 MEDSV DEF RBRVS 01/01/2025 399.35 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4230F NOCOV DEF SYSMAN 01/01/2008 Y Description: ANTICONV THXPY FOR 6 MOS/> Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 161.8 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42310 MEDSV DEF RBRVS 01/01/2025 157.16 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.57 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42320 MEDSV DEF RBRVS 01/01/2025 239.32 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 220.33 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42330 MEDSV DEF RBRVS 01/01/2025 214.94 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 407.44 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42335 MEDSV DEF RBRVS 01/01/2025 397.03 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 502.6 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42340 MEDSV DEF RBRVS 01/01/2025 488.85 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 91.31 Description: BIOPSY OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42400 MEDSV DEF RBRVS 01/01/2025 87.49 Description: BIOPSY OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 286.67 Description: BIOPSY OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42405 MEDSV DEF RBRVS 01/01/2025 279.86 Description: BIOPSY OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42408 MEDSV DEF RBRVS 01/01/2024 12/31/2024 513.55 Description: EXCISION OF SALIVARY CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42408 MEDSV DEF RBRVS 01/01/2025 496.67 Description: EXCISION OF SALIVARY CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42409 MEDSV DEF RBRVS 01/01/2024 12/31/2024 373.03 Description: DRAINAGE OF SALIVARY CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42409 MEDSV DEF RBRVS 01/01/2025 362.19 Description: DRAINAGE OF SALIVARY CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4240F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 591.71 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42410 MEDSV DEF RBRVS 01/01/2025 577.81 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 994.67 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42415 MEDSV DEF RBRVS 01/01/2025 970.12 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1114.41 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42420 MEDSV DEF RBRVS 01/01/2025 1085.41 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 789.81 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42425 MEDSV DEF RBRVS 01/01/2025 769.34 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42426 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1265.61 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42426 MEDSV DEF RBRVS 01/01/2025 1232.27 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4242F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 391.73 Description: EXCISE SUBMAXILLARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42440 MEDSV DEF RBRVS 01/01/2025 383.22 Description: EXCISE SUBMAXILLARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 444.32 Description: EXCISE SUBLINGUAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42450 MEDSV DEF RBRVS 01/01/2025 434.27 Description: EXCISE SUBLINGUAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4245F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT INSTR NRML ACTIVITIES Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 4248F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 424.46 Description: REPAIR SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42500 MEDSV DEF RBRVS 01/01/2025 413.15 Description: REPAIR SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 542.14 Description: REPAIR SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42505 MEDSV DEF RBRVS 01/01/2025 529.33 Description: REPAIR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42507 MEDSV DEF RBRVS 01/01/2024 12/31/2024 466.61 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42507 MEDSV DEF RBRVS 01/01/2025 455.05 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42509 MEDSV DEF RBRVS 01/01/2024 12/31/2024 770.84 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42509 MEDSV DEF RBRVS 01/01/2025 750.06 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4250F NOCOV DEF SYSMAN 01/01/2009 Y Description: WRMNG 4 SURG NORMOTHERMIA Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 42510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 572.85 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42510 MEDSV DEF RBRVS 01/01/2025 558.46 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 146.93 Description: INJECTION FOR SALIVARY X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42550 MEDSV DEF RBRVS 01/01/2025 140.19 Description: INJECTION FOR SALIVARY X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4255F NOCOV DEF SYSMAN 01/01/2010 Y Description: ANESTH 60 MIN/> AS DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 4256F NOCOV DEF SYSMAN 01/01/2010 Y Description: ANESTHE <60 MIN AS DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 42600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 515.02 Description: CLOSURE OF SALIVARY FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42600 MEDSV DEF RBRVS 01/01/2025 500.75 Description: CLOSURE OF SALIVARY FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4260F NOCOV DEF SYSMAN 01/01/2009 Y Description: WOUND SRFC CULTURETECH USED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4261F NOCOV DEF SYSMAN 01/01/2009 Y Description: TECH OTHER THAN SURFC CULTR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 70.16 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42650 MEDSV DEF RBRVS 01/01/2025 68.32 Description: DILATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4265F NOCOV DEF SYSMAN 01/01/2009 Y Description: WET-DRY DRESSINGS RX RECMD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 107.49 Description: DILATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42660 MEDSV DEF RBRVS 01/01/2025 100.76 Description: DILATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 354.71 Description: LIGATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42665 MEDSV DEF RBRVS 01/01/2025 344.7 Description: LIGATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4266F NOCOV DEF SYSMAN 01/01/2009 Y Description: NO WET-DRY DRSSINGS RX RECMD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4267F NOCOV DEF SYSMAN 01/01/2009 Y Description: COMPRSSION THXPY PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4268F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT ED RE COMP THXPY RCVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42699 MEDSV DEF BILL20 10/15/2020 Y Description: UNLISTED PX SALIVRY GLND/DUX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4269F NOCOV DEF SYSMAN 01/01/2009 Y Description: APPROPOS MTHD OFFLOADING RXD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 181.32 Description: DRAINAGE OF TONSIL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42700 MEDSV DEF RBRVS 01/01/2025 176.39 Description: DRAINAGE OF TONSIL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4270F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT RCVNG ANTI R-VIRAL THXPY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4271F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 421.54 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42720 MEDSV DEF RBRVS 01/01/2025 410.36 Description: DRAINAGE OF THROAT ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 747.57 Description: DRAINAGE OF THROAT ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42725 MEDSV DEF RBRVS 01/01/2025 731.63 Description: DRAINAGE OF THROAT ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4274F NOCOV DEF SYSMAN 01/01/2009 Y Description: FLU IMMUNO ADMIND RCVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4276F NOCOV DEF SYSMAN 01/01/2007 Y Description: POTENT ANTIVIR THXPY RXD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4279F NOCOV DEF SYSMAN 01/01/2009 Y Description: PCP PROPHYLAXIS RXD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 148.95 Description: BIOPSY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42800 MEDSV DEF RBRVS 01/01/2025 145.59 Description: BIOPSY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42804 MEDSV DEF RBRVS 01/01/2024 12/31/2024 202.67 Description: BIOPSY OF UPPER NOSE/THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42804 MEDSV DEF RBRVS 01/01/2025 197.72 Description: BIOPSY OF UPPER NOSE/THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42806 MEDSV DEF RBRVS 01/01/2024 12/31/2024 226.26 Description: BIOPSY OF UPPER NOSE/THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42806 MEDSV DEF RBRVS 01/01/2025 220.82 Description: BIOPSY OF UPPER NOSE/THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42808 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.78 Description: EXCISE PHARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42808 MEDSV DEF RBRVS 01/01/2025 213.68 Description: EXCISE PHARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42809 MEDSV DEF RBRVS 01/01/2024 12/31/2024 191.18 Description: REMOVE PHARYNX FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42809 MEDSV DEF RBRVS 01/01/2025 189.45 Description: REMOVE PHARYNX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4280F NOCOV DEF SYSMAN 01/01/2009 Y Description: PCP PROPHYLAX RXD 3MON LOW % Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 366.91 Description: EXCISION OF NECK CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42810 MEDSV DEF RBRVS 01/01/2025 358.47 Description: EXCISION OF NECK CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42815 MEDSV DEF RBRVS 01/01/2024 12/31/2024 508.55 Description: EXCISION OF NECK CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42815 MEDSV DEF RBRVS 01/01/2025 494.58 Description: EXCISION OF NECK CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 274.44 0-11Years Description: REMOVE TONSILS AND ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42820 MEDSV DEF RBRVS 01/01/2025 269.23 0-11Years Description: REMOVE TONSILS AND ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 287.09 12-999Years Description: REMOVE TONSILS AND ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42821 MEDSV DEF RBRVS 01/01/2025 281.08 12-999Years Description: REMOVE TONSILS AND ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 253.26 0-11Years Description: REMOVAL OF TONSILS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42825 MEDSV DEF RBRVS 01/01/2025 248.46 0-11Years Description: REMOVAL OF TONSILS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42826 MEDSV DEF RBRVS 01/01/2024 12/31/2024 241.03 12-999Years Description: REMOVAL OF TONSILS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42826 MEDSV DEF RBRVS 01/01/2025 236.54 12-999Years Description: REMOVAL OF TONSILS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 200.1 0-11Years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42830 MEDSV DEF RBRVS 01/01/2025 197.12 0-11Years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42831 MEDSV DEF RBRVS 01/01/2024 12/31/2024 217.74 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42831 MEDSV DEF RBRVS 01/01/2025 214.29 12-999Years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42835 MEDSV DEF RBRVS 01/01/2024 12/31/2024 186.62 0-11Years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42835 MEDSV DEF RBRVS 01/01/2025 184.02 0-11Years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42836 MEDSV DEF RBRVS 01/01/2024 12/31/2024 231.17 12-999Years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42836 MEDSV DEF RBRVS 01/01/2025 227.12 12-999Years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42842 MEDSV DEF RBRVS 01/01/2024 12/31/2024 948.75 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42842 MEDSV DEF RBRVS 01/01/2025 921.46 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42844 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1291.67 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42844 MEDSV DEF RBRVS 01/01/2025 1254.73 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2067.13 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42845 MEDSV DEF RBRVS 01/01/2025 2002.89 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 182.82 Description: EXCISION OF TONSIL TAGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42860 MEDSV DEF RBRVS 01/01/2025 180.04 Description: EXCISION OF TONSIL TAGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42870 MEDSV DEF RBRVS 01/01/2024 12/31/2024 554.18 Description: EXCISION OF LINGUAL TONSIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42870 MEDSV DEF RBRVS 01/01/2025 537.92 Description: EXCISION OF LINGUAL TONSIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42890 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1330.34 Description: LIMITED PHARYNGECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42890 MEDSV DEF RBRVS 01/01/2025 1289.63 Description: LIMITED PHARYNGECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42892 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1747.69 Description: REVISION OF PHARYNGEAL WALLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42892 MEDSV DEF RBRVS 01/01/2025 1694.91 Description: REVISION OF PHARYNGEAL WALLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42894 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2218.34 Description: REVISION OF PHARYNGEAL WALLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42894 MEDSV DEF RBRVS 01/01/2025 2149.34 Description: REVISION OF PHARYNGEAL WALLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 311.73 Description: REPAIR THROAT WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42900 MEDSV DEF RBRVS 01/01/2025 304.39 Description: REPAIR THROAT WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4290F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT SCRNED FOR INJ DRUG USE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4293F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 749.97 Description: RECONSTRUCTION OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42950 MEDSV DEF RBRVS 01/01/2025 727.02 Description: RECONSTRUCTION OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42953 MEDSV DEF RBRVS 01/01/2024 12/31/2024 896.29 Description: REPAIR THROAT ESOPHAGUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42953 MEDSV DEF RBRVS 01/01/2025 870.45 Description: REPAIR THROAT ESOPHAGUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42955 MEDSV DEF RBRVS 01/01/2024 12/31/2024 713.49 Description: SURGICAL OPENING OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42955 MEDSV DEF RBRVS 01/01/2025 692.51 Description: SURGICAL OPENING OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42960 MEDSV DEF RBRVS 01/01/2024 12/31/2024 151.54 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42960 MEDSV DEF RBRVS 01/01/2025 147.95 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42961 MEDSV DEF RBRVS 01/01/2024 12/31/2024 395.19 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42961 MEDSV DEF RBRVS 01/01/2025 386.59 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42962 MEDSV DEF RBRVS 01/01/2024 12/31/2024 488.87 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42962 MEDSV DEF RBRVS 01/01/2025 476.08 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42970 MEDSV DEF RBRVS 01/01/2024 12/31/2024 387.62 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42970 MEDSV DEF RBRVS 01/01/2025 379.17 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42971 MEDSV DEF RBRVS 01/01/2024 12/31/2024 427.09 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42971 MEDSV DEF RBRVS 01/01/2025 417.49 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42972 MEDSV DEF RBRVS 01/01/2024 12/31/2024 477.72 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42972 MEDSV DEF RBRVS 01/01/2025 466.48 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42975 MEDSV DEF RBRVS 01/01/2024 12/31/2024 89.81 Description: DISE EVAL SLP DO BRTH FLX DX Category: Medical Services CMS Add: 01/01/2022 CMS Term: 42975 MEDSV DEF RBRVS 01/01/2025 88.6 Description: DISE EVAL SLP DO BRTH FLX DX Category: Medical Services CMS Add: 01/01/2022 CMS Term: 42999 MEDSV DEF BILL20 10/15/2020 Y Description: UNLISTED PX PHRNX ADND/TNSL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4300F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT RCVNG WARF THXPY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4301F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT NOT RCVNG WARF THXPY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 518.12 Description: INCISION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43020 MEDSV DEF RBRVS 01/01/2025 507.24 Description: INCISION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 491.97 Description: CRICOPHARYNGEAL MYOTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43030 MEDSV DEF RBRVS 01/01/2025 481.18 Description: CRICOPHARYNGEAL MYOTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43045 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1178.21 Description: ESOPHAGOTOMY THRC RMVL FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43045 MEDSV DEF RBRVS 01/01/2025 1149.85 Description: ESOPHAGOTOMY THRC RMVL FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4305F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT ED RE FT CARE INSPCT RCVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4306F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 598.99 Description: EXCISION OF ESOPHAGUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43100 MEDSV DEF RBRVS 01/01/2025 585.51 Description: EXCISION OF ESOPHAGUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 909.65 Description: EXCISION OF ESOPHAGUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43101 MEDSV DEF RBRVS 01/01/2025 886.79 Description: EXCISION OF ESOPHAGUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2684.72 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43107 MEDSV DEF RBRVS 01/01/2025 2610.64 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43108 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3981.39 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43108 MEDSV DEF RBRVS 01/01/2025 3865.68 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3122.54 Description: ESPHG TOT W/THRCM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43112 MEDSV DEF RBRVS 01/01/2025 3028.37 Description: ESPHG TOT W/THRCM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43113 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3894.37 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43113 MEDSV DEF RBRVS 01/01/2025 3784.29 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43116 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4450.97 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43116 MEDSV DEF RBRVS 01/01/2025 4320.68 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43117 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2928.99 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43117 MEDSV DEF RBRVS 01/01/2025 2851.45 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43118 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3248.82 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43118 MEDSV DEF RBRVS 01/01/2025 3155.66 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2565.69 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43121 MEDSV DEF RBRVS 01/01/2025 2496.8 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43122 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2309.2 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43122 MEDSV DEF RBRVS 01/01/2025 2264.3 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43123 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4036.69 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43123 MEDSV DEF RBRVS 01/01/2025 3921.61 Description: PARTIAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43124 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3415.92 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43124 MEDSV DEF RBRVS 01/01/2025 3321.82 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 739.07 Description: REMOVAL OF ESOPHAGUS POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43130 MEDSV DEF RBRVS 01/01/2025 721.37 Description: REMOVAL OF ESOPHAGUS POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1322.73 Description: REMOVAL OF ESOPHAGUS POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43135 MEDSV DEF RBRVS 01/01/2025 1287.53 Description: REMOVAL OF ESOPHAGUS POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 513.09 Description: ESOPHAGOSCOPY RIGID TRNSO Category: Medical Services CMS Add: 01/01/2015 CMS Term: 43180 MEDSV DEF RBRVS 01/01/2025 500.66 Description: ESOPHAGOSCOPY RIGID TRNSO Category: Medical Services CMS Add: 01/01/2015 CMS Term: 43191 MEDSV DEF RBRVS 01/01/2024 12/31/2024 144.98 Description: ESOPHAGOSCOPY RIGID TRNSO DX Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43191 MEDSV DEF RBRVS 01/01/2025 141.61 Description: ESOPHAGOSCOPY RIGID TRNSO DX Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43192 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.57 Description: ESOPHAGOSCP RIG TRNSO INJECT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43192 MEDSV DEF RBRVS 01/01/2025 154.93 Description: ESOPHAGOSCP RIG TRNSO INJECT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43193 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.1 Description: ESOPHAGOSCP RIG TRNSO BIOPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43193 MEDSV DEF RBRVS 01/01/2025 154.32 Description: ESOPHAGOSCP RIG TRNSO BIOPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43194 MEDSV DEF RBRVS 01/01/2024 12/31/2024 178.6 Description: ESOPHAGOSCP RIG TRNSO REM FB Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43194 MEDSV DEF RBRVS 01/01/2025 172.43 Description: ESOPHAGOSCP RIG TRNSO REM FB 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43195 MEDSV DEF RBRVS 01/01/2024 12/31/2024 172.86 Description: ESOPHAGOSCOPY RIGID BALLOON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43195 MEDSV DEF RBRVS 01/01/2025 168.66 Description: ESOPHAGOSCOPY RIGID BALLOON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43196 MEDSV DEF RBRVS 01/01/2024 12/31/2024 182.84 Description: ESOPHAGOSCP GUIDE WIRE DILAT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43196 MEDSV DEF RBRVS 01/01/2025 178.93 Description: ESOPHAGOSCP GUIDE WIRE DILAT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43197 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.31 Description: ESOPHAGOSCOPY FLEX DX BRUSH Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43197 MEDSV DEF RBRVS 01/01/2025 173.14 Description: ESOPHAGOSCOPY FLEX DX BRUSH Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43198 MEDSV DEF RBRVS 01/01/2024 12/31/2024 199.37 Description: ESOPHAGOSC FLEX TRNSN BIOPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43198 MEDSV DEF RBRVS 01/01/2025 192.48 Description: ESOPHAGOSC FLEX TRNSN BIOPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.77 Description: ESOPHAGOSCOPY FLEXIBLE BRUSH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43200 MEDSV DEF RBRVS 01/01/2025 238.98 Description: ESOPHAGOSCOPY FLEXIBLE BRUSH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43201 MEDSV DEF RBRVS 01/01/2024 12/31/2024 243.52 Description: ESOPH SCOPE W/SUBMUCOUS INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 43201 MEDSV DEF RBRVS 01/01/2025 236.14 Description: ESOPH SCOPE W/SUBMUCOUS INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 43202 MEDSV DEF RBRVS 01/01/2024 12/31/2024 334.58 Description: ESOPHAGOSCOPY FLEX BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43202 MEDSV DEF RBRVS 01/01/2025 322.93 Description: ESOPHAGOSCOPY FLEX BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43204 MEDSV DEF RBRVS 01/01/2024 12/31/2024 125.6 Description: ESOPH SCOPE W/SCLEROSIS INJ Category: Medical Services CMS Add: 01/01/1982 CMS Term: 43204 MEDSV DEF RBRVS 01/01/2025 122.55 Description: ESOPH SCOPE W/SCLEROSIS INJ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 130.87 Description: ESOPHAGUS ENDOSCOPY/LIGATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43205 MEDSV DEF RBRVS 01/01/2025 127.98 Description: ESOPHAGUS ENDOSCOPY/LIGATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43206 NOCOV DEF SYSMAN 01/01/2013 Y Description: ESOPH OPTICAL ENDOMICROSCOPY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4320F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT TALK PSYCHSOC&RX OH DPND Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 43210 NOCOV DEF SYSMAN 01/01/2016 Y Description: EGD ESOPHAGOGASTRC FNDOPLSTY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 43211 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.13 Description: ESOPHAGOSCOP MUCOSAL RESECT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43211 MEDSV DEF RBRVS 01/01/2025 212.63 Description: ESOPHAGOSCOP MUCOSAL RESECT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43212 MEDSV DEF RBRVS 01/01/2024 12/31/2024 173.95 Description: ESOPHAGOSCOP STENT PLACEMENT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43212 MEDSV DEF RBRVS 01/01/2025 169.27 Description: ESOPHAGOSCOP STENT PLACEMENT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43213 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1159.61 Description: ESOPHAGOSCOPY RETRO BALLOON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43213 MEDSV DEF RBRVS 01/01/2025 1099.25 Description: ESOPHAGOSCOPY RETRO BALLOON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43214 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.76 Description: ESOPHAGOSC DILATE BALLOON 30 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43214 MEDSV DEF RBRVS 01/01/2025 174.84 Description: ESOPHAGOSC DILATE BALLOON 30 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 367.72 Description: ESOPHAGOSCOPY FLEX REMOVE FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43215 MEDSV DEF RBRVS 01/01/2025 355.53 Description: ESOPHAGOSCOPY FLEX REMOVE FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43216 MEDSV DEF RBRVS 01/01/2024 12/31/2024 384.21 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43216 MEDSV DEF RBRVS 01/01/2025 370.93 Description: ESOPHAGOSCOPY LESION REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43217 MEDSV DEF RBRVS 01/01/2024 12/31/2024 394.39 Description: ESOPHAGOSCOPY SNARE LES REMV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43217 MEDSV DEF RBRVS 01/01/2025 382.52 Description: ESOPHAGOSCOPY SNARE LES REMV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 844.21 Description: ESOPHAGOSCOPY BALLOON <30MM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43220 MEDSV DEF RBRVS 01/01/2025 807.02 Description: ESOPHAGOSCOPY BALLOON <30MM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43226 MEDSV DEF RBRVS 01/01/2024 12/31/2024 361.23 Description: ESOPH ENDOSCOPY DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43226 MEDSV DEF RBRVS 01/01/2025 349.27 Description: ESOPH ENDOSCOPY DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43227 MEDSV DEF RBRVS 01/01/2024 12/31/2024 556.92 Description: ESOPHAGOSCOPY CONTROL BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43227 MEDSV DEF RBRVS 01/01/2025 537.66 Description: ESOPHAGOSCOPY CONTROL BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43229 MEDSV DEF RBRVS 01/01/2024 12/31/2024 666.36 Description: ESOPHAGOSCOPY LESION ABLATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43229 MEDSV DEF RBRVS 01/01/2025 641.44 Description: ESOPHAGOSCOPY LESION ABLATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 4322F NOCOV DEF SYSMAN 01/01/2012 Y 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 12/31/2024 146.95 Description: ESOPHAGOSCOP ULTRASOUND EXAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43231 MEDSV DEF RBRVS 01/01/2025 142.8 Description: ESOPHAGOSCOP ULTRASOUND EXAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43232 MEDSV DEF RBRVS 01/01/2024 12/31/2024 183.96 Description: ESOPHAGOSCOPY W/US NEEDLE BX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43232 MEDSV DEF RBRVS 01/01/2025 180.52 Description: ESOPHAGOSCOPY W/US NEEDLE BX 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43233 MEDSV DEF RBRVS 01/01/2024 12/31/2024 210.7 Description: EGD BALLOON DIL ESOPH30 MM/> Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43233 MEDSV DEF RBRVS 01/01/2025 205.77 Description: EGD BALLOON DIL ESOPH30 MM/> Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 269.81 Description: EGD DIAGNOSTIC BRUSH WASH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43235 MEDSV DEF RBRVS 01/01/2025 262.16 Description: EGD DIAGNOSTIC BRUSH WASH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43236 MEDSV DEF RBRVS 01/01/2024 12/31/2024 376.14 Description: UPPR GI SCOPE W/SUBMUC INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 43236 MEDSV DEF RBRVS 01/01/2025 364.7 Description: UPPR GI SCOPE W/SUBMUC INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 43237 MEDSV DEF RBRVS 01/01/2024 12/31/2024 181.76 Description: ENDOSCOPIC US EXAM ESOPH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 43237 MEDSV DEF RBRVS 01/01/2025 177.34 Description: ENDOSCOPIC US EXAM ESOPH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 43238 MEDSV DEF RBRVS 01/01/2024 12/31/2024 215.53 Description: EGD US FINE NEEDLE BX/ASPIR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 43238 MEDSV DEF RBRVS 01/01/2025 210.26 Description: EGD US FINE NEEDLE BX/ASPIR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 43239 MEDSV DEF RBRVS 01/01/2024 12/31/2024 353 Description: EGD BIOPSY SINGLE/MULTIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43239 MEDSV DEF RBRVS 01/01/2025 342.36 Description: EGD BIOPSY SINGLE/MULTIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 363.23 Description: EGD W/TRANSMURAL DRAIN CYST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43240 MEDSV DEF RBRVS 01/01/2025 354.49 Description: EGD W/TRANSMURAL DRAIN CYST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43241 MEDSV DEF RBRVS 01/01/2024 12/31/2024 131.5 Description: EGD TUBE/CATH INSERTION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 43241 MEDSV DEF RBRVS 01/01/2025 128.74 Description: EGD TUBE/CATH INSERTION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43242 MEDSV DEF RBRVS 01/01/2024 12/31/2024 244.16 Description: EGD US FINE NEEDLE BX/ASPIR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43242 MEDSV DEF RBRVS 01/01/2025 237.88 Description: EGD US FINE NEEDLE BX/ASPIR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43243 MEDSV DEF RBRVS 01/01/2024 12/31/2024 219.76 Description: EGD INJECTION VARICES Category: Medical Services CMS Add: 01/01/1989 CMS Term: 43243 MEDSV DEF RBRVS 01/01/2025 214.38 Description: EGD INJECTION VARICES Category: Medical Services CMS Add: 01/01/1989 CMS Term: 43244 MEDSV DEF RBRVS 01/01/2024 12/31/2024 227.54 Description: EGD VARICES LIGATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43244 MEDSV DEF RBRVS 01/01/2025 221.91 Description: EGD VARICES LIGATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43245 MEDSV DEF RBRVS 01/01/2024 12/31/2024 556.77 Description: EGD DILATE STRICTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43245 MEDSV DEF RBRVS 01/01/2025 536.54 Description: EGD DILATE STRICTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43246 MEDSV DEF RBRVS 01/01/2024 12/31/2024 184.59 Description: EGD PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43246 MEDSV DEF RBRVS 01/01/2025 179.95 Description: EGD PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43247 MEDSV DEF RBRVS 01/01/2024 12/31/2024 359.42 Description: EGD REMOVE FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43247 MEDSV DEF RBRVS 01/01/2025 349.1 Description: EGD REMOVE FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43248 MEDSV DEF RBRVS 01/01/2024 12/31/2024 387.33 Description: EGD GUIDE WIRE INSERTION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43248 MEDSV DEF RBRVS 01/01/2025 376.04 Description: EGD GUIDE WIRE INSERTION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43249 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1012.52 Description: ESOPH EGD DILATION <30 MM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43249 MEDSV DEF RBRVS 01/01/2025 969.25 Description: ESOPH EGD DILATION <30 MM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4324F NOCOV DEF SYSMAN 01/01/2011 Y Description: PT QUERIED PRKNS COMPLIC Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 43250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.14 Description: EGD CAUTERY TUMOR POLYP Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43250 MEDSV DEF RBRVS 01/01/2025 407.49 Description: EGD CAUTERY TUMOR POLYP Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43251 MEDSV DEF RBRVS 01/01/2024 12/31/2024 464.86 Description: EGD REMOVE LESION SNARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43251 MEDSV DEF RBRVS 01/01/2025 449.37 Description: EGD REMOVE LESION SNARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43252 NOCOV DEF SYSMAN 01/01/2013 Y Description: EGD OPTICAL ENDOMICROSCOPY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 43253 MEDSV DEF RBRVS 01/01/2024 12/31/2024 243.85 Description: EGD US TRANSMURAL INJXN/MARK Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43253 MEDSV DEF RBRVS 01/01/2025 237.58 Description: EGD US TRANSMURAL INJXN/MARK Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43254 MEDSV DEF RBRVS 01/01/2024 12/31/2024 250.61 Description: EGD ENDO MUCOSAL RESECTION Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43254 MEDSV DEF RBRVS 01/01/2025 244.29 Description: EGD ENDO MUCOSAL RESECTION Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43255 MEDSV DEF RBRVS 01/01/2024 12/31/2024 587.84 Description: EGD CONTROL BLEEDING ANY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43255 MEDSV DEF RBRVS 01/01/2025 567.18 Description: EGD CONTROL BLEEDING ANY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43257 MEDSV DEF RBRVS 01/01/2024 12/31/2024 214.62 0-1 Description: EGD W/THRML TXMNT GERD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43257 MEDSV DEF RBRVS 01/01/2025 210.48 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 12/31/2024 209.43 Description: EGD US EXAM DUODENUM/JEJUNUM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43259 MEDSV DEF RBRVS 01/01/2025 204.5 Description: EGD US EXAM DUODENUM/JEJUNUM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4325F NOCOV DEF SYSMAN 01/01/2011 Y Description: MED TXMNT OPTIONS RVWD W/PT Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 43260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 298.86 Description: ERCP W/SPECIMEN COLLECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43260 MEDSV DEF RBRVS 01/01/2025 291.73 Description: ERCP W/SPECIMEN COLLECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43261 MEDSV DEF RBRVS 01/01/2024 12/31/2024 313.84 Description: ENDO CHOLANGIOPANCREATOGRAPH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43261 MEDSV DEF RBRVS 01/01/2025 306.11 Description: ENDO CHOLANGIOPANCREATOGRAPH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43262 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.13 Description: ENDO CHOLANGIOPANCREATOGRAPH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43262 MEDSV DEF RBRVS 01/01/2025 322.72 Description: ENDO CHOLANGIOPANCREATOGRAPH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43263 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.44 Description: ERCP SPHINCTER PRESSURE MEAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43263 MEDSV DEF RBRVS 01/01/2025 323.18 Description: ERCP SPHINCTER PRESSURE MEAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43264 MEDSV DEF RBRVS 01/01/2024 12/31/2024 337.4 Description: ERCP REMOVE DUCT CALCULI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43264 MEDSV DEF RBRVS 01/01/2025 329.11 Description: ERCP REMOVE DUCT CALCULI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 401.3 Description: ERCP LITHOTRIPSY CALCULI Category: Medical Services CMS Add: 01/01/1989 CMS Term: 43265 MEDSV DEF RBRVS 01/01/2025 391.43 Description: ERCP LITHOTRIPSY CALCULI Category: Medical Services CMS Add: 01/01/1989 CMS Term: 43266 MEDSV DEF RBRVS 01/01/2024 12/31/2024 201.25 Description: EGD ENDOSCOPIC STENT PLACE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43266 MEDSV DEF RBRVS 01/01/2025 196.39 Description: EGD ENDOSCOPIC STENT PLACE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 4326F NOCOV DEF SYSMAN 01/01/2011 Y Description: PT ASKED RE SYMP AUTO DYSFXN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 685.08 Description: EGD LESION ABLATION Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43270 MEDSV DEF RBRVS 01/01/2025 660.76 Description: EGD LESION ABLATION Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43273 MEDSV DEF RBRVS 01/01/2024 12/31/2024 110.19 Description: ENDOSCOPIC PANCREATOSCOPY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 43273 MEDSV DEF RBRVS 01/01/2025 107.67 Description: ENDOSCOPIC PANCREATOSCOPY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 43274 MEDSV DEF RBRVS 01/01/2024 12/31/2024 428.78 Description: ERCP DUCT STENT PLACEMENT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43274 MEDSV DEF RBRVS 01/01/2025 417.95 Description: ERCP DUCT STENT PLACEMENT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.6 Description: ERCP REMOVE FORGN BODY DUCT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43275 MEDSV DEF RBRVS 01/01/2025 340.14 Description: ERCP REMOVE FORGN BODY DUCT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43276 MEDSV DEF RBRVS 01/01/2024 12/31/2024 446.57 Description: ERCP STENT EXCHANGE W/DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43276 MEDSV DEF RBRVS 01/01/2025 435.2 Description: ERCP STENT EXCHANGE W/DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43277 MEDSV DEF RBRVS 01/01/2024 12/31/2024 350.88 Description: ERCP EA DUCT/AMPULLA DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43277 MEDSV DEF RBRVS 01/01/2025 342.05 Description: ERCP EA DUCT/AMPULLA DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43278 MEDSV DEF RBRVS 01/01/2024 12/31/2024 400.96 Description: ERCP LESION ABLATE W/DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43278 MEDSV DEF RBRVS 01/01/2025 391.26 Description: ERCP LESION ABLATE W/DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43279 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1166.14 Description: LAP MYOTOMY HELLER Category: Medical Services CMS Add: 01/01/2009 CMS Term: 43279 MEDSV DEF RBRVS 01/01/2025 1136.3 Description: LAP MYOTOMY HELLER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 981.96 0-1 Description: LAPAROSCOPY FUNDOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43280 MEDSV DEF RBRVS 01/01/2025 956.87 0-1 Description: LAPAROSCOPY FUNDOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43281 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1397.2 0-1 Description: LAP PARAESOPHAG HERN REPAIR Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43281 MEDSV DEF RBRVS 01/01/2025 1358.72 0-1 Description: LAP PARAESOPHAG HERN REPAIR Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43282 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 1529.88 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 12/31/2024 141.81 0-1 Description: LAP ESOPH LENGTHENING Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43283 MEDSV DEF RBRVS 01/01/2025 137.93 0-1 Description: LAP ESOPH LENGTHENING Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43284 MEDSV DEF RBRVS 01/01/2024 12/31/2024 596.09 Description: LAPS ESOPHGL SPHNCTR AGMNTJ Category: Medical Services CMS Add: 01/01/2017 CMS Term: 43284 MEDSV DEF RBRVS 01/01/2025 582.67 Description: LAPS ESOPHGL SPHNCTR AGMNTJ Category: Medical Services CMS Add: 01/01/2017 CMS Term: 43285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 613.08 Description: RMVL ESOPHGL SPHNCTR DEV Category: Medical Services CMS Add: 01/01/2017 CMS Term: 43285 MEDSV DEF RBRVS 01/01/2025 598.85 Description: RMVL ESOPHGL SPHNCTR DEV Category: Medical Services CMS Add: 01/01/2017 CMS Term: 43286 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2872.67 Description: ESPHG TOT W/LAPS MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43286 MEDSV DEF RBRVS 01/01/2025 2782.96 Description: ESPHG TOT W/LAPS MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43287 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3193.63 Description: ESPHG DSTL 2/3 W/LAPS MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43287 MEDSV DEF RBRVS 01/01/2025 3109.81 Description: ESPHG DSTL 2/3 W/LAPS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43288 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3372.89 Description: ESPHG THRSC MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43288 MEDSV DEF RBRVS 01/01/2025 3281.39 Description: ESPHG THRSC MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43289 MEDSV DEF BILL20 01/01/2014 0-1 Description: UNLISTED LAPS PX ESOPH Category: Medical Services CMS Add: 01/01/2000 CMS Term: 4328F NOCOV DEF SYSMAN 01/01/2011 Y Description: PT ASKED RE SLEEP DISTURB Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 43290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2494.19 Y 18-999Years Description: EGD FLX TRNSORL DPLMNT BALO Category: Medical Services CMS Add: 01/01/2023 CMS Term: 43290 MEDSV DEF RBRVS 01/01/2025 2352.9 Y 18-999Years Description: EGD FLX TRNSORL DPLMNT BALO Category: Medical Services CMS Add: 01/01/2023 CMS Term: 43291 MEDSV DEF RBRVS 01/01/2024 12/31/2024 431 Y 18-999Years Description: EGD FLX TRNSORL RMVL BALO Category: Medical Services CMS Add: 01/01/2023 CMS Term: 43291 MEDSV DEF RBRVS 01/01/2025 417.27 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 12/31/2024 589.63 Description: REPAIR OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43300 MEDSV DEF RBRVS 01/01/2025 576.47 Description: REPAIR OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1029.65 Description: REPAIR ESOPHAGUS AND FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43305 MEDSV DEF RBRVS 01/01/2025 1002.92 Description: REPAIR ESOPHAGUS AND FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4330F NOCOV DEF SYSMAN 01/01/2010 Y Description: CNSLNG EPI SPEC SFTY ISSUES Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 43310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1334.75 Description: REPAIR OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43310 MEDSV DEF RBRVS 01/01/2025 1299.25 Description: REPAIR OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43312 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1425.27 Description: REPAIR ESOPHAGUS AND 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43312 MEDSV DEF RBRVS 01/01/2025 1385.67 Description: REPAIR ESOPHAGUS AND FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43313 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2634.05 Description: ESOPHAGOPLASTY CONGENITAL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 43313 MEDSV DEF RBRVS 01/01/2025 2568.86 Description: ESOPHAGOPLASTY CONGENITAL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 43314 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2821.84 Description: TRACHEO-ESOPHAGOPLASTY CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 43314 MEDSV DEF RBRVS 01/01/2025 2746.66 Description: TRACHEO-ESOPHAGOPLASTY CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 43320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1272.13 Description: FUSE ESOPHAGUS & STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43320 MEDSV DEF RBRVS 01/01/2025 1239.41 Description: FUSE ESOPHAGUS & STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1236.99 Description: REVISE ESOPHAGUS & STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43325 MEDSV DEF RBRVS 01/01/2025 1205.14 Description: REVISE ESOPHAGUS & STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43327 MEDSV DEF RBRVS 01/01/2024 12/31/2024 748.15 Description: ESOPH FUNDOPLASTY LAP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43327 MEDSV DEF RBRVS 01/01/2025 726.25 Description: ESOPH FUNDOPLASTY LAP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43328 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1011.42 Description: ESOPH FUNDOPLASTY THOR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43328 MEDSV DEF RBRVS 01/01/2025 983.81 Description: ESOPH FUNDOPLASTY THOR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1216.85 Description: ESOPHAGOMYOTOMY ABDOMINAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43330 MEDSV DEF RBRVS 01/01/2025 1185.9 Description: ESOPHAGOMYOTOMY ABDOMINAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43331 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1208.97 Description: ESOPHAGOMYOTOMY THORACIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43331 MEDSV DEF RBRVS 01/01/2025 1178.14 Description: ESOPHAGOMYOTOMY THORACIC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43332 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1042.78 Description: TRANSAB ESOPH HIAT HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43332 MEDSV DEF RBRVS 01/01/2025 1018.2 Description: TRANSAB ESOPH HIAT HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43333 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1141.43 Description: TRANSAB ESOPH HIAT HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43333 MEDSV DEF RBRVS 01/01/2025 1115.06 Description: TRANSAB ESOPH HIAT HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43334 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1119.21 Description: TRANSTHOR DIAPHRAG HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43334 MEDSV DEF RBRVS 01/01/2025 1087.95 Description: TRANSTHOR DIAPHRAG HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1199.5 Description: TRANSTHOR DIAPHRAG HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43335 MEDSV DEF RBRVS 01/01/2025 1166.92 Description: TRANSTHOR DIAPHRAG HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43336 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1303.51 Description: THORABD DIAPHR HERN REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43336 MEDSV DEF RBRVS 01/01/2025 1268.12 Description: THORABD DIAPHR HERN REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43337 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1389 Description: THORABD DIAPHR HERN REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43337 MEDSV DEF RBRVS 01/01/2025 1350.61 Description: THORABD DIAPHR HERN REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43338 MEDSV DEF RBRVS 01/01/2024 12/31/2024 102.72 Description: ESOPH LENGTHENING Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43338 MEDSV DEF RBRVS 01/01/2025 99.36 Description: ESOPH LENGTHENING Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1256.13 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43340 MEDSV DEF RBRVS 01/01/2025 1224.34 Description: FUSE ESOPHAGUS & INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43341 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1262.69 Description: FUSE ESOPHAGUS & INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43341 MEDSV DEF RBRVS 01/01/2025 1231.34 Description: FUSE ESOPHAGUS & INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43351 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1192.01 Description: SURGICAL OPENING ESOPHAGUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43351 MEDSV DEF RBRVS 01/01/2025 1163.9 Description: SURGICAL OPENING ESOPHAGUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43352 MEDSV DEF RBRVS 01/01/2024 12/31/2024 965.4 Description: SURGICAL OPENING ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43352 MEDSV DEF RBRVS 01/01/2025 942.11 Description: SURGICAL OPENING ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2022.83 Description: GASTROINTESTINAL REPAIR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43360 MEDSV DEF RBRVS 01/01/2025 1969.82 Description: GASTROINTESTINAL REPAIR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43361 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2448.01 Description: GASTROINTESTINAL REPAIR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43361 MEDSV DEF RBRVS 01/01/2025 2385.82 Description: GASTROINTESTINAL REPAIR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1385.47 Description: LIGATE ESOPHAGUS VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43400 MEDSV DEF RBRVS 01/01/2025 1349.43 Description: LIGATE ESOPHAGUS VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1316.62 Description: LIGATE/STAPLE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43405 MEDSV DEF RBRVS 01/01/2025 1284.03 Description: LIGATE/STAPLE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 4340F NOCOV DEF SYSMAN 01/01/2010 Y Description: CNSLNG CHLDBRNG WOMEN EPI 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 971 Description: REPAIR ESOPHAGUS WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43410 MEDSV DEF RBRVS 01/01/2025 948.14 Description: REPAIR ESOPHAGUS WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2323.67 Description: REPAIR ESOPHAGUS WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43415 MEDSV DEF RBRVS 01/01/2025 2266.98 Description: REPAIR ESOPHAGUS WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 957.03 Description: REPAIR ESOPHAGUS OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43420 MEDSV DEF RBRVS 01/01/2025 932.36 Description: REPAIR ESOPHAGUS OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1300.62 Description: REPAIR ESOPHAGUS OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43425 MEDSV DEF RBRVS 01/01/2025 1267.36 Description: REPAIR ESOPHAGUS OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 175.46 Description: DILATE ESOPHAGUS 1/MULT PASS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43450 MEDSV DEF RBRVS 01/01/2025 170.65 Description: DILATE ESOPHAGUS 1/MULT PASS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43453 MEDSV DEF RBRVS 01/01/2024 12/31/2024 751.31 Description: DILATE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43453 MEDSV DEF RBRVS 01/01/2025 717.29 Description: DILATE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 197.26 Description: PRESSURE TREATMENT ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43460 MEDSV DEF RBRVS 01/01/2025 192.37 Description: PRESSURE TREATMENT ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43496 MEDSV DEF MAXFEE 01/01/2024 1014.88 0 Description: FREE JEJUNUM FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 43497 MEDSV DEF RBRVS 01/01/2024 12/31/2024 737.22 Description: TRANSORL LWR ESOPHGL MYOTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43497 MEDSV DEF RBRVS 01/01/2025 715.92 Description: TRANSORL LWR ESOPHGL MYOTOMY Category: Medical Services CMS Add: 01/01/2022 CMS Term: 43499 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PROCEDURE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 717.71 Description: SURGICAL OPENING OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43500 MEDSV DEF RBRVS 01/01/2025 701.92 Description: SURGICAL OPENING OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1227.33 Description: SURGICAL REPAIR OF STOMACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 43501 MEDSV DEF RBRVS 01/01/2025 1201.56 Description: SURGICAL REPAIR OF STOMACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 43502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1388.68 Description: SURGICAL REPAIR OF STOMACH Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43502 MEDSV DEF RBRVS 01/01/2025 1352.69 Description: SURGICAL REPAIR OF STOMACH Category: Medical Services CMS Add: 01/01/1995 CMS Term: 4350F NOCOV DEF SYSMAN 01/01/2012 Y Description: CNSLNG PROVIDED SYMP MNGMNT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 43510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 867.79 Description: SURGICAL OPENING OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43510 MEDSV DEF RBRVS 01/01/2025 847.05 Description: SURGICAL OPENING OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 633.53 Description: INCISION OF PYLORIC MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43520 MEDSV DEF RBRVS 01/01/2025 619.44 Description: INCISION OF PYLORIC MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 761.17 Description: BIOPSY OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43605 MEDSV DEF RBRVS 01/01/2025 746.23 Description: BIOPSY OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 894.36 Description: EXCISION OF STOMACH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43610 MEDSV DEF RBRVS 01/01/2025 870.74 Description: EXCISION OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43611 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1120.47 Description: EXCISION OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43611 MEDSV DEF RBRVS 01/01/2025 1093.65 Description: EXCISION OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1800.36 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43620 MEDSV DEF RBRVS 01/01/2025 1752.49 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43621 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2064.25 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43621 MEDSV DEF RBRVS 01/01/2025 2011.34 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43622 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2096.02 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43622 MEDSV DEF RBRVS 01/01/2025 2039.82 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43631 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1319.76 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43631 MEDSV DEF RBRVS 01/01/2025 1287.97 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43632 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1850.95 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43632 MEDSV DEF RBRVS 01/01/2025 1801.98 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43633 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1749.32 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43633 MEDSV DEF RBRVS 01/01/2025 1705.29 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43634 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1928.55 Description: REMOVAL OF STOMACH PARTIAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43634 MEDSV DEF RBRVS 01/01/2025 1877.4 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 101.79 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43635 MEDSV DEF RBRVS 01/01/2025 98.66 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1086.08 Description: VAGOTOMY & PYLORUS REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43640 MEDSV DEF RBRVS 01/01/2025 1058.95 Description: VAGOTOMY & PYLORUS REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43641 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1098.3 Description: VAGOTOMY & PYLORUS REPAIR Category: Medical Services CMS Add: 01/01/1987 CMS Term: 43641 MEDSV DEF RBRVS 01/01/2025 1071.11 Description: VAGOTOMY & PYLORUS REPAIR Category: Medical Services CMS Add: 01/01/1987 CMS Term: 43644 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1580.43 Y Description: LAP GASTRIC BYPASS/ROUX-EN-Y Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43644 MEDSV DEF RBRVS 01/01/2025 1539.66 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 12/31/2024 1680.8 Y Description: LAP GASTR BYPASS INCL SMLL I Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43645 MEDSV DEF RBRVS 01/01/2025 1637.78 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 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 Description: LAP REVISE/REMV ELTRD ANTRUM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 43651 MEDSV DEF RBRVS 01/01/2024 12/31/2024 601.03 0-1 Description: LAPAROSCOPY VAGUS NERVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43651 MEDSV DEF RBRVS 01/01/2025 588.1 0-1 Description: LAPAROSCOPY VAGUS NERVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43652 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.16 0-1 Description: LAPAROSCOPY VAGUS NERVE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43652 MEDSV DEF RBRVS 01/01/2025 683.89 0-1 Description: LAPAROSCOPY VAGUS NERVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43653 MEDSV DEF RBRVS 01/01/2024 12/31/2024 530.46 0-1 Description: LAPAROSCOPY GASTROSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43653 MEDSV DEF RBRVS 01/01/2025 518.76 0-1 Description: LAPAROSCOPY GASTROSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43659 MEDSV DEF BILL20 01/01/2018 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 12/31/2024 37.7 Description: NASAL/OROGASTRIC W/TUBE PLMT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43752 MEDSV DEF RBRVS 01/01/2025 36.26 Description: NASAL/OROGASTRIC W/TUBE PLMT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43753 MEDSV DEF RBRVS 01/01/2024 12/31/2024 19.93 Description: TX GASTRO INTUB W/ASP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43753 MEDSV DEF RBRVS 01/01/2025 19.33 Description: TX GASTRO INTUB W/ASP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43754 MEDSV DEF RBRVS 01/01/2024 12/31/2024 219.99 Description: DX GASTR INTUB W/ASP SPEC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43754 MEDSV DEF RBRVS 01/01/2025 211.96 Description: DX GASTR INTUB W/ASP SPEC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43755 MEDSV DEF RBRVS 01/01/2024 12/31/2024 189.52 Description: DX GASTR INTUB W/ASP SPECS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43755 MEDSV DEF RBRVS 01/01/2025 184.68 Description: DX GASTR INTUB W/ASP SPECS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43756 MEDSV DEF RBRVS 01/01/2024 12/31/2024 259.55 Description: DX DUOD INTUB W/ASP SPEC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43756 MEDSV DEF RBRVS 01/01/2025 250.05 Description: DX DUOD INTUB W/ASP SPEC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43757 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.59 Description: DX DUOD INTUB W/ASP SPECS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43757 MEDSV DEF RBRVS 01/01/2025 335.88 Description: DX DUOD INTUB W/ASP SPECS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43761 MEDSV DEF RBRVS 01/01/2024 12/31/2024 115.42 Description: REPOSITION GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 43761 MEDSV DEF RBRVS 01/01/2025 111.69 Description: REPOSITION GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 43762 MEDSV DEF RBRVS 01/01/2024 12/31/2024 211.96 Description: RPLC GTUBE NO REVJ TRC Category: Medical Services CMS Add: 01/01/2019 CMS Term: 43762 MEDSV DEF RBRVS 01/01/2025 204 Description: RPLC GTUBE NO REVJ TRC Category: Medical Services CMS Add: 01/01/2019 CMS Term: 43763 MEDSV DEF RBRVS 01/01/2024 12/31/2024 313.92 Description: RPLC GTUBE REVJ GSTRST TRC Category: Medical Services CMS Add: 01/01/2019 CMS Term: 43763 MEDSV DEF RBRVS 01/01/2025 301.64 Description: RPLC GTUBE REVJ GSTRST TRC Category: Medical Services CMS Add: 01/01/2019 CMS Term: 43770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1027.7 Y 18-999Years Description: LAP PLACE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43770 MEDSV DEF RBRVS 01/01/2025 1002.71 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 12/31/2024 1166.4 Y 18-999Years Description: LAP REVISE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43771 MEDSV DEF RBRVS 01/01/2025 1136.45 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 12/31/2024 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 01/01/2025 845.25 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 12/31/2024 1166.4 Y 18-999Years Description: LAP REPLACE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43773 MEDSV DEF RBRVS 01/01/2025 1136.45 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 12/31/2024 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 01/01/2025 855.22 Y 18-999Years Description: LAP RMVL GASTR ADJ ALL PARTS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43775 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1004.54 Y Description: LAP SLEEVE GASTRECTOMY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43775 MEDSV DEF RBRVS 01/01/2025 974.82 Y Description: LAP SLEEVE GASTRECTOMY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 848.13 Description: PYLOROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43800 MEDSV DEF RBRVS 01/01/2025 827.56 Description: PYLOROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 926.74 Description: GASTRODUODENOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43810 MEDSV DEF RBRVS 01/01/2025 903.62 Description: GASTRODUODENOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1226.59 Description: GASTROJEJUNOSTOMY WO VAGOTMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43820 MEDSV DEF RBRVS 01/01/2025 1196.63 Description: GASTROJEJUNOSTOMY WO VAGOTMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1194.8 Description: GASTROJEJUNOSTOMY W/VAGOTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43825 MEDSV DEF RBRVS 01/01/2025 1164.49 Description: GASTROJEJUNOSTOMY W/VAGOTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 644.78 Description: GSTRST OPEN WO CONSTJ TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43830 MEDSV DEF RBRVS 01/01/2025 629.24 Description: GSTRST OPEN WO CONSTJ TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43831 MEDSV DEF RBRVS 01/01/2024 12/31/2024 560 0-28Days Description: GASTROSTOMY OPEN NEONATAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43831 MEDSV DEF RBRVS 01/01/2025 547.5 0-28Days Description: GASTROSTOMY OPEN NEONATAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43832 MEDSV DEF RBRVS 01/01/2024 12/31/2024 952.79 Description: GSTRST OPEN W/CONSTJ TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43832 MEDSV DEF RBRVS 01/01/2025 931.68 Description: GSTRST OPEN W/CONSTJ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1240.67 Description: REPAIR OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43840 MEDSV DEF RBRVS 01/01/2025 1208.93 Description: REPAIR OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43842 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1090.81 Y Description: V-BAND GASTROPLASTY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 43842 MEDSV DEF RBRVS 01/01/2025 1064.36 Y Description: V-BAND GASTROPLASTY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 43843 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1170.35 Y Description: GASTROPLASTY W/O V-BAND Category: Medical Services CMS Add: 01/01/1993 CMS Term: 43843 MEDSV DEF RBRVS 01/01/2025 1141.08 Y Description: GASTROPLASTY W/O V-BAND Category: Medical Services CMS Add: 01/01/1993 CMS Term: 43845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1783.54 Y Description: GASTROPLASTY DUODENAL SWITCH Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43845 MEDSV DEF RBRVS 01/01/2025 1737.22 Y Description: GASTROPLASTY DUODENAL SWITCH Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43846 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1504.51 Y Description: GASTRIC BYPASS FOR OBESITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43846 MEDSV DEF RBRVS 01/01/2025 1465.97 Y Description: GASTRIC BYPASS FOR OBESITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43847 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1645.92 Y Description: GASTRIC BYPASS INCL SMALL I Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43847 MEDSV DEF RBRVS 01/01/2025 1603.24 Y Description: GASTRIC BYPASS INCL SMALL I Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43848 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1760.76 Y Description: REVISION GASTROPLASTY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43848 MEDSV DEF RBRVS 01/01/2025 1717.31 Y Description: REVISION GASTROPLASTY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1491.65 Description: REVISE STOMACH-BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43860 MEDSV DEF RBRVS 01/01/2025 1452.69 Description: REVISE STOMACH-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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43865 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1554.18 Description: REVISE STOMACH-BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43865 MEDSV DEF RBRVS 01/01/2025 1513.82 Description: REVISE STOMACH-BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43870 MEDSV DEF RBRVS 01/01/2024 12/31/2024 651.38 Description: REPAIR STOMACH OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43870 MEDSV DEF RBRVS 01/01/2025 634.41 Description: REPAIR STOMACH OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1450.14 Description: REPAIR STOMACH-BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43880 MEDSV DEF RBRVS 01/01/2025 1423.66 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 Description: IMPL/REDO ELECTRD ANTRUM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 43882 MEDSV DEF MAXFEE 01/01/2024 831.2 0 Description: REVISE/REMOVE ELECTRD ANTRUM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 43886 MEDSV DEF RBRVS 01/01/2024 12/31/2024 338.76 Description: REVISE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43886 MEDSV DEF RBRVS 01/01/2025 332.67 Description: REVISE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43887 MEDSV DEF RBRVS 01/01/2024 12/31/2024 305.48 Description: REMOVE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43887 MEDSV DEF RBRVS 01/01/2025 300.39 Description: REMOVE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43888 MEDSV DEF RBRVS 01/01/2024 12/31/2024 427.52 Description: CHANGE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43888 MEDSV DEF RBRVS 01/01/2025 418.52 Description: CHANGE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43999 MEDSV DEF BILL20 10/15/2020 Y Description: UNLISTED PROCEDURE STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 995.95 Description: FREEING OF BOWEL ADHESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44005 MEDSV DEF RBRVS 01/01/2025 970.56 Description: FREEING OF BOWEL ADHESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4400F NOCOV DEF SYSMAN 01/01/2011 Y Description: REHAB THXPY OPTIONS W/PT Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 44010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 785.96 Description: INCISION OF SMALL BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44010 MEDSV DEF RBRVS 01/01/2025 768.43 Description: INCISION OF SMALL BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 128.27 Description: INSERT NEEDLE CATH BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44015 MEDSV DEF RBRVS 01/01/2025 124.03 Description: INSERT NEEDLE CATH BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 888.86 Description: EXPLORE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44020 MEDSV DEF RBRVS 01/01/2025 866.17 Description: EXPLORE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44021 MEDSV DEF RBRVS 01/01/2024 12/31/2024 888.2 Description: DECOMPRESS SMALL BOWEL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44021 MEDSV DEF RBRVS 01/01/2025 864.13 Description: DECOMPRESS SMALL BOWEL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 896.45 Description: INCISION OF LARGE BOWEL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44025 MEDSV DEF RBRVS 01/01/2025 874.73 Description: INCISION OF LARGE BOWEL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 854.86 Description: REDUCE BOWEL OBSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44050 MEDSV DEF RBRVS 01/01/2025 833.92 Description: REDUCE BOWEL OBSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44055 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1353.56 Description: CORRECT MALROTATION OF BOWEL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44055 MEDSV DEF RBRVS 01/01/2025 1320.62 Description: CORRECT MALROTATION OF BOWEL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 99.29 Description: BIOPSY OF BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44100 MEDSV DEF RBRVS 01/01/2025 96.8 Description: BIOPSY OF BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 779.47 Description: EXCISE INTESTINE LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44110 MEDSV DEF RBRVS 01/01/2025 762.97 Description: EXCISE INTESTINE LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 904.36 Description: EXCISION OF BOWEL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44111 MEDSV DEF RBRVS 01/01/2025 875.55 Description: EXCISION OF BOWEL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1113.65 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44120 MEDSV DEF RBRVS 01/01/2025 1085.43 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.28 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 44121 MEDSV DEF RBRVS 01/01/2025 211.89 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 44125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1074.52 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44125 MEDSV DEF RBRVS 01/01/2025 1048.17 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44126 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2241.48 Description: ENTERECTOMY W/O TAPER CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44126 MEDSV DEF RBRVS 01/01/2025 2181.87 Description: ENTERECTOMY W/O TAPER CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44127 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2587.2 Description: ENTERECTOMY W/TAPER CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44127 MEDSV DEF RBRVS 01/01/2025 2517.47 Description: ENTERECTOMY W/TAPER CONG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44128 MEDSV DEF RBRVS 01/01/2024 12/31/2024 219.12 Description: ENTERECTOMY CONG ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44128 MEDSV DEF RBRVS 01/01/2025 212.71 Description: ENTERECTOMY CONG ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1201.05 Description: BOWEL TO BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44130 MEDSV DEF RBRVS 01/01/2025 1171.16 Description: BOWEL TO BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44132 MEDSV DEF BILL20 01/01/2014 Y Description: ENTERECTOMY CADAVER DONOR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44133 MEDSV DEF BILL20 01/01/2014 Y Description: ENTERECTOMY LIVE DONOR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44135 MEDSV DEF BILL20 01/01/2014 Y Description: INTESTINE TRANSPLNT CADAVER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44136 MEDSV DEF BILL20 01/01/2014 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 Y Description: REMOVE INTESTINAL ALLOGRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44139 MEDSV DEF RBRVS 01/01/2024 12/31/2024 109.39 Y Description: MOBILIZATION OF COLON Category: Medical Services CMS Add: 01/01/1995 CMS Term: 44139 MEDSV DEF RBRVS 01/01/2025 106.02 Y Description: MOBILIZATION OF COLON Category: Medical Services CMS Add: 01/01/1995 CMS Term: 44140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1224.62 Y Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44140 MEDSV DEF RBRVS 01/01/2025 1194.18 Y Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44141 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1653.91 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44141 MEDSV DEF RBRVS 01/01/2025 1610.34 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44143 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1508.43 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44143 MEDSV DEF RBRVS 01/01/2025 1466.83 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44144 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1610.04 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44144 MEDSV DEF RBRVS 01/01/2025 1566.9 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1510.24 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44145 MEDSV DEF RBRVS 01/01/2025 1471.24 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44146 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1919.35 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44146 MEDSV DEF RBRVS 01/01/2025 1868.26 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44147 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1760.78 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44147 MEDSV DEF RBRVS 01/01/2025 1715.02 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1695.12 Description: REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44150 MEDSV DEF RBRVS 01/01/2025 1649.69 Description: REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1954.27 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44151 MEDSV DEF RBRVS 01/01/2025 1901.19 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1894.26 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44155 MEDSV DEF RBRVS 01/01/2025 1845.19 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44156 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2089.88 Description: REMOVAL OF COLON/ILEOSTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44156 MEDSV DEF RBRVS 01/01/2025 2032.16 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44157 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1985.46 Description: COLECTOMY W/ILEOANAL ANAST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 44157 MEDSV DEF RBRVS 01/01/2025 1932.32 Description: COLECTOMY W/ILEOANAL ANAST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 44158 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2034.96 Description: COLECTOMY W/NEO-RECTUM POUCH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 44158 MEDSV DEF RBRVS 01/01/2025 1980.22 Description: COLECTOMY W/NEO-RECTUM POUCH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 44160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1134.74 Description: REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44160 MEDSV DEF RBRVS 01/01/2025 1106.12 Description: REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 839.85 Description: LAP ENTEROLYSIS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44180 MEDSV DEF RBRVS 01/01/2025 819.34 Description: LAP ENTEROLYSIS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44186 MEDSV DEF RBRVS 01/01/2024 12/31/2024 595.44 0-1 Description: LAP JEJUNOSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44186 MEDSV DEF RBRVS 01/01/2025 581.64 0-1 Description: LAP JEJUNOSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44187 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1006.58 Description: LAP ILEO/JEJUNO-STOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44187 MEDSV DEF RBRVS 01/01/2025 979.81 Description: LAP ILEO/JEJUNO-STOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44188 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1114.26 Description: LAP COLOSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44188 MEDSV DEF RBRVS 01/01/2025 1084.76 Description: LAP COLOSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44202 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1266.22 0-1 Description: LAP ENTERECTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44202 MEDSV DEF RBRVS 01/01/2025 1233.36 0-1 Description: LAP ENTERECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 44203 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.77 Description: LAP RESECT S/INTESTINE ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44203 MEDSV DEF RBRVS 01/01/2025 211.27 Description: LAP RESECT S/INTESTINE ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44204 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1405.14 Description: LAPARO PARTIAL COLECTOMY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44204 MEDSV DEF RBRVS 01/01/2025 1368.2 Description: LAPARO PARTIAL COLECTOMY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1222.75 Description: LAP COLECTOMY PART W/ILEUM Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44205 MEDSV DEF RBRVS 01/01/2025 1190.43 Description: LAP COLECTOMY PART W/ILEUM Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44206 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1591.45 Description: LAP PART COLECTOMY W/STOMA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44206 MEDSV DEF RBRVS 01/01/2025 1548.62 Description: LAP PART COLECTOMY W/STOMA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44207 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1660.46 Description: L COLECTOMY/COLOPROCTOSTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44207 MEDSV DEF RBRVS 01/01/2025 1615.81 Description: L COLECTOMY/COLOPROCTOSTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44208 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1807.88 Description: L COLECTOMY/COLOPROCTOSTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44208 MEDSV DEF RBRVS 01/01/2025 1759.4 Description: L COLECTOMY/COLOPROCTOSTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1630.34 Description: LAPARO TOTAL PROCTOCOLECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44210 MEDSV DEF RBRVS 01/01/2025 1587.82 Description: LAPARO TOTAL PROCTOCOLECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44211 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1968.43 Description: LAP COLECTOMY W/PROCTECTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44211 MEDSV DEF RBRVS 01/01/2025 1915.51 Description: LAP COLECTOMY W/PROCTECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44212 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1868.63 Description: LAPARO TOTAL PROCTOCOLECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44212 MEDSV DEF RBRVS 01/01/2025 1819.94 Description: LAPARO TOTAL PROCTOCOLECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44213 MEDSV DEF RBRVS 01/01/2024 12/31/2024 169.84 Description: LAP MOBIL SPLENIC FL ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44213 MEDSV DEF RBRVS 01/01/2025 165.13 Description: LAP MOBIL SPLENIC FL ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44227 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1515.08 Description: LAP CLOSE ENTEROSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44227 MEDSV DEF RBRVS 01/01/2025 1474.15 Description: LAP CLOSE ENTEROSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44238 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED LAPS PX INTESTINE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 768.67 Description: OPEN BOWEL TO SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44300 MEDSV DEF RBRVS 01/01/2025 750.28 Description: OPEN BOWEL TO SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 953.55 Description: ILEOSTOMY/JEJUNOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44310 MEDSV DEF RBRVS 01/01/2025 929.32 Description: ILEOSTOMY/JEJUNOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44312 MEDSV DEF RBRVS 01/01/2024 12/31/2024 550.04 Description: REVISION OF ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44312 MEDSV DEF RBRVS 01/01/2025 539.29 Description: REVISION OF ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44314 MEDSV DEF RBRVS 01/01/2024 12/31/2024 925.84 Description: REVISION OF ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44314 MEDSV DEF RBRVS 01/01/2025 903.65 Description: REVISION OF ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44316 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1287.99 Description: DEVISE BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44316 MEDSV DEF RBRVS 01/01/2025 1255.12 Description: DEVISE BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1098.2 Description: COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44320 MEDSV DEF RBRVS 01/01/2025 1072.08 Description: COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44322 MEDSV DEF RBRVS 01/01/2024 12/31/2024 920.51 Description: COLOSTOMY WITH BIOPSIES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44322 MEDSV DEF RBRVS 01/01/2025 897.29 Description: COLOSTOMY WITH BIOPSIES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 578.21 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44340 MEDSV DEF RBRVS 01/01/2025 567.41 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 964.75 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44345 MEDSV DEF RBRVS 01/01/2025 941.42 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44346 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1084.13 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44346 MEDSV DEF RBRVS 01/01/2025 1057.48 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 133.19 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44360 MEDSV DEF RBRVS 01/01/2025 130.37 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44361 MEDSV DEF RBRVS 01/01/2024 12/31/2024 147.02 Description: SMALL BOWEL ENDOSCOPY/BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44361 MEDSV DEF RBRVS 01/01/2025 143.64 Description: SMALL BOWEL ENDOSCOPY/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44363 MEDSV DEF RBRVS 01/01/2024 12/31/2024 177.81 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44363 MEDSV DEF RBRVS 01/01/2025 173.51 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44364 MEDSV DEF RBRVS 01/01/2024 12/31/2024 189.66 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44364 MEDSV DEF RBRVS 01/01/2025 185.01 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 168.76 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44365 MEDSV DEF RBRVS 01/01/2025 165.04 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44366 MEDSV DEF RBRVS 01/01/2024 12/31/2024 222.75 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44366 MEDSV DEF RBRVS 01/01/2025 217.11 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44369 MEDSV DEF RBRVS 01/01/2024 12/31/2024 227.88 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44369 MEDSV DEF RBRVS 01/01/2025 222.24 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 247.43 Description: SMALL BOWEL ENDOSCOPY/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44370 MEDSV DEF RBRVS 01/01/2025 241.7 Description: SMALL BOWEL ENDOSCOPY/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44372 MEDSV DEF RBRVS 01/01/2024 12/31/2024 221.41 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 44372 MEDSV DEF RBRVS 01/01/2025 216.11 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 44373 MEDSV DEF RBRVS 01/01/2024 12/31/2024 177.22 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 44373 MEDSV DEF RBRVS 01/01/2025 172.78 Description: SMALL BOWEL ENDOSCOPY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44376 MEDSV DEF RBRVS 01/01/2024 12/31/2024 263.81 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44376 MEDSV DEF RBRVS 01/01/2025 256.94 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44377 MEDSV DEF RBRVS 01/01/2024 12/31/2024 277.48 Description: SMALL BOWEL ENDOSCOPY/BIOPSY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44377 MEDSV DEF RBRVS 01/01/2025 270.37 Description: SMALL BOWEL ENDOSCOPY/BIOPSY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44378 MEDSV DEF RBRVS 01/01/2024 12/31/2024 356.65 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44378 MEDSV DEF RBRVS 01/01/2025 347.65 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44379 MEDSV DEF RBRVS 01/01/2024 12/31/2024 379.17 Description: S BOWEL ENDOSCOPE W/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44379 MEDSV DEF RBRVS 01/01/2025 370.3 Description: S BOWEL ENDOSCOPE W/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 182.83 Description: SMALL BOWEL ENDOSCOPY BR/WA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44380 MEDSV DEF RBRVS 01/01/2025 179.07 Description: SMALL BOWEL ENDOSCOPY BR/WA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44381 MEDSV DEF RBRVS 01/01/2024 12/31/2024 921.94 Description: SMALL BOWEL ENDOSCOPY BR/WA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44381 MEDSV DEF RBRVS 01/01/2025 880.39 Description: SMALL BOWEL ENDOSCOPY BR/WA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44382 MEDSV DEF RBRVS 01/01/2024 12/31/2024 279.48 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44382 MEDSV DEF RBRVS 01/01/2025 270.44 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44384 MEDSV DEF RBRVS 01/01/2024 12/31/2024 143.74 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44384 MEDSV DEF RBRVS 01/01/2025 138.13 Description: SMALL BOWEL ENDOSCOPY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44385 MEDSV DEF RBRVS 01/01/2024 12/31/2024 201.62 Description: ENDOSCOPY OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44385 MEDSV DEF RBRVS 01/01/2025 196.57 Description: ENDOSCOPY OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44386 MEDSV DEF RBRVS 01/01/2024 12/31/2024 291.29 Description: ENDOSCOPY BOWEL POUCH/BIOP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44386 MEDSV DEF RBRVS 01/01/2025 281.88 Description: ENDOSCOPY BOWEL POUCH/BIOP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44388 MEDSV DEF RBRVS 01/01/2024 12/31/2024 295.11 Description: COLONOSCOPY THRU STOMA SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44388 MEDSV DEF RBRVS 01/01/2025 287.28 Description: COLONOSCOPY THRU STOMA SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44389 MEDSV DEF RBRVS 01/01/2024 12/31/2024 385.85 Description: COLONOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44389 MEDSV DEF RBRVS 01/01/2025 374.23 Description: COLONOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 379.56 Description: COLONOSCOPY FOR FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44390 MEDSV DEF RBRVS 01/01/2025 369.16 Description: COLONOSCOPY FOR FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44391 MEDSV DEF RBRVS 01/01/2024 12/31/2024 599.78 Description: COLONOSCOPY FOR BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44391 MEDSV DEF RBRVS 01/01/2025 579.25 Description: COLONOSCOPY FOR BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44392 MEDSV DEF RBRVS 01/01/2024 12/31/2024 361.71 Description: COLONOSCOPY & POLYPECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44392 MEDSV DEF RBRVS 01/01/2025 353.05 Description: COLONOSCOPY & POLYPECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44394 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.75 Description: COLONOSCOPY W/SNARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44394 MEDSV DEF RBRVS 01/01/2025 398.96 Description: COLONOSCOPY W/SNARE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44401 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2223.04 Description: COLONOSCOPY WITH ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44401 MEDSV DEF RBRVS 01/01/2025 2122.53 Description: COLONOSCOPY WITH ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44402 MEDSV DEF RBRVS 01/01/2024 12/31/2024 242.83 Description: COLONOSCOPY W/STENT PLCMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44402 MEDSV DEF RBRVS 01/01/2025 236.6 Description: COLONOSCOPY W/STENT PLCMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44403 MEDSV DEF RBRVS 01/01/2024 12/31/2024 282.36 Description: COLONOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44403 MEDSV DEF RBRVS 01/01/2025 275.11 Description: COLONOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44404 MEDSV DEF RBRVS 01/01/2024 12/31/2024 394.81 Description: COLONOSCOPY W/INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44404 MEDSV DEF RBRVS 01/01/2025 382.39 Description: COLONOSCOPY W/INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 520.75 Description: COLONOSCOPY W/DILATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44405 MEDSV DEF RBRVS 01/01/2025 503.52 Description: COLONOSCOPY W/DILATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44406 MEDSV DEF RBRVS 01/01/2024 12/31/2024 212.88 Description: COLONOSCOPY W/ULTRASOUND Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44406 MEDSV DEF RBRVS 01/01/2025 207.69 Description: COLONOSCOPY W/ULTRASOUND Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44407 MEDSV DEF RBRVS 01/01/2024 12/31/2024 255.52 Description: COLONOSCOPY W/NDL ASPIR/BX Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44407 MEDSV DEF RBRVS 01/01/2025 248.91 Description: COLONOSCOPY W/NDL ASPIR/BX Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44408 MEDSV DEF RBRVS 01/01/2024 12/31/2024 214.85 Description: COLONOSCOPY W/DECOMPRESSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44408 MEDSV DEF RBRVS 01/01/2025 209.6 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 18.18 Description: INTRO GASTROINTESTINAL TUBE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44500 MEDSV DEF RBRVS 01/01/2025 17.33 Description: INTRO GASTROINTESTINAL TUBE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 4450F NOCOV DEF SYSMAN 01/01/2012 Y 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 12/31/2024 1281.29 Description: SUTURE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44602 MEDSV DEF RBRVS 01/01/2025 1246.14 Description: SUTURE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44603 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1475.68 Description: SUTURE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44603 MEDSV DEF RBRVS 01/01/2025 1436.19 Description: SUTURE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44604 MEDSV DEF RBRVS 01/01/2024 12/31/2024 963.42 Description: SUTURE LARGE INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44604 MEDSV DEF RBRVS 01/01/2025 938.18 Description: SUTURE LARGE INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1184.47 Description: REPAIR OF BOWEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44605 MEDSV DEF RBRVS 01/01/2025 1145.83 Description: REPAIR OF BOWEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 977.73 Description: INTESTINAL STRICTUROPLASTY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44615 MEDSV DEF RBRVS 01/01/2025 953.13 Description: INTESTINAL STRICTUROPLASTY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 794 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44620 MEDSV DEF RBRVS 01/01/2025 773.64 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44625 MEDSV DEF RBRVS 01/01/2024 12/31/2024 928.94 Description: REPAIR BOWEL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44625 MEDSV DEF RBRVS 01/01/2025 905.48 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44626 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1453.93 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1998 CMS Term: 44626 MEDSV DEF RBRVS 01/01/2025 1413.41 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1998 CMS Term: 44640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1274.45 Description: REPAIR BOWEL-SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44640 MEDSV DEF RBRVS 01/01/2025 1241.67 Description: REPAIR BOWEL-SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1316.47 Description: REPAIR BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44650 MEDSV DEF RBRVS 01/01/2025 1282.68 Description: REPAIR BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1231.07 Description: REPAIR BOWEL-BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44660 MEDSV DEF RBRVS 01/01/2025 1202.6 Description: REPAIR BOWEL-BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44661 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1414.12 Description: REPAIR BOWEL-BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44661 MEDSV DEF RBRVS 01/01/2025 1374.91 Description: REPAIR BOWEL-BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 980.97 Description: SURGICAL REVISION INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44680 MEDSV DEF RBRVS 01/01/2025 955.35 Description: SURGICAL REVISION INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 923.7 Description: SUSPEND BOWEL W/PROSTHESIS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 44700 MEDSV DEF RBRVS 01/01/2025 903.43 Description: SUSPEND BOWEL W/PROSTHESIS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 44701 MEDSV DEF RBRVS 01/01/2024 12/31/2024 152.8 Description: INTRAOP COLON LAVAGE ADD-ON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44701 MEDSV DEF RBRVS 01/01/2025 148.47 Description: INTRAOP COLON LAVAGE ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 105.19 Y Description: PREPARE FECAL MICROBIOTA Category: Medical Services CMS Add: 01/01/2013 CMS Term: 44705 MEDSV DEF RBRVS 01/01/2025 103.22 Y Description: PREPARE FECAL MICROBIOTA Category: Medical Services CMS Add: 01/01/2013 CMS Term: 4470F NOCOV DEF SYSMAN 01/01/2012 Y Description: ICD COUNSELING PROVIDED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 44715 MEDSV DEF BILL20 01/01/2010 Y Description: PREPARE DONOR INTESTINE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.83 Y Description: PREP DONOR INTESTINE/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44720 MEDSV DEF RBRVS 01/01/2025 239.3 Y Description: PREP DONOR INTESTINE/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44721 MEDSV DEF RBRVS 01/01/2024 12/31/2024 345.17 Y Description: PREP DONOR INTESTINE/ARTERY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44721 MEDSV DEF RBRVS 01/01/2025 334.92 Y Description: PREP DONOR INTESTINE/ARTERY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44799 MEDSV DEF BILL20 09/09/2021 Y Y Description: UNLISTED PX SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 710.73 Description: EXCISION OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44800 MEDSV DEF RBRVS 01/01/2025 696.33 Description: EXCISION OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4480F NOCOV DEF SYSMAN 01/01/2012 Y Description: PT RCVNG ACE/ARB B-BLOCKERTX Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4481F NOCOV DEF SYSMAN 01/01/2012 Y 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 12/31/2024 777.18 Description: EXCISION OF MESENTERY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44820 MEDSV DEF RBRVS 01/01/2025 758.49 Description: EXCISION OF MESENTERY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 683.9 Description: REPAIR OF MESENTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44850 MEDSV DEF RBRVS 01/01/2025 669.59 Description: REPAIR OF MESENTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44899 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX MECKEL'S DVRTCLM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 716.86 Description: DRAIN APPENDIX ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44900 MEDSV DEF RBRVS 01/01/2025 698.68 Description: DRAIN APPENDIX ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44950 MEDSV DEF RBRVS 01/01/2024 12/31/2024 587.33 Description: APPENDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44950 MEDSV DEF RBRVS 01/01/2025 573 Description: APPENDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44955 MEDSV DEF RBRVS 01/01/2024 12/31/2024 76.15 Description: APPENDECTOMY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44955 MEDSV DEF RBRVS 01/01/2025 73.91 Description: APPENDECTOMY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44960 MEDSV DEF RBRVS 01/01/2024 12/31/2024 801.02 Description: APPENDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44960 MEDSV DEF RBRVS 01/01/2025 780.6 Description: APPENDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44970 MEDSV DEF RBRVS 01/01/2024 12/31/2024 552.2 Description: LAPAROSCOPY APPENDECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 44970 MEDSV DEF RBRVS 01/01/2025 539.51 Description: LAPAROSCOPY APPENDECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 44979 MEDSV DEF BILL20 01/01/2014 0-1 Description: UNLISTED LAPS PX APPENDIX Category: Medical Services CMS Add: 01/01/2000 CMS Term: 45000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 397.95 Description: DRAINAGE OF PELVIC ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45000 MEDSV DEF RBRVS 01/01/2025 390.31 Description: DRAINAGE OF PELVIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 294.3 Description: DRAINAGE OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45005 MEDSV DEF RBRVS 01/01/2025 284.06 Description: DRAINAGE OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4500F NOCOV DEF SYSMAN 01/01/2012 Y 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 12/31/2024 533.05 Description: DRAINAGE OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45020 MEDSV DEF RBRVS 01/01/2025 515.84 Description: DRAINAGE OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 281.56 Description: BIOPSY OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45100 MEDSV DEF RBRVS 01/01/2025 276.73 Description: BIOPSY OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45108 MEDSV DEF RBRVS 01/01/2024 12/31/2024 343.52 Description: ANORECTAL MYOMECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45108 MEDSV DEF RBRVS 01/01/2025 337.29 Description: ANORECTAL MYOMECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4510F NOCOV DEF SYSMAN 01/01/2012 Y Description: PREV CARDREHAB QUALCARDEVENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 45110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1678.88 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45110 MEDSV DEF RBRVS 01/01/2025 1632.7 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 998.79 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45111 MEDSV DEF RBRVS 01/01/2025 976.75 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1691.14 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45112 MEDSV DEF RBRVS 01/01/2025 1645.49 Description: REMOVAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45113 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1739.11 Description: PARTIAL PROCTECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45113 MEDSV DEF RBRVS 01/01/2025 1691.18 Description: PARTIAL PROCTECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45114 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1650.95 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45114 MEDSV DEF RBRVS 01/01/2025 1607.51 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45116 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1440.34 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45116 MEDSV DEF RBRVS 01/01/2025 1403.03 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45119 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1751.65 Description: REMOVE RECTUM W/RESERVOIR Category: Medical Services CMS Add: 01/01/1998 CMS Term: 45119 MEDSV DEF RBRVS 01/01/2025 1703.5 Description: REMOVE RECTUM W/RESERVOIR Category: Medical Services CMS Add: 01/01/1998 CMS Term: 45120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1456.84 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45120 MEDSV DEF RBRVS 01/01/2025 1419.7 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1589.31 Description: REMOVAL OF RECTUM AND COLON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45121 MEDSV DEF RBRVS 01/01/2025 1548.47 Description: REMOVAL OF RECTUM AND COLON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45123 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1032.3 Description: PARTIAL PROCTECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45123 MEDSV DEF RBRVS 01/01/2025 1005.3 Description: PARTIAL PROCTECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45126 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2528.8 Y Y Description: PELVIC EXENTERATION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 45126 MEDSV DEF RBRVS 01/01/2025 2472.86 Y Y Description: PELVIC EXENTERATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1004.5 Description: EXCISION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45130 MEDSV DEF RBRVS 01/01/2025 978.84 Description: EXCISION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1210.39 Description: EXCISION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45135 MEDSV DEF RBRVS 01/01/2025 1180.6 Description: EXCISION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45136 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1664.05 Description: EXCISE ILEOANAL RESERVIOR Category: Medical Services CMS Add: 01/01/2002 CMS Term: 45136 MEDSV DEF RBRVS 01/01/2025 1619.44 Description: EXCISE ILEOANAL RESERVIOR Category: Medical Services CMS Add: 01/01/2002 CMS Term: 45150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 389.08 Description: EXCISION OF RECTAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45150 MEDSV DEF RBRVS 01/01/2025 381.28 Description: EXCISION OF RECTAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 936.88 Description: EXCISION OF RECTAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45160 MEDSV DEF RBRVS 01/01/2025 914.63 Description: EXCISION OF RECTAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45171 MEDSV DEF RBRVS 01/01/2024 12/31/2024 573.65 Description: EXC RECT TUM TRANSANAL PART Category: Medical Services CMS Add: 01/01/2010 CMS Term: 45171 MEDSV DEF RBRVS 01/01/2025 559.82 Description: EXC RECT TUM TRANSANAL PART Category: Medical Services CMS Add: 01/01/2010 CMS Term: 45172 MEDSV DEF RBRVS 01/01/2024 12/31/2024 765.9 Description: EXC RECT TUM TRANSANAL FULL Category: Medical Services CMS Add: 01/01/2010 CMS Term: 45172 MEDSV DEF RBRVS 01/01/2025 747.42 Description: EXC RECT TUM TRANSANAL FULL Category: Medical Services CMS Add: 01/01/2010 CMS Term: 45190 MEDSV DEF RBRVS 01/01/2024 12/31/2024 651.73 Description: DESTRUCTION RECTAL TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45190 MEDSV DEF RBRVS 01/01/2025 637.09 Description: DESTRUCTION RECTAL TUMOR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4525F NOCOV DEF SYSMAN 01/01/2012 Y Description: NEUROPSYCHIA INTERVEN ORDER Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4526F NOCOV DEF SYSMAN 01/01/2012 Y Description: NEUROPSYCHIA INTERVEN RCVD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 45300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.11 Description: PROCTOSIGMOIDOSCOPY DX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45300 MEDSV DEF RBRVS 01/01/2025 116.42 Description: PROCTOSIGMOIDOSCOPY DX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45303 MEDSV DEF RBRVS 01/01/2024 12/31/2024 895.16 Description: PROCTOSIGMOIDOSCOPY DILATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45303 MEDSV DEF RBRVS 01/01/2025 847.58 Description: PROCTOSIGMOIDOSCOPY DILATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 169.84 Description: PROCTOSIGMOIDOSCOPY W/BX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45305 MEDSV DEF RBRVS 01/01/2025 164.31 Description: PROCTOSIGMOIDOSCOPY W/BX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45307 MEDSV DEF RBRVS 01/01/2024 12/31/2024 198.96 Description: PROCTOSIGMOIDOSCOPY FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45307 MEDSV DEF RBRVS 01/01/2025 191.88 Description: PROCTOSIGMOIDOSCOPY FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45308 MEDSV DEF RBRVS 01/01/2024 12/31/2024 190.3 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45308 MEDSV DEF RBRVS 01/01/2025 183.82 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45309 MEDSV DEF RBRVS 01/01/2024 12/31/2024 196.01 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45309 MEDSV DEF RBRVS 01/01/2025 189.53 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45315 MEDSV DEF RBRVS 01/01/2024 12/31/2024 211.48 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45315 MEDSV DEF RBRVS 01/01/2025 204.39 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45317 MEDSV DEF RBRVS 01/01/2024 12/31/2024 207.34 Description: PROCTOSIGMOIDOSCOPY BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45317 MEDSV DEF RBRVS 01/01/2025 200.72 Description: PROCTOSIGMOIDOSCOPY BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 207.55 Description: PROCTOSIGMOIDOSCOPY ABLATE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45320 MEDSV DEF RBRVS 01/01/2025 199.95 Description: PROCTOSIGMOIDOSCOPY ABLATE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45321 MEDSV DEF RBRVS 01/01/2024 12/31/2024 93.55 Description: PROCTOSIGMOIDOSCOPY VOLVUL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 45321 MEDSV DEF RBRVS 01/01/2025 91.79 Description: PROCTOSIGMOIDOSCOPY VOLVUL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 45327 MEDSV DEF RBRVS 01/01/2024 12/31/2024 105.91 Description: PROCTOSIGMOIDOSCOPY W/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45327 MEDSV DEF RBRVS 01/01/2025 103.65 Description: PROCTOSIGMOIDOSCOPY W/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 173.64 Description: DIAGNOSTIC SIGMOIDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45330 MEDSV DEF RBRVS 01/01/2025 169.19 Description: DIAGNOSTIC SIGMOIDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45331 MEDSV DEF RBRVS 01/01/2024 12/31/2024 267.79 Description: SIGMOIDOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45331 MEDSV DEF RBRVS 01/01/2025 259.8 Description: SIGMOIDOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45332 MEDSV DEF RBRVS 01/01/2024 12/31/2024 259.07 Description: SIGMOIDOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45332 MEDSV DEF RBRVS 01/01/2025 252.24 Description: SIGMOIDOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45333 MEDSV DEF RBRVS 01/01/2024 12/31/2024 307.83 Description: SIGMOIDOSCOPY & POLYPECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45333 MEDSV DEF RBRVS 01/01/2025 297.29 Description: SIGMOIDOSCOPY & POLYPECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45334 MEDSV DEF RBRVS 01/01/2024 12/31/2024 461.7 Description: SIGMOIDOSCOPY FOR BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45334 MEDSV DEF RBRVS 01/01/2025 444.87 Description: SIGMOIDOSCOPY FOR BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 272.74 Description: SIGMOIDOSCOPY W/SUBMUC INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45335 MEDSV DEF RBRVS 01/01/2025 263.61 Description: SIGMOIDOSCOPY W/SUBMUC INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45337 MEDSV DEF RBRVS 01/01/2024 12/31/2024 106.07 Description: SIGMOIDOSCOPY & DECOMPRESS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45337 MEDSV DEF RBRVS 01/01/2025 103.54 Description: SIGMOIDOSCOPY & DECOMPRESS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45338 MEDSV DEF RBRVS 01/01/2024 12/31/2024 280.18 Description: SIGMOIDOSCOPY W/TUMR REMOVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45338 MEDSV DEF RBRVS 01/01/2025 272.32 Description: SIGMOIDOSCOPY W/TUMR REMOVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 427.75 Description: SIG W/TNDSC BALLOON DILATION Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45340 MEDSV DEF RBRVS 01/01/2025 411.5 Description: SIG W/TNDSC BALLOON DILATION Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45341 MEDSV DEF RBRVS 01/01/2024 12/31/2024 114.76 Description: SIGMOIDOSCOPY W/ULTRASOUND Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45341 MEDSV DEF RBRVS 01/01/2025 112.64 Description: SIGMOIDOSCOPY W/ULTRASOUND Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45342 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.05 Description: SIGMOIDOSCOPY W/US GUIDE BX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45342 MEDSV DEF RBRVS 01/01/2025 154.05 Description: SIGMOIDOSCOPY W/US GUIDE BX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45346 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2147.62 0 Description: SIGMOIDOSCOPY W/ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45346 MEDSV DEF RBRVS 01/01/2025 2050.27 Description: SIGMOIDOSCOPY W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45347 MEDSV DEF RBRVS 01/01/2024 12/31/2024 142.85 Description: SIGMOIDOSCOPY W/PLCMT STENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45347 MEDSV DEF RBRVS 01/01/2025 139.59 Description: SIGMOIDOSCOPY W/PLCMT STENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45349 MEDSV DEF RBRVS 01/01/2024 12/31/2024 184.08 Description: SIGMOIDOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45349 MEDSV DEF RBRVS 01/01/2025 179.43 Description: SIGMOIDOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 627.89 Description: SGMDSC W/BAND LIGATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45350 MEDSV DEF RBRVS 01/01/2025 604.2 Description: SGMDSC W/BAND LIGATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45378 MEDSV DEF RBRVS 01/01/2024 12/31/2024 318.2 Description: DIAGNOSTIC COLONOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45378 MEDSV DEF RBRVS 01/01/2025 309.95 Description: DIAGNOSTIC COLONOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45379 MEDSV DEF RBRVS 01/01/2024 12/31/2024 407.95 Description: COLONOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45379 MEDSV DEF RBRVS 01/01/2025 396.26 Description: COLONOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 406.8 Description: COLONOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45380 MEDSV DEF RBRVS 01/01/2025 394.97 Description: COLONOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45381 MEDSV DEF RBRVS 01/01/2024 12/31/2024 415.28 Description: COLONOSCOPY SUBMUCOUS NJX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45381 MEDSV DEF RBRVS 01/01/2025 403.12 Description: COLONOSCOPY SUBMUCOUS NJX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45382 MEDSV DEF RBRVS 01/01/2024 12/31/2024 624.59 Description: COLONOSCOPY W/CONTROL BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45382 MEDSV DEF RBRVS 01/01/2025 603.61 Description: COLONOSCOPY W/CONTROL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45384 MEDSV DEF RBRVS 01/01/2024 12/31/2024 457.06 Description: COLONOSCOPY W/LESION REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45384 MEDSV DEF RBRVS 01/01/2025 442.9 Description: COLONOSCOPY W/LESION REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45385 MEDSV DEF RBRVS 01/01/2024 12/31/2024 425.81 Description: COLONOSCOPY W/LESION REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45385 MEDSV DEF RBRVS 01/01/2025 414.24 Description: COLONOSCOPY W/LESION REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45386 MEDSV DEF RBRVS 01/01/2024 12/31/2024 572.15 Description: COLONOSCOPY W/BALLOON DILAT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45386 MEDSV DEF RBRVS 01/01/2025 552.22 Description: COLONOSCOPY W/BALLOON DILAT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45388 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2297.14 Description: COLONOSCOPY W/ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45388 MEDSV DEF RBRVS 01/01/2025 2192.23 Description: COLONOSCOPY W/ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45389 MEDSV DEF RBRVS 01/01/2024 12/31/2024 268.91 Description: COLONOSCOPY W/STENT PLCMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45389 MEDSV DEF RBRVS 01/01/2025 261.89 Description: COLONOSCOPY W/STENT PLCMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 308.41 Description: COLONOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45390 MEDSV DEF RBRVS 01/01/2025 300.69 Description: COLONOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45391 MEDSV DEF RBRVS 01/01/2024 12/31/2024 239.4 Description: COLONOSCOPY W/ENDOSCOPE US Category: Medical Services CMS Add: 01/01/2005 CMS Term: 45391 MEDSV DEF RBRVS 01/01/2025 233.27 Description: COLONOSCOPY W/ENDOSCOPE US Category: Medical Services CMS Add: 01/01/2005 CMS Term: 45392 MEDSV DEF RBRVS 01/01/2024 12/31/2024 282.36 Description: COLONOSCOPY W/ENDOSCOPIC FNB Category: Medical Services CMS Add: 01/01/2005 CMS Term: 45392 MEDSV DEF RBRVS 01/01/2025 275.11 Description: COLONOSCOPY W/ENDOSCOPIC FNB 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45393 MEDSV DEF RBRVS 01/01/2024 12/31/2024 233.23 Description: COLONOSCOPY W/DECOMPRESSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45393 MEDSV DEF RBRVS 01/01/2025 226.93 Description: COLONOSCOPY W/DECOMPRESSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45395 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1804.67 Description: LAP REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45395 MEDSV DEF RBRVS 01/01/2025 1756.07 Description: LAP REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45397 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1963.52 Description: LAP REMOVE RECTUM W/POUCH Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45397 MEDSV DEF RBRVS 01/01/2025 1908.01 Description: LAP REMOVE RECTUM W/POUCH Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45398 MEDSV DEF RBRVS 01/01/2024 12/31/2024 773.45 Description: COLONOSCOPY W/BAND LIGATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45398 MEDSV DEF RBRVS 01/01/2025 741.97 Description: COLONOSCOPY W/BAND LIGATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45399 MEDSV DEF BILL20 01/01/2015 Description: UNLISTED PROCEDURE COLON Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1048.3 Description: LAPAROSCOPIC PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45400 MEDSV DEF RBRVS 01/01/2025 1022.24 Description: LAPAROSCOPIC PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45402 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1397.17 Description: LAP PROCTOPEXY W/SIG RESECT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45402 MEDSV DEF RBRVS 01/01/2025 1360.39 Description: LAP PROCTOPEXY W/SIG RESECT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 4540F NOCOV DEF SYSMAN 01/01/2013 Y Description: DISEASE MODIF PHARMACOTHXPY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4541F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT OFFERED TX FOR PSEUDOBULB Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45499 MEDSV DEF BILL20 01/01/2014 Description: LAPAROSCOPE PROC RECTUM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 523.17 Description: REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45500 MEDSV DEF RBRVS 01/01/2025 511 Description: REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 561.32 Description: REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45505 MEDSV DEF RBRVS 01/01/2025 548.27 Description: REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4550F NOCOV DEF SYSMAN 01/01/2013 Y Description: NONINVAS RESP SUPPORT TALK Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4551F NOCOV DEF SYSMAN 01/01/2013 Y Description: NUTRITIONAL SUPPORT OFFERED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 152.51 Description: TREATMENT OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45520 MEDSV DEF RBRVS 01/01/2025 147.13 Description: TREATMENT OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4552F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT REF FOR SPEECH LANG PATH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4553F NOCOV DEF SYSMAN 01/01/2013 Y 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 12/31/2024 975.82 Description: CORRECT RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45540 MEDSV DEF RBRVS 01/01/2025 949.21 Description: CORRECT RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45541 MEDSV DEF RBRVS 01/01/2024 12/31/2024 868.4 Description: CORRECT RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45541 MEDSV DEF RBRVS 01/01/2025 846.08 Description: CORRECT RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4554F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT RECVD INHAL ANESTHETIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1346.97 Description: REPAIR RECTUM/REMOVE SIGMOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45550 MEDSV DEF RBRVS 01/01/2025 1307.87 Description: REPAIR RECTUM/REMOVE SIGMOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4555F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT RECVD NO INHAL ANESTHIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 645.43 Description: REPAIR OF RECTOCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45560 MEDSV DEF RBRVS 01/01/2025 629.95 Description: REPAIR OF RECTOCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45562 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1043.33 Description: EXPLORATION/REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45562 MEDSV DEF RBRVS 01/01/2025 1040.09 Description: EXPLORATION/REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45563 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1511.11 Description: EXPLORATION/REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45563 MEDSV DEF RBRVS 01/01/2025 1470.06 Description: EXPLORATION/REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 4556F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT W/3+ POST-OP NAUSEA&VOM Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4557F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT W/O 3+ POST-OPNAUSEA&VOM Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4558F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT RECVD 2 RX ANTI-EMET AGT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4559F NOCOV DEF SYSMAN 01/01/2013 Y Description: 1 BODYTEMP >=35.5CW/IN 30MIN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4560F NOCOV DEF SYSMAN 01/01/2013 Y Description: ANESTH W/O GEN/NEURAX ANESTH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4561F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT W/ CORONARY ARTERY STENT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4562F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT W/O CORONARY ARTERY STENT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4563F NOCOV DEF SYSMAN 01/01/2013 Y Description: PT RECVD ASPIRIN W/IN 24 HRS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1159.32 Description: REPAIR RECT/BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45800 MEDSV DEF RBRVS 01/01/2025 1128.93 Description: REPAIR RECT/BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1338.22 Description: REPAIR FISTULA W/COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45805 MEDSV DEF RBRVS 01/01/2025 1302.23 Description: REPAIR FISTULA W/COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1162.44 Description: REPAIR RECTOURETHRAL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45820 MEDSV DEF RBRVS 01/01/2025 1131.82 Description: REPAIR RECTOURETHRAL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1401.89 Description: REPAIR FISTULA W/COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45825 MEDSV DEF RBRVS 01/01/2025 1364.19 Description: REPAIR FISTULA W/COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 194.9 Description: REDUCTION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45900 MEDSV DEF RBRVS 01/01/2025 190.58 Description: REDUCTION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.33 Description: DILATION OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45905 MEDSV DEF RBRVS 01/01/2025 155.17 Description: DILATION OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45910 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.48 Description: DILATION OF RECTAL NARROWING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45910 MEDSV DEF RBRVS 01/01/2025 176.12 Description: DILATION OF RECTAL NARROWING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45915 MEDSV DEF RBRVS 01/01/2024 12/31/2024 328.6 Description: REMOVE RECTAL OBSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45915 MEDSV DEF RBRVS 01/01/2025 320.48 Description: REMOVE RECTAL OBSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45990 MEDSV DEF RBRVS 01/01/2024 12/31/2024 97.01 Description: SURG DX EXAM ANORECTAL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45990 MEDSV DEF RBRVS 01/01/2025 95.42 Description: SURG DX EXAM ANORECTAL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45999 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PROCEDURE RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 107.56 Description: PLACEMENT OF SETON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 46020 MEDSV DEF RBRVS 01/01/2025 105.41 Description: PLACEMENT OF SETON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 46030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 239.4 Description: REMOVAL ANAL SETON OTH MRK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46030 MEDSV DEF RBRVS 01/01/2025 230.09 Description: REMOVAL ANAL SETON OTH MRK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 515.36 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46040 MEDSV DEF RBRVS 01/01/2025 502.66 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46045 MEDSV DEF RBRVS 01/01/2024 12/31/2024 407.89 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46045 MEDSV DEF RBRVS 01/01/2025 399.65 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 220.78 Description: INCISION OF ANAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46050 MEDSV DEF RBRVS 01/01/2025 214.69 Description: INCISION OF ANAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.88 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46060 MEDSV DEF RBRVS 01/01/2025 443.64 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 250.76 0-364Days Description: INCISION ANAL SEPTUM INFANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46070 MEDSV DEF RBRVS 01/01/2025 244.99 0-364Days Description: INCISION ANAL SEPTUM INFANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 268.79 Description: INCISION OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46080 MEDSV DEF RBRVS 01/01/2025 260.57 Description: INCISION OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46083 MEDSV DEF RBRVS 01/01/2024 12/31/2024 193.95 Description: INCISE EXTERNAL HEMORRHOID Category: Medical Services CMS Add: 01/01/1985 CMS Term: 46083 MEDSV DEF RBRVS 01/01/2025 189.13 Description: INCISE EXTERNAL HEMORRHOID Category: Medical Services CMS Add: 01/01/1985 CMS Term: 46200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 444.04 Description: REMOVAL OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46200 MEDSV DEF RBRVS 01/01/2025 433.07 Description: REMOVAL OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 234.57 Description: EXCISE ANAL EXT TAG/PAPILLA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46220 MEDSV DEF RBRVS 01/01/2025 228.06 Description: EXCISE ANAL EXT TAG/PAPILLA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46221 MEDSV DEF RBRVS 01/01/2024 12/31/2024 265.59 Description: LIGATION OF HEMORRHOID(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46221 MEDSV DEF RBRVS 01/01/2025 258.54 Description: LIGATION OF HEMORRHOID(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 291.9 Description: REMOVAL OF ANAL TAGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46230 MEDSV DEF RBRVS 01/01/2025 284.66 Description: REMOVAL OF ANAL TAGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 446 Description: REMOVE EXT HEM GROUPS 2+ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46250 MEDSV DEF RBRVS 01/01/2025 434.16 Description: REMOVE EXT HEM GROUPS 2+ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46255 MEDSV DEF RBRVS 01/01/2024 12/31/2024 485.88 Description: REMOVE INT/EXT HEM 1 GROUP Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46255 MEDSV DEF RBRVS 01/01/2025 471.84 Description: REMOVE INT/EXT HEM 1 GROUP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46257 MEDSV DEF RBRVS 01/01/2024 12/31/2024 391.87 Description: REMOVE IN/EX HEM GRP & FISS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46257 MEDSV DEF RBRVS 01/01/2025 383.34 Description: REMOVE IN/EX HEM GRP & FISS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46258 MEDSV DEF RBRVS 01/01/2024 12/31/2024 442.71 Description: REMOVE IN/EX HEM GRP W/FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46258 MEDSV DEF RBRVS 01/01/2025 434.44 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 12/31/2024 448.11 Description: REMOVE IN/EX HEM GROUPS 2+ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46260 MEDSV DEF RBRVS 01/01/2025 437.73 Description: REMOVE IN/EX HEM GROUPS 2+ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46261 MEDSV DEF RBRVS 01/01/2024 12/31/2024 493.56 Description: REMOVE IN/EX HEM GRPS & FISS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46261 MEDSV DEF RBRVS 01/01/2025 485.58 Description: REMOVE IN/EX HEM GRPS & FISS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46262 MEDSV DEF RBRVS 01/01/2024 12/31/2024 539.33 Description: REMOVE IN/EX HEM GRPS W/FIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46262 MEDSV DEF RBRVS 01/01/2025 526.43 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 12/31/2024 498.45 Description: REMOVE ANAL FIST SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46270 MEDSV DEF RBRVS 01/01/2025 484.6 Description: REMOVE ANAL FIST SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 527.26 Description: REMOVE ANAL FIST INTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46275 MEDSV DEF RBRVS 01/01/2025 513.64 Description: REMOVE ANAL FIST INTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 448.96 Description: REMOVE ANAL FIST COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46280 MEDSV DEF RBRVS 01/01/2025 438.81 Description: REMOVE ANAL FIST COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 525.24 Description: REMOVE ANAL FIST 2 STAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46285 MEDSV DEF RBRVS 01/01/2025 513.05 Description: REMOVE ANAL FIST 2 STAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46288 MEDSV DEF RBRVS 01/01/2024 12/31/2024 521.29 Description: REPAIR ANAL FISTULA Category: Medical Services CMS Add: 01/01/1995 CMS Term: 46288 MEDSV DEF RBRVS 01/01/2025 510.24 Description: REPAIR ANAL FISTULA Category: Medical Services CMS Add: 01/01/1995 CMS Term: 46320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 199.46 Description: REMOVAL OF HEMORRHOID CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46320 MEDSV DEF RBRVS 01/01/2025 194.46 Description: REMOVAL OF HEMORRHOID CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 294.37 Description: INJECTION INTO HEMORRHOID(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46500 MEDSV DEF RBRVS 01/01/2025 283.91 Description: INJECTION INTO HEMORRHOID(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 294.43 Description: CHEMODENERVATION ANAL MUSC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46505 MEDSV DEF RBRVS 01/01/2025 286.6 Description: CHEMODENERVATION ANAL MUSC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 111.32 Description: DIAGNOSTIC ANOSCOPY SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46600 MEDSV DEF RBRVS 01/01/2025 106.99 Description: DIAGNOSTIC ANOSCOPY SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 139.88 Description: DIAGNOSTIC ANOSCOPY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 46601 MEDSV DEF RBRVS 01/01/2025 136.79 Description: DIAGNOSTIC ANOSCOPY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 46604 MEDSV DEF RBRVS 01/01/2024 12/31/2024 611.7 Description: ANOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46604 MEDSV DEF RBRVS 01/01/2025 580.01 Description: ANOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 262.45 Description: ANOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46606 MEDSV DEF RBRVS 01/01/2025 253.66 Description: ANOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46607 MEDSV DEF RBRVS 01/01/2024 12/31/2024 193.6 Description: DIAGNOSTIC ANOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 46607 MEDSV DEF RBRVS 01/01/2025 189.12 Description: DIAGNOSTIC ANOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 46608 MEDSV DEF RBRVS 01/01/2024 12/31/2024 272.42 Description: ANOSCOPY REMOVE FOR BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46608 MEDSV DEF RBRVS 01/01/2025 260.81 Description: ANOSCOPY REMOVE FOR BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 259.18 Description: ANOSCOPY REMOVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46610 MEDSV DEF RBRVS 01/01/2025 248 Description: ANOSCOPY REMOVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46611 MEDSV DEF RBRVS 01/01/2024 12/31/2024 209.19 Description: ANOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46611 MEDSV DEF RBRVS 01/01/2025 202.43 Description: ANOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46612 MEDSV DEF RBRVS 01/01/2024 12/31/2024 311.47 Description: ANOSCOPY REMOVE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46612 MEDSV DEF RBRVS 01/01/2025 297.74 Description: ANOSCOPY REMOVE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46614 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.26 Description: ANOSCOPY CONTROL BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46614 MEDSV DEF RBRVS 01/01/2025 152.72 Description: ANOSCOPY CONTROL BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 166.88 Description: ANOSCOPY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46615 MEDSV DEF RBRVS 01/01/2025 161.44 Description: ANOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 612.23 15-999Years Description: REPAIR OF ANAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46700 MEDSV DEF RBRVS 01/01/2025 596.41 15-999Years Description: REPAIR OF ANAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 526.23 0-364Days Description: REPAIR OF ANAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46705 MEDSV DEF RBRVS 01/01/2025 513.78 0-364Days Description: REPAIR OF ANAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46706 MEDSV DEF RBRVS 01/01/2024 12/31/2024 164.58 Description: REPR OF ANAL FISTULA W/GLUE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 46706 MEDSV DEF RBRVS 01/01/2025 161.9 Description: REPR OF ANAL FISTULA W/GLUE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 46707 MEDSV DEF RBRVS 01/01/2024 12/31/2024 463.95 Description: REPAIR ANORECTAL FIST W/PLUG Category: Medical Services CMS Add: 01/01/2010 CMS Term: 46707 MEDSV DEF RBRVS 01/01/2025 453.55 Description: REPAIR ANORECTAL FIST W/PLUG Category: Medical Services CMS Add: 01/01/2010 CMS Term: 46710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1014.79 Description: REPR PER/VAG POUCH SNGL PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46710 MEDSV DEF RBRVS 01/01/2025 988.56 Description: REPR PER/VAG POUCH SNGL PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46712 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2017.02 Description: REPR PER/VAG POUCH DBL PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46712 MEDSV DEF RBRVS 01/01/2025 1960.66 Description: REPR PER/VAG POUCH DBL PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 510.47 Description: REP PERF ANOPER FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46715 MEDSV DEF RBRVS 01/01/2025 498.01 Description: REP PERF ANOPER FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46716 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1129.97 Description: REP PERF ANOPER/VESTIB FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46716 MEDSV DEF RBRVS 01/01/2025 1105.29 Description: REP PERF ANOPER/VESTIB FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1813.97 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46730 MEDSV DEF RBRVS 01/01/2025 1770.15 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46735 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2084.73 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46735 MEDSV DEF RBRVS 01/01/2025 2033.47 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1977.58 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46740 MEDSV DEF RBRVS 01/01/2025 1929.62 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46742 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2282.06 Description: REPAIR OF IMPERFORATED ANUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46742 MEDSV DEF RBRVS 01/01/2025 2225.34 Description: REPAIR OF IMPERFORATED ANUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46744 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3213.07 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46744 MEDSV DEF RBRVS 01/01/2025 3128.82 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46746 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3538.13 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46746 MEDSV DEF RBRVS 01/01/2025 3444.56 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46748 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3832.99 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46748 MEDSV DEF RBRVS 01/01/2025 3730.94 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 699.03 15-999Years 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46750 MEDSV DEF RBRVS 01/01/2025 681.39 15-999Years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46751 MEDSV DEF RBRVS 01/01/2024 12/31/2024 614.91 0-19Years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46751 MEDSV DEF RBRVS 01/01/2025 599.84 0-19Years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46753 MEDSV DEF RBRVS 01/01/2024 12/31/2024 569.16 Description: RECONSTRUCTION OF ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46753 MEDSV DEF RBRVS 01/01/2025 554.94 Description: RECONSTRUCTION OF ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46754 MEDSV DEF RBRVS 01/01/2024 12/31/2024 326.7 Description: REMOVAL OF SUTURE FROM ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46754 MEDSV DEF RBRVS 01/01/2025 319.87 Description: REMOVAL OF SUTURE FROM ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1033.4 15-999Years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46760 MEDSV DEF RBRVS 01/01/2025 1008.58 15-999Years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46761 MEDSV DEF RBRVS 01/01/2024 12/31/2024 852.87 15-999Years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 46761 MEDSV DEF RBRVS 01/01/2025 829.15 15-999Years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 46900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 223.88 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46900 MEDSV DEF RBRVS 01/01/2025 220.04 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46910 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.83 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46910 MEDSV DEF RBRVS 01/01/2025 240.91 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46916 MEDSV DEF RBRVS 01/01/2024 12/31/2024 244.84 Description: CRYOSURGERY ANAL LESION(S) 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46916 MEDSV DEF RBRVS 01/01/2025 239.02 Description: CRYOSURGERY ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46917 MEDSV DEF RBRVS 01/01/2024 12/31/2024 418.24 Description: LASER SURGERY ANAL LESIONS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46917 MEDSV DEF RBRVS 01/01/2025 402.72 Description: LASER SURGERY ANAL LESIONS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46922 MEDSV DEF RBRVS 01/01/2024 12/31/2024 293.56 Description: EXCISION OF ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46922 MEDSV DEF RBRVS 01/01/2025 284.72 Description: EXCISION OF ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46924 MEDSV DEF RBRVS 01/01/2024 12/31/2024 513.35 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46924 MEDSV DEF RBRVS 01/01/2025 505.2 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 202.27 Description: DESTROY INTERNAL HEMORRHOIDS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 46930 MEDSV DEF RBRVS 01/01/2025 197.66 Description: DESTROY INTERNAL HEMORRHOIDS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 46940 MEDSV DEF RBRVS 01/01/2024 12/31/2024 250.12 Description: TREATMENT OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46940 MEDSV DEF RBRVS 01/01/2025 243.87 Description: TREATMENT OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46942 MEDSV DEF RBRVS 01/01/2024 12/31/2024 238.12 Description: TREATMENT OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46942 MEDSV DEF RBRVS 01/01/2025 232.25 Description: TREATMENT OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46945 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 310.91 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 12/31/2024 355.79 Description: INT HRHC LIG 2+HROID W/O IMG Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46946 MEDSV DEF RBRVS 01/01/2025 347.92 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 12/31/2024 359.48 Description: HEMORRHOIDOPEXY BY STAPLING Category: Medical Services CMS Add: 01/01/2005 CMS Term: 46947 MEDSV DEF RBRVS 01/01/2025 352.41 Description: HEMORRHOIDOPEXY BY STAPLING Category: Medical Services CMS Add: 01/01/2005 CMS Term: 46948 MEDSV DEF RBRVS 01/01/2024 12/31/2024 413.28 Description: INT HRHC TRANAL DARTLZJ 2+ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 46948 MEDSV DEF RBRVS 01/01/2025 403.03 Description: INT HRHC TRANAL DARTLZJ 2+ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 46999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PROCEDURE ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 283.39 Description: NEEDLE BIOPSY OF LIVER PERQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47000 MEDSV DEF RBRVS 01/01/2025 271.38 Description: NEEDLE BIOPSY OF LIVER PERQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 93.71 Description: NDL BIOPSY LVR TM OTH MAJ PX Category: Medical Services CMS Add: 01/01/1992 CMS Term: 47001 MEDSV DEF RBRVS 01/01/2025 90.81 Description: NDL BIOPSY LVR TM OTH MAJ PX Category: Medical Services CMS Add: 01/01/1992 CMS Term: 47010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1108.15 Description: HEPATOT OPN DRG ABSC/CST 1/2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47010 MEDSV DEF RBRVS 01/01/2025 1079.67 Description: HEPATOT OPN DRG ABSC/CST 1/2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1063.25 Description: LAPT ASPIR&/NJX HEP PRST CST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47015 MEDSV DEF RBRVS 01/01/2025 1035.78 Description: LAPT ASPIR&/NJX HEP PRST CST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 777.42 Description: WEDGE BIOPSY OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47100 MEDSV DEF RBRVS 01/01/2025 759.75 Description: WEDGE BIOPSY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2127.43 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47120 MEDSV DEF RBRVS 01/01/2025 2071.86 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47122 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3110.65 Y Description: EXTENSIVE REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47122 MEDSV DEF RBRVS 01/01/2025 3021.55 Y Description: EXTENSIVE REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2793.69 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47125 MEDSV DEF RBRVS 01/01/2025 2718.77 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3000.59 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47130 MEDSV DEF RBRVS 01/01/2025 2916.19 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47133 MEDSV PRF MAXFEE 01/01/2024 12/31/2024 3712.5 0 Description: REMOVAL OF DONOR LIVER Category: Medical Services CMS Add: 01/01/1986 CMS Term: 47133 MEDSV PRF MAXFEE 01/01/2025 3638.25 0 Description: REMOVAL OF DONOR LIVER Category: Medical Services CMS Add: 01/01/1986 CMS Term: 47135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4895.83 Y Description: TRANSPLANTATION OF LIVER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 47135 MEDSV DEF RBRVS 01/01/2025 4778.64 Y Description: TRANSPLANTATION OF LIVER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 47140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3241.69 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47140 MEDSV DEF RBRVS 01/01/2025 3163.6 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47141 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3873.54 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47141 MEDSV DEF RBRVS 01/01/2025 3778.26 Description: PARTIAL REMOVAL DONOR LIVER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47142 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4256.66 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47142 MEDSV DEF RBRVS 01/01/2025 4158.18 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 Y Description: PREP DONOR LIVER WHOLE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47144 MEDSV DEF MAXFEE 01/01/2024 392.87 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 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 12/31/2024 295.68 Y Description: PREP DONOR LIVER/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47146 MEDSV DEF RBRVS 01/01/2025 286.72 Y Description: PREP DONOR LIVER/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47147 MEDSV DEF RBRVS 01/01/2024 12/31/2024 344.69 Y Description: PREP DONOR LIVER/ARTERIAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47147 MEDSV DEF RBRVS 01/01/2025 335.05 Y Description: PREP DONOR LIVER/ARTERIAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1038.87 Description: SURGERY FOR LIVER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47300 MEDSV DEF RBRVS 01/01/2025 1012.22 Description: SURGERY FOR LIVER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1249.54 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47350 MEDSV DEF RBRVS 01/01/2025 1214.6 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1704.61 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47360 MEDSV DEF RBRVS 01/01/2025 1658.3 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47361 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2744.39 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47361 MEDSV DEF RBRVS 01/01/2025 2661.26 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1996 CMS Term: 47362 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1309.68 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1996 CMS Term: 47362 MEDSV DEF RBRVS 01/01/2025 1286.24 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1996 CMS Term: 47370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1144.13 Description: LAPARO ABLATE LIVER TUMOR RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47370 MEDSV DEF RBRVS 01/01/2025 1115.25 Description: LAPARO ABLATE LIVER TUMOR RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47371 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1147.29 Description: LAPARO ABLATE LIVER CRYOSURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47371 MEDSV DEF RBRVS 01/01/2025 1118.22 Description: LAPARO ABLATE LIVER CRYOSURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47379 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED LAPS PX LIVER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 47380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1319.56 Description: OPEN ABLATE LIVER TUMOR RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47380 MEDSV DEF RBRVS 01/01/2025 1287.38 Description: OPEN ABLATE LIVER TUMOR RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47381 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1348.12 Description: OPEN ABLATE LIVER TUMOR CRYO Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47381 MEDSV DEF RBRVS 01/01/2025 1313.31 Description: OPEN ABLATE LIVER TUMOR CRYO Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47382 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3449.88 Description: PERCUT ABLATE LIVER RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47382 MEDSV DEF RBRVS 01/01/2025 3253.52 Description: PERCUT ABLATE LIVER RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47383 MEDSV PRF MAXFEE 01/01/2024 12/31/2024 5586.52 0 Description: PERQ ABLTJ LVR CRYOABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 47383 MEDSV DEF RBRVS 01/01/2025 5224.42 Description: PERQ ABLTJ LVR CRYOABLATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47399 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PROCEDURE LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1953.6 Description: INCISION OF LIVER DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47400 MEDSV DEF RBRVS 01/01/2025 1900.33 Description: INCISION OF LIVER DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1216.19 Description: INCISION OF BILE DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47420 MEDSV DEF RBRVS 01/01/2025 1190.88 Description: INCISION OF BILE DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1246.25 Description: INCISION OF BILE DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47425 MEDSV DEF RBRVS 01/01/2025 1213.25 Description: INCISION OF BILE DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1157.67 Description: INCISE BILE DUCT SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47460 MEDSV DEF RBRVS 01/01/2025 1127.4 Description: INCISE BILE DUCT SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47480 MEDSV DEF RBRVS 01/01/2024 12/31/2024 804.41 Description: INCISION OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47480 MEDSV DEF RBRVS 01/01/2025 784.29 Description: INCISION OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47490 MEDSV DEF RBRVS 01/01/2024 12/31/2024 311.02 Description: INCISION OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47490 MEDSV DEF RBRVS 01/01/2025 300.99 Description: INCISION OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47531 MEDSV DEF RBRVS 01/01/2024 12/31/2024 399.15 Description: INJECTION FOR CHOLANGIOGRAM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47531 MEDSV DEF RBRVS 01/01/2025 378.23 Description: INJECTION FOR CHOLANGIOGRAM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47532 MEDSV DEF RBRVS 01/01/2024 12/31/2024 788.29 Description: INJECTION FOR CHOLANGIOGRAM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47532 MEDSV DEF RBRVS 01/01/2025 751.64 Description: INJECTION FOR CHOLANGIOGRAM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47533 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1096.93 Description: PLMT BILIARY DRAINAGE CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47533 MEDSV DEF RBRVS 01/01/2025 1039.88 Description: PLMT BILIARY DRAINAGE CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47534 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1204.4 Description: PLMT BILIARY DRAINAGE CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47534 MEDSV DEF RBRVS 01/01/2025 1144.15 Description: PLMT BILIARY DRAINAGE CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 835.2 Description: CONVERSION EXT BIL DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47535 MEDSV DEF RBRVS 01/01/2025 791.72 Description: CONVERSION EXT BIL DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47536 MEDSV DEF RBRVS 01/01/2024 12/31/2024 598.61 Description: EXCHANGE BILIARY DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47536 MEDSV DEF RBRVS 01/01/2025 566.75 Description: EXCHANGE BILIARY DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47537 MEDSV DEF RBRVS 01/01/2024 12/31/2024 463.34 Description: REMOVAL BILIARY DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47537 MEDSV DEF RBRVS 01/01/2025 438.53 Description: REMOVAL BILIARY DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47538 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3535.04 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47538 MEDSV DEF RBRVS 01/01/2025 3324.53 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47539 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3944.88 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47539 MEDSV DEF RBRVS 01/01/2025 3741.31 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3981.05 Description: PERQ PLMT BILE DUCT STENT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47540 MEDSV DEF RBRVS 01/01/2025 3733.89 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47541 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1092.99 Description: PLMT ACCESS BIL TREE SM BWL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47541 MEDSV DEF RBRVS 01/01/2025 1041.86 Description: PLMT ACCESS BIL TREE SM BWL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47542 MEDSV DEF RBRVS 01/01/2024 12/31/2024 469.54 Description: DILATE BILIARY DUCT/AMPULLA Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47542 MEDSV DEF RBRVS 01/01/2025 445.27 Description: DILATE BILIARY DUCT/AMPULLA Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47543 MEDSV DEF RBRVS 01/01/2024 12/31/2024 369.51 Description: ENDOLUMINAL BX BILIARY TREE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47543 MEDSV DEF RBRVS 01/01/2025 351.92 Description: ENDOLUMINAL BX BILIARY TREE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47544 MEDSV DEF RBRVS 01/01/2024 12/31/2024 786.22 Description: REMOVAL DUCT GLBLDR CALCULI Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47544 MEDSV DEF RBRVS 01/01/2025 744.84 Description: REMOVAL DUCT GLBLDR CALCULI Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 148.5 Description: BILE DUCT ENDOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47550 MEDSV DEF RBRVS 01/01/2025 143.83 Description: BILE DUCT ENDOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 258.38 Description: BILIARY ENDO PERQ DX W/SPECI Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47552 MEDSV DEF RBRVS 01/01/2025 250.56 Description: BILIARY ENDO PERQ DX W/SPECI Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47553 MEDSV DEF RBRVS 01/01/2024 12/31/2024 259.65 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47553 MEDSV DEF RBRVS 01/01/2025 251.08 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 415.52 Description: BILIARY ENDOSCOPY THRU SKIN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47554 MEDSV DEF RBRVS 01/01/2025 401.64 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 309.09 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47555 MEDSV DEF RBRVS 01/01/2025 298.98 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 350.15 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 47556 MEDSV DEF RBRVS 01/01/2025 338.62 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 47562 MEDSV DEF RBRVS 01/01/2024 12/31/2024 603.77 Description: LAPAROSCOPIC CHOLECYSTECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47562 MEDSV DEF RBRVS 01/01/2025 590.35 Description: LAPAROSCOPIC CHOLECYSTECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47563 MEDSV DEF RBRVS 01/01/2024 12/31/2024 657.75 Description: LAPARO CHOLECYSTECTOMY/GRAPH Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47563 MEDSV DEF RBRVS 01/01/2025 641.56 Description: LAPARO CHOLECYSTECTOMY/GRAPH Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47564 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1020.86 Description: LAPARO CHOLECYSTECTOMY/EXPLR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47564 MEDSV DEF RBRVS 01/01/2025 996.62 Description: LAPARO CHOLECYSTECTOMY/EXPLR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 709.11 0-1 Description: LAPARO CHOLECYSTOENTEROSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47570 MEDSV DEF RBRVS 01/01/2025 691.4 0-1 Description: LAPARO CHOLECYSTOENTEROSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47579 MEDSV DEF BILL20 01/01/2014 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 12/31/2024 977.63 Description: CHOLECYSTECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47600 MEDSV DEF RBRVS 01/01/2025 953.76 Description: CHOLECYSTECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1029.94 Description: CHOLECYSTECTOMY W/CHOLANG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47605 MEDSV DEF RBRVS 01/01/2025 1003.34 Description: CHOLECYSTECTOMY W/CHOLANG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1142.66 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47610 MEDSV DEF RBRVS 01/01/2025 1109.39 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47612 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1159.86 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47612 MEDSV DEF RBRVS 01/01/2025 1129.31 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1252.06 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47620 MEDSV DEF RBRVS 01/01/2025 1218.52 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 968.29 Description: EXPLORATION OF BILE DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47700 MEDSV DEF RBRVS 01/01/2025 943.79 Description: EXPLORATION OF BILE DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47701 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1581.25 Description: BILE DUCT REVISION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47701 MEDSV DEF RBRVS 01/01/2025 1538.3 Description: BILE DUCT REVISION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47711 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1421.32 Description: EXCISION OF BILE DUCT TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47711 MEDSV DEF RBRVS 01/01/2025 1384.78 Description: EXCISION OF BILE DUCT TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47712 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1814.63 Description: EXCISION OF BILE DUCT TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47712 MEDSV DEF RBRVS 01/01/2025 1765.03 Description: EXCISION OF BILE DUCT TUMOR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1213.72 Description: EXCISION OF BILE DUCT CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47715 MEDSV DEF RBRVS 01/01/2025 1182.02 Description: EXCISION OF BILE DUCT CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1055.49 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47720 MEDSV DEF RBRVS 01/01/2025 1028.09 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47721 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1235.67 Description: FUSE UPPER GI STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47721 MEDSV DEF RBRVS 01/01/2025 1203.17 Description: FUSE UPPER GI STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1197.89 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47740 MEDSV DEF RBRVS 01/01/2025 1166.65 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47741 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1344.9 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47741 MEDSV DEF RBRVS 01/01/2025 1309.51 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2050.06 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47760 MEDSV DEF RBRVS 01/01/2025 1997.34 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47765 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2702.42 Description: FUSE LIVER DUCTS & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47765 MEDSV DEF RBRVS 01/01/2025 2673.97 Description: FUSE LIVER DUCTS & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2248.11 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47780 MEDSV DEF RBRVS 01/01/2025 2190.45 Description: FUSE BILE DUCTS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47785 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2941.19 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47785 MEDSV DEF RBRVS 01/01/2025 2860.57 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1426.66 Description: RECONSTRUCTION OF BILE DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47800 MEDSV DEF RBRVS 01/01/2025 1387.11 Description: RECONSTRUCTION OF BILE DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47801 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1019.02 Description: PLACEMENT BILE DUCT SUPPORT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47801 MEDSV DEF RBRVS 01/01/2025 992.85 Description: PLACEMENT BILE DUCT SUPPORT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47802 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1389.49 Description: FUSE LIVER DUCT & INTESTINE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 12/31/2024 47802 MEDSV DEF RBRVS 01/01/2025 1352.7 Description: FUSE LIVER DUCT & INTESTINE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 12/31/2024 47900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1257.93 Description: SUTURE BILE DUCT INJURY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47900 MEDSV DEF RBRVS 01/01/2025 1224.62 Description: SUTURE BILE DUCT INJURY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47999 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX BILIARY TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1710.82 Description: DRAINAGE OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48000 MEDSV DEF RBRVS 01/01/2025 1665.05 Description: DRAINAGE OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2092.93 Description: PLACEMENT OF DRAIN PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48001 MEDSV DEF RBRVS 01/01/2025 2036.01 Description: PLACEMENT OF DRAIN PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1076.56 Description: REMOVAL OF PANCREATIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 48020 MEDSV DEF RBRVS 01/01/2025 1049.04 Description: REMOVAL OF PANCREATIC STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 812.11 Description: BIOPSY OF PANCREAS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48100 MEDSV DEF RBRVS 01/01/2025 795.71 Description: BIOPSY OF PANCREAS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 486.19 Description: NEEDLE BIOPSY PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48102 MEDSV DEF RBRVS 01/01/2025 463.87 Description: NEEDLE BIOPSY PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2584.46 Description: RESECT/DEBRIDE PANCREAS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 48105 MEDSV DEF RBRVS 01/01/2025 2511.44 Description: RESECT/DEBRIDE PANCREAS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 48120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1016.04 Description: REMOVAL OF PANCREAS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48120 MEDSV DEF RBRVS 01/01/2025 989.34 Description: REMOVAL OF PANCREAS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1428.2 Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48140 MEDSV DEF RBRVS 01/01/2025 1391.97 Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1485.77 Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48145 MEDSV DEF RBRVS 01/01/2025 1446.74 Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48146 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1716.24 Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48146 MEDSV DEF RBRVS 01/01/2025 1670.24 Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48148 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1140.74 Description: REMOVAL OF PANCREATIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 48148 MEDSV DEF RBRVS 01/01/2025 1111.34 Description: REMOVAL OF PANCREATIC DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2833.74 Y Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48150 MEDSV DEF RBRVS 01/01/2025 2759.22 Y Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48152 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2622.49 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48152 MEDSV DEF RBRVS 01/01/2025 2549.04 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48153 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2821.67 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48153 MEDSV DEF RBRVS 01/01/2025 2744.75 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48154 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2633.39 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48154 MEDSV DEF RBRVS 01/01/2025 2560.24 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1664.32 Y Description: REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48155 MEDSV DEF RBRVS 01/01/2025 1616.6 Y Description: REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48160 MEDSV PRF MAXFEE 01/01/2024 12/31/2024 2595.24 0 Y Description: PANCREAS REMOVAL/TRANSPLANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 48160 MEDSV PRF MAXFEE 01/01/2025 2543.34 0 Y Description: PANCREAS REMOVAL/TRANSPLANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 48400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 96.5 Description: INJECTION INTRAOP ADD-ON Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48400 MEDSV DEF RBRVS 01/01/2025 93.37 Description: INJECTION INTRAOP ADD-ON Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1050.13 Description: SURGERY OF PANCREATIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 48500 MEDSV DEF RBRVS 01/01/2025 1023.07 Description: SURGERY OF PANCREATIC CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1002.29 Description: DRAIN PANCREATIC PSEUDOCYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 48510 MEDSV DEF RBRVS 01/01/2025 976.47 Description: DRAIN PANCREATIC PSEUDOCYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 48520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1003.49 Description: FUSE PANCREAS CYST AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48520 MEDSV DEF RBRVS 01/01/2025 976.86 Description: FUSE PANCREAS CYST AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1190.28 Description: FUSE PANCREAS CYST AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48540 MEDSV DEF RBRVS 01/01/2025 1158.64 Description: FUSE PANCREAS CYST AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1227.01 Description: PANCREATORRHAPHY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48545 MEDSV DEF RBRVS 01/01/2025 1195.52 Description: PANCREATORRHAPHY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48547 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1629.42 Description: DUODENAL EXCLUSION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48547 MEDSV DEF RBRVS 01/01/2025 1585.7 Description: DUODENAL EXCLUSION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48548 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1520.41 Description: FUSE PANCREAS AND BOWEL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 48548 MEDSV DEF RBRVS 01/01/2025 1480.53 Description: FUSE PANCREAS AND BOWEL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 48550 MEDSV DEF BILL20 01/01/2010 Y Description: DONOR PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48551 MEDSV DEF MAXFEE 01/01/2024 249.42 0 Y Description: PREP DONOR PANCREAS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 48552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 212.18 Y Description: PREP DONOR PANCREAS/VENOUS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 48552 MEDSV DEF RBRVS 01/01/2025 205.99 Y Description: PREP DONOR PANCREAS/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 48554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2386.29 Y Description: TRANSPL ALLOGRAFT PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48554 MEDSV DEF RBRVS 01/01/2025 2347.37 Y Description: TRANSPL ALLOGRAFT PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1175.63 Y Description: REMOVAL ALLOGRAFT PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48556 MEDSV DEF RBRVS 01/01/2025 1151.37 Y Description: REMOVAL ALLOGRAFT PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48999 MEDSV DEF BILL20 09/09/2021 Y Description: UNLISTED PROCEDURE PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 703.92 Description: EXPLORATION OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49000 MEDSV DEF RBRVS 01/01/2025 687.21 Description: EXPLORATION OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49002 MEDSV DEF RBRVS 01/01/2024 12/31/2024 951.63 Description: REOPENING OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49002 MEDSV DEF RBRVS 01/01/2025 927.5 Description: REOPENING OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 840.72 Description: EXPLORATION BEHIND ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49010 MEDSV DEF RBRVS 01/01/2025 820.91 Description: EXPLORATION BEHIND ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49013 MEDSV DEF RBRVS 01/01/2024 12/31/2024 411.52 Description: PRPERTL PEL PACK HEMRRG TRMA Category: Medical Services CMS Add: 01/01/2020 CMS Term: 49013 MEDSV DEF RBRVS 01/01/2025 399.94 Description: PRPERTL PEL PACK HEMRRG TRMA Category: Medical Services CMS Add: 01/01/2020 CMS Term: 49014 MEDSV DEF RBRVS 01/01/2024 12/31/2024 342.62 Description: REEXPLORATION PELVIC WOUND Category: Medical Services CMS Add: 01/01/2020 CMS Term: 49014 MEDSV DEF RBRVS 01/01/2025 333.42 Description: REEXPLORATION PELVIC WOUND 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1456.08 Description: DRAINAGE ABDOM ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49020 MEDSV DEF RBRVS 01/01/2025 1420.76 Description: DRAINAGE ABDOM ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 919.66 Description: DRAIN OPEN ABDOM ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49040 MEDSV DEF RBRVS 01/01/2025 894.55 Description: DRAIN OPEN ABDOM ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1003.39 Description: DRAIN OPEN RETROPERI ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49060 MEDSV DEF RBRVS 01/01/2025 977.91 Description: DRAIN OPEN RETROPERI ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49062 MEDSV DEF RBRVS 01/01/2024 12/31/2024 702.3 Description: DRAIN TO PERITONEAL CAVITY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49062 MEDSV DEF RBRVS 01/01/2025 685.94 Description: DRAIN TO PERITONEAL CAVITY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49082 MEDSV DEF RBRVS 01/01/2024 12/31/2024 197.89 Description: ABD PARACENTESIS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49082 MEDSV DEF RBRVS 01/01/2025 192.16 Description: ABD PARACENTESIS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49083 MEDSV DEF RBRVS 01/01/2024 12/31/2024 276.44 Description: ABD PARACENTESIS W/IMAGING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49083 MEDSV DEF RBRVS 01/01/2025 265.2 Description: ABD PARACENTESIS W/IMAGING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49084 MEDSV DEF RBRVS 01/01/2024 12/31/2024 97.7 Description: PERITONEAL LAVAGE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49084 MEDSV DEF RBRVS 01/01/2025 94.37 Description: PERITONEAL LAVAGE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 164.63 Description: BIOPSY ABDOMINAL MASS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49180 MEDSV DEF RBRVS 01/01/2025 158.67 Description: BIOPSY ABDOMINAL MASS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49185 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1188.23 Description: SCLEROTX FLUID COLLECTION Category: Medical Services CMS Add: 01/01/2016 CMS Term: 49185 MEDSV DEF RBRVS 01/01/2025 1122.5 Description: SCLEROTX FLUID COLLECTION Category: Medical Services CMS Add: 01/01/2016 CMS Term: 49186 MEDSV DEF RBRVS 01/01/2025 1185.74 Description: OPN EXC/DSTR NTRA-ABD 5 CM/< Category: Medical Services CMS Add: 01/01/2025 CMS Term: 49187 MEDSV DEF RBRVS 01/01/2025 1507.31 Description: OPN EXC/DSTR NTRA-ABD 5.1-10 Category: Medical Services CMS Add: 01/01/2025 CMS Term: 49188 MEDSV DEF RBRVS 01/01/2025 1801.16 Description: OPN EXC/DST NTRA-ABD 10.1-20 Category: Medical Services CMS Add: 01/01/2025 CMS Term: 49189 MEDSV DEF RBRVS 01/01/2025 2094.68 Description: OPN EXC/DST NTRA-ABD 20.1-30 Category: Medical Services CMS Add: 01/01/2025 CMS Term: 49190 MEDSV DEF RBRVS 01/01/2025 2585.18 Description: OPN EXC/DSTR NTRA-ABD >30 CM Category: Medical Services CMS Add: 01/01/2025 CMS Term: 49203 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1096.71 Description: EXC ABD TUM 5 CM OR LESS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 12/31/2024 49203 MEDSV DEF RBRVS 01/01/2025 1070.05 Description: EXC ABD TUM 5 CM OR LESS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 12/31/2024 49204 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1396.98 Description: EXC ABD TUM OVER 5 CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 12/31/2024 49204 MEDSV DEF RBRVS 01/01/2025 1363.39 Description: EXC ABD TUM OVER 5 CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 12/31/2024 49205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1602.74 Description: EXC ABD TUM OVER 10 CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 12/31/2024 49205 MEDSV DEF RBRVS 01/01/2025 1563.17 Description: EXC ABD TUM OVER 10 CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 12/31/2024 49215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2020.87 Description: EXCISE SACRAL SPINE TUMOR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 49215 MEDSV DEF RBRVS 01/01/2025 1983.48 Description: EXCISE SACRAL SPINE TUMOR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 49250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 546.26 Description: EXCISION OF UMBILICUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49250 MEDSV DEF RBRVS 01/01/2025 535.32 Description: EXCISION OF UMBILICUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49255 MEDSV DEF RBRVS 01/01/2024 12/31/2024 729.62 Description: REMOVAL OF OMENTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49255 MEDSV DEF RBRVS 01/01/2025 713.96 Description: REMOVAL OF OMENTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 301.84 0-1 Description: DIAG LAPARO SEPARATE PROC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49320 MEDSV DEF RBRVS 01/01/2025 295.76 0-1 Description: DIAG LAPARO SEPARATE PROC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49321 MEDSV DEF RBRVS 01/01/2024 12/31/2024 316.96 0-1 Description: LAPAROSCOPY BIOPSY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49321 MEDSV DEF RBRVS 01/01/2025 310.11 0-1 Description: LAPAROSCOPY BIOPSY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49322 MEDSV DEF RBRVS 01/01/2024 12/31/2024 344.72 0-1 Description: LAPAROSCOPY ASPIRATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49322 MEDSV DEF RBRVS 01/01/2025 336.61 0-1 Description: LAPAROSCOPY ASPIRATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49323 MEDSV DEF RBRVS 01/01/2024 12/31/2024 585.26 0-1 Description: LAPARO DRAIN LYMPHOCELE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49323 MEDSV DEF RBRVS 01/01/2025 574.09 0-1 Description: LAPARO DRAIN LYMPHOCELE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49324 MEDSV DEF RBRVS 01/01/2024 12/31/2024 353.5 Description: LAP INSERT TUNNEL IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49324 MEDSV DEF RBRVS 01/01/2025 344.5 Description: LAP INSERT TUNNEL IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 377.15 Description: LAP REVISION PERM IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49325 MEDSV DEF RBRVS 01/01/2025 367.16 Description: LAP REVISION PERM IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49326 MEDSV DEF RBRVS 01/01/2024 12/31/2024 169.8 Description: LAP W/OMENTOPEXY ADD-ON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49326 MEDSV DEF RBRVS 01/01/2025 164.97 Description: LAP W/OMENTOPEXY ADD-ON Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49327 MEDSV DEF RBRVS 01/01/2024 12/31/2024 117.32 Description: LAP INS DEVICE FOR RT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49327 MEDSV DEF RBRVS 01/01/2025 113.88 Description: LAP INS DEVICE FOR RT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49329 MEDSV DEF BILL20 01/01/2014 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 12/31/2024 141.33 Description: AIR INJECTION INTO ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49400 MEDSV DEF RBRVS 01/01/2025 136.14 Description: AIR INJECTION INTO ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49402 MEDSV DEF RBRVS 01/01/2024 12/31/2024 781.13 Description: REMOVE FOREIGN BODY ADBOMEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49402 MEDSV DEF RBRVS 01/01/2025 762.19 Description: REMOVE FOREIGN BODY ADBOMEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 834.72 Description: IMAGE CATH FLUID COLXN VISC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49405 MEDSV DEF RBRVS 01/01/2025 792.46 Description: IMAGE CATH FLUID COLXN VISC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49406 MEDSV DEF RBRVS 01/01/2024 12/31/2024 835.03 Description: IMAGE CATH FLUID PERI/RETRO Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49406 MEDSV DEF RBRVS 01/01/2025 792.76 Description: IMAGE CATH FLUID PERI/RETRO Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49407 MEDSV DEF RBRVS 01/01/2024 12/31/2024 706.17 Description: IMAGE CATH FLUID TRNS/VGNL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49407 MEDSV DEF RBRVS 01/01/2025 676.62 Description: IMAGE CATH FLUID TRNS/VGNL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49411 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.99 Description: INS MARK ABD/PEL FOR RT PERQ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 49411 MEDSV DEF RBRVS 01/01/2025 436.88 Description: INS MARK ABD/PEL FOR RT PERQ 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49412 MEDSV DEF RBRVS 01/01/2024 12/31/2024 74.07 Description: INS DEVICE FOR RT GUIDE OPEN Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49412 MEDSV DEF RBRVS 01/01/2025 71.91 Description: INS DEVICE FOR RT GUIDE OPEN Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49418 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 924.94 0 Description: INSERT TUN IP CATH PERC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49418 MEDSV DEF RBRVS 01/01/2025 877.06 Description: INSERT TUN IP CATH PERC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49419 MEDSV DEF RBRVS 01/01/2024 12/31/2024 385.38 Description: INSERT TUN IP CATH W/PORT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 49419 MEDSV DEF RBRVS 01/01/2025 372.82 Description: INSERT TUN IP CATH W/PORT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 49421 MEDSV DEF RBRVS 01/01/2024 12/31/2024 205.06 Description: INS TUN IP CATH FOR DIAL OPN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49421 MEDSV DEF RBRVS 01/01/2025 199.48 Description: INS TUN IP CATH FOR DIAL OPN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49422 MEDSV DEF RBRVS 01/01/2024 12/31/2024 200.83 Description: REMOVE TUNNELED IP CATH Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49422 MEDSV DEF RBRVS 01/01/2025 195.27 Description: REMOVE TUNNELED IP CATH Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49423 MEDSV DEF RBRVS 01/01/2024 12/31/2024 554.8 Description: EXCHANGE DRAINAGE CATHETER Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49423 MEDSV DEF RBRVS 01/01/2025 521.92 Description: EXCHANGE DRAINAGE CATHETER Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49424 MEDSV DEF RBRVS 01/01/2024 12/31/2024 171.52 Description: ASSESS CYST CONTRAST INJECT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49424 MEDSV DEF RBRVS 01/01/2025 162.31 Description: ASSESS CYST CONTRAST INJECT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 713.72 Description: INSERT ABDOMEN-VENOUS DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49425 MEDSV DEF RBRVS 01/01/2025 696.81 Description: INSERT ABDOMEN-VENOUS DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49426 MEDSV DEF RBRVS 01/01/2024 12/31/2024 613.51 Description: REVISE ABDOMEN-VENOUS SHUNT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 49426 MEDSV DEF RBRVS 01/01/2025 598.99 Description: REVISE ABDOMEN-VENOUS SHUNT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 49427 NOCOV DEF SYSMAN 12/01/1993 Y Description: INJECTION ABDOMINAL SHUNT Category: Non Covered Services CMS Add: 01/01/1993 CMS Term: 49428 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.55 Description: LIGATION OF SHUNT Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49428 MEDSV DEF RBRVS 01/01/2025 383.93 Description: LIGATION OF SHUNT Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49429 MEDSV DEF RBRVS 01/01/2024 12/31/2024 418.22 Description: REMOVAL OF SHUNT Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49429 MEDSV DEF RBRVS 01/01/2025 406.93 Description: REMOVAL OF SHUNT Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 106.71 Description: INSERT SUBQ EXTEN TO IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49435 MEDSV DEF RBRVS 01/01/2025 103.1 Description: INSERT SUBQ EXTEN TO IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49436 MEDSV DEF RBRVS 01/01/2024 12/31/2024 504.74 Description: EMBEDDED IP CATH EXIT-SITE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49436 MEDSV DEF RBRVS 01/01/2025 482.53 Description: EMBEDDED IP CATH EXIT-SITE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 784.06 Description: PLACE GASTROSTOMY TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49440 MEDSV DEF RBRVS 01/01/2025 743.23 Description: PLACE GASTROSTOMY TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49441 MEDSV DEF RBRVS 01/01/2024 12/31/2024 889.07 Description: PLACE DUOD/JEJ TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49441 MEDSV DEF RBRVS 01/01/2025 857.67 Description: PLACE DUOD/JEJ TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49442 MEDSV DEF RBRVS 01/01/2024 12/31/2024 749.49 Description: PLACE CECOSTOMY TUBE PERC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49442 MEDSV DEF RBRVS 01/01/2025 710.7 Description: PLACE CECOSTOMY TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49446 MEDSV DEF RBRVS 01/01/2024 12/31/2024 751.42 Description: CHANGE G-TUBE TO G-J PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49446 MEDSV DEF RBRVS 01/01/2025 712.86 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 12/31/2024 561.29 Description: REPLACE G/C TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49450 MEDSV DEF RBRVS 01/01/2025 530.26 Description: REPLACE G/C TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49451 MEDSV DEF RBRVS 01/01/2024 12/31/2024 600.41 Description: REPLACE DUOD/JEJ TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49451 MEDSV DEF RBRVS 01/01/2025 567.3 Description: REPLACE DUOD/JEJ TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49452 MEDSV DEF RBRVS 01/01/2024 12/31/2024 730.12 Description: REPLACE G-J TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49452 MEDSV DEF RBRVS 01/01/2025 689.54 Description: REPLACE G-J TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 658.37 Description: FIX G/COLON TUBE W/DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49460 MEDSV DEF RBRVS 01/01/2025 651.79 Description: FIX G/COLON TUBE W/DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49465 MEDSV DEF RBRVS 01/01/2024 12/31/2024 127.86 Description: FLUORO EXAM OF G/COLON TUBE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49465 MEDSV DEF RBRVS 01/01/2025 123.6 Description: FLUORO EXAM OF G/COLON TUBE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49491 MEDSV DEF RBRVS 01/01/2024 12/31/2024 730.92 0-6Months Description: RPR HERN PREEMIE REDUC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 49491 MEDSV DEF RBRVS 01/01/2025 713.51 0-6Months Description: RPR HERN PREEMIE REDUC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 49492 MEDSV DEF RBRVS 01/01/2024 12/31/2024 876.91 0-6Months Description: RPR ING HERN PREMIE BLOCKED 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49492 MEDSV DEF RBRVS 01/01/2025 856 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 12/31/2024 375.37 0-5Months Description: RPR ING HERNIA BABY REDUC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49495 MEDSV DEF RBRVS 01/01/2025 366.84 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 12/31/2024 564.04 0-5Months Description: RPR ING HERNIA BABY BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49496 MEDSV DEF RBRVS 01/01/2025 551.87 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 12/31/2024 382.56 6-59Months Description: RPR ING HERNIA INIT REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49500 MEDSV DEF RBRVS 01/01/2025 374.91 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 12/31/2024 556.29 6-59Months Description: RPR ING HERNIA INIT BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49501 MEDSV DEF RBRVS 01/01/2025 543.55 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 12/31/2024 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 01/01/2025 469.18 5-999Years Description: PRP I/HERN INIT REDUC >5 YR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49507 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 527.07 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 12/31/2024 580.34 Description: REREPAIR ING HERNIA REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49520 MEDSV DEF RBRVS 01/01/2025 567.15 Description: REREPAIR ING HERNIA REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49521 MEDSV DEF RBRVS 01/01/2024 12/31/2024 656.69 Description: REREPAIR ING HERNIA BLOCKED 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49521 MEDSV DEF RBRVS 01/01/2025 640.82 Description: REREPAIR ING HERNIA BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 526.8 Description: REPAIR ING HERNIA SLIDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49525 MEDSV DEF RBRVS 01/01/2025 514.25 Description: REPAIR ING HERNIA SLIDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 623.29 Description: REPAIR LUMBAR HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49540 MEDSV DEF RBRVS 01/01/2025 601.59 Description: REPAIR LUMBAR HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 530.09 Description: RPR REM HERNIA INIT REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49550 MEDSV DEF RBRVS 01/01/2025 518.04 Description: RPR REM HERNIA INIT REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49553 MEDSV DEF RBRVS 01/01/2024 12/31/2024 580.42 Description: RPR FEM HERNIA INIT BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49553 MEDSV DEF RBRVS 01/01/2025 566.48 Description: RPR FEM HERNIA INIT BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 554.38 Description: REREPAIR FEM HERNIA REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49555 MEDSV DEF RBRVS 01/01/2025 541.37 Description: REREPAIR FEM HERNIA REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49557 MEDSV DEF RBRVS 01/01/2024 12/31/2024 662.86 Description: REREPAIR FEM HERNIA BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49557 MEDSV DEF RBRVS 01/01/2025 646.18 Description: REREPAIR FEM HERNIA BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49591 MEDSV DEF RBRVS 01/01/2024 12/31/2024 311.44 Description: RPR AA HRN 1ST < 3 CM RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49591 MEDSV DEF RBRVS 01/01/2025 303.35 Description: RPR AA HRN 1ST < 3 CM RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49592 MEDSV DEF RBRVS 01/01/2024 12/31/2024 432.85 Description: RPR AA HRN 1ST < 3 NCR/STRN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49592 MEDSV DEF RBRVS 01/01/2025 421.04 Description: RPR AA HRN 1ST < 3 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49593 MEDSV DEF RBRVS 01/01/2024 12/31/2024 521.89 Description: RPR AA HRN 1ST 3-10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49593 MEDSV DEF RBRVS 01/01/2025 507.33 Description: RPR AA HRN 1ST 3-10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49594 MEDSV DEF RBRVS 01/01/2024 12/31/2024 678.87 Description: RPR AA HRN 1ST 3-10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49594 MEDSV DEF RBRVS 01/01/2025 659.86 Description: RPR AA HRN 1ST 3-10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49595 MEDSV DEF RBRVS 01/01/2024 12/31/2024 701.95 Description: RPR AA HRN 1ST > 10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49595 MEDSV DEF RBRVS 01/01/2025 682.72 Description: RPR AA HRN 1ST > 10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49596 MEDSV DEF RBRVS 01/01/2024 12/31/2024 932.72 Description: RPR AA HRN 1ST > 10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49596 MEDSV DEF RBRVS 01/01/2025 906.4 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 12/31/2024 672.85 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49600 MEDSV DEF RBRVS 01/01/2025 656.76 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4452.75 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49605 MEDSV DEF RBRVS 01/01/2025 4328.59 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1035.05 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49606 MEDSV DEF RBRVS 01/01/2025 1008.18 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49610 MEDSV DEF RBRVS 01/01/2025 620.73 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49611 MEDSV DEF RBRVS 01/01/2024 12/31/2024 560.55 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49611 MEDSV DEF RBRVS 01/01/2025 547.87 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49613 MEDSV DEF RBRVS 01/01/2024 12/31/2024 384.28 Description: RPR AA HRN RCR < 3 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49613 MEDSV DEF RBRVS 01/01/2025 374.21 Description: RPR AA HRN RCR < 3 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49614 MEDSV DEF RBRVS 01/01/2024 12/31/2024 520.63 Description: RPR AA HRN RCR < 3 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49614 MEDSV DEF RBRVS 01/01/2025 506.09 Description: RPR AA HRN RCR < 3 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 582.35 Description: RPR AA HRN RCR 3-10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49615 MEDSV DEF RBRVS 01/01/2025 566.01 Description: RPR AA HRN RCR 3-10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49616 MEDSV DEF RBRVS 01/01/2024 12/31/2024 781.66 Description: RPR AA HRN RCR 3-10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49616 MEDSV DEF RBRVS 01/01/2025 759.78 Description: RPR AA HRN RCR 3-10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49617 MEDSV DEF RBRVS 01/01/2024 12/31/2024 806.88 Description: RPR AA HRN RCR > 10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49617 MEDSV DEF RBRVS 01/01/2025 784.41 Description: RPR AA HRN RCR > 10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49618 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1129.74 Description: RPR AA HRN RCR > 10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49618 MEDSV DEF RBRVS 01/01/2025 1098.08 Description: RPR AA HRN RCR > 10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49621 MEDSV DEF RBRVS 01/01/2024 12/31/2024 680.59 Description: RPR PARASTOMAL HERNIA RDC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49621 MEDSV DEF RBRVS 01/01/2025 661.41 Description: RPR PARASTOMAL HERNIA RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49622 MEDSV DEF RBRVS 01/01/2024 12/31/2024 840.28 Description: RPR PARASTOMAL HRNA NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49622 MEDSV DEF RBRVS 01/01/2025 816.34 Description: RPR PARASTOMAL HRNA NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49623 MEDSV DEF RBRVS 01/01/2024 12/31/2024 181.16 Description: RMVL NINFCT MESH HERNIA RPR Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49623 MEDSV DEF RBRVS 01/01/2025 175.79 Description: RMVL NINFCT MESH HERNIA RPR Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 397.46 0-1 Description: LAP ING HERNIA REPAIR INIT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49650 MEDSV DEF RBRVS 01/01/2025 389.3 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 12/31/2024 518.74 0-1 Description: LAP ING HERNIA REPAIR RECUR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49651 MEDSV DEF RBRVS 01/01/2025 507.78 0-1 Description: LAP ING HERNIA REPAIR RECUR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49659 MEDSV DEF BILL20 01/01/2014 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 12/31/2024 753.68 Description: REPAIR OF ABDOMINAL WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49900 MEDSV DEF RBRVS 01/01/2025 739.71 Description: REPAIR OF ABDOMINAL WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49904 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1276.41 Description: OMENTAL FLAP EXTRA-ABDOM Category: Medical Services CMS Add: 01/01/2003 CMS Term: 49904 MEDSV DEF RBRVS 01/01/2025 1244.9 Description: OMENTAL FLAP EXTRA-ABDOM Category: Medical Services CMS Add: 01/01/2003 CMS Term: 49905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 320.46 Description: OMENTAL FLAP INTRA-ABDOM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 49905 MEDSV DEF RBRVS 01/01/2025 311.19 Description: OMENTAL FLAP INTRA-ABDOM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49906 MEDSV DEF BILL20 01/01/2010 Description: FREE OMENTAL FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 49999 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX ABD PERTM&OMN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 687.9 Description: RENAL EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50010 MEDSV DEF RBRVS 01/01/2025 647.07 Description: RENAL EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 946.12 Description: DRG PERIRNL/RENAL ABSC OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50020 MEDSV DEF RBRVS 01/01/2025 929.01 Description: DRG PERIRNL/RENAL ABSC OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 862.45 Description: NFROS NFROT W/DRG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50040 MEDSV DEF RBRVS 01/01/2025 846.5 Description: NFROS NFROT W/DRG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50045 MEDSV DEF RBRVS 01/01/2024 12/31/2024 868.76 Description: NEPHROTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50045 MEDSV DEF RBRVS 01/01/2025 852.61 Description: NEPHROTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5005F NOCOV DEF SYSMAN 01/01/2007 Y 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 12/31/2024 1060.42 Description: NL REMOVAL CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50060 MEDSV DEF RBRVS 01/01/2025 1039.72 Description: NL REMOVAL CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1124.11 Description: NL SEC SURG OPERJ CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50065 MEDSV DEF RBRVS 01/01/2025 1101.61 Description: NL SEC SURG OPERJ CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1102.58 Description: NL COMP CGEN KDN ABNORMALITY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50070 MEDSV DEF RBRVS 01/01/2025 1080.6 Description: NL COMP CGEN KDN ABNORMALITY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50075 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1354.8 Description: NL RMVL LG STAGHORN CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50075 MEDSV DEF RBRVS 01/01/2025 1327.55 Description: NL RMVL LG STAGHORN CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 649.82 Description: PERQ NL/PL LITHOTRP SMPL<2CM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50080 MEDSV DEF RBRVS 01/01/2025 637.6 Description: PERQ NL/PL LITHOTRP SMPL<2CM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50081 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1048.57 Description: PERQ NL/PL LITHOTRP CPLX>2CM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50081 MEDSV DEF RBRVS 01/01/2025 1026.48 Description: PERQ NL/PL LITHOTRP CPLX>2CM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 986.75 Description: TRNSXJ/REPOS ABRRNT RNL VSLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50100 MEDSV DEF RBRVS 01/01/2025 962.85 Description: TRNSXJ/REPOS ABRRNT RNL VSLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5010F NOCOV DEF SYSMAN 01/01/2007 Y 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 12/31/2024 884.31 Description: PYELOTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50120 MEDSV DEF RBRVS 01/01/2025 867.99 Description: PYELOTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 914.9 Description: PYELOTOMY W/DRG PYELOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50125 MEDSV DEF RBRVS 01/01/2025 898.13 Description: PYELOTOMY W/DRG PYELOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 961.69 Description: PYELOTOMY W/REMOVAL CALCULUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50130 MEDSV DEF RBRVS 01/01/2025 943.04 Description: PYELOTOMY W/REMOVAL CALCULUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1044.03 Description: PYELOTOMY COMPLICATED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12/31/2024 50135 MEDSV DEF RBRVS 01/01/2025 1023.05 Description: PYELOTOMY COMPLICATED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12/31/2024 5015F NOCOV DEF SYSMAN 01/01/2007 Y 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 12/31/2024 484.14 Description: RENAL BIOPSY PERQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50200 MEDSV DEF RBRVS 01/01/2025 461.53 Description: RENAL BIOPSY PERQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 690.65 Description: RENAL BX SURG EXPOSURE KDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50205 MEDSV DEF RBRVS 01/01/2025 675.08 Description: RENAL BX SURG EXPOSURE KDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5020F NOCOV DEF SYSMAN 01/01/2008 Y Description: TXMNTS 2 PHYS/QHP BY 1 MON Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 50220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 975.1 Description: REMOVE KIDNEY OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50220 MEDSV DEF RBRVS 01/01/2025 954.49 Description: REMOVE KIDNEY OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1115.67 Description: REMOVAL KIDNEY OPEN COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50225 MEDSV DEF RBRVS 01/01/2025 1098.64 Description: REMOVAL KIDNEY OPEN COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1188.16 Description: REMOVAL KIDNEY OPEN RADICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50230 MEDSV DEF RBRVS 01/01/2025 1162.85 Description: REMOVAL KIDNEY OPEN RADICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50234 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1210.79 Description: REMOVAL OF KIDNEY & URETER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50234 MEDSV DEF RBRVS 01/01/2025 1184.34 Description: REMOVAL OF KIDNEY & URETER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50236 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1362.08 Description: REMOVAL OF KIDNEY & URETER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50236 MEDSV DEF RBRVS 01/01/2025 1334.09 Description: REMOVAL OF KIDNEY & URETER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1233.58 Description: NEPHRECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50240 MEDSV DEF RBRVS 01/01/2025 1210.89 Description: NEPHRECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1132.43 Description: OPN ABLTJ 1/> RNL MAS CRYSRG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50250 MEDSV DEF RBRVS 01/01/2025 1110.25 Description: OPN ABLTJ 1/> RNL MAS CRYSRG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 892.5 Description: EXC/UNROOFING CYST KIDNEY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50280 MEDSV DEF RBRVS 01/01/2025 864.95 Description: EXC/UNROOFING CYST KIDNEY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 837.97 Description: EXCISION PERINEPHRIC CYST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50290 MEDSV DEF RBRVS 01/01/2025 822.62 Description: EXCISION PERINEPHRIC CYST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50300 MEDSV DEF BILL35 01/01/2010 Y Description: REMOVE CADAVER DONOR KIDNEY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1388.8 Y Description: REMOVE KIDNEY LIVING DONOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50320 MEDSV DEF RBRVS 01/01/2025 1361.96 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 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 Y Description: PREP DONOR RENAL GRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50327 MEDSV DEF RBRVS 01/01/2024 12/31/2024 195.91 Y Description: PREP RENAL GRAFT/VENOUS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50327 MEDSV DEF RBRVS 01/01/2025 190.16 Y Description: PREP RENAL GRAFT/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50328 MEDSV DEF RBRVS 01/01/2024 12/31/2024 171.32 Y Description: PREP RENAL GRAFT/ARTERIAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50328 MEDSV DEF RBRVS 01/01/2025 166.75 Y Description: PREP RENAL GRAFT/ARTERIAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50329 MEDSV DEF RBRVS 01/01/2024 12/31/2024 163.24 Y Description: PREP RENAL GRAFT/URETERAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50329 MEDSV DEF RBRVS 01/01/2025 158.14 Y Description: PREP RENAL GRAFT/URETERAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 876.96 Y Description: RECIPIENT NEPHRECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50340 MEDSV DEF RBRVS 01/01/2025 860.02 Y Description: RECIPIENT NEPHRECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2217.52 Y Description: RNL ALTRNSPLJ W/O RCP NFRCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50360 MEDSV DEF RBRVS 01/01/2025 2167.83 Y Description: RNL ALTRNSPLJ W/O RCP NFRCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2644.62 Y Description: RNL ALTRNSPLJ W/RCP NFRCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50365 MEDSV DEF RBRVS 01/01/2025 2591.57 Y Description: RNL ALTRNSPLJ W/RCP NFRCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50370 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1112.1 Description: RMVL TRANSPLANTED RNL ALGRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50370 MEDSV DEF RBRVS 01/01/2025 1089.88 Description: RMVL TRANSPLANTED RNL ALGRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1860.86 Y Description: RNL AUTOTRNSPLJ RIMPLTJ KDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50380 MEDSV DEF RBRVS 01/01/2025 1823.61 Y Description: RNL AUTOTRNSPLJ RIMPLTJ KDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50382 MEDSV DEF RBRVS 01/01/2024 12/31/2024 947.12 Description: CHANGE URETER STENT PERCUT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50382 MEDSV DEF RBRVS 01/01/2025 894.8 Description: CHANGE URETER STENT PERCUT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50384 MEDSV DEF RBRVS 01/01/2024 12/31/2024 809.44 Description: REMOVE URETER STENT PERCUT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50384 MEDSV DEF RBRVS 01/01/2025 767.44 Description: REMOVE URETER STENT PERCUT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50385 MEDSV DEF RBRVS 01/01/2024 12/31/2024 947.88 Description: CHANGE STENT VIA TRANSURETH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50385 MEDSV DEF RBRVS 01/01/2025 907.12 Description: CHANGE STENT VIA TRANSURETH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50386 MEDSV DEF RBRVS 01/01/2024 12/31/2024 700.95 Description: REMOVE STENT VIA TRANSURETH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50386 MEDSV DEF RBRVS 01/01/2025 676.94 Description: REMOVE STENT VIA TRANSURETH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50387 MEDSV DEF RBRVS 01/01/2024 12/31/2024 522.18 Description: CHANGE NEPHROURETERAL CATH Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50387 MEDSV DEF RBRVS 01/01/2025 492.48 Description: CHANGE NEPHROURETERAL CATH Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50389 MEDSV DEF RBRVS 01/01/2024 12/31/2024 390.36 Description: REMOVE RENAL TUBE W/FLUORO Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50389 MEDSV DEF RBRVS 01/01/2025 370.02 Description: REMOVE RENAL TUBE W/FLUORO Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 88.62 Description: DRAINAGE OF KIDNEY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50390 MEDSV DEF RBRVS 01/01/2025 85.47 Description: DRAINAGE OF KIDNEY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50391 MEDSV DEF RBRVS 01/01/2024 12/31/2024 116.74 Description: INSTLL RX AGNT INTO RNAL TUB Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50391 MEDSV DEF RBRVS 01/01/2025 114.78 Description: INSTLL RX AGNT INTO RNAL TUB Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50396 MEDSV DEF RBRVS 01/01/2024 12/31/2024 108.77 Description: MEASURE KIDNEY PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50396 MEDSV DEF RBRVS 01/01/2025 105.57 Description: MEASURE KIDNEY PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1075.3 Description: REVISION OF KIDNEY/URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50400 MEDSV DEF RBRVS 01/01/2025 1054.15 Description: REVISION OF KIDNEY/URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1298.06 Description: REVISION OF KIDNEY/URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50405 MEDSV DEF RBRVS 01/01/2025 1271.61 Description: REVISION OF KIDNEY/URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 592.72 Description: NJX PX NFROSGRM &/URTRGRM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50430 MEDSV DEF RBRVS 01/01/2025 568.43 Description: NJX PX NFROSGRM &/URTRGRM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50431 MEDSV DEF RBRVS 01/01/2024 12/31/2024 302.69 Description: NJX PX NFROSGRM &/URTRGRM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50431 MEDSV DEF RBRVS 01/01/2025 288.8 Description: NJX PX NFROSGRM &/URTRGRM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50432 MEDSV DEF RBRVS 01/01/2024 12/31/2024 853.26 Description: PLMT NEPHROSTOMY CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50432 MEDSV DEF RBRVS 01/01/2025 811.48 Description: PLMT NEPHROSTOMY CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50433 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1063.18 Description: PLMT NEPHROURETERAL CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50433 MEDSV DEF RBRVS 01/01/2025 1010.19 Description: PLMT NEPHROURETERAL CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50434 MEDSV DEF RBRVS 01/01/2024 12/31/2024 853.26 Description: CONVERT NEPHROSTOMY CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50434 MEDSV DEF RBRVS 01/01/2025 810.53 Description: CONVERT NEPHROSTOMY CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 564.23 Description: EXCHANGE NEPHROSTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50435 MEDSV DEF RBRVS 01/01/2025 533.28 Description: EXCHANGE NEPHROSTOMY CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50436 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138.7 Description: DILAT XST TRC NDURLGC PX Category: Medical Services CMS Add: 01/01/2019 CMS Term: 50436 MEDSV DEF RBRVS 01/01/2025 135.18 Description: DILAT XST TRC NDURLGC PX Category: Medical Services CMS Add: 01/01/2019 CMS Term: 50437 MEDSV DEF RBRVS 01/01/2024 12/31/2024 232.12 Description: DILAT XST TRC NEW ACCESS RCS Category: Medical Services CMS Add: 01/01/2019 CMS Term: 50437 MEDSV DEF RBRVS 01/01/2025 224.54 Description: DILAT XST TRC NEW ACCESS RCS Category: Medical Services CMS Add: 01/01/2019 CMS Term: 50500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1145.52 Description: REPAIR OF KIDNEY WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50500 MEDSV DEF RBRVS 01/01/2025 1143.98 Description: REPAIR OF KIDNEY WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5050F NOCOV DEF SYSMAN 01/01/2008 Y Description: PLAN 2 MAIN DR BY 1 MONTH Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 50520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1057.83 Description: CLOSE KIDNEY-SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50520 MEDSV DEF RBRVS 01/01/2025 1031.55 Description: CLOSE KIDNEY-SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1339.46 Description: CLOSE NEPHROVISCERAL FISTULA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50525 MEDSV DEF RBRVS 01/01/2025 1305.63 Description: CLOSE NEPHROVISCERAL FISTULA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50526 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1434.48 Description: CLOSE NEPHROVISCERAL FISTULA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50526 MEDSV DEF RBRVS 01/01/2025 1397.41 Description: CLOSE NEPHROVISCERAL FISTULA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1067.37 Description: REVISION OF HORSESHOE KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50540 MEDSV DEF RBRVS 01/01/2025 1046.46 Description: REVISION OF HORSESHOE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50541 MEDSV DEF RBRVS 01/01/2024 12/31/2024 854.1 0-2 Description: LAPARO ABLATE RENAL CYST Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50541 MEDSV DEF RBRVS 01/01/2025 836.76 0-2 Description: LAPARO ABLATE RENAL CYST Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50542 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1086.29 Description: LAPARO ABLATE RENAL MASS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50542 MEDSV DEF RBRVS 01/01/2025 1059.09 Description: LAPARO ABLATE RENAL MASS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50543 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1385.6 Description: LAPARO PARTIAL NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50543 MEDSV DEF RBRVS 01/01/2025 1358.16 Description: LAPARO PARTIAL NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50544 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1154.99 0-2 Description: LAPAROSCOPY PYELOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50544 MEDSV DEF RBRVS 01/01/2025 1130.21 0-2 Description: LAPAROSCOPY PYELOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1240.66 Description: LAPARO RADICAL NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50545 MEDSV DEF RBRVS 01/01/2025 1215.33 Description: LAPARO RADICAL NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50546 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1117.78 Description: LAPAROSCOPIC NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50546 MEDSV DEF RBRVS 01/01/2025 1095.33 Description: LAPAROSCOPIC NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50547 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1480.89 0-1 Description: LAPARO REMOVAL DONOR KIDNEY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50547 MEDSV DEF RBRVS 01/01/2025 1450.39 0-1 Description: LAPARO REMOVAL DONOR KIDNEY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50548 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1247.6 0-2 Description: LAPARO REMOVE W/URETER Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50548 MEDSV DEF RBRVS 01/01/2025 1221.87 0-2 Description: LAPARO REMOVE W/URETER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50549 MEDSV DEF BILL35 12/01/2015 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 12/31/2024 337.28 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50551 MEDSV DEF RBRVS 01/01/2025 330.6 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50553 MEDSV DEF RBRVS 01/01/2024 12/31/2024 361.49 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50553 MEDSV DEF RBRVS 01/01/2025 354.73 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 384.46 Description: KIDNEY ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50555 MEDSV DEF RBRVS 01/01/2025 378.2 Description: KIDNEY ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50557 MEDSV DEF RBRVS 01/01/2024 12/31/2024 391.38 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50557 MEDSV DEF RBRVS 01/01/2025 384.62 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50561 MEDSV DEF RBRVS 01/01/2024 12/31/2024 443.77 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50561 MEDSV DEF RBRVS 01/01/2025 436.72 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50562 MEDSV DEF RBRVS 01/01/2024 12/31/2024 535.54 Description: RENAL SCOPE W/TUMOR RESECT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50562 MEDSV DEF RBRVS 01/01/2025 524.46 Description: RENAL SCOPE W/TUMOR RESECT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 453.81 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50570 MEDSV DEF RBRVS 01/01/2025 444.31 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50572 MEDSV DEF RBRVS 01/01/2024 12/31/2024 490.86 Description: KIDNEY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50572 MEDSV DEF RBRVS 01/01/2025 480.23 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50574 MEDSV DEF RBRVS 01/01/2024 12/31/2024 522.11 Description: KIDNEY ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50574 MEDSV DEF RBRVS 01/01/2025 510.38 Description: KIDNEY ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 659.55 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 50575 MEDSV DEF RBRVS 01/01/2025 644.42 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 50576 MEDSV DEF RBRVS 01/01/2024 12/31/2024 520.78 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50576 MEDSV DEF RBRVS 01/01/2025 508.94 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 560.98 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50580 MEDSV DEF RBRVS 01/01/2025 548.39 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50590 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.95 Description: FRAGMENTING OF KIDNEY STONE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 50590 MEDSV DEF RBRVS 01/01/2025 679.67 Description: FRAGMENTING OF KIDNEY STONE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 50592 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2653.04 Description: PERC RF ABLATE RENAL TUMOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50592 MEDSV DEF RBRVS 01/01/2025 2499.34 Description: PERC RF ABLATE RENAL TUMOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50593 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3551.78 Description: PERC CRYO ABLATE RENAL TUM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50593 MEDSV DEF RBRVS 01/01/2025 3342.21 Description: PERC CRYO ABLATE RENAL TUM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 873.38 Description: EXPLORATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50600 MEDSV DEF RBRVS 01/01/2025 856.55 Description: EXPLORATION OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 920.44 Description: INSERT URETERAL SUPPORT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50605 MEDSV DEF RBRVS 01/01/2025 899.85 Description: INSERT URETERAL SUPPORT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.48 Description: ENDOLUMINAL BX URTR RNL PLVS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50606 MEDSV DEF RBRVS 01/01/2025 433.3 Description: ENDOLUMINAL BX URTR RNL PLVS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 5060F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 879.65 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50610 MEDSV DEF RBRVS 01/01/2025 862.65 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 841.46 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50620 MEDSV DEF RBRVS 01/01/2025 825.46 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5062F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 831.36 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50630 MEDSV DEF RBRVS 01/01/2025 815.68 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 964.67 Description: REMOVAL OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50650 MEDSV DEF RBRVS 01/01/2025 947.54 Description: REMOVAL OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1063.41 Description: REMOVAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50660 MEDSV DEF RBRVS 01/01/2025 1043.07 Description: REMOVAL OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50684 MEDSV DEF RBRVS 01/01/2024 12/31/2024 118.74 Description: INJECTION FOR URETER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50684 MEDSV DEF RBRVS 01/01/2025 115.98 Description: INJECTION FOR URETER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50686 MEDSV DEF RBRVS 01/01/2024 12/31/2024 133.1 Description: MEASURE URETER PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50686 MEDSV DEF RBRVS 01/01/2025 131.26 Description: MEASURE URETER PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50688 MEDSV DEF RBRVS 01/01/2024 12/31/2024 72.23 Description: CHANGE OF URETER TUBE/STENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50688 MEDSV DEF RBRVS 01/01/2025 70.94 Description: CHANGE OF URETER TUBE/STENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50690 MEDSV DEF RBRVS 01/01/2024 12/31/2024 111.94 Description: INJECTION FOR URETER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50690 MEDSV DEF RBRVS 01/01/2025 108.42 Description: INJECTION FOR URETER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50693 MEDSV DEF RBRVS 01/01/2024 12/31/2024 934.32 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50693 MEDSV DEF RBRVS 01/01/2025 888.06 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50694 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1049.28 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50694 MEDSV DEF RBRVS 01/01/2025 996.81 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50695 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1259.65 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50695 MEDSV DEF RBRVS 01/01/2025 1197.59 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 862.79 Description: REVISION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50700 MEDSV DEF RBRVS 01/01/2025 846.99 Description: REVISION OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1725.37 Description: URETERAL EMBOLIZATION/OCCL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50705 MEDSV DEF RBRVS 01/01/2025 1624.79 Description: URETERAL EMBOLIZATION/OCCL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50706 MEDSV DEF RBRVS 01/01/2024 12/31/2024 788.12 Description: BALLOON DILATE URTRL STRIX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50706 MEDSV DEF RBRVS 01/01/2025 748.17 Description: BALLOON DILATE URTRL STRIX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1115.59 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50715 MEDSV DEF RBRVS 01/01/2025 1091.16 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50722 MEDSV DEF RBRVS 01/01/2024 12/31/2024 951.36 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50722 MEDSV DEF RBRVS 01/01/2025 927.21 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1025.85 Description: RELEASE/REVISE URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50725 MEDSV DEF RBRVS 01/01/2025 1005.72 Description: RELEASE/REVISE URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50727 MEDSV DEF RBRVS 01/01/2024 12/31/2024 476.39 Description: REVISE URETER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50727 MEDSV DEF RBRVS 01/01/2025 470.34 Description: REVISE URETER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50728 MEDSV DEF RBRVS 01/01/2024 12/31/2024 653.42 Description: REVISE URETER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50728 MEDSV DEF RBRVS 01/01/2025 642.57 Description: REVISE URETER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1116.09 Description: FUSION OF URETER & 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50740 MEDSV DEF RBRVS 01/01/2025 1089.04 Description: FUSION OF URETER & KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1072.83 Description: FUSION OF URETER & KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50750 MEDSV DEF RBRVS 01/01/2025 1052.05 Description: FUSION OF URETER & KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1047.3 Description: URETEROURETEROSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50760 MEDSV DEF RBRVS 01/01/2025 1023.48 Description: URETEROURETEROSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1072.83 Description: SPLICING OF URETERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50770 MEDSV DEF RBRVS 01/01/2025 1052.05 Description: SPLICING OF URETERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1029.39 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50780 MEDSV DEF RBRVS 01/01/2025 1010.59 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50782 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1000.56 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50782 MEDSV DEF RBRVS 01/01/2025 981.19 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50783 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1048.85 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50783 MEDSV DEF RBRVS 01/01/2025 1028.34 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50785 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1128.6 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50785 MEDSV DEF RBRVS 01/01/2025 1104.22 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 862.31 Description: IMPLANT URETER IN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50800 MEDSV DEF RBRVS 01/01/2025 843.82 Description: IMPLANT URETER IN BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1282.1 Description: FUSION OF URETER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50810 MEDSV DEF RBRVS 01/01/2025 1250.91 Description: FUSION OF URETER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50815 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1139.96 Description: URINE SHUNT TO INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50815 MEDSV DEF RBRVS 01/01/2025 1118.2 Description: URINE SHUNT TO INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1221 Description: CONSTRUCT BOWEL BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50820 MEDSV DEF RBRVS 01/01/2025 1195.58 Description: CONSTRUCT BOWEL BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1530.92 Description: CONSTRUCT BOWEL BLADDER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 50825 MEDSV DEF RBRVS 01/01/2025 1499.63 Description: CONSTRUCT BOWEL BLADDER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 50830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1674.31 Description: REVISE URINE FLOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50830 MEDSV DEF RBRVS 01/01/2025 1639.45 Description: REVISE URINE FLOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1146.23 Description: REPLACE URETER BY BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50840 MEDSV DEF RBRVS 01/01/2025 1124.13 Description: REPLACE URETER BY BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1168.06 Description: APPENDICO-VESICOSTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 50845 MEDSV DEF RBRVS 01/01/2025 1146.51 Description: APPENDICO-VESICOSTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 50860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 880.67 Y Description: TRANSPLANT URETER TO SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50860 MEDSV DEF RBRVS 01/01/2025 864.62 Y Description: TRANSPLANT URETER TO SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 786.21 Description: REPAIR OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50900 MEDSV DEF RBRVS 01/01/2025 771.95 Description: REPAIR OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 821.94 Description: CLOSURE URETER/SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50920 MEDSV DEF RBRVS 01/01/2025 806.91 Description: CLOSURE URETER/SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1025.51 Description: CLOSURE URETER/BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50930 MEDSV DEF RBRVS 01/01/2025 1004.93 Description: CLOSURE URETER/BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50940 MEDSV DEF RBRVS 01/01/2024 12/31/2024 828.03 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50940 MEDSV DEF RBRVS 01/01/2025 812.2 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50945 MEDSV DEF RBRVS 01/01/2024 12/31/2024 903.64 0-2 Description: LAPAROSCOPY URETEROLITHOTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50945 MEDSV DEF RBRVS 01/01/2025 885.54 0-2 Description: LAPAROSCOPY URETEROLITHOTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50947 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1286.41 Description: LAPARO NEW URETER/BLADDER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50947 MEDSV DEF RBRVS 01/01/2025 1260.87 Description: LAPARO NEW URETER/BLADDER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50948 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1184.03 Description: LAPARO NEW URETER/BLADDER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50948 MEDSV DEF RBRVS 01/01/2025 1157.35 Description: LAPARO NEW URETER/BLADDER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50949 MEDSV DEF BILL35 01/01/2014 Description: UNLISTED LAPS PX URETER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50951 MEDSV DEF RBRVS 01/01/2024 12/31/2024 352.53 Description: ENDOSCOPY OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50951 MEDSV DEF RBRVS 01/01/2025 346.94 Description: ENDOSCOPY OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50953 MEDSV DEF RBRVS 01/01/2024 12/31/2024 373.37 Description: ENDOSCOPY OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50953 MEDSV DEF RBRVS 01/01/2025 366.86 Description: ENDOSCOPY OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50955 MEDSV DEF RBRVS 01/01/2024 12/31/2024 397.94 Description: URETER ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50955 MEDSV DEF RBRVS 01/01/2025 391.31 Description: URETER ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50957 MEDSV DEF RBRVS 01/01/2024 12/31/2024 401.62 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50957 MEDSV DEF RBRVS 01/01/2025 395.04 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50961 MEDSV DEF RBRVS 01/01/2024 12/31/2024 362.6 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50961 MEDSV DEF RBRVS 01/01/2025 356.55 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50970 MEDSV DEF RBRVS 01/01/2024 12/31/2024 342.5 Description: URETER ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50970 MEDSV DEF RBRVS 01/01/2025 335.14 Description: URETER ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50972 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.24 Description: URETER ENDOSCOPY & CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50972 MEDSV DEF RBRVS 01/01/2025 323.6 Description: URETER ENDOSCOPY & CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50974 MEDSV DEF RBRVS 01/01/2024 12/31/2024 436.78 Description: URETER ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50974 MEDSV DEF RBRVS 01/01/2025 427.47 Description: URETER ENDOSCOPY & 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50976 MEDSV DEF RBRVS 01/01/2024 12/31/2024 430.5 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50976 MEDSV DEF RBRVS 01/01/2025 421.55 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50980 MEDSV DEF RBRVS 01/01/2024 12/31/2024 329.27 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50980 MEDSV DEF RBRVS 01/01/2025 321.99 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5100F NOCOV DEF SYSMAN 01/01/2009 Y 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 12/31/2024 439.78 Description: CYSTOTOMY/CYSTOSTOMY W/FULG Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51020 MEDSV DEF RBRVS 01/01/2025 433.68 Description: CYSTOTOMY/CYSTOSTOMY W/FULG Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 442.62 Description: INCISE & TREAT BLADDER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12/31/2024 51030 MEDSV DEF RBRVS 01/01/2025 436.72 Description: INCISE & TREAT BLADDER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12/31/2024 51040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 272.29 Description: INCISE & DRAIN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51040 MEDSV DEF RBRVS 01/01/2025 269.27 Description: INCISE & DRAIN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51045 MEDSV DEF RBRVS 01/01/2024 12/31/2024 464.03 Description: INCISE BLADDER/DRAIN URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51045 MEDSV DEF RBRVS 01/01/2025 453.74 Description: INCISE BLADDER/DRAIN URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 440.96 Description: REMOVAL OF BLADDER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51050 MEDSV DEF RBRVS 01/01/2025 434.43 Description: REMOVAL OF BLADDER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 544.96 Description: REMOVAL OF URETER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51060 MEDSV DEF RBRVS 01/01/2025 535.98 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 542.49 Description: REMOVE URETER CALCULUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51065 MEDSV DEF RBRVS 01/01/2025 533.57 Description: REMOVE URETER CALCULUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 382.72 Description: DRAINAGE OF BLADDER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51080 MEDSV DEF RBRVS 01/01/2025 377.19 Description: DRAINAGE OF BLADDER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 68.48 Description: DRAIN BLADDER BY NEEDLE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51100 MEDSV DEF RBRVS 01/01/2025 67.58 Description: DRAIN BLADDER BY NEEDLE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 144.24 Description: DRAIN BLADDER BY TROCAR/CATH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51101 MEDSV DEF RBRVS 01/01/2025 140.22 Description: DRAIN BLADDER BY TROCAR/CATH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 225.98 Description: DRAIN BL W/CATH INSERTION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51102 MEDSV DEF RBRVS 01/01/2025 218.62 Description: DRAIN BL W/CATH INSERTION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 595.59 Description: REMOVAL OF BLADDER CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51500 MEDSV DEF RBRVS 01/01/2025 585.38 Description: REMOVAL OF BLADDER CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 556.87 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51520 MEDSV DEF RBRVS 01/01/2025 547.53 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 801.03 Description: REMOVAL OF BLADDER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51525 MEDSV DEF RBRVS 01/01/2025 784.32 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 718.66 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51530 MEDSV DEF RBRVS 01/01/2025 705.49 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 727.74 Description: REPAIR OF URETER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51535 MEDSV DEF RBRVS 01/01/2025 714.15 Description: REPAIR OF URETER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 894.28 Description: PARTIAL REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51550 MEDSV DEF RBRVS 01/01/2025 877.63 Description: PARTIAL REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1171.3 Description: PARTIAL REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51555 MEDSV DEF RBRVS 01/01/2025 1148.28 Description: PARTIAL REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51565 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1199.46 Description: REVISE BLADDER & URETER(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51565 MEDSV DEF RBRVS 01/01/2025 1175.39 Description: REVISE BLADDER & URETER(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1369.16 Description: REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51570 MEDSV DEF RBRVS 01/01/2025 1340.25 Description: REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1690.9 Description: REMOVAL OF BLADDER & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51575 MEDSV DEF RBRVS 01/01/2025 1652.46 Description: REMOVAL OF BLADDER & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1761.68 Description: REMOVE BLADDER/REVISE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51580 MEDSV DEF RBRVS 01/01/2025 1725.81 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51585 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1959.81 Description: REMOVAL OF BLADDER & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51585 MEDSV DEF RBRVS 01/01/2025 1918.71 Description: REMOVAL OF BLADDER & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51590 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1792.36 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51590 MEDSV DEF RBRVS 01/01/2025 1753.67 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51595 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2029.12 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51595 MEDSV DEF RBRVS 01/01/2025 1986.05 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51596 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2188.49 Description: REMOVE BLADDER/CREATE POUCH Category: Medical Services CMS Add: 01/01/1988 CMS Term: 51596 MEDSV DEF RBRVS 01/01/2025 2139.69 Description: REMOVE BLADDER/CREATE POUCH Category: Medical Services CMS Add: 01/01/1988 CMS Term: 51597 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2132.08 Y Y Description: REMOVAL OF PELVIC STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51597 MEDSV DEF RBRVS 01/01/2025 2086.94 Y Y Description: REMOVAL OF PELVIC STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 199.06 Description: INJECTION FOR BLADDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51600 MEDSV DEF RBRVS 01/01/2025 190.86 Description: INJECTION FOR BLADDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 35.63 Description: PREPARATION FOR BLADDER XRAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51605 MEDSV DEF RBRVS 01/01/2025 35.21 Description: PREPARATION FOR BLADDER XRAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.87 Description: INJECTION FOR BLADDER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51610 MEDSV DEF RBRVS 01/01/2025 117.5 Description: INJECTION FOR BLADDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 71.01 Description: IRRIGATION OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51700 MEDSV DEF RBRVS 01/01/2025 69.83 Description: IRRIGATION OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51701 MEDSV DEF RBRVS 01/01/2024 12/31/2024 41.53 Description: INSERT BLADDER CATHETER Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51701 MEDSV DEF RBRVS 01/01/2025 40.73 Description: INSERT BLADDER CATHETER Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 57.42 Description: INSERT TEMP BLADDER CATH Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51702 MEDSV DEF RBRVS 01/01/2025 56.87 Description: INSERT TEMP BLADDER CATH Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51703 MEDSV DEF RBRVS 01/01/2024 12/31/2024 140.08 Description: INSERT BLADDER CATH COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51703 MEDSV DEF RBRVS 01/01/2025 136.73 Description: INSERT BLADDER CATH COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 90.62 Description: CHANGE OF BLADDER TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51705 MEDSV DEF RBRVS 01/01/2025 89.18 Description: CHANGE OF BLADDER TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 127.06 Description: CHANGE OF BLADDER TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51710 MEDSV DEF RBRVS 01/01/2025 124.49 Description: CHANGE OF BLADDER TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 347.62 Description: ENDOSCOPIC INJECTION/IMPLANT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 51715 MEDSV DEF RBRVS 01/01/2025 337.34 Description: ENDOSCOPIC INJECTION/IMPLANT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 51720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 81.88 Description: TREATMENT OF BLADDER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51720 MEDSV DEF RBRVS 01/01/2025 80.95 Description: TREATMENT OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51721 NOCOV DEF SYSMAN 01/01/2025 Y Description: INS TRURL ABLT TRNSDC THR US Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 51725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 213.52 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 71.19 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 142.33 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 MEDSV DEF RBRVS 01/01/2025 207.48 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 26 MEDSV DEF RBRVS 01/01/2025 69.19 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 TC MEDSV DEF RBRVS 01/01/2025 138.29 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51726 MEDSV DEF RBRVS 01/01/2024 12/31/2024 281.43 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 79.51 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 201.91 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 MEDSV DEF RBRVS 01/01/2025 273.95 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 26 MEDSV DEF RBRVS 01/01/2025 77.09 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 TC MEDSV DEF RBRVS 01/01/2025 196.86 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51727 MEDSV DEF RBRVS 01/01/2024 12/31/2024 341.48 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 99.12 Description: CYSTOMETROGRAM W/UP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51727 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 242.35 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 MEDSV DEF RBRVS 01/01/2025 333.3 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 26 MEDSV DEF RBRVS 01/01/2025 96.59 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 TC MEDSV DEF RBRVS 01/01/2025 236.71 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 MEDSV DEF RBRVS 01/01/2024 12/31/2024 340.99 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 97.41 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 243.59 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 MEDSV DEF RBRVS 01/01/2025 331.76 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 26 MEDSV DEF RBRVS 01/01/2025 94.75 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 TC MEDSV DEF RBRVS 01/01/2025 237.01 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 MEDSV DEF RBRVS 01/01/2024 12/31/2024 360.92 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 117.64 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 243.28 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 MEDSV DEF RBRVS 01/01/2025 349.75 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 26 MEDSV DEF RBRVS 01/01/2025 114.39 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 TC MEDSV DEF RBRVS 01/01/2025 235.36 Description: CYSTOMETROGRAM W/VP&UP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51736 MEDSV DEF RBRVS 01/01/2024 12/31/2024 12.57 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 7.77 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 4.79 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 MEDSV DEF RBRVS 01/01/2025 12.53 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 26 MEDSV DEF RBRVS 01/01/2025 7.54 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 TC MEDSV DEF RBRVS 01/01/2025 4.99 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 MEDSV DEF RBRVS 01/01/2024 12/31/2024 13.04 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 7.94 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 5.1 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 MEDSV DEF RBRVS 01/01/2025 12.99 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 26 MEDSV DEF RBRVS 01/01/2025 7.7 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 TC MEDSV DEF RBRVS 01/01/2025 5.29 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51784 MEDSV DEF RBRVS 01/01/2024 12/31/2024 60.04 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 34.88 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 25.17 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 MEDSV DEF RBRVS 01/01/2025 59.04 Description: ANAL/URINARY MUSCLE STUDY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51784 26 MEDSV DEF RBRVS 01/01/2025 33.82 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 TC MEDSV DEF RBRVS 01/01/2025 25.22 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51785 MEDSV DEF RBRVS 01/01/2024 12/31/2024 401.81 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 82.27 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 319.54 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 MEDSV DEF RBRVS 01/01/2025 392.7 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 26 MEDSV DEF RBRVS 01/01/2025 80.06 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 TC MEDSV DEF RBRVS 01/01/2025 312.64 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 MEDSV DEF RBRVS 01/01/2024 12/31/2024 252.85 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 50.93 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 201.92 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 MEDSV DEF RBRVS 01/01/2025 248.54 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 26 MEDSV DEF RBRVS 01/01/2025 50.32 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 TC MEDSV DEF RBRVS 01/01/2025 198.22 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51797 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.67 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 37.35 Description: INTRAABDOMINAL PRESSURE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51797 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 142.32 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 MEDSV DEF RBRVS 01/01/2025 172.08 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 26 MEDSV DEF RBRVS 01/01/2025 36.22 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 TC MEDSV DEF RBRVS 01/01/2025 135.86 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51798 MEDSV DEF RBRVS 01/01/2024 12/31/2024 9.73 Description: US URINE CAPACITY MEASURE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51798 MEDSV DEF RBRVS 01/01/2025 10.12 Description: US URINE CAPACITY MEASURE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 967.01 Description: REVISION OF BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51800 MEDSV DEF RBRVS 01/01/2025 948.21 Description: REVISION OF BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1010.99 Description: REVISION OF URINARY TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51820 MEDSV DEF RBRVS 01/01/2025 991.42 Description: REVISION OF URINARY TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 650.52 Description: ATTACH BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51840 MEDSV DEF RBRVS 01/01/2025 637.05 Description: ATTACH BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51841 MEDSV DEF RBRVS 01/01/2024 12/31/2024 753.29 Description: ATTACH BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51841 MEDSV DEF RBRVS 01/01/2025 738.32 Description: ATTACH BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 544.48 Description: REPAIR BLADDER NECK Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51845 MEDSV DEF RBRVS 01/01/2025 535.14 Description: REPAIR BLADDER NECK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 692.65 Description: REPAIR OF BLADDER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51860 MEDSV DEF RBRVS 01/01/2025 679.16 Description: REPAIR OF BLADDER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51865 MEDSV DEF RBRVS 01/01/2024 12/31/2024 833.81 Description: REPAIR OF BLADDER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51865 MEDSV DEF RBRVS 01/01/2025 816.89 Description: REPAIR OF BLADDER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 433.29 Description: REPAIR OF BLADDER OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51880 MEDSV DEF RBRVS 01/01/2025 427.45 Description: REPAIR OF BLADDER OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 768.9 Description: REPAIR BLADDER/VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51900 MEDSV DEF RBRVS 01/01/2025 755.02 Description: REPAIR BLADDER/VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 712.64 Description: CLOSE BLADDER-UTERUS FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51920 MEDSV DEF RBRVS 01/01/2025 699.87 Description: CLOSE BLADDER-UTERUS FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51925 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1008.69 Y Y Description: HYSTERECTOMY/BLADDER REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51925 MEDSV DEF RBRVS 01/01/2025 981.33 Y Y Description: HYSTERECTOMY/BLADDER REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51940 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1525.3 Description: CORRECTION OF BLADDER DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51940 MEDSV DEF RBRVS 01/01/2025 1493.84 Description: CORRECTION OF BLADDER DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51960 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1288.14 Description: REVISION OF BLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51960 MEDSV DEF RBRVS 01/01/2025 1262.84 Description: REVISION OF BLADDER & 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51980 MEDSV DEF RBRVS 01/01/2024 12/31/2024 666.37 Description: CONSTRUCT BLADDER OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51980 MEDSV DEF RBRVS 01/01/2025 654.47 Description: CONSTRUCT BLADDER OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51990 MEDSV DEF RBRVS 01/01/2024 12/31/2024 694.45 0-1 Description: LAPARO URETHRAL SUSPENSION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 51990 MEDSV DEF RBRVS 01/01/2025 680.91 0-1 Description: LAPARO URETHRAL SUSPENSION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 51992 MEDSV DEF RBRVS 01/01/2024 12/31/2024 776.89 0-1 Description: LAPARO SLING OPERATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 51992 MEDSV DEF RBRVS 01/01/2025 761.06 0-1 Description: LAPARO SLING OPERATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 51999 MEDSV DEF BILL35 01/01/2014 Description: UNLISTED LAPS PX BLADDER Category: Medical Services CMS Add: 01/01/2006 CMS Term: 52000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 224.39 Description: CYSTOURETHROSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52000 MEDSV DEF RBRVS 01/01/2025 218.26 Description: CYSTOURETHROSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 411.22 Description: CYSTO W/IRRG&EVAC MLT CLOTS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 52001 MEDSV DEF RBRVS 01/01/2025 401.31 Description: CYSTO W/IRRG&EVAC MLT CLOTS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 52005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 284.09 Description: CYSTO W/URTRL CATHJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52005 MEDSV DEF RBRVS 01/01/2025 276.63 Description: CYSTO W/URTRL CATHJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52007 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.56 Description: CYSTO URTRL CATHJ BRUSH BX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52007 MEDSV DEF RBRVS 01/01/2025 408.79 Description: CYSTO URTRL CATHJ BRUSH BX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5200F NOCOV DEF SYSMAN 01/01/2010 Y Description: EVAL APPROS SURG THXPY EPI 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 357.57 Description: CYSTOSCOPY & DUCT CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52010 MEDSV DEF RBRVS 01/01/2025 348.1 Description: CYSTOSCOPY & DUCT CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52204 MEDSV DEF RBRVS 01/01/2024 12/31/2024 353.77 Description: CYSTOSCOPY W/BIOPSY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52204 MEDSV DEF RBRVS 01/01/2025 343.49 Description: CYSTOSCOPY W/BIOPSY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52214 MEDSV DEF RBRVS 01/01/2024 12/31/2024 699.57 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52214 MEDSV DEF RBRVS 01/01/2025 676.47 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52224 MEDSV DEF RBRVS 01/01/2024 12/31/2024 731.07 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52224 MEDSV DEF RBRVS 01/01/2025 707.06 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52234 MEDSV DEF RBRVS 01/01/2024 12/31/2024 227.46 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52234 MEDSV DEF RBRVS 01/01/2025 222.67 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 266.74 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52235 MEDSV DEF RBRVS 01/01/2025 261.23 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 362.18 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52240 MEDSV DEF RBRVS 01/01/2025 354.69 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 221.35 Description: CYSTOSCOPY AND RADIOTRACER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52250 MEDSV DEF RBRVS 01/01/2025 216.58 Description: CYSTOSCOPY AND RADIOTRACER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 194.88 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52260 MEDSV DEF RBRVS 01/01/2025 190.61 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 350.25 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52265 MEDSV DEF RBRVS 01/01/2025 339.01 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 394.13 Description: CYSTOSCOPY & REVISE URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52270 MEDSV DEF RBRVS 01/01/2025 382.65 Description: CYSTOSCOPY & REVISE URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 505.52 Description: CYSTOSCOPY & REVISE URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52275 MEDSV DEF RBRVS 01/01/2025 491.23 Description: CYSTOSCOPY & REVISE URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52276 MEDSV DEF RBRVS 01/01/2024 12/31/2024 244.35 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52276 MEDSV DEF RBRVS 01/01/2025 239.34 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52277 MEDSV DEF RBRVS 01/01/2024 12/31/2024 298.91 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52277 MEDSV DEF RBRVS 01/01/2025 292.41 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52281 MEDSV DEF RBRVS 01/01/2024 12/31/2024 305.5 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52281 MEDSV DEF RBRVS 01/01/2025 297.72 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52282 MEDSV DEF RBRVS 01/01/2024 12/31/2024 310.9 Description: CYSTOSCOPY IMPLANT STENT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 52282 MEDSV DEF RBRVS 01/01/2025 304.82 Description: CYSTOSCOPY IMPLANT STENT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52283 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.68 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52283 MEDSV DEF RBRVS 01/01/2025 323.26 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52284 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2482.08 Y Description: CYSTO RX BALO CATH URTL STRX Category: Medical Services CMS Add: 01/01/2024 CMS Term: 52284 MEDSV DEF RBRVS 01/01/2025 2425.84 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 12/31/2024 328.5 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52285 MEDSV DEF RBRVS 01/01/2025 319.77 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52287 MEDSV DEF RBRVS 01/01/2024 12/31/2024 363.86 Description: CYSTOSCOPY CHEMODENERVATION Category: Medical Services CMS Add: 01/01/2013 CMS Term: 52287 MEDSV DEF RBRVS 01/01/2025 353.12 Description: CYSTOSCOPY CHEMODENERVATION Category: Medical Services CMS Add: 01/01/2013 CMS Term: 52290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 225.49 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52290 MEDSV DEF RBRVS 01/01/2025 220.59 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 259.22 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52300 MEDSV DEF RBRVS 01/01/2025 253.45 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52301 MEDSV DEF RBRVS 01/01/2024 12/31/2024 268.15 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 52301 MEDSV DEF RBRVS 01/01/2025 262.59 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 52305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 257.67 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52305 MEDSV DEF RBRVS 01/01/2025 251.64 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 298.12 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52310 MEDSV DEF RBRVS 01/01/2025 291.39 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52315 MEDSV DEF RBRVS 01/01/2024 12/31/2024 439.97 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52315 MEDSV DEF RBRVS 01/01/2025 429.2 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52317 MEDSV DEF RBRVS 01/01/2024 12/31/2024 828.81 Description: REMOVE BLADDER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52317 MEDSV DEF RBRVS 01/01/2025 803.47 Description: REMOVE BLADDER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52318 MEDSV DEF RBRVS 01/01/2024 12/31/2024 437.46 Description: REMOVE BLADDER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52318 MEDSV DEF RBRVS 01/01/2025 427.98 Description: REMOVE BLADDER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 227.67 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 52320 MEDSV DEF RBRVS 01/01/2025 222.84 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 52325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 296.1 Description: CYSTOSCOPY STONE REMOVAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52325 MEDSV DEF RBRVS 01/01/2025 289.51 Description: CYSTOSCOPY STONE REMOVAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52327 MEDSV DEF RBRVS 01/01/2024 12/31/2024 240.14 Description: CYSTOSCOPY INJECT MATERIAL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52327 MEDSV DEF RBRVS 01/01/2025 234.41 Description: CYSTOSCOPY INJECT MATERIAL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 564.91 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52330 MEDSV DEF RBRVS 01/01/2025 548.75 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52332 MEDSV DEF RBRVS 01/01/2024 12/31/2024 375.33 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52332 MEDSV DEF RBRVS 01/01/2025 364.17 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52334 MEDSV DEF RBRVS 01/01/2024 12/31/2024 169.27 Description: CREATE PASSAGE TO KIDNEY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52334 MEDSV DEF RBRVS 01/01/2025 165.61 Description: CREATE PASSAGE TO KIDNEY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52341 MEDSV DEF RBRVS 01/01/2024 12/31/2024 262.76 Description: CYSTO W/URETER STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52341 MEDSV DEF RBRVS 01/01/2025 257.21 Description: CYSTO W/URETER STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52342 MEDSV DEF RBRVS 01/01/2024 12/31/2024 285.6 Description: CYSTO W/UP STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52342 MEDSV DEF RBRVS 01/01/2025 279.97 Description: CYSTO W/UP STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52343 MEDSV DEF RBRVS 01/01/2024 12/31/2024 318.18 Description: CYSTO W/RENAL STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52343 MEDSV DEF RBRVS 01/01/2025 311.25 Description: CYSTO W/RENAL STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52344 MEDSV DEF RBRVS 01/01/2024 12/31/2024 340.87 Description: CYSTO/URETERO STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52344 MEDSV DEF RBRVS 01/01/2025 334.33 Description: CYSTO/URETERO STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 364.18 Description: CYSTO/URETERO W/UP STRICTURE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52345 MEDSV DEF RBRVS 01/01/2025 356.79 Description: CYSTO/URETERO W/UP STRICTURE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52346 MEDSV DEF RBRVS 01/01/2024 12/31/2024 412.13 Description: CYSTOURETERO W/RENAL STRICT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52346 MEDSV DEF RBRVS 01/01/2025 403.44 Description: CYSTOURETERO W/RENAL STRICT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52351 MEDSV DEF RBRVS 01/01/2024 12/31/2024 279.73 Description: CYSTOURETERO & OR PYELOSCOPE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52351 MEDSV DEF RBRVS 01/01/2025 274.12 Description: CYSTOURETERO & OR PYELOSCOPE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52352 MEDSV DEF RBRVS 01/01/2024 12/31/2024 327.44 Description: CYSTOURETERO W/STONE REMOVE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52352 MEDSV DEF RBRVS 01/01/2025 320.39 Description: CYSTOURETERO W/STONE REMOVE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52353 MEDSV DEF RBRVS 01/01/2024 12/31/2024 362.18 Description: CYSTOURETERO W/LITHOTRIPSY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52353 MEDSV DEF RBRVS 01/01/2025 354.39 Description: CYSTOURETERO W/LITHOTRIPSY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52354 MEDSV DEF RBRVS 01/01/2024 12/31/2024 385.18 Description: CYSTOURETERO W/BIOPSY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52354 MEDSV DEF RBRVS 01/01/2025 377.14 Description: CYSTOURETERO W/BIOPSY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52355 MEDSV DEF RBRVS 01/01/2024 12/31/2024 431.64 Description: CYSTOURETERO W/EXCISE TUMOR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52355 MEDSV DEF RBRVS 01/01/2025 422.52 Description: CYSTOURETERO W/EXCISE TUMOR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52356 MEDSV DEF RBRVS 01/01/2024 12/31/2024 383.94 Description: CYSTO/URETERO W/LITHOTRIPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 52356 MEDSV DEF RBRVS 01/01/2025 375.94 Description: CYSTO/URETERO W/LITHOTRIPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 52400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 444.42 Description: CYSTOURETERO W/CONGEN REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52400 MEDSV DEF RBRVS 01/01/2025 436.35 Description: CYSTOURETERO W/CONGEN REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52402 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.31 Description: CYSTOURETHRO CUT EJACUL DUCT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 52402 MEDSV DEF RBRVS 01/01/2025 240.09 Description: CYSTOURETHRO CUT EJACUL DUCT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52441 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1184.4 Y Description: CYSTOURETHRO W/IMPLANT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 52441 MEDSV DEF RBRVS 01/01/2025 1141.82 Y Description: CYSTOURETHRO W/IMPLANT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 52442 MEDSV DEF RBRVS 01/01/2024 12/31/2024 807.63 Y Description: CYSTOURETHRO W/ADDL IMPLANT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 52442 MEDSV DEF RBRVS 01/01/2025 774.94 Y Description: CYSTOURETHRO W/ADDL IMPLANT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 52450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 443.14 Description: INCISION OF PROSTATE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 52450 MEDSV DEF RBRVS 01/01/2025 437.39 Description: INCISION OF PROSTATE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 52500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 460.01 Description: REVISION OF BLADDER NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52500 MEDSV DEF RBRVS 01/01/2025 453.76 Description: REVISION OF BLADDER NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5250F NOCOV DEF SYSMAN 01/01/2012 Y Description: ASTHMA DISCHARGE PLAN PRESNT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 52601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 679.14 Description: PROSTATECTOMY (TURP) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52601 MEDSV DEF RBRVS 01/01/2025 666.61 Description: PROSTATECTOMY (TURP) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 378.99 Description: REMOVE PROSTATE REGROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52630 MEDSV DEF RBRVS 01/01/2025 373.74 Description: REMOVE PROSTATE REGROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 301.01 Description: RELIEVE BLADDER CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52640 MEDSV DEF RBRVS 01/01/2025 297.99 Description: RELIEVE BLADDER CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52647 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1461.98 Description: LASER SURGERY OF PROSTATE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52647 MEDSV DEF RBRVS 01/01/2025 1420.5 Description: LASER SURGERY OF PROSTATE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52648 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1508.46 Description: LASER SURGERY OF PROSTATE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52648 MEDSV DEF RBRVS 01/01/2025 1465.18 Description: LASER SURGERY OF PROSTATE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52649 MEDSV DEF RBRVS 01/01/2024 12/31/2024 770.07 Description: PROSTATE LASER ENUCLEATION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 52649 MEDSV DEF RBRVS 01/01/2025 755.74 Description: PROSTATE LASER ENUCLEATION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 52700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 413.71 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52700 MEDSV DEF RBRVS 01/01/2025 407.19 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138.56 Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53000 MEDSV DEF RBRVS 01/01/2025 136.75 Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 277.57 Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53010 MEDSV DEF RBRVS 01/01/2025 274.75 Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 89.76 1-999Years Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53020 MEDSV DEF RBRVS 01/01/2025 88.02 1-999Years Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 63.7 0-364Days Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53025 MEDSV DEF RBRVS 01/01/2025 62.77 0-364Days Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 367.26 Description: DRAINAGE OF URETHRA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53040 MEDSV DEF RBRVS 01/01/2025 361.37 Description: DRAINAGE OF URETHRA ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 176.93 Description: DRAINAGE OF URETHRA ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53060 MEDSV DEF RBRVS 01/01/2025 173.09 Description: DRAINAGE OF URETHRA ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53080 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.41 Description: DRAINAGE OF URINARY LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53080 MEDSV DEF RBRVS 01/01/2025 387.72 Description: DRAINAGE OF URINARY LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53085 MEDSV DEF RBRVS 01/01/2024 12/31/2024 605.71 Description: DRAINAGE OF URINARY LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53085 MEDSV DEF RBRVS 01/01/2025 595.08 Description: DRAINAGE OF URINARY LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 148.19 Description: BIOPSY OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53200 MEDSV DEF RBRVS 01/01/2025 145.92 Description: BIOPSY OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 723.98 Description: REMOVAL OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53210 MEDSV DEF RBRVS 01/01/2025 710.7 Description: REMOVAL OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 864.68 Description: REMOVAL OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53215 MEDSV DEF RBRVS 01/01/2025 846.95 Description: REMOVAL OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.62 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53220 MEDSV DEF RBRVS 01/01/2025 416.02 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 568.62 Description: REMOVAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53230 MEDSV DEF RBRVS 01/01/2025 558.68 Description: REMOVAL OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 592.47 Description: REMOVAL OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53235 MEDSV DEF RBRVS 01/01/2025 582.51 Description: REMOVAL OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 397.61 Description: SURGERY FOR URETHRA POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53240 MEDSV DEF RBRVS 01/01/2025 391.46 Description: SURGERY FOR URETHRA POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 370.88 Description: REMOVAL OF URETHRA GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53250 MEDSV DEF RBRVS 01/01/2025 365.21 Description: REMOVAL OF URETHRA GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 193.86 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53260 MEDSV DEF RBRVS 01/01/2025 190.56 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 214.22 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53265 MEDSV DEF RBRVS 01/01/2025 210.57 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 198.18 Description: REMOVAL OF URETHRA GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53270 MEDSV DEF RBRVS 01/01/2025 195.5 Description: REMOVAL OF URETHRA GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.55 Description: REPAIR OF URETHRA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53275 MEDSV DEF RBRVS 01/01/2025 240.54 Description: REPAIR OF URETHRA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 746.53 Description: REVISE URETHRA STAGE 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53400 MEDSV DEF RBRVS 01/01/2025 732.74 Description: REVISE URETHRA STAGE 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 814.54 Description: REVISE URETHRA STAGE 2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53405 MEDSV DEF RBRVS 01/01/2025 799.26 Description: REVISE URETHRA STAGE 2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 912.62 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53410 MEDSV DEF RBRVS 01/01/2025 895.51 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1051.79 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 53415 MEDSV DEF RBRVS 01/01/2025 1031.06 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 53420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 784.29 Description: RECONSTRUCT URETHRA STAGE 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53420 MEDSV DEF RBRVS 01/01/2025 769.28 Description: RECONSTRUCT URETHRA STAGE 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 872.61 Description: RECONSTRUCT URETHRA STAGE 2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53425 MEDSV DEF RBRVS 01/01/2025 855.54 Description: RECONSTRUCT URETHRA STAGE 2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 905.88 Y Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53430 MEDSV DEF RBRVS 01/01/2025 887.82 Y Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53431 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1073.02 Description: RECONSTRUCT URETHRA/BLADDER Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53431 MEDSV DEF RBRVS 01/01/2025 1051.95 Description: RECONSTRUCT URETHRA/BLADDER Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 702.76 Description: MALE SLING 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53440 MEDSV DEF RBRVS 01/01/2025 690.08 Description: MALE SLING PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53442 MEDSV DEF RBRVS 01/01/2024 12/31/2024 733.57 Description: REMOVE/REVISE MALE SLING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53442 MEDSV DEF RBRVS 01/01/2025 721.36 Description: REMOVE/REVISE MALE SLING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53444 MEDSV DEF RBRVS 01/01/2024 12/31/2024 740.2 Description: INSERT TANDEM CUFF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53444 MEDSV DEF RBRVS 01/01/2025 726.83 Description: INSERT TANDEM CUFF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 706.59 Description: INSERT URO/VES NCK SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53445 MEDSV DEF RBRVS 01/01/2025 694.56 Description: INSERT URO/VES NCK SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53446 MEDSV DEF RBRVS 01/01/2024 12/31/2024 600.13 Description: REMOVE URO SPHINCTER Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53446 MEDSV DEF RBRVS 01/01/2025 590.29 Description: REMOVE URO SPHINCTER Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53447 MEDSV DEF RBRVS 01/01/2024 12/31/2024 752.53 Description: REMOVE/REPLACE UR SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53447 MEDSV DEF RBRVS 01/01/2025 738.7 Description: REMOVE/REPLACE UR SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53448 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1188.07 Description: REMOV/REPLC UR SPHINCTR COMP Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53448 MEDSV DEF RBRVS 01/01/2025 1164.34 Description: REMOV/REPLC UR SPHINCTR COMP Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53449 MEDSV DEF RBRVS 01/01/2024 12/31/2024 573.56 Description: REPAIR URO SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53449 MEDSV DEF RBRVS 01/01/2025 562.95 Description: REPAIR URO SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 382.76 Description: REVISION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53450 MEDSV DEF RBRVS 01/01/2025 376.9 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53451 MEDSV DEF BILL35 01/01/2022 Description: TPRNL BALO CNTNC DEV BI Category: Medical Services CMS Add: 01/01/2022 CMS Term: 53452 MEDSV DEF BILL35 01/01/2022 Description: TPRNL BALO CNTNC DEV UNI Category: Medical Services CMS Add: 01/01/2022 CMS Term: 53453 MEDSV DEF BILL35 01/01/2022 Description: TPRNL BALO CNTNC DEV RMVL EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 53454 MEDSV DEF BILL35 01/01/2022 Description: TPRNL BALO CNTNC DEV ADJMT Category: Medical Services CMS Add: 01/01/2022 CMS Term: 53460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 427.93 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53460 MEDSV DEF RBRVS 01/01/2025 421.62 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 698.14 Description: URETHRLYS TRANSVAG W/ SCOPE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 53500 MEDSV DEF RBRVS 01/01/2025 683.02 Description: URETHRLYS TRANSVAG W/ SCOPE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 53502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.36 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53502 MEDSV DEF RBRVS 01/01/2025 447.58 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 454.05 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53505 MEDSV DEF RBRVS 01/01/2025 447.28 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 591.14 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53510 MEDSV DEF RBRVS 01/01/2025 581.06 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 742.16 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53515 MEDSV DEF RBRVS 01/01/2025 728.42 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 522.51 Description: REPAIR OF URETHRA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53520 MEDSV DEF RBRVS 01/01/2025 514.36 Description: REPAIR OF URETHRA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 82.95 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53600 MEDSV DEF RBRVS 01/01/2025 81.25 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 79.6 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53601 MEDSV DEF RBRVS 01/01/2025 78.68 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 59.7 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53605 MEDSV DEF RBRVS 01/01/2025 58.04 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 159.21 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53620 MEDSV DEF RBRVS 01/01/2025 155.25 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53621 MEDSV DEF RBRVS 01/01/2024 12/31/2024 151.9 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53621 MEDSV DEF RBRVS 01/01/2025 148.34 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 70.43 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53660 MEDSV DEF RBRVS 01/01/2025 69.66 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53661 MEDSV DEF RBRVS 01/01/2024 12/31/2024 69.23 Description: DILATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53661 MEDSV DEF RBRVS 01/01/2025 68.48 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53665 MEDSV DEF RBRVS 01/01/2024 12/31/2024 35.39 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53665 MEDSV DEF RBRVS 01/01/2025 34.47 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1321.55 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 26 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 558.6 0 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 TC MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1373.73 0 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 MEDSV DEF RBRVS 01/01/2025 1277.82 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 26 MEDSV DEF MAXFEE 01/01/2025 547.43 0 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 TC MEDSV DEF MAXFEE 01/01/2025 1346.26 0 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1291.18 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 26 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 583.85 0 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 TC MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1374.27 0 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 MEDSV DEF RBRVS 01/01/2025 1247.93 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 26 MEDSV DEF MAXFEE 01/01/2025 572.17 0 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 TC MEDSV DEF MAXFEE 01/01/2025 1346.78 0 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53854 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1559.29 Description: TRURL DSTRJ PRST8 TISS RF WV 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53854 MEDSV DEF RBRVS 01/01/2025 1504.85 Description: TRURL DSTRJ PRST8 TISS RF WV Category: Medical Services CMS Add: 01/01/2019 CMS Term: 53855 NOCOV DEF SYSMAN 01/01/2012 Y Description: INSERT PROST URETHRAL STENT Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 53865 NOCOV DEF SYSMAN 01/01/2025 Y Description: CYSTO INSJ DEV ISCHMC RMDLG Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 53866 NOCOV DEF SYSMAN 01/01/2025 Y Description: CATHJ RMVL DEV ISCHMC RMDLG Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 53899 MEDSV DEF BILL35 10/15/2020 Description: UNLISTED PX URINARY SYSTEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 152.02 0-28Days Description: SLITTING OF PREPUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54000 MEDSV DEF RBRVS 01/01/2025 150.48 0-28Days Description: SLITTING OF PREPUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 185.52 Description: SLITTING OF PREPUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54001 MEDSV DEF RBRVS 01/01/2025 183 Description: SLITTING OF PREPUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 284.4 Description: DRAIN PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54015 MEDSV DEF RBRVS 01/01/2025 279.58 Description: DRAIN PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 134.74 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54050 MEDSV DEF RBRVS 01/01/2025 133.08 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54055 MEDSV DEF RBRVS 01/01/2024 12/31/2024 128.45 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54055 MEDSV DEF RBRVS 01/01/2025 126.94 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54056 MEDSV DEF RBRVS 01/01/2024 12/31/2024 134.88 Description: CRYOSURGERY PENIS LESION(S) 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54056 MEDSV DEF RBRVS 01/01/2025 133.52 Description: CRYOSURGERY PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 54057 MEDSV DEF RBRVS 01/01/2024 12/31/2024 133.51 Description: LASER SURG PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 54057 MEDSV DEF RBRVS 01/01/2025 131.12 Description: LASER SURG PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 54060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 182.24 Description: EXCISION OF PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54060 MEDSV DEF RBRVS 01/01/2025 180.65 Description: EXCISION OF PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 208.59 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54065 MEDSV DEF RBRVS 01/01/2025 205.47 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 189.86 Description: BIOPSY OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54100 MEDSV DEF RBRVS 01/01/2025 186.01 Description: BIOPSY OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 258.23 Description: BIOPSY OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54105 MEDSV DEF RBRVS 01/01/2025 254.67 Description: BIOPSY OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 583.14 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54110 MEDSV DEF RBRVS 01/01/2025 573.41 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 745.55 Description: TREAT PENIS LESION GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54111 MEDSV DEF RBRVS 01/01/2025 731.82 Description: TREAT PENIS LESION GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 873.72 Description: TREAT PENIS LESION GRAFT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54112 MEDSV DEF RBRVS 01/01/2025 857.56 Description: TREAT PENIS LESION GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 427.77 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54115 MEDSV DEF RBRVS 01/01/2025 422.51 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 590.53 Description: PARTIAL REMOVAL OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54120 MEDSV DEF RBRVS 01/01/2025 581.21 Description: PARTIAL REMOVAL OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 768.75 Y Description: REMOVAL OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54125 MEDSV DEF RBRVS 01/01/2025 752.5 Y Description: REMOVAL OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1111.2 Description: REMOVE PENIS & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54130 MEDSV DEF RBRVS 01/01/2025 1089.93 Description: REMOVE PENIS & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1404.91 Description: REMOVE PENIS & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54135 MEDSV DEF RBRVS 01/01/2025 1376.45 Description: REMOVE PENIS & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 139.1 Description: CIRCUMCISION W/REGIONL BLOCK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54150 MEDSV DEF RBRVS 01/01/2025 136.07 Description: CIRCUMCISION W/REGIONL BLOCK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 206.02 0-28Days Description: CIRCUMCISION NEONATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54160 MEDSV DEF RBRVS 01/01/2025 203.09 0-28Days Description: CIRCUMCISION NEONATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54161 MEDSV DEF RBRVS 01/01/2024 12/31/2024 184.39 Description: CIRCUM 28 DAYS OR OLDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54161 MEDSV DEF RBRVS 01/01/2025 181.48 Description: CIRCUM 28 DAYS OR OLDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54162 MEDSV DEF RBRVS 01/01/2024 12/31/2024 240.58 Description: LYSIS PENIL CIRCUMIC LESION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54162 MEDSV DEF RBRVS 01/01/2025 236.43 Description: LYSIS PENIL CIRCUMIC LESION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54163 MEDSV DEF RBRVS 01/01/2024 12/31/2024 204.46 Description: REPAIR OF CIRCUMCISION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54163 MEDSV DEF RBRVS 01/01/2025 202.31 Description: REPAIR OF CIRCUMCISION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54164 MEDSV DEF RBRVS 01/01/2024 12/31/2024 180.99 Description: FRENULOTOMY OF PENIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54164 MEDSV DEF RBRVS 01/01/2025 179.41 Description: FRENULOTOMY OF PENIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 108.09 Description: INJECTION PX PEYRONIE DS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54200 MEDSV DEF RBRVS 01/01/2025 107.4 Description: INJECTION PX PEYRONIE DS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 497.31 Description: NJX PX PEYRONIE DS EXPS PLAQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54205 MEDSV DEF RBRVS 01/01/2025 489.77 Description: NJX PX PEYRONIE DS EXPS PLAQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 204.96 Description: IRRG CRPRA CAVRNOSA PRIAPISM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54220 MEDSV DEF RBRVS 01/01/2025 203.03 Description: IRRG CRPRA CAVRNOSA PRIAPISM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 99.08 Description: NJX CORPORA CAVERNOSOGRAPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54230 MEDSV DEF RBRVS 01/01/2025 98.04 Description: NJX CORPORA CAVERNOSOGRAPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54231 MEDSV DEF RBRVS 01/01/2024 12/31/2024 133.97 Description: DYNAMIC CAVERNOSOMETRY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54231 MEDSV DEF RBRVS 01/01/2025 132.2 Description: DYNAMIC CAVERNOSOMETRY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 54235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 83.81 Description: NJX CORPORA CAVERNOSA RX AGT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 54235 MEDSV DEF RBRVS 01/01/2025 83.01 Description: NJX CORPORA CAVERNOSA RX AGT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 54240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 99.62 Description: PENILE PLETHYSMOGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 61.33 Description: PENILE PLETHYSMOGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 38.29 Description: PENILE PLETHYSMOGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 MEDSV DEF RBRVS 01/01/2025 98.41 Description: PENILE PLETHYSMOGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 26 MEDSV DEF RBRVS 01/01/2025 58.85 Description: PENILE PLETHYSMOGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 TC MEDSV DEF RBRVS 01/01/2025 39.56 Description: PENILE PLETHYSMOGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 115.19 Description: NCTRNL PEN TMSCN&/RGDITY TST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 102.06 Description: NCTRNL PEN TMSCN&/RGDITY TST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 13.13 Description: NCTRNL PEN TMSCN&/RGDITY TST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 MEDSV DEF RBRVS 01/01/2025 112.4 Description: NCTRNL PEN TMSCN&/RGDITY TST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 26 MEDSV DEF RBRVS 01/01/2025 99.26 Description: NCTRNL PEN TMSCN&/RGDITY TST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 TC MEDSV DEF RBRVS 01/01/2025 13.14 Description: NCTRNL PEN TMSCN&/RGDITY TST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 602.39 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54300 MEDSV DEF RBRVS 01/01/2025 592.28 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54304 MEDSV DEF RBRVS 01/01/2024 12/31/2024 697.88 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54304 MEDSV DEF RBRVS 01/01/2025 685.18 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54308 MEDSV DEF RBRVS 01/01/2024 12/31/2024 668.99 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54308 MEDSV DEF RBRVS 01/01/2025 656.87 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54312 MEDSV DEF RBRVS 01/01/2024 12/31/2024 763.89 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54312 MEDSV DEF RBRVS 01/01/2025 750.02 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54316 MEDSV DEF RBRVS 01/01/2024 12/31/2024 926.58 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54316 MEDSV DEF RBRVS 01/01/2025 909.15 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54318 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54318 MEDSV DEF RBRVS 01/01/2025 653.35 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54322 MEDSV DEF RBRVS 01/01/2024 12/31/2024 729.07 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54322 MEDSV DEF RBRVS 01/01/2025 715.41 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54324 MEDSV DEF RBRVS 01/01/2024 12/31/2024 902.34 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54324 MEDSV DEF RBRVS 01/01/2025 885.49 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54326 MEDSV DEF RBRVS 01/01/2024 12/31/2024 878.47 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54326 MEDSV DEF RBRVS 01/01/2025 862.05 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54328 MEDSV DEF RBRVS 01/01/2024 12/31/2024 872.67 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54328 MEDSV DEF RBRVS 01/01/2025 856.57 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54332 MEDSV DEF RBRVS 01/01/2024 12/31/2024 941.29 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54332 MEDSV DEF RBRVS 01/01/2025 923.43 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54336 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1106.33 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54336 MEDSV DEF RBRVS 01/01/2025 1085.27 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 532.17 Description: RPR HYPSPAD COMP SIMPLE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54340 MEDSV DEF RBRVS 01/01/2025 523.58 Description: RPR HYPSPAD COMP SIMPLE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54344 MEDSV DEF RBRVS 01/01/2024 12/31/2024 880.14 Description: RRP HYPSPAD COMP MOBLJ&URTP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54344 MEDSV DEF RBRVS 01/01/2025 863.96 Description: RRP HYPSPAD COMP MOBLJ&URTP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54348 MEDSV DEF RBRVS 01/01/2024 12/31/2024 941.14 Description: RPR HYPSPAD COMP DSJ & URTP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54348 MEDSV DEF RBRVS 01/01/2025 923.6 Description: RPR HYPSPAD COMP DSJ & URTP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54352 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1315.87 Description: REVJ PRIOR HYPSPAD REPAIR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54352 MEDSV DEF RBRVS 01/01/2025 1289.38 Description: REVJ PRIOR HYPSPAD REPAIR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 673.5 Y Description: PENIS PLASTIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54360 MEDSV DEF RBRVS 01/01/2025 661.22 Y Description: PENIS PLASTIC SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54380 MEDSV DEF RBRVS 01/01/2024 12/31/2024 746.04 Description: REPAIR PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54380 MEDSV DEF RBRVS 01/01/2025 732.55 Description: REPAIR PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54385 MEDSV DEF RBRVS 01/01/2024 12/31/2024 867.94 Description: REPAIR PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54385 MEDSV DEF RBRVS 01/01/2025 852.37 Description: REPAIR PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54390 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1156.36 Description: REPAIR PENIS AND BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54390 MEDSV DEF RBRVS 01/01/2025 1133.44 Description: REPAIR PENIS AND BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54400 NOCOV DEF SYSMAN 10/06/1994 Y Description: INSERT SEMI-RIGID PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 54401 NOCOV DEF SYSMAN 10/06/1994 Y Description: INSERT SELF-CONTD PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: 54405 NOCOV DEF SYSMAN 10/06/1994 Y Description: INSERT MULTI-COMP PENIS PROS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 54406 MEDSV DEF RBRVS 01/01/2024 12/31/2024 682.94 Description: REMOVE MUTI-COMP PENIS PROS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54406 MEDSV DEF RBRVS 01/01/2025 670.87 Description: REMOVE MUTI-COMP PENIS PROS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54408 NOCOV DEF SYSMAN 01/01/2002 Y Description: REPAIR MULTI-COMP PENIS PROS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54410 NOCOV DEF SYSMAN 01/01/2002 Y Description: REMOVE/REPLACE PENIS PROSTH Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54411 NOCOV DEF SYSMAN 01/01/2002 Y Description: REMOV/REPLC PENIS PROS COMP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 496.73 Description: REMOVE SELF-CONTD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54415 MEDSV DEF RBRVS 01/01/2025 489.84 Description: REMOVE SELF-CONTD PENIS PROS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54416 NOCOV DEF SYSMAN 01/01/2002 Y Description: REMV/REPL PENIS CONTAIN PROS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54417 NOCOV DEF SYSMAN 01/01/2002 Y Description: REMV/REPLC PENIS PROS COMPL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 656.08 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54420 MEDSV DEF RBRVS 01/01/2025 644.49 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 596.85 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54430 MEDSV DEF RBRVS 01/01/2025 586.77 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 387.82 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54435 MEDSV DEF RBRVS 01/01/2025 382.13 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54437 MEDSV DEF RBRVS 01/01/2024 12/31/2024 633.56 Description: REPAIR CORPOREAL TEAR Category: Medical Services CMS Add: 01/01/2016 CMS Term: 54437 MEDSV DEF RBRVS 01/01/2025 624.01 Description: REPAIR CORPOREAL TEAR Category: Medical Services CMS Add: 01/01/2016 CMS Term: 54438 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1244.43 Description: REPLANTATION OF PENIS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 12/31/2024 54438 MEDSV DEF RBRVS 01/01/2025 1220.13 Description: REPLANTATION OF PENIS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 12/31/2024 54440 MEDSV DEF MAXFEE 01/01/2024 1090.48 0 Description: REPAIR OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 63.98 Description: PREPUTIAL STRETCHING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54450 MEDSV DEF RBRVS 01/01/2025 63.35 Description: PREPUTIAL STRETCHING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 69.36 Description: BIOPSY OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54500 MEDSV DEF RBRVS 01/01/2025 68.08 Description: BIOPSY OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 196.06 Description: BIOPSY OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54505 MEDSV DEF RBRVS 01/01/2025 192.52 Description: BIOPSY OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 501.99 Description: EXCISE LESION TESTIS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 54512 MEDSV DEF RBRVS 01/01/2025 493.91 Description: EXCISE LESION TESTIS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 54520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 306.17 Y Description: REMOVAL OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54520 MEDSV DEF RBRVS 01/01/2025 301.81 Y Description: REMOVAL OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54522 MEDSV DEF RBRVS 01/01/2024 12/31/2024 549.27 Description: ORCHIECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 54522 MEDSV DEF RBRVS 01/01/2025 539.64 Description: ORCHIECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 54530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 475.39 Description: REMOVAL OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54530 MEDSV DEF RBRVS 01/01/2025 468.06 Description: REMOVAL OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 694.97 Description: EXTENSIVE TESTIS SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54535 MEDSV DEF RBRVS 01/01/2025 682.68 Description: EXTENSIVE TESTIS SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 459.77 Description: EXPLORATION FOR TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54550 MEDSV DEF RBRVS 01/01/2025 452.51 Description: EXPLORATION FOR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 642.37 Description: EXPLORATION FOR TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54560 MEDSV DEF RBRVS 01/01/2025 630.74 Description: EXPLORATION FOR TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 423.58 Description: REDUCE TESTIS TORSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54600 MEDSV DEF RBRVS 01/01/2025 417.25 Description: REDUCE TESTIS TORSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 278.85 Description: SUSPENSION OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54620 MEDSV DEF RBRVS 01/01/2025 273.89 Description: SUSPENSION OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 402.75 Description: ORCHIOPEXY INGUN/SCROT APPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54640 MEDSV DEF RBRVS 01/01/2025 395.2 Description: ORCHIOPEXY INGUN/SCROT APPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665.34 Description: ORCHIOPEXY (FOWLER-STEPHENS) Category: Medical Services CMS Add: 01/01/1994 CMS Term: 54650 MEDSV DEF RBRVS 01/01/2025 654.15 Description: ORCHIOPEXY (FOWLER-STEPHENS) Category: Medical Services CMS Add: 01/01/1994 CMS Term: 54660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 335.57 Y Description: REVISION OF TESTIS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 54660 MEDSV DEF RBRVS 01/01/2025 331 Y Description: REVISION OF TESTIS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 54670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 383.16 Description: REPAIR TESTIS INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54670 MEDSV DEF RBRVS 01/01/2025 377.34 Description: REPAIR TESTIS INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 735.12 Description: RELOCATION OF TESTIS(ES) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54680 MEDSV DEF RBRVS 01/01/2025 721.46 Description: RELOCATION OF TESTIS(ES) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54690 MEDSV DEF RBRVS 01/01/2024 12/31/2024 611.95 Description: LAPAROSCOPY ORCHIECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54690 MEDSV DEF RBRVS 01/01/2025 601.15 Description: LAPAROSCOPY ORCHIECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54692 MEDSV DEF RBRVS 01/01/2024 12/31/2024 705.17 0-2 Description: LAPAROSCOPY ORCHIOPEXY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54692 MEDSV DEF RBRVS 01/01/2025 691.68 0-2 Description: LAPAROSCOPY ORCHIOPEXY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54699 MEDSV DEF BILL35 01/01/2014 0-1 Description: UNLISTED LAPS PX TESTIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 198.45 Description: DRAINAGE OF SCROTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54700 MEDSV DEF RBRVS 01/01/2025 195.66 Description: DRAINAGE OF SCROTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 116.03 Description: BIOPSY OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54800 MEDSV DEF RBRVS 01/01/2025 114.41 Description: BIOPSY OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.62 Description: REMOVE EPIDIDYMIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54830 MEDSV DEF RBRVS 01/01/2025 343.8 Description: REMOVE EPIDIDYMIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 301.73 Description: REMOVE EPIDIDYMIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54840 MEDSV DEF RBRVS 01/01/2025 297.15 Description: REMOVE EPIDIDYMIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 392.27 Description: REMOVAL OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54860 MEDSV DEF RBRVS 01/01/2025 386.29 Description: REMOVAL OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54861 MEDSV DEF RBRVS 01/01/2024 12/31/2024 531.21 Description: REMOVAL OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54861 MEDSV DEF RBRVS 01/01/2025 522.95 Description: REMOVAL OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54865 MEDSV DEF RBRVS 01/01/2024 12/31/2024 337.22 Description: EXPLORE EPIDIDYMIS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 54865 MEDSV DEF RBRVS 01/01/2025 332.44 Description: EXPLORE EPIDIDYMIS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 54900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 747.34 Description: FUSION OF SPERMATIC DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54900 MEDSV DEF RBRVS 01/01/2025 733.5 Description: FUSION OF SPERMATIC DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54901 MEDSV DEF RBRVS 01/01/2024 12/31/2024 986.79 Description: FUSION OF SPERMATIC DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54901 MEDSV DEF RBRVS 01/01/2025 967.48 Description: FUSION OF SPERMATIC DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 112.48 Description: DRAINAGE OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55000 MEDSV DEF RBRVS 01/01/2025 110.36 Description: DRAINAGE OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 316.18 Description: REMOVAL OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55040 MEDSV DEF RBRVS 01/01/2025 312.14 Description: REMOVAL OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55041 MEDSV DEF RBRVS 01/01/2024 12/31/2024 478.55 Description: REMOVAL OF HYDROCELES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55041 MEDSV DEF RBRVS 01/01/2025 470.98 Description: REMOVAL OF HYDROCELES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55060 MEDSV DEF RBRVS 01/01/2024 12/31/2024 355.69 Description: REPAIR OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55060 MEDSV DEF RBRVS 01/01/2025 350.21 Description: REPAIR OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 214.92 Description: DRAINAGE OF SCROTUM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55100 MEDSV DEF RBRVS 01/01/2025 211.83 Description: DRAINAGE OF SCROTUM ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 363.06 Description: EXPLORE SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55110 MEDSV DEF RBRVS 01/01/2025 357.5 Description: EXPLORE SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 332.43 Description: REMOVAL OF SCROTUM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55120 MEDSV DEF RBRVS 01/01/2025 328.23 Description: REMOVAL OF SCROTUM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 461.29 Description: REMOVAL OF SCROTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55150 MEDSV DEF RBRVS 01/01/2025 453.34 Description: REMOVAL OF SCROTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55175 MEDSV DEF RBRVS 01/01/2024 12/31/2024 341.87 Y Description: REVISION OF SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55175 MEDSV DEF RBRVS 01/01/2025 336.5 Y Description: REVISION OF SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 643.13 Y Description: REVISION OF SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55180 MEDSV DEF RBRVS 01/01/2025 631.75 Y Description: REVISION OF SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 359.07 Description: INCISION OF SPERM DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55200 MEDSV DEF RBRVS 01/01/2025 351.84 Description: INCISION OF SPERM DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 307.5 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 12/31/2024 172.91 Description: PREPARE SPERM DUCT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55300 MEDSV DEF RBRVS 01/01/2025 169.28 Description: PREPARE SPERM DUCT X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55400 NOCOV DEF SYSMAN 10/06/1994 Y Description: REPAIR OF SPERM DUCT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 55500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 365.89 Description: REMOVAL OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55500 MEDSV DEF RBRVS 01/01/2025 359.27 Description: REMOVAL OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 421.07 Description: REMOVAL OF SPERM CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55520 MEDSV DEF RBRVS 01/01/2025 412.87 Description: REMOVAL OF SPERM CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 329.46 Description: REVISE SPERMATIC CORD VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55530 MEDSV DEF RBRVS 01/01/2025 324.56 Description: REVISE SPERMATIC CORD VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 403.04 Description: REVISE SPERMATIC CORD VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55535 MEDSV DEF RBRVS 01/01/2025 396.73 Description: REVISE SPERMATIC CORD VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 508.62 Description: REVISE HERNIA & SPERM VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55540 MEDSV DEF RBRVS 01/01/2025 497.47 Description: REVISE HERNIA & SPERM VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 402.15 0-2 Description: LAPARO LIGATE SPERMATIC VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 55550 MEDSV DEF RBRVS 01/01/2025 396.16 0-2 Description: LAPARO LIGATE SPERMATIC VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 55559 MEDSV DEF BILL35 01/01/2014 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 12/31/2024 395.08 Description: VESICULOTOMY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55600 MEDSV DEF RBRVS 01/01/2025 389.01 Description: VESICULOTOMY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 490.19 Description: VESICULOTOMY COMPLICATED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55605 MEDSV DEF RBRVS 01/01/2025 482.72 Description: VESICULOTOMY COMPLICATED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 670.78 Description: REMOVE SPERM DUCT POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55650 MEDSV DEF RBRVS 01/01/2025 658.92 Description: REMOVE SPERM DUCT POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 325.18 Description: REMOVE SPERM POUCH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55680 MEDSV DEF RBRVS 01/01/2025 320.4 Description: REMOVE SPERM POUCH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 225.69 Description: BIOPSY OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55700 MEDSV DEF RBRVS 01/01/2025 220.22 Description: BIOPSY OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 247.5 Description: BIOPSY OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55705 MEDSV DEF RBRVS 01/01/2025 242.87 Description: BIOPSY OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55706 MEDSV DEF RBRVS 01/01/2024 12/31/2024 351.44 Description: PROSTATE SATURATION SAMPLING Category: Medical Services CMS Add: 01/01/2009 CMS Term: 55706 MEDSV DEF RBRVS 01/01/2025 345.25 Description: PROSTATE SATURATION SAMPLING Category: Medical Services CMS Add: 01/01/2009 CMS Term: 55720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.62 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55720 MEDSV DEF RBRVS 01/01/2025 416.13 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 556.84 Description: DRAINAGE OF PROSTATE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55725 MEDSV DEF RBRVS 01/01/2025 548.17 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55801 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1020.75 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55801 MEDSV DEF RBRVS 01/01/2025 1000.89 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1216.16 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55810 MEDSV DEF RBRVS 01/01/2025 1191.81 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55812 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1495.45 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55812 MEDSV DEF RBRVS 01/01/2025 1464.93 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55815 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1637.35 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55815 MEDSV DEF RBRVS 01/01/2025 1603.16 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 782.47 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55821 MEDSV DEF RBRVS 01/01/2025 767.66 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55831 MEDSV DEF RBRVS 01/01/2024 12/31/2024 802.78 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55831 MEDSV DEF RBRVS 01/01/2025 786.75 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1088.41 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55840 MEDSV DEF RBRVS 01/01/2025 1068.16 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55842 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1088.73 Description: EXTENSIVE PROSTATE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55842 MEDSV DEF RBRVS 01/01/2025 1067.7 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55845 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1266.17 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55845 MEDSV DEF RBRVS 01/01/2025 1241.46 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 816.18 Description: SURGICAL EXPOSURE PROSTATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55860 MEDSV DEF RBRVS 01/01/2025 800.04 Description: SURGICAL EXPOSURE PROSTATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55862 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1020.58 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55862 MEDSV DEF RBRVS 01/01/2025 1000.17 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55865 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1242.19 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55865 MEDSV DEF RBRVS 01/01/2025 1217.45 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55866 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1114.19 Description: LAPS SURG PRST8ECT RPBIC RAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 55866 MEDSV DEF RBRVS 01/01/2025 1090.81 Description: LAPS SURG PRST8ECT RPBIC RAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 55867 MEDSV DEF RBRVS 01/01/2024 12/31/2024 978.09 Description: LAPS SURG PRST8ECT SMPL STOT Category: Medical Services CMS Add: 01/01/2023 CMS Term: 55867 MEDSV DEF RBRVS 01/01/2025 958.06 Description: LAPS SURG PRST8ECT SMPL STOT Category: Medical Services CMS Add: 01/01/2023 CMS Term: 55870 NOCOV DEF SYSMAN 01/01/1993 Y Description: ELECTROEJACULATION Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 55873 MEDSV DEF RBRVS 01/01/2024 12/31/2024 5354.87 Description: CRYOABLATE PROSTATE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 55873 MEDSV DEF RBRVS 01/01/2025 5148.88 Description: CRYOABLATE PROSTATE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55874 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2692.05 0 Description: TPRNL PLMT BIODEGRDABL MATRL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 55874 MEDSV DEF RBRVS 01/01/2025 2575.96 Description: TPRNL PLMT BIODEGRDABL MATRL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 55875 MEDSV DEF RBRVS 01/01/2024 12/31/2024 730.71 Description: TRANSPERI NEEDLE PLACE PROS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 55875 MEDSV DEF RBRVS 01/01/2025 717.5 Description: TRANSPERI NEEDLE PLACE PROS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 55876 MEDSV DEF RBRVS 01/01/2024 12/31/2024 141.95 Description: PLACE RT DEVICE/MARKER PROS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 55876 MEDSV DEF RBRVS 01/01/2025 139.06 Description: PLACE RT DEVICE/MARKER PROS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 55880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 912.77 Description: ABLTJ MAL PRST8 TISS HIFU Category: Medical Services CMS Add: 01/01/2021 CMS Term: 55880 MEDSV DEF RBRVS 01/01/2025 896.23 Description: ABLTJ MAL PRST8 TISS HIFU Category: Medical Services CMS Add: 01/01/2021 CMS Term: 55881 NOCOV DEF SYSMAN 01/01/2025 Y Description: ABLT TRURL PRST8 TIS THRM US Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 55882 NOCOV DEF SYSMAN 01/01/2025 Y Description: ABLT TRURL PRST8 TIS TRNSDCR Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 55899 MEDSV DEF BILL35 09/01/2021 Y Description: UNLISTED PX MALE GENITAL SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 437.17 Description: PLACE NEEDLES PELVIC FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 55920 MEDSV DEF RBRVS 01/01/2025 425.42 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 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 Y Description: SEX TRANSFORMATION F TO M Category: Medical Services CMS Add: 01/01/1982 CMS Term: 56405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138.49 Description: I & D 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 56405 MEDSV DEF RBRVS 01/01/2025 134.27 Description: I & D OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 174.45 Description: DRAINAGE OF GLAND ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56420 MEDSV DEF RBRVS 01/01/2025 170.21 Description: DRAINAGE OF GLAND ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 169.4 Description: MRSPLZATN BRTHLNS GLND CST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56440 MEDSV DEF RBRVS 01/01/2025 166.26 Description: MRSPLZATN BRTHLNS GLND CST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56441 MEDSV DEF RBRVS 01/01/2024 12/31/2024 172.38 Description: LYSIS OF LABIAL ADHESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 56441 MEDSV DEF RBRVS 01/01/2025 168.44 Description: LYSIS OF LABIAL ADHESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 56442 MEDSV DEF RBRVS 01/01/2024 12/31/2024 44.12 Description: HYMENOTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 56442 MEDSV DEF RBRVS 01/01/2025 43.19 Description: HYMENOTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 56501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 181.36 Description: DESTROY VULVA LESIONS SIM Category: Medical Services CMS Add: 01/01/1987 CMS Term: 56501 MEDSV DEF RBRVS 01/01/2025 176.31 Description: DESTROY VULVA LESIONS SIM Category: Medical Services CMS Add: 01/01/1987 CMS Term: 56515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 260.6 Description: DESTROY VULVA LESION/S COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56515 MEDSV DEF RBRVS 01/01/2025 254.01 Description: DESTROY VULVA LESION/S COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 90.49 0-1 Description: BIOPSY OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56605 MEDSV DEF RBRVS 01/01/2025 88.09 0-1 Description: BIOPSY OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 35.99 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 56606 MEDSV DEF RBRVS 01/01/2025 34.53 Description: BIOPSY OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 549.12 Description: VULVECTOMY SIMPLE PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56620 MEDSV DEF RBRVS 01/01/2025 538.75 Description: VULVECTOMY SIMPLE PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56625 MEDSV DEF RBRVS 01/01/2024 12/31/2024 625.11 Description: VULVECTOMY SIMPLE COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56625 MEDSV DEF RBRVS 01/01/2025 613.19 Description: VULVECTOMY SIMPLE COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 898.15 Description: VULVECTOMY RADICAL PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56630 MEDSV DEF RBRVS 01/01/2025 879.65 Description: VULVECTOMY RADICAL PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56631 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1107.25 Description: VLVCTMY RAD PRTL UNI LYMPHAD Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56631 MEDSV DEF RBRVS 01/01/2025 1085.93 Description: VLVCTMY RAD PRTL UNI LYMPHAD Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56632 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1340.36 Description: VLVCTMY RAD PRTL BI LYMPHAD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 56632 MEDSV DEF RBRVS 01/01/2025 1312.7 Description: VLVCTMY RAD PRTL BI LYMPHAD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 56633 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1151.06 Description: VULVECTOMY RADICAL COMPLETE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56633 MEDSV DEF RBRVS 01/01/2025 1133.24 Description: VULVECTOMY RADICAL COMPLETE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56634 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1207.41 Description: VLVCTMY RAD COMP UNI LYMPHAD Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56634 MEDSV DEF RBRVS 01/01/2025 1185.53 Description: VLVCTMY RAD COMP UNI LYMPHAD Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56637 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1414.21 Description: VLVCTMY RAD COMP BI LYMPHAD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 56637 MEDSV DEF RBRVS 01/01/2025 1388.08 Description: VLVCTMY RAD COMP BI LYMPHAD Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56640 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1422.95 Description: VLVCTMY RAD COMP W/LYMPHADEC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56640 MEDSV DEF RBRVS 01/01/2025 1395.4 Description: VLVCTMY RAD COMP W/LYMPHADEC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 191.01 Description: PRTL HYMNCTMY/REVJ HYMNL RNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56700 MEDSV DEF RBRVS 01/01/2025 186.2 Description: PRTL HYMNCTMY/REVJ HYMNL RNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 295.26 Description: EXC BARTHOLINS GLAND/CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56740 MEDSV DEF RBRVS 01/01/2025 288 Description: EXC BARTHOLINS GLAND/CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 237.49 Description: PLASTIC REPAIR INTROITUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56800 MEDSV DEF RBRVS 01/01/2025 232.14 Description: PLASTIC REPAIR INTROITUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1091.99 Y Description: CLITOROPLASTY INTERSEX STATE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 56805 MEDSV DEF RBRVS 01/01/2025 1062.53 Y Description: CLITOROPLASTY INTERSEX STATE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 56810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 254.96 Y Description: PERINEOPLASTY RPR PER NONOB Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56810 MEDSV DEF RBRVS 01/01/2025 250.17 Y Description: PERINEOPLASTY RPR PER NONOB Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 117.21 Description: COLPOSCOPY VULVA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 56820 MEDSV DEF RBRVS 01/01/2025 114.82 Description: COLPOSCOPY VULVA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 56821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 156.91 Description: COLPOSCOPY VULVA W/BIOPSY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 56821 MEDSV DEF RBRVS 01/01/2025 153.59 Description: COLPOSCOPY VULVA W/BIOPSY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 189.73 Description: COLPOTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57000 MEDSV DEF RBRVS 01/01/2025 185.02 Description: COLPOTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 429.65 Description: COLPOTOMY DRG PEL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57010 MEDSV DEF RBRVS 01/01/2025 419.47 Description: COLPOTOMY DRG PEL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 118.14 Description: COLPOCENTESIS SEP PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57020 MEDSV DEF RBRVS 01/01/2025 114.07 Description: COLPOCENTESIS SEP PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57022 MEDSV DEF RBRVS 01/01/2024 12/31/2024 170.29 Description: I&D VAGINAL HEMATOMA OB/PP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57022 MEDSV DEF RBRVS 01/01/2025 165.98 Description: I&D VAGINAL HEMATOMA OB/PP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57023 MEDSV DEF RBRVS 01/01/2024 12/31/2024 299.74 Description: I&D VAGINAL HEMATOMA NON-OB Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57023 MEDSV DEF RBRVS 01/01/2025 292.58 Description: I&D VAGINAL HEMATOMA NON-OB Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57061 MEDSV DEF RBRVS 01/01/2024 12/31/2024 157.19 Description: DESTRUCTION VAG LESIONS SMPL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57061 MEDSV DEF RBRVS 01/01/2025 153.24 Description: DESTRUCTION VAG LESIONS SMPL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57065 MEDSV DEF RBRVS 01/01/2024 12/31/2024 232.28 Description: DESTRUCTION VAG LESION XTNSV Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57065 MEDSV DEF RBRVS 01/01/2025 226.16 Description: DESTRUCTION VAG LESION XTNSV Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 96.82 Description: BIOPSY VAGINAL MUCOSA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57100 MEDSV DEF RBRVS 01/01/2025 94.7 Description: BIOPSY VAGINAL MUCOSA SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 166.11 Description: BIOPSY VAGINAL MUCOSA XTNSV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57105 MEDSV DEF RBRVS 01/01/2025 162.42 Description: BIOPSY VAGINAL MUCOSA XTNSV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57106 MEDSV DEF RBRVS 01/01/2024 12/31/2024 503.15 Y Description: VAGNC PRTL RMVL VAG WALL Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57106 MEDSV DEF RBRVS 01/01/2025 493.05 Y Description: VAGNC PRTL RMVL VAG WALL Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1361.82 Description: VAGNC COMPL RMVL PARAVAG TIS Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57107 MEDSV DEF RBRVS 01/01/2025 1332.22 Description: VAGNC COMPL RMVL PARAVAG TIS Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57109 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1612.7 Description: VAGNC BI TOTAL PEL LYMPHADEC Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57109 MEDSV DEF RBRVS 01/01/2025 1581.29 Description: VAGNC BI TOTAL PEL LYMPHADEC Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 847.27 Y Description: VAGNC COMPL RMVL VAG WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57110 MEDSV DEF RBRVS 01/01/2025 825.11 Y Description: VAGNC COMPL RMVL VAG WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57111 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1612.7 Description: VAGNC COMPL RMVL PARAVAG TIS Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57111 MEDSV DEF RBRVS 01/01/2025 1581.29 Description: VAGNC COMPL RMVL PARAVAG TIS Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 498.47 Description: COLPOCLEISIS LE FORT TYPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57120 MEDSV DEF RBRVS 01/01/2025 486.67 Description: COLPOCLEISIS LE FORT TYPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 217.46 Description: EXCISION VAGINAL SEPTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57130 MEDSV DEF RBRVS 01/01/2025 210.84 Description: EXCISION VAGINAL SEPTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 233.18 Description: EXCISION VAGINAL CYST/TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57135 MEDSV DEF RBRVS 01/01/2025 226.72 Description: EXCISION VAGINAL CYST/TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 54.35 Description: TREAT VAGINA INFECTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 57150 MEDSV DEF RBRVS 01/01/2025 52.66 Description: TREAT VAGINA INFECTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 57155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 375.47 Description: INSERT UTERI TANDEM/OVOIDS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 57155 MEDSV DEF RBRVS 01/01/2025 368.09 Description: INSERT UTERI TANDEM/OVOIDS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 57156 MEDSV DEF RBRVS 01/01/2024 12/31/2024 216.64 Description: INS VAG BRACHYTX DEVICE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 57156 MEDSV DEF RBRVS 01/01/2025 211.73 Description: INS VAG BRACHYTX DEVICE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 57160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 69.77 Description: INSERT PESSARY/OTHER DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57160 MEDSV DEF RBRVS 01/01/2025 67.9 Description: INSERT PESSARY/OTHER DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57170 MEDSV DEF RBRVS 01/01/2024 12/31/2024 73.09 Description: FITTING OF DIAPHRAGM/CAP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 57170 MEDSV DEF RBRVS 01/01/2025 70.82 Description: FITTING OF DIAPHRAGM/CAP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 57180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 187.54 Description: TREAT VAGINAL BLEEDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57180 MEDSV DEF RBRVS 01/01/2025 181.28 Description: TREAT VAGINAL BLEEDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 310.79 Description: REPAIR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57200 MEDSV DEF RBRVS 01/01/2025 305.32 Description: REPAIR OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 368.98 Description: REPAIR VAGINA/PERINEUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57210 MEDSV DEF RBRVS 01/01/2025 360.86 Description: REPAIR VAGINA/PERINEUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 325.22 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57220 MEDSV DEF RBRVS 01/01/2025 317.92 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.86 Description: REPAIR OF URETHRAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57230 MEDSV DEF RBRVS 01/01/2025 384.05 Description: REPAIR OF URETHRAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 575.99 Description: ANTERIOR COLPORRHAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57240 MEDSV DEF RBRVS 01/01/2025 562.1 Description: ANTERIOR COLPORRHAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 577.88 Description: REPAIR RECTUM & VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57250 MEDSV DEF RBRVS 01/01/2025 563.66 Description: REPAIR RECTUM & VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 730.23 Description: CMBN ANT PST COLPRHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57260 MEDSV DEF RBRVS 01/01/2025 711.64 Description: CMBN ANT PST COLPRHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 816.77 Description: CMBN AP COLPRHY W/NTRCL RPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57265 MEDSV DEF RBRVS 01/01/2025 795.44 Description: CMBN AP COLPRHY W/NTRCL RPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57267 MEDSV DEF RBRVS 01/01/2024 12/31/2024 233.47 Description: INSERT MESH/PELVIC FLR ADDON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57267 MEDSV DEF RBRVS 01/01/2025 226.95 Description: INSERT MESH/PELVIC FLR ADDON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 57268 MEDSV DEF RBRVS 01/01/2024 12/31/2024 475.87 Description: REPAIR OF BOWEL BULGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57268 MEDSV DEF RBRVS 01/01/2025 464.84 Description: REPAIR OF BOWEL BULGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 762.91 Description: REPAIR OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57270 MEDSV DEF RBRVS 01/01/2025 743.41 Description: REPAIR OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 904.78 Description: SUSPENSION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57280 MEDSV DEF RBRVS 01/01/2025 881.79 Description: SUSPENSION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57282 MEDSV DEF RBRVS 01/01/2024 12/31/2024 651.37 Description: COLPOPEXY EXTRAPERITONEAL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 57282 MEDSV DEF RBRVS 01/01/2025 635.1 Description: COLPOPEXY EXTRAPERITONEAL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 57283 MEDSV DEF RBRVS 01/01/2024 12/31/2024 655.69 Description: COLPOPEXY INTRAPERITONEAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 57283 MEDSV DEF RBRVS 01/01/2025 638.7 Description: COLPOPEXY INTRAPERITONEAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 57284 MEDSV DEF RBRVS 01/01/2024 12/31/2024 779.53 Description: REPAIR PARAVAG DEFECT OPEN Category: Medical Services CMS Add: 01/01/1996 CMS Term: 57284 MEDSV DEF RBRVS 01/01/2025 761.83 Description: REPAIR PARAVAG DEFECT OPEN Category: Medical Services CMS Add: 01/01/1996 CMS Term: 57285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 650.18 Description: REPAIR PARAVAG DEFECT VAG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 57285 MEDSV DEF RBRVS 01/01/2025 633.65 Description: REPAIR PARAVAG DEFECT VAG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 57287 MEDSV DEF RBRVS 01/01/2024 12/31/2024 696.74 Description: REVISE/REMOVE SLING REPAIR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57287 MEDSV DEF RBRVS 01/01/2025 681 Description: REVISE/REMOVE SLING REPAIR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57288 MEDSV DEF RBRVS 01/01/2024 12/31/2024 697.02 Description: REPAIR BLADDER DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57288 MEDSV DEF RBRVS 01/01/2025 681.37 Description: REPAIR BLADDER DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57289 MEDSV DEF RBRVS 01/01/2024 12/31/2024 744.16 Description: REPAIR BLADDER & VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57289 MEDSV DEF RBRVS 01/01/2025 725.3 Description: REPAIR BLADDER & VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57291 MEDSV DEF RBRVS 01/01/2024 12/31/2024 515.67 Description: CONSTRUCTION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57291 MEDSV DEF RBRVS 01/01/2025 503.4 Description: CONSTRUCTION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57292 MEDSV DEF RBRVS 01/01/2024 12/31/2024 776.36 Description: CONSTRUCT VAGINA WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57292 MEDSV DEF RBRVS 01/01/2025 755.86 Description: CONSTRUCT VAGINA WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57295 MEDSV DEF RBRVS 01/01/2024 12/31/2024 471.38 Y Description: REVISE VAG GRAFT VIA VAGINA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 57295 MEDSV DEF RBRVS 01/01/2025 460.2 Y Description: REVISE VAG GRAFT VIA VAGINA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 57296 MEDSV DEF RBRVS 01/01/2024 12/31/2024 897.63 Description: REVISE VAG GRAFT OPEN ABD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 57296 MEDSV DEF RBRVS 01/01/2025 873.66 Description: REVISE VAG GRAFT OPEN ABD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 57300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 572.12 Description: REPAIR RECTUM-VAGINA FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57300 MEDSV DEF RBRVS 01/01/2025 560.52 Description: REPAIR RECTUM-VAGINA FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 915.84 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57305 MEDSV DEF RBRVS 01/01/2025 887.11 Description: REPAIR RECTUM-VAGINA FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57307 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1018.02 Description: FISTULA REPAIR & COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57307 MEDSV DEF RBRVS 01/01/2025 990.33 Description: FISTULA REPAIR & COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57308 MEDSV DEF RBRVS 01/01/2024 12/31/2024 624.5 Description: FISTULA REPAIR TRANSPERINE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 57308 MEDSV DEF RBRVS 01/01/2025 610.4 Description: FISTULA REPAIR TRANSPERINE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 57310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 463.13 Description: REPAIR URETHROVAGINAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57310 MEDSV DEF RBRVS 01/01/2025 455.32 Description: REPAIR URETHROVAGINAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57311 MEDSV DEF RBRVS 01/01/2024 12/31/2024 521.82 Description: REPAIR URETHROVAGINAL LESION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57311 MEDSV DEF RBRVS 01/01/2025 512.7 Description: REPAIR URETHROVAGINAL LESION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 530.34 Description: REPAIR BLADDER-VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57320 MEDSV DEF RBRVS 01/01/2025 517.02 Description: REPAIR BLADDER-VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 719.42 Description: REPAIR BLADDER-VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57330 MEDSV DEF RBRVS 01/01/2025 705.38 Description: REPAIR BLADDER-VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1102.92 Description: REPAIR VAGINA Category: Medical Services CMS Add: 01/01/1992 CMS Term: 57335 MEDSV DEF RBRVS 01/01/2025 1073.47 Description: REPAIR VAGINA Category: Medical Services CMS Add: 01/01/1992 CMS Term: 57400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.54 Description: DILATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57400 MEDSV DEF RBRVS 01/01/2025 118.26 Description: DILATION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 98.22 Description: PELVIC EXAMINATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57410 MEDSV DEF RBRVS 01/01/2025 96.63 Description: PELVIC EXAMINATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 164.59 Description: REMOVE VAGINAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 57415 MEDSV DEF RBRVS 01/01/2025 161.25 Description: REMOVE VAGINAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 57420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 124 Description: EXAM OF VAGINA W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57420 MEDSV DEF RBRVS 01/01/2025 121.73 Description: EXAM OF VAGINA W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57421 MEDSV DEF RBRVS 01/01/2024 12/31/2024 166.17 Description: EXAM/BIOPSY OF VAG W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57421 MEDSV DEF RBRVS 01/01/2025 162.6 Description: EXAM/BIOPSY OF VAG W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57423 MEDSV DEF RBRVS 01/01/2024 12/31/2024 869.79 Description: REPAIR PARAVAG DEFECT LAP Category: Medical Services CMS Add: 01/01/2008 CMS Term: 57423 MEDSV DEF RBRVS 01/01/2025 847.22 Description: REPAIR PARAVAG DEFECT LAP Category: Medical Services CMS Add: 01/01/2008 CMS Term: 57425 MEDSV DEF RBRVS 01/01/2024 12/31/2024 911.15 Description: LAPAROSCOPY SURG COLPOPEXY Category: Medical Services CMS Add: 01/01/2004 CMS Term: 57425 MEDSV DEF RBRVS 01/01/2025 888.65 Description: LAPAROSCOPY SURG COLPOPEXY Category: Medical Services CMS Add: 01/01/2004 CMS Term: 57426 MEDSV DEF RBRVS 01/01/2024 12/31/2024 817.1 Description: REVISE PROSTH VAG GRAFT LAP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 57426 MEDSV DEF RBRVS 01/01/2025 799.23 Description: REVISE PROSTH VAG GRAFT LAP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 57452 MEDSV DEF RBRVS 01/01/2024 12/31/2024 118.76 Description: EXAM OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57452 MEDSV DEF RBRVS 01/01/2025 116.03 Description: EXAM OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57454 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.39 Description: BX/CURETT OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57454 MEDSV DEF RBRVS 01/01/2025 154.34 Description: BX/CURETT OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57455 MEDSV DEF RBRVS 01/01/2024 12/31/2024 151.15 Description: BIOPSY OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57455 MEDSV DEF RBRVS 01/01/2025 147.99 Description: BIOPSY OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57456 MEDSV DEF RBRVS 01/01/2024 12/31/2024 142.54 Description: ENDOCERV CURETTAGE W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57456 MEDSV DEF RBRVS 01/01/2025 139.47 Description: ENDOCERV CURETTAGE W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 295.63 Description: BX OF CERVIX W/SCOPE LEEP Category: Medical Services CMS Add: 01/01/1993 CMS Term: 57460 MEDSV DEF RBRVS 01/01/2025 285.8 Description: BX OF CERVIX W/SCOPE LEEP Category: Medical Services CMS Add: 01/01/1993 CMS Term: 57461 MEDSV DEF RBRVS 01/01/2024 12/31/2024 329.61 Description: CONZ OF CERVIX W/SCOPE LEEP Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57461 MEDSV DEF RBRVS 01/01/2025 318.51 Description: CONZ OF CERVIX W/SCOPE LEEP Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57465 MEDSV DEF RBRVS 01/01/2024 12/31/2024 51.31 Description: CAM CERVIX UTERI DRG COLP Category: Medical Services CMS Add: 01/01/2021 CMS Term: 57465 MEDSV DEF RBRVS 01/01/2025 49.88 Description: CAM CERVIX UTERI DRG COLP Category: Medical Services CMS Add: 01/01/2021 CMS Term: 57500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 144.36 Description: BIOPSY OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57500 MEDSV DEF RBRVS 01/01/2025 139.98 Description: BIOPSY OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 145.57 Description: ENDOCERVICAL CURETTAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57505 MEDSV DEF RBRVS 01/01/2025 141.77 Description: ENDOCERVICAL CURETTAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 157.2 Description: CAUTERIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57510 MEDSV DEF RBRVS 01/01/2025 153.04 Description: CAUTERIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57511 MEDSV DEF RBRVS 01/01/2024 12/31/2024 187.45 Description: CRYOCAUTERY OF CERVIX Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57511 MEDSV DEF RBRVS 01/01/2025 182.61 Description: CRYOCAUTERY OF CERVIX Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57513 MEDSV DEF RBRVS 01/01/2024 12/31/2024 193.63 Description: LASER SURGERY OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57513 MEDSV DEF RBRVS 01/01/2025 188.34 Description: LASER SURGERY OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.58 Description: CONIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57520 MEDSV DEF RBRVS 01/01/2025 324.12 Description: CONIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57522 MEDSV DEF RBRVS 01/01/2024 12/31/2024 284.82 Description: CONIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1995 CMS Term: 57522 MEDSV DEF RBRVS 01/01/2025 278.09 Description: CONIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1995 CMS Term: 57530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 350.95 Description: REMOVAL OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57530 MEDSV DEF RBRVS 01/01/2025 343.97 Description: REMOVAL OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57531 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1654.15 Description: REMOVAL OF CERVIX RADICAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 57531 MEDSV DEF RBRVS 01/01/2025 1612.25 Description: REMOVAL OF CERVIX RADICAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 57540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 742.15 Description: REMOVAL OF RESIDUAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57540 MEDSV DEF RBRVS 01/01/2025 722.53 Description: REMOVAL OF RESIDUAL CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 781.42 Description: REMOVE CERVIX/REPAIR PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57545 MEDSV DEF RBRVS 01/01/2025 760.94 Description: REMOVE CERVIX/REPAIR PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 405.4 Description: REMOVAL OF RESIDUAL CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57550 MEDSV DEF RBRVS 01/01/2025 396.09 Description: REMOVAL OF RESIDUAL CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57555 MEDSV DEF RBRVS 01/01/2024 12/31/2024 581.04 Description: REMOVE CERVIX/REPAIR VAGINA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57555 MEDSV DEF RBRVS 01/01/2025 566.21 Description: REMOVE CERVIX/REPAIR VAGINA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 551.75 Description: REMOVE CERVIX REPAIR BOWEL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57556 MEDSV DEF RBRVS 01/01/2025 537.78 Description: REMOVE CERVIX REPAIR BOWEL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57558 MEDSV DEF RBRVS 01/01/2024 12/31/2024 148.76 Description: D&C OF CERVICAL STUMP Category: Medical Services CMS Add: 01/01/2007 CMS Term: 57558 MEDSV DEF RBRVS 01/01/2025 145.16 Description: D&C OF CERVICAL STUMP Category: Medical Services CMS Add: 01/01/2007 CMS Term: 57700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 335.27 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57700 MEDSV DEF RBRVS 01/01/2025 327.78 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 314.31 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57720 MEDSV DEF RBRVS 01/01/2025 306.88 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 72.79 Description: DILATION OF CERVICAL CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57800 MEDSV DEF RBRVS 01/01/2025 71.05 Description: DILATION OF CERVICAL CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 95.31 Description: BIOPSY OF UTERUS LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58100 MEDSV DEF RBRVS 01/01/2025 92.61 Description: BIOPSY OF UTERUS LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 46.55 Description: BX DONE W/COLPOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 58110 MEDSV DEF RBRVS 01/01/2025 45.69 Description: BX DONE W/COLPOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 58120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 279.33 Description: DILATION AND CURETTAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58120 MEDSV DEF RBRVS 01/01/2025 272.9 Description: DILATION AND CURETTAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 872.92 Description: MYOMECTOMY ABDOM METHOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58140 MEDSV DEF RBRVS 01/01/2025 840.66 Description: MYOMECTOMY ABDOM METHOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 532.29 Description: MYOMECTOMY VAG METHOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58145 MEDSV DEF RBRVS 01/01/2025 520.88 Description: MYOMECTOMY VAG METHOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58146 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1081.08 Description: MYOMECTOMY ABDOM COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58146 MEDSV DEF RBRVS 01/01/2025 1051.69 Description: MYOMECTOMY ABDOM COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 947.2 Y Y Description: TOTAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58150 MEDSV DEF RBRVS 01/01/2025 926.99 Y Y Description: TOTAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58152 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1158.06 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58152 MEDSV DEF RBRVS 01/01/2025 1127.17 Y Y Description: TOTAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 896.36 Y Y Description: PARTIAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58180 MEDSV DEF RBRVS 01/01/2025 876.35 Y Y Description: PARTIAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1255 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58200 MEDSV DEF RBRVS 01/01/2025 1229.06 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1697.43 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58210 MEDSV DEF RBRVS 01/01/2025 1659.15 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2731.18 Y Y Description: REMOVAL OF PELVIS CONTENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58240 MEDSV DEF RBRVS 01/01/2025 2657.86 Y Y Description: REMOVAL OF PELVIS CONTENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 786.35 Y Y Description: VAGINAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58260 MEDSV DEF RBRVS 01/01/2025 766.34 Y Y Description: VAGINAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58262 MEDSV DEF RBRVS 01/01/2024 12/31/2024 868.63 Y Y Description: VAG HYST INCLUDING T/O Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58262 MEDSV DEF RBRVS 01/01/2025 846.91 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 12/31/2024 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 01/01/2025 907.58 Y Y Description: VAG HYST W/T/O & VAG REPAIR Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58267 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1002.19 Y Y Description: VAG HYST W/URINARY REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58267 MEDSV DEF RBRVS 01/01/2025 975.42 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 12/31/2024 839.03 Y Y Description: VAG HYST W/ENTEROCELE REPAIR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 58270 MEDSV DEF RBRVS 01/01/2025 816.21 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 12/31/2024 927.26 Y Y Description: HYSTERECTOMY/REVISE VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58275 MEDSV DEF RBRVS 01/01/2025 905.05 Y Y Description: HYSTERECTOMY/REVISE VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 992.84 Y Y Description: HYSTERECTOMY/REVISE VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58280 MEDSV DEF RBRVS 01/01/2025 966.59 Y Y Description: HYSTERECTOMY/REVISE VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1325.36 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58285 MEDSV DEF RBRVS 01/01/2025 1298.65 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1077.62 Y Y Description: VAG HYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58290 MEDSV DEF RBRVS 01/01/2025 1048.33 Y Y Description: VAG HYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58291 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 1132.38 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 12/31/2024 1227.1 Y Y Description: VAG HYST T/O & REPAIR COMPL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58292 MEDSV DEF RBRVS 01/01/2025 1193.21 Y Y Description: VAG HYST T/O & REPAIR COMPL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58294 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1139.67 Y Y Description: VAG HYST W/ENTEROCELE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58294 MEDSV DEF RBRVS 01/01/2025 1108.22 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 12/31/2024 104.06 Description: INSERT INTRAUTERINE DEVICE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58300 MEDSV DEF RBRVS 01/01/2025 101.08 Description: INSERT INTRAUTERINE DEVICE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58301 MEDSV DEF RBRVS 01/01/2024 12/31/2024 103.37 Description: REMOVE INTRAUTERINE DEVICE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58301 MEDSV DEF RBRVS 01/01/2025 100.77 Description: REMOVE INTRAUTERINE DEVICE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58321 NOCOV DEF SYSMAN 10/06/1994 Y Description: ARTIFICIAL INSEMINATION Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 58322 NOCOV DEF SYSMAN 10/06/1994 Y Description: ARTIFICIAL INSEMINATION Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 58323 NOCOV DEF SYSMAN 10/06/1994 Y Description: SPERM WASHING Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 58340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 229.65 Description: CATHETER FOR HYSTEROGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58340 MEDSV DEF RBRVS 01/01/2025 219.42 Description: CATHETER FOR HYSTEROGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 270.92 Description: REOPEN FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58345 MEDSV DEF RBRVS 01/01/2025 264.26 Description: REOPEN FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58346 MEDSV DEF RBRVS 01/01/2024 12/31/2024 472.36 Description: INSERT HEYMAN UTERI CAPSULE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58346 MEDSV DEF RBRVS 01/01/2025 461.76 Description: INSERT HEYMAN UTERI CAPSULE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 144.71 Description: REOPEN FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58350 MEDSV DEF RBRVS 01/01/2025 140.52 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58353 MEDSV DEF RBRVS 01/01/2024 12/31/2024 878.57 Description: ENDOMETR ABLATE THERMAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 58353 MEDSV DEF RBRVS 01/01/2025 835.06 Description: ENDOMETR ABLATE THERMAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 58356 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1577.49 Description: ENDOMETRIAL CRYOABLATION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58356 MEDSV DEF RBRVS 01/01/2025 1506.82 Description: ENDOMETRIAL CRYOABLATION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 435.91 Description: SUSPENSION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58400 MEDSV DEF RBRVS 01/01/2025 425.78 Description: SUSPENSION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 764.9 Description: SUSPENSION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58410 MEDSV DEF RBRVS 01/01/2025 744.58 Description: SUSPENSION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 749.7 Description: REPAIR OF RUPTURED UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58520 MEDSV DEF RBRVS 01/01/2025 729.23 Description: REPAIR OF RUPTURED UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 858.99 Description: REVISION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58540 MEDSV DEF RBRVS 01/01/2025 836.82 Description: REVISION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58541 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 668.73 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 12/31/2024 778.64 Y Y Description: LSH W/T/O UT 250 G OR LESS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58542 MEDSV DEF RBRVS 01/01/2025 758.47 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58543 MEDSV DEF RBRVS 01/01/2024 12/31/2024 789.9 Y Y Description: LSH UTERUS ABOVE 250 G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58543 MEDSV DEF RBRVS 01/01/2025 769.11 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 12/31/2024 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 01/01/2025 826.26 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 12/31/2024 842.18 Description: LAPAROSCOPIC MYOMECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58545 MEDSV DEF RBRVS 01/01/2025 821.95 Description: LAPAROSCOPIC MYOMECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58546 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1042.01 Description: LAPARO-MYOMECTOMY COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58546 MEDSV DEF RBRVS 01/01/2025 1013.93 Description: LAPARO-MYOMECTOMY COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58548 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1754.15 Y Y Description: LAP RADICAL HYST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58548 MEDSV DEF RBRVS 01/01/2025 1716.47 Y Y Description: LAP RADICAL HYST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 825.44 Y Y Description: LAPARO-ASST VAG HYSTERECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58550 MEDSV DEF RBRVS 01/01/2025 805.28 Y Y Description: LAPARO-ASST VAG HYSTERECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 894.51 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 12/31/2024 1047.63 Y Y Description: LAPARO-VAG HYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58553 MEDSV DEF RBRVS 01/01/2025 1019.69 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 1188.63 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 12/31/2024 340.15 0-1 Description: HYSTEROSCOPY DX SEP PROC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58555 MEDSV DEF RBRVS 01/01/2025 327.73 0-1 Description: HYSTEROSCOPY DX SEP PROC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58558 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1252.67 Description: HYSTEROSCOPY BIOPSY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58558 MEDSV DEF RBRVS 01/01/2025 1194.51 Description: HYSTEROSCOPY BIOPSY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58559 MEDSV DEF RBRVS 01/01/2024 12/31/2024 264.13 0-1 Description: HYSTEROSCOPY LYSIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58559 MEDSV DEF RBRVS 01/01/2025 257 0-1 Description: HYSTEROSCOPY LYSIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 290.56 0-1 Description: HYSTEROSCOPY RESECT SEPTUM Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58560 MEDSV DEF RBRVS 01/01/2025 282.94 0-1 Description: HYSTEROSCOPY RESECT SEPTUM Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58561 MEDSV DEF RBRVS 01/01/2024 12/31/2024 332.43 0-1 Description: HYSTEROSCOPY REMOVE MYOMA Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58561 MEDSV DEF RBRVS 01/01/2025 323.72 0-1 Description: HYSTEROSCOPY REMOVE MYOMA Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58562 MEDSV DEF RBRVS 01/01/2024 12/31/2024 406.11 0-1 Description: HYSTEROSCOPY REMOVE FB Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58562 MEDSV DEF RBRVS 01/01/2025 391.75 0-1 Description: HYSTEROSCOPY REMOVE FB Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58563 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1992.2 Description: HYSTEROSCOPY ABLATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58563 MEDSV DEF RBRVS 01/01/2025 1892.4 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58565 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1570.75 Y 21-999Years 0-1 Description: HYSTEROSCOPY STERILIZATION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58565 MEDSV DEF RBRVS 01/01/2025 1501.62 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 12/31/2024 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 01/01/2025 737.5 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 12/31/2024 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 01/01/2025 830.08 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 12/31/2024 970.07 Y Y Description: TLH UTERUS OVER 250 G Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58572 MEDSV DEF RBRVS 01/01/2025 925.2 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 12/31/2024 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 01/01/2025 1111.17 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 01/01/2024 12/31/2024 1800.85 Description: LAPS TOT HYST RESJ MAL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 58575 MEDSV DEF RBRVS 01/01/2025 1761.5 Description: LAPS TOT HYST RESJ MAL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 58578 MEDSV DEF BILL35 01/01/2014 0-1 Description: UNLISTED LAPS PX UTERUS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58579 MEDSV DEF BILL35 01/01/2014 0-1 Description: UNLISTED HYSTSC PX UTERUS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2884.62 Description: TRANSCRV ABLTJ UTRN FIBRD RF Category: Medical Services CMS Add: 01/01/2024 CMS Term: 58580 MEDSV DEF RBRVS 01/01/2025 2818.23 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.02 Y 21-999Years Description: DIVISION OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58600 MEDSV DEF RBRVS 01/01/2025 339.68 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 12/31/2024 316.27 Y 21-999Years Description: DIVISION OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58605 MEDSV DEF RBRVS 01/01/2025 308.85 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 12/31/2024 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 01/01/2025 68.2 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 12/31/2024 237.83 Y 21-999Years Description: OCCLUDE FALLOPIAN TUBE(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58615 MEDSV DEF RBRVS 01/01/2025 232.03 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 12/31/2024 634.36 Description: LAPAROSCOPY LYSIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58660 MEDSV DEF RBRVS 01/01/2025 620.83 Description: LAPAROSCOPY LYSIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58661 MEDSV DEF RBRVS 01/01/2024 12/31/2024 610 Y Y Description: LAPAROSCOPY REMOVE ADNEXA Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58661 MEDSV DEF RBRVS 01/01/2025 594.75 Y Y Description: LAPAROSCOPY REMOVE ADNEXA Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58662 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665.75 Description: LAPAROSCOPY EXCISE LESIONS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58662 MEDSV DEF RBRVS 01/01/2025 650.52 Description: LAPAROSCOPY EXCISE LESIONS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.63 Y Description: LAPAROSCOPY TUBAL CAUTERY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58670 MEDSV DEF RBRVS 01/01/2025 340.28 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58671 MEDSV DEF RBRVS 01/01/2024 12/31/2024 348.63 Y Description: LAPAROSCOPY TUBAL BLOCK Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58671 MEDSV DEF RBRVS 01/01/2025 340.28 Y Description: LAPAROSCOPY TUBAL BLOCK Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58672 MEDSV DEF RBRVS 01/01/2024 12/31/2024 684.16 Y Description: LAPAROSCOPY FIMBRIOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58672 MEDSV DEF RBRVS 01/01/2025 665.82 Y Description: LAPAROSCOPY FIMBRIOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58673 MEDSV DEF RBRVS 01/01/2024 12/31/2024 742.49 0-1 Description: LAPAROSCOPY SALPINGOSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58673 MEDSV DEF RBRVS 01/01/2025 722.58 0-1 Description: LAPAROSCOPY SALPINGOSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58674 MEDSV DEF RBRVS 01/01/2024 12/31/2024 761.61 Description: LAPS ABLTJ UTERINE FIBROIDS Category: Medical Services CMS Add: 01/01/2017 CMS Term: 58674 MEDSV DEF RBRVS 01/01/2025 741.4 Description: LAPS ABLTJ UTERINE FIBROIDS Category: Medical Services CMS Add: 01/01/2017 CMS Term: 58679 MEDSV DEF BILL35 01/01/2014 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 12/31/2024 746.02 Description: REMOVAL OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58700 MEDSV DEF RBRVS 01/01/2025 728.59 Description: REMOVAL OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 708.26 Y Description: REMOVAL OF OVARY/TUBE(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58720 MEDSV DEF RBRVS 01/01/2025 693.46 Y Description: REMOVAL OF OVARY/TUBE(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 841.48 Description: ADHESIOLYSIS TUBE OVARY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58740 MEDSV DEF RBRVS 01/01/2025 819.88 Description: ADHESIOLYSIS TUBE OVARY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58750 NOCOV DEF SYSMAN 10/06/1994 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58752 NOCOV DEF SYSMAN 10/06/1994 Y Description: REVISE OVARIAN TUBE(S) Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 58760 NOCOV DEF SYSMAN 10/06/1994 Y Description: FIMBRIOPLASTY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 58770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 808.37 Description: CREATE NEW TUBAL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58770 MEDSV DEF RBRVS 01/01/2025 786.43 Description: CREATE NEW TUBAL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 340.89 Description: DRAINAGE OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58800 MEDSV DEF RBRVS 01/01/2025 332.13 Description: DRAINAGE OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 402.25 Description: DRAINAGE OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58805 MEDSV DEF RBRVS 01/01/2025 392.53 Description: DRAINAGE OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 318.77 Description: DRAIN OVARY ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58820 MEDSV DEF RBRVS 01/01/2025 311.36 Description: DRAIN OVARY ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58822 MEDSV DEF RBRVS 01/01/2024 12/31/2024 670.38 Description: DRAIN OVARY ABSCESS PERCUT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58822 MEDSV DEF RBRVS 01/01/2025 653.05 Description: DRAIN OVARY ABSCESS PERCUT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665.35 Description: TRANSPOSITION OVARY(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58825 MEDSV DEF RBRVS 01/01/2025 648.14 Description: TRANSPOSITION OVARY(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.81 Description: BIOPSY OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58900 MEDSV DEF RBRVS 01/01/2025 400.68 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 670.36 Description: PARTIAL REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58920 MEDSV DEF RBRVS 01/01/2025 652.52 Description: PARTIAL REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58925 MEDSV DEF RBRVS 01/01/2024 12/31/2024 715.84 Description: REMOVAL OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58925 MEDSV DEF RBRVS 01/01/2025 697.61 Description: REMOVAL OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58940 MEDSV DEF RBRVS 01/01/2024 12/31/2024 518.67 Description: REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58940 MEDSV DEF RBRVS 01/01/2025 505.87 Description: REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58943 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1092.62 Description: REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58943 MEDSV DEF RBRVS 01/01/2025 1096.28 Description: REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58950 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1075.28 Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58950 MEDSV DEF RBRVS 01/01/2025 1050.35 Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58951 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1344.79 Y Y Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58951 MEDSV DEF RBRVS 01/01/2025 1315.66 Y Y Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58952 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1535.34 Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58952 MEDSV DEF RBRVS 01/01/2025 1502.71 Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58953 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1864.95 Y Y Description: TAH RAD DISSECT FOR DEBULK Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58953 MEDSV DEF RBRVS 01/01/2025 1824.18 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58954 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2016.34 Y Y Description: TAH RAD DEBULK/LYMPH REMOVE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58954 MEDSV DEF RBRVS 01/01/2025 1973.13 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 12/31/2024 1267.83 Y Y Description: BSO OMENTECTOMY W/TAH Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58956 MEDSV DEF RBRVS 01/01/2025 1241.56 Y Y Description: BSO OMENTECTOMY W/TAH Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58957 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1479.38 Description: RESECT RECURRENT GYN MAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 12/31/2024 58957 MEDSV DEF RBRVS 01/01/2025 1449.33 Description: RESECT RECURRENT GYN MAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 12/31/2024 58958 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1550.43 Description: RESC RECR OVR TBL PP UTR MAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58958 MEDSV DEF RBRVS 01/01/2025 1507.71 Description: RESC RECR OVR TBL PP UTR MAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58960 MEDSV DEF RBRVS 01/01/2024 12/31/2024 928.87 Description: EXPLORATION OF ABDOMEN Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58960 MEDSV DEF RBRVS 01/01/2025 911.45 Description: EXPLORATION OF ABDOMEN Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58970 NOCOV DEF SYSMAN 12/01/1993 Y Description: RETRIEVAL OF OOCYTE Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: 58974 NOCOV DEF SYSMAN 12/01/1993 Y Description: EMBRYO TRANSFER INTRAUTERINE Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: 58976 NOCOV DEF SYSMAN 12/01/1993 Y Description: TRANSFER OF EMBRYO Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: 58999 MEDSV DEF BILL35 01/01/2014 Description: UNLISTED PX FML GENITAL SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 106.97 Description: AMNIOCENTESIS DIAGNOSTIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59000 MEDSV DEF RBRVS 01/01/2025 105.38 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 159.99 Description: AMNIOCENTESIS THERAPEUTIC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 59001 MEDSV DEF RBRVS 01/01/2025 156.01 Description: AMNIOCENTESIS THERAPEUTIC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 59012 MEDSV DEF RBRVS 01/01/2024 12/31/2024 180.69 Description: FETAL CORD PUNCTURE PRENATAL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59012 MEDSV DEF RBRVS 01/01/2025 176.13 Description: FETAL CORD PUNCTURE PRENATAL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 142.9 Description: CHORION BIOPSY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 59015 MEDSV DEF RBRVS 01/01/2025 140.2 Description: CHORION BIOPSY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 59020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 64.32 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 33.29 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 31.03 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 MEDSV DEF RBRVS 01/01/2025 63.88 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 26 MEDSV DEF RBRVS 01/01/2025 32.32 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 TC MEDSV DEF RBRVS 01/01/2025 31.56 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 44.75 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 26.37 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 18.37 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 MEDSV DEF RBRVS 01/01/2025 44.03 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59025 26 MEDSV DEF RBRVS 01/01/2025 25.76 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 TC MEDSV DEF RBRVS 01/01/2025 18.27 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 100.7 Description: FETAL SCALP BLOOD SAMPLING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59030 MEDSV DEF RBRVS 01/01/2025 97.94 Description: FETAL SCALP BLOOD SAMPLING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59050 NOCOV DEF SYSMAN 10/06/1994 Y Description: FETAL MONITOR W/REPORT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 59051 MEDSV DEF RBRVS 01/01/2024 12/31/2024 37.57 Description: FETAL MONITOR/INTERPRET ONLY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59051 MEDSV DEF RBRVS 01/01/2025 36.64 Description: FETAL MONITOR/INTERPRET ONLY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 362.28 Description: TRANSABDOM AMNIOINFUS W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59070 MEDSV DEF RBRVS 01/01/2025 353.68 Description: TRANSABDOM AMNIOINFUS W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59072 NOCOV DEF SYSMAN 01/01/2004 Y Description: UMBILICAL CORD OCCLUD W/US Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 59074 MEDSV DEF RBRVS 01/01/2024 12/31/2024 347.77 Description: FETAL FLUID DRAINAGE W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59074 MEDSV DEF RBRVS 01/01/2025 339.79 Description: FETAL FLUID DRAINAGE W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59076 MEDSV DEF RBRVS 01/01/2024 12/31/2024 467.11 Description: FETAL SHUNT PLACEMENT W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59076 MEDSV DEF RBRVS 01/01/2025 454.88 Description: FETAL SHUNT PLACEMENT W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 777.69 Description: REMOVE UTERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59100 MEDSV DEF RBRVS 01/01/2025 758.91 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 742.41 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59120 MEDSV DEF RBRVS 01/01/2025 724.35 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 742.62 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59121 MEDSV DEF RBRVS 01/01/2025 724.54 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 861.45 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59130 MEDSV DEF RBRVS 01/01/2025 839.91 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59136 MEDSV DEF RBRVS 01/01/2024 12/31/2024 817.1 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59136 MEDSV DEF RBRVS 01/01/2025 796.85 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 381.2 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59140 MEDSV DEF RBRVS 01/01/2025 372.38 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 720.5 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59150 MEDSV DEF RBRVS 01/01/2025 702.75 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 705.09 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59151 MEDSV DEF RBRVS 01/01/2025 687.31 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 252.44 Description: D & C AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59160 MEDSV DEF RBRVS 01/01/2025 244.86 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 97.61 Description: INSERT CERVICAL DILATOR Category: Medical Services CMS Add: 01/01/1987 CMS Term: 59200 MEDSV DEF RBRVS 01/01/2025 94.13 Description: INSERT CERVICAL DILATOR Category: Medical Services CMS Add: 01/01/1987 CMS Term: 59300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 211.8 Description: EPISIOTOMY OR VAGINAL REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59300 MEDSV DEF RBRVS 01/01/2025 205.69 Description: EPISIOTOMY OR VAGINAL REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 136.08 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59320 MEDSV DEF RBRVS 01/01/2025 133.27 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 216.33 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59325 MEDSV DEF RBRVS 01/01/2025 210.9 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 250.35 Description: REPAIR OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59350 MEDSV DEF RBRVS 01/01/2025 243.26 Description: REPAIR OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59400* MEDSV DEF RBRVS 01/01/2025 2152.43 Y 8-60Years 0-1 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59400* MEDSV DEF MAXFEE 12/31/2021 12/31/2024 1759.06 0 Y 8-60Years 0-1 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59409 UA MEDSV DEF MAXFEE 01/01/2024 12/31/2024 726.43 0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59409 UB MEDSV DEF MAXFEE 01/01/2024 12/31/2024 726.43 0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59409 UC MEDSV DEF MAXFEE 01/01/2024 12/31/2024 726.43 0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59409 UA MEDSV DEF MAXFEE 01/01/2025 705.62 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59409 UB MEDSV DEF MAXFEE 01/01/2025 705.62 0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59409 UC MEDSV DEF MAXFEE 01/01/2025 705.62 0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59410* MEDSV DEF RBRVS 01/01/2025 955.7 Y 8-60Years 0-1 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59410* MEDSV DEF MAXFEE 12/31/2021 12/31/2024 776.58 0 Y 8-60Years 0-1 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59412 MEDSV DEF RBRVS 01/01/2024 12/31/2024 92.4 10-60Years Description: ANTEPARTUM MANIPULATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 59412 MEDSV DEF RBRVS 01/01/2025 90.21 10-60Years Description: ANTEPARTUM MANIPULATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 59414 MEDSV DEF RBRVS 01/01/2024 12/31/2024 81.57 10-60Years Description: DELIVER PLACENTA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59414 MEDSV DEF RBRVS 01/01/2025 79.22 10-60Years Description: DELIVER PLACENTA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59426 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 93.86 0 Description: ANTEPARTUM CARE ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59426 MEDSV DEF MAXFEE 01/01/2025 91.85 0 Description: ANTEPARTUM CARE ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 242.91 10-60Years Description: CARE AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59430 MEDSV DEF RBRVS 01/01/2025 236.57 10-60Years Description: CARE AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59510* MEDSV DEF RBRVS 01/01/2025 2376.66 Y 8-60Years 0-1 Description: CESAREAN DELIVERY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59510* MEDSV DEF MAXFEE 12/31/2021 12/31/2024 1934.43 0 Y 8-60Years 0-1 Description: CESAREAN DELIVERY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59514 UA MEDSV DEF MAXFEE 01/01/2024 12/31/2024 817.19 0 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UB MEDSV DEF MAXFEE 01/01/2024 12/31/2024 817.19 0 0-1 Description: CESAREAN DELIVERY ONLY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59514 UC MEDSV DEF MAXFEE 01/01/2024 12/31/2024 817.19 0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UA MEDSV DEF MAXFEE 01/01/2025 794.88 0 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UB MEDSV DEF MAXFEE 01/01/2025 794.88 0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UC MEDSV DEF MAXFEE 01/01/2025 794.88 0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59515* MEDSV DEF RBRVS 01/01/2025 1178.39 Y 8-60Years 0-1 Description: CESAREAN DELIVERY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59515* MEDSV DEF MAXFEE 12/31/2021 12/31/2024 951.91 0 Y 8-60Years 0-1 Description: CESAREAN DELIVERY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 431.67 Y Y Description: REMOVE UTERUS AFTER CESAREAN Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59525 MEDSV DEF RBRVS 01/01/2025 420.24 Y Y Description: REMOVE UTERUS AFTER CESAREAN Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59610* MEDSV DEF RBRVS 01/01/2025 2239.04 Y 8-60Years 0-1 Description: VBAC DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59610* MEDSV DEF MAXFEE 12/31/2021 12/31/2024 1831.02 0 Y 8-60Years 0-1 Description: VBAC DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UA MEDSV DEF MAXFEE 01/01/2024 12/31/2024 814.69 0 Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UB MEDSV DEF MAXFEE 01/01/2024 12/31/2024 814.69 0 10-60Years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UC MEDSV DEF MAXFEE 01/01/2024 12/31/2024 814.69 0 10-60Years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UA MEDSV DEF MAXFEE 01/01/2025 792.17 0 Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UB MEDSV DEF MAXFEE 01/01/2025 792.17 0 10-60Years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UC MEDSV DEF MAXFEE 01/01/2025 792.17 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59614* MEDSV DEF RBRVS 01/01/2025 1023.77 Y 8-60Years 0-1 Description: VBAC CARE AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59614* MEDSV DEF MAXFEE 12/31/2021 12/31/2024 833.79 0 Y 8-60Years 0-1 Description: VBAC CARE AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59618* MEDSV DEF RBRVS 01/01/2025 2400.1 Y 8-60Years 0-1 Description: ATTEMPTED VBAC DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59618* MEDSV DEF MAXFEE 12/31/2021 12/31/2024 1954.43 0 Y 8-60Years 0-1 Description: ATTEMPTED VBAC DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59620 UA MEDSV DEF MAXFEE 01/01/2024 12/31/2024 843.37 0 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59620 UB MEDSV DEF MAXFEE 01/01/2024 12/31/2024 843.37 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 12/31/2024 843.37 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 01/01/2025 820.49 0 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59620 UB MEDSV DEF MAXFEE 01/01/2025 820.49 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 01/01/2025 820.49 0 10-60Years 0-1 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59622* MEDSV DEF RBRVS 01/01/2025 1220.42 Y 8-60Years 0-1 Description: ATTEMPTED VBAC AFTER CARE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59622* MEDSV DEF MAXFEE 12/31/2021 12/31/2024 987.21 0 Y 8-60Years 0-1 Description: ATTEMPTED VBAC AFTER CARE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59812 MEDSV DEF RBRVS 01/01/2024 12/31/2024 333.15 Description: TREATMENT OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59812 MEDSV DEF RBRVS 01/01/2025 324.72 Description: TREATMENT OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 404.22 Description: CARE OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59820 MEDSV DEF RBRVS 01/01/2025 394.97 Description: CARE OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 397.78 Description: TREATMENT OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59821 MEDSV DEF RBRVS 01/01/2025 388.28 Description: TREATMENT OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 423.89 Description: TREAT UTERUS INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59830 MEDSV DEF RBRVS 01/01/2025 413.91 Description: TREAT UTERUS INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 229.17 Description: INDUCED ABORTION D&C Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59840 MEDSV DEF RBRVS 01/01/2025 224.13 Description: INDUCED ABORTION D&C Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59841 MEDSV DEF RBRVS 01/01/2024 12/31/2024 390.61 Description: INDUCED ABORTION DILAT&EVAC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59841 MEDSV DEF RBRVS 01/01/2025 381.08 Description: INDUCED ABORTION DILAT&EVAC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 356.53 Description: INDUCED ABORTION 1+ NJX Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59850 MEDSV DEF RBRVS 01/01/2025 348.58 Description: INDUCED ABORTION 1+ NJX Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59851 MEDSV DEF RBRVS 01/01/2024 12/31/2024 391.32 Description: INDUCED ABORTION 1+NJX D&C Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59851 MEDSV DEF RBRVS 01/01/2025 382.74 Description: INDUCED ABORTION 1+NJX D&C Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59852 MEDSV DEF RBRVS 01/01/2024 12/31/2024 538.6 Description: INDUCED ABORTION 1+NJX HYST Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59852 MEDSV DEF RBRVS 01/01/2025 525.51 Description: INDUCED ABORTION 1+NJX HYST Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59855 MEDSV DEF RBRVS 01/01/2024 12/31/2024 387.26 Description: INDUCED ABORTION 1+VAG SUPP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59855 MEDSV DEF RBRVS 01/01/2025 378.15 Description: INDUCED ABORTION 1+VAG SUPP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59856 MEDSV DEF RBRVS 01/01/2024 12/31/2024 452.45 Description: INDUCED AB 1+VAG SUPP D&C Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59856 MEDSV DEF RBRVS 01/01/2025 441.71 Description: INDUCED AB 1+VAG SUPP D&C Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59857 MEDSV DEF RBRVS 01/01/2024 12/31/2024 526.86 Description: INDUCED AB 1+VAG SUPP HYST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59857 MEDSV DEF RBRVS 01/01/2025 513.63 Description: INDUCED AB 1+VAG SUPP HYST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59866 NOCOV DEF SYSMAN 01/01/1997 Y Description: ABORTION (MPR) Category: Non Covered Services CMS Add: 01/01/1997 CMS Term: 59870 MEDSV DEF RBRVS 01/01/2024 12/31/2024 492.37 Description: EVACUATE MOLE OF UTERUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59870 MEDSV DEF RBRVS 01/01/2025 480.72 Description: EVACUATE MOLE OF UTERUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59871 MEDSV DEF RBRVS 01/01/2024 12/31/2024 119.69 Description: REMOVE CERCLAGE SUTURE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 59871 MEDSV DEF RBRVS 01/01/2025 117.36 Description: REMOVE CERCLAGE SUTURE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 59897 MEDSV DEF BILL35 01/01/2010 Y Description: UNLISTED FETAL INVAS PX W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59898 MEDSV DEF BILL35 01/01/2014 Description: UNLSTD LAPS PX MAT CARE&DLVR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 59899 MEDSV DEF BILL35 01/01/2014 Description: UNLISTED PX MAT CARE&DLVR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 174.34 Description: DRAIN THYROID/TONGUE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60000 MEDSV DEF RBRVS 01/01/2025 171.48 Description: DRAIN THYROID/TONGUE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6005F NOCOV DEF SYSMAN 01/01/2007 Y Description: CARE LEVEL RATIONALE DOC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 60100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 103.92 Description: BIOPSY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 60100 MEDSV DEF RBRVS 01/01/2025 100.88 Description: BIOPSY OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6010F NOCOV DEF SYSMAN 01/01/2008 Y Description: DYSPHAG TEST DONE B/4 EATING Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 6015F NOCOV DEF SYSMAN 01/01/2008 Y 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 12/31/2024 620.73 Description: REMOVE THYROID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60200 MEDSV DEF RBRVS 01/01/2025 606.26 Description: REMOVE THYROID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6020F NOCOV DEF SYSMAN 01/01/2008 Y Description: NPO (NOTHING-MOUTH) ORDERED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 60210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 655.55 Description: PARTIAL THYROID EXCISION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60210 MEDSV DEF RBRVS 01/01/2025 640.01 Description: PARTIAL THYROID EXCISION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60212 MEDSV DEF RBRVS 01/01/2024 12/31/2024 937.21 Description: PARTIAL THYROID EXCISION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60212 MEDSV DEF RBRVS 01/01/2025 913.41 Description: PARTIAL THYROID EXCISION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 657.34 Description: PARTIAL REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60220 MEDSV DEF RBRVS 01/01/2025 641.31 Description: PARTIAL REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 868.53 Description: PARTIAL REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60225 MEDSV DEF RBRVS 01/01/2025 850.31 Description: PARTIAL REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60240 MEDSV DEF RBRVS 01/01/2024 12/31/2024 849.06 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60240 MEDSV DEF RBRVS 01/01/2025 827.72 Description: 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 60252 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1222.57 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60252 MEDSV DEF RBRVS 01/01/2025 1190.56 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60254 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1549.06 Description: EXTENSIVE THYROID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60254 MEDSV DEF RBRVS 01/01/2025 1504.12 Description: EXTENSIVE THYROID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1010 Description: REPEAT THYROID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60260 MEDSV DEF RBRVS 01/01/2025 983.9 Description: REPEAT THYROID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1258.09 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60270 MEDSV DEF RBRVS 01/01/2025 1226.46 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60271 MEDSV DEF RBRVS 01/01/2024 12/31/2024 977.65 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60271 MEDSV DEF RBRVS 01/01/2025 952.36 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 427 Description: REMOVE THYROID DUCT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60280 MEDSV DEF RBRVS 01/01/2025 418.16 Description: REMOVE THYROID DUCT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60281 MEDSV DEF RBRVS 01/01/2024 12/31/2024 561.81 Description: REMOVE THYROID DUCT LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 60281 MEDSV DEF RBRVS 01/01/2025 548.54 Description: REMOVE THYROID DUCT LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 60300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 100.85 Description: ASPIR/INJ THYROID CYST Category: Medical Services CMS Add: 01/01/2008 CMS Term: 60300 MEDSV DEF RBRVS 01/01/2025 97.96 Description: ASPIR/INJ THYROID CYST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 6030F NOCOV DEF SYSMAN 01/01/2008 Y Description: MAX STERILE BARRIERS FLWD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 6040F NOCOV DEF SYSMAN 01/01/2009 Y Description: APPRO RAD DS DVCS TECHS DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 6045F NOCOV DEF SYSMAN 01/01/2009 Y Description: RADXPS IN END RPRT4FLURO PXD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 60500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 894.35 Description: EXPLORE PARATHYROID GLANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60500 MEDSV DEF RBRVS 01/01/2025 872.6 Description: EXPLORE PARATHYROID GLANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1196.46 Description: RE-EXPLORE PARATHYROIDS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 60502 MEDSV DEF RBRVS 01/01/2025 1168.22 Description: RE-EXPLORE PARATHYROIDS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 60505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1291.84 Description: EXPLORE PARATHYROID GLANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60505 MEDSV DEF RBRVS 01/01/2025 1264.65 Description: EXPLORE PARATHYROID GLANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 221.6 Y Description: AUTOTRANSPLANT PARATHYROID Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60512 MEDSV DEF RBRVS 01/01/2025 215.1 Y Description: AUTOTRANSPLANT PARATHYROID Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 960.31 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60520 MEDSV DEF RBRVS 01/01/2025 936.32 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60521 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1017.55 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60521 MEDSV DEF RBRVS 01/01/2025 992.28 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60522 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1232.32 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 60522 MEDSV DEF RBRVS 01/01/2025 1199.33 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 988.83 Description: EXPLORE ADRENAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60540 MEDSV DEF RBRVS 01/01/2025 968.19 Description: EXPLORE ADRENAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1142.23 Description: EXPLORE ADRENAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60545 MEDSV DEF RBRVS 01/01/2025 1118.21 Description: EXPLORE ADRENAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1241.85 Description: REMOVE CAROTID BODY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60600 MEDSV DEF RBRVS 01/01/2025 1207.74 Description: REMOVE CAROTID BODY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1469.25 Description: REMOVE CAROTID BODY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60605 MEDSV DEF RBRVS 01/01/2025 1426.51 Description: REMOVE CAROTID BODY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1091.37 0-2 Description: LAPAROSCOPY ADRENALECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 60650 MEDSV DEF RBRVS 01/01/2025 1066.17 0-2 Description: LAPAROSCOPY ADRENALECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 60659 MEDSV DEF BILL20 01/01/2014 0-1 Description: UNLISTED LAPS PX ENDOC SYS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 60660 NOCOV DEF SYSMAN 01/01/2025 Y Description: ABLTJ 1/+THYR NDUL 1LOBE PRQ Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 60661 NOCOV DEF SYSMAN 01/01/2025 Y Description: ABLTJ 1/+THYR NDUL ADDL PRQ Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 60699 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX ENDOCRINE SYSTEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6070F NOCOV DEF SYSMAN 01/01/2010 Y 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 6080F NOCOV DEF SYSMAN 01/01/2011 Y Description: PT/CAREGIVER QUERIED FALLS Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 6090F NOCOV DEF SYSMAN 01/01/2011 Y Description: PT/CAREGIVER COUNSEL SAFETY Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 61000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 100.43 Description: REMOVE CRANIAL CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61000 MEDSV DEF RBRVS 01/01/2025 98.75 Description: REMOVE CRANIAL CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 95.18 Description: REMOVE CRANIAL CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61001 MEDSV DEF RBRVS 01/01/2025 93.8 Description: REMOVE CRANIAL CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6100F NOCOV DEF SYSMAN 01/01/2012 Y Description: VERIFY PT SITE PXD DOCD Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 6101F NOCOV DEF SYSMAN 01/01/2012 Y Description: SAFETY COUNSELING DEMENTIA Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 61020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 94.6 Description: REMOVE BRAIN CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61020 MEDSV DEF RBRVS 01/01/2025 93.66 Description: REMOVE BRAIN CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61026 MEDSV DEF RBRVS 01/01/2024 12/31/2024 97.67 Description: INJECTION INTO BRAIN CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61026 MEDSV DEF RBRVS 01/01/2025 97.66 Description: INJECTION INTO BRAIN CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 6102F NOCOV DEF SYSMAN 01/01/2012 Y Description: SAFETY COUNSELING DEM ORDER Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 61050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 75.95 Description: REMOVE BRAIN CANAL FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61050 MEDSV DEF RBRVS 01/01/2025 73.55 Description: REMOVE BRAIN CANAL FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61055 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61055 MEDSV DEF RBRVS 01/01/2025 105.72 Description: INJECTION INTO BRAIN CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61070 MEDSV DEF RBRVS 01/01/2024 12/31/2024 52.04 Description: BRAIN CANAL SHUNT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61070 MEDSV DEF RBRVS 01/01/2025 50.7 Description: BRAIN CANAL SHUNT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 419.39 Description: TDH SDRL/VENTR PNXR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61105 MEDSV DEF RBRVS 01/01/2025 413.14 Description: TDH SDRL/VENTR PNXR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 274.59 Description: TDH PNXR IMPLT VENTR CATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61107 MEDSV DEF RBRVS 01/01/2025 267.64 Description: TDH PNXR IMPLT VENTR CATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61108 MEDSV DEF RBRVS 01/01/2024 12/31/2024 815.91 Description: TDH PNXR EVAC&/DRG SDRL HMTA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61108 MEDSV DEF RBRVS 01/01/2025 800.95 Description: TDH PNXR EVAC&/DRG SDRL HMTA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 6110F NOCOV DEF SYSMAN 01/01/2012 Y Description: COUNSEL PROV DRIVING RISKS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 61120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 674.26 Description: BURR HOLE FOR VENTR PUNCTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61120 MEDSV DEF RBRVS 01/01/2025 662.7 Description: BURR HOLE FOR VENTR PUNCTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1135.8 Description: BURR HOLE/TREPH BX BRAIN/LES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61140 MEDSV DEF RBRVS 01/01/2025 1116.55 Description: BURR HOLE/TREPH BX BRAIN/LES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1204.76 Description: BUR HOL/TRPH DRG BRN ABS/CST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61150 MEDSV DEF RBRVS 01/01/2025 1180.54 Description: BUR HOL/TRPH DRG BRN ABS/CST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61151 MEDSV DEF RBRVS 01/01/2024 12/31/2024 889.55 Description: BURR HOLE/TREPH SBSQ TAPPING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61151 MEDSV DEF RBRVS 01/01/2025 872.26 Description: BURR HOLE/TREPH SBSQ TAPPING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61154 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1143.77 Description: BURR HOLE W/EVAC&/DRG HMTMA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61154 MEDSV DEF RBRVS 01/01/2025 1123.17 Description: BURR HOLE W/EVAC&/DRG HMTMA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61156 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1100.93 Description: BURR HOL ASPIR HMTM/CST ICER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61156 MEDSV DEF RBRVS 01/01/2025 1083.81 Description: BURR HOL ASPIR HMTM/CST ICER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 322.14 Description: BURR HOLE IMPLT VENTR CATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61210 MEDSV DEF RBRVS 01/01/2025 313.55 Description: BURR HOLE IMPLT VENTR CATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61215 MEDSV DEF RBRVS 01/01/2024 12/31/2024 467.14 Description: INS SUBQ RSVR PMP/NFS SYS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61215 MEDSV DEF RBRVS 01/01/2025 460.34 Description: INS SUBQ RSVR PMP/NFS SYS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 779.42 Description: BURR HOLE/TREPH STTL EXPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61250 MEDSV DEF RBRVS 01/01/2025 764.15 Description: BURR HOLE/TREPH STTL EXPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61253 MEDSV DEF RBRVS 01/01/2024 12/31/2024 889.55 Description: BURR HOLE TREPH ITTL UNI/BI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61253 MEDSV DEF RBRVS 01/01/2025 872.26 Description: BURR HOLE TREPH ITTL UNI/BI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61304 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1460.04 Description: CRNEC/CRNOT EXPL SUPRATNTORL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61304 MEDSV DEF RBRVS 01/01/2025 1432.49 Description: CRNEC/CRNOT EXPL SUPRATNTORL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1784.55 Description: CRNEC/CRNOT EXPL INFRATNTORL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61305 MEDSV DEF RBRVS 01/01/2025 1746.76 Description: CRNEC/CRNOT EXPL INFRATNTORL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61312 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1839.53 Description: CRNEC/CRNOT STTL XDRL/SDRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61312 MEDSV DEF RBRVS 01/01/2025 1800.01 Description: CRNEC/CRNOT STTL XDRL/SDRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61313 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1766.48 Description: CRNEC/CRNOT STTL ICERE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61313 MEDSV DEF RBRVS 01/01/2025 1732.15 Description: CRNEC/CRNOT STTL ICERE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61314 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1624.92 Description: CRNEC/CRNOT ITTL XDRL/SDRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61314 MEDSV DEF RBRVS 01/01/2025 1593.23 Description: CRNEC/CRNOT ITTL XDRL/SDRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61315 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1839.86 Description: CRNEC/CRNOT ITTL NTRACEREBLR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61315 MEDSV DEF RBRVS 01/01/2025 1801.61 Description: CRNEC/CRNOT ITTL NTRACEREBLR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61316 MEDSV DEF RBRVS 01/01/2024 12/31/2024 76.8 Description: INC&SUBQ PLMT CRNL BONE GRF Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61316 MEDSV DEF RBRVS 01/01/2025 74.79 Description: INC&SUBQ PLMT CRNL BONE GRF Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1683.96 Description: CRNEC/CRNOT DRG ICR ABS STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61320 MEDSV DEF RBRVS 01/01/2025 1648.64 Description: CRNEC/CRNOT DRG ICR ABS STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61321 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1889.23 Description: CRNEC/CRNOT DRG ICR ABS ITTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61321 MEDSV DEF RBRVS 01/01/2025 1848.66 Description: CRNEC/CRNOT DRG ICR ABS ITTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61322 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2116.92 Description: CRNEC/CRNOT DCMPRV W/O LOBEC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61322 MEDSV DEF RBRVS 01/01/2025 2073.72 Description: CRNEC/CRNOT DCMPRV W/O LOBEC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61323 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2122.33 Description: CRNEC/CRNOT DCMPRV W/LOBEC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61323 MEDSV DEF RBRVS 01/01/2025 2076.17 Description: CRNEC/CRNOT DCMPRV W/LOBEC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1598.23 Description: DCMPRN ORBIT ONLY TRANSCRNL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61330 MEDSV DEF RBRVS 01/01/2025 1565.52 Description: DCMPRN ORBIT ONLY TRANSCRNL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61333 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1791.55 Description: EXPL ORBIT W/REMOVAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61333 MEDSV DEF RBRVS 01/01/2025 1752.95 Description: EXPL ORBIT W/REMOVAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1285.3 Description: SUBTEMPORAL CRANIAL DCMPRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61340 MEDSV DEF RBRVS 01/01/2025 1259.2 Description: SUBTEMPORAL CRANIAL DCMPRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61343 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1954.42 Description: CRNEC SOPL CRV LAM DCMPRN Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61343 MEDSV DEF RBRVS 01/01/2025 1909.59 Description: CRNEC SOPL CRV LAM DCMPRN Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1817.51 Description: OTH CRANIAL DCMPRN PST FOSSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61345 MEDSV DEF RBRVS 01/01/2025 1778.8 Description: OTH CRANIAL DCMPRN PST FOSSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1706.57 Description: CRNEC STPL SCTJ CMPRN/DCMPRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61450 MEDSV DEF RBRVS 01/01/2025 1670.53 Description: CRNEC STPL SCTJ CMPRN/DCMPRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61458 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1794.6 Description: CRNEC SOPL XPL/DCMPR CRL NRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61458 MEDSV DEF RBRVS 01/01/2025 1751.94 Description: CRNEC SOPL XPL/DCMPR CRL NRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61460 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1873.46 Description: CRNEC SOPL SCTJ 1+CRNL NRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61460 MEDSV DEF RBRVS 01/01/2025 1833.33 Description: CRNEC SOPL SCTJ 1+CRNL NRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1184.7 Description: CRNEC EXC TUM/BONE LES SKULL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61500 MEDSV DEF RBRVS 01/01/2025 1156.41 Description: CRNEC EXC TUM/BONE LES SKULL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1034.15 Description: CRANIECTOMY F/OSTEOMYELITIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61501 MEDSV DEF RBRVS 01/01/2025 1010.35 Description: CRANIECTOMY F/OSTEOMYELITIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 6150F NOCOV DEF SYSMAN 01/01/2012 Y Description: PT NOTRCVNG1ST ANTITNF TXMNT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 61510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1961.34 Description: CRNEC TREPH EXC BRN TUM STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61510 MEDSV DEF RBRVS 01/01/2025 1921.79 Description: CRNEC TREPH EXC BRN TUM STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2268.38 Description: CRNEC TREPH EXC MNGIOMA STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61512 MEDSV DEF RBRVS 01/01/2025 2217.82 Description: CRNEC TREPH EXC MNGIOMA STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61514 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1707.37 Description: CRNEC TREPH EXC BRN ABS STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61514 MEDSV DEF RBRVS 01/01/2025 1669.4 Description: CRNEC TREPH EXC BRN ABS STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61516 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1667.67 Description: CRNEC TREPH EXC CYST STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61516 MEDSV DEF RBRVS 01/01/2025 1634.98 Description: CRNEC TREPH EXC CYST STTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61517 MEDSV DEF RBRVS 01/01/2024 12/31/2024 76.3 Description: IMPLT BRN INTRCV CHEMOTX AGT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61517 MEDSV DEF RBRVS 01/01/2025 74.47 Description: IMPLT BRN INTRCV CHEMOTX AGT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61518 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2460.76 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61518 MEDSV DEF RBRVS 01/01/2025 2409.47 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61519 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2614.69 Description: REMOVE BRAIN LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61519 MEDSV DEF RBRVS 01/01/2025 2552.07 Description: REMOVE BRAIN LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3336.03 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61520 MEDSV DEF RBRVS 01/01/2025 3246 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61521 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2810.01 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61521 MEDSV DEF RBRVS 01/01/2025 2752.43 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61522 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1944.86 Description: REMOVAL OF BRAIN ABSCESS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61522 MEDSV DEF RBRVS 01/01/2025 1903.2 Description: REMOVAL OF BRAIN ABSCESS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61524 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1854.26 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61524 MEDSV DEF RBRVS 01/01/2025 1814.52 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61526 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61526 MEDSV DEF RBRVS 01/01/2025 2955.53 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2720.56 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61530 MEDSV DEF RBRVS 01/01/2025 2658.5 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61531 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1098.25 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1993 CMS Term: 61531 MEDSV DEF RBRVS 01/01/2025 1078.11 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1993 CMS Term: 61533 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1362.27 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61533 MEDSV DEF RBRVS 01/01/2025 1334.35 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61534 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1474.02 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61534 MEDSV DEF RBRVS 01/01/2025 1443.73 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 902.78 Description: REMOVE BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61535 MEDSV DEF RBRVS 01/01/2025 886.98 Description: REMOVE BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61536 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2286.85 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61536 MEDSV DEF RBRVS 01/01/2025 2236.03 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61537 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2177.72 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61537 MEDSV DEF RBRVS 01/01/2025 2128.07 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61538 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61538 MEDSV DEF RBRVS 01/01/2025 2303.37 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61539 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2096.8 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61539 MEDSV DEF RBRVS 01/01/2025 2050.41 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1934.48 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61540 MEDSV DEF RBRVS 01/01/2025 1892.78 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61541 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1912.51 Description: INCISION OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61541 MEDSV DEF RBRVS 01/01/2025 1870.82 Description: INCISION OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61543 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1932.69 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61543 MEDSV DEF RBRVS 01/01/2025 1890.91 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61544 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1688.19 Description: REMOVE & TREAT BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61544 MEDSV DEF RBRVS 01/01/2025 1652.51 Description: REMOVE & TREAT BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61545 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2826.83 Description: EXCISION OF BRAIN TUMOR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61545 MEDSV DEF RBRVS 01/01/2025 2764.55 Description: EXCISION OF BRAIN TUMOR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61546 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2050.69 Description: REMOVAL OF PITUITARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61546 MEDSV DEF RBRVS 01/01/2025 2005.89 Description: REMOVAL OF PITUITARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61548 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61548 MEDSV DEF RBRVS 01/01/2025 1380.02 Description: REMOVAL OF PITUITARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1074.58 Description: RELEASE OF SKULL SEAMS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61550 MEDSV DEF RBRVS 01/01/2025 1055.53 Description: RELEASE OF SKULL SEAMS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1329.47 Description: RELEASE OF SKULL SEAMS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61552 MEDSV DEF RBRVS 01/01/2025 1302.9 Description: RELEASE OF SKULL SEAMS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61556 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1523.56 Description: INCISE SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61556 MEDSV DEF RBRVS 01/01/2025 1491.68 Description: INCISE SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61557 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1506.66 Description: INCISE SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61557 MEDSV DEF RBRVS 01/01/2025 1476.59 Description: INCISE SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61558 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1677.98 Description: EXCISION OF SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61558 MEDSV DEF RBRVS 01/01/2025 1643.54 Description: EXCISION OF SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61559 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2135.47 Description: EXCISION OF SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61559 MEDSV DEF RBRVS 01/01/2025 2090.57 Description: EXCISION OF SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61563 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1763.51 Description: EXCISION OF SKULL TUMOR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61563 MEDSV DEF RBRVS 01/01/2025 1726.26 Description: EXCISION OF SKULL TUMOR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61564 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2138.45 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61564 MEDSV DEF RBRVS 01/01/2025 2092.2 Description: EXCISION OF SKULL TUMOR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61566 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1990.61 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61566 MEDSV DEF RBRVS 01/01/2025 1947.48 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61567 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2267.03 Description: INCISION OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61567 MEDSV DEF RBRVS 01/01/2025 2217.96 Description: INCISION OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1667.51 Description: REMOVE FOREIGN BODY BRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61570 MEDSV DEF RBRVS 01/01/2025 1632.7 Description: REMOVE FOREIGN BODY BRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61571 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1772.71 Description: INCISE SKULL FOR BRAIN WOUND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61571 MEDSV DEF RBRVS 01/01/2025 1735.41 Description: INCISE SKULL FOR BRAIN WOUND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2222.84 Description: SKULL BASE/BRAINSTEM SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61575 MEDSV DEF RBRVS 01/01/2025 2173.52 Description: SKULL BASE/BRAINSTEM SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61576 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3721.62 Description: SKULL BASE/BRAINSTEM SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61576 MEDSV DEF RBRVS 01/01/2025 3631.52 Description: SKULL BASE/BRAINSTEM SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2306.24 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61580 MEDSV DEF RBRVS 01/01/2025 2239.06 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61581 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61581 MEDSV DEF RBRVS 01/01/2025 2477.83 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61582 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2835.6 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61582 MEDSV DEF RBRVS 01/01/2025 2649.21 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61583 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2631.96 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61583 MEDSV DEF RBRVS 01/01/2025 2555.33 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61584 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2603.57 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61584 MEDSV DEF RBRVS 01/01/2025 2520.43 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61585 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2934.39 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61585 MEDSV DEF RBRVS 01/01/2025 2856.08 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61586 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2287.65 Description: RESECT NASOPHARYNX SKULL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 61586 MEDSV DEF RBRVS 01/01/2025 2224.5 Description: RESECT NASOPHARYNX SKULL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 61590 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2810.62 Description: INFRATEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61590 MEDSV DEF RBRVS 01/01/2025 2728.65 Description: INFRATEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61591 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2840.37 Description: INFRATEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61591 MEDSV DEF RBRVS 01/01/2025 2758.94 Description: INFRATEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61592 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61592 MEDSV DEF RBRVS 01/01/2025 2771.15 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61595 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2194.85 Description: TRANSTEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61595 MEDSV DEF RBRVS 01/01/2025 2141.06 Description: TRANSTEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61596 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2294.1 Description: TRANSCOCHLEAR APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61596 MEDSV DEF RBRVS 01/01/2025 2225.33 Description: TRANSCOCHLEAR APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61597 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2648.57 Description: TRANSCONDYLAR APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61597 MEDSV DEF RBRVS 01/01/2025 2587.4 Description: TRANSCONDYLAR APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61598 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2555.38 Description: TRANSPETROSAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61598 MEDSV DEF RBRVS 01/01/2025 2489.07 Description: TRANSPETROSAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1974.49 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61600 MEDSV DEF RBRVS 01/01/2025 1912.8 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2188.45 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61601 MEDSV DEF RBRVS 01/01/2025 2133.69 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2033.82 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61605 MEDSV DEF RBRVS 01/01/2025 1972.09 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61606 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61606 MEDSV DEF RBRVS 01/01/2025 2556.52 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61607 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2444.39 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61607 MEDSV DEF RBRVS 01/01/2025 2642.13 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61608 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2930.47 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61608 MEDSV DEF RBRVS 01/01/2025 2853.65 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61611 MEDSV DEF RBRVS 01/01/2024 12/31/2024 409.6 Description: TRANSECT ARTERY SINUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61611 MEDSV DEF RBRVS 01/01/2025 398.87 Description: TRANSECT ARTERY SINUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61613 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2929.05 Description: REMOVE ANEURYSM SINUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61613 MEDSV DEF RBRVS 01/01/2025 2853.79 Description: REMOVE ANEURYSM SINUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2522.79 Description: RESECT/EXCISE LESION SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61615 MEDSV DEF RBRVS 01/01/2025 2456.98 Description: RESECT/EXCISE LESION SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61616 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3003.35 Description: RESECT/EXCISE LESION SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61616 MEDSV DEF RBRVS 01/01/2025 2926.85 Description: RESECT/EXCISE LESION SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61618 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1166.37 Description: REPAIR DURA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61618 MEDSV DEF RBRVS 01/01/2025 1138.69 Description: REPAIR DURA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61619 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61619 MEDSV DEF RBRVS 01/01/2025 1276.31 Description: REPAIR DURA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61623 MEDSV DEF RBRVS 01/01/2024 12/31/2024 516.47 Description: ENDOVASC TEMPORY VESSEL OCCL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61623 MEDSV DEF RBRVS 01/01/2025 502.39 Description: ENDOVASC TEMPORY VESSEL OCCL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61624 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1037.75 Description: TRANSCATH OCCLUSION CNS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 61624 MEDSV DEF RBRVS 01/01/2025 1011.09 Description: TRANSCATH OCCLUSION CNS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 61626 MEDSV DEF RBRVS 01/01/2024 12/31/2024 816.32 Description: TRANSCATH OCCLUSION NON-CNS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 61626 MEDSV DEF RBRVS 01/01/2025 797.93 Description: TRANSCATH OCCLUSION NON-CNS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 61630 NOCOV DEF SYSMAN 01/01/2006 Y Description: INTRACRANIAL ANGIOPLASTY Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 61635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1332.56 Y Description: INTRACRAN ANGIOPLSTY W/STENT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 61635 MEDSV DEF RBRVS 01/01/2025 1301.22 Y Description: INTRACRAN ANGIOPLSTY W/STENT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 61640 NOCOV DEF SYSMAN 01/01/2006 Y Description: DILATE IC VASOSPASM INIT Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 61641 NOCOV DEF SYSMAN 01/01/2006 Y Description: DILAT IC VSPSM EA VSL SM TER Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 61642 NOCOV DEF SYSMAN 01/01/2006 Y 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 12/31/2024 758.23 Description: PERQ ART M-THROMBECT &/NFS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61645 MEDSV DEF RBRVS 01/01/2025 738.24 Description: PERQ ART M-THROMBECT &/NFS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 512.61 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61650 MEDSV DEF RBRVS 01/01/2025 505.81 Description: EVASC PRLNG ADMN RX AGNT 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61651 MEDSV DEF RBRVS 01/01/2024 12/31/2024 219.6 Description: EVASC PRLNG ADMN RX AGNT ADD Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61651 MEDSV DEF RBRVS 01/01/2025 215.72 Description: EVASC PRLNG ADMN RX AGNT ADD Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1992.27 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61680 MEDSV DEF RBRVS 01/01/2025 1974.49 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61682 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3669.71 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61682 MEDSV DEF RBRVS 01/01/2025 3593.74 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61684 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2519.99 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61684 MEDSV DEF RBRVS 01/01/2025 2463.94 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61686 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3964.78 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61686 MEDSV DEF RBRVS 01/01/2025 3872.26 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61690 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1938.34 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61690 MEDSV DEF RBRVS 01/01/2025 1898.55 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61692 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3224.54 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61692 MEDSV DEF RBRVS 01/01/2025 3150.19 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61697 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61697 MEDSV DEF RBRVS 01/01/2025 3646.57 Description: BRAIN ANEURYSM REPR COMPLX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 61698 MEDSV DEF RBRVS 01/01/2024 12/31/2024 4082.61 Description: BRAIN ANEURYSM REPR COMPLX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 61698 MEDSV DEF RBRVS 01/01/2025 3986.92 Description: BRAIN ANEURYSM REPR COMPLX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 61700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3007.92 Description: BRAIN ANEURYSM REPR SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61700 MEDSV DEF RBRVS 01/01/2025 2953.67 Description: BRAIN ANEURYSM REPR SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 3552.54 Description: INNER SKULL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61702 MEDSV DEF RBRVS 01/01/2025 3470.34 Description: INNER SKULL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61703 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1214.92 Description: CLAMP NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61703 MEDSV DEF RBRVS 01/01/2025 1191.12 Description: CLAMP NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2308 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61705 MEDSV DEF RBRVS 01/01/2025 2256.45 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61708 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2257.97 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61708 MEDSV DEF RBRVS 01/01/2025 2208.44 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1905.47 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61710 MEDSV DEF RBRVS 01/01/2025 1863.84 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61711 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61711 MEDSV DEF RBRVS 01/01/2025 2261.76 Description: FUSION OF SKULL ARTERIES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61715 MEDSV DEF RBRVS 01/01/2025 1041.54 Y Description: MRGFUS STRTCTC ABLT TRGT ICR Category: Medical Services CMS Add: 01/01/2025 CMS Term: 61720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1136.65 Description: INCISE SKULL/BRAIN SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61720 MEDSV DEF RBRVS 01/01/2025 1114.07 Description: INCISE SKULL/BRAIN SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61735 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1424.16 Description: INCISE SKULL/BRAIN SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61735 MEDSV DEF RBRVS 01/01/2025 1394.89 Description: INCISE SKULL/BRAIN SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61736 MEDSV DEF RBRVS 01/01/2024 12/31/2024 842.06 Description: LITT ICR 1 TRAJ 1 SMPL LES Category: Medical Services CMS Add: 01/01/2022 CMS Term: 61736 MEDSV DEF RBRVS 01/01/2025 1043.97 Description: LITT ICR 1 TRAJ 1 SMPL LES Category: Medical Services CMS Add: 01/01/2022 CMS Term: 61737 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1002.45 Description: LITT ICR MLT TRJ MLT/CPLX LS Category: Medical Services CMS Add: 01/01/2022 CMS Term: 61737 MEDSV DEF RBRVS 01/01/2025 1249.23 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 12/31/2024 1256.08 Description: INCISE SKULL/BRAIN BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61750 MEDSV DEF RBRVS 01/01/2025 1230.42 Description: INCISE SKULL/BRAIN BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61751 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1241.27 Description: BRAIN BIOPSY W/CT/MR GUIDE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61751 MEDSV DEF RBRVS 01/01/2025 1217.79 Description: BRAIN BIOPSY W/CT/MR GUIDE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1414.72 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1993 CMS Term: 61760 MEDSV DEF RBRVS 01/01/2025 1377.69 Description: IMPLANT BRAIN ELECTRODES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1444.35 Description: INCISE SKULL FOR TREATMENT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61770 MEDSV DEF RBRVS 01/01/2025 1413.9 Description: INCISE SKULL FOR TREATMENT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61781 MEDSV DEF RBRVS 01/01/2024 12/31/2024 206.95 Description: SCAN PROC CRANIAL INTRA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61781 MEDSV DEF RBRVS 01/01/2025 201.29 Description: SCAN PROC CRANIAL INTRA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61782 MEDSV DEF RBRVS 01/01/2024 12/31/2024 161.47 Description: SCAN PROC CRANIAL EXTRA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61782 MEDSV DEF RBRVS 01/01/2025 156.27 Description: SCAN PROC CRANIAL EXTRA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61783 MEDSV DEF RBRVS 01/01/2024 12/31/2024 205.13 Description: SCAN PROC SPINAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61783 MEDSV DEF RBRVS 01/01/2025 199.48 Description: SCAN PROC SPINAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61790 MEDSV DEF RBRVS 01/01/2024 12/31/2024 793.93 Description: TREAT TRIGEMINAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61790 MEDSV DEF RBRVS 01/01/2025 777.81 Description: TREAT TRIGEMINAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61791 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1008.99 Description: TREAT TRIGEMINAL TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61791 MEDSV DEF RBRVS 01/01/2025 989.04 Description: TREAT TRIGEMINAL TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61796 MEDSV DEF RBRVS 01/01/2024 12/31/2024 911.03 Description: SRS CRANIAL LESION SIMPLE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61796 MEDSV DEF RBRVS 01/01/2025 893.87 Description: SRS CRANIAL LESION SIMPLE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61797 MEDSV DEF RBRVS 01/01/2024 12/31/2024 191.86 Description: SRS CRAN LES SIMPLE ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61797 MEDSV DEF RBRVS 01/01/2025 187.39 Description: SRS CRAN LES SIMPLE ADDL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61798 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1231.04 Description: SRS CRANIAL LESION COMPLEX Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61798 MEDSV DEF RBRVS 01/01/2025 1206.37 Description: SRS CRANIAL LESION COMPLEX Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61799 MEDSV DEF RBRVS 01/01/2024 12/31/2024 265.38 Description: SRS CRAN LES COMPLEX ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61799 MEDSV DEF RBRVS 01/01/2025 259 Description: SRS CRAN LES COMPLEX ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 132.88 Description: APPLY SRS HEADFRAME ADD-ON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61800 MEDSV DEF RBRVS 01/01/2025 129.5 Description: APPLY SRS HEADFRAME ADD-ON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 883.65 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61850 MEDSV DEF RBRVS 01/01/2025 866.7 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1393.3 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61860 MEDSV DEF RBRVS 01/01/2025 1363.82 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61863 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1344.51 Y Description: IMPLANT NEUROELECTRODE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61863 MEDSV DEF RBRVS 01/01/2025 1318.6 Y Description: IMPLANT NEUROELECTRODE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61864 MEDSV DEF RBRVS 01/01/2024 12/31/2024 247.81 Y Description: IMPLANT NEUROELECTRDE ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61864 MEDSV DEF RBRVS 01/01/2025 241.31 Y Description: IMPLANT NEUROELECTRDE ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61867 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2026.18 Y Description: IMPLANT NEUROELECTRODE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61867 MEDSV DEF RBRVS 01/01/2025 1982.36 Y Description: IMPLANT NEUROELECTRODE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61868 MEDSV DEF RBRVS 01/01/2024 12/31/2024 437.01 Y Description: IMPLANT NEUROELECTRDE ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61868 MEDSV DEF RBRVS 01/01/2025 425.98 Y Description: IMPLANT NEUROELECTRDE ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 529.88 Description: REVISE/REMOVE NEUROELECTRODE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61880 MEDSV DEF RBRVS 01/01/2025 521.46 Description: REVISE/REMOVE NEUROELECTRODE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61885 MEDSV DEF RBRVS 01/01/2024 12/31/2024 477.16 Y Description: INSRT/REDO NEUROSTIM 1 ARRAY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61885 MEDSV DEF RBRVS 01/01/2025 470.33 Y Description: INSRT/REDO NEUROSTIM 1 ARRAY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61886 MEDSV DEF RBRVS 01/01/2024 12/31/2024 792.79 Y 0-1 Description: IMPLANT NEUROSTIM ARRAYS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 61886 MEDSV DEF RBRVS 01/01/2025 782.73 Y 0-1 Description: IMPLANT NEUROSTIM ARRAYS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 61888 MEDSV DEF RBRVS 01/01/2024 12/31/2024 358.25 Description: REVISE/REMOVE NEURORECEIVER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61888 MEDSV DEF RBRVS 01/01/2025 351.01 Description: REVISE/REMOVE NEURORECEIVER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61889 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1204.42 Description: INS SK-MNT CRNL NSTM PG/RCVR Category: Medical Services CMS Add: 01/01/2024 CMS Term: 61889 MEDSV DEF RBRVS 01/01/2025 1168.08 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 12/31/2024 569.21 Description: REV/RPLCMT SK-MNT CRNL NSTM Category: Medical Services CMS Add: 01/01/2024 CMS Term: 61891 MEDSV DEF RBRVS 01/01/2025 552.39 Description: REV/RPLCMT SK-MNT CRNL NSTM Category: Medical Services CMS Add: 01/01/2024 CMS Term: 61892 MEDSV DEF RBRVS 01/01/2024 12/31/2024 788.71 Description: RMV SK-MNT CRNL NSTM PG/RCVR Category: Medical Services CMS Add: 01/01/2024 CMS Term: 61892 MEDSV DEF RBRVS 01/01/2025 765.59 Description: RMV SK-MNT CRNL NSTM PG/RCVR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 927.42 Description: TREAT SKULL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62000 MEDSV DEF RBRVS 01/01/2025 909.6 Description: TREAT SKULL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1137.46 Description: TREAT SKULL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62005 MEDSV DEF RBRVS 01/01/2025 1114.86 Description: TREAT SKULL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1372.97 Description: TREATMENT OF HEAD INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62010 MEDSV DEF RBRVS 01/01/2025 1345.13 Description: TREATMENT OF HEAD INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1420.13 Description: REPAIR BRAIN FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62100 MEDSV DEF RBRVS 01/01/2025 1389.87 Description: REPAIR BRAIN FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1507.8 Description: REDUCTION OF SKULL DEFECT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62115 MEDSV DEF RBRVS 01/01/2025 1478.77 Description: REDUCTION OF SKULL DEFECT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62117 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1747.79 Description: REDUCTION OF SKULL DEFECT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62117 MEDSV DEF RBRVS 01/01/2025 1709.39 Description: REDUCTION OF SKULL DEFECT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1868.03 Description: REPAIR SKULL CAVITY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62120 MEDSV DEF RBRVS 01/01/2025 1824.45 Description: REPAIR SKULL CAVITY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1435.41 Description: INCISE SKULL REPAIR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62121 MEDSV DEF RBRVS 01/01/2025 1396.92 Description: INCISE SKULL REPAIR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 924.02 Description: CRNOP SKULL DEFECT<5 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62140 MEDSV DEF RBRVS 01/01/2025 905.18 Description: CRNOP SKULL DEFECT<5 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62141 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1027.7 Description: CRNOP SKULL DEFECT>5 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62141 MEDSV DEF RBRVS 01/01/2025 1007.36 Description: CRNOP SKULL DEFECT>5 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62142 MEDSV DEF RBRVS 01/01/2024 12/31/2024 803.02 Description: RMVL B1 FLP/PROSTC PLATE SKL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62142 MEDSV DEF RBRVS 01/01/2025 788.76 Description: RMVL B1 FLP/PROSTC PLATE SKL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62143 MEDSV DEF RBRVS 01/01/2024 12/31/2024 938.07 Description: RPL B1 FLP/PROSTC PLATE SKL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62143 MEDSV DEF RBRVS 01/01/2025 918.53 Description: RPL B1 FLP/PROSTC PLATE SKL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1264.88 Description: REPAIR OF SKULL & BRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62145 MEDSV DEF RBRVS 01/01/2025 1242.02 Description: REPAIR OF SKULL & BRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62146 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1117.93 Description: CRNOP W/AUTOGRAFT<5 CM DIAM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62146 MEDSV DEF RBRVS 01/01/2025 1095.72 Description: CRNOP W/AUTOGRAFT<5 CM DIAM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62147 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1273.5 Description: CRNOP W/AUTOGRAFT>5 CM DIAM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62147 MEDSV DEF RBRVS 01/01/2025 1245.3 Description: CRNOP W/AUTOGRAFT>5 CM DIAM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62148 MEDSV DEF RBRVS 01/01/2024 12/31/2024 110.29 Description: RETR BONE FLAP TO FIX SKULL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62148 MEDSV DEF RBRVS 01/01/2025 107.49 Description: RETR BONE FLAP TO FIX SKULL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 165.12 Description: NEUROENDOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62160 MEDSV DEF RBRVS 01/01/2025 160.64 Description: NEUROENDOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62161 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1358.22 Description: DISSECT BRAIN W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62161 MEDSV DEF RBRVS 01/01/2025 1334.29 Description: DISSECT BRAIN W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62162 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1682.96 Description: REMOVE COLLOID CYST W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62162 MEDSV DEF RBRVS 01/01/2025 1648.03 Description: REMOVE COLLOID CYST W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62164 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1866.48 Description: REMOVE BRAIN TUMOR W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62164 MEDSV DEF RBRVS 01/01/2025 1828.28 Description: REMOVE BRAIN TUMOR W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62165 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1383.85 Description: REMOVE PITUIT TUMOR W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62165 MEDSV DEF RBRVS 01/01/2025 1349.69 Description: REMOVE PITUIT TUMOR W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1425.99 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62180 MEDSV DEF RBRVS 01/01/2025 1397.21 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62190 MEDSV DEF RBRVS 01/01/2024 12/31/2024 835.2 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62190 MEDSV DEF RBRVS 01/01/2025 820.31 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62192 MEDSV DEF RBRVS 01/01/2024 12/31/2024 877.29 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62192 MEDSV DEF RBRVS 01/01/2025 875.69 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62194 MEDSV DEF RBRVS 01/01/2024 12/31/2024 447.01 Description: REPLACE/IRRIGATE CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62194 MEDSV DEF RBRVS 01/01/2025 439.76 Description: REPLACE/IRRIGATE CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1228.88 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62200 MEDSV DEF RBRVS 01/01/2025 1204 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62201 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1091.33 Description: BRAIN CAVITY SHUNT W/SCOPE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 62201 MEDSV DEF RBRVS 01/01/2025 1069.17 Description: BRAIN CAVITY SHUNT W/SCOPE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 62220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 870.48 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62220 MEDSV DEF RBRVS 01/01/2025 858.17 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62223 MEDSV DEF RBRVS 01/01/2024 12/31/2024 934.85 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62223 MEDSV DEF RBRVS 01/01/2025 913.99 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 484.6 Description: REPLACE/IRRIGATE CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62225 MEDSV DEF RBRVS 01/01/2025 477.74 Description: REPLACE/IRRIGATE CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62230 MEDSV DEF RBRVS 01/01/2024 12/31/2024 756.49 Description: REPLACE/REVISE BRAIN SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62230 MEDSV DEF RBRVS 01/01/2025 741.86 Description: REPLACE/REVISE BRAIN SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62252 MEDSV DEF RBRVS 01/01/2024 12/31/2024 75.89 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 40.54 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62252 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 35.35 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 MEDSV DEF RBRVS 01/01/2025 76.08 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 26 MEDSV DEF RBRVS 01/01/2025 39.39 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 TC MEDSV DEF RBRVS 01/01/2025 36.69 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62256 MEDSV DEF RBRVS 01/01/2024 12/31/2024 550.86 Description: REMOVE BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62256 MEDSV DEF RBRVS 01/01/2025 543.67 Description: REMOVE BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62258 MEDSV DEF RBRVS 01/01/2024 12/31/2024 999.14 Description: REPLACE BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62258 MEDSV DEF RBRVS 01/01/2025 979.89 Description: REPLACE BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62263 MEDSV DEF RBRVS 01/01/2024 12/31/2024 598.09 0-1 Description: EPIDURAL LYSIS MULT SESSIONS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 62263 MEDSV DEF RBRVS 01/01/2025 591.91 0-1 Description: EPIDURAL LYSIS MULT SESSIONS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 62264 MEDSV DEF RBRVS 01/01/2024 12/31/2024 413.71 0-1 Description: EPIDURAL LYSIS ON SINGLE DAY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62264 MEDSV DEF RBRVS 01/01/2025 402.6 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 12/31/2024 252.04 Description: INTERDISCAL PERQ ASPIR DX Category: Medical Services CMS Add: 01/01/2009 CMS Term: 62267 MEDSV DEF RBRVS 01/01/2025 241.57 Description: INTERDISCAL PERQ ASPIR DX Category: Medical Services CMS Add: 01/01/2009 CMS Term: 62268 MEDSV DEF RBRVS 01/01/2024 12/31/2024 240.12 Description: DRAIN SPINAL CORD CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62268 MEDSV DEF RBRVS 01/01/2025 284.73 Description: DRAIN SPINAL CORD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62269 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.01 Description: NEEDLE BIOPSY SPINAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62269 MEDSV DEF RBRVS 01/01/2025 237.45 Description: NEEDLE BIOPSY SPINAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 123.15 Description: DX LMBR SPI PNXR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62270 MEDSV DEF RBRVS 01/01/2025 131.79 Description: DX LMBR SPI PNXR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62272 MEDSV DEF RBRVS 01/01/2024 12/31/2024 163.57 Description: THER SPI PNXR DRG CSF Category: Medical Services CMS Add: 01/01/1985 CMS Term: 62272 MEDSV DEF RBRVS 01/01/2025 165.31 Description: THER SPI PNXR DRG CSF Category: Medical Services CMS Add: 01/01/1985 CMS Term: 62273 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.82 Description: INJECT EPIDURAL PATCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62273 MEDSV DEF RBRVS 01/01/2025 154.5 Description: INJECT EPIDURAL PATCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 306.17 Description: TREAT SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62280 MEDSV DEF RBRVS 01/01/2025 300.53 Description: TREAT SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62281 MEDSV DEF RBRVS 01/01/2024 12/31/2024 226.6 Description: TREAT SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 62281 MEDSV DEF RBRVS 01/01/2025 221.17 Description: TREAT SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 62282 MEDSV DEF RBRVS 01/01/2024 12/31/2024 294.57 Description: TREAT SPINAL CANAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62282 MEDSV DEF RBRVS 01/01/2025 284.48 Description: TREAT SPINAL CANAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62284 MEDSV DEF RBRVS 01/01/2024 12/31/2024 178.88 Description: INJECTION FOR MYELOGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62284 MEDSV DEF RBRVS 01/01/2025 170.57 Description: INJECTION FOR MYELOGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62287 MEDSV DEF RBRVS 01/01/2024 12/31/2024 532.26 Description: DCMPRN PX PERQ 1/MLT LUMBAR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62287 MEDSV DEF RBRVS 01/01/2025 555.47 Description: DCMPRN PX PERQ 1/MLT LUMBAR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62290 ANEST DEF RBRVS 01/01/2024 12/31/2024 329.52 Description: NJX PX DISCOGRAPHY LUMBAR Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 62290 ANEST DEF RBRVS 01/01/2025 314.15 Description: NJX PX DISCOGRAPHY LUMBAR Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 62291 ANEST DEF RBRVS 01/01/2024 12/31/2024 303.92 Description: NJX PX DISCOGRAPHY CRV/THRC Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 62291 ANEST DEF RBRVS 01/01/2025 283.26 Description: NJX PX DISCOGRAPHY CRV/THRC Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 62292 MEDSV DEF RBRVS 01/01/2024 12/31/2024 542.66 Description: NJX CHEMONUCLEOLYSIS LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62292 MEDSV DEF RBRVS 01/01/2025 536.7 Description: NJX CHEMONUCLEOLYSIS LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62294 MEDSV DEF RBRVS 01/01/2024 12/31/2024 853.56 Description: INJECTION INTO SPINAL ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62294 MEDSV DEF RBRVS 01/01/2025 838.17 Description: INJECTION INTO SPINAL ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62302 MEDSV DEF RBRVS 01/01/2024 12/31/2024 242.6 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62302 MEDSV DEF RBRVS 01/01/2025 231.84 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62303 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.92 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62303 MEDSV DEF RBRVS 01/01/2025 235.91 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62304 MEDSV DEF RBRVS 01/01/2024 12/31/2024 240.94 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62304 MEDSV DEF RBRVS 01/01/2025 230.53 Description: MYELOGRAPHY LUMBAR INJECTION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 261.92 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62305 MEDSV DEF RBRVS 01/01/2025 251.02 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 154.4 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62320 MEDSV DEF RBRVS 01/01/2025 149.56 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62321 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.41 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62321 MEDSV DEF RBRVS 01/01/2025 240.46 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62322 MEDSV DEF RBRVS 01/01/2024 12/31/2024 129.82 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62322 MEDSV DEF RBRVS 01/01/2025 124.1 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62323 MEDSV DEF RBRVS 01/01/2024 12/31/2024 241.71 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62323 MEDSV DEF RBRVS 01/01/2025 236.3 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62324 MEDSV DEF RBRVS 01/01/2024 12/31/2024 130.69 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62324 MEDSV DEF RBRVS 01/01/2025 126.62 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 238.3 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62325 MEDSV DEF RBRVS 01/01/2025 229.18 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62326 MEDSV DEF RBRVS 01/01/2024 12/31/2024 131.28 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62326 MEDSV DEF RBRVS 01/01/2025 126.64 Description: NJX INTERLAMINAR LMBR/SAC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62327 MEDSV DEF RBRVS 01/01/2024 12/31/2024 251.44 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62327 MEDSV DEF RBRVS 01/01/2025 249.25 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62328 MEDSV DEF RBRVS 01/01/2024 12/31/2024 216.97 Description: DX LMBR SPI PNXR W/FLUOR/CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 62328 MEDSV DEF RBRVS 01/01/2025 202.45 Description: DX LMBR SPI PNXR W/FLUOR/CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 62329 MEDSV DEF RBRVS 01/01/2024 12/31/2024 265.69 Description: THER SPI PNXR CSF FLUOR/CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 62329 MEDSV DEF RBRVS 01/01/2025 237.28 Description: THER SPI PNXR CSF FLUOR/CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 62350 MEDSV DEF RBRVS 01/01/2024 12/31/2024 368.33 Description: IMPLANT SPINAL CANAL CATH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62350 MEDSV DEF RBRVS 01/01/2025 361.63 Description: IMPLANT SPINAL CANAL CATH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62351 MEDSV DEF RBRVS 01/01/2024 12/31/2024 817.24 Description: IMPLANT SPINAL CANAL CATH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62351 MEDSV DEF RBRVS 01/01/2025 809.08 Description: IMPLANT SPINAL CANAL CATH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62355 MEDSV DEF RBRVS 01/01/2024 12/31/2024 253.59 Description: REMOVE SPINAL CANAL CATHETER Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62355 MEDSV DEF RBRVS 01/01/2025 249.9 Description: REMOVE SPINAL CANAL CATHETER Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 293.12 Description: INSERT SPINE INFUSION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62360 MEDSV DEF RBRVS 01/01/2025 281.13 Description: INSERT SPINE INFUSION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62361 MEDSV DEF RBRVS 01/01/2024 12/31/2024 391.81 Description: IMPLANT SPINE INFUSION PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62361 MEDSV DEF RBRVS 01/01/2025 386.35 Description: IMPLANT SPINE INFUSION PUMP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62362 MEDSV DEF RBRVS 01/01/2024 12/31/2024 354.54 Description: IMPLANT SPINE INFUSION PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62362 MEDSV DEF RBRVS 01/01/2025 348.04 Description: IMPLANT SPINE INFUSION PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62365 MEDSV DEF RBRVS 01/01/2024 12/31/2024 272.28 Description: REMOVE SPINE INFUSION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62365 MEDSV DEF RBRVS 01/01/2025 269.11 Description: REMOVE SPINE INFUSION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62367 MEDSV DEF RBRVS 01/01/2024 12/31/2024 29.89 Description: ANALYZE SPINE INFUS PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62367 26 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 29.45 0 Description: ANALYZE SPINE INFUS PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62367 MEDSV DEF RBRVS 01/01/2025 29.35 Description: ANALYZE SPINE INFUS PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62367 26 MEDSV DEF MAXFEE 01/01/2025 28.86 0 Description: ANALYZE SPINE INFUS PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62368 MEDSV DEF RBRVS 01/01/2024 12/31/2024 41.28 Description: ANALYZE SP INF PUMP W/REPROG Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62368 MEDSV DEF RBRVS 01/01/2025 40.72 Description: ANALYZE SP INF PUMP W/REPROG Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62369 MEDSV DEF RBRVS 01/01/2024 12/31/2024 85.73 Description: ANAL SP INF PMP W/REPRG&FILL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 62369 MEDSV DEF RBRVS 01/01/2025 84.19 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 12/31/2024 86.75 Description: ANL SP INF PMP W/MDREPRG&FIL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 62370 MEDSV DEF RBRVS 01/01/2025 84.49 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 Description: NDSC DCMPRN 1 NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/2017 CMS Term: 63001 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1108.31 Description: REMOVE SPINE LAMINA 1/2 CRVL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63001 MEDSV DEF RBRVS 01/01/2025 1083.57 Description: REMOVE SPINE LAMINA 1/2 CRVL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63003 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1111.22 Description: REMOVE SPINE LAMINA 1/2 THRC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63003 MEDSV DEF RBRVS 01/01/2025 1088.42 Description: REMOVE SPINE LAMINA 1/2 THRC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1080.35 Description: REMOVE SPINE LAMINA 1/2 LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63005 MEDSV DEF RBRVS 01/01/2025 1060.35 Description: REMOVE SPINE LAMINA 1/2 LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63011 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1001.27 Description: REMOVE SPINE LAMINA 1/2 SCRL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63011 MEDSV DEF RBRVS 01/01/2025 976.83 Description: REMOVE SPINE LAMINA 1/2 SCRL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63012 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1080.41 Description: REMOVE LAMINA/FACETS LUMBAR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 63012 MEDSV DEF RBRVS 01/01/2025 1057.39 Description: REMOVE LAMINA/FACETS LUMBAR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 63015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1329.18 Description: REMOVE SPINE LAMINA >2 CRVCL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63015 MEDSV DEF RBRVS 01/01/2025 1302.83 Description: REMOVE SPINE LAMINA >2 CRVCL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63016 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1373.62 Description: REMOVE SPINE LAMINA >2 THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63016 MEDSV DEF RBRVS 01/01/2025 1342.04 Description: REMOVE SPINE LAMINA >2 THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63017 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1137.02 Description: REMOVE SPINE LAMINA >2 LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63017 MEDSV DEF RBRVS 01/01/2025 1114.86 Description: REMOVE SPINE LAMINA >2 LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 995.23 Description: NECK SPINE DISK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63020 MEDSV DEF RBRVS 01/01/2025 976.46 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 830.23 Description: LOW BACK DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63030 MEDSV DEF RBRVS 01/01/2025 815.64 Description: LOW BACK DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63035 MEDSV DEF RBRVS 01/01/2024 12/31/2024 209.23 Description: SPINAL DISK SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63035 MEDSV DEF RBRVS 01/01/2025 203.27 Description: SPINAL DISK SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1252.47 Description: LAMINOTOMY SINGLE CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63040 MEDSV DEF RBRVS 01/01/2025 1223.58 Description: LAMINOTOMY SINGLE CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63042 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1177.87 Description: LAMINOTOMY SINGLE LUMBAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63042 MEDSV DEF RBRVS 01/01/2025 1153.52 Description: LAMINOTOMY SINGLE LUMBAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63043 MEDSV DEF MAXFEE 01/01/2024 252.45 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 Description: LAMINOTOMY ADDL LUMBAR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 63045 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1160.69 Description: LAM FACETEC & FORAMOT CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63045 MEDSV DEF RBRVS 01/01/2025 1137.43 Description: LAM FACETEC & FORAMOT CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63046 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1112.01 Description: LAM FACETEC & FORAMOT THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63046 MEDSV DEF RBRVS 01/01/2025 1090.18 Description: LAM FACETEC & FORAMOT THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63047 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1003.92 Description: LAM FACETEC & FORAMOT LUMBAR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63047 MEDSV DEF RBRVS 01/01/2025 983.55 Description: LAM FACETEC & FORAMOT LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63048 MEDSV DEF RBRVS 01/01/2024 12/31/2024 188.06 Description: LAM FACETEC &FORAMOT EA ADDL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63048 MEDSV DEF RBRVS 01/01/2025 183.18 Description: LAM FACETEC &FORAMOT EA ADDL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63050 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1343.25 Description: CERVICAL LAMINOPLSTY 2/> SEG Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63050 MEDSV DEF RBRVS 01/01/2025 1306.62 Description: CERVICAL LAMINOPLSTY 2/> SEG Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63051 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1537.1 Description: C-LAMINOPLASTY W/GRAFT/PLATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63051 MEDSV DEF RBRVS 01/01/2025 1500.79 Description: C-LAMINOPLASTY W/GRAFT/PLATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63052 MEDSV DEF RBRVS 01/01/2024 12/31/2024 230.71 Description: LAM FACETC/FRMT ARTHRD LUM 1 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 63052 MEDSV DEF RBRVS 01/01/2025 224.46 Description: LAM FACETC/FRMT ARTHRD LUM 1 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 63053 MEDSV DEF RBRVS 01/01/2024 12/31/2024 204.64 Description: LAM FACTC/FRMT ARTHRD LUM EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 63053 MEDSV DEF RBRVS 01/01/2025 199.44 Description: LAM FACTC/FRMT ARTHRD LUM EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 63055 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1458.57 Description: DECOMPRESS SPINAL CORD THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63055 MEDSV DEF RBRVS 01/01/2025 1426.59 Description: DECOMPRESS SPINAL CORD THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63056 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1347.15 Description: DECOMPRESS SPINAL CORD LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63056 MEDSV DEF RBRVS 01/01/2025 1315.79 Description: DECOMPRESS SPINAL CORD LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63057 MEDSV DEF RBRVS 01/01/2024 12/31/2024 285.87 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63057 MEDSV DEF RBRVS 01/01/2025 278.22 Description: DECOMPRESS SPINE CORD ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63064 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1598.98 Description: DECOMPRESS SPINAL CORD THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63064 MEDSV DEF RBRVS 01/01/2025 1560.3 Description: DECOMPRESS SPINAL CORD THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63066 MEDSV DEF RBRVS 01/01/2024 12/31/2024 180.19 Description: DECOMPRESS SPINE CORD ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63066 MEDSV DEF RBRVS 01/01/2025 175.28 Description: DECOMPRESS SPINE CORD ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63075 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1227.7 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63075 MEDSV DEF RBRVS 01/01/2025 1198.2 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63076 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.1 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63076 MEDSV DEF RBRVS 01/01/2025 211.41 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63077 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1377.24 Description: SPINE DISK SURGERY THORAX Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63077 MEDSV DEF RBRVS 01/01/2025 1316.69 Description: SPINE DISK SURGERY THORAX Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63078 MEDSV DEF RBRVS 01/01/2024 12/31/2024 181.17 Description: SPINE DISK SURGERY THORAX Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63078 MEDSV DEF RBRVS 01/01/2025 176.4 Description: SPINE DISK SURGERY THORAX Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63081 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1586.74 Description: REMOVE VERT BODY DCMPRN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63081 MEDSV DEF RBRVS 01/01/2025 1553.91 Description: REMOVE VERT BODY DCMPRN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63082 MEDSV DEF RBRVS 01/01/2024 12/31/2024 236.63 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63082 MEDSV DEF RBRVS 01/01/2025 230.84 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63085 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1736.73 Description: REMOVE VERT BODY DCMPRN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63085 MEDSV DEF RBRVS 01/01/2025 1708.79 Description: REMOVE VERT BODY DCMPRN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63086 MEDSV DEF RBRVS 01/01/2024 12/31/2024 169.83 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63086 MEDSV DEF RBRVS 01/01/2025 166.11 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63087 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2174.87 Description: REMOV VERTBR DCMPRN THRCLMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63087 MEDSV DEF RBRVS 01/01/2025 2129.2 Description: REMOV VERTBR DCMPRN THRCLMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63088 MEDSV DEF RBRVS 01/01/2024 12/31/2024 230.34 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63088 MEDSV DEF RBRVS 01/01/2025 224.4 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63090 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1769.17 Description: REMOVE VERT BODY DCMPRN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63090 MEDSV DEF RBRVS 01/01/2025 1729.18 Description: REMOVE VERT BODY DCMPRN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63091 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.78 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63091 MEDSV DEF RBRVS 01/01/2025 154.19 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2085.42 Description: REMOVE VERT BODY DCMPRN THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63101 MEDSV DEF RBRVS 01/01/2025 2041.23 Description: REMOVE VERT BODY DCMPRN THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63102 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2063.3 Description: REMOVE VERT BODY DCMPRN LMBR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63102 MEDSV DEF RBRVS 01/01/2025 2015.37 Description: REMOVE VERT BODY DCMPRN LMBR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63103 MEDSV DEF RBRVS 01/01/2024 12/31/2024 262.39 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63103 MEDSV DEF RBRVS 01/01/2025 254.91 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63170 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1422.92 Description: INCISE SPINAL CORD TRACT(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63170 MEDSV DEF RBRVS 01/01/2025 1394.77 Description: INCISE SPINAL CORD TRACT(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63172 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1261.76 Description: DRAINAGE OF SPINAL CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63172 MEDSV DEF RBRVS 01/01/2025 1236.46 Description: DRAINAGE OF SPINAL CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63173 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1538.94 Description: DRAINAGE OF SPINAL CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63173 MEDSV DEF RBRVS 01/01/2025 1508.17 Description: DRAINAGE OF SPINAL CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63185 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1043.27 0-1 Description: INCISE SPINE NRV HALF SEGMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63185 MEDSV DEF RBRVS 01/01/2025 1080.9 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 12/31/2024 1146.14 Description: INCISE SPINE NRV >2 SEGMNTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63190 MEDSV DEF RBRVS 01/01/2025 1120.34 Description: INCISE SPINE NRV >2 SEGMNTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63191 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1236 Description: INCISE SPINE ACCESSORY NERVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63191 MEDSV DEF RBRVS 01/01/2025 1211.85 Description: INCISE SPINE ACCESSORY NERVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63197 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1526.3 Description: LAM W/CORDOTOMY 1STG THRC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63197 MEDSV DEF RBRVS 01/01/2025 1495.57 Description: LAM W/CORDOTOMY 1STG THRC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1369.6 Description: RELEASE SPINAL CORD LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63200 MEDSV DEF RBRVS 01/01/2025 1343.84 Description: RELEASE SPINAL CORD LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2626.21 Description: REVISE SPINAL CORD VSLS CRVL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63250 MEDSV DEF RBRVS 01/01/2025 2566.64 Description: REVISE SPINAL CORD VSLS CRVL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63251 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2685.74 Description: REVISE SPINAL CORD VSLS THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63251 MEDSV DEF RBRVS 01/01/2025 2625.04 Description: REVISE SPINAL CORD VSLS THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63252 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2685.08 Description: REVISE SPINE CORD VSL THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63252 MEDSV DEF RBRVS 01/01/2025 2624.71 Description: REVISE SPINE CORD VSL THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1497.15 Description: EXCISE INTRASPINL LESION CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63265 MEDSV DEF RBRVS 01/01/2025 1465.38 Description: EXCISE INTRASPINL LESION CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63266 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1540.63 Description: EXCISE INTRSPINL LESION THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63266 MEDSV DEF RBRVS 01/01/2025 1505.74 Description: EXCISE INTRSPINL LESION THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63267 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1239.04 Description: EXCISE INTRSPINL LESION LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63267 MEDSV DEF RBRVS 01/01/2025 1212.94 Description: EXCISE INTRSPINL LESION LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63268 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1265.67 Description: EXCISE INTRSPINL LESION SCRL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63268 MEDSV DEF RBRVS 01/01/2025 1282.64 Description: EXCISE INTRSPINL LESION SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1849.33 Description: EXCISE INTRSPINL LESION CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63270 MEDSV DEF RBRVS 01/01/2025 1809.43 Description: EXCISE INTRSPINL LESION CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63271 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1850.81 Description: EXCISE INTRSPINL LESION THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63271 MEDSV DEF RBRVS 01/01/2025 1807 Description: EXCISE INTRSPINL LESION THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63272 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1680.75 Description: EXCISE INTRSPINL LESION LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63272 MEDSV DEF RBRVS 01/01/2025 1647.41 Description: EXCISE INTRSPINL LESION LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63273 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1665.21 Description: EXCISE INTRSPINL LESION SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63273 MEDSV DEF RBRVS 01/01/2025 1630.47 Description: EXCISE INTRSPINL LESION SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1616.38 Description: BX/EXC XDRL SPINE LESN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63275 MEDSV DEF RBRVS 01/01/2025 1577.63 Description: BX/EXC XDRL SPINE LESN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63276 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1600.25 Description: BX/EXC XDRL SPINE LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63276 MEDSV DEF RBRVS 01/01/2025 1567.36 Description: BX/EXC XDRL SPINE LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63277 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1407 Description: BX/EXC XDRL SPINE LESN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63277 MEDSV DEF RBRVS 01/01/2025 1375.42 Description: BX/EXC XDRL SPINE LESN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63278 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1424.63 Description: BX/EXC XDRL SPINE LESN SCRL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63278 MEDSV DEF RBRVS 01/01/2025 1395.87 Description: BX/EXC XDRL SPINE LESN SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1887.57 Description: BX/EXC IDRL SPINE LESN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63280 MEDSV DEF RBRVS 01/01/2025 1847.73 Description: BX/EXC IDRL SPINE LESN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63281 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1870.04 Description: BX/EXC IDRL SPINE LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63281 MEDSV DEF RBRVS 01/01/2025 1833.11 Description: BX/EXC IDRL SPINE LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63282 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1767.51 Description: BX/EXC IDRL SPINE LESN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63282 MEDSV DEF RBRVS 01/01/2025 1730.05 Description: BX/EXC IDRL SPINE LESN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63283 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1697.35 Description: BX/EXC IDRL SPINE LESN SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63283 MEDSV DEF RBRVS 01/01/2025 1662.7 Description: BX/EXC IDRL SPINE LESN SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2321.26 Description: BX/EXC IDRL IMED LESN CERVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63285 MEDSV DEF RBRVS 01/01/2025 2270.8 Description: BX/EXC IDRL IMED LESN CERVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63286 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2298.1 Description: BX/EXC IDRL IMED LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63286 MEDSV DEF RBRVS 01/01/2025 2238.04 Description: BX/EXC IDRL IMED LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63287 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2433.36 Description: BX/EXC IDRL IMED LESN THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63287 MEDSV DEF RBRVS 01/01/2025 2379.75 Description: BX/EXC IDRL IMED LESN THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2474.38 Description: BX/EXC XDRL/IDRL LSN ANY LVL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63290 MEDSV DEF RBRVS 01/01/2025 2419.61 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 12/31/2024 290.12 Description: REPAIR LAMINECTOMY DEFECT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63295 MEDSV DEF RBRVS 01/01/2025 281.64 Description: REPAIR LAMINECTOMY DEFECT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1635.72 Description: REMOVE VERT XDRL BODY CRVCL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63300 MEDSV DEF RBRVS 01/01/2025 1596.75 Description: REMOVE VERT XDRL BODY CRVCL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63301 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1963.19 Description: REMOVE VERT XDRL BODY THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63301 MEDSV DEF RBRVS 01/01/2025 1921.7 Description: REMOVE VERT XDRL BODY THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63302 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1939.73 Description: REMOVE VERT XDRL BODY THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63302 MEDSV DEF RBRVS 01/01/2025 1899.05 Description: REMOVE VERT XDRL BODY THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63303 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2056.44 Description: REMOV VERT XDRL BDY LMBR/SAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63303 MEDSV DEF RBRVS 01/01/2025 2011.64 Description: REMOV VERT XDRL BDY LMBR/SAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63304 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2089.06 Description: REMOVE VERT IDRL BODY CRVCL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63304 MEDSV DEF RBRVS 01/01/2025 2044.04 Description: REMOVE VERT IDRL BODY CRVCL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63305 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2221.17 Description: REMOVE VERT IDRL BODY THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63305 MEDSV DEF RBRVS 01/01/2025 2173.05 Description: REMOVE VERT IDRL BODY THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63306 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2183.25 Description: REMOV VERT IDRL BDY THRCLMBR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63306 MEDSV DEF RBRVS 01/01/2025 2135.73 Description: REMOV VERT IDRL BDY THRCLMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63307 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2137.16 Description: REMOV VERT IDRL BDY LMBR/SAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63307 MEDSV DEF RBRVS 01/01/2025 2090.26 Description: REMOV VERT IDRL BDY LMBR/SAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63308 MEDSV DEF RBRVS 01/01/2024 12/31/2024 283.86 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63308 MEDSV DEF RBRVS 01/01/2025 277.04 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 977.78 Description: REMOVE SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63600 MEDSV DEF RBRVS 01/01/2025 959.22 Description: REMOVE SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 510.99 Description: STIMULATION OF SPINAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63610 MEDSV DEF RBRVS 01/01/2025 499.4 Description: STIMULATION OF SPINAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1005.76 Description: SRS SPINAL LESION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 63620 MEDSV DEF RBRVS 01/01/2025 986.12 Description: SRS SPINAL LESION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 63621 MEDSV DEF RBRVS 01/01/2024 12/31/2024 221.05 Description: SRS SPINAL LESION ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 63621 MEDSV DEF RBRVS 01/01/2025 215.3 Description: SRS SPINAL LESION ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 63650 ANEST DEF RBRVS 01/01/2024 12/31/2024 2142.48 Description: IMPLANT NEUROELECTRODES Category: Anesthesia CMS Add: 01/01/1982 CMS Term: 63650 ANEST DEF RBRVS 01/01/2025 2068.52 Description: IMPLANT NEUROELECTRODES Category: Anesthesia CMS Add: 01/01/1982 CMS Term: 63655 MEDSV DEF RBRVS 01/01/2024 12/31/2024 759.48 Description: IMPLANT NEUROELECTRODES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63655 MEDSV DEF RBRVS 01/01/2025 746.1 Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63661 ANEST DEF RBRVS 01/01/2024 12/31/2024 634.78 Description: REMOVE SPINE ELTRD PERQ ARAY Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 63661 ANEST DEF RBRVS 01/01/2025 620.9 Description: REMOVE SPINE ELTRD PERQ ARAY Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 63662 MEDSV DEF RBRVS 01/01/2024 12/31/2024 768.25 Description: REMOVE SPINE ELTRD PLATE Category: Medical Services CMS Add: 01/01/2010 CMS Term: 63662 MEDSV DEF RBRVS 01/01/2025 756.5 Description: REMOVE SPINE ELTRD PLATE Category: Medical Services CMS Add: 01/01/2010 CMS Term: 63663 ANEST DEF RBRVS 01/01/2024 12/31/2024 841.88 Description: REVISE SPINE ELTRD PERQ ARAY Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 63663 ANEST DEF RBRVS 01/01/2025 823.14 Description: REVISE SPINE ELTRD PERQ ARAY Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 63664 MEDSV DEF RBRVS 01/01/2024 12/31/2024 799.93 Description: REVISE SPINE ELTRD PLATE Category: Medical Services CMS Add: 01/01/2010 CMS Term: 63664 MEDSV DEF RBRVS 01/01/2025 786.97 Description: REVISE SPINE ELTRD PLATE Category: Medical Services CMS Add: 01/01/2010 CMS Term: 63685 MEDSV DEF RBRVS 01/01/2024 12/31/2024 333.9 Description: INS/RPLC SPI NPG/RCVR POCKET Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63685 MEDSV DEF RBRVS 01/01/2025 307.73 Description: INS/RPLC SPI NPG/RCVR POCKET Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63688 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2025 271.09 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 12/31/2024 1176.91 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63700 MEDSV DEF RBRVS 01/01/2025 1154.39 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1283.91 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63702 MEDSV DEF RBRVS 01/01/2025 1258.84 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63704 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1493.11 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63704 MEDSV DEF RBRVS 01/01/2025 1464.4 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63706 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1654.74 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63706 MEDSV DEF RBRVS 01/01/2025 1621.81 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63707 MEDSV DEF RBRVS 01/01/2024 12/31/2024 852.4 Description: REPAIR SPINAL FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63707 MEDSV DEF RBRVS 01/01/2025 833.92 Description: REPAIR SPINAL FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63709 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1011.82 Description: REPAIR SPINAL FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63709 MEDSV DEF RBRVS 01/01/2025 990.3 Description: REPAIR SPINAL FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 985.96 Description: GRAFT REPAIR OF SPINE DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63710 MEDSV DEF RBRVS 01/01/2025 967.64 Description: GRAFT REPAIR OF SPINE DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 887.04 Description: INSTALL SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63740 MEDSV DEF RBRVS 01/01/2025 870.83 Description: INSTALL SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63741 MEDSV DEF RBRVS 01/01/2024 12/31/2024 622.24 Description: INSTALL SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 63741 MEDSV DEF RBRVS 01/01/2025 606.3 Description: INSTALL SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 63744 MEDSV DEF RBRVS 01/01/2024 12/31/2024 615.24 Description: REVISION OF SPINAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63744 MEDSV DEF RBRVS 01/01/2025 606.84 Description: REVISION OF SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63746 MEDSV DEF RBRVS 01/01/2024 12/31/2024 551.65 Description: REMOVAL OF SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63746 MEDSV DEF RBRVS 01/01/2025 543.1 Description: REMOVAL OF SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64400 ANEST DEF RBRVS 01/01/2024 12/31/2024 103.18 Description: NJX AA&/STRD TRIGEMINAL NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64400 ANEST DEF RBRVS 01/01/2025 102.16 Description: NJX AA&/STRD TRIGEMINAL NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64405 ANEST DEF RBRVS 01/01/2024 12/31/2024 68.74 Description: NJX AA&/STRD GR OCPL NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64405 ANEST DEF RBRVS 01/01/2025 67.78 Description: NJX AA&/STRD GR OCPL NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64408 ANEST DEF RBRVS 01/01/2024 12/31/2024 76.58 Description: NJX AA&/STRD VAGUS NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64408 ANEST DEF RBRVS 01/01/2025 74.31 Description: NJX AA&/STRD VAGUS NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64415 ANEST DEF RBRVS 01/01/2024 12/31/2024 127.16 Description: NJX AA&/STRD BRCH PLXS IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64415 ANEST DEF RBRVS 01/01/2025 123.34 Description: NJX AA&/STRD BRCH PLXS IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64416 ANEST DEF RBRVS 01/01/2024 12/31/2024 74.23 Description: NJX AA&/STRD BRCH PL NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64416 ANEST DEF RBRVS 01/01/2025 71.28 Description: NJX AA&/STRD BRCH PL NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64417 ANEST DEF RBRVS 01/01/2024 12/31/2024 150.05 Description: NJX AA&/STRD AX NERVE IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64417 ANEST DEF RBRVS 01/01/2025 146.7 Description: NJX AA&/STRD AX NERVE IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64418 ANEST DEF RBRVS 01/01/2024 12/31/2024 81.81 Description: NJX AA&/STRD SPRSCAP 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64418 ANEST DEF RBRVS 01/01/2025 79.28 Description: NJX AA&/STRD SPRSCAP NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64420 ANEST DEF RBRVS 01/01/2024 12/31/2024 91.62 0-3 Description: NJX AA&/STRD NTRCOST NRV 1 Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64420 ANEST DEF RBRVS 01/01/2025 90.09 0-3 Description: NJX AA&/STRD NTRCOST NRV 1 Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64421 ANEST DEF RBRVS 01/01/2024 12/31/2024 31.17 Description: NJX AA&/STRD NTRCOST NRV EA Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64421 ANEST DEF RBRVS 01/01/2025 30.75 Description: NJX AA&/STRD NTRCOST NRV EA Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64425 ANEST DEF RBRVS 01/01/2024 12/31/2024 103.72 Description: NJX AA&/STRD II IH NERVES Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64425 ANEST DEF RBRVS 01/01/2025 101.35 Description: NJX AA&/STRD II IH NERVES Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64430 ANEST DEF RBRVS 01/01/2024 12/31/2024 92.31 Description: NJX AA&/STRD PUDENDAL NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64430 ANEST DEF RBRVS 01/01/2025 89.9 Description: NJX AA&/STRD PUDENDAL NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64435 ANEST DEF RBRVS 01/01/2024 12/31/2024 75.51 Description: NJX AA&/STRD PARACRV NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64435 ANEST DEF RBRVS 01/01/2025 73.12 Description: NJX AA&/STRD PARACRV NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64445 ANEST DEF RBRVS 01/01/2024 12/31/2024 150.48 Description: NJX AA&/STRD SCIATIC NRV IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64445 ANEST DEF RBRVS 01/01/2025 145.25 Description: NJX AA&/STRD SCIATIC NRV IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64446 ANEST DEF RBRVS 01/01/2024 12/31/2024 72.54 Description: NJX AA&/STRD SC NRV NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64446 ANEST DEF RBRVS 01/01/2025 69.65 Description: NJX AA&/STRD SC NRV NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64447 ANEST DEF RBRVS 01/01/2024 12/31/2024 109.85 Description: NJX AA&/STRD FEMORAL NRV IMG Category: Anesthesia 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64447 ANEST DEF RBRVS 01/01/2025 106.91 Description: NJX AA&/STRD FEMORAL NRV IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64448 ANEST DEF RBRVS 01/01/2024 12/31/2024 68.75 Description: NJX AA&/STRD FEM NRV NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64448 ANEST DEF RBRVS 01/01/2025 66.59 Description: NJX AA&/STRD FEM NRV NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64449 ANEST DEF RBRVS 01/01/2024 12/31/2024 58.55 Description: NJX AA&/STRD LMBR PLEX NFS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 64449 ANEST DEF RBRVS 01/01/2025 58.3 Description: NJX AA&/STRD LMBR PLEX NFS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 64450 ANEST DEF RBRVS 01/01/2024 12/31/2024 70.23 Description: NJX AA&/STRD OTHER PN/BRANCH Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64450 ANEST DEF RBRVS 01/01/2025 68.86 Description: NJX AA&/STRD OTHER PN/BRANCH Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64451 MEDSV DEF RBRVS 01/01/2024 12/31/2024 213.06 Description: NJX AA&/STRD NRV NRVTG SI JT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64451 MEDSV DEF RBRVS 01/01/2025 208.38 Description: NJX AA&/STRD NRV NRVTG SI JT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64454 MEDSV DEF RBRVS 01/01/2024 12/31/2024 206.88 Y Description: NJX AA&/STRD GNCLR NRV BRNCH Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64454 MEDSV DEF RBRVS 01/01/2025 202.95 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 12/31/2024 47.06 Description: NJX AA&/STRD PLTR COM DG NRV Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 64455 ANEST DEF RBRVS 01/01/2025 46.34 Description: NJX AA&/STRD PLTR COM DG NRV Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 64461 MEDSV DEF RBRVS 01/01/2024 12/31/2024 127.49 Description: PVB THORACIC SINGLE INJ SITE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64461 MEDSV DEF RBRVS 01/01/2025 123.54 Description: PVB THORACIC SINGLE INJ SITE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64462 MEDSV DEF RBRVS 01/01/2024 12/31/2024 68.21 Description: PVB THORACIC 2ND+ INJ SITE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64462 MEDSV DEF RBRVS 01/01/2025 65.83 Description: PVB THORACIC 2ND+ INJ SITE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64463 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.39 Description: PVB THORACIC CONT INFUSION Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64463 MEDSV DEF RBRVS 01/01/2025 208.76 Description: PVB THORACIC CONT INFUSION Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64466 MEDSV DEF RBRVS 01/01/2025 113.69 Description: THRC FASCIAL PLN BLK UNI NJX Category: Medical Services CMS Add: 01/01/2025 CMS Term: 64467 MEDSV DEF RBRVS 01/01/2025 209.26 Description: THRC FASCIAL PLN BLK UNI NFS Category: Medical Services CMS Add: 01/01/2025 CMS Term: 64468 MEDSV DEF RBRVS 01/01/2025 131.19 Description: THRC FASCIAL PLN BLK BI NJX Category: Medical Services CMS Add: 01/01/2025 CMS Term: 64469 MEDSV DEF RBRVS 01/01/2025 318.48 Description: THRC FASCIAL PLN BLK BI NFS Category: Medical Services CMS Add: 01/01/2025 CMS Term: 64473 MEDSV DEF RBRVS 01/01/2025 107.23 Description: LWR XTR FSCL PLN BLK UNI NJX Category: Medical Services CMS Add: 01/01/2025 CMS Term: 64474 MEDSV DEF RBRVS 01/01/2025 206.67 Description: LWR XTR FSCL PLN BLK UNI NFS Category: Medical Services CMS Add: 01/01/2025 CMS Term: 64479 ANEST DEF RBRVS 01/01/2024 12/31/2024 248.47 0-1 Description: NJX AA&/STRD TFRM EPI C/T 1 Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64479 ANEST DEF RBRVS 01/01/2025 243.76 0-1 Description: NJX AA&/STRD TFRM EPI C/T 1 Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64480 ANEST DEF RBRVS 01/01/2024 12/31/2024 125.95 Description: NJX AA&/STRD TFRM EPI C/T EA Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64480 ANEST DEF RBRVS 01/01/2025 123.46 Description: NJX AA&/STRD TFRM EPI C/T EA Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64483 ANEST DEF RBRVS 01/01/2024 12/31/2024 230.28 0-1 Description: NJX AA&/STRD TFRM EPI L/S 1 Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64483 ANEST DEF RBRVS 01/01/2025 225.68 0-1 Description: NJX AA&/STRD TFRM EPI L/S 1 Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64484 ANEST DEF RBRVS 01/01/2024 12/31/2024 104.65 Description: NJX AA&/STRD TFRM EPI L/S EA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64484 ANEST DEF RBRVS 01/01/2025 101.96 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 12/31/2024 105.93 0-1 Description: TAP BLOCK UNIL BY INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64486 MEDSV DEF RBRVS 01/01/2025 102.5 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 12/31/2024 203.66 0-1 Description: TAP BLOCK UNI BY INFUSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64487 MEDSV DEF RBRVS 01/01/2025 194.98 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 12/31/2024 131.17 0-2 Description: TAP BLOCK BI INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64488 MEDSV DEF RBRVS 01/01/2025 126.61 0-2 Description: TAP BLOCK BI INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64489 MEDSV DEF RBRVS 01/01/2024 12/31/2024 331.39 0-2 Description: TAP BLOCK BI BY INFUSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64489 MEDSV DEF RBRVS 01/01/2025 315.22 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 12/31/2024 178.8 0-1 Description: INJ PARAVERT F JNT C/T 1 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64490 ANEST DEF RBRVS 01/01/2025 176.87 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 12/31/2024 90.94 Description: INJ PARAVERT F JNT C/T 2 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64491 ANEST DEF RBRVS 01/01/2025 89.4 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 12/31/2024 91.56 Description: INJ PARAVERT F JNT C/T 3 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64492 ANEST DEF RBRVS 01/01/2025 89.7 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 12/31/2024 164.76 0-1 Description: INJ PARAVERT F JNT L/S 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64493 ANEST DEF RBRVS 01/01/2025 162.65 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 12/31/2024 84.89 Description: INJ PARAVERT F JNT L/S 2 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64494 ANEST DEF RBRVS 01/01/2025 83.54 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 12/31/2024 84.89 Description: INJ PARAVERT F JNT L/S 3 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64495 ANEST DEF RBRVS 01/01/2025 83.54 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 12/31/2024 131.53 Description: N BLOCK SPENOPALATINE GANGL Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64505 ANEST DEF RBRVS 01/01/2025 130.11 Description: N BLOCK SPENOPALATINE GANGL Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64510 ANEST DEF RBRVS 01/01/2024 12/31/2024 136.96 Description: N BLOCK STELLATE GANGLION Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64510 ANEST DEF RBRVS 01/01/2025 134.24 Description: N BLOCK STELLATE GANGLION Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64517 ANEST DEF RBRVS 01/01/2024 12/31/2024 182.57 Description: N BLOCK INJ HYPOGAS PLXS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 64517 ANEST DEF RBRVS 01/01/2025 179.21 Description: N BLOCK INJ HYPOGAS PLXS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 64520 ANEST DEF RBRVS 01/01/2024 12/31/2024 214.38 Description: N BLOCK LUMBAR/THORACIC Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64520 ANEST DEF RBRVS 01/01/2025 210.5 Description: N BLOCK LUMBAR/THORACIC Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64530 ANEST DEF RBRVS 01/01/2024 12/31/2024 215.88 Description: N BLOCK INJ CELIAC PELUS Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64530 ANEST DEF RBRVS 01/01/2025 208.99 Description: N BLOCK INJ CELIAC PELUS Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64553 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2351.65 Y Description: IMPLANT NEUROELECTRODES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64553 MEDSV DEF RBRVS 01/01/2025 3482.73 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64555 ANEST DEF RBRVS 01/01/2024 12/31/2024 2009.3 Y Description: IMPLANT NEUROELECTRODES Category: Anesthesia CMS Add: 01/01/1982 CMS Term: 64555 ANEST DEF RBRVS 01/01/2025 1927.74 Y Description: IMPLANT NEUROELECTRODES Category: Anesthesia CMS Add: 01/01/1982 CMS Term: 64561 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.11 Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64561 MEDSV DEF RBRVS 01/01/2025 667.49 Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64566 MEDSV DEF RBRVS 01/01/2024 12/31/2024 108.99 Description: NEUROELTRD STIM POST TIBIAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64566 MEDSV DEF RBRVS 01/01/2025 106.05 Description: NEUROELTRD STIM POST TIBIAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64568 MEDSV DEF RBRVS 01/01/2024 12/31/2024 556.08 Description: OPN IMPLTJ CRNL NRV NEA&PG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64568 MEDSV DEF RBRVS 01/01/2025 545.88 Description: OPN IMPLTJ CRNL NRV NEA&PG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64569 MEDSV DEF RBRVS 01/01/2024 12/31/2024 696.9 Description: REVISE/REPL VAGUS N ELTRD Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64569 MEDSV DEF RBRVS 01/01/2025 682.58 Description: REVISE/REPL VAGUS N ELTRD Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 662.28 Description: REMOVE VAGUS N ELTRD Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64570 MEDSV DEF RBRVS 01/01/2025 651.45 Description: REMOVE VAGUS N ELTRD Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64575 MEDSV DEF RBRVS 01/01/2024 12/31/2024 285.18 Y Description: OPN IMPLTJ NEA PERPH NERVE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64575 MEDSV DEF RBRVS 01/01/2025 286.62 Y Description: OPN IMPLTJ NEA PERPH NERVE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64580 MEDSV DEF RBRVS 01/01/2024 12/31/2024 289.02 Y Description: OPN IMPLTJ NEA NEUROMUSCULAR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64580 MEDSV DEF RBRVS 01/01/2025 283.12 Y Description: OPN IMPLTJ NEA NEUROMUSCULAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64581 MEDSV DEF RBRVS 01/01/2024 12/31/2024 613.16 Description: OPN IMPLTJ NEA SACRAL NERVE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64581 MEDSV DEF RBRVS 01/01/2025 599.45 Description: OPN IMPLTJ NEA SACRAL NERVE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64582 MEDSV DEF RBRVS 01/01/2024 12/31/2024 797.41 Description: OPN MPLTJ HPGLSL NSTM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64582 MEDSV DEF RBRVS 01/01/2025 765.24 Description: OPN MPLTJ HPGLSL NSTM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64583 MEDSV DEF RBRVS 01/01/2024 12/31/2024 810.55 Description: REV/RPLCT HPGLSL NSTM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64583 MEDSV DEF RBRVS 01/01/2025 789.83 Description: REV/RPLCT HPGLSL NSTM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64584 MEDSV DEF RBRVS 01/01/2024 12/31/2024 683.6 Description: RMVL HPGLSL NSTIM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64584 MEDSV DEF RBRVS 01/01/2025 666.61 Description: RMVL HPGLSL NSTIM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64585 MEDSV DEF RBRVS 01/01/2024 12/31/2024 225.9 Description: REV/RMV PERPH NSTIM ELTRD RA Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64585 MEDSV DEF RBRVS 01/01/2025 220.88 Description: REV/RMV PERPH NSTIM ELTRD RA Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64590 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.17 Y Description: INS/RPL PRPH SAC/GSTR NPG/R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64590 MEDSV DEF RBRVS 01/01/2025 403.2 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 12/31/2024 215.92 Description: REV/RMV PRPH SAC/GSTR NPG/R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64595 MEDSV DEF RBRVS 01/01/2025 331.95 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 12/31/2024 431.16 Description: INJECTION TREATMENT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64600 MEDSV DEF RBRVS 01/01/2025 431.46 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 600.79 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64605 MEDSV DEF RBRVS 01/01/2025 805.14 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 713.89 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64610 MEDSV DEF RBRVS 01/01/2025 688.18 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64611 MEDSV DEF RBRVS 01/01/2024 12/31/2024 117.58 Description: CHEMODENERV SALIV GLANDS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64611 MEDSV DEF RBRVS 01/01/2025 117.97 Description: CHEMODENERV SALIV GLANDS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64612 ANEST DEF RBRVS 01/01/2024 12/31/2024 126.23 Description: DESTROY NERVE FACE MUSCLE Category: Anesthesia CMS Add: 01/01/1992 CMS Term: 64612 ANEST DEF RBRVS 01/01/2025 124.9 Description: DESTROY NERVE FACE MUSCLE Category: Anesthesia CMS Add: 01/01/1992 CMS Term: 64615 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138.91 0-1 Description: CHEMODENERV MUSC MIGRAINE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 64615 MEDSV DEF RBRVS 01/01/2025 135.79 0-1 Description: CHEMODENERV MUSC MIGRAINE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 64616 MEDSV DEF RBRVS 01/01/2024 12/31/2024 123.96 Description: CHEMODENERV MUSC NECK DYSTON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64616 MEDSV DEF RBRVS 01/01/2025 122.96 Description: CHEMODENERV MUSC NECK DYSTON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64617 MEDSV DEF RBRVS 01/01/2024 12/31/2024 152.7 Description: CHEMODENER MUSCLE LARYNX EMG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64617 MEDSV DEF RBRVS 01/01/2025 148.02 Description: CHEMODENER MUSCLE LARYNX EMG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64620 ANEST DEF RBRVS 01/01/2024 12/31/2024 196.02 Description: INJECTION TREATMENT OF NERVE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64620 ANEST DEF RBRVS 01/01/2025 193.32 Description: INJECTION TREATMENT OF NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64624 MEDSV DEF RBRVS 01/01/2024 12/31/2024 363.48 Description: DSTRJ NULYT AGT GNCLR NRV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64624 MEDSV DEF RBRVS 01/01/2025 355.11 Description: DSTRJ NULYT AGT GNCLR NRV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64625 MEDSV DEF RBRVS 01/01/2024 12/31/2024 442 Description: RF ABLTJ NRV NRVTG SI JT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64625 MEDSV DEF RBRVS 01/01/2025 432.48 Description: RF ABLTJ NRV NRVTG SI JT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64628 NOCOV DEF SYSMAN 01/01/2022 Y Description: TRML DSTRJ IOS BVN 1ST 2 L/S Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 64629 NOCOV DEF SYSMAN 01/01/2022 Y 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 12/31/2024 237.83 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64630 MEDSV DEF RBRVS 01/01/2025 233.4 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64632 MEDSV DEF RBRVS 01/01/2024 12/31/2024 84.97 Description: N BLOCK INJ COMMON DIGIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 64632 MEDSV DEF RBRVS 01/01/2025 84.13 Description: N BLOCK INJ COMMON DIGIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 64633 MEDSV DEF RBRVS 01/01/2024 12/31/2024 409.99 Description: DESTROY CERV/THOR FACET JNT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64633 MEDSV DEF RBRVS 01/01/2025 400.9 Description: DESTROY CERV/THOR FACET JNT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64634 MEDSV DEF RBRVS 01/01/2024 12/31/2024 240.23 Description: DESTROY C/TH FACET JNT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64634 MEDSV DEF RBRVS 01/01/2025 233.07 Description: DESTROY C/TH FACET JNT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 413.7 Description: DESTROY LUMB/SAC FACET JNT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64635 MEDSV DEF RBRVS 01/01/2025 404.22 Description: DESTROY LUMB/SAC FACET JNT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64636 MEDSV DEF RBRVS 01/01/2024 12/31/2024 225.69 Description: DESTROY L/S FACET JNT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64636 MEDSV DEF RBRVS 01/01/2025 218.76 Description: DESTROY L/S FACET JNT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64640 ANEST DEF RBRVS 01/01/2024 12/31/2024 230.69 Description: INJECTION TREATMENT OF NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64640 ANEST DEF RBRVS 01/01/2025 227.27 Description: INJECTION TREATMENT OF NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64642 MEDSV DEF RBRVS 01/01/2024 12/31/2024 138.59 Description: CHEMODENERV 1 EXTREMITY 1-4 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64642 MEDSV DEF RBRVS 01/01/2025 137.97 Description: CHEMODENERV 1 EXTREMITY 1-4 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64643 MEDSV DEF RBRVS 01/01/2024 12/31/2024 85.5 Description: CHEMODENERV 1 EXTREM 1-4 EA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64643 MEDSV DEF RBRVS 01/01/2025 84.52 Description: CHEMODENERV 1 EXTREM 1-4 EA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64644 MEDSV DEF RBRVS 01/01/2024 12/31/2024 162.43 Description: CHEMODENERV 1 EXTREM 5/> MUS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64644 MEDSV DEF RBRVS 01/01/2025 160.74 Description: CHEMODENERV 1 EXTREM 5/> MUS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64645 MEDSV DEF RBRVS 01/01/2024 12/31/2024 110.31 Description: CHEMODENERV 1 EXTREM 5/> EA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64645 MEDSV DEF RBRVS 01/01/2025 108.42 Description: CHEMODENERV 1 EXTREM 5/> EA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64646 MEDSV DEF RBRVS 01/01/2024 12/31/2024 145.75 Description: CHEMODENERV TRUNK MUSC 1-5 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64646 MEDSV DEF RBRVS 01/01/2025 144.61 Description: CHEMODENERV TRUNK MUSC 1-5 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64647 MEDSV DEF RBRVS 01/01/2024 12/31/2024 166.2 Description: CHEMODENERV TRUNK MUSC 6/> 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64647 MEDSV DEF RBRVS 01/01/2025 164.5 Description: CHEMODENERV TRUNK MUSC 6/> Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 82.46 Description: CHEMODENERV ECCRINE GLANDS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 64650 MEDSV DEF RBRVS 01/01/2025 80.68 Description: CHEMODENERV ECCRINE GLANDS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 64653 MEDSV DEF RBRVS 01/01/2024 12/31/2024 96.93 Description: CHEMODENERV ECCRINE GLANDS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 64653 MEDSV DEF RBRVS 01/01/2025 94.33 Description: CHEMODENERV ECCRINE GLANDS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 64680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 325.58 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64680 MEDSV DEF RBRVS 01/01/2025 311.94 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64681 MEDSV DEF RBRVS 01/01/2024 12/31/2024 431.19 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 64681 MEDSV DEF RBRVS 01/01/2025 413.72 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 64702 MEDSV DEF RBRVS 01/01/2024 12/31/2024 480.82 Description: REVISE FINGER/TOE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64702 MEDSV DEF RBRVS 01/01/2025 472.76 Description: REVISE FINGER/TOE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64704 MEDSV DEF RBRVS 01/01/2024 12/31/2024 305.93 Description: REVISE HAND/FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64704 MEDSV DEF RBRVS 01/01/2025 301.18 Description: REVISE HAND/FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64708 MEDSV DEF RBRVS 01/01/2024 12/31/2024 468.75 Description: REVISE ARM/LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64708 MEDSV DEF RBRVS 01/01/2025 468.55 Description: REVISE ARM/LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64712 MEDSV DEF RBRVS 01/01/2024 12/31/2024 552.23 Description: REVISION OF 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64712 MEDSV DEF RBRVS 01/01/2025 541.38 Description: REVISION OF SCIATIC NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64713 MEDSV DEF RBRVS 01/01/2024 12/31/2024 733.51 Description: REVISION OF ARM NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64713 MEDSV DEF RBRVS 01/01/2025 723.51 Description: REVISION OF ARM NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64714 MEDSV DEF RBRVS 01/01/2024 12/31/2024 702.77 Description: REVISE LOW BACK NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64714 MEDSV DEF RBRVS 01/01/2025 692.62 Description: REVISE LOW BACK NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64716 MEDSV DEF RBRVS 01/01/2024 12/31/2024 479.19 Description: REVISION OF CRANIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64716 MEDSV DEF RBRVS 01/01/2025 468.61 Description: REVISION OF CRANIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64718 MEDSV DEF RBRVS 01/01/2024 12/31/2024 562.33 Description: REVISE ULNAR NERVE AT ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64718 MEDSV DEF RBRVS 01/01/2025 553.17 Description: REVISE ULNAR NERVE AT ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64719 MEDSV DEF RBRVS 01/01/2024 12/31/2024 381.43 Description: REVISE ULNAR NERVE AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64719 MEDSV DEF RBRVS 01/01/2025 374.98 Description: REVISE ULNAR NERVE AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64721 MEDSV DEF RBRVS 01/01/2024 12/31/2024 415.57 Description: CARPAL TUNNEL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64721 MEDSV DEF RBRVS 01/01/2025 408.83 Description: CARPAL TUNNEL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64722 MEDSV DEF RBRVS 01/01/2024 12/31/2024 339.35 Description: RELIEVE PRESSURE ON NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64722 MEDSV DEF RBRVS 01/01/2025 338.29 Description: RELIEVE PRESSURE ON NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64726 MEDSV DEF RBRVS 01/01/2024 12/31/2024 256.09 Description: RELEASE FOOT/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64726 MEDSV DEF RBRVS 01/01/2025 250.63 Description: RELEASE FOOT/TOE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64727 MEDSV DEF RBRVS 01/01/2024 12/31/2024 167.38 Description: INTERNAL NERVE REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64727 MEDSV DEF RBRVS 01/01/2025 163.81 Description: INTERNAL NERVE REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64732 MEDSV DEF RBRVS 01/01/2024 12/31/2024 411.36 Description: INCISION OF BROW NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64732 MEDSV DEF RBRVS 01/01/2025 406.1 Description: INCISION OF BROW NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64734 MEDSV DEF RBRVS 01/01/2024 12/31/2024 464.63 Description: INCISION OF CHEEK NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64734 MEDSV DEF RBRVS 01/01/2025 458.27 Description: INCISION OF CHEEK NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64736 MEDSV DEF RBRVS 01/01/2024 12/31/2024 313.7 Description: INCISION OF CHIN NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64736 MEDSV DEF RBRVS 01/01/2025 307.2 Description: INCISION OF CHIN NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64738 MEDSV DEF RBRVS 01/01/2024 12/31/2024 425.41 Description: INCISION OF JAW NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64738 MEDSV DEF RBRVS 01/01/2025 414.37 Description: INCISION OF JAW NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 435.02 Description: INCISION OF TONGUE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64740 MEDSV DEF RBRVS 01/01/2025 422.89 Description: INCISION OF TONGUE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64742 MEDSV DEF RBRVS 01/01/2024 12/31/2024 465.09 Description: INCISION OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64742 MEDSV DEF RBRVS 01/01/2025 457.63 Description: INCISION OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64744 MEDSV DEF RBRVS 01/01/2024 12/31/2024 457.46 Description: INCISE NERVE BACK OF HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64744 MEDSV DEF RBRVS 01/01/2025 450.76 Description: INCISE NERVE BACK OF HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64746 MEDSV DEF RBRVS 01/01/2024 12/31/2024 393.9 Description: INCISE DIAPHRAGM NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64746 MEDSV DEF RBRVS 01/01/2025 385.44 Description: INCISE DIAPHRAGM NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64755 MEDSV DEF RBRVS 01/01/2024 12/31/2024 840.35 Description: INCISION OF STOMACH NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64755 MEDSV DEF RBRVS 01/01/2025 819.63 Description: INCISION OF STOMACH NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 477.97 Description: INCISION OF VAGUS NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64760 MEDSV DEF RBRVS 01/01/2025 467.58 Description: INCISION OF VAGUS NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64763 MEDSV DEF RBRVS 01/01/2024 12/31/2024 473.08 Description: INCISE HIP/THIGH NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64763 MEDSV DEF RBRVS 01/01/2025 462.66 Description: INCISE HIP/THIGH NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64766 MEDSV DEF RBRVS 01/01/2024 12/31/2024 583.35 Description: INCISE HIP/THIGH NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64766 MEDSV DEF RBRVS 01/01/2025 570.27 Description: INCISE HIP/THIGH NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64771 MEDSV DEF RBRVS 01/01/2024 12/31/2024 540.59 Description: SEVER CRANIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64771 MEDSV DEF RBRVS 01/01/2025 527.27 Description: SEVER CRANIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64772 MEDSV DEF RBRVS 01/01/2024 12/31/2024 521.07 Description: INCISION OF SPINAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64772 MEDSV DEF RBRVS 01/01/2025 509.39 Description: INCISION OF SPINAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64774 MEDSV DEF RBRVS 01/01/2024 12/31/2024 397.48 Description: REMOVE SKIN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64774 MEDSV DEF RBRVS 01/01/2025 390.99 Description: REMOVE SKIN NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64776 MEDSV DEF RBRVS 01/01/2024 12/31/2024 373.42 Description: REMOVE DIGIT NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64776 MEDSV DEF RBRVS 01/01/2025 372.49 Description: REMOVE DIGIT NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64778 MEDSV DEF RBRVS 01/01/2024 12/31/2024 165.39 Description: DIGIT NERVE SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64778 MEDSV DEF RBRVS 01/01/2025 160.3 Description: DIGIT NERVE SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64782 MEDSV DEF RBRVS 01/01/2024 12/31/2024 427.88 Description: REMOVE LIMB NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64782 MEDSV DEF RBRVS 01/01/2025 419.96 Description: REMOVE LIMB NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64783 MEDSV DEF RBRVS 01/01/2024 12/31/2024 197.07 Description: LIMB NERVE SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64783 MEDSV DEF RBRVS 01/01/2025 191.21 Description: LIMB NERVE SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64784 MEDSV DEF RBRVS 01/01/2024 12/31/2024 674.09 Description: REMOVE NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64784 MEDSV DEF RBRVS 01/01/2025 658.22 Description: REMOVE NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64786 MEDSV DEF RBRVS 01/01/2024 12/31/2024 917.79 Description: REMOVE SCIATIC NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64786 MEDSV DEF RBRVS 01/01/2025 894.94 Description: REMOVE SCIATIC NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64787 MEDSV DEF RBRVS 01/01/2024 12/31/2024 218.09 Description: IMPLANT NERVE END Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64787 MEDSV DEF RBRVS 01/01/2025 209.89 Description: IMPLANT NERVE END Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64788 MEDSV DEF RBRVS 01/01/2024 12/31/2024 376.15 Description: REMOVE SKIN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64788 MEDSV DEF RBRVS 01/01/2025 373.64 Description: REMOVE SKIN NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64790 MEDSV DEF RBRVS 01/01/2024 12/31/2024 776.36 Description: REMOVAL OF NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64790 MEDSV DEF RBRVS 01/01/2025 763.53 Description: REMOVAL OF NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64792 MEDSV DEF RBRVS 01/01/2024 12/31/2024 975.76 Description: REMOVAL OF NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64792 MEDSV DEF RBRVS 01/01/2025 964.35 Description: REMOVAL OF NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64795 MEDSV DEF RBRVS 01/01/2024 12/31/2024 175.69 Description: BIOPSY OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64795 MEDSV DEF RBRVS 01/01/2025 172.15 Description: BIOPSY OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64802 MEDSV DEF RBRVS 01/01/2024 12/31/2024 761.69 Description: SYMPATHECTOMY CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64802 MEDSV DEF RBRVS 01/01/2025 749.45 Description: SYMPATHECTOMY CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64804 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1068.37 Description: SYMPATHECTOMY CERVICOTHORAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64804 MEDSV DEF RBRVS 01/01/2025 1047.85 Description: SYMPATHECTOMY CERVICOTHORAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64809 MEDSV DEF RBRVS 01/01/2024 12/31/2024 975.84 Description: SYMPATHECTOMY THORACOLUMBAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64809 MEDSV DEF RBRVS 01/01/2025 957.14 Description: SYMPATHECTOMY THORACOLUMBAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64818 MEDSV DEF RBRVS 01/01/2024 12/31/2024 721.52 Description: SYMPATHECTOMY LUMBAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64818 MEDSV DEF RBRVS 01/01/2025 705.69 Description: SYMPATHECTOMY LUMBAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 713.73 Description: SYMPATHECTOMY DIGITAL ARTERY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64820 MEDSV DEF RBRVS 01/01/2025 700.13 Description: SYMPATHECTOMY DIGITAL ARTERY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 64821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 648.07 Description: SYMPATHECTOMY RADIAL ARTERY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64821 MEDSV DEF RBRVS 01/01/2025 637.59 Description: SYMPATHECTOMY RADIAL ARTERY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64822 MEDSV DEF RBRVS 01/01/2024 12/31/2024 650.2 Description: SYMPATHECTOMY ULNAR ARTERY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64822 MEDSV DEF RBRVS 01/01/2025 637.59 Description: SYMPATHECTOMY ULNAR ARTERY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64823 MEDSV DEF RBRVS 01/01/2024 12/31/2024 735.53 Description: SYMPATHECTOMY SUPFC PALMAR Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64823 MEDSV DEF RBRVS 01/01/2025 720.91 Description: SYMPATHECTOMY SUPFC PALMAR Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64831 MEDSV DEF RBRVS 01/01/2024 12/31/2024 647.24 Description: REPAIR OF DIGIT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64831 MEDSV DEF RBRVS 01/01/2025 634.43 Description: REPAIR OF DIGIT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64832 MEDSV DEF RBRVS 01/01/2024 12/31/2024 306.05 Description: REPAIR NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64832 MEDSV DEF RBRVS 01/01/2025 296.95 Description: REPAIR NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64834 MEDSV DEF RBRVS 01/01/2024 12/31/2024 684.65 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64834 MEDSV DEF RBRVS 01/01/2025 680.72 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64835 MEDSV DEF RBRVS 01/01/2024 12/31/2024 756.85 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64835 MEDSV DEF RBRVS 01/01/2025 740.87 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64836 MEDSV DEF RBRVS 01/01/2024 12/31/2024 756.85 Description: REPAIR OF HAND OR FOOT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64836 MEDSV DEF RBRVS 01/01/2025 740.87 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64837 MEDSV DEF RBRVS 01/01/2024 12/31/2024 332.1 Description: REPAIR NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64837 MEDSV DEF RBRVS 01/01/2025 322.65 Description: REPAIR NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 890.8 Description: REPAIR OF LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64840 MEDSV DEF RBRVS 01/01/2025 871.32 Description: REPAIR OF LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64856 MEDSV DEF RBRVS 01/01/2024 12/31/2024 933.7 Description: REPAIR/TRANSPOSE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64856 MEDSV DEF RBRVS 01/01/2025 908.61 Description: REPAIR/TRANSPOSE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64857 MEDSV DEF RBRVS 01/01/2024 12/31/2024 975.99 Description: REPAIR ARM/LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64857 MEDSV DEF RBRVS 01/01/2025 951.02 Description: REPAIR ARM/LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64858 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1084.74 Description: REPAIR SCIATIC NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64858 MEDSV DEF RBRVS 01/01/2025 1059.63 Description: REPAIR SCIATIC NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64859 MEDSV DEF RBRVS 01/01/2024 12/31/2024 225.93 Description: NERVE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64859 MEDSV DEF RBRVS 01/01/2025 219.25 Description: NERVE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64861 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1359.79 Description: REPAIR OF ARM NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64861 MEDSV DEF RBRVS 01/01/2025 1332.55 Description: REPAIR OF ARM NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64862 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1266.21 Description: REPAIR OF LOW BACK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64862 MEDSV DEF RBRVS 01/01/2025 1236.06 Description: REPAIR OF LOW BACK NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64864 MEDSV DEF RBRVS 01/01/2024 12/31/2024 805.16 Description: REPAIR OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64864 MEDSV DEF RBRVS 01/01/2025 781.52 Description: REPAIR OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64865 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1020.48 Description: REPAIR OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64865 MEDSV DEF RBRVS 01/01/2025 991.51 Description: REPAIR OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64866 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1156.87 Description: FUSION OF FACIAL/OTHER NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64866 MEDSV DEF RBRVS 01/01/2025 1123.53 Description: FUSION OF FACIAL/OTHER NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64868 MEDSV DEF RBRVS 01/01/2024 12/31/2024 936.03 Description: FUSION OF FACIAL/OTHER NERVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 64868 MEDSV DEF RBRVS 01/01/2025 909.69 Description: FUSION OF FACIAL/OTHER NERVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 64872 MEDSV DEF RBRVS 01/01/2024 12/31/2024 105.67 Description: SUBSEQUENT REPAIR OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64872 MEDSV DEF RBRVS 01/01/2025 102.61 Description: SUBSEQUENT REPAIR OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64874 MEDSV DEF RBRVS 01/01/2024 12/31/2024 158.02 Description: REPAIR & REVISE NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64874 MEDSV DEF RBRVS 01/01/2025 153.76 Description: REPAIR & REVISE NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64876 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.01 Description: REPAIR NERVE/SHORTEN BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64876 MEDSV DEF RBRVS 01/01/2025 174 Description: REPAIR NERVE/SHORTEN BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64885 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1007.41 Description: NERVE GRAFT HEAD/NECK <4 CM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64885 MEDSV DEF RBRVS 01/01/2025 981.81 Description: NERVE GRAFT HEAD/NECK <4 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 64886 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1207.98 Description: NERVE GRAFT HEAD/NECK >4 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 64886 MEDSV DEF RBRVS 01/01/2025 1172.58 Description: NERVE GRAFT HEAD/NECK >4 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 64890 MEDSV DEF RBRVS 01/01/2024 12/31/2024 996.88 Description: NRV GRF 1STRND HND/FOOT <4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64890 MEDSV DEF RBRVS 01/01/2025 973.67 Description: NRV GRF 1STRND HND/FOOT <4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64891 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1059.65 Description: NRV GRF 1STRND HND/FOOT >4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64891 MEDSV DEF RBRVS 01/01/2025 1035.11 Description: NRV GRF 1STRND HND/FOOT >4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64892 MEDSV DEF RBRVS 01/01/2024 12/31/2024 970.46 Description: NRV GRF 1STRND ARM/LEG <4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64892 MEDSV DEF RBRVS 01/01/2025 947.86 Description: NRV GRF 1STRND ARM/LEG <4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64893 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1034.21 Description: NRV GRF 1STRND ARM/LEG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64893 MEDSV DEF RBRVS 01/01/2025 1010.25 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 12/31/2024 1221.58 Description: NRV GRF MLTST HND/FOOT <4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64895 MEDSV DEF RBRVS 01/01/2025 1191.73 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 12/31/2024 1316.19 Description: NRV GRF MLTST HND/FOOT >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64896 MEDSV DEF RBRVS 01/01/2025 1285.37 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 12/31/2024 1167.45 Description: NRV GRF MLTST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64897 MEDSV DEF RBRVS 01/01/2025 1139.79 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 12/31/2024 1263.84 Description: NRV GRF MLTST ARM/LEG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64898 MEDSV DEF RBRVS 01/01/2025 1234.23 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 12/31/2024 541.96 Description: NERVE GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64901 MEDSV DEF RBRVS 01/01/2025 526.6 Description: NERVE GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64902 MEDSV DEF RBRVS 01/01/2024 12/31/2024 627.76 Description: NERVE GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64902 MEDSV DEF RBRVS 01/01/2025 609.46 Description: NERVE GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 931.91 Description: NERVE PEDICLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64905 MEDSV DEF RBRVS 01/01/2025 905.26 Description: NERVE PEDICLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64907 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1198.05 Description: NERVE PEDICLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64907 MEDSV DEF RBRVS 01/01/2025 1169.48 Description: NERVE PEDICLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64910 MEDSV DEF RBRVS 01/01/2024 12/31/2024 708.97 Description: NERVE REPAIR W/ALLOGRAFT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 64910 MEDSV DEF RBRVS 01/01/2025 694.6 Description: NERVE REPAIR W/ALLOGRAFT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 64911 MEDSV DEF RBRVS 01/01/2024 12/31/2024 946.92 Description: NEURORRAPHY W/VEIN AUTOGRAFT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 64911 MEDSV DEF RBRVS 01/01/2025 925.45 Description: NEURORRAPHY W/VEIN AUTOGRAFT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 64912 MEDSV DEF RBRVS 01/01/2024 12/31/2024 829.69 Description: NRV RPR W/NRV ALGRFT 1ST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64912 MEDSV DEF RBRVS 01/01/2025 811.38 Description: NRV RPR W/NRV ALGRFT 1ST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 64913 MEDSV DEF RBRVS 01/01/2024 12/31/2024 159.59 Y Description: NRV RPR W/NRV ALGRFT EA ADDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 64913 MEDSV DEF RBRVS 01/01/2025 154.65 Y Description: NRV RPR W/NRV ALGRFT EA ADDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 64999 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX NERVOUS SYSTEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65091 MEDSV DEF RBRVS 01/01/2024 12/31/2024 699.73 Description: REVISE EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65091 MEDSV DEF RBRVS 01/01/2025 681.66 Description: REVISE EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65093 MEDSV DEF RBRVS 01/01/2024 12/31/2024 693.82 Description: REVISE EYE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65093 MEDSV DEF RBRVS 01/01/2025 675.66 Description: REVISE EYE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 799.87 Description: REMOVAL OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65101 MEDSV DEF RBRVS 01/01/2025 780.09 Description: REMOVAL OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65103 MEDSV DEF RBRVS 01/01/2024 12/31/2024 824.35 Description: REMOVE EYE/INSERT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65103 MEDSV DEF RBRVS 01/01/2025 805.51 Description: REMOVE EYE/INSERT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 898.4 Description: REMOVE EYE/ATTACH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65105 MEDSV DEF RBRVS 01/01/2025 876.43 Description: REMOVE EYE/ATTACH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1240.39 Description: REMOVAL OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65110 MEDSV DEF RBRVS 01/01/2025 1211.08 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65112 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1420.33 Description: REMOVE EYE/REVISE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65112 MEDSV DEF RBRVS 01/01/2025 1387.66 Description: REMOVE EYE/REVISE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65114 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1483.12 Description: REMOVE EYE/REVISE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65114 MEDSV DEF RBRVS 01/01/2025 1448.3 Description: REMOVE EYE/REVISE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65125 MEDSV DEF RBRVS 01/01/2024 12/31/2024 425.4 Description: REVISE OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 65125 MEDSV DEF RBRVS 01/01/2025 415.66 Description: REVISE OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 65130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 802.7 Description: INSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65130 MEDSV DEF RBRVS 01/01/2025 782.97 Description: INSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 812.36 Description: INSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65135 MEDSV DEF RBRVS 01/01/2025 792.65 Description: INSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 872.72 Description: ATTACH OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65140 MEDSV DEF RBRVS 01/01/2025 851.65 Description: ATTACH OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 660.61 Description: REVISE OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65150 MEDSV DEF RBRVS 01/01/2025 642.96 Description: REVISE OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 908.03 Description: REINSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65155 MEDSV DEF RBRVS 01/01/2025 885.78 Description: REINSERT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65175 MEDSV DEF RBRVS 01/01/2024 12/31/2024 733.67 Description: REMOVAL OF OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65175 MEDSV DEF RBRVS 01/01/2025 714.78 Description: REMOVAL OF OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 27.44 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65205 MEDSV DEF RBRVS 01/01/2025 26.48 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 36.44 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65210 MEDSV DEF RBRVS 01/01/2025 35.55 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 56.23 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65220 MEDSV DEF RBRVS 01/01/2025 55.47 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65222 MEDSV DEF RBRVS 01/01/2024 12/31/2024 63.68 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65222 MEDSV DEF RBRVS 01/01/2025 62.72 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65235 MEDSV DEF RBRVS 01/01/2024 12/31/2024 682.87 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65235 MEDSV DEF RBRVS 01/01/2025 671.16 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65260 MEDSV DEF RBRVS 01/01/2024 12/31/2024 917.36 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65260 MEDSV DEF RBRVS 01/01/2025 898.51 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65265 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1032.63 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65265 MEDSV DEF RBRVS 01/01/2025 1011.46 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65270 MEDSV DEF RBRVS 01/01/2024 12/31/2024 266.7 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65270 MEDSV DEF RBRVS 01/01/2025 259.45 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65272 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.06 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65272 MEDSV DEF RBRVS 01/01/2025 483.05 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65273 MEDSV DEF RBRVS 01/01/2024 12/31/2024 354.79 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65273 MEDSV DEF RBRVS 01/01/2025 347.7 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65275 MEDSV DEF RBRVS 01/01/2024 12/31/2024 551.36 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65275 MEDSV DEF RBRVS 01/01/2025 540.4 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65280 MEDSV DEF RBRVS 01/01/2024 12/31/2024 626.04 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65280 MEDSV DEF RBRVS 01/01/2025 613.72 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65285 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1031.75 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65285 MEDSV DEF RBRVS 01/01/2025 1011.41 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65286 MEDSV DEF RBRVS 01/01/2024 12/31/2024 652.73 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1989 CMS Term: 65286 MEDSV DEF RBRVS 01/01/2025 638.05 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1989 CMS Term: 65290 MEDSV DEF RBRVS 01/01/2024 12/31/2024 457.47 Description: REPAIR OF EYE SOCKET WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65290 MEDSV DEF RBRVS 01/01/2025 448.65 Description: REPAIR OF EYE SOCKET 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 647.53 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65400 MEDSV DEF RBRVS 01/01/2025 635.65 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65410 MEDSV DEF RBRVS 01/01/2024 12/31/2024 133.39 Description: BIOPSY OF CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65410 MEDSV DEF RBRVS 01/01/2025 131.25 Description: BIOPSY OF CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 503.61 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65420 MEDSV DEF RBRVS 01/01/2025 492.94 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65426 MEDSV DEF RBRVS 01/01/2024 12/31/2024 626.39 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65426 MEDSV DEF RBRVS 01/01/2025 612.53 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 107.77 Description: CORNEAL SMEAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65430 MEDSV DEF RBRVS 01/01/2025 105.73 Description: CORNEAL SMEAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65435 MEDSV DEF RBRVS 01/01/2024 12/31/2024 77.07 Description: CURETTE/TREAT CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65435 MEDSV DEF RBRVS 01/01/2025 75.62 Description: CURETTE/TREAT CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65436 MEDSV DEF RBRVS 01/01/2024 12/31/2024 362.24 Description: CURETTE/TREAT CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65436 MEDSV DEF RBRVS 01/01/2025 356.17 Description: CURETTE/TREAT CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 306.69 Description: TREATMENT OF CORNEAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 65450 MEDSV DEF RBRVS 01/01/2025 303.12 Description: TREATMENT OF CORNEAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 409.25 Description: REVISION OF CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65600 MEDSV DEF RBRVS 01/01/2025 401.04 Description: REVISION OF CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1066 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65710 MEDSV DEF RBRVS 01/01/2025 1042.82 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1169.84 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65730 MEDSV DEF RBRVS 01/01/2025 1146.21 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1178.31 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65750 MEDSV DEF RBRVS 01/01/2025 1153.53 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65755 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1173.96 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 65755 MEDSV DEF RBRVS 01/01/2025 1149.79 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 65756 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1100.8 Description: CORNEAL TRNSPL ENDOTHELIAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 65756 MEDSV DEF RBRVS 01/01/2025 1081.08 Description: CORNEAL TRNSPL ENDOTHELIAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 65757 MEDSV DEF MAXFEE 01/01/2024 93.13 0 Description: PREP CORNEAL ENDO ALLOGRAFT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 65760 NOCOV DEF SYSMAN 12/01/1993 Y Description: KERATOMILEUSIS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 65765 NOCOV DEF SYSMAN 12/01/1993 Y Description: KERATOPHAKIA Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 65767 NOCOV DEF SYSMAN 12/01/1993 Y Description: EPIKERATOPLASTY Category: Non Covered 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1314.23 Description: KERATOPROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65770 MEDSV DEF RBRVS 01/01/2025 1287.77 Description: KERATOPROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65771 NOCOV DEF SYSMAN 07/11/2002 Y Description: RADIAL KERATOTOMY Category: Non Covered Services CMS Add: 01/01/1991 CMS Term: 65772 MEDSV DEF RBRVS 01/01/2024 12/31/2024 426.5 Description: CORRECTION OF ASTIGMATISM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 65772 MEDSV DEF RBRVS 01/01/2025 418.77 Description: CORRECTION OF ASTIGMATISM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 65775 MEDSV DEF RBRVS 01/01/2024 12/31/2024 535.97 Description: CORRECTION OF ASTIGMATISM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 65775 MEDSV DEF RBRVS 01/01/2025 526.17 Description: CORRECTION OF ASTIGMATISM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 65778 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1228.32 0 Description: COVER EYE W/MEMBRANE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 65778 MEDSV DEF RBRVS 01/01/2025 986.98 Description: COVER EYE W/MEMBRANE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 65779 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 1059.6 0 Description: COVER EYE W/MEMBRANE SUTURE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 65779 MEDSV DEF RBRVS 01/01/2025 1049.16 Description: COVER EYE W/MEMBRANE SUTURE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 65780 MEDSV DEF RBRVS 01/01/2024 12/31/2024 623.31 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65780 MEDSV DEF RBRVS 01/01/2025 541.88 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65781 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1236.76 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65781 MEDSV DEF RBRVS 01/01/2025 1213.25 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65782 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1067.61 Y Description: OCULAR RECONST TRANSPLANT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65782 MEDSV DEF RBRVS 01/01/2025 1047.81 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65785 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2005.72 Y 0-20Years Description: IMPLTJ NTRSTRML CRNL RNG SEG Category: Medical Services CMS Add: 01/01/2016 CMS Term: 65785 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2005.72 Y 21-999Years Description: IMPLTJ NTRSTRML CRNL RNG SEG Category: Medical Services CMS Add: 01/01/2016 CMS Term: 65785 MEDSV DEF RBRVS 01/01/2025 1926.34 Y 0-20Years Description: IMPLTJ NTRSTRML CRNL RNG SEG Category: Medical Services CMS Add: 01/01/2016 CMS Term: 65785 MEDSV DEF RBRVS 01/01/2025 1926.34 Y 21-999Years Description: IMPLTJ NTRSTRML CRNL RNG SEG Category: Medical Services CMS Add: 01/01/2016 CMS Term: 65800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 112.13 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65800 MEDSV DEF RBRVS 01/01/2025 109.67 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 432.44 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65810 MEDSV DEF RBRVS 01/01/2025 425.65 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65815 MEDSV DEF RBRVS 01/01/2024 12/31/2024 600.62 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65815 MEDSV DEF RBRVS 01/01/2025 587.49 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 770.54 Description: GONIOTOMY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65820 MEDSV DEF RBRVS 01/01/2025 753.61 Description: GONIOTOMY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 788.19 Description: TRABECULOTOMY AB EXTERNO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65850 MEDSV DEF RBRVS 01/01/2025 772.17 Description: TRABECULOTOMY AB EXTERNO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65855 MEDSV DEF RBRVS 01/01/2024 12/31/2024 229.77 Description: TRABECULOPLASTY LASER SURG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65855 MEDSV DEF RBRVS 01/01/2025 224.92 Description: TRABECULOPLASTY LASER SURG Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65860 MEDSV DEF RBRVS 01/01/2024 12/31/2024 287.46 Description: SEVERING ADS ANT SGM LASER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 65860 MEDSV DEF RBRVS 01/01/2025 282.16 Description: SEVERING ADS ANT SGM LASER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 65865 MEDSV DEF RBRVS 01/01/2024 12/31/2024 446.49 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65865 MEDSV DEF RBRVS 01/01/2025 438.51 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65870 MEDSV DEF RBRVS 01/01/2024 12/31/2024 555.19 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65870 MEDSV DEF RBRVS 01/01/2025 544.78 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65875 MEDSV DEF RBRVS 01/01/2024 12/31/2024 592.13 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65875 MEDSV DEF RBRVS 01/01/2025 581.51 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 622.23 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65880 MEDSV DEF RBRVS 01/01/2025 610.88 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 926.53 Description: REMOVE EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65900 MEDSV DEF RBRVS 01/01/2025 907.19 Description: REMOVE EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 738.98 Description: REMOVE IMPLANT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65920 MEDSV DEF RBRVS 01/01/2025 725.33 Description: REMOVE IMPLANT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 600.09 Description: REMOVE BLOOD CLOT 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65930 MEDSV DEF RBRVS 01/01/2025 588.31 Description: REMOVE BLOOD CLOT FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 184.39 Description: INJECTION TREATMENT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66020 MEDSV DEF RBRVS 01/01/2025 180.45 Description: INJECTION TREATMENT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 165.75 Description: INJECTION TREATMENT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66030 MEDSV DEF RBRVS 01/01/2025 162.5 Description: INJECTION TREATMENT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 661.03 Description: REMOVE EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66130 MEDSV DEF RBRVS 01/01/2025 645.87 Description: REMOVE EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 817.96 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66150 MEDSV DEF RBRVS 01/01/2025 804.03 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 817.31 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66155 MEDSV DEF RBRVS 01/01/2025 803.7 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66160 MEDSV DEF RBRVS 01/01/2024 12/31/2024 919.83 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66160 MEDSV DEF RBRVS 01/01/2025 903.4 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66170 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1019.51 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66170 MEDSV DEF RBRVS 01/01/2025 1002.11 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66172 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1112.57 Description: INCISION OF EYE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66172 MEDSV DEF RBRVS 01/01/2025 1093.98 Description: INCISION OF EYE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 66174 NOCOV DEF SYSMAN 01/01/2011 Y 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 01/01/2011 Y 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 12/31/2024 1007.34 Description: AQUEOUS SHUNT EYE W/O GRAFT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 66179 MEDSV DEF RBRVS 01/01/2025 989.74 Description: AQUEOUS SHUNT EYE W/O GRAFT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 66180 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1062.27 Description: AQUEOUS SHUNT EYE W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66180 MEDSV DEF RBRVS 01/01/2025 1042.92 Description: AQUEOUS SHUNT EYE W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66183 MEDSV DEF RBRVS 01/01/2024 12/31/2024 959.67 Description: INSERT ANT DRAINAGE DEVICE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 66183 MEDSV DEF RBRVS 01/01/2025 943.11 Description: INSERT ANT DRAINAGE DEVICE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 66184 MEDSV DEF RBRVS 01/01/2024 12/31/2024 738.02 Description: REVISION OF AQUEOUS SHUNT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 66184 MEDSV DEF RBRVS 01/01/2025 725.62 Description: REVISION OF AQUEOUS SHUNT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 66185 MEDSV DEF RBRVS 01/01/2024 12/31/2024 793.12 Description: REVISE AQUEOUS SHUNT EYE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66185 MEDSV DEF RBRVS 01/01/2025 779.26 Description: REVISE AQUEOUS SHUNT EYE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 873.18 Description: REPAIR/GRAFT EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66225 MEDSV DEF RBRVS 01/01/2025 856.79 Description: REPAIR/GRAFT EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66250 MEDSV DEF RBRVS 01/01/2024 12/31/2024 703.26 Description: FOLLOW-UP SURGERY OF EYE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66250 MEDSV DEF RBRVS 01/01/2025 687.29 Description: FOLLOW-UP SURGERY OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 66500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 369.39 Description: INCISION OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66500 MEDSV DEF RBRVS 01/01/2025 361.43 Description: INCISION OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 401.14 Description: INCISION OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66505 MEDSV DEF RBRVS 01/01/2025 393.09 Description: INCISION OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66600 MEDSV DEF RBRVS 01/01/2024 12/31/2024 847.89 Description: REMOVE IRIS AND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66600 MEDSV DEF RBRVS 01/01/2025 828.47 Description: REMOVE IRIS AND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66605 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1018.84 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66605 MEDSV DEF RBRVS 01/01/2025 996.8 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66625 MEDSV DEF RBRVS 01/01/2024 12/31/2024 399.83 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66625 MEDSV DEF RBRVS 01/01/2025 393.2 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66630 MEDSV DEF RBRVS 01/01/2024 12/31/2024 528.45 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66630 MEDSV DEF RBRVS 01/01/2025 519.75 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 533.21 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66635 MEDSV DEF RBRVS 01/01/2025 524.5 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66680 MEDSV DEF RBRVS 01/01/2024 12/31/2024 486.52 Description: REPAIR IRIS & 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66680 MEDSV DEF RBRVS 01/01/2025 477.86 Description: REPAIR IRIS & CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66682 MEDSV DEF RBRVS 01/01/2024 12/31/2024 667.38 Description: REPAIR IRIS & CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66682 MEDSV DEF RBRVS 01/01/2025 651.8 Description: REPAIR IRIS & CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66683 NOCOV DEF SYSMAN 01/01/2025 Y Description: IMPLANTATION IRIS PROSTHESIS Category: Non Covered Services CMS Add: 01/01/2025 CMS Term: 66700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 422.64 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66700 MEDSV DEF RBRVS 01/01/2025 415.57 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 413.68 Description: CILIARY TRANSSLERAL THERAPY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 66710 MEDSV DEF RBRVS 01/01/2025 406.22 Description: CILIARY TRANSSLERAL THERAPY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 66711 MEDSV DEF RBRVS 01/01/2024 12/31/2024 470.89 Description: ECP CILIARY BODY DESTRUCTION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 66711 MEDSV DEF RBRVS 01/01/2025 464.07 Description: ECP CILIARY BODY DESTRUCTION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 66720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 435.65 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66720 MEDSV DEF RBRVS 01/01/2025 429.66 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66740 MEDSV DEF RBRVS 01/01/2024 12/31/2024 410.91 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66740 MEDSV DEF RBRVS 01/01/2025 403.8 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66761 MEDSV DEF RBRVS 01/01/2024 12/31/2024 279.48 Description: REVISION OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66761 MEDSV DEF RBRVS 01/01/2025 273.83 Description: REVISION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66762 MEDSV DEF RBRVS 01/01/2024 12/31/2024 446.07 Description: REVISION OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66762 MEDSV DEF RBRVS 01/01/2025 438.08 Description: REVISION OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 494.52 Description: REMOVAL OF INNER EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66770 MEDSV DEF RBRVS 01/01/2025 486.24 Description: REMOVAL OF INNER EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 439.86 Description: INCISION SECONDARY CATARACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66820 MEDSV DEF RBRVS 01/01/2025 428.77 Description: INCISION SECONDARY CATARACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66821 MEDSV DEF RBRVS 01/01/2024 12/31/2024 311.94 Description: AFTER CATARACT LASER SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 66821 MEDSV DEF RBRVS 01/01/2025 306.46 Description: AFTER CATARACT LASER SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 66825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 779.81 Description: REPOSITION INTRAOCULAR LENS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 66825 MEDSV DEF RBRVS 01/01/2025 762.17 Description: REPOSITION INTRAOCULAR LENS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 66830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 660.97 Description: REMOVAL OF LENS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66830 MEDSV DEF RBRVS 01/01/2025 650.01 Description: REMOVAL OF LENS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 646.04 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66840 MEDSV DEF RBRVS 01/01/2025 634.46 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 734.98 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66850 MEDSV DEF RBRVS 01/01/2025 721.66 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66852 MEDSV DEF RBRVS 01/01/2024 12/31/2024 782.08 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66852 MEDSV DEF RBRVS 01/01/2025 767.7 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66920 MEDSV DEF RBRVS 01/01/2024 12/31/2024 698.5 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66920 MEDSV DEF RBRVS 01/01/2025 685.39 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 799.51 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66930 MEDSV DEF RBRVS 01/01/2025 784.53 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66940 MEDSV DEF RBRVS 01/01/2024 12/31/2024 731.19 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66940 MEDSV DEF RBRVS 01/01/2025 718.33 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66982 MEDSV DEF RBRVS 01/01/2024 12/31/2024 695.31 Description: XCAPSL CTRC RMVL CPLX WO ECP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 66982 MEDSV DEF RBRVS 01/01/2025 682.38 Description: XCAPSL CTRC RMVL CPLX WO ECP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 66983 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 700.49 0 Description: CATARACT SURG W/IOL 1 STAGE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66983 MEDSV DEF MAXFEE 01/01/2025 686.48 0 Description: CATARACT SURG W/IOL 1 STAGE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66984 MEDSV DEF RBRVS 01/01/2024 12/31/2024 507.67 Description: XCAPSL CTRC RMVL W/O ECP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66984 MEDSV DEF RBRVS 01/01/2025 498.17 Description: XCAPSL CTRC RMVL W/O ECP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66985 MEDSV DEF RBRVS 01/01/2024 12/31/2024 717.02 Description: INSERT LENS PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66985 MEDSV DEF RBRVS 01/01/2025 704.32 Description: INSERT LENS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66986 MEDSV DEF RBRVS 01/01/2024 12/31/2024 842.09 Description: EXCHANGE LENS PROSTHESIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 66986 MEDSV DEF RBRVS 01/01/2025 825.77 Description: EXCHANGE LENS PROSTHESIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 66987 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 748.57 0 Description: XCAPSL CTRC RMVL CPLX W/ECP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 66987 MEDSV DEF MAXFEE 01/01/2025 727.01 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 12/31/2024 610.48 0 Description: XCAPSL CTRC RMVL W/ECP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 66988 MEDSV DEF MAXFEE 01/01/2025 593.05 0 Description: XCAPSL CTRC RMVL W/ECP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 66989 MEDSV DEF RBRVS 01/01/2024 12/31/2024 798.01 Description: XCPSL CTRC RMVL CPLX INSJ 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 66989 MEDSV DEF RBRVS 01/01/2025 783.31 Description: XCPSL CTRC RMVL CPLX INSJ 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 66990 MEDSV DEF RBRVS 01/01/2024 12/31/2024 82.43 Description: OPHTHALMIC ENDOSCOPE ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 66990 MEDSV DEF RBRVS 01/01/2025 80.63 Description: OPHTHALMIC ENDOSCOPE ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 66991 MEDSV DEF RBRVS 01/01/2024 12/31/2024 637.22 Description: XCAPSL CTRC RMVL INSJ 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 66991 MEDSV DEF RBRVS 01/01/2025 625.81 Description: XCAPSL CTRC RMVL INSJ 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 66999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX ANT SEGMENT EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 443.46 Description: PARTIAL REMOVAL OF EYE FLUID Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67005 MEDSV DEF RBRVS 01/01/2025 437.61 Description: PARTIAL REMOVAL OF EYE FLUID Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67010 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67010 MEDSV DEF RBRVS 01/01/2025 500.45 Description: PARTIAL REMOVAL OF EYE FLUID Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67015 MEDSV DEF RBRVS 01/01/2024 12/31/2024 565.08 Description: RELEASE OF EYE FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67015 MEDSV DEF RBRVS 01/01/2025 553.79 Description: RELEASE OF EYE FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67025 MEDSV DEF RBRVS 01/01/2024 12/31/2024 692.94 Description: REPLACE EYE FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67025 MEDSV DEF RBRVS 01/01/2025 678.3 Description: REPLACE EYE FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67027 MEDSV DEF RBRVS 01/01/2024 12/31/2024 790.13 Description: IMPLANT EYE DRUG SYSTEM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 67027 MEDSV DEF RBRVS 01/01/2025 775.19 Description: IMPLANT EYE DRUG SYSTEM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 67028 MEDSV DEF RBRVS 01/01/2024 12/31/2024 106.14 Description: INJECTION EYE DRUG Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67028 MEDSV DEF RBRVS 01/01/2025 103.84 Description: INJECTION EYE DRUG Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67030 MEDSV DEF RBRVS 01/01/2024 12/31/2024 520.39 Description: INCISE INNER EYE STRANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67030 MEDSV DEF RBRVS 01/01/2025 510.94 Description: INCISE INNER EYE STRANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67031 MEDSV DEF RBRVS 01/01/2024 12/31/2024 363.33 Description: LASER SURGERY EYE STRANDS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67031 MEDSV DEF RBRVS 01/01/2025 356.15 Description: LASER SURGERY EYE STRANDS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67036 MEDSV DEF RBRVS 01/01/2024 12/31/2024 835.05 Description: REMOVAL OF INNER EYE FLUID Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67036 MEDSV DEF RBRVS 01/01/2025 820 Description: REMOVAL OF INNER EYE FLUID Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67039 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67039 MEDSV DEF RBRVS 01/01/2025 877.3 Description: LASER TREATMENT OF RETINA Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 965.36 Description: LASER TREATMENT OF RETINA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 67040 MEDSV DEF RBRVS 01/01/2025 946.67 Description: LASER TREATMENT OF RETINA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 67041 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1065.75 Description: VIT FOR MACULAR PUCKER Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67041 MEDSV DEF RBRVS 01/01/2025 1044.12 Description: VIT FOR MACULAR PUCKER Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67042 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1065.44 Description: VIT FOR MACULAR HOLE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67042 MEDSV DEF RBRVS 01/01/2025 1044.12 Description: VIT FOR MACULAR HOLE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67043 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1123.66 Description: VIT FOR MEMBRANE DISSECT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67043 MEDSV DEF RBRVS 01/01/2025 1101.26 Description: VIT FOR MEMBRANE DISSECT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67101 MEDSV DEF RBRVS 01/01/2024 12/31/2024 312.19 Description: REPAIR DETACHED RETINA CRTX Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67101 MEDSV DEF RBRVS 01/01/2025 306.98 Description: REPAIR DETACHED RETINA CRTX Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 276.51 Description: REPAIR DETACHED RETINA PC Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67105 MEDSV DEF RBRVS 01/01/2025 271.82 Description: REPAIR DETACHED RETINA PC Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67107 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1047.28 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67107 MEDSV DEF RBRVS 01/01/2025 1026.5 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67108 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67108 MEDSV DEF RBRVS 01/01/2025 1086.67 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 831.46 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67110 MEDSV DEF RBRVS 01/01/2025 815.07 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67113 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1239.41 Description: REPAIR RETINAL DETACH CPLX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67113 MEDSV DEF RBRVS 01/01/2025 1214.44 Description: REPAIR RETINAL DETACH CPLX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 464.51 Description: RELEASE ENCIRCLING MATERIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67115 MEDSV DEF RBRVS 01/01/2025 457.2 Description: RELEASE ENCIRCLING MATERIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 626.7 Description: REMOVE EYE IMPLANT MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67120 MEDSV DEF RBRVS 01/01/2025 613.76 Description: REMOVE EYE IMPLANT MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67121 MEDSV DEF RBRVS 01/01/2024 12/31/2024 841.75 Description: REMOVE EYE IMPLANT MATERIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67121 MEDSV DEF RBRVS 01/01/2025 826.5 Description: REMOVE EYE IMPLANT MATERIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67141 MEDSV DEF RBRVS 01/01/2024 12/31/2024 251.18 Description: PROPH RTA DTCHMNT CRTX DTHRM Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67141 MEDSV DEF RBRVS 01/01/2025 246.93 Description: PROPH RTA DTCHMNT CRTX DTHRM Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 226.48 Description: PROPH RTA DTCHMNT PC Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67145 MEDSV DEF RBRVS 01/01/2025 222.78 Description: PROPH RTA DTCHMNT PC Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67208 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67208 MEDSV DEF RBRVS 01/01/2025 552.1 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 481.35 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67210 MEDSV DEF RBRVS 01/01/2025 472.21 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67218 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1300.68 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67218 MEDSV DEF RBRVS 01/01/2025 1271.13 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67220 MEDSV DEF RBRVS 01/01/2024 12/31/2024 495.08 Description: TREATMENT OF CHOROID LESION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 67220 MEDSV DEF RBRVS 01/01/2025 485.93 Description: TREATMENT OF CHOROID LESION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 67221 MEDSV DEF RBRVS 01/01/2024 12/31/2024 255.08 Description: OCULAR PHOTODYNAMIC THER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 67221 MEDSV DEF RBRVS 01/01/2025 249.03 Description: OCULAR PHOTODYNAMIC THER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 67225 MEDSV DEF RBRVS 01/01/2024 12/31/2024 27.38 Description: EYE PHOTODYNAMIC THER ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 67225 MEDSV DEF RBRVS 01/01/2025 26.59 Description: EYE PHOTODYNAMIC THER ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 67227 MEDSV DEF RBRVS 01/01/2024 12/31/2024 275.76 Description: DSTRJ EXTENSIVE RETINOPATHY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67227 MEDSV DEF RBRVS 01/01/2025 270.75 Description: DSTRJ EXTENSIVE RETINOPATHY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67228 MEDSV DEF RBRVS 01/01/2024 12/31/2024 317.4 Description: TREATMENT X10SV RETINOPATHY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67228 MEDSV DEF RBRVS 01/01/2025 311.43 Description: TREATMENT X10SV RETINOPATHY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67229 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67229 MEDSV DEF RBRVS 01/01/2025 1058.23 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 12/31/2024 850.03 Description: REINFORCE EYE WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67250 MEDSV DEF RBRVS 01/01/2025 828.34 Description: REINFORCE EYE WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67255 MEDSV DEF RBRVS 01/01/2024 12/31/2024 641.74 Description: REINFORCE/GRAFT EYE WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67255 MEDSV DEF RBRVS 01/01/2025 631.16 Description: REINFORCE/GRAFT EYE WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67299 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX POSTERIOR SEGMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67311 MEDSV DEF RBRVS 01/01/2024 12/31/2024 424.75 Description: REVISE EYE MUSCLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67311 MEDSV DEF RBRVS 01/01/2025 417.64 Description: REVISE EYE MUSCLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67312 MEDSV DEF RBRVS 01/01/2024 12/31/2024 620.47 Description: REVISE TWO EYE MUSCLES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67312 MEDSV DEF RBRVS 01/01/2025 608.72 Description: REVISE TWO EYE MUSCLES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67314 MEDSV DEF RBRVS 01/01/2024 12/31/2024 424.75 Description: REVISE EYE MUSCLE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67314 MEDSV DEF RBRVS 01/01/2025 417.64 Description: REVISE EYE MUSCLE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67316 MEDSV DEF RBRVS 01/01/2024 12/31/2024 665.56 Description: REVISE TWO EYE MUSCLES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67316 MEDSV DEF RBRVS 01/01/2025 652.8 Description: REVISE TWO EYE MUSCLES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67318 MEDSV DEF RBRVS 01/01/2024 12/31/2024 642.07 Description: REVISE EYE MUSCLE(S) Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67318 MEDSV DEF RBRVS 01/01/2025 631.24 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 190.26 Description: REVISE EYE MUSCLE(S) ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67320 MEDSV DEF RBRVS 01/01/2025 159.71 Description: REVISE EYE MUSCLE(S) ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67331 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.18 Description: EYE SURGERY FOLLOW-UP ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67331 MEDSV DEF RBRVS 01/01/2025 142 Description: EYE SURGERY FOLLOW-UP ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67332 MEDSV DEF RBRVS 01/01/2024 12/31/2024 196.73 Description: REREVISE EYE MUSCLES ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67332 MEDSV DEF RBRVS 01/01/2025 185.91 Description: REREVISE EYE MUSCLES ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67334 MEDSV DEF RBRVS 01/01/2024 12/31/2024 176.89 Description: REVISE EYE MUSCLE W/SUTURE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67334 MEDSV DEF RBRVS 01/01/2025 140.04 Description: REVISE EYE MUSCLE W/SUTURE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 175.84 Description: EYE SUTURE DURING SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 67335 MEDSV DEF RBRVS 01/01/2025 170.86 Description: EYE SUTURE DURING SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 67340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 273.25 Description: REVISE EYE MUSCLE ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67340 MEDSV DEF RBRVS 01/01/2025 266.82 Description: REVISE EYE MUSCLE ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67343 MEDSV DEF RBRVS 01/01/2024 12/31/2024 625.37 Description: RELEASE EYE TISSUE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67343 MEDSV DEF RBRVS 01/01/2025 616.63 Description: RELEASE EYE TISSUE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67345 MEDSV DEF RBRVS 01/01/2024 12/31/2024 224.53 Description: DESTROY NERVE OF EYE MUSCLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 67345 MEDSV DEF RBRVS 01/01/2025 220.57 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67346 MEDSV DEF RBRVS 01/01/2024 12/31/2024 178.9 Description: BIOPSY EYE MUSCLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 67346 MEDSV DEF RBRVS 01/01/2025 176.12 Description: BIOPSY EYE MUSCLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 67399 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX EXTRAOCULAR MUSC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 973.93 Description: EXPLORE/BIOPSY EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67400 MEDSV DEF RBRVS 01/01/2025 949.67 Description: EXPLORE/BIOPSY EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67405 MEDSV DEF RBRVS 01/01/2024 12/31/2024 848.54 Description: EXPLORE/DRAIN EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67405 MEDSV DEF RBRVS 01/01/2025 829.7 Description: EXPLORE/DRAIN EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67412 MEDSV DEF RBRVS 01/01/2024 12/31/2024 931.36 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67412 MEDSV DEF RBRVS 01/01/2025 905.21 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67413 MEDSV DEF RBRVS 01/01/2024 12/31/2024 906.69 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67413 MEDSV DEF RBRVS 01/01/2025 882.55 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67414 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1364.6 Description: EXPLR/DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67414 MEDSV DEF RBRVS 01/01/2025 1328.14 Description: EXPLR/DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67415 MEDSV DEF RBRVS 01/01/2024 12/31/2024 96.16 Description: ASPIRATION ORBITAL CONTENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67415 MEDSV DEF RBRVS 01/01/2025 93.97 Description: ASPIRATION ORBITAL CONTENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67420 MEDSV DEF RBRVS 01/01/2025 1586.94 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67430 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1301.65 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67430 MEDSV DEF RBRVS 01/01/2025 1269.8 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1262.91 Description: EXPLORE/DRAIN EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67440 MEDSV DEF RBRVS 01/01/2025 1231.64 Description: EXPLORE/DRAIN EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67445 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1435.69 Description: EXPLR/DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67445 MEDSV DEF RBRVS 01/01/2025 1398.59 Description: EXPLR/DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1308.35 Description: EXPLORE/BIOPSY EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67450 MEDSV DEF RBRVS 01/01/2025 1276 Description: EXPLORE/BIOPSY EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 72.16 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67500 MEDSV DEF RBRVS 01/01/2025 71.32 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 81.11 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67505 MEDSV DEF RBRVS 01/01/2025 79.01 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67515 MEDSV DEF RBRVS 01/01/2024 12/31/2024 48.61 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67515 MEDSV DEF RBRVS 01/01/2025 47.25 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67516 MEDSV DEF RBRVS 01/01/2024 12/31/2024 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67516 MEDSV DEF RBRVS 01/01/2025 110.27 Description: SPRCHOROIDAL SPC NJX RX AGT Category: Medical Services CMS Add: 01/01/2024 CMS Term: 67550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1019.54 Description: INSERT EYE SOCKET IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67550 MEDSV DEF RBRVS 01/01/2025 993.13 Description: INSERT EYE SOCKET IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67560 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1040.39 Description: REVISE EYE SOCKET IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67560 MEDSV DEF RBRVS 01/01/2025 1015.22 Description: REVISE EYE SOCKET IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67570 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1196.74 Description: DECOMPRESS OPTIC NERVE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67570 MEDSV DEF RBRVS 01/01/2025 1166.04 Description: DECOMPRESS OPTIC NERVE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67599 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PROCEDURE ORBIT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 265.93 Description: BLEPHAROTOMY DRG ABSC EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67700 MEDSV DEF RBRVS 01/01/2025 258.01 Description: BLEPHAROTOMY DRG ABSC EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67710 MEDSV DEF RBRVS 01/01/2024 12/31/2024 227.11 Description: SEVERING TARSORRHAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67710 MEDSV DEF RBRVS 01/01/2025 220.32 Description: SEVERING TARSORRHAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67715 MEDSV DEF RBRVS 01/01/2024 12/31/2024 246.6 Description: CANTHOTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67715 MEDSV DEF RBRVS 01/01/2025 236.44 Description: CANTHOTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67800 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.86 Description: REMOVE EYELID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67800 MEDSV DEF RBRVS 01/01/2025 118.56 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67801 MEDSV DEF RBRVS 01/01/2024 12/31/2024 153.28 Description: REMOVE EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67801 MEDSV DEF RBRVS 01/01/2025 150.06 Description: REMOVE EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 190.34 Description: REMOVE EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67805 MEDSV DEF RBRVS 01/01/2025 187.38 Description: REMOVE EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67808 MEDSV DEF RBRVS 01/01/2024 12/31/2024 342.89 Description: REMOVE EYELID LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67808 MEDSV DEF RBRVS 01/01/2025 337.2 Description: REMOVE EYELID LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 173.27 Description: INCAL BX EYELID SKN LID MRGN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67810 MEDSV DEF RBRVS 01/01/2025 167.49 Description: INCAL BX EYELID SKN LID MRGN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67820 MEDSV DEF RBRVS 01/01/2024 12/31/2024 18.27 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67820 MEDSV DEF RBRVS 01/01/2025 17.44 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67825 MEDSV DEF RBRVS 01/01/2024 12/31/2024 126.79 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67825 MEDSV DEF RBRVS 01/01/2025 123.74 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67830 MEDSV DEF RBRVS 01/01/2024 12/31/2024 252.65 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67830 MEDSV DEF RBRVS 01/01/2025 245.8 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67835 MEDSV DEF RBRVS 01/01/2024 12/31/2024 411.71 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67835 MEDSV DEF RBRVS 01/01/2025 404.36 Description: REVISE EYELASHES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 262.96 Description: REMOVE EYELID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67840 MEDSV DEF RBRVS 01/01/2025 255.6 Description: REMOVE EYELID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 203.71 Description: DSTRJ LESION LID MARGIN <1CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67850 MEDSV DEF RBRVS 01/01/2025 197.48 Description: DSTRJ LESION LID MARGIN <1CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67875 MEDSV DEF RBRVS 01/01/2024 12/31/2024 170.55 Description: CLOSURE OF EYELID BY SUTURE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67875 MEDSV DEF RBRVS 01/01/2025 165.97 Description: CLOSURE OF EYELID BY SUTURE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67880 MEDSV DEF RBRVS 01/01/2024 12/31/2024 437.52 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67880 MEDSV DEF RBRVS 01/01/2025 428.67 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67882 MEDSV DEF RBRVS 01/01/2024 12/31/2024 535.1 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67882 MEDSV DEF RBRVS 01/01/2025 524.15 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67900 MEDSV DEF RBRVS 01/01/2024 12/31/2024 608.45 Y Description: REPAIR BROW DEFECT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67900 MEDSV DEF RBRVS 01/01/2025 596.35 Y Description: REPAIR BROW DEFECT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67901 MEDSV DEF RBRVS 01/01/2024 12/31/2024 746.01 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67901 MEDSV DEF RBRVS 01/01/2025 727.39 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67902 MEDSV DEF RBRVS 01/01/2024 12/31/2024 677.33 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67902 MEDSV DEF RBRVS 01/01/2025 664.36 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67903 MEDSV DEF RBRVS 01/01/2024 12/31/2024 565.31 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67903 MEDSV DEF RBRVS 01/01/2025 553.51 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67904 MEDSV DEF RBRVS 01/01/2024 12/31/2024 693.45 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67904 MEDSV DEF RBRVS 01/01/2025 678.43 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67906 MEDSV DEF RBRVS 01/01/2024 12/31/2024 471.05 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67906 MEDSV DEF RBRVS 01/01/2025 462.22 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67908 MEDSV DEF RBRVS 01/01/2024 12/31/2024 507.57 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67908 MEDSV DEF RBRVS 01/01/2025 496.75 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67909 MEDSV DEF RBRVS 01/01/2024 12/31/2024 514.92 Description: REVISE EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67909 MEDSV DEF RBRVS 01/01/2025 502.76 Description: REVISE EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67911 MEDSV DEF RBRVS 01/01/2024 12/31/2024 521.12 Description: REVISE EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67911 MEDSV DEF RBRVS 01/01/2025 512.04 Description: REVISE EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67912 MEDSV DEF RBRVS 01/01/2024 12/31/2024 845.42 Y Description: CORRECTION EYELID W/IMPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 67912 MEDSV DEF RBRVS 01/01/2025 817.58 Y Description: CORRECTION EYELID W/IMPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 67914 MEDSV DEF RBRVS 01/01/2024 12/31/2024 456.83 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67914 MEDSV DEF RBRVS 01/01/2025 446.39 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67915 MEDSV DEF RBRVS 01/01/2024 12/31/2024 295.96 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67915 MEDSV DEF RBRVS 01/01/2025 288.8 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67916 MEDSV DEF RBRVS 01/01/2024 12/31/2024 571.57 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67916 MEDSV DEF RBRVS 01/01/2025 557.62 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67917 MEDSV DEF RBRVS 01/01/2024 12/31/2024 584.85 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67917 MEDSV DEF RBRVS 01/01/2025 570.88 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67921 MEDSV DEF RBRVS 01/01/2024 12/31/2024 447.32 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67921 MEDSV DEF RBRVS 01/01/2025 436.72 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67922 MEDSV DEF RBRVS 01/01/2024 12/31/2024 287.32 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67922 MEDSV DEF RBRVS 01/01/2025 280.64 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67923 MEDSV DEF RBRVS 01/01/2024 12/31/2024 571.88 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67923 MEDSV DEF RBRVS 01/01/2025 558.07 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67924 MEDSV DEF RBRVS 01/01/2024 12/31/2024 608.61 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67924 MEDSV DEF RBRVS 01/01/2025 593.97 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 347.39 Description: REPAIR EYELID WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67930 MEDSV DEF RBRVS 01/01/2025 339.85 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67935 MEDSV DEF RBRVS 01/01/2024 12/31/2024 560.72 Description: REPAIR EYELID WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67935 MEDSV DEF RBRVS 01/01/2025 548.95 Description: REPAIR EYELID WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67938 MEDSV DEF RBRVS 01/01/2024 12/31/2024 255.21 Description: REMOVE EYELID FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67938 MEDSV DEF RBRVS 01/01/2025 246.17 Description: REMOVE EYELID FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67950 MEDSV DEF RBRVS 01/01/2024 12/31/2024 547.7 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67950 MEDSV DEF RBRVS 01/01/2025 535.88 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67961 MEDSV DEF RBRVS 01/01/2024 12/31/2024 550.51 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67961 MEDSV DEF RBRVS 01/01/2025 539.44 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67966 MEDSV DEF RBRVS 01/01/2024 12/31/2024 728.47 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67966 MEDSV DEF RBRVS 01/01/2025 712.89 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67971 MEDSV DEF RBRVS 01/01/2024 12/31/2024 670.38 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67971 MEDSV DEF RBRVS 01/01/2025 657.18 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67973 MEDSV DEF RBRVS 01/01/2024 12/31/2024 861.78 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67973 MEDSV DEF RBRVS 01/01/2025 845.16 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67974 MEDSV DEF RBRVS 01/01/2024 12/31/2024 860.12 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67974 MEDSV DEF RBRVS 01/01/2025 843.69 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67975 MEDSV DEF RBRVS 01/01/2024 12/31/2024 634.86 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67975 MEDSV DEF RBRVS 01/01/2025 622.26 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67999 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PROCEDURE EYELIDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 113.94 Description: INCISE/DRAIN EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68020 MEDSV DEF RBRVS 01/01/2025 111.79 Description: INCISE/DRAIN EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68040 MEDSV DEF RBRVS 01/01/2024 12/31/2024 58.47 Description: TREATMENT OF EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68040 MEDSV DEF RBRVS 01/01/2025 57.75 Description: TREATMENT OF EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 168.53 Description: BIOPSY CONJUNCTIVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68100 MEDSV DEF RBRVS 01/01/2025 164 Description: BIOPSY CONJUNCTIVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 221.37 Description: EXC LES CONJUNCTIVA <1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68110 MEDSV DEF RBRVS 01/01/2025 216.09 Description: EXC LES CONJUNCTIVA <1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68115 MEDSV DEF RBRVS 01/01/2024 12/31/2024 311.32 Description: EXC LES CONJUNCTIVA >1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68115 MEDSV DEF RBRVS 01/01/2025 303.22 Description: EXC LES CONJUNCTIVA >1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68130 MEDSV DEF RBRVS 01/01/2024 12/31/2024 516.36 Description: EXC LES CONJUNCTIVA ADJ SCL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68130 MEDSV DEF RBRVS 01/01/2025 506.04 Description: EXC LES CONJUNCTIVA ADJ SCL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68135 MEDSV DEF RBRVS 01/01/2024 12/31/2024 147.97 Description: DESTRUCTION LES CONJUNCTIVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68135 MEDSV DEF RBRVS 01/01/2025 144.88 Description: DESTRUCTION LES CONJUNCTIVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 38.86 Description: TREAT EYELID BY INJECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68200 MEDSV DEF RBRVS 01/01/2025 38.11 Description: TREAT EYELID BY INJECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 695.07 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68320 MEDSV DEF RBRVS 01/01/2025 679.9 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68325 MEDSV DEF RBRVS 01/01/2024 12/31/2024 610.86 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68325 MEDSV DEF RBRVS 01/01/2025 600.42 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68326 MEDSV DEF RBRVS 01/01/2024 12/31/2024 599.73 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68326 MEDSV DEF RBRVS 01/01/2025 589.47 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68328 MEDSV DEF RBRVS 01/01/2024 12/31/2024 656.48 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68328 MEDSV DEF RBRVS 01/01/2025 644.22 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68330 MEDSV DEF RBRVS 01/01/2024 12/31/2024 582.98 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68330 MEDSV DEF RBRVS 01/01/2025 570.46 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68335 MEDSV DEF RBRVS 01/01/2024 12/31/2024 601.54 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68335 MEDSV DEF RBRVS 01/01/2025 591.23 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68340 MEDSV DEF RBRVS 01/01/2024 12/31/2024 564.63 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68340 MEDSV DEF RBRVS 01/01/2025 550.14 Description: SEPARATE EYELID ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68360 MEDSV DEF RBRVS 01/01/2024 12/31/2024 507.94 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68360 MEDSV DEF RBRVS 01/01/2025 497.17 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68362 MEDSV DEF RBRVS 01/01/2024 12/31/2024 610.03 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68362 MEDSV DEF RBRVS 01/01/2025 599.46 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68371 MEDSV DEF RBRVS 01/01/2024 12/31/2024 383.59 Y Description: HARVEST EYE TISSUE ALOGRAFT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 68371 MEDSV DEF RBRVS 01/01/2025 377.71 Y Description: HARVEST EYE TISSUE ALOGRAFT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 68399 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX CONJUNCTIVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68400 MEDSV DEF RBRVS 01/01/2024 12/31/2024 277.93 Description: I&D LACRIMAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68400 MEDSV DEF RBRVS 01/01/2025 270.53 Description: I&D LACRIMAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 310.83 Description: I&D LACRIMAL SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68420 MEDSV DEF RBRVS 01/01/2025 302.32 Description: I&D LACRIMAL SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 97.5 Description: SNIP INC LACRIMAL PUNCTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68440 MEDSV DEF RBRVS 01/01/2025 96.18 Description: SNIP INC LACRIMAL PUNCTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68500 MEDSV DEF RBRVS 01/01/2024 12/31/2024 995.24 Description: REMOVAL OF TEAR GLAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68500 MEDSV DEF RBRVS 01/01/2025 973.54 Description: REMOVAL OF 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 990.83 Description: PARTIAL REMOVAL TEAR GLAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68505 MEDSV DEF RBRVS 01/01/2025 969.25 Description: PARTIAL REMOVAL TEAR GLAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 423.92 Description: BIOPSY OF TEAR GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68510 MEDSV DEF RBRVS 01/01/2025 412.65 Description: BIOPSY OF TEAR GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68520 MEDSV DEF RBRVS 01/01/2024 12/31/2024 691.47 Description: REMOVAL OF TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68520 MEDSV DEF RBRVS 01/01/2025 676.75 Description: REMOVAL OF TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68525 MEDSV DEF RBRVS 01/01/2024 12/31/2024 241.25 Description: BIOPSY OF TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68525 MEDSV DEF RBRVS 01/01/2025 235.01 Description: BIOPSY OF TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 406.35 Description: CLEARANCE OF TEAR DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68530 MEDSV DEF RBRVS 01/01/2025 396.42 Description: CLEARANCE OF TEAR DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 920.88 Description: REMOVE TEAR GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68540 MEDSV DEF RBRVS 01/01/2025 901.64 Description: REMOVE TEAR GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1146.58 Description: REMOVE TEAR GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68550 MEDSV DEF RBRVS 01/01/2025 1122.14 Description: REMOVE TEAR GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 560.98 Description: REPAIR TEAR DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68700 MEDSV DEF RBRVS 01/01/2025 551.63 Description: REPAIR TEAR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68705 MEDSV DEF RBRVS 01/01/2024 12/31/2024 245.73 Description: REVISE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68705 MEDSV DEF RBRVS 01/01/2025 238.74 Description: REVISE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 759.13 Description: CREATE TEAR SAC DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68720 MEDSV DEF RBRVS 01/01/2025 742.5 Description: CREATE TEAR SAC DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68745 MEDSV DEF RBRVS 01/01/2024 12/31/2024 763.08 Description: CREATE TEAR DUCT DRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68745 MEDSV DEF RBRVS 01/01/2025 746.98 Description: CREATE TEAR DUCT DRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68750 MEDSV DEF RBRVS 01/01/2024 12/31/2024 804.18 Description: CREATE TEAR DUCT DRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68750 MEDSV DEF RBRVS 01/01/2025 787.87 Description: CREATE TEAR DUCT DRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68760 MEDSV DEF RBRVS 01/01/2024 12/31/2024 206.43 Description: CLOSE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68760 MEDSV DEF RBRVS 01/01/2025 200.59 Description: CLOSE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68761 MEDSV DEF RBRVS 01/01/2024 12/31/2024 137.36 Description: CLOSE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1993 CMS Term: 68761 MEDSV DEF RBRVS 01/01/2025 134.09 Description: CLOSE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1993 CMS Term: 68770 MEDSV DEF RBRVS 01/01/2024 12/31/2024 584.66 Description: CLOSE TEAR SYSTEM FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68770 MEDSV DEF RBRVS 01/01/2025 573.85 Description: CLOSE TEAR SYSTEM FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68801 MEDSV DEF RBRVS 01/01/2024 12/31/2024 90.17 Description: DILATE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68801 MEDSV DEF RBRVS 01/01/2025 88.63 Description: DILATE TEAR DUCT OPENING 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68810 MEDSV DEF RBRVS 01/01/2024 12/31/2024 150.74 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68810 MEDSV DEF RBRVS 01/01/2025 147.73 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68811 MEDSV DEF RBRVS 01/01/2024 12/31/2024 125.74 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68811 MEDSV DEF RBRVS 01/01/2025 123.66 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68815 MEDSV DEF RBRVS 01/01/2024 12/31/2024 351.89 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68815 MEDSV DEF RBRVS 01/01/2025 342.18 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68816 MEDSV DEF RBRVS 01/01/2024 12/31/2024 799.23 Description: PROBE NL DUCT W/BALLOON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 68816 MEDSV DEF RBRVS 01/01/2025 766.74 Description: PROBE NL DUCT W/BALLOON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 68840 MEDSV DEF RBRVS 01/01/2024 12/31/2024 124.69 Description: EXPLORE/IRRIGATE TEAR DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68840 MEDSV DEF RBRVS 01/01/2025 122.35 Description: EXPLORE/IRRIGATE TEAR DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68841 MEDSV DEF RBRVS 01/01/2024 12/31/2024 35.77 Description: INSJ RX ELUT IMPLT LAC CANAL Category: Medical Services CMS Add: 01/01/2022 CMS Term: 68841 MEDSV DEF RBRVS 01/01/2025 35.1 Description: INSJ RX ELUT IMPLT LAC CANAL Category: Medical Services CMS Add: 01/01/2022 CMS Term: 68850 MEDSV DEF RBRVS 01/01/2024 12/31/2024 55.09 Description: INJECTION FOR TEAR SAC X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68850 MEDSV DEF RBRVS 01/01/2025 53.57 Description: INJECTION FOR TEAR SAC X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68899 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX LACRIMAL SYSTEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69000 MEDSV DEF RBRVS 01/01/2024 12/31/2024 175.08 Description: DRG XTRNL EAR ABSC/HEM SMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69000 MEDSV DEF RBRVS 01/01/2025 170.21 Description: DRG XTRNL EAR ABSC/HEM SMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69005 MEDSV DEF RBRVS 01/01/2024 12/31/2024 206.14 Description: DRG XTRNL EAR ABSC/HEM COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69005 MEDSV DEF RBRVS 01/01/2025 200.96 Description: DRG XTRNL EAR ABSC/HEM COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69020 MEDSV DEF RBRVS 01/01/2024 12/31/2024 220.55 Description: DRG XTRNL AUD CANAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69020 MEDSV DEF RBRVS 01/01/2025 212.39 Description: DRG XTRNL AUD CANAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69090 NOCOV DEF SYSMAN 12/01/1993 Y Description: EAR PIERCING Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 69100 MEDSV DEF RBRVS 01/01/2024 12/31/2024 90.49 Description: BIOPSY OF EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69100 MEDSV DEF RBRVS 01/01/2025 87.43 Description: BIOPSY OF EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69105 MEDSV DEF RBRVS 01/01/2024 12/31/2024 136.32 Description: BIOPSY OF EXTERNAL EAR CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69105 MEDSV DEF RBRVS 01/01/2025 131.78 Description: BIOPSY OF EXTERNAL EAR CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69110 MEDSV DEF RBRVS 01/01/2024 12/31/2024 442.1 Description: REMOVE EXTERNAL EAR PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69110 MEDSV DEF RBRVS 01/01/2025 429.37 Description: REMOVE EXTERNAL EAR PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69120 MEDSV DEF RBRVS 01/01/2024 12/31/2024 366.2 Description: REMOVAL OF EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69120 MEDSV DEF RBRVS 01/01/2025 355.8 Description: REMOVAL OF EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69140 MEDSV DEF RBRVS 01/01/2024 12/31/2024 850.49 Description: REMOVE EAR CANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69140 MEDSV DEF RBRVS 01/01/2025 824.95 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69145 MEDSV DEF RBRVS 01/01/2024 12/31/2024 387.49 Description: REMOVE EAR CANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69145 MEDSV DEF RBRVS 01/01/2025 375.83 Description: REMOVE EAR CANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69150 MEDSV DEF RBRVS 01/01/2024 12/31/2024 950.14 Description: EXTENSIVE EAR CANAL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69150 MEDSV DEF RBRVS 01/01/2025 920.65 Description: EXTENSIVE EAR CANAL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69155 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1532.67 Description: EXTENSIVE EAR/NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69155 MEDSV DEF RBRVS 01/01/2025 1489.86 Description: EXTENSIVE EAR/NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69200 MEDSV DEF RBRVS 01/01/2024 12/31/2024 75.1 Description: CLEAR OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69200 MEDSV DEF RBRVS 01/01/2025 73.45 Description: CLEAR OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69205 MEDSV DEF RBRVS 01/01/2024 12/31/2024 89.9 Description: CLEAR OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69205 MEDSV DEF RBRVS 01/01/2025 87.61 Description: CLEAR OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69209 MEDSV DEF RBRVS 01/01/2024 12/31/2024 14.05 Description: REMOVE IMPACTED EAR WAX UNI Category: Medical Services CMS Add: 01/01/2016 CMS Term: 69209 MEDSV DEF RBRVS 01/01/2025 14.35 Description: REMOVE IMPACTED EAR WAX UNI Category: Medical Services CMS Add: 01/01/2016 CMS Term: 69210 MEDSV DEF RBRVS 01/01/2024 12/31/2024 44.49 0-1 Description: REMOVE IMPACTED EAR WAX UNI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69210 MEDSV DEF RBRVS 01/01/2025 43.89 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 12/31/2024 73.28 Description: CLEAN OUT MASTOID CAVITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69220 MEDSV DEF RBRVS 01/01/2025 71.65 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69222 MEDSV DEF RBRVS 01/01/2024 12/31/2024 203.32 Description: CLEAN OUT MASTOID CAVITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69222 MEDSV DEF RBRVS 01/01/2025 197.84 Description: CLEAN OUT MASTOID CAVITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69300 MEDSV DEF RBRVS 01/01/2024 12/31/2024 611.36 Y Description: REVISE EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 69300 MEDSV DEF RBRVS 01/01/2025 596.54 Y Description: REVISE EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 69310 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1053.67 Description: REBUILD OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69310 MEDSV DEF RBRVS 01/01/2025 1019.72 Description: REBUILD OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69320 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1472.12 Description: REBUILD OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69320 MEDSV DEF RBRVS 01/01/2025 1424.93 Description: REBUILD OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69399 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69420 MEDSV DEF RBRVS 01/01/2024 12/31/2024 179.79 Description: INCISION OF EARDRUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69420 MEDSV DEF RBRVS 01/01/2025 174.86 Description: INCISION OF EARDRUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69421 MEDSV DEF RBRVS 01/01/2024 12/31/2024 143.06 Description: INCISION OF EARDRUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69421 MEDSV DEF RBRVS 01/01/2025 139.54 Description: INCISION OF EARDRUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69424 MEDSV DEF RBRVS 01/01/2024 12/31/2024 120.25 Description: REMOVE VENTILATING TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69424 MEDSV DEF RBRVS 01/01/2025 116.67 Description: REMOVE VENTILATING TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69433 MEDSV DEF RBRVS 01/01/2024 12/31/2024 190.11 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69433 MEDSV DEF RBRVS 01/01/2025 185.18 Description: CREATE EARDRUM OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69436 MEDSV DEF RBRVS 01/01/2024 12/31/2024 150.25 Description: CREATE EARDRUM OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69436 MEDSV DEF RBRVS 01/01/2025 147.1 Description: CREATE EARDRUM OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69440 MEDSV DEF RBRVS 01/01/2024 12/31/2024 653.91 Description: EXPLORATION OF MIDDLE EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69440 MEDSV DEF RBRVS 01/01/2025 635.42 Description: EXPLORATION OF MIDDLE EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69450 MEDSV DEF RBRVS 01/01/2024 12/31/2024 517.2 Description: EARDRUM REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69450 MEDSV DEF RBRVS 01/01/2025 503.22 Description: EARDRUM REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69501 MEDSV DEF RBRVS 01/01/2024 12/31/2024 671.54 Description: MASTOIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69501 MEDSV DEF RBRVS 01/01/2025 652.23 Description: MASTOIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69502 MEDSV DEF RBRVS 01/01/2024 12/31/2024 891.72 Description: MASTOIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69502 MEDSV DEF RBRVS 01/01/2025 866.01 Description: MASTOIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69505 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1160.04 Description: REMOVE MASTOID STRUCTURES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69505 MEDSV DEF RBRVS 01/01/2025 1123.04 Description: REMOVE MASTOID STRUCTURES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69511 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1187 Description: EXTENSIVE MASTOID SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69511 MEDSV DEF RBRVS 01/01/2025 1149.37 Description: EXTENSIVE MASTOID SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69530 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1580.54 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69530 MEDSV DEF RBRVS 01/01/2025 1530.37 Description: EXTENSIVE MASTOID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69535 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2511.04 Description: REMOVE PART OF TEMPORAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69535 MEDSV DEF RBRVS 01/01/2025 2431.56 Description: REMOVE PART OF TEMPORAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69540 MEDSV DEF RBRVS 01/01/2024 12/31/2024 199.16 Description: EXCISION AURAL POLYP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69540 MEDSV DEF RBRVS 01/01/2025 193.09 Description: EXCISION AURAL POLYP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69550 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1003.88 Description: EXC AURL GLOMUS TUM TRNSCANL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69550 MEDSV DEF RBRVS 01/01/2025 971.99 Description: EXC AURL GLOMUS TUM TRNSCANL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69552 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1497.12 Description: EXC AURL GLOMUS TUM TRNSMSTD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69552 MEDSV DEF RBRVS 01/01/2025 1449.3 Description: EXC AURL GLOMUS TUM TRNSMSTD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69554 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2383.99 Description: EXC AURL GLOMUS TUM EXTENDED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69554 MEDSV DEF RBRVS 01/01/2025 2311.64 Description: EXC AURL GLOMUS TUM EXTENDED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69601 MEDSV DEF RBRVS 01/01/2024 12/31/2024 961.65 Description: REVJ MSTDC RSLTG COMPL MSTDC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69601 MEDSV DEF RBRVS 01/01/2025 933.14 Description: REVJ MSTDC RSLTG COMPL MSTDC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69602 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1028.2 Description: REV MSTDC RSLT MOD RAD MSTDC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69602 MEDSV DEF RBRVS 01/01/2025 998.13 Description: REV MSTDC RSLT MOD RAD MSTDC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69603 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1212.33 Description: REVJ MSTDC RSLTG RAD MSTDC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69603 MEDSV DEF RBRVS 01/01/2025 1173.8 Description: REVJ MSTDC RSLTG RAD MSTDC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69604 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1050.56 Description: REVJ MSTDC RSLTG TYMPANPLSTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69604 MEDSV DEF RBRVS 01/01/2025 1019.53 Description: REVJ MSTDC RSLTG TYMPANPLSTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69610 MEDSV DEF RBRVS 01/01/2024 12/31/2024 361.06 Description: TYMPANIC MEMBRANE REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69610 MEDSV DEF RBRVS 01/01/2025 351.57 Description: TYMPANIC MEMBRANE REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69620 MEDSV DEF RBRVS 01/01/2024 12/31/2024 699.77 Description: MYRINGOPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69620 MEDSV DEF RBRVS 01/01/2025 678.62 Description: MYRINGOPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69631 MEDSV DEF RBRVS 01/01/2024 12/31/2024 840.87 Description: REPAIR EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69631 MEDSV DEF RBRVS 01/01/2025 816.16 Description: REPAIR EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69632 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1022.96 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69632 MEDSV DEF RBRVS 01/01/2025 991.13 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69633 MEDSV DEF RBRVS 01/01/2024 12/31/2024 992.09 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69633 MEDSV DEF RBRVS 01/01/2025 963.82 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69635 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1201.53 Description: REPAIR EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69635 MEDSV DEF RBRVS 01/01/2025 1163.88 Description: REPAIR EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69636 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1329.6 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69636 MEDSV DEF RBRVS 01/01/2025 1286.81 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69637 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1323.85 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69637 MEDSV DEF RBRVS 01/01/2025 1281.54 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69641 MEDSV DEF RBRVS 01/01/2024 12/31/2024 985.22 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69641 MEDSV DEF RBRVS 01/01/2025 955.04 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69642 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1263.82 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69642 MEDSV DEF RBRVS 01/01/2025 1225.96 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69643 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1156.32 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69643 MEDSV DEF RBRVS 01/01/2025 1120.29 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69644 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1421.82 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69644 MEDSV DEF RBRVS 01/01/2025 1375.85 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69645 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1395.18 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69645 MEDSV DEF RBRVS 01/01/2025 1349.72 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69646 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1481.1 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69646 MEDSV DEF RBRVS 01/01/2025 1435.12 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69650 MEDSV DEF RBRVS 01/01/2024 12/31/2024 759.03 Description: STAPES MOBILIZATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69650 MEDSV DEF RBRVS 01/01/2025 737.14 Description: STAPES MOBILIZATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69660 MEDSV DEF RBRVS 01/01/2024 12/31/2024 873.42 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69660 MEDSV DEF RBRVS 01/01/2025 847.24 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69661 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1138.04 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69661 MEDSV DEF RBRVS 01/01/2025 1103.81 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69662 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1089.86 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 69662 MEDSV DEF RBRVS 01/01/2025 1058.96 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 69666 MEDSV DEF RBRVS 01/01/2024 12/31/2024 763.48 Description: REPAIR MIDDLE EAR STRUCTURES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69666 MEDSV DEF RBRVS 01/01/2025 741.75 Description: REPAIR MIDDLE EAR STRUCTURES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69667 MEDSV DEF RBRVS 01/01/2024 12/31/2024 763.81 Description: REPAIR MIDDLE EAR STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69667 MEDSV DEF RBRVS 01/01/2025 743.62 Description: REPAIR MIDDLE EAR STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69670 MEDSV DEF RBRVS 01/01/2024 12/31/2024 891.46 Description: REMOVE MASTOID AIR CELLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69670 MEDSV DEF RBRVS 01/01/2025 865.31 Description: REMOVE MASTOID AIR CELLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69676 MEDSV DEF RBRVS 01/01/2024 12/31/2024 787.86 Description: REMOVE MIDDLE EAR NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69676 MEDSV DEF RBRVS 01/01/2025 765.22 Description: REMOVE MIDDLE EAR NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69700 MEDSV DEF RBRVS 01/01/2024 12/31/2024 628.79 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69700 MEDSV DEF RBRVS 01/01/2025 611.2 Description: CLOSE MASTOID FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69705 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2569.95 0 Description: NPS SURG DILAT EUST TUBE UNI Category: Medical Services CMS Add: 01/01/2021 CMS Term: 69705 MEDSV DEF RBRVS 01/01/2025 2433.33 Description: NPS SURG DILAT EUST TUBE UNI Category: Medical Services CMS Add: 01/01/2021 CMS Term: 69706 MEDSV DEF MAXFEE 01/01/2024 12/31/2024 2657.7 0 Description: NPS SURG DILAT EUST TUBE BI Category: Medical Services CMS Add: 01/01/2021 CMS Term: 69706 MEDSV DEF RBRVS 01/01/2025 2514.16 Description: NPS SURG DILAT EUST TUBE BI Category: Medical Services CMS Add: 01/01/2021 CMS Term: 69710 MEDSV DEF BILL20 01/01/2010 Description: IMPLANT/REPLACE HEARING AID Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69711 MEDSV DEF RBRVS 01/01/2024 12/31/2024 792.16 Description: REMOVE/REPAIR HEARING AID Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69711 MEDSV DEF RBRVS 01/01/2025 769.06 Description: REMOVE/REPAIR HEARING AID Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69714 MEDSV DEF RBRVS 01/01/2024 12/31/2024 464.24 Description: IMPL OI IMPLT SKULL PERQ ESP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 69714 MEDSV DEF RBRVS 01/01/2025 453.63 Description: IMPL OI IMPLT SKULL PERQ ESP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 69716 MEDSV DEF RBRVS 01/01/2024 12/31/2024 583.45 Description: IMPL OI IMPLT SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69716 MEDSV DEF RBRVS 01/01/2025 568.27 Description: IMPL OI IMPLT SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69717 MEDSV DEF RBRVS 01/01/2024 12/31/2024 526.72 Description: RPLCMT OI IMPLT SKL PRQ ESP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 69717 MEDSV DEF RBRVS 01/01/2025 513.98 Description: RPLCMT OI IMPLT SKL PRQ ESP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 69719 MEDSV DEF RBRVS 01/01/2024 12/31/2024 605 Description: RPLCM OI IMPLT SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69719 MEDSV DEF RBRVS 01/01/2025 590.1 Description: RPLCM OI IMPLT SK TC ESP<100 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69720 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1121.55 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69720 MEDSV DEF RBRVS 01/01/2025 1077.95 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69725 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1759.8 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69725 MEDSV DEF RBRVS 01/01/2025 1708.41 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69726 MEDSV DEF RBRVS 01/01/2024 12/31/2024 448.12 Description: RMV NTR OI IMPLT SKL PRQ ESP Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69726 MEDSV DEF RBRVS 01/01/2025 437.37 Description: RMV NTR OI IMPLT SKL PRQ ESP Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69727 MEDSV DEF RBRVS 01/01/2024 12/31/2024 499.92 Description: RMV NTR OI IMP SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69727 MEDSV DEF RBRVS 01/01/2025 487.8 Description: RMV NTR OI IMP SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69728 MEDSV DEF RBRVS 01/01/2024 12/31/2024 557.13 Description: RMV NTR OI IMP SK TC>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69728 MEDSV DEF RBRVS 01/01/2025 549.77 Description: RMV NTR OI IMP SK TC>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69729 MEDSV DEF RBRVS 01/01/2024 12/31/2024 631.47 Description: IMPL OI IMPLT SK TC ESP>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69729 MEDSV DEF RBRVS 01/01/2025 615.8 Description: IMPL OI IMPLT SK TC ESP>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69730 MEDSV DEF RBRVS 01/01/2024 12/31/2024 645.93 Description: RPLC OI IMPLT SK TC ESP>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69730 MEDSV DEF RBRVS 01/01/2025 636.43 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 12/31/2024 1094.67 Description: REPAIR FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69740 MEDSV DEF RBRVS 01/01/2025 1062.63 Description: REPAIR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69745 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1167.07 Description: REPAIR FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69745 MEDSV DEF RBRVS 01/01/2025 1132.41 Description: REPAIR FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69799 MEDSV DEF BILL20 10/15/2020 Description: UNLISTED PX MIDDLE EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69801 MEDSV DEF RBRVS 01/01/2024 12/31/2024 214.63 Description: INCISE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69801 MEDSV DEF RBRVS 01/01/2025 208.37 Description: INCISE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69805 MEDSV DEF RBRVS 01/01/2024 12/31/2024 969.72 Description: EXPLORE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69805 MEDSV DEF RBRVS 01/01/2025 942.7 Description: EXPLORE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69806 MEDSV DEF RBRVS 01/01/2024 12/31/2024 869.56 Description: EXPLORE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69806 MEDSV DEF RBRVS 01/01/2025 844.45 Description: EXPLORE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69905 MEDSV DEF RBRVS 01/01/2024 12/31/2024 867.61 Description: REMOVE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69905 MEDSV DEF RBRVS 01/01/2025 842.16 Description: REMOVE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69910 MEDSV DEF RBRVS 01/01/2024 12/31/2024 934.66 Description: REMOVE INNER EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69910 MEDSV DEF RBRVS 01/01/2025 907.66 Description: REMOVE INNER EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69915 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1415.57 Description: INCISE INNER EAR NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69915 MEDSV DEF RBRVS 01/01/2025 1374.2 Description: INCISE INNER EAR NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69930 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1146.13 Y Description: IMPLANT COCHLEAR DEVICE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69930 MEDSV DEF RBRVS 01/01/2025 1111.83 Y Description: IMPLANT COCHLEAR DEVICE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 69949 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69950 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1641.85 Description: INCISE INNER EAR NERVE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 69950 MEDSV DEF RBRVS 01/01/2025 1594.87 Description: INCISE INNER EAR NERVE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 69955 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1851 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69955 MEDSV DEF RBRVS 01/01/2025 1796.78 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69960 MEDSV DEF RBRVS 01/01/2024 12/31/2024 1772.9 Description: RELEASE INNER EAR CANAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 69960 MEDSV DEF RBRVS 01/01/2025 1721.61 Description: RELEASE INNER EAR CANAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 69970 MEDSV DEF RBRVS 01/01/2024 12/31/2024 2001.53 Description: REMOVE INNER EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69970 MEDSV DEF RBRVS 01/01/2025 1942.72 Description: REMOVE INNER EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69979 MEDSV DEF BILL20 01/01/2014 Description: UNLISTED PX TEMPORAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69990 MEDSV DEF RBRVS 01/01/2024 12/31/2024 190.7 Description: MICROSURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1999 CMS Term: 69990 MEDSV DEF RBRVS 01/01/2025 185.64 Description: MICROSURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1999 CMS Term: 70010 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.68 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 26 RADIO DEF MAXFEE 01/01/2024 12/31/2024 49.63 0 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 TC RADIO DEF MAXFEE 01/01/2024 12/31/2024 114.63 0 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70010 RADIO DEF RBRVS 01/01/2025 53.39 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 26 RADIO DEF MAXFEE 01/01/2025 48.04 0 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 TC RADIO DEF MAXFEE 01/01/2025 110.96 0 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 RADIO DEF RBRVS 01/01/2024 12/31/2024 158.76 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 54.87 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 103.89 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 RADIO DEF RBRVS 01/01/2025 152.38 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 26 RADIO DEF RBRVS 01/01/2025 52.6 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 TC RADIO DEF RBRVS 01/01/2025 99.79 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.5 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.42 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.08 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 RADIO DEF RBRVS 01/01/2025 29.76 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 26 RADIO DEF RBRVS 01/01/2025 7.86 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 TC RADIO DEF RBRVS 01/01/2025 21.9 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 RADIO DEF RBRVS 01/01/2024 12/31/2024 36.06 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70100 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.42 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.64 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 RADIO DEF RBRVS 01/01/2025 35.5 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 26 RADIO DEF RBRVS 01/01/2025 8.17 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 TC RADIO DEF RBRVS 01/01/2025 27.33 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 7010F NOCOV DEF SYSMAN 01/01/2008 Y Description: PT INFO INTO RECALL SYSTEM Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 70110 RADIO DEF RBRVS 01/01/2024 12/31/2024 40.59 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 11.41 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 12/31/2024 29.18 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 RADIO DEF RBRVS 01/01/2025 39.9 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 26 RADIO DEF RBRVS 01/01/2025 11.06 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 TC RADIO DEF RBRVS 01/01/2025 28.84 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 RADIO DEF RBRVS 01/01/2024 12/31/2024 36.06 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.42 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.64 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 RADIO DEF RBRVS 01/01/2025 34.89 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70120 26 RADIO DEF RBRVS 01/01/2025 8.17 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 TC RADIO DEF RBRVS 01/01/2025 26.73 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.62 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 15.86 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 42.76 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 RADIO DEF RBRVS 01/01/2025 56.59 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 26 RADIO DEF RBRVS 01/01/2025 15.07 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 TC RADIO DEF RBRVS 01/01/2025 41.52 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 RADIO DEF RBRVS 01/01/2024 12/31/2024 57.84 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 16.62 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 41.22 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 RADIO DEF RBRVS 01/01/2025 56.74 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 26 RADIO DEF RBRVS 01/01/2025 16.12 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 TC RADIO DEF RBRVS 01/01/2025 40.61 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.22 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 9.38 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70140 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 20.84 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 RADIO DEF RBRVS 01/01/2025 29.18 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 26 RADIO DEF RBRVS 01/01/2025 8.8 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 TC RADIO DEF RBRVS 01/01/2025 20.39 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 RADIO DEF RBRVS 01/01/2024 12/31/2024 44.02 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 12.06 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 31.96 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 RADIO DEF RBRVS 01/01/2025 43.25 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 26 RADIO DEF RBRVS 01/01/2025 11.69 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 TC RADIO DEF RBRVS 01/01/2025 31.56 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 RADIO DEF RBRVS 01/01/2024 12/31/2024 35.72 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.64 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 RADIO DEF RBRVS 01/01/2025 34.26 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 26 RADIO DEF RBRVS 01/01/2025 7.54 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 TC RADIO DEF RBRVS 01/01/2025 26.73 Description: X-RAY EXAM OF NASAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70170 RADIO DEF MAXFEE 01/01/2024 52.5 0 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70170 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 13.88 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 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70170 26 RADIO DEF RBRVS 01/01/2025 13.46 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 RADIO DEF RBRVS 01/01/2024 12/31/2024 35.22 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 10.36 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 24.86 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 RADIO DEF RBRVS 01/01/2025 34.37 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 26 RADIO DEF RBRVS 01/01/2025 10.05 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 TC RADIO DEF RBRVS 01/01/2025 24.31 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 RADIO DEF RBRVS 01/01/2024 12/31/2024 45 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 13.05 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 31.96 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 RADIO DEF RBRVS 01/01/2025 43.9 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 26 RADIO DEF RBRVS 01/01/2025 12.65 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 TC RADIO DEF RBRVS 01/01/2025 31.25 Description: X-RAY EXAM OF EYE SOCKETS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 7020F NOCOV DEF SYSMAN 01/01/2009 Y Description: MAMMO ASSESS CAT IN DBASE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 70210 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.16 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.08 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 RADIO DEF RBRVS 01/01/2025 29.43 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 26 RADIO DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 TC RADIO DEF RBRVS 01/01/2025 21.59 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 RADIO DEF RBRVS 01/01/2024 12/31/2024 35.25 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 10.09 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 25.17 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 RADIO DEF RBRVS 01/01/2025 34.39 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 26 RADIO DEF RBRVS 01/01/2025 9.78 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 TC RADIO DEF RBRVS 01/01/2025 24.61 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.84 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.76 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.08 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70240 RADIO DEF RBRVS 01/01/2025 30.09 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 26 RADIO DEF RBRVS 01/01/2025 8.49 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 TC RADIO DEF RBRVS 01/01/2025 21.59 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 SE MRT DEF RBRVS 01/01/2024 12/31/2024 33.59 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 RADIO DEF RBRVS 01/01/2024 12/31/2024 33.59 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.42 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 12/31/2024 8.42 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 25.17 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 12/31/2024 25.17 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 SE MRT DEF RBRVS 01/01/2025 32.78 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 RADIO DEF RBRVS 01/01/2025 32.78 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 26 SE MRT DEF RBRVS 01/01/2025 8.17 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 26 RADIO DEF RBRVS 01/01/2025 8.17 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 TC SE MRT DEF RBRVS 01/01/2025 24.61 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 TC RADIO DEF RBRVS 01/01/2025 24.61 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 7025F NOCOV DEF SYSMAN 01/01/2009 Y Description: PT INFOSYS ALARM 4 NXT MAMMO 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70260 SE MRT DEF RBRVS 01/01/2024 12/31/2024 41.92 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 RADIO DEF RBRVS 01/01/2024 12/31/2024 41.92 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 13.05 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 12/31/2024 13.05 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 28.87 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 12/31/2024 28.87 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 SE MRT DEF RBRVS 01/01/2025 40.88 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 RADIO DEF RBRVS 01/01/2025 40.88 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 26 SE MRT DEF RBRVS 01/01/2025 12.65 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 26 RADIO DEF RBRVS 01/01/2025 12.65 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 TC SE MRT DEF RBRVS 01/01/2025 28.24 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 TC RADIO DEF RBRVS 01/01/2025 28.24 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 RADIO DEF RBRVS 01/01/2024 12/31/2024 12.05 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 4.78 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 7.26 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 RADIO DEF RBRVS 01/01/2025 11.74 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70300 26 RADIO DEF RBRVS 01/01/2025 4.64 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 TC RADIO DEF RBRVS 01/01/2025 7.1 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 RADIO DEF RBRVS 01/01/2024 12/31/2024 36.62 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.44 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 29.18 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 RADIO DEF RBRVS 01/01/2025 36.95 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 26 RADIO DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 TC RADIO DEF RBRVS 01/01/2025 29.44 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.14 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 10.39 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 38.75 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 RADIO DEF RBRVS 01/01/2025 48.58 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 26 RADIO DEF RBRVS 01/01/2025 10.08 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 TC RADIO DEF RBRVS 01/01/2025 38.5 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 RADIO DEF RBRVS 01/01/2024 12/31/2024 32.35 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.42 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70328 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 23.93 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 RADIO DEF RBRVS 01/01/2025 31.57 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 26 RADIO DEF RBRVS 01/01/2025 8.17 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 TC RADIO DEF RBRVS 01/01/2025 23.41 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.51 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 11.07 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 38.44 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 RADIO DEF RBRVS 01/01/2025 48.33 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 26 RADIO DEF RBRVS 01/01/2025 10.73 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 TC RADIO DEF RBRVS 01/01/2025 37.59 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 RADIO DEF RBRVS 01/01/2024 12/31/2024 79.61 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 25.12 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 54.49 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 RADIO DEF RBRVS 01/01/2025 75.68 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 26 RADIO DEF RBRVS 01/01/2025 23.89 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 TC RADIO DEF RBRVS 01/01/2025 51.78 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70336 RADIO DEF RBRVS 01/01/2024 12/31/2024 259.53 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 67.49 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 192.03 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 RADIO DEF RBRVS 01/01/2025 248.4 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 26 RADIO DEF RBRVS 01/01/2025 65.13 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 TC RADIO DEF RBRVS 01/01/2025 183.27 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70350 RADIO DEF RBRVS 01/01/2024 12/31/2024 15.34 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 7.26 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 RADIO DEF RBRVS 01/01/2025 15.24 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 26 RADIO DEF RBRVS 01/01/2025 7.84 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 TC RADIO DEF RBRVS 01/01/2025 7.4 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 RADIO DEF RBRVS 01/01/2024 12/31/2024 16.98 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 9.41 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 7.57 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 RADIO DEF RBRVS 01/01/2025 16.83 Description: PANORAMIC X-RAY OF JAWS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70355 26 RADIO DEF RBRVS 01/01/2025 9.12 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 TC RADIO DEF RBRVS 01/01/2025 7.71 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 RADIO DEF RBRVS 01/01/2024 12/31/2024 29.58 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.42 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 21.15 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 RADIO DEF RBRVS 01/01/2025 28.55 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 26 RADIO DEF RBRVS 01/01/2025 8.17 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 TC RADIO DEF RBRVS 01/01/2025 20.39 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 RADIO DEF RBRVS 01/01/2024 12/31/2024 94.99 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 14.25 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 80.73 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 RADIO DEF RBRVS 01/01/2025 95.49 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 26 RADIO DEF RBRVS 01/01/2025 14.12 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 TC RADIO DEF RBRVS 01/01/2025 81.37 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70371 RADIO DEF RBRVS 01/01/2024 12/31/2024 102.13 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70371 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.61 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70371 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 62.52 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70371 RADIO DEF RBRVS 01/01/2025 100.45 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70371 26 RADIO DEF RBRVS 01/01/2025 38.71 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70371 TC RADIO DEF RBRVS 01/01/2025 61.75 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70380 RADIO DEF RBRVS 01/01/2024 12/31/2024 35.1 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.77 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.33 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 RADIO DEF RBRVS 01/01/2025 34.26 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 26 RADIO DEF RBRVS 01/01/2025 7.54 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 TC RADIO DEF RBRVS 01/01/2025 26.73 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 RADIO DEF RBRVS 01/01/2024 12/31/2024 110.3 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 17.52 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 92.77 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 RADIO DEF RBRVS 01/01/2025 105.3 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 26 RADIO DEF RBRVS 01/01/2025 16.69 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 TC RADIO DEF RBRVS 01/01/2025 88.62 Description: X-RAY EXAM OF SALIVARY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70450 RADIO DEF RBRVS 01/01/2024 12/31/2024 103.39 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.02 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 64.37 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 RADIO DEF RBRVS 01/01/2025 99.88 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 26 RADIO DEF RBRVS 01/01/2025 37.52 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 TC RADIO DEF RBRVS 01/01/2025 62.35 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 RADIO DEF RBRVS 01/01/2024 12/31/2024 144.07 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 51.92 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 92.16 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 RADIO DEF RBRVS 01/01/2025 139.55 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 26 RADIO DEF RBRVS 01/01/2025 50.03 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 TC RADIO DEF RBRVS 01/01/2025 89.52 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 RADIO DEF RBRVS 01/01/2024 12/31/2024 169.21 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.36 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 12/31/2024 110.84 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 RADIO DEF RBRVS 01/01/2025 163.17 Description: CT HEAD/BRAIN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70470 26 RADIO DEF RBRVS 01/01/2025 56.28 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 TC RADIO DEF RBRVS 01/01/2025 106.89 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 RADIO DEF RBRVS 01/01/2024 12/31/2024 154.56 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 59.01 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 12/31/2024 95.55 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 RADIO DEF RBRVS 01/01/2025 149.61 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 26 RADIO DEF RBRVS 01/01/2025 56.91 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 TC RADIO DEF RBRVS 01/01/2025 92.7 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 RADIO DEF RBRVS 01/01/2024 12/31/2024 175.72 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 51.92 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 123.81 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 RADIO DEF RBRVS 01/01/2025 169.6 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 26 RADIO DEF RBRVS 01/01/2025 50.03 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 TC RADIO DEF RBRVS 01/01/2025 119.57 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 RADIO DEF RBRVS 01/01/2024 12/31/2024 205.02 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.06 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70482 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 146.96 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 RADIO DEF RBRVS 01/01/2025 197.89 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 26 RADIO DEF RBRVS 01/01/2025 55.98 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 TC RADIO DEF RBRVS 01/01/2025 141.91 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 RADIO DEF RBRVS 01/01/2024 12/31/2024 124.69 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.33 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 85.37 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 RADIO DEF RBRVS 01/01/2025 120.4 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 26 RADIO DEF RBRVS 01/01/2025 37.83 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 TC RADIO DEF RBRVS 01/01/2025 82.58 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 RADIO DEF RBRVS 01/01/2024 12/31/2024 148.09 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 51.92 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 96.17 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 RADIO DEF RBRVS 01/01/2025 143.03 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 26 RADIO DEF RBRVS 01/01/2025 49.73 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 TC RADIO DEF RBRVS 01/01/2025 93.3 Description: CT MAXILLOFACIAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70488 RADIO DEF RBRVS 01/01/2024 12/31/2024 180.01 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.36 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 121.65 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 RADIO DEF RBRVS 01/01/2025 173.13 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 26 RADIO DEF RBRVS 01/01/2025 55.98 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 TC RADIO DEF RBRVS 01/01/2025 117.15 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 RADIO DEF RBRVS 01/01/2024 12/31/2024 146.54 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 59.01 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 12/31/2024 87.53 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 RADIO DEF RBRVS 01/01/2025 141.3 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 26 RADIO DEF RBRVS 01/01/2025 56.61 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 TC RADIO DEF RBRVS 01/01/2025 84.69 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 RADIO DEF RBRVS 01/01/2024 12/31/2024 180.03 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 63.64 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 116.4 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 RADIO DEF RBRVS 01/01/2025 173.41 Description: CT SOFT TISSUE NECK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70491 26 RADIO DEF RBRVS 01/01/2025 61.09 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 TC RADIO DEF RBRVS 01/01/2025 112.32 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 RADIO DEF RBRVS 01/01/2024 12/31/2024 216.42 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 74.09 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 12/31/2024 142.33 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 RADIO DEF RBRVS 01/01/2025 208 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 26 RADIO DEF RBRVS 01/01/2025 71.22 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 TC RADIO DEF RBRVS 01/01/2025 136.78 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70496 RADIO DEF RBRVS 01/01/2024 12/31/2024 268.39 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 80.36 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 188.03 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 RADIO DEF RBRVS 01/01/2025 259.07 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 26 RADIO DEF RBRVS 01/01/2025 77.15 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 TC RADIO DEF RBRVS 01/01/2025 181.92 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 RADIO DEF RBRVS 01/01/2024 12/31/2024 268.08 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 80.36 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70498 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 187.72 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 RADIO DEF RBRVS 01/01/2025 258.76 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 26 RADIO DEF RBRVS 01/01/2025 77.15 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 TC RADIO DEF RBRVS 01/01/2025 181.62 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70540 RADIO DEF RBRVS 01/01/2024 12/31/2024 221.31 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 61.69 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 12/31/2024 159.62 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 RADIO DEF RBRVS 01/01/2025 212.89 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 26 RADIO DEF RBRVS 01/01/2025 59.51 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 TC RADIO DEF RBRVS 01/01/2025 153.38 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70542 RADIO DEF RBRVS 01/01/2024 12/31/2024 263.04 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 74.4 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 188.64 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 RADIO DEF RBRVS 01/01/2025 252.54 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 26 RADIO DEF RBRVS 01/01/2025 71.52 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 TC RADIO DEF RBRVS 01/01/2025 181.01 Description: MRI ORBIT/FACE/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70543 RADIO DEF RBRVS 01/01/2024 12/31/2024 332.12 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 98.4 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 12/31/2024 233.72 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 RADIO DEF RBRVS 01/01/2025 318.98 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 26 RADIO DEF RBRVS 01/01/2025 94.79 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 TC RADIO DEF RBRVS 01/01/2025 224.19 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 RADIO DEF RBRVS 01/01/2024 12/31/2024 209.89 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.21 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 154.68 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 RADIO DEF RBRVS 01/01/2025 202.54 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 26 RADIO DEF RBRVS 01/01/2025 52.93 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 TC RADIO DEF RBRVS 01/01/2025 149.62 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 RADIO DEF RBRVS 01/01/2024 12/31/2024 221.33 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 54.91 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 166.42 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 RADIO DEF RBRVS 01/01/2025 213.41 Description: MR ANGIOGRAPHY HEAD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70545 26 RADIO DEF RBRVS 01/01/2025 52.93 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 TC RADIO DEF RBRVS 01/01/2025 160.48 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 RADIO DEF RBRVS 01/01/2024 12/31/2024 320.36 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 67.8 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 12/31/2024 252.55 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 RADIO DEF RBRVS 01/01/2025 309.4 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 26 RADIO DEF RBRVS 01/01/2025 65.43 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 TC RADIO DEF RBRVS 01/01/2025 243.97 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 RADIO DEF RBRVS 01/01/2024 12/31/2024 210.2 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.21 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 154.99 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 RADIO DEF RBRVS 01/01/2025 202.84 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 26 RADIO DEF RBRVS 01/01/2025 52.93 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 TC RADIO DEF RBRVS 01/01/2025 149.92 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 RADIO DEF RBRVS 01/01/2024 12/31/2024 239.84 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 68.79 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70548 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 171.05 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 RADIO DEF RBRVS 01/01/2025 231.4 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 26 RADIO DEF RBRVS 01/01/2025 66.39 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 TC RADIO DEF RBRVS 01/01/2025 165.01 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 RADIO DEF RBRVS 01/01/2024 12/31/2024 336.46 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.67 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 12/31/2024 253.79 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 RADIO DEF RBRVS 01/01/2025 324.56 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 26 RADIO DEF RBRVS 01/01/2025 79.39 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 TC RADIO DEF RBRVS 01/01/2025 245.18 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70551 RADIO DEF RBRVS 01/01/2024 12/31/2024 191.61 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 68.11 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 123.5 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 RADIO DEF RBRVS 01/01/2025 185 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 26 RADIO DEF RBRVS 01/01/2025 65.43 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 TC RADIO DEF RBRVS 01/01/2025 119.57 Description: MRI BRAIN STEM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70552 RADIO DEF RBRVS 01/01/2024 12/31/2024 264.47 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 182.48 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 RADIO DEF RBRVS 01/01/2025 254.61 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 26 RADIO DEF RBRVS 01/01/2025 78.73 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 TC RADIO DEF RBRVS 01/01/2025 175.88 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70553 RADIO DEF RBRVS 01/01/2024 12/31/2024 312.02 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 105.16 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 12/31/2024 206.86 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 RADIO DEF RBRVS 01/01/2025 300.17 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 26 RADIO DEF RBRVS 01/01/2025 101.04 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 TC RADIO DEF RBRVS 01/01/2025 199.13 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70554 RADIO DEF RBRVS 01/01/2024 12/31/2024 370.13 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 96.9 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 273.24 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 RADIO DEF RBRVS 01/01/2025 357.23 Description: FMRI BRAIN BY TECH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70554 26 RADIO DEF RBRVS 01/01/2025 93.64 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 TC RADIO DEF RBRVS 01/01/2025 263.59 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70555 RADIO DEF MAXFEE 01/01/2024 637.79 0 Description: FMRI BRAIN BY PHYS/PSYCH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70555 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 115.17 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 Description: FMRI BRAIN BY PHYS/PSYCH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70555 26 RADIO DEF RBRVS 01/01/2025 110.44 Description: FMRI BRAIN BY PHYS/PSYCH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70557 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 145.62 Description: MRI BRAIN W/O DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70557 26 RADIO DEF RBRVS 01/01/2025 141.4 Description: MRI BRAIN W/O DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70558 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 159.78 Description: MRI BRAIN W/DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70558 26 RADIO DEF RBRVS 01/01/2025 155.91 Description: MRI BRAIN W/DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70559 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 151.24 Description: MRI BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70559 26 RADIO DEF RBRVS 01/01/2025 145.14 Description: MRI BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 71045 SE MRT DEF RBRVS 01/01/2024 12/31/2024 24.33 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71045 RADIO DEF RBRVS 01/01/2024 12/31/2024 24.33 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71045 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 8.42 Description: X-RAY EXAM CHEST 1 VIEW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71045 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 15.91 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71045 SE MRT DEF RBRVS 01/01/2025 23.42 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71045 RADIO DEF RBRVS 01/01/2025 23.42 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71045 26 SE MRT DEF RBRVS 01/01/2025 7.86 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71045 26 RADIO DEF RBRVS 01/01/2025 7.86 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71045 TC SE MRT DEF RBRVS 01/01/2025 15.56 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71045 TC RADIO DEF RBRVS 01/01/2025 15.56 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 SE MRT DEF RBRVS 01/01/2024 12/31/2024 31.55 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 RADIO DEF RBRVS 01/01/2024 12/31/2024 31.55 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 10.09 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 21.46 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 SE MRT DEF RBRVS 01/01/2025 30.77 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 RADIO DEF RBRVS 01/01/2025 30.77 Description: X-RAY EXAM CHEST 2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71046 26 SE MRT DEF RBRVS 01/01/2025 9.78 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 26 RADIO DEF RBRVS 01/01/2025 9.78 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 TC SE MRT DEF RBRVS 01/01/2025 20.99 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 TC RADIO DEF RBRVS 01/01/2025 20.99 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 SE MRT DEF RBRVS 01/01/2024 12/31/2024 39.73 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.73 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 12.71 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 27.02 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 SE MRT DEF RBRVS 01/01/2025 38.74 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 RADIO DEF RBRVS 01/01/2025 38.74 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 26 SE MRT DEF RBRVS 01/01/2025 12.32 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 26 RADIO DEF RBRVS 01/01/2025 12.32 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 TC SE MRT DEF RBRVS 01/01/2025 26.42 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 TC RADIO DEF RBRVS 01/01/2025 26.42 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71048 SE MRT DEF RBRVS 01/01/2024 12/31/2024 43.55 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 RADIO DEF RBRVS 01/01/2024 12/31/2024 43.55 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 14.37 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 29.18 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 SE MRT DEF RBRVS 01/01/2025 41.87 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 RADIO DEF RBRVS 01/01/2025 41.87 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 26 SE MRT DEF RBRVS 01/01/2025 13.63 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 26 RADIO DEF RBRVS 01/01/2025 13.63 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 TC SE MRT DEF RBRVS 01/01/2025 28.24 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 TC RADIO DEF RBRVS 01/01/2025 28.24 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71100 SE MRT DEF RBRVS 01/01/2024 12/31/2024 34.64 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 12/31/2024 34.64 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71100 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 10.39 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 12/31/2024 10.39 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71100 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 24.24 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 12/31/2024 24.24 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71100 SE MRT DEF RBRVS 01/01/2025 33.48 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 RADIO DEF RBRVS 01/01/2025 33.48 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71100 26 SE MRT DEF RBRVS 01/01/2025 9.78 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 26 RADIO DEF RBRVS 01/01/2025 9.78 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71100 TC SE MRT DEF RBRVS 01/01/2025 23.71 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 TC RADIO DEF RBRVS 01/01/2025 23.71 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.73 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 12.4 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.33 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 RADIO DEF RBRVS 01/01/2025 38.74 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 26 RADIO DEF RBRVS 01/01/2025 12.02 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 TC RADIO DEF RBRVS 01/01/2025 26.73 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 RADIO DEF RBRVS 01/01/2024 12/31/2024 41.33 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 13.38 Description: X-RAY EXAM RIBS BIL 3 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71110 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.95 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 RADIO DEF RBRVS 01/01/2025 40.31 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 26 RADIO DEF RBRVS 01/01/2025 12.98 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 TC RADIO DEF RBRVS 01/01/2025 27.33 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.3 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 14.87 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 34.43 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 RADIO DEF RBRVS 01/01/2025 48.09 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 26 RADIO DEF RBRVS 01/01/2025 14.42 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 TC RADIO DEF RBRVS 01/01/2025 33.67 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 RADIO DEF RBRVS 01/01/2024 12/31/2024 31.49 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 9.1 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.39 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 RADIO DEF RBRVS 01/01/2025 30.72 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 26 RADIO DEF RBRVS 01/01/2025 8.82 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 TC RADIO DEF RBRVS 01/01/2025 21.9 Description: X-RAY EXAM BREASTBONE 2/>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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71130 RADIO DEF RBRVS 01/01/2024 12/31/2024 38.65 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 10.09 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 28.56 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 RADIO DEF RBRVS 01/01/2025 37.71 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 26 RADIO DEF RBRVS 01/01/2025 9.78 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 TC RADIO DEF RBRVS 01/01/2025 27.93 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 RADIO DEF RBRVS 01/01/2024 12/31/2024 129.72 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.6 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 80.12 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 RADIO DEF RBRVS 01/01/2025 125.23 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 26 RADIO DEF RBRVS 01/01/2025 47.79 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 TC RADIO DEF RBRVS 01/01/2025 77.45 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 RADIO DEF RBRVS 01/01/2024 12/31/2024 162.23 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 53.55 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 108.68 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 RADIO DEF RBRVS 01/01/2025 157 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71260 26 RADIO DEF RBRVS 01/01/2025 51.62 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 TC RADIO DEF RBRVS 01/01/2025 105.38 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 RADIO DEF RBRVS 01/01/2024 12/31/2024 191.21 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 57.22 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 133.99 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 RADIO DEF RBRVS 01/01/2025 184.4 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 26 RADIO DEF RBRVS 01/01/2025 55.17 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 TC RADIO DEF RBRVS 01/01/2025 129.23 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71271 RADIO DEF RBRVS 01/01/2024 12/31/2024 134.04 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.6 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 84.44 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 RADIO DEF RBRVS 01/01/2025 129.32 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 26 RADIO DEF RBRVS 01/01/2025 47.79 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 TC RADIO DEF RBRVS 01/01/2025 81.53 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71275 RADIO DEF RBRVS 01/01/2024 12/31/2024 273.54 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 83.35 Description: CT ANGIOGRAPHY CHEST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71275 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 190.19 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 RADIO DEF RBRVS 01/01/2025 264.23 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 26 RADIO DEF RBRVS 01/01/2025 80.2 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 TC RADIO DEF RBRVS 01/01/2025 184.03 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71550 RADIO DEF RBRVS 01/01/2024 12/31/2024 330.79 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 67.12 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 263.67 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 RADIO DEF RBRVS 01/01/2025 317.04 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 26 RADIO DEF RBRVS 01/01/2025 64.47 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 TC RADIO DEF RBRVS 01/01/2025 252.56 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71551 RADIO DEF RBRVS 01/01/2024 12/31/2024 365.89 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 79.37 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 286.51 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 RADIO DEF RBRVS 01/01/2025 350.79 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 26 RADIO DEF RBRVS 01/01/2025 76.49 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 TC RADIO DEF RBRVS 01/01/2025 274.3 Description: MRI CHEST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71552 RADIO DEF RBRVS 01/01/2024 12/31/2024 462.58 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 103.83 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 358.75 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 RADIO DEF RBRVS 01/01/2025 442.75 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 26 RADIO DEF RBRVS 01/01/2025 99.76 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 TC RADIO DEF RBRVS 01/01/2025 342.99 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71555 RADIO DEF RBRVS 01/01/2024 12/31/2024 325.69 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 71555 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.39 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 12/31/2024 243.29 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 71555 RADIO DEF RBRVS 01/01/2025 313.72 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 71555 26 RADIO DEF RBRVS 01/01/2025 79.11 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 71555 TC RADIO DEF RBRVS 01/01/2025 234.61 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72020 RADIO DEF RBRVS 01/01/2024 12/31/2024 23.03 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72020 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.44 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 12/31/2024 15.6 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72020 RADIO DEF RBRVS 01/01/2025 22.16 Description: X-RAY EXAM OF SPINE 1 VIEW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72020 26 RADIO DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72020 TC RADIO DEF RBRVS 01/01/2025 14.95 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 SE MRT DEF RBRVS 01/01/2024 12/31/2024 37.1 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 12/31/2024 37.1 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 10.39 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 12/31/2024 10.39 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 26.71 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 12/31/2024 26.71 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 SE MRT DEF RBRVS 01/01/2025 36.2 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 01/01/2025 36.2 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 26 SE MRT DEF RBRVS 01/01/2025 10.08 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 01/01/2025 10.08 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 TC SE MRT DEF RBRVS 01/01/2025 26.12 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 01/01/2025 26.12 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 SE MRT DEF RBRVS 01/01/2024 12/31/2024 49.91 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 12/31/2024 49.91 Description: X-RAY EXAM NECK SPINE 4/5VWS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72050 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 12.71 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 12/31/2024 12.71 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 37.21 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 12/31/2024 37.21 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 SE MRT DEF RBRVS 01/01/2025 49.01 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72050 RADIO DEF RBRVS 01/01/2025 49.01 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 26 SE MRT DEF RBRVS 01/01/2025 12.02 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72050 26 RADIO DEF RBRVS 01/01/2025 12.02 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 TC SE MRT DEF RBRVS 01/01/2025 36.99 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72050 TC RADIO DEF RBRVS 01/01/2025 36.99 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 SE MRT DEF RBRVS 01/01/2024 12/31/2024 58.19 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 12/31/2024 58.19 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 13.88 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 12/31/2024 13.88 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 44.31 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 12/31/2024 44.31 Description: X-RAY EXAM NECK SPINE 6/>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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72052 SE MRT DEF RBRVS 01/01/2025 57.09 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 RADIO DEF RBRVS 01/01/2025 57.09 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 26 SE MRT DEF RBRVS 01/01/2025 13.46 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 26 RADIO DEF RBRVS 01/01/2025 13.46 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 TC SE MRT DEF RBRVS 01/01/2025 43.63 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 TC RADIO DEF RBRVS 01/01/2025 43.63 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 SE MRT DEF RBRVS 01/01/2024 12/31/2024 30.87 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 12/31/2024 30.87 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 9.41 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 12/31/2024 9.41 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 21.46 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 12/31/2024 21.46 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 SE MRT DEF RBRVS 01/01/2025 30.11 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72070 RADIO DEF RBRVS 01/01/2025 30.11 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 26 SE MRT DEF RBRVS 01/01/2025 9.12 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72070 26 RADIO DEF RBRVS 01/01/2025 9.12 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72070 TC SE MRT DEF RBRVS 01/01/2025 20.99 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72070 TC RADIO DEF RBRVS 01/01/2025 20.99 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 SE MRT DEF RBRVS 01/01/2024 12/31/2024 36.83 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 12/31/2024 36.83 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 10.42 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 12/31/2024 10.42 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 26.4 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 12/31/2024 26.4 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 SE MRT DEF RBRVS 01/01/2025 36.23 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72072 RADIO DEF RBRVS 01/01/2025 36.23 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 26 SE MRT DEF RBRVS 01/01/2025 10.11 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72072 26 RADIO DEF RBRVS 01/01/2025 10.11 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 TC SE MRT DEF RBRVS 01/01/2025 26.12 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72072 TC RADIO DEF RBRVS 01/01/2025 26.12 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 SE MRT DEF RBRVS 01/01/2024 12/31/2024 41.52 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 12/31/2024 41.52 Description: X-RAY EXAM THORAC SPINE4/>VW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72074 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 11.41 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 12/31/2024 11.41 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 30.11 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 12/31/2024 30.11 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 SE MRT DEF RBRVS 01/01/2025 40.81 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72074 RADIO DEF RBRVS 01/01/2025 40.81 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 26 SE MRT DEF RBRVS 01/01/2025 11.06 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72074 26 RADIO DEF RBRVS 01/01/2025 11.06 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 TC SE MRT DEF RBRVS 01/01/2025 29.75 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72074 TC RADIO DEF RBRVS 01/01/2025 29.75 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 SE MRT DEF RBRVS 01/01/2024 12/31/2024 32.44 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 RADIO DEF RBRVS 01/01/2024 12/31/2024 32.44 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 9.75 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 22.7 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.7 Description: X-RAY EXAM THORACOLMB 2/> VW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72080 SE MRT DEF RBRVS 01/01/2025 31.65 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 RADIO DEF RBRVS 01/01/2025 31.65 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 26 SE MRT DEF RBRVS 01/01/2025 9.45 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 26 RADIO DEF RBRVS 01/01/2025 9.45 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 TC SE MRT DEF RBRVS 01/01/2025 22.2 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 TC RADIO DEF RBRVS 01/01/2025 22.2 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72081 SE MRT DEF RBRVS 01/01/2024 12/31/2024 40 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 RADIO DEF RBRVS 01/01/2024 12/31/2024 40 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 12.06 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 27.95 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 SE MRT DEF RBRVS 01/01/2025 39.02 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 RADIO DEF RBRVS 01/01/2025 39.02 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 26 SE MRT DEF RBRVS 01/01/2025 11.69 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 26 RADIO DEF RBRVS 01/01/2025 11.69 Description: X-RAY EXAM ENTIRE SPI 1 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72081 TC SE MRT DEF RBRVS 01/01/2025 27.33 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 TC RADIO DEF RBRVS 01/01/2025 27.33 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 RADIO DEF RBRVS 01/01/2024 12/31/2024 65.63 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 12/31/2024 14.53 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 51.1 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 RADIO DEF RBRVS 01/01/2025 64.06 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 26 RADIO DEF RBRVS 01/01/2025 14.09 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 TC RADIO DEF RBRVS 01/01/2025 49.97 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 RADIO DEF RBRVS 01/01/2024 12/31/2024 73.92 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 16.65 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 12/31/2024 57.27 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 RADIO DEF RBRVS 01/01/2025 72.46 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 26 RADIO DEF RBRVS 01/01/2025 16.15 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 TC RADIO DEF RBRVS 01/01/2025 56.31 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 RADIO DEF RBRVS 01/01/2024 12/31/2024 92.64 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 19.46 Description: X-RAY EXAM ENTIRE SPI 6/> 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72084 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 73.18 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 RADIO DEF RBRVS 01/01/2025 89.84 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 26 RADIO DEF RBRVS 01/01/2025 18.57 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 TC RADIO DEF RBRVS 01/01/2025 71.26 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72100 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 RADIO DEF RBRVS 01/01/2024 12/31/2024 37.41 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 10.39 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 12/31/2024 10.39 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 27.02 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 12/31/2024 27.02 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 SE MRT DEF RBRVS 01/01/2025 36.5 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 01/01/2025 36.5 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 26 SE MRT DEF RBRVS 01/01/2025 10.08 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 01/01/2025 10.08 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 TC SE MRT DEF RBRVS 01/01/2025 26.42 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 01/01/2025 26.42 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72110 SE MRT DEF RBRVS 01/01/2024 12/31/2024 48.03 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 12/31/2024 48.03 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 12.06 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 12.06 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 35.97 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 35.97 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 SE MRT DEF RBRVS 01/01/2025 47.47 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 RADIO DEF RBRVS 01/01/2025 47.47 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 26 SE MRT DEF RBRVS 01/01/2025 11.69 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 01/01/2025 11.69 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 TC SE MRT DEF RBRVS 01/01/2025 35.78 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 01/01/2025 35.78 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 SE MRT DEF RBRVS 01/01/2024 12/31/2024 57.88 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 12/31/2024 57.88 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 14.19 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 12/31/2024 14.19 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72114 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 43.69 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 12/31/2024 43.69 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 SE MRT DEF RBRVS 01/01/2025 55.89 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 RADIO DEF RBRVS 01/01/2025 55.89 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 26 SE MRT DEF RBRVS 01/01/2025 13.46 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 26 RADIO DEF RBRVS 01/01/2025 13.46 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 TC SE MRT DEF RBRVS 01/01/2025 42.43 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 TC RADIO DEF RBRVS 01/01/2025 42.43 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 RADIO DEF RBRVS 01/01/2024 12/31/2024 38.03 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 10.39 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 12/31/2024 27.64 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 RADIO DEF RBRVS 01/01/2025 37.11 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 26 RADIO DEF RBRVS 01/01/2025 10.08 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 TC RADIO DEF RBRVS 01/01/2025 27.03 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 RADIO DEF RBRVS 01/01/2024 12/31/2024 126.38 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.64 Description: CT NECK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72125 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 80.73 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 RADIO DEF RBRVS 01/01/2025 122.46 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 26 RADIO DEF RBRVS 01/01/2025 44.1 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 TC RADIO DEF RBRVS 01/01/2025 78.35 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 RADIO DEF RBRVS 01/01/2024 12/31/2024 164.26 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.89 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 108.37 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 RADIO DEF RBRVS 01/01/2025 158.66 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 26 RADIO DEF RBRVS 01/01/2025 53.88 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 TC RADIO DEF RBRVS 01/01/2025 104.78 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72127 RADIO DEF RBRVS 01/01/2024 12/31/2024 192.05 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.06 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 12/31/2024 133.99 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 RADIO DEF RBRVS 01/01/2025 185.51 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 26 RADIO DEF RBRVS 01/01/2025 55.98 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 TC RADIO DEF RBRVS 01/01/2025 129.53 Description: CT NECK SPINE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72128 RADIO DEF RBRVS 01/01/2024 12/31/2024 126.38 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.64 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 80.73 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 RADIO DEF RBRVS 01/01/2025 122.15 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 26 RADIO DEF RBRVS 01/01/2025 44.1 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 TC RADIO DEF RBRVS 01/01/2025 78.05 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 RADIO DEF RBRVS 01/01/2024 12/31/2024 165.35 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 56.05 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 109.3 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 RADIO DEF RBRVS 01/01/2025 159.72 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 26 RADIO DEF RBRVS 01/01/2025 54.04 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 TC RADIO DEF RBRVS 01/01/2025 105.68 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72130 RADIO DEF RBRVS 01/01/2024 12/31/2024 193.9 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72130 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.36 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 12/31/2024 135.54 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72130 RADIO DEF RBRVS 01/01/2025 186.72 Description: CT CHEST SPINE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72130 26 RADIO DEF RBRVS 01/01/2025 56.28 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72130 TC RADIO DEF RBRVS 01/01/2025 130.44 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72131 RADIO DEF RBRVS 01/01/2024 12/31/2024 125.76 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.64 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 80.12 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 RADIO DEF RBRVS 01/01/2025 121.55 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 26 RADIO DEF RBRVS 01/01/2025 44.1 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 TC RADIO DEF RBRVS 01/01/2025 77.45 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 RADIO DEF RBRVS 01/01/2024 12/31/2024 164.57 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.89 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 108.68 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 RADIO DEF RBRVS 01/01/2025 158.96 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 26 RADIO DEF RBRVS 01/01/2025 53.88 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 TC RADIO DEF RBRVS 01/01/2025 105.08 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72133 RADIO DEF RBRVS 01/01/2024 12/31/2024 192.67 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.36 Description: CT LUMBAR SPINE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72133 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 134.3 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 RADIO DEF RBRVS 01/01/2025 185.81 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 26 RADIO DEF RBRVS 01/01/2025 55.98 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 TC RADIO DEF RBRVS 01/01/2025 129.83 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72141 RADIO DEF RBRVS 01/01/2024 12/31/2024 186.36 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 68.11 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 118.25 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 RADIO DEF RBRVS 01/01/2025 179.87 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 26 RADIO DEF RBRVS 01/01/2025 65.43 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 TC RADIO DEF RBRVS 01/01/2025 114.44 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72142 RADIO DEF RBRVS 01/01/2024 12/31/2024 269.4 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.3 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 187.09 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 RADIO DEF RBRVS 01/01/2025 259.3 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 26 RADIO DEF RBRVS 01/01/2025 79.19 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 TC RADIO DEF RBRVS 01/01/2025 180.11 Description: MRI NECK 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72146 RADIO DEF RBRVS 01/01/2024 12/31/2024 186.36 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 68.11 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 118.25 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 RADIO DEF RBRVS 01/01/2025 179.57 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 26 RADIO DEF RBRVS 01/01/2025 65.43 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 TC RADIO DEF RBRVS 01/01/2025 114.13 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 RADIO DEF RBRVS 01/01/2024 12/31/2024 267.24 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 185.24 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 RADIO DEF RBRVS 01/01/2025 257.03 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 26 RADIO DEF RBRVS 01/01/2025 78.73 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 TC RADIO DEF RBRVS 01/01/2025 178.3 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 RADIO DEF RBRVS 01/01/2024 12/31/2024 186.98 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 68.11 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 118.87 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 RADIO DEF RBRVS 01/01/2025 180.47 Description: MRI LUMBAR SPINE W/O 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72148 26 RADIO DEF RBRVS 01/01/2025 65.73 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 TC RADIO DEF RBRVS 01/01/2025 114.74 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 RADIO DEF RBRVS 01/01/2024 12/31/2024 264.77 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 182.77 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 RADIO DEF RBRVS 01/01/2025 254.77 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 26 RADIO DEF RBRVS 01/01/2025 78.89 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 TC RADIO DEF RBRVS 01/01/2025 175.88 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72156 RADIO DEF RBRVS 01/01/2024 12/31/2024 313.56 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 105.16 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 12/31/2024 208.41 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 RADIO DEF RBRVS 01/01/2025 301.68 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 26 RADIO DEF RBRVS 01/01/2025 101.34 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 TC RADIO DEF RBRVS 01/01/2025 200.34 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 RADIO DEF RBRVS 01/01/2024 12/31/2024 314.18 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 105.16 Description: MRI CHEST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72157 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 209.02 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 RADIO DEF RBRVS 01/01/2025 302.28 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 26 RADIO DEF RBRVS 01/01/2025 101.34 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 TC RADIO DEF RBRVS 01/01/2025 200.94 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 RADIO DEF RBRVS 01/01/2024 12/31/2024 312.95 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 105.16 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 12/31/2024 207.79 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 RADIO DEF RBRVS 01/01/2025 301.08 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 26 RADIO DEF RBRVS 01/01/2025 101.34 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 TC RADIO DEF RBRVS 01/01/2025 199.73 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72159 RADIO DEF RBRVS 01/01/2024 12/31/2024 337.7 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.98 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 12/31/2024 254.71 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 RADIO DEF RBRVS 01/01/2025 324.56 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 26 RADIO DEF RBRVS 01/01/2025 79.69 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 TC RADIO DEF RBRVS 01/01/2025 244.87 Description: MR ANGIO SPINE W/O&W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72170 SE MRT DEF RBRVS 01/01/2024 12/31/2024 26.15 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.15 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.08 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 12/31/2024 8.08 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 18.07 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 12/31/2024 18.07 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 SE MRT DEF RBRVS 01/01/2025 25.51 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 RADIO DEF RBRVS 01/01/2025 25.51 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 26 SE MRT DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 26 RADIO DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 TC SE MRT DEF RBRVS 01/01/2025 17.67 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 TC RADIO DEF RBRVS 01/01/2025 17.67 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.66 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 11.72 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.95 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 RADIO DEF RBRVS 01/01/2025 38.69 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72190 26 RADIO DEF RBRVS 01/01/2025 11.36 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 TC RADIO DEF RBRVS 01/01/2025 27.33 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72191 RADIO DEF RBRVS 01/01/2024 12/31/2024 296.98 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72191 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.09 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 12/31/2024 214.89 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72191 RADIO DEF RBRVS 01/01/2025 285.64 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72191 26 RADIO DEF RBRVS 01/01/2025 78.97 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72191 TC RADIO DEF RBRVS 01/01/2025 206.68 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72192 RADIO DEF RBRVS 01/01/2024 12/31/2024 129.75 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.94 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 79.81 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 RADIO DEF RBRVS 01/01/2025 125.26 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 26 RADIO DEF RBRVS 01/01/2025 48.12 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 TC RADIO DEF RBRVS 01/01/2025 77.14 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 RADIO DEF RBRVS 01/01/2024 12/31/2024 224.28 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 53.24 Description: CT PELVIS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72193 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 171.04 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 RADIO DEF RBRVS 01/01/2025 214.66 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 26 RADIO DEF RBRVS 01/01/2025 51.31 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 TC RADIO DEF RBRVS 01/01/2025 163.34 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 RADIO DEF RBRVS 01/01/2024 12/31/2024 247.31 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.89 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 191.41 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 RADIO DEF RBRVS 01/01/2025 236.85 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 26 RADIO DEF RBRVS 01/01/2025 53.58 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 TC RADIO DEF RBRVS 01/01/2025 183.27 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72195 RADIO DEF RBRVS 01/01/2024 12/31/2024 224.27 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 67.12 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 157.15 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 RADIO DEF RBRVS 01/01/2025 215.74 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 26 RADIO DEF RBRVS 01/01/2025 64.78 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 TC RADIO DEF RBRVS 01/01/2025 150.97 Description: MRI PELVIS W/O 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72196 RADIO DEF RBRVS 01/01/2024 12/31/2024 263.38 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 79.68 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 183.7 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 RADIO DEF RBRVS 01/01/2025 252.68 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 26 RADIO DEF RBRVS 01/01/2025 76.19 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 TC RADIO DEF RBRVS 01/01/2025 176.49 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72197 RADIO DEF RBRVS 01/01/2024 12/31/2024 330.73 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 100.71 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 230.02 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 RADIO DEF RBRVS 01/01/2025 317.29 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 26 RADIO DEF RBRVS 01/01/2025 97.03 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 TC RADIO DEF RBRVS 01/01/2025 220.26 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72198 RADIO DEF RBRVS 01/01/2024 12/31/2024 329.67 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72198 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.06 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 12/31/2024 247.61 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72198 RADIO DEF RBRVS 01/01/2025 317.62 Description: MR ANGIO PELVIS W/O & W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72198 26 RADIO DEF RBRVS 01/01/2025 78.78 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72198 TC RADIO DEF RBRVS 01/01/2025 238.84 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72200 SE MRT DEF RBRVS 01/01/2024 12/31/2024 30.78 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.78 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.77 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 12/31/2024 7.77 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 23.01 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 12/31/2024 23.01 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 SE MRT DEF RBRVS 01/01/2025 30.34 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 RADIO DEF RBRVS 01/01/2025 30.34 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 26 SE MRT DEF RBRVS 01/01/2025 7.54 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 26 RADIO DEF RBRVS 01/01/2025 7.54 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 TC SE MRT DEF RBRVS 01/01/2025 22.8 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 TC RADIO DEF RBRVS 01/01/2025 22.8 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 SE MRT DEF RBRVS 01/01/2024 12/31/2024 36.83 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 12/31/2024 36.83 Description: X-RAY EXAM SI JOINTS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72202 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 10.42 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 12/31/2024 10.42 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 26.4 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 12/31/2024 26.4 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 SE MRT DEF RBRVS 01/01/2025 35.93 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72202 RADIO DEF RBRVS 01/01/2025 35.93 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 26 SE MRT DEF RBRVS 01/01/2025 10.11 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72202 26 RADIO DEF RBRVS 01/01/2025 10.11 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 TC SE MRT DEF RBRVS 01/01/2025 25.82 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72202 TC RADIO DEF RBRVS 01/01/2025 25.82 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 SE MRT DEF RBRVS 01/01/2024 12/31/2024 30.47 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.47 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.08 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 12/31/2024 8.08 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 22.39 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 12/31/2024 22.39 Description: X-RAY EXAM SACRUM TAILBONE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72220 SE MRT DEF RBRVS 01/01/2025 29.73 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 RADIO DEF RBRVS 01/01/2025 29.73 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 26 SE MRT DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 26 RADIO DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 TC SE MRT DEF RBRVS 01/01/2025 21.9 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 TC RADIO DEF RBRVS 01/01/2025 21.9 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72240 RADIO DEF RBRVS 01/01/2024 12/31/2024 108.07 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 42.46 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 65.61 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 RADIO DEF RBRVS 01/01/2025 102.76 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 26 RADIO DEF RBRVS 01/01/2025 40.41 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 TC RADIO DEF RBRVS 01/01/2025 62.35 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 RADIO DEF RBRVS 01/01/2024 12/31/2024 112.56 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 44.18 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 68.39 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 RADIO DEF RBRVS 01/01/2025 98.98 Description: MYELOGRAPHY THORACIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72255 26 RADIO DEF RBRVS 01/01/2025 40.25 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 TC RADIO DEF RBRVS 01/01/2025 58.73 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72265 RADIO DEF RBRVS 01/01/2024 12/31/2024 103.33 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 38.34 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 64.99 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 RADIO DEF RBRVS 01/01/2025 100.13 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 26 RADIO DEF RBRVS 01/01/2025 37.17 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 TC RADIO DEF RBRVS 01/01/2025 62.95 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 RADIO DEF RBRVS 01/01/2024 12/31/2024 155.33 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 63.48 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 91.85 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 RADIO DEF RBRVS 01/01/2025 140.38 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 26 RADIO DEF RBRVS 01/01/2025 60.52 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 TC RADIO DEF RBRVS 01/01/2025 79.86 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72285 ANEST DEF RBRVS 01/01/2024 12/31/2024 121.92 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 26 ANEST DEF RBRVS 01/01/2024 12/31/2024 53.85 Description: DISCOGRAPHY CERV/THOR SPINE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72285 TC ANEST DEF RBRVS 01/01/2024 12/31/2024 68.08 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 ANEST DEF RBRVS 01/01/2025 121.8 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 26 ANEST DEF RBRVS 01/01/2025 52.2 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 TC ANEST DEF RBRVS 01/01/2025 69.6 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 ANEST DEF RBRVS 01/01/2024 12/31/2024 104.57 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 26 ANEST DEF RBRVS 01/01/2024 12/31/2024 38.34 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 TC ANEST DEF RBRVS 01/01/2024 12/31/2024 66.23 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 ANEST DEF RBRVS 01/01/2025 102.24 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 26 ANEST DEF RBRVS 01/01/2025 36.87 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 TC ANEST DEF RBRVS 01/01/2025 65.37 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73000 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.13 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.39 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 RADIO DEF RBRVS 01/01/2025 29.71 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 26 RADIO DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 TC RADIO DEF RBRVS 01/01/2025 22.2 Description: X-RAY EXAM OF COLLAR BONE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73010 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.14 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.39 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 13.74 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 RADIO DEF RBRVS 01/01/2025 21.88 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 26 RADIO DEF RBRVS 01/01/2025 8.14 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 TC RADIO DEF RBRVS 01/01/2025 13.74 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 SE MRT DEF RBRVS 01/01/2024 12/31/2024 20.22 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 RADIO DEF RBRVS 01/01/2024 12/31/2024 20.22 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.1 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 12/31/2024 7.1 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 13.13 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 12/31/2024 13.13 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 SE MRT DEF RBRVS 01/01/2025 19.72 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 RADIO DEF RBRVS 01/01/2025 19.72 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 26 SE MRT DEF RBRVS 01/01/2025 6.88 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 26 RADIO DEF RBRVS 01/01/2025 6.88 Description: X-RAY EXAM OF SHOULDER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73020 TC SE MRT DEF RBRVS 01/01/2025 12.84 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 TC RADIO DEF RBRVS 01/01/2025 12.84 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 SE MRT DEF RBRVS 01/01/2024 12/31/2024 32.35 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 RADIO DEF RBRVS 01/01/2024 12/31/2024 32.35 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.73 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 12/31/2024 8.73 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 23.62 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 12/31/2024 23.62 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 SE MRT DEF RBRVS 01/01/2025 31.87 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 RADIO DEF RBRVS 01/01/2025 31.87 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 26 SE MRT DEF RBRVS 01/01/2025 8.47 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 26 RADIO DEF RBRVS 01/01/2025 8.47 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 TC SE MRT DEF RBRVS 01/01/2025 23.41 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 TC RADIO DEF RBRVS 01/01/2025 23.41 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73040 ANEST DEF RBRVS 01/01/2024 12/31/2024 123.14 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 26 ANEST DEF RBRVS 01/01/2024 12/31/2024 25.73 Description: CONTRAST X-RAY OF SHOULDER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73040 TC ANEST DEF RBRVS 01/01/2024 12/31/2024 97.41 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 ANEST DEF RBRVS 01/01/2025 120.06 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 26 ANEST DEF RBRVS 01/01/2025 24.8 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 TC ANEST DEF RBRVS 01/01/2025 95.26 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73050 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.8 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.73 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 18.07 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 RADIO DEF RBRVS 01/01/2025 26.44 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 26 RADIO DEF RBRVS 01/01/2025 8.47 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 TC RADIO DEF RBRVS 01/01/2025 17.97 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 SE MRT DEF RBRVS 01/01/2024 12/31/2024 30.13 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.13 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 22.39 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.39 Description: X-RAY EXAM OF HUMERUS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73060 SE MRT DEF RBRVS 01/01/2025 29.11 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 RADIO DEF RBRVS 01/01/2025 29.11 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 26 SE MRT DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 26 RADIO DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 TC SE MRT DEF RBRVS 01/01/2025 21.9 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 TC RADIO DEF RBRVS 01/01/2025 21.9 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 SE MRT DEF RBRVS 01/01/2024 12/31/2024 27.35 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 RADIO DEF RBRVS 01/01/2024 12/31/2024 27.35 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 19.61 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 19.61 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 SE MRT DEF RBRVS 01/01/2025 26.69 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 RADIO DEF RBRVS 01/01/2025 26.69 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 26 SE MRT DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 26 RADIO DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF ELBOW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73070 TC SE MRT DEF RBRVS 01/01/2025 19.18 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 TC RADIO DEF RBRVS 01/01/2025 19.18 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 SE MRT DEF RBRVS 01/01/2024 12/31/2024 30.47 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.47 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 22.39 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.39 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 SE MRT DEF RBRVS 01/01/2025 30.04 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 RADIO DEF RBRVS 01/01/2025 30.04 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 26 SE MRT DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 26 RADIO DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 TC SE MRT DEF RBRVS 01/01/2025 22.2 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 TC RADIO DEF RBRVS 01/01/2025 22.2 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 RADIO DEF RBRVS 01/01/2024 12/31/2024 104.62 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.04 Description: CONTRAST X-RAY OF ELBOW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73085 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 78.57 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 RADIO DEF RBRVS 01/01/2025 91.38 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 26 RADIO DEF RBRVS 01/01/2025 23.89 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 TC RADIO DEF RBRVS 01/01/2025 67.48 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 SE MRT DEF RBRVS 01/01/2024 12/31/2024 27.35 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 RADIO DEF RBRVS 01/01/2024 12/31/2024 27.35 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.44 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.44 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 19.92 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 19.92 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 SE MRT DEF RBRVS 01/01/2025 26.69 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 RADIO DEF RBRVS 01/01/2025 26.69 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 26 SE MRT DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 26 RADIO DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 TC SE MRT DEF RBRVS 01/01/2025 19.48 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 TC RADIO DEF RBRVS 01/01/2025 19.48 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73092 RADIO DEF RBRVS 01/01/2024 12/31/2024 29.51 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.44 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 22.08 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 RADIO DEF RBRVS 01/01/2025 28.8 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 26 RADIO DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 TC RADIO DEF RBRVS 01/01/2025 21.59 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 SE MRT DEF RBRVS 01/01/2024 12/31/2024 31.68 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 RADIO DEF RBRVS 01/01/2024 12/31/2024 31.68 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 23.93 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 23.93 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 SE MRT DEF RBRVS 01/01/2025 30.92 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 RADIO DEF RBRVS 01/01/2025 30.92 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 26 SE MRT DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 26 RADIO DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF WRIST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73100 TC SE MRT DEF RBRVS 01/01/2025 23.41 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 TC RADIO DEF RBRVS 01/01/2025 23.41 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 SE MRT DEF RBRVS 01/01/2024 12/31/2024 38.19 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 RADIO DEF RBRVS 01/01/2024 12/31/2024 38.19 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 30.11 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 30.11 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 SE MRT DEF RBRVS 01/01/2025 37.58 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 RADIO DEF RBRVS 01/01/2025 37.58 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 26 SE MRT DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 26 RADIO DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 TC SE MRT DEF RBRVS 01/01/2025 29.75 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 TC RADIO DEF RBRVS 01/01/2025 29.75 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 RADIO DEF RBRVS 01/01/2024 12/31/2024 126.84 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.04 Description: CONTRAST X-RAY OF WRIST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73115 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 100.8 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 RADIO DEF RBRVS 01/01/2025 123.08 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 26 RADIO DEF RBRVS 01/01/2025 25.1 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 TC RADIO DEF RBRVS 01/01/2025 97.97 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 SE MRT DEF RBRVS 01/01/2024 12/31/2024 29.21 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 RADIO DEF RBRVS 01/01/2024 12/31/2024 29.21 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 21.46 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 21.46 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 SE MRT DEF RBRVS 01/01/2025 28.8 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 RADIO DEF RBRVS 01/01/2025 28.8 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 26 SE MRT DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 26 RADIO DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 TC SE MRT DEF RBRVS 01/01/2025 21.29 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 TC RADIO DEF RBRVS 01/01/2025 21.29 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73130 SE MRT DEF RBRVS 01/01/2024 12/31/2024 34.48 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 RADIO DEF RBRVS 01/01/2024 12/31/2024 34.48 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.08 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 26.4 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 26.4 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 SE MRT DEF RBRVS 01/01/2025 33.96 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 RADIO DEF RBRVS 01/01/2025 33.96 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 26 SE MRT DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 26 RADIO DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 TC SE MRT DEF RBRVS 01/01/2025 26.12 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 TC RADIO DEF RBRVS 01/01/2025 26.12 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 RADIO DEF RBRVS 01/01/2024 12/31/2024 35.29 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 6.42 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 28.87 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 RADIO DEF RBRVS 01/01/2025 34.76 Description: X-RAY EXAM OF FINGER(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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73140 26 RADIO DEF RBRVS 01/01/2025 6.23 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 TC RADIO DEF RBRVS 01/01/2025 28.54 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 RADIO DEF RBRVS 01/01/2024 12/31/2024 157.56 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.64 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 111.91 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 RADIO DEF RBRVS 01/01/2025 151.44 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 26 RADIO DEF RBRVS 01/01/2025 44.1 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 TC RADIO DEF RBRVS 01/01/2025 107.33 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 RADIO DEF RBRVS 01/01/2024 12/31/2024 196.19 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 53.24 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 142.95 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 RADIO DEF RBRVS 01/01/2025 188.39 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 26 RADIO DEF RBRVS 01/01/2025 51.31 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 TC RADIO DEF RBRVS 01/01/2025 137.08 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 RADIO DEF RBRVS 01/01/2024 12/31/2024 242.98 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.89 Description: CT UPPR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73202 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 187.09 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 RADIO DEF RBRVS 01/01/2025 233.23 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 26 RADIO DEF RBRVS 01/01/2025 53.58 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 TC RADIO DEF RBRVS 01/01/2025 179.65 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73206 RADIO DEF RBRVS 01/01/2024 12/31/2024 289.57 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73206 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.09 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 12/31/2024 207.48 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73206 RADIO DEF RBRVS 01/01/2025 278.7 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73206 26 RADIO DEF RBRVS 01/01/2025 78.97 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73206 TC RADIO DEF RBRVS 01/01/2025 199.73 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 RADIO DEF RBRVS 01/01/2024 12/31/2024 297.27 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 62.31 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 234.96 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 RADIO DEF RBRVS 01/01/2025 284.9 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 26 RADIO DEF RBRVS 01/01/2025 60.11 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 TC RADIO DEF RBRVS 01/01/2025 224.79 Description: MRI UPPER EXTREMITY W/O 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73219 RADIO DEF RBRVS 01/01/2024 12/31/2024 325.1 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 74.4 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 250.7 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 RADIO DEF RBRVS 01/01/2025 311.41 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 26 RADIO DEF RBRVS 01/01/2025 71.83 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 TC RADIO DEF RBRVS 01/01/2025 239.58 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73220 RADIO DEF RBRVS 01/01/2024 12/31/2024 402.2 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73220 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 98.71 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 12/31/2024 303.49 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73220 RADIO DEF RBRVS 01/01/2025 385.39 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73220 26 RADIO DEF RBRVS 01/01/2025 95.09 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73220 TC RADIO DEF RBRVS 01/01/2025 290.3 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73221 RADIO DEF RBRVS 01/01/2024 12/31/2024 197.85 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73221 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 62.62 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 12/31/2024 135.23 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73221 RADIO DEF RBRVS 01/01/2025 191.15 Description: MRI JOINT UPR EXTREM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73221 26 RADIO DEF RBRVS 01/01/2025 60.11 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73221 TC RADIO DEF RBRVS 01/01/2025 131.04 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73222 RADIO DEF RBRVS 01/01/2024 12/31/2024 306.87 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 74.71 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 232.16 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 RADIO DEF RBRVS 01/01/2025 294.5 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 26 RADIO DEF RBRVS 01/01/2025 72.13 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 TC RADIO DEF RBRVS 01/01/2025 222.37 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 RADIO DEF RBRVS 01/01/2024 12/31/2024 379.97 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 99.02 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 12/31/2024 280.95 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 RADIO DEF RBRVS 01/01/2025 364.26 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 26 RADIO DEF RBRVS 01/01/2025 95.39 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 TC RADIO DEF RBRVS 01/01/2025 268.87 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73225 RADIO DEF RBRVS 01/01/2024 12/31/2024 334.4 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 79.68 Description: MR ANGIO UPR EXTR W/O&W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73225 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 254.71 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 RADIO DEF RBRVS 01/01/2025 321.37 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 26 RADIO DEF RBRVS 01/01/2025 76.49 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 TC RADIO DEF RBRVS 01/01/2025 244.87 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73501 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 30.81 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 8.73 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 22.08 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 SE MRT DEF RBRVS 01/01/2025 30.06 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 RADIO DEF RBRVS 01/01/2025 30.06 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 26 SE MRT DEF RBRVS 01/01/2025 8.47 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 26 RADIO DEF RBRVS 01/01/2025 8.47 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 TC SE MRT DEF RBRVS 01/01/2025 21.59 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 TC RADIO DEF RBRVS 01/01/2025 21.59 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73502 SE MRT DEF RBRVS 01/01/2024 12/31/2024 43.9 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73502 RADIO DEF RBRVS 01/01/2024 12/31/2024 43.9 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 10.39 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 33.5 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 01/01/2024 12/31/2024 33.5 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 SE MRT DEF RBRVS 01/01/2025 43.45 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73502 RADIO DEF RBRVS 01/01/2025 43.45 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 26 SE MRT DEF RBRVS 01/01/2025 10.08 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 01/01/2025 10.08 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 TC SE MRT DEF RBRVS 01/01/2025 33.37 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 01/01/2025 33.37 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 55.47 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 12.71 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73503 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 42.76 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 SE MRT DEF RBRVS 01/01/2025 54.75 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 RADIO DEF RBRVS 01/01/2025 54.75 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 26 SE MRT DEF RBRVS 01/01/2025 12.32 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 26 RADIO DEF RBRVS 01/01/2025 12.32 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 TC SE MRT DEF RBRVS 01/01/2025 42.43 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 TC RADIO DEF RBRVS 01/01/2025 42.43 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 38.65 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 10.39 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 28.25 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 SE MRT DEF RBRVS 01/01/2025 37.71 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 RADIO DEF RBRVS 01/01/2025 37.71 Description: X-RAY EXAM HIPS BI 2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73521 26 SE MRT DEF RBRVS 01/01/2025 10.08 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 26 RADIO DEF RBRVS 01/01/2025 10.08 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 TC SE MRT DEF RBRVS 01/01/2025 27.63 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 TC RADIO DEF RBRVS 01/01/2025 27.63 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 50.28 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 13.69 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 36.59 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 SE MRT DEF RBRVS 01/01/2025 49.36 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73522 RADIO DEF RBRVS 01/01/2025 49.36 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 26 SE MRT DEF RBRVS 01/01/2025 13.28 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 01/01/2025 13.28 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 TC SE MRT DEF RBRVS 01/01/2025 36.09 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 01/01/2025 36.09 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73523 RADIO DEF RBRVS 01/01/2024 12/31/2024 57.91 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 12/31/2024 14.53 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 12/31/2024 43.38 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 RADIO DEF RBRVS 01/01/2025 56.52 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 26 RADIO DEF RBRVS 01/01/2025 14.09 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 TC RADIO DEF RBRVS 01/01/2025 42.43 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73525 ANEST DEF RBRVS 01/01/2024 12/31/2024 122.21 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 26 ANEST DEF RBRVS 01/01/2024 12/31/2024 26.66 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 TC ANEST DEF RBRVS 01/01/2024 12/31/2024 95.55 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 ANEST DEF RBRVS 01/01/2025 117.36 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 26 ANEST DEF RBRVS 01/01/2025 26.02 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 TC ANEST DEF RBRVS 01/01/2025 91.33 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73551 RADIO DEF RBRVS 01/01/2024 12/31/2024 27.35 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 19.61 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 RADIO DEF RBRVS 01/01/2025 26.69 Description: X-RAY EXAM OF FEMUR 1 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73551 26 RADIO DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 TC RADIO DEF RBRVS 01/01/2025 19.18 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 SE MRT DEF RBRVS 01/01/2024 12/31/2024 33.28 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 RADIO DEF RBRVS 01/01/2024 12/31/2024 33.28 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 8.42 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 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 01/01/2024 12/31/2024 24.86 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 SE MRT DEF RBRVS 01/01/2025 32.48 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 RADIO DEF RBRVS 01/01/2025 32.48 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 26 SE MRT DEF RBRVS 01/01/2025 8.17 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 26 RADIO DEF RBRVS 01/01/2025 8.17 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 TC SE MRT DEF RBRVS 01/01/2025 24.31 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 TC RADIO DEF RBRVS 01/01/2025 24.31 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73560 SE MRT DEF RBRVS 01/01/2024 12/31/2024 31.98 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 12/31/2024 31.98 Description: X-RAY EXAM OF KNEE 1 OR 2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73560 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73560 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.74 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 24.24 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 12/31/2024 24.24 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 SE MRT DEF RBRVS 01/01/2025 31.22 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73560 RADIO DEF RBRVS 01/01/2025 31.22 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 26 SE MRT DEF RBRVS 01/01/2025 7.51 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 01/01/2025 7.51 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 TC SE MRT DEF RBRVS 01/01/2025 23.71 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 01/01/2025 23.71 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 SE MRT DEF RBRVS 01/01/2024 12/31/2024 37.91 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 12/31/2024 37.91 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.73 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 12/31/2024 8.73 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 29.18 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 12/31/2024 29.18 Description: X-RAY EXAM OF KNEE 3 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73562 SE MRT DEF RBRVS 01/01/2025 37.31 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 RADIO DEF RBRVS 01/01/2025 37.31 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 26 SE MRT DEF RBRVS 01/01/2025 8.47 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 26 RADIO DEF RBRVS 01/01/2025 8.47 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 TC SE MRT DEF RBRVS 01/01/2025 28.84 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 TC RADIO DEF RBRVS 01/01/2025 28.84 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73564 SE MRT DEF RBRVS 01/01/2024 12/31/2024 43.59 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 12/31/2024 43.59 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 10.7 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 12/31/2024 10.7 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 32.88 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 12/31/2024 32.88 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 SE MRT DEF RBRVS 01/01/2025 43.15 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: 73564 RADIO DEF RBRVS 01/01/2025 43.15 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 26 SE MRT DEF RBRVS 01/01/2025 10.38 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: 73564 26 RADIO DEF RBRVS 01/01/2025 10.38 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73564 TC SE MRT DEF RBRVS 01/01/2025 32.76 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: 73564 TC RADIO DEF RBRVS 01/01/2025 32.76 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73565 SE MRT DEF RBRVS 01/01/2024 12/31/2024 37.23 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 RADIO DEF RBRVS 01/01/2024 12/31/2024 37.23 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.05 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 12/31/2024 8.05 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 29.18 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 12/31/2024 29.18 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 SE MRT DEF RBRVS 01/01/2025 36.35 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 RADIO DEF RBRVS 01/01/2025 36.35 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 26 SE MRT DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 26 RADIO DEF RBRVS 01/01/2025 7.51 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 TC SE MRT DEF RBRVS 01/01/2025 28.84 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 TC RADIO DEF RBRVS 01/01/2025 28.84 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73580 RADIO DEF RBRVS 01/01/2024 12/31/2024 119.29 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 28.68 Description: CONTRAST X-RAY OF KNEE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73580 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 90.61 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 RADIO DEF RBRVS 01/01/2025 100.74 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 26 RADIO DEF RBRVS 01/01/2025 28.12 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 TC RADIO DEF RBRVS 01/01/2025 72.62 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 SE MRT DEF RBRVS 01/01/2024 12/31/2024 29.51 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 12/31/2024 29.51 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.44 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 12/31/2024 7.44 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 22.08 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 12/31/2024 22.08 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 SE MRT DEF RBRVS 01/01/2025 28.8 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 RADIO DEF RBRVS 01/01/2025 28.8 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 26 SE MRT DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 26 RADIO DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 TC SE MRT DEF RBRVS 01/01/2025 21.59 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 TC RADIO DEF RBRVS 01/01/2025 21.59 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73592 RADIO DEF RBRVS 01/01/2024 12/31/2024 29.51 0-364Days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.44 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 12/31/2024 22.08 0-364Days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 RADIO DEF RBRVS 01/01/2025 28.8 0-364Days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 26 RADIO DEF RBRVS 01/01/2025 7.21 0-364Days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 TC RADIO DEF RBRVS 01/01/2025 21.59 0-364Days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 SE MRT DEF RBRVS 01/01/2024 12/31/2024 30.44 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.44 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.74 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 12/31/2024 7.74 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 22.7 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 12/31/2024 22.7 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 SE MRT DEF RBRVS 01/01/2025 29.41 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 RADIO DEF RBRVS 01/01/2025 29.41 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 26 SE MRT DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 26 RADIO DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF ANKLE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73600 TC SE MRT DEF RBRVS 01/01/2025 22.2 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 TC RADIO DEF RBRVS 01/01/2025 22.2 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 SE MRT DEF RBRVS 01/01/2024 12/31/2024 34.48 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 RADIO DEF RBRVS 01/01/2024 12/31/2024 34.48 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.08 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 12/31/2024 8.08 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 26.4 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 12/31/2024 26.4 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 SE MRT DEF RBRVS 01/01/2025 33.36 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 RADIO DEF RBRVS 01/01/2025 33.36 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 26 SE MRT DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 26 RADIO DEF RBRVS 01/01/2025 7.84 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 TC SE MRT DEF RBRVS 01/01/2025 25.52 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 TC RADIO DEF RBRVS 01/01/2025 25.52 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 RADIO DEF RBRVS 01/01/2024 12/31/2024 121.29 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.04 Description: CONTRAST X-RAY OF ANKLE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73615 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 95.24 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 RADIO DEF RBRVS 01/01/2025 116.74 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 26 RADIO DEF RBRVS 01/01/2025 25.4 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 TC RADIO DEF RBRVS 01/01/2025 91.33 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 SE MRT DEF RBRVS 01/01/2024 12/31/2024 26.43 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.43 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.13 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 12/31/2024 7.13 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 19.3 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 12/31/2024 19.3 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 SE MRT DEF RBRVS 01/01/2025 26.09 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 RADIO DEF RBRVS 01/01/2025 26.09 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 26 SE MRT DEF RBRVS 01/01/2025 6.91 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 26 RADIO DEF RBRVS 01/01/2025 6.91 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 TC SE MRT DEF RBRVS 01/01/2025 19.18 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 TC RADIO DEF RBRVS 01/01/2025 19.18 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73630 SE MRT DEF RBRVS 01/01/2024 12/31/2024 32.01 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 RADIO DEF RBRVS 01/01/2024 12/31/2024 32.01 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 7.77 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 12/31/2024 7.77 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 24.24 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 12/31/2024 24.24 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 SE MRT DEF RBRVS 01/01/2025 31.24 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 RADIO DEF RBRVS 01/01/2025 31.24 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 26 SE MRT DEF RBRVS 01/01/2025 7.54 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 26 RADIO DEF RBRVS 01/01/2025 7.54 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 TC SE MRT DEF RBRVS 01/01/2025 23.71 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 TC RADIO DEF RBRVS 01/01/2025 23.71 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.74 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 7.44 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 19.3 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 RADIO DEF RBRVS 01/01/2025 26.09 Description: X-RAY EXAM OF HEEL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73650 26 RADIO DEF RBRVS 01/01/2025 7.21 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 TC RADIO DEF RBRVS 01/01/2025 18.88 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 RADIO DEF RBRVS 01/01/2024 12/31/2024 27.26 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 6.11 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 21.15 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 RADIO DEF RBRVS 01/01/2025 26.61 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 26 RADIO DEF RBRVS 01/01/2025 5.93 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 TC RADIO DEF RBRVS 01/01/2025 20.69 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 RADIO DEF RBRVS 01/01/2024 12/31/2024 126.07 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.64 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 80.43 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 RADIO DEF RBRVS 01/01/2025 121.85 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 26 RADIO DEF RBRVS 01/01/2025 44.1 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 TC RADIO DEF RBRVS 01/01/2025 77.75 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 RADIO DEF RBRVS 01/01/2024 12/31/2024 162.23 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 53.24 Description: CT LOWER EXTREMITY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73701 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 108.99 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 RADIO DEF RBRVS 01/01/2025 156.69 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 26 RADIO DEF RBRVS 01/01/2025 51.31 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 TC RADIO DEF RBRVS 01/01/2025 105.38 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 RADIO DEF RBRVS 01/01/2024 12/31/2024 189.89 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.58 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 12/31/2024 134.3 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 RADIO DEF RBRVS 01/01/2025 183.41 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 26 RADIO DEF RBRVS 01/01/2025 53.58 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 TC RADIO DEF RBRVS 01/01/2025 129.83 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73706 RADIO DEF RBRVS 01/01/2024 12/31/2024 314.84 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 86.37 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 12/31/2024 228.47 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 RADIO DEF RBRVS 01/01/2025 302.94 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 26 RADIO DEF RBRVS 01/01/2025 83.12 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 TC RADIO DEF RBRVS 01/01/2025 219.82 Description: CT ANGIO LWR EXTR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73718 RADIO DEF RBRVS 01/01/2024 12/31/2024 218.84 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 62 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 156.84 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 RADIO DEF RBRVS 01/01/2025 210.17 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 26 RADIO DEF RBRVS 01/01/2025 59.51 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 TC RADIO DEF RBRVS 01/01/2025 150.66 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 RADIO DEF RBRVS 01/01/2024 12/31/2024 257.17 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 74.4 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 182.77 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 RADIO DEF RBRVS 01/01/2025 247.71 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 26 RADIO DEF RBRVS 01/01/2025 71.52 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 TC RADIO DEF RBRVS 01/01/2025 176.18 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73720 RADIO DEF RBRVS 01/01/2024 12/31/2024 330.89 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73720 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 98.71 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 12/31/2024 232.18 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73720 RADIO DEF RBRVS 01/01/2025 317.47 Description: MRI LWR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73720 26 RADIO DEF RBRVS 01/01/2025 94.79 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73720 TC RADIO DEF RBRVS 01/01/2025 222.68 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73721 RADIO DEF RBRVS 01/01/2024 12/31/2024 197.54 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73721 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 62.31 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 12/31/2024 135.23 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73721 RADIO DEF RBRVS 01/01/2025 190.85 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73721 26 RADIO DEF RBRVS 01/01/2025 60.11 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73721 TC RADIO DEF RBRVS 01/01/2025 130.74 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73722 RADIO DEF RBRVS 01/01/2024 12/31/2024 307.18 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 74.71 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 12/31/2024 232.47 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 RADIO DEF RBRVS 01/01/2025 294.8 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 26 RADIO DEF RBRVS 01/01/2025 71.83 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 TC RADIO DEF RBRVS 01/01/2025 222.98 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 RADIO DEF RBRVS 01/01/2024 12/31/2024 378.74 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 98.71 Description: MRI JOINT LWR EXTR 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73723 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 280.03 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 RADIO DEF RBRVS 01/01/2025 362.75 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 26 RADIO DEF RBRVS 01/01/2025 95.09 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 TC RADIO DEF RBRVS 01/01/2025 267.66 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73725 RADIO DEF RBRVS 01/01/2024 12/31/2024 327.26 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73725 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.42 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 12/31/2024 244.84 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73725 RADIO DEF RBRVS 01/01/2025 315.42 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73725 26 RADIO DEF RBRVS 01/01/2025 79.3 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73725 TC RADIO DEF RBRVS 01/01/2025 236.12 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 74018 SE MRT DEF RBRVS 01/01/2024 12/31/2024 28.03 Description: RADEX ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 RADIO DEF RBRVS 01/01/2024 12/31/2024 28.03 Description: RADEX ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74018 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 8.42 Description: RADEX ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.42 Description: RADEX ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74018 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 19.61 Description: RADEX ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 19.61 Description: RADEX ABDOMEN 1 VIEW 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74018 SE MRT DEF RBRVS 01/01/2025 27.65 Description: RADEX ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 RADIO DEF RBRVS 01/01/2025 27.65 Description: RADEX ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74018 26 SE MRT DEF RBRVS 01/01/2025 8.17 Description: RADEX ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 26 RADIO DEF RBRVS 01/01/2025 8.17 Description: RADEX ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74018 TC SE MRT DEF RBRVS 01/01/2025 19.48 Description: RADEX ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 TC RADIO DEF RBRVS 01/01/2025 19.48 Description: RADEX ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 SE MRT DEF RBRVS 01/01/2024 12/31/2024 34.67 Description: RADEX ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 RADIO DEF RBRVS 01/01/2024 12/31/2024 34.67 Description: RADEX ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 10.73 Description: RADEX ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 10.73 Description: RADEX ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 23.93 Description: RADEX ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 23.93 Description: RADEX ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 SE MRT DEF RBRVS 01/01/2025 33.51 Description: RADEX ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 RADIO DEF RBRVS 01/01/2025 33.51 Description: RADEX ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 26 SE MRT DEF RBRVS 01/01/2025 10.11 Description: RADEX ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 26 RADIO DEF RBRVS 01/01/2025 10.11 Description: RADEX ABDOMEN 2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74019 TC SE MRT DEF RBRVS 01/01/2025 23.41 Description: RADEX ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 TC RADIO DEF RBRVS 01/01/2025 23.41 Description: RADEX ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 SE MRT DEF RBRVS 01/01/2024 12/31/2024 40.34 Description: RADEX ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 RADIO DEF RBRVS 01/01/2024 12/31/2024 40.34 Description: RADEX ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 12.4 Description: RADEX ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 12.4 Description: RADEX ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 27.95 Description: RADEX ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.95 Description: RADEX ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 SE MRT DEF RBRVS 01/01/2025 39.35 Description: RADEX ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 RADIO DEF RBRVS 01/01/2025 39.35 Description: RADEX ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 26 SE MRT DEF RBRVS 01/01/2025 12.02 Description: RADEX ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 26 RADIO DEF RBRVS 01/01/2025 12.02 Description: RADEX ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 TC SE MRT DEF RBRVS 01/01/2025 27.33 Description: RADEX ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 TC RADIO DEF RBRVS 01/01/2025 27.33 Description: RADEX ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74022 SE MRT DEF RBRVS 01/01/2024 12/31/2024 46.83 Description: RADEX COMPL AQT ABD SERIES Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 RADIO DEF RBRVS 01/01/2024 12/31/2024 46.83 Description: RADEX COMPL AQT ABD SERIES 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74022 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 14.87 Description: RADEX COMPL AQT ABD SERIES Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 14.87 Description: RADEX COMPL AQT ABD SERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 31.96 Description: RADEX COMPL AQT ABD SERIES Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 31.96 Description: RADEX COMPL AQT ABD SERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 SE MRT DEF RBRVS 01/01/2025 45.67 Description: RADEX COMPL AQT ABD SERIES Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 RADIO DEF RBRVS 01/01/2025 45.67 Description: RADEX COMPL AQT ABD SERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 26 SE MRT DEF RBRVS 01/01/2025 14.12 Description: RADEX COMPL AQT ABD SERIES Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 26 RADIO DEF RBRVS 01/01/2025 14.12 Description: RADEX COMPL AQT ABD SERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 TC SE MRT DEF RBRVS 01/01/2025 31.56 Description: RADEX COMPL AQT ABD SERIES Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 TC RADIO DEF RBRVS 01/01/2025 31.56 Description: RADEX COMPL AQT ABD SERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 RADIO DEF RBRVS 01/01/2024 12/31/2024 133.45 Description: CT ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 54.57 Description: CT ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 78.88 Description: CT ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 RADIO DEF RBRVS 01/01/2025 128.84 Description: CT ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 26 RADIO DEF RBRVS 01/01/2025 52.6 Description: CT ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 TC RADIO DEF RBRVS 01/01/2025 76.24 Description: CT ABDOMEN W/O CONTRAST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74160 RADIO DEF RBRVS 01/01/2024 12/31/2024 228.48 Description: CT ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.36 Description: CT ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 170.11 Description: CT ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 RADIO DEF RBRVS 01/01/2025 218.72 Description: CT ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 26 RADIO DEF RBRVS 01/01/2025 56.28 Description: CT ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 TC RADIO DEF RBRVS 01/01/2025 162.44 Description: CT ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 RADIO DEF RBRVS 01/01/2024 12/31/2024 256.35 Description: CT ABD WO CNTRST FLWD CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 64 Description: CT ABD WO CNTRST FLWD CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 192.34 Description: CT ABD WO CNTRST FLWD CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 RADIO DEF RBRVS 01/01/2025 245.92 Description: CT ABD WO CNTRST FLWD CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 26 RADIO DEF RBRVS 01/01/2025 61.75 Description: CT ABD WO CNTRST FLWD CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 TC RADIO DEF RBRVS 01/01/2025 184.18 Description: CT ABD WO CNTRST FLWD CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74174 RADIO DEF RBRVS 01/01/2024 12/31/2024 370.4 Description: CTA ABD&PLVS W/CONTRAST Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 100.25 Description: CTA ABD&PLVS W/CONTRAST Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 270.15 Description: CTA ABD&PLVS W/CONTRAST Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 RADIO DEF RBRVS 01/01/2025 356.86 Description: CTA ABD&PLVS W/CONTRAST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74174 26 RADIO DEF RBRVS 01/01/2025 96.59 Description: CTA ABD&PLVS W/CONTRAST Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 TC RADIO DEF RBRVS 01/01/2025 260.27 Description: CTA ABD&PLVS W/CONTRAST Category: Radiology CMS Add: 01/01/2012 CMS Term: 74175 RADIO DEF RBRVS 01/01/2024 12/31/2024 298.55 Description: CTA ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 83.04 Description: CTA ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 215.51 Description: CTA ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 RADIO DEF RBRVS 01/01/2025 286.88 Description: CTA ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 26 RADIO DEF RBRVS 01/01/2025 79.9 Description: CTA ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 TC RADIO DEF RBRVS 01/01/2025 206.98 Description: CTA ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74176 RADIO DEF RBRVS 01/01/2024 12/31/2024 178.82 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 80.02 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 98.8 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 RADIO DEF RBRVS 01/01/2025 172.84 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 26 RADIO DEF RBRVS 01/01/2025 76.82 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 TC RADIO DEF RBRVS 01/01/2025 96.02 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 RADIO DEF RBRVS 01/01/2024 12/31/2024 297.61 Description: CT ABD & PELVIS W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 83.66 Description: CT ABD & PELVIS W/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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74177 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 213.95 Description: CT ABD & PELVIS W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 RADIO DEF RBRVS 01/01/2025 285.05 Description: CT ABD & PELVIS W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 26 RADIO DEF RBRVS 01/01/2025 80.35 Description: CT ABD & PELVIS W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 TC RADIO DEF RBRVS 01/01/2025 204.7 Description: CT ABD & PELVIS W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 RADIO DEF RBRVS 01/01/2024 12/31/2024 333.38 Description: CT ABD&PLV WO CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 91.95 Description: CT ABD&PLV WO CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 241.43 Description: CT ABD&PLV WO CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 RADIO DEF RBRVS 01/01/2025 319.67 Description: CT ABD&PLV WO CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 26 RADIO DEF RBRVS 01/01/2025 88.54 Description: CT ABD&PLV WO CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 TC RADIO DEF RBRVS 01/01/2025 231.13 Description: CT ABD&PLV WO CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 74181 RADIO DEF RBRVS 01/01/2024 12/31/2024 192.17 Description: MRI ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 67.12 Description: MRI ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 125.04 Description: MRI ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 RADIO DEF RBRVS 01/01/2025 184.65 Description: MRI ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 26 RADIO DEF RBRVS 01/01/2025 64.47 Description: MRI ABDOMEN W/O CONTRAST Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 TC RADIO DEF RBRVS 01/01/2025 120.17 Description: MRI ABDOMEN W/O CONTRAST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74182 RADIO DEF RBRVS 01/01/2024 12/31/2024 296.43 Description: MRI ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 79.37 Description: MRI ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 217.05 Description: MRI ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 RADIO DEF RBRVS 01/01/2025 284.38 Description: MRI ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 26 RADIO DEF RBRVS 01/01/2025 76.19 Description: MRI ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 TC RADIO DEF RBRVS 01/01/2025 208.18 Description: MRI ABDOMEN W/CONTRAST Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 RADIO DEF RBRVS 01/01/2024 12/31/2024 331.96 Description: MRI ABD W/O CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 100.71 Description: MRI ABD W/O CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 231.25 Description: MRI ABD W/O CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 RADIO DEF RBRVS 01/01/2025 318.5 Description: MRI ABD W/O CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 26 RADIO DEF RBRVS 01/01/2025 97.03 Description: MRI ABD W/O CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 TC RADIO DEF RBRVS 01/01/2025 221.47 Description: MRI ABD W/O CNTR FLWD CNTR Category: Radiology CMS Add: 01/01/2001 CMS Term: 74185 RADIO DEF RBRVS 01/01/2024 12/31/2024 329.05 Description: MRA ABD W OR W/O CNTRST Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.06 Description: MRA ABD W OR W/O CNTRST Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 247 Description: MRA ABD W OR W/O CNTRST Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 RADIO DEF RBRVS 01/01/2025 316.41 Description: MRA ABD W OR W/O CNTRST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74185 26 RADIO DEF RBRVS 01/01/2025 78.78 Description: MRA ABD W OR W/O CNTRST Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 TC RADIO DEF RBRVS 01/01/2025 237.63 Description: MRA ABD W OR W/O CNTRST Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 RADIO DEF MAXFEE 01/01/2024 75.51 0 Description: PERITONEOGRAM RS&I Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 21.23 Description: PERITONEOGRAM RS&I Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 TC RADIO DEF MAXFEE 01/01/2024 51.03 0 Description: PERITONEOGRAM RS&I Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 26 RADIO DEF RBRVS 01/01/2025 20.42 Description: PERITONEOGRAM RS&I Category: Radiology CMS Add: 01/01/1994 CMS Term: 74210 RADIO DEF RBRVS 01/01/2024 12/31/2024 91.18 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74210 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 27.12 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 12/31/2024 64.06 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74210 RADIO DEF RBRVS 01/01/2025 86.67 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74210 26 RADIO DEF RBRVS 01/01/2025 25.83 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74210 TC RADIO DEF RBRVS 01/01/2025 60.84 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 RADIO DEF RBRVS 01/01/2024 12/31/2024 93.38 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 27.77 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 65.61 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 RADIO DEF RBRVS 01/01/2025 89.12 Description: X-RAY XM ESOPHAGUS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74220 26 RADIO DEF RBRVS 01/01/2025 26.46 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 TC RADIO DEF RBRVS 01/01/2025 62.65 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74221 RADIO DEF RBRVS 01/01/2024 12/31/2024 105.1 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 32.08 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 73.02 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 RADIO DEF RBRVS 01/01/2025 100.4 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 26 RADIO DEF RBRVS 01/01/2025 30.8 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 TC RADIO DEF RBRVS 01/01/2025 69.6 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74230 RADIO DEF RBRVS 01/01/2024 12/31/2024 118.79 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 24.47 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 94.32 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 RADIO DEF RBRVS 01/01/2025 113.69 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 26 RADIO DEF RBRVS 01/01/2025 23.57 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 TC RADIO DEF RBRVS 01/01/2025 90.13 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74235 RADIO DEF MAXFEE 01/01/2024 169.6 0 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74235 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 54.87 Description: REMOVE ESOPHAGUS OBSTRUCTION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74235 TC RADIO DEF MAXFEE 01/01/2024 104.03 0 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74235 26 RADIO DEF RBRVS 01/01/2025 52.6 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74240 RADIO DEF RBRVS 01/01/2024 12/31/2024 117.13 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74240 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 37.01 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 12/31/2024 80.12 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74240 RADIO DEF RBRVS 01/01/2025 112.43 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74240 26 RADIO DEF RBRVS 01/01/2025 35.59 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74240 TC RADIO DEF RBRVS 01/01/2025 76.84 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 RADIO DEF RBRVS 01/01/2024 12/31/2024 132.87 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 41.02 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 12/31/2024 91.85 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 RADIO DEF RBRVS 01/01/2025 127.33 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 26 RADIO DEF RBRVS 01/01/2025 39.62 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 TC RADIO DEF RBRVS 01/01/2025 87.71 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74248 RADIO DEF RBRVS 01/01/2024 12/31/2024 78.86 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 12/31/2024 32.08 Description: X-RAY SM INT F-THRU STD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74248 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 46.78 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74248 RADIO DEF RBRVS 01/01/2025 75.64 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74248 26 RADIO DEF RBRVS 01/01/2025 30.8 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74248 TC RADIO DEF RBRVS 01/01/2025 44.84 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74250 RADIO DEF RBRVS 01/01/2024 12/31/2024 116.55 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74250 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 37.05 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 12/31/2024 79.5 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74250 RADIO DEF RBRVS 01/01/2025 111.55 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74250 26 RADIO DEF RBRVS 01/01/2025 35.61 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74250 TC RADIO DEF RBRVS 01/01/2025 75.94 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74251 RADIO DEF RBRVS 01/01/2024 12/31/2024 349.18 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 53.89 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 12/31/2024 295.29 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 RADIO DEF RBRVS 01/01/2025 330.15 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 26 RADIO DEF RBRVS 01/01/2025 51.64 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 TC RADIO DEF RBRVS 01/01/2025 278.51 Description: X-RAY XM SM INT 2CNTRST STD 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74261 NOCOV DEF SYSMAN 01/01/2010 Y Description: CT COLONOGRAPHY DX Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 74262 NOCOV DEF SYSMAN 01/01/2010 Y Description: CT COLONOGRAPHY DX W/DYE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 74263 RADIO DEF RBRVS 01/01/2024 12/31/2024 640.41 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 105.07 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 535.33 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 RADIO DEF RBRVS 01/01/2025 615.12 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 26 RADIO DEF RBRVS 01/01/2025 102.02 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 TC RADIO DEF RBRVS 01/01/2025 513.11 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74270 RADIO DEF RBRVS 01/01/2024 12/31/2024 146.57 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 47.62 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 98.95 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 RADIO DEF RBRVS 01/01/2025 140.67 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 26 RADIO DEF RBRVS 01/01/2025 45.72 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 TC RADIO DEF RBRVS 01/01/2025 94.96 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 RADIO DEF RBRVS 01/01/2024 12/31/2024 210.23 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 57.72 Description: X-RAY XM COLON 2CNTRST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74280 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 152.52 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 RADIO DEF RBRVS 01/01/2025 200.88 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 26 RADIO DEF RBRVS 01/01/2025 55.65 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 TC RADIO DEF RBRVS 01/01/2025 145.23 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74283 RADIO DEF RBRVS 01/01/2024 12/31/2024 242.03 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 95.85 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 146.18 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 RADIO DEF RBRVS 01/01/2025 234.24 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 26 RADIO DEF RBRVS 01/01/2025 92.79 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 TC RADIO DEF RBRVS 01/01/2025 141.45 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74290 RADIO DEF RBRVS 01/01/2024 12/31/2024 81.4 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 14.87 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 66.53 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 RADIO DEF RBRVS 01/01/2025 77.37 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 26 RADIO DEF RBRVS 01/01/2025 14.12 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 TC RADIO DEF RBRVS 01/01/2025 63.26 Description: CONTRAST X-RAY GALLBLADDER 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74300 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 12.56 Description: X-RAY BILE DUCTS/PANCREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74300 26 RADIO DEF RBRVS 01/01/2025 12.18 Description: X-RAY BILE DUCTS/PANCREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74301 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 9.75 Description: X-RAYS AT SURGERY ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 74301 26 RADIO DEF RBRVS 01/01/2025 9.15 Description: X-RAYS AT SURGERY ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 74328 RADIO DEF MAXFEE 01/01/2024 158.85 0 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74328 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.11 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 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74328 26 RADIO DEF RBRVS 01/01/2025 21.44 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 RADIO DEF MAXFEE 01/01/2024 166.99 0 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.42 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 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 26 RADIO DEF RBRVS 01/01/2025 21.75 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 RADIO DEF MAXFEE 01/01/2024 168.85 0 Description: X-RAY BILE/PANC ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.41 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 Description: X-RAY BILE/PANC ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 26 RADIO DEF RBRVS 01/01/2025 25.15 Description: X-RAY BILE/PANC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74340 RADIO DEF MAXFEE 01/01/2024 130.19 0 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74340 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 24.81 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 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74340 26 RADIO DEF RBRVS 01/01/2025 23.59 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74355 RADIO DEF MAXFEE 01/01/2024 140.64 0 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74355 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 35.04 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 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74355 26 RADIO DEF RBRVS 01/01/2025 33.67 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74360 RADIO DEF MAXFEE 01/01/2024 151.66 0 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: 74360 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 25.43 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 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: 74360 26 RADIO DEF RBRVS 01/01/2025 24.82 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: 74363 RADIO DEF MAXFEE 01/01/2024 288.88 0 Description: X-RAY BILE DUCT DILATION Category: Radiology CMS Add: 01/01/1991 CMS Term: 74363 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 40.03 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 Description: X-RAY BILE DUCT DILATION Category: Radiology CMS Add: 01/01/1991 CMS Term: 74363 26 RADIO DEF RBRVS 01/01/2025 38.36 Description: X-RAY BILE DUCT DILATION 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74400 RADIO DEF RBRVS 01/01/2024 12/31/2024 127.16 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.5 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 104.67 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 RADIO DEF RBRVS 01/01/2025 122.81 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 26 RADIO DEF RBRVS 01/01/2025 21.65 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 TC RADIO DEF RBRVS 01/01/2025 101.15 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74410 RADIO DEF RBRVS 01/01/2024 12/31/2024 132.09 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.17 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 109.91 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 RADIO DEF RBRVS 01/01/2025 128.99 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 26 RADIO DEF RBRVS 01/01/2025 21.49 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 TC RADIO DEF RBRVS 01/01/2025 107.49 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 RADIO DEF RBRVS 01/01/2024 12/31/2024 145.06 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.48 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 122.57 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 RADIO DEF RBRVS 01/01/2025 137.44 Description: UROGRAPHY NFS DRIP&/BLS W/NF 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74415 26 RADIO DEF RBRVS 01/01/2025 21.49 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 TC RADIO DEF RBRVS 01/01/2025 115.95 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 RADIO DEF RBRVS 01/01/2024 12/31/2024 72.44 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 23.5 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 48.94 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 RADIO DEF RBRVS 01/01/2025 71.54 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 26 RADIO DEF RBRVS 01/01/2025 22.78 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 TC RADIO DEF RBRVS 01/01/2025 48.76 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 RADIO DEF RBRVS 01/01/2024 12/31/2024 128.28 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 23.16 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 105.12 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 RADIO DEF RBRVS 01/01/2025 123.75 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 26 RADIO DEF RBRVS 01/01/2025 22.15 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 TC RADIO DEF RBRVS 01/01/2025 101.6 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 RADIO DEF RBRVS 01/01/2024 12/31/2024 38.8 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 14.56 Description: CONTRAST X-RAY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74430 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 24.24 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 RADIO DEF RBRVS 01/01/2025 37.82 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 26 RADIO DEF RBRVS 01/01/2025 14.12 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 TC RADIO DEF RBRVS 01/01/2025 23.71 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 RADIO DEF RBRVS 01/01/2024 12/31/2024 90.99 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 17.05 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 73.94 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 RADIO DEF RBRVS 01/01/2025 88.84 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 26 RADIO DEF RBRVS 01/01/2025 16.53 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 TC RADIO DEF RBRVS 01/01/2025 72.31 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 RADIO DEF MAXFEE 01/01/2024 103.3 0 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 51.32 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 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 26 RADIO DEF RBRVS 01/01/2025 50.04 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 RADIO DEF MAXFEE 01/01/2024 74.04 0 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 15.21 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74450 TC RADIO DEF MAXFEE 01/01/2024 56.92 0 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 26 RADIO DEF RBRVS 01/01/2025 14.59 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 RADIO DEF RBRVS 01/01/2024 12/31/2024 97.94 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 15.05 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 82.9 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 RADIO DEF RBRVS 01/01/2025 94.75 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 26 RADIO DEF RBRVS 01/01/2025 14.59 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 TC RADIO DEF RBRVS 01/01/2025 80.16 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 RADIO DEF MAXFEE 01/01/2024 76.11 0 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 24.19 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 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 26 RADIO DEF RBRVS 01/01/2025 22.99 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74485 RADIO DEF RBRVS 01/01/2024 12/31/2024 112.28 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 37.72 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 74.56 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 RADIO DEF RBRVS 01/01/2025 109.63 Description: DILATION URTR/URT RS&I 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74485 26 RADIO DEF RBRVS 01/01/2025 36.41 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 TC RADIO DEF RBRVS 01/01/2025 73.22 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74712 RADIO DEF RBRVS 01/01/2024 12/31/2024 401.71 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 138.05 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 263.67 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 RADIO DEF RBRVS 01/01/2025 385.48 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 26 RADIO DEF RBRVS 01/01/2025 132.92 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 TC RADIO DEF RBRVS 01/01/2025 252.56 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 RADIO DEF RBRVS 01/01/2024 12/31/2024 195.97 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 85.29 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 110.68 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 RADIO DEF RBRVS 01/01/2025 188.06 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 26 RADIO DEF RBRVS 01/01/2025 81.93 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 TC RADIO DEF RBRVS 01/01/2025 106.13 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74740 RADIO DEF RBRVS 01/01/2024 12/31/2024 89.61 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 17.52 Description: X-RAY FEMALE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74740 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 72.09 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 RADIO DEF RBRVS 01/01/2025 85.38 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 26 RADIO DEF RBRVS 01/01/2025 16.99 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 TC RADIO DEF RBRVS 01/01/2025 68.39 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74742 RADIO DEF MAXFEE 01/01/2024 157.51 0 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74742 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 28.11 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74742 TC RADIO DEF MAXFEE 01/01/2024 124.8 0 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74742 26 RADIO DEF RBRVS 01/01/2025 27.09 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74775 RADIO DEF MAXFEE 01/01/2024 88.53 0 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 74775 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 28.75 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 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 74775 26 RADIO DEF RBRVS 01/01/2025 27.42 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75557 RADIO DEF RBRVS 01/01/2024 12/31/2024 273.59 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 106.87 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 166.72 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 RADIO DEF RBRVS 01/01/2025 263.32 Description: CARDIAC MRI FOR MORPH 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75557 26 RADIO DEF RBRVS 01/01/2025 102.99 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 TC RADIO DEF RBRVS 01/01/2025 160.33 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 RADIO DEF RBRVS 01/01/2024 12/31/2024 366.77 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 132.45 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 234.33 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 RADIO DEF RBRVS 01/01/2025 354.35 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 26 RADIO DEF RBRVS 01/01/2025 128.52 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 TC RADIO DEF RBRVS 01/01/2025 225.84 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 RADIO DEF RBRVS 01/01/2024 12/31/2024 357.24 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 118.28 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 238.96 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 RADIO DEF RBRVS 01/01/2025 343.07 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 26 RADIO DEF RBRVS 01/01/2025 114.05 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 TC RADIO DEF RBRVS 01/01/2025 229.02 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 RADIO DEF RBRVS 01/01/2024 12/31/2024 415.41 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 134.76 Description: CARD MRI W/STRESS IMG & 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75563 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 280.65 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 RADIO DEF RBRVS 01/01/2025 400.24 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 26 RADIO DEF RBRVS 01/01/2025 130.77 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 TC RADIO DEF RBRVS 01/01/2025 269.47 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75565 RADIO DEF RBRVS 01/01/2024 12/31/2024 44.44 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 11.41 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 33.03 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 RADIO DEF RBRVS 01/01/2025 42.76 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 26 RADIO DEF RBRVS 01/01/2025 11.06 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 TC RADIO DEF RBRVS 01/01/2025 31.7 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 RADIO DEF RBRVS 01/01/2024 12/31/2024 96.4 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.78 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 12/31/2024 69.62 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 RADIO DEF RBRVS 01/01/2025 93.45 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 26 RADIO DEF RBRVS 01/01/2025 25.51 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 TC RADIO DEF RBRVS 01/01/2025 67.94 Description: CT HRT W/O DYE W/CA TEST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75572 RADIO DEF RBRVS 01/01/2024 12/31/2024 220.53 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 79.73 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 140.8 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 RADIO DEF RBRVS 01/01/2025 214.23 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 26 RADIO DEF RBRVS 01/01/2025 76.69 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 TC RADIO DEF RBRVS 01/01/2025 137.54 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 RADIO DEF RBRVS 01/01/2024 12/31/2024 293.97 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 116.13 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 12/31/2024 177.84 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 RADIO DEF RBRVS 01/01/2025 286.2 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 26 RADIO DEF RBRVS 01/01/2025 111.97 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 TC RADIO DEF RBRVS 01/01/2025 174.23 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 RADIO DEF RBRVS 01/01/2024 12/31/2024 311.57 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 109.34 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 202.23 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 RADIO DEF RBRVS 01/01/2025 302.87 Description: CT ANGIO HRT W/3D IMAGE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75574 26 RADIO DEF RBRVS 01/01/2025 105.39 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 TC RADIO DEF RBRVS 01/01/2025 197.48 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75580 RADIO DEF RBRVS 01/01/2024 12/31/2024 838.16 Description: N-INVAS EST C FFR SW ALY CTA Category: Radiology CMS Add: 01/01/2024 CMS Term: 75580 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 33.92 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 12/31/2024 804.24 Description: N-INVAS EST C FFR SW ALY CTA Category: Radiology CMS Add: 01/01/2024 CMS Term: 75580 RADIO DEF RBRVS 01/01/2025 819.38 Description: N-INVAS EST C FFR SW ALY CTA Category: Radiology CMS Add: 01/01/2024 CMS Term: 75580 26 RADIO DEF RBRVS 01/01/2025 32.88 Description: N-INVAS EST C FFR SW ALY CTA Category: Radiology CMS Add: 01/01/2024 CMS Term: 75580 TC RADIO DEF RBRVS 01/01/2025 786.5 Description: N-INVAS EST C FFR SW ALY CTA Category: Radiology CMS Add: 01/01/2024 CMS Term: 75600 RADIO DEF RBRVS 01/01/2024 12/31/2024 171.03 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 21.91 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 149.12 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 RADIO DEF RBRVS 01/01/2025 165.1 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 26 RADIO DEF RBRVS 01/01/2025 21.08 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 TC RADIO DEF RBRVS 01/01/2025 144.02 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75605 RADIO DEF RBRVS 01/01/2024 12/31/2024 112.96 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 50.28 Description: CONTRAST EXAM THORACIC AORTA 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75605 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 62.68 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 RADIO DEF RBRVS 01/01/2025 110.34 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 26 RADIO DEF RBRVS 01/01/2025 48.74 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 TC RADIO DEF RBRVS 01/01/2025 61.6 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75625 RADIO DEF RBRVS 01/01/2024 12/31/2024 118.08 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 62.66 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 55.42 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 RADIO DEF RBRVS 01/01/2025 114.95 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 26 RADIO DEF RBRVS 01/01/2025 60.75 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 TC RADIO DEF RBRVS 01/01/2025 54.2 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75630 RADIO DEF RBRVS 01/01/2024 12/31/2024 147.72 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 88.28 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 59.43 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 RADIO DEF RBRVS 01/01/2025 143.71 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 26 RADIO DEF RBRVS 01/01/2025 85.43 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 TC RADIO DEF RBRVS 01/01/2025 58.28 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75635 RADIO DEF RBRVS 01/01/2024 12/31/2024 397.87 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 108.27 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 289.6 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 RADIO DEF RBRVS 01/01/2025 385.16 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 26 RADIO DEF RBRVS 01/01/2025 104.5 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 TC RADIO DEF RBRVS 01/01/2025 280.66 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75705 RADIO DEF RBRVS 01/01/2024 12/31/2024 229.31 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 106.42 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 122.89 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 RADIO DEF RBRVS 01/01/2025 225.57 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 26 RADIO DEF RBRVS 01/01/2025 103.13 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 TC RADIO DEF RBRVS 01/01/2025 122.44 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75710 RADIO DEF RBRVS 01/01/2024 12/31/2024 140.65 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 77.04 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 63.61 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 RADIO DEF RBRVS 01/01/2025 136.75 Description: ARTERY X-RAYS ARM/LEG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75710 26 RADIO DEF RBRVS 01/01/2025 74.54 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 TC RADIO DEF RBRVS 01/01/2025 62.21 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75716 RADIO DEF RBRVS 01/01/2024 12/31/2024 152.73 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 86.65 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 66.08 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 RADIO DEF RBRVS 01/01/2025 149.07 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 26 RADIO DEF RBRVS 01/01/2025 84.14 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 TC RADIO DEF RBRVS 01/01/2025 64.92 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 RADIO DEF RBRVS 01/01/2024 12/31/2024 161.74 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 90.11 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 71.63 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 RADIO DEF RBRVS 01/01/2025 156.47 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 26 RADIO DEF RBRVS 01/01/2025 86.41 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 TC RADIO DEF RBRVS 01/01/2025 70.06 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75731 RADIO DEF RBRVS 01/01/2024 12/31/2024 143.66 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 52.56 Description: ARTERY X-RAYS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75731 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 91.1 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 RADIO DEF RBRVS 01/01/2025 140.5 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 26 RADIO DEF RBRVS 01/01/2025 50.36 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 TC RADIO DEF RBRVS 01/01/2025 90.14 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 RADIO DEF RBRVS 01/01/2024 12/31/2024 158.98 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.93 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 100.05 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 RADIO DEF RBRVS 01/01/2025 158.28 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 26 RADIO DEF RBRVS 01/01/2025 57.12 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 TC RADIO DEF RBRVS 01/01/2025 101.17 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75736 RADIO DEF RBRVS 01/01/2024 12/31/2024 133.5 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.81 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 83.69 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 RADIO DEF RBRVS 01/01/2025 131.01 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 26 RADIO DEF RBRVS 01/01/2025 47.81 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 TC RADIO DEF RBRVS 01/01/2025 83.2 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75741 RADIO DEF RBRVS 01/01/2024 12/31/2024 123.19 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 57.73 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 65.46 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 RADIO DEF RBRVS 01/01/2025 119.21 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 26 RADIO DEF RBRVS 01/01/2025 55.49 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 TC RADIO DEF RBRVS 01/01/2025 63.72 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75743 RADIO DEF RBRVS 01/01/2024 12/31/2024 140.01 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 73.31 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 66.7 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 RADIO DEF RBRVS 01/01/2025 135.68 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 26 RADIO DEF RBRVS 01/01/2025 70.75 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 TC RADIO DEF RBRVS 01/01/2025 64.92 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 RADIO DEF RBRVS 01/01/2024 12/31/2024 126.68 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 50.72 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 75.96 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 RADIO DEF RBRVS 01/01/2025 123.59 Description: ARTERY X-RAYS LUNG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75746 26 RADIO DEF RBRVS 01/01/2025 48.7 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 TC RADIO DEF RBRVS 01/01/2025 74.89 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75756 RADIO DEF RBRVS 01/01/2024 12/31/2024 150.49 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 51.99 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 98.51 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 RADIO DEF RBRVS 01/01/2025 150.35 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 26 RADIO DEF RBRVS 01/01/2025 49.94 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 TC RADIO DEF RBRVS 01/01/2025 100.41 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75774 RADIO DEF RBRVS 01/01/2024 12/31/2024 91.55 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 44.16 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 47.39 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 RADIO DEF RBRVS 01/01/2025 88.54 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 26 RADIO DEF RBRVS 01/01/2025 42.49 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 TC RADIO DEF RBRVS 01/01/2025 46.05 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75801 RADIO DEF MAXFEE 01/01/2024 253.48 0 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75801 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.26 Description: LYMPH VESSEL X-RAY ARM/LEG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75801 TC RADIO DEF MAXFEE 01/01/2024 211.53 0 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75801 26 RADIO DEF RBRVS 01/01/2025 38.25 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75803 RADIO DEF MAXFEE 01/01/2024 270.15 0 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75803 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 53.89 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 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75803 26 RADIO DEF RBRVS 01/01/2025 51.94 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75805 RADIO DEF MAXFEE 01/01/2024 279.88 0 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75805 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 37.35 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 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75805 26 RADIO DEF RBRVS 01/01/2025 35.91 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 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75807 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 50.51 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 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75807 26 RADIO DEF RBRVS 01/01/2025 48.64 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75809 RADIO DEF RBRVS 01/01/2024 12/31/2024 76.93 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.13 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75809 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 54.8 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 RADIO DEF RBRVS 01/01/2025 74.59 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 26 RADIO DEF RBRVS 01/01/2025 21 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 TC RADIO DEF RBRVS 01/01/2025 53.6 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75810 RADIO DEF MAXFEE 01/01/2024 549.75 0 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75810 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 46.11 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 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75810 26 RADIO DEF RBRVS 01/01/2025 44.35 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 RADIO DEF RBRVS 01/01/2024 12/31/2024 102.79 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 47.06 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 55.73 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 RADIO DEF RBRVS 01/01/2025 98.91 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 26 RADIO DEF RBRVS 01/01/2025 45.31 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 TC RADIO DEF RBRVS 01/01/2025 53.6 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 RADIO DEF RBRVS 01/01/2024 12/31/2024 125.41 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 65.05 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75822 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 60.36 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 RADIO DEF RBRVS 01/01/2025 122.54 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 26 RADIO DEF RBRVS 01/01/2025 63.21 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 TC RADIO DEF RBRVS 01/01/2025 59.33 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75825 RADIO DEF RBRVS 01/01/2024 12/31/2024 106.8 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.84 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 56.96 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 RADIO DEF RBRVS 01/01/2025 104.02 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 26 RADIO DEF RBRVS 01/01/2025 48.31 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 TC RADIO DEF RBRVS 01/01/2025 55.71 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 RADIO DEF RBRVS 01/01/2024 12/31/2024 111.74 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 50.45 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 61.29 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 RADIO DEF RBRVS 01/01/2025 108.39 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 26 RADIO DEF RBRVS 01/01/2025 48.75 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 TC RADIO DEF RBRVS 01/01/2025 59.63 Description: VEIN X-RAY CHEST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75831 RADIO DEF RBRVS 01/01/2024 12/31/2024 113.11 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.5 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 63.61 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 RADIO DEF RBRVS 01/01/2025 109.42 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 26 RADIO DEF RBRVS 01/01/2025 47.51 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 TC RADIO DEF RBRVS 01/01/2025 61.91 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 RADIO DEF RBRVS 01/01/2024 12/31/2024 137.37 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 65.43 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 71.94 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 RADIO DEF RBRVS 01/01/2025 134.84 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 26 RADIO DEF RBRVS 01/01/2025 63.28 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 TC RADIO DEF RBRVS 01/01/2025 71.57 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 RADIO DEF RBRVS 01/01/2024 12/31/2024 122.04 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 52.56 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 69.47 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 RADIO DEF RBRVS 01/01/2025 118 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75840 26 RADIO DEF RBRVS 01/01/2025 50.36 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 TC RADIO DEF RBRVS 01/01/2025 67.64 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 RADIO DEF RBRVS 01/01/2024 12/31/2024 150.27 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 68.76 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 81.51 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 RADIO DEF RBRVS 01/01/2025 146.08 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 26 RADIO DEF RBRVS 01/01/2025 66.06 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 TC RADIO DEF RBRVS 01/01/2025 80.02 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75860 RADIO DEF RBRVS 01/01/2024 12/31/2024 118.36 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 51.05 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 67.31 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 RADIO DEF RBRVS 01/01/2025 114.85 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 26 RADIO DEF RBRVS 01/01/2025 49.02 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 TC RADIO DEF RBRVS 01/01/2025 65.83 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 RADIO DEF RBRVS 01/01/2024 12/31/2024 145.58 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 54.8 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75870 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 90.77 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 RADIO DEF RBRVS 01/01/2025 140.88 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 26 RADIO DEF RBRVS 01/01/2025 52.41 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 TC RADIO DEF RBRVS 01/01/2025 88.47 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 RADIO DEF RBRVS 01/01/2024 12/31/2024 122.04 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 52.56 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 69.47 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 RADIO DEF RBRVS 01/01/2025 118 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 26 RADIO DEF RBRVS 01/01/2025 50.36 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 TC RADIO DEF RBRVS 01/01/2025 67.64 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 RADIO DEF RBRVS 01/01/2024 12/31/2024 101.56 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 32.39 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 69.16 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 RADIO DEF RBRVS 01/01/2025 98.44 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 26 RADIO DEF RBRVS 01/01/2025 31.1 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 TC RADIO DEF RBRVS 01/01/2025 67.34 Description: VEIN X-RAY EYE SOCKET 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75885 RADIO DEF RBRVS 01/01/2024 12/31/2024 128.83 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 62.14 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 66.7 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 RADIO DEF RBRVS 01/01/2025 125.44 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 26 RADIO DEF RBRVS 01/01/2025 60.21 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 TC RADIO DEF RBRVS 01/01/2025 65.23 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 RADIO DEF RBRVS 01/01/2024 12/31/2024 130.69 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 63.06 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 12/31/2024 67.62 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 RADIO DEF RBRVS 01/01/2025 126.34 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 26 RADIO DEF RBRVS 01/01/2025 60.51 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 TC RADIO DEF RBRVS 01/01/2025 65.83 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 RADIO DEF RBRVS 01/01/2024 12/31/2024 116.49 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.49 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 67 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 RADIO DEF RBRVS 01/01/2025 113.18 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75889 26 RADIO DEF RBRVS 01/01/2025 47.96 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 TC RADIO DEF RBRVS 01/01/2025 65.23 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 RADIO DEF RBRVS 01/01/2024 12/31/2024 117.26 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 49.95 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 67.31 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 RADIO DEF RBRVS 01/01/2025 113.93 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 26 RADIO DEF RBRVS 01/01/2025 48.1 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 TC RADIO DEF RBRVS 01/01/2025 65.83 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75893 RADIO DEF RBRVS 01/01/2024 12/31/2024 96.75 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 23.88 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 72.87 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 RADIO DEF RBRVS 01/01/2025 95.48 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 26 RADIO DEF RBRVS 01/01/2025 23.31 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 TC RADIO DEF RBRVS 01/01/2025 72.17 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75894 RADIO DEF MAXFEE 01/01/2024 1009.26 0 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: 75894 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 64.94 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75894 TC RADIO DEF MAXFEE 01/01/2024 942.38 0 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: 75894 26 RADIO DEF RBRVS 01/01/2025 63.18 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: 75898 RADIO DEF MAXFEE 01/01/2024 125.21 0 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75898 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.23 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75898 TC RADIO DEF MAXFEE 01/01/2024 40.98 0 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75898 26 RADIO DEF RBRVS 01/01/2025 80.27 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75901 RADIO DEF RBRVS 01/01/2024 12/31/2024 214.84 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 21.57 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 193.27 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 RADIO DEF RBRVS 01/01/2025 206.43 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 26 RADIO DEF RBRVS 01/01/2025 20.75 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 TC RADIO DEF RBRVS 01/01/2025 185.69 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 RADIO DEF RBRVS 01/01/2024 12/31/2024 84.41 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 17.56 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 66.84 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 RADIO DEF RBRVS 01/01/2025 79.82 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75902 26 RADIO DEF RBRVS 01/01/2025 16.57 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 TC RADIO DEF RBRVS 01/01/2025 63.26 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75956 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 303.68 Description: XRAY ENDOVASC THOR AO REPR Category: Radiology CMS Add: 01/01/2006 CMS Term: 75956 26 RADIO DEF RBRVS 01/01/2025 293.53 Description: XRAY ENDOVASC THOR AO REPR Category: Radiology CMS Add: 01/01/2006 CMS Term: 75957 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 260.1 Description: XRAY ENDOVASC THOR AO REPR Category: Radiology CMS Add: 01/01/2006 CMS Term: 75957 26 RADIO DEF RBRVS 01/01/2025 252.04 Description: XRAY ENDOVASC THOR AO REPR Category: Radiology CMS Add: 01/01/2006 CMS Term: 75958 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 172.63 Description: XRAY PLACE PROX EXT THOR AO Category: Radiology CMS Add: 01/01/2006 CMS Term: 75958 26 RADIO DEF RBRVS 01/01/2025 165.83 Description: XRAY PLACE PROX EXT THOR AO Category: Radiology CMS Add: 01/01/2006 CMS Term: 75959 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 151.3 Description: XRAY PLACE DIST EXT THOR AO Category: Radiology CMS Add: 01/01/2006 CMS Term: 75959 26 RADIO DEF RBRVS 01/01/2025 146.7 Description: XRAY PLACE DIST EXT THOR AO Category: Radiology CMS Add: 01/01/2006 CMS Term: 75970 RADIO DEF MAXFEE 01/01/2024 493.26 0 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75970 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 36.19 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75970 TC RADIO DEF MAXFEE 01/01/2024 450.42 0 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75970 26 RADIO DEF RBRVS 01/01/2025 34.77 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 RADIO DEF RBRVS 01/01/2024 12/31/2024 90.67 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 36.18 Description: XRAY CONTROL CATHETER CHANGE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75984 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 54.49 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 RADIO DEF RBRVS 01/01/2025 87.46 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 26 RADIO DEF RBRVS 01/01/2025 35.07 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 TC RADIO DEF RBRVS 01/01/2025 52.39 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75989 RADIO DEF RBRVS 01/01/2024 12/31/2024 106.6 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 53.04 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 53.57 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 RADIO DEF RBRVS 01/01/2025 102.59 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 26 RADIO DEF RBRVS 01/01/2025 51.1 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 TC RADIO DEF RBRVS 01/01/2025 51.48 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 76000 RADIO DEF RBRVS 01/01/2024 12/31/2024 40.3 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 14.51 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 25.78 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 RADIO DEF RBRVS 01/01/2025 38.84 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 26 RADIO DEF RBRVS 01/01/2025 13.62 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 TC RADIO DEF RBRVS 01/01/2025 25.22 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76010 RADIO DEF RBRVS 01/01/2024 12/31/2024 28.03 0-19Years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 8.42 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 12/31/2024 19.61 0-19Years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 RADIO DEF RBRVS 01/01/2025 26.74 0-19Years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 26 RADIO DEF RBRVS 01/01/2025 7.86 0-19Years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 TC RADIO DEF RBRVS 01/01/2025 18.88 0-19Years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76014 RADIO DEF RBRVS 01/01/2025 9.82 Y Description: MR SFTY IMPLT&/FB ASMT STF 1 Category: Radiology CMS Add: 01/01/2025 CMS Term: 76015 RADIO DEF RBRVS 01/01/2025 47.29 Y Description: MR SFTY MPLT&/FB ASMT STF EA Category: Radiology CMS Add: 01/01/2025 CMS Term: 76016 RADIO DEF RBRVS 01/01/2025 67.24 Y Description: MR SAFETY DETER PHYS/QHP Category: Radiology CMS Add: 01/01/2025 CMS Term: 76016 26 RADIO DEF RBRVS 01/01/2025 26.46 Y Description: MR SAFETY DETER PHYS/QHP Category: Radiology CMS Add: 01/01/2025 CMS Term: 76016 TC RADIO DEF RBRVS 01/01/2025 40.77 Y Description: MR SAFETY DETER PHYS/QHP Category: Radiology CMS Add: 01/01/2025 CMS Term: 76017 RADIO DEF RBRVS 01/01/2025 205.36 Y Description: MR SFTY MED PHYSICS XM CSTMZ Category: Radiology CMS Add: 01/01/2025 CMS Term: 76017 26 RADIO DEF RBRVS 01/01/2025 33.67 Y Description: MR SFTY MED PHYSICS XM CSTMZ Category: Radiology CMS Add: 01/01/2025 CMS Term: 76017 TC RADIO DEF RBRVS 01/01/2025 171.69 Y Description: MR SFTY MED PHYSICS XM CSTMZ Category: Radiology CMS Add: 01/01/2025 CMS Term: 76018 RADIO DEF RBRVS 01/01/2025 105.5 Y Description: MR SAFETY IMPLANT ELEC PREPJ Category: Radiology CMS Add: 01/01/2025 CMS Term: 76018 26 RADIO DEF RBRVS 01/01/2025 33.19 Y Description: MR SAFETY IMPLANT ELEC PREPJ Category: Radiology CMS Add: 01/01/2025 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76018 TC RADIO DEF RBRVS 01/01/2025 72.31 Y Description: MR SAFETY IMPLANT ELEC PREPJ Category: Radiology CMS Add: 01/01/2025 CMS Term: 76019 RADIO DEF RBRVS 01/01/2025 136.53 Y Description: MR SAFETY IMPLT POS&/IMMOBLJ Category: Radiology CMS Add: 01/01/2025 CMS Term: 76019 26 RADIO DEF RBRVS 01/01/2025 25.87 Y Description: MR SAFETY IMPLT POS&/IMMOBLJ Category: Radiology CMS Add: 01/01/2025 CMS Term: 76019 TC RADIO DEF RBRVS 01/01/2025 110.65 Y Description: MR SAFETY IMPLT POS&/IMMOBLJ Category: Radiology CMS Add: 01/01/2025 CMS Term: 76080 RADIO DEF RBRVS 01/01/2024 12/31/2024 56.46 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 23.88 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 32.58 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 RADIO DEF RBRVS 01/01/2025 54.7 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 26 RADIO DEF RBRVS 01/01/2025 22.85 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 TC RADIO DEF RBRVS 01/01/2025 31.86 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76098 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.39 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 14.53 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 24.86 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 RADIO DEF RBRVS 01/01/2025 39.01 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 26 RADIO DEF RBRVS 01/01/2025 14.09 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 TC RADIO DEF RBRVS 01/01/2025 24.91 Description: X-RAY EXAM SURGICAL SPECIMEN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76100 RADIO DEF RBRVS 01/01/2024 12/31/2024 84.36 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 27.09 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 57.27 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 RADIO DEF RBRVS 01/01/2025 81.82 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 26 RADIO DEF RBRVS 01/01/2025 25.81 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 TC RADIO DEF RBRVS 01/01/2025 56.01 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 RADIO DEF RBRVS 01/01/2024 12/31/2024 109.07 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 18.15 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 90.92 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 RADIO DEF RBRVS 01/01/2025 107.27 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 26 RADIO DEF RBRVS 01/01/2025 17.75 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 TC RADIO DEF RBRVS 01/01/2025 89.52 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 RADIO DEF MAXFEE 01/01/2024 44.21 0 Description: CINE/VIDEO X-RAYS ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 12.4 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 Description: CINE/VIDEO X-RAYS ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 26 RADIO DEF RBRVS 01/01/2025 12.18 Description: CINE/VIDEO X-RAYS ADD-ON 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76140 RADIO DEF BILL25 01/01/2010 Description: X-RAY CONSULTATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76145 NOCOV DEF SYSMAN 01/01/2021 Y Description: MED PHYSIC DOS EVAL RAD EXPS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 76376 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.53 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 9.1 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 13.44 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 RADIO DEF RBRVS 01/01/2025 22.87 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 26 RADIO DEF RBRVS 01/01/2025 8.82 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 TC RADIO DEF RBRVS 01/01/2025 14.05 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 RADIO DEF RBRVS 01/01/2024 12/31/2024 71.72 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 36.37 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 35.35 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 RADIO DEF RBRVS 01/01/2025 71.66 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 26 RADIO DEF RBRVS 01/01/2025 35.12 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 TC RADIO DEF RBRVS 01/01/2025 36.55 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76380 RADIO DEF RBRVS 01/01/2024 12/31/2024 127.88 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 43.75 Description: CAT SCAN FOLLOW-UP STUDY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76380 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 84.13 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 RADIO DEF RBRVS 01/01/2025 122.87 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 26 RADIO DEF RBRVS 01/01/2025 42.1 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 TC RADIO DEF RBRVS 01/01/2025 80.77 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76390 RADIO DEF MAXFEE 01/01/2024 12/31/2024 331.74 0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 26 RADIO DEF MAXFEE 01/01/2024 12/31/2024 55.08 0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 TC RADIO DEF MAXFEE 01/01/2024 12/31/2024 276.67 0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 RADIO DEF MAXFEE 01/01/2025 321.12 0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 26 RADIO DEF MAXFEE 01/01/2025 53.32 0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 TC RADIO DEF MAXFEE 01/01/2025 267.82 0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76391 NOCOV DEF SYSMAN 01/01/2019 Y Description: MR ELASTOGRAPHY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 76496 TC RADIO DEF MAXFEE 01/01/2024 12/31/2024 44.09 0 Description: UNLISTED FLUOROSCOPIC PX Category: Radiology CMS Add: 01/01/2003 CMS Term: 76496 TC RADIO DEF MAXFEE 01/01/2025 42.68 0 Description: UNLISTED FLUOROSCOPIC PX Category: Radiology CMS Add: 01/01/2003 CMS Term: 76497 TC RADIO DEF MAXFEE 01/01/2024 12/31/2024 55.28 0 Description: UNLISTED CT PROCEDURE Category: Radiology CMS Add: 01/01/2003 CMS Term: 76497 TC RADIO DEF MAXFEE 01/01/2025 53.51 0 Description: UNLISTED CT PROCEDURE Category: Radiology CMS Add: 01/01/2003 CMS Term: 76498 RADIO DEF BILL25 01/01/2010 Description: UNLISTED MR PROCEDURE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76499 RADIO DEF BILL25 01/01/2014 Description: UNLISTED DX RADIOGRAPHIC PX Category: Radiology CMS Add: 01/01/1984 CMS Term: 76506 RADIO DEF RBRVS 01/01/2024 12/31/2024 106.43 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 29.09 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 77.34 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 RADIO DEF RBRVS 01/01/2025 102.95 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 26 RADIO DEF RBRVS 01/01/2025 28.53 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 TC RADIO DEF RBRVS 01/01/2025 74.43 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76510 MEDSV DEF RBRVS 01/01/2024 12/31/2024 65.41 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76510 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 37.47 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 12/31/2024 27.95 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76510 MEDSV DEF RBRVS 01/01/2025 63.69 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76510 26 MEDSV DEF RBRVS 01/01/2025 36.36 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76510 TC MEDSV DEF RBRVS 01/01/2025 27.33 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76511 MEDSV DEF RBRVS 01/01/2024 12/31/2024 54.12 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76511 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 34.2 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 12/31/2024 19.92 Description: OPH US DX QUAN A-SCAN ONLY 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76511 MEDSV DEF RBRVS 01/01/2025 52.97 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76511 26 MEDSV DEF RBRVS 01/01/2025 33.19 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76511 TC MEDSV DEF RBRVS 01/01/2025 19.78 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 MEDSV DEF RBRVS 01/01/2024 12/31/2024 45.54 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 29.33 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 16.21 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 MEDSV DEF RBRVS 01/01/2025 44.62 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 26 MEDSV DEF RBRVS 01/01/2025 28.46 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 TC MEDSV DEF RBRVS 01/01/2025 16.16 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76513 MEDSV DEF RBRVS 01/01/2024 12/31/2024 70.67 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 30.99 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 12/31/2024 39.68 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 MEDSV DEF RBRVS 01/01/2025 69.17 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 26 MEDSV DEF RBRVS 01/01/2025 30.07 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 TC MEDSV DEF RBRVS 01/01/2025 39.1 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76514 MEDSV DEF RBRVS 01/01/2024 12/31/2024 10.62 Description: ECHO EXAM OF EYE THICKNESS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76514 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 7.37 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 3.25 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 MEDSV DEF RBRVS 01/01/2025 10.34 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 26 MEDSV DEF RBRVS 01/01/2025 7.16 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 TC MEDSV DEF RBRVS 01/01/2025 3.18 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76516 MEDSV DEF RBRVS 01/01/2024 12/31/2024 43.82 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 21.43 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 22.39 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 MEDSV DEF RBRVS 01/01/2025 43 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 26 MEDSV DEF RBRVS 01/01/2025 20.8 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 TC MEDSV DEF RBRVS 01/01/2025 22.2 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76519 MEDSV DEF RBRVS 01/01/2024 12/31/2024 63.38 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 28.96 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 34.43 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 MEDSV DEF RBRVS 01/01/2025 62.68 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 26 MEDSV DEF RBRVS 01/01/2025 28.11 Description: ECHO EXAM OF EYE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76519 TC MEDSV DEF RBRVS 01/01/2025 34.58 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76529 MEDSV DEF RBRVS 01/01/2024 12/31/2024 80.45 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 26 MEDSV DEF RBRVS 01/01/2024 12/31/2024 30.59 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 TC MEDSV DEF RBRVS 01/01/2024 12/31/2024 49.86 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 MEDSV DEF RBRVS 01/01/2025 78.76 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 26 MEDSV DEF RBRVS 01/01/2025 29.99 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 TC MEDSV DEF RBRVS 01/01/2025 48.76 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76536 RADIO DEF RBRVS 01/01/2024 12/31/2024 104.37 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.1 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 78.27 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 RADIO DEF RBRVS 01/01/2025 100.79 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 26 RADIO DEF RBRVS 01/01/2025 24.85 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 TC RADIO DEF RBRVS 01/01/2025 75.94 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76604 RADIO DEF RBRVS 01/01/2024 12/31/2024 53.52 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.5 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 27.02 Description: US EXAM CHEST 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76604 RADIO DEF RBRVS 01/01/2025 52.56 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 26 RADIO DEF RBRVS 01/01/2025 25.23 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 TC RADIO DEF RBRVS 01/01/2025 27.33 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76641 RADIO DEF RBRVS 01/01/2024 12/31/2024 97.47 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 33.72 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 63.76 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 RADIO DEF RBRVS 01/01/2025 94.13 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 26 RADIO DEF RBRVS 01/01/2025 32.39 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 TC RADIO DEF RBRVS 01/01/2025 61.75 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 RADIO DEF RBRVS 01/01/2024 12/31/2024 80.34 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 31.4 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 48.94 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 RADIO DEF RBRVS 01/01/2025 78.01 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 26 RADIO DEF RBRVS 01/01/2025 30.15 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 TC RADIO DEF RBRVS 01/01/2025 47.86 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76700 SE MRT DEF RBRVS 01/01/2024 12/31/2024 110.06 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76700 RADIO DEF RBRVS 01/01/2024 12/31/2024 110.06 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 26 SE MRT DEF RBRVS 01/01/2024 12/31/2024 37.05 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 37.05 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 TC SE MRT DEF RBRVS 01/01/2024 12/31/2024 73.02 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 73.02 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 SE MRT DEF RBRVS 01/01/2025 106.57 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 RADIO DEF RBRVS 01/01/2025 106.57 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 26 SE MRT DEF RBRVS 01/01/2025 35.61 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 26 RADIO DEF RBRVS 01/01/2025 35.61 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 TC SE MRT DEF RBRVS 01/01/2025 70.96 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 TC RADIO DEF RBRVS 01/01/2025 70.96 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.85 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 27.12 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 55.73 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 RADIO DEF RBRVS 01/01/2025 79.73 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 26 RADIO DEF RBRVS 01/01/2025 25.83 Description: ECHO EXAM OF ABDOMEN 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76705 TC RADIO DEF RBRVS 01/01/2025 53.9 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76706 RADIO DEF RBRVS 01/01/2024 12/31/2024 100.02 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 12/31/2024 25.15 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 12/31/2024 74.87 65-999Years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76706 RADIO DEF RBRVS 01/01/2025 97.44 65-999Years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76706 26 RADIO DEF RBRVS 01/01/2025 24.22 65-999Years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76706 TC RADIO DEF RBRVS 01/01/2025 73.22 65-999Years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76770 RADIO DEF RBRVS 01/01/2024 12/31/2024 102.44 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 33.75 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 68.7 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 RADIO DEF RBRVS 01/01/2025 99.29 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 26 RADIO DEF RBRVS 01/01/2025 32.72 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 TC RADIO DEF RBRVS 01/01/2025 66.58 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.65 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.47 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 29.18 Description: US EXAM ABDO BACK WALL LIM 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76775 RADIO DEF RBRVS 01/01/2025 54.95 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 26 RADIO DEF RBRVS 01/01/2025 25.51 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 TC RADIO DEF RBRVS 01/01/2025 29.44 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76776 RADIO DEF RBRVS 01/01/2024 12/31/2024 139.09 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 34.73 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 104.36 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 RADIO DEF RBRVS 01/01/2025 134.52 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 26 RADIO DEF RBRVS 01/01/2025 33.37 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 TC RADIO DEF RBRVS 01/01/2025 101.15 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76800 RADIO DEF RBRVS 01/01/2024 12/31/2024 145.7 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 56.32 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 89.38 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 RADIO DEF RBRVS 01/01/2025 156.71 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 26 RADIO DEF RBRVS 01/01/2025 55.72 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 TC RADIO DEF RBRVS 01/01/2025 100.99 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76801 RADIO DEF RBRVS 01/01/2024 12/31/2024 111.53 Description: OB US < 14 WKS SINGLE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76801 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.61 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 65.92 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 RADIO DEF RBRVS 01/01/2025 108.08 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 26 RADIO DEF RBRVS 01/01/2025 43.92 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 TC RADIO DEF RBRVS 01/01/2025 64.16 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 RADIO DEF RBRVS 01/01/2024 12/31/2024 58.41 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 38.65 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 19.76 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 RADIO DEF RBRVS 01/01/2025 56.03 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 26 RADIO DEF RBRVS 01/01/2025 37.01 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 TC RADIO DEF RBRVS 01/01/2025 19.02 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76805 RADIO DEF RBRVS 01/01/2024 12/31/2024 128.05 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.92 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 82.13 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 RADIO DEF RBRVS 01/01/2025 124.54 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 26 RADIO DEF RBRVS 01/01/2025 44.22 Description: OB US >= 14 WKS SNGL FETUS 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76805 TC RADIO DEF RBRVS 01/01/2025 80.32 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76810 RADIO DEF RBRVS 01/01/2024 12/31/2024 84.03 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.58 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 38.44 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 RADIO DEF RBRVS 01/01/2025 81.17 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 26 RADIO DEF RBRVS 01/01/2025 43.88 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 TC RADIO DEF RBRVS 01/01/2025 37.29 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76811 RADIO DEF RBRVS 01/01/2024 12/31/2024 167.24 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 87.87 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 79.37 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 RADIO DEF RBRVS 01/01/2025 164.46 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 26 RADIO DEF RBRVS 01/01/2025 84.89 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 TC RADIO DEF RBRVS 01/01/2025 79.57 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 RADIO DEF RBRVS 01/01/2024 12/31/2024 181.99 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 82.26 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 99.73 Description: OB US DETAILED 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76812 RADIO DEF RBRVS 01/01/2025 177.28 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 26 RADIO DEF RBRVS 01/01/2025 79.75 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 TC RADIO DEF RBRVS 01/01/2025 97.53 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76813 RADIO DEF RBRVS 01/01/2024 12/31/2024 111.49 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 54.83 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 56.66 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 RADIO DEF RBRVS 01/01/2025 107.2 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 26 RADIO DEF RBRVS 01/01/2025 52.7 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 TC RADIO DEF RBRVS 01/01/2025 54.5 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 RADIO DEF RBRVS 01/01/2024 12/31/2024 71.69 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 45.6 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 26.09 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 RADIO DEF RBRVS 01/01/2025 69.42 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 26 RADIO DEF RBRVS 01/01/2025 44.21 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 TC RADIO DEF RBRVS 01/01/2025 25.22 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76815 RADIO DEF RBRVS 01/01/2024 12/31/2024 76.86 Description: OB US LIMITED FETUS(S) 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76815 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 30.08 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 46.78 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 RADIO DEF RBRVS 01/01/2025 74.45 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 26 RADIO DEF RBRVS 01/01/2025 28.7 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 TC RADIO DEF RBRVS 01/01/2025 45.75 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76816 RADIO DEF RBRVS 01/01/2024 12/31/2024 103.69 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 39.31 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 64.37 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 RADIO DEF RBRVS 01/01/2025 101.37 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 26 RADIO DEF RBRVS 01/01/2025 38.11 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 TC RADIO DEF RBRVS 01/01/2025 63.26 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76817 RADIO DEF RBRVS 01/01/2024 12/31/2024 87.65 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 34.7 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 52.95 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 RADIO DEF RBRVS 01/01/2025 85.27 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 26 RADIO DEF RBRVS 01/01/2025 33.49 Description: TRANSVAGINAL US OBSTETRIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76817 TC RADIO DEF RBRVS 01/01/2025 51.78 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76818 RADIO DEF RBRVS 01/01/2024 12/31/2024 110.33 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 48.88 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 61.45 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 RADIO DEF RBRVS 01/01/2025 109.44 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 26 RADIO DEF RBRVS 01/01/2025 47.08 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 TC RADIO DEF RBRVS 01/01/2025 62.37 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76819 RADIO DEF RBRVS 01/01/2024 12/31/2024 79.67 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 35.37 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 44.31 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 RADIO DEF RBRVS 01/01/2025 78.98 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 26 RADIO DEF RBRVS 01/01/2025 34.29 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 TC RADIO DEF RBRVS 01/01/2025 44.7 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76820 RADIO DEF RBRVS 01/01/2024 12/31/2024 42.58 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.97 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 19.61 Description: UMBILICAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76820 RADIO DEF RBRVS 01/01/2025 41.45 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 26 RADIO DEF RBRVS 01/01/2025 22.27 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 TC RADIO DEF RBRVS 01/01/2025 19.18 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 RADIO DEF RBRVS 01/01/2024 12/31/2024 83.79 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 32.38 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 51.41 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 RADIO DEF RBRVS 01/01/2025 81.97 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 26 RADIO DEF RBRVS 01/01/2025 31.39 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 TC RADIO DEF RBRVS 01/01/2025 50.58 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76825 RADIO DEF RBRVS 01/01/2024 12/31/2024 246.81 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 76.68 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 170.13 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 RADIO DEF RBRVS 01/01/2025 240.26 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 26 RADIO DEF RBRVS 01/01/2025 74.34 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 TC RADIO DEF RBRVS 01/01/2025 165.92 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76826 RADIO DEF RBRVS 01/01/2024 12/31/2024 147.32 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76826 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 38.02 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 109.3 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 RADIO DEF RBRVS 01/01/2025 143.44 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 26 RADIO DEF RBRVS 01/01/2025 36.85 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 TC RADIO DEF RBRVS 01/01/2025 106.59 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 RADIO DEF RBRVS 01/01/2024 12/31/2024 65.83 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 26.77 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 39.06 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 RADIO DEF RBRVS 01/01/2025 64.45 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 26 RADIO DEF RBRVS 01/01/2025 25.95 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 TC RADIO DEF RBRVS 01/01/2025 38.5 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 RADIO DEF RBRVS 01/01/2024 12/31/2024 46.77 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 25.62 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 21.15 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 RADIO DEF RBRVS 01/01/2025 45.22 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 26 RADIO DEF RBRVS 01/01/2025 24.84 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76828 TC RADIO DEF RBRVS 01/01/2025 20.39 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76830 RADIO DEF RBRVS 01/01/2024 12/31/2024 112.79 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 32.05 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 80.73 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 RADIO DEF RBRVS 01/01/2025 109.13 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 26 RADIO DEF RBRVS 01/01/2025 30.62 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 TC RADIO DEF RBRVS 01/01/2025 78.51 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76831 RADIO DEF RBRVS 01/01/2024 12/31/2024 109.78 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 33.36 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 76.41 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 RADIO DEF RBRVS 01/01/2025 106.77 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 26 RADIO DEF RBRVS 01/01/2025 32.35 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 TC RADIO DEF RBRVS 01/01/2025 74.43 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76856 RADIO DEF RBRVS 01/01/2024 12/31/2024 99.51 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 31.74 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 67.77 Description: US EXAM PELVIC COMPLETE 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76856 RADIO DEF RBRVS 01/01/2025 96.59 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 26 RADIO DEF RBRVS 01/01/2025 30.32 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 TC RADIO DEF RBRVS 01/01/2025 66.28 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76857 RADIO DEF RBRVS 01/01/2024 12/31/2024 46.14 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 22.82 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 23.31 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 RADIO DEF RBRVS 01/01/2025 45.53 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 26 RADIO DEF RBRVS 01/01/2025 21.82 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 TC RADIO DEF RBRVS 01/01/2025 23.71 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76870 RADIO DEF RBRVS 01/01/2024 12/31/2024 95.04 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 29.43 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 65.61 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 RADIO DEF RBRVS 01/01/2025 91.63 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 26 RADIO DEF RBRVS 01/01/2025 28.07 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 TC RADIO DEF RBRVS 01/01/2025 63.56 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76872 RADIO DEF RBRVS 01/01/2024 12/31/2024 187.64 Description: US TRANSRECTAL 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76872 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 31.11 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 156.53 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 RADIO DEF RBRVS 01/01/2025 183.54 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 26 RADIO DEF RBRVS 01/01/2025 30.46 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 TC RADIO DEF RBRVS 01/01/2025 153.08 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76873 RADIO DEF RBRVS 01/01/2024 12/31/2024 164.95 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 12/31/2024 73.56 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 12/31/2024 91.39 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76873 RADIO DEF RBRVS 01/01/2025 161.92 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76873 26 RADIO DEF RBRVS 01/01/2025 71.33 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76873 TC RADIO DEF RBRVS 01/01/2025 90.59 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76881 RADIO DEF RBRVS 01/01/2024 12/31/2024 51.68 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 12/31/2024 41.64 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 12/31/2024 10.04 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76881 RADIO DEF RBRVS 01/01/2025 50.19 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76881 26 RADIO DEF RBRVS 01/01/2025 40.37 Description: US COMPL JOINT R-T W/IMG 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76881 TC RADIO DEF RBRVS 01/01/2025 9.82 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 RADIO DEF RBRVS 01/01/2024 12/31/2024 40.24 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 12/31/2024 31.74 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 12/31/2024 8.5 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 RADIO DEF RBRVS 01/01/2025 58.41 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 26 RADIO DEF RBRVS 01/01/2025 30.47 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 TC RADIO DEF RBRVS 01/01/2025 27.93 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76883 RADIO DEF RBRVS 01/01/2024 12/31/2024 68.99 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76883 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 55.55 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76883 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 13.44 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76883 RADIO DEF RBRVS 01/01/2025 66.7 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76883 26 RADIO DEF RBRVS 01/01/2025 53.86 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76883 TC RADIO DEF RBRVS 01/01/2025 12.84 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76885 RADIO DEF RBRVS 01/01/2024 12/31/2024 128.53 0-364Days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76885 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 34.06 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 12/31/2024 94.48 0-364Days Description: US EXAM INFANT HIPS DYNAMIC 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76885 RADIO DEF RBRVS 01/01/2025 123.91 0-364Days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76885 26 RADIO DEF RBRVS 01/01/2025 32.72 0-364Days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76885 TC RADIO DEF RBRVS 01/01/2025 91.19 0-364Days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 RADIO DEF RBRVS 01/01/2024 12/31/2024 94.98 0-364Days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 28.75 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 12/31/2024 66.23 0-364Days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 RADIO DEF RBRVS 01/01/2025 91.28 0-364Days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 26 RADIO DEF RBRVS 01/01/2025 27.42 0-364Days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 TC RADIO DEF RBRVS 01/01/2025 63.86 0-364Days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76932 RADIO DEF MAXFEE 01/01/2024 95.72 0 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: 76932 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 33.27 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 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: 76932 26 RADIO DEF RBRVS 01/01/2025 32.42 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: 76936 RADIO DEF RBRVS 01/01/2024 12/31/2024 241.72 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 87.96 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 153.77 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology 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: 03/22/2025 Process : REFJW013 Run Time: 12:33:02 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 ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76936 RADIO DEF RBRVS 01/01/2025 237.43 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 26 RADIO DEF RBRVS 01/01/2025 85.4 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 TC RADIO DEF RBRVS 01/01/2025 152.03 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76937 RADIO DEF RBRVS 01/01/2024 12/31/2024 36.74 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 13.28 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 TC RADIO DEF RBRVS 01/01/2024 12/31/2024 23.46 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 RADIO DEF RBRVS 01/01/2025 34.91 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 26 RADIO DEF RBRVS 01/01/2025 12.71 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 TC RADIO DEF RBRVS 01/01/2025 22.2 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 RADIO DEF MAXFEE 01/01/2024 168.04 0 Description: US GUIDE TISSUE ABLATION Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 26 RADIO DEF RBRVS 01/01/2024 12/31/2024 93.11 Description: US GUIDE TISSUE ABLATION Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 TC RADIO DEF MAXFE