The Centers for Medicare & Medicaid Services (CMS) establishes reimbursement amounts for many procedures through various fee schedules and other pricing methodologies. Reimbursement for some services, however, is determined by Medicare contractors. These codes are designated as status 'C' on the 2007 Medicare Physician Fee Schedule Database (MPFSDB). These services are known as 'carrier-priced' procedures. Carriers will establish RVUs and payment amounts for these services, generally on an individual case basis following review of documentation such as an operative report.
Palmetto GBA has designated reimbursement amounts for some carrier-priced procedures, which are noted in the table below. This reimbursement information applies to services performed in Ohio in calendar year 2007.
Note: For carrier-priced procedures that are not listed in this table or published elsewhere on our Web site, Palmetto GBA is unable to determine 'set' reimbursement amounts because of the complexity or variable nature of these procedures.
|
CPT Code
|
CPT & HCPCS Modifier*
|
Non-Facility
|
Facility
|
Fees Subject to OPPS Payment Caps
|
| 0016T |
 |
$869.32
|
$822.25
|
|
| 0067T |
|
$343.95
|
$343.95
|
|
| 0067T |
26 |
$65.86
|
$65.86
|
|
| 0067T |
TC |
$278.09
|
$278.09
|
Y
|
| 0146T |
|
$376.67
|
$376.67
|
|
| 0146T |
26 |
$90.43
|
$90.43
|
|
| 0146T |
TC |
$286.24
|
$286.24
|
Y
|
| 0147T |
|
$376.67
|
$376.67
|
|
| 0147T |
26 |
$90.43
|
$90.43
|
|
| 0147T |
TC |
$286.24
|
$286.24
|
Y
|
| 0171T |
|
$806.24
|
$806.24
|
|
| 0172T |
|
$403.12
|
$403.12
|
|
| 32855 |
|
$192.64
|
$192.64
|
|
| 32856 |
|
$288.96
|
$288.96
|
|
| 33933 |
|
$192.64
|
$192.64
|
|
| 33944 |
|
$192.64
|
$192.64
|
|
| 47143 |
|
$272.52
|
$272.52
|
|
| 48551 |
|
$196.45
|
$196.45
|
|
| 50323 |
|
$183.01
|
$183.01
|
|
| 70170 |
|
$184.32
|
$184.32
|
Y
|
| 70170 |
TC |
$170.19
|
$170.19
|
Y
|
| 70555 |
|
$515.58
|
$515.58
|
|
| 70555 |
TC |
$486.09
|
$486.09
|
|
| 71090 |
|
$101.51
|
$101.51
|
Y
|
| 71090 |
TC |
$74.07
|
$74.07
|
Y
|
| 72291 |
|
$211.37
|
$211.37
|
Y
|
| 72291 |
TC |
$146.73
|
$146.73
|
Y
|
| 72292 |
|
$300.53
|
$300.53
|
|
| 72292 |
TC |
$234.71
|
$234.71
|
|
| 73530 |
|
$83.95
|
$83.95
|
Y
|
| 73530 |
TC |
$70.19
|
$70.19
|
Y
|
| 74190 |
|
$192.78
|
$192.78
|
Y
|
| 74190 |
TC |
$170.09
|
$170.09
|
Y
|
| 74235 |
|
$119.25
|
$119.25
|
Y
|
| 74235 |
TC |
$63.07
|
$63.07
|
Y
|
| 74300 |
|
$114.48
|
$114.48
|
Y
|
| 74300 |
TC |
$97.38
|
$97.38
|
Y
|
| 74301 |
|
$107.42
|
$107.42
|
Y
|
| 74301 |
TC |
$97.38
|
$97.38
|
Y
|
| 74305 |
|
$117.65
|
$117.65
|
Y
|
| 74305 |
TC |
$97.57
|
$97.57
|
Y
|
| 74340 |
|
$99.81
|
$99.81
|
Y
|
| 74340 |
TC |
$74.15
|
$74.15
|
Y
|
| 74355 |
|
$132.92
|
$132.92
|
Y
|
| 74355 |
TC |
$97.57
|
$97.57
|
Y
|
| 74360 |
|
$89.53
|
$89.53
|
Y
|
| 74360 |
TC |
$63.15
|
$63.15
|
Y
|
| 74363 |
|
$250.64
|
$250.64
|
Y
|
| 74363 |
TC |
$209.33
|
$209.33
|
Y
|
| 74420 |
|
$156.01
|
$156.01
|
Y
|
| 74420 |
TC |
$138.91
|
$138.91
|
Y
|
| 74425 |
|
$156.01
|
$156.01
|
Y
|
| 74425 |
TC |
$138.91
|
$138.91
|
Y
|
| 74445 |
|
$194.26
|
$194.26
|
Y
|
| 74445 |
TC |
$138.87
|
$138.87
|
Y
|
| 74450 |
|
$154.94
|
$154.94
|
Y
|
| 74450 |
TC |
$138.95
|
$138.95
|
Y
|
| 74470 |
|
$122.79
|
$122.79
|
Y
|
| 74470 |
TC |
$97.48
|
$97.48
|
Y
|
| 74742 |
|
$198.75
|
$198.75
|
Y
|
| 74742 |
TC |
$170.09
|
$170.09
|
Y
|
| 74775 |
|
$168.30
|
$168.30
|
Y
|
| 74775 |
TC |
$138.91
|
$138.91
|
Y
|
| 75801 |
|
$209.81
|
$209.81
|
Y
|
| 75801 |
TC |
$170.03
|
$170.03
|
Y
|
| 75803 |
|
$224.38
|
$224.38
|
Y
|
| 75803 |
TC |
$170.03
|
$170.03
|
Y
|
| 75805 |
|
$208.72
|
$208.72
|
Y
|
| 75805 |
TC |
$170.03
|
$170.03
|
Y
|
| 75807 |
|
$224.74
|
$224.74
|
Y
|
| 75807 |
TC |
$170.03
|
$170.03
|
Y
|
| 75810 |
|
$599.80
|
$599.80
|
Y
|
| 75810 |
TC |
$546.20
|
$546.20
|
Y
|
| 75894 |
|
$547.06
|
$547.06
|
Y
|
| 75894 |
TC |
$484.56
|
$484.56
|
Y
|
| 75896 |
|
$547.38
|
$547.38
|
Y
|
| 75896 |
TC |
$484.56
|
$484.56
|
Y
|
| 75898 |
|
$176.01
|
$176.01
|
Y
|
| 75898 |
TC |
$97.91
|
$97.91
|
Y
|
| 75940 |
|
$510.15
|
$510.15
|
Y
|
| 75940 |
TC |
$483.75
|
$483.75
|
Y
|
| 75945 |
|
$161.88
|
$161.88
|
Y
|
| 75945 |
TC |
$141.82
|
$141.82
|
Y
|
| 75946 |
|
$110.34
|
$110.34
|
Y
|
| 75946 |
TC |
$89.93
|
$89.93
|
Y
|
| 75960 |
|
$400.19
|
$400.19
|
Y
|
| 75960 |
TC |
$360.06
|
$360.06
|
Y
|
| 75970 |
|
$400.55
|
$400.55
|
Y
|
| 75970 |
TC |
$360.76
|
$360.76
|
Y
|
| 75980 |
|
$277.85
|
$277.85
|
Y
|
| 75980 |
TC |
$210.12
|
$210.12
|
Y
|
| 75982 |
|
$276.86
|
$276.86
|
Y
|
| 75982 |
TC |
$209.12
|
$209.12
|
Y
|
| 75992 |
|
$385.81
|
$385.81
|
Y
|
| 75992 |
TC |
$359.07
|
$359.07
|
Y
|
| 76125 |
|
$53.38
|
$53.38
|
Y
|
| 76125 |
TC |
$40.74
|
$40.74
|
Y
|
| 76932 |
|
$154.29
|
$154.29
|
Y
|
| 76932 |
TC |
$120.91
|
$120.91
|
Y
|
| 76940 |
|
$170.23
|
$170.23
|
Y
|
| 76940 |
TC |
$68.43
|
$68.43
|
Y
|
| 76941 |
|
$133.12
|
$133.12
|
Y
|
| 76941 |
TC |
$68.43
|
$68.43
|
Y
|
| 76945 |
|
$100.40
|
$100.40
|
Y
|
| 76945 |
TC |
$68.78
|
$68.78
|
Y
|
| 76975 |
|
$128.65
|
$128.65
|
Y
|
| 76975 |
TC |
$89.62
|
$89.62
|
Y
|
| 76998 |
|
$149.56
|
$149.56
|
|
| 76998 |
TC |
$90.10
|
$90.10
|
Y
|
| 77013 |
|
$465.79
|
$465.79
|
|
| 77013 |
TC |
$278.24
|
$278.24
|
Y
|
| 77022 |
|
$461.99
|
$461.99
|
|
| 77022 |
TC |
$261.44
|
$261.44
|
Y
|
| 78282 |
|
$227.57
|
$227.57
|
Y
|
| 78282 |
TC |
$209.71
|
$209.71
|
Y
|
| 78414 |
|
$83.78
|
$83.78
|
|
| 78414 |
TC |
$62.23
|
$62.23
|
|
| 78459 |
|
$757.29
|
$757.29
|
Y
|
| 78459 |
TC |
$684.49
|
$684.49
|
Y
|
| 78491 |
|
$758.72
|
$758.72
|
Y
|
| 78491 |
TC |
$684.49
|
$684.49
|
Y
|
| 78492 |
|
$778.31
|
$778.31
|
Y
|
| 78492 |
TC |
$684.49
|
$684.49
|
Y
|
| 78608 |
|
$871.14
|
$871.14
|
Y
|
| 78608 |
TC |
$800.45
|
$800.45
|
Y
|
| 78609 |
|
$871.14
|
$871.14
|
|
| 78609 |
TC |
$800.45
|
$800.45
|
|
| 78811 |
|
$875.18
|
$875.18
|
Y
|
| 78811 |
TC |
$800.45
|
$800.45
|
Y
|
| 78812 |
|
$893.05
|
$893.05
|
Y
|
| 78812 |
TC |
$800.45
|
$800.45
|
Y
|
| 78813 |
|
$896.03
|
$896.03
|
Y
|
| 78813 |
TC |
$800.45
|
$800.45
|
Y
|
| 78814 |
|
$994.00
|
$994.00
|
Y
|
| 78814 |
TC |
$889.12
|
$889.12
|
Y
|
| 78815 |
|
$1,004.79
|
$1,004.79
|
Y
|
| 78815 |
TC |
$889.12
|
$889.12
|
Y
|
| 78816 |
|
$1,007.77
|
$1,007.77
|
Y
|
| 78816 |
TC |
$889.12
|
$889.12
|
Y
|
| 92978 |
|
$261.65
|
$261.65
|
|
| 92978 |
TC |
$170.46
|
$170.46
|
|
| 92979 |
|
$159.53
|
$159.53
|
|
| 92979 |
TC |
$86.13
|
$86.13
|
|
| 93235 |
|
$121.62
|
$121.62
|
|
| 93236 |
|
$98.17
|
$98.17
|
|
| 93315 |
|
$496.37
|
$496.37
|
Y
|
| 93315 |
TC |
$359.42
|
$359.42
|
Y
|
| 93318 |
|
$460.43
|
$460.43
|
Y
|
| 93318 |
TC |
$359.42
|
$359.42
|
Y
|
| 93501 |
|
$793.83
|
$793.83
|
|
| 93501 |
TC |
$638.16
|
$638.16
|
|
| 93505 |
|
$301.61
|
$301.61
|
|
| 93505 |
TC |
$76.28
|
$76.28
|
|
| 93508 |
|
$696.01
|
$696.01
|
|
| 93508 |
TC |
$470.97
|
$470.97
|
|
| 93510 |
|
$1,632.74
|
$1,632.74
|
|
| 93510 |
TC |
$1,395.82
|
$1,395.82
|
|
| 93511 |
|
$1,630.37
|
$1,630.37
|
|
| 93511 |
TC |
$1,358.23
|
$1,358.23
|
|
| 93514 |
|
IC
|
IC
|
|
| 93514 |
TC |
IC
|
IC
|
|
| 93524 |
|
$2,147.72
|
$2,147.72
|
|
| 93524 |
TC |
$1,775.91
|
$1,775.91
|
|
| 93526 |
|
$2,147.73
|
$2,147.73
|
|
| 93526 |
TC |
$1,824.85
|
$1,824.85
|
|
| 93527 |
|
$2,165.85
|
$2,165.85
|
|
| 93527 |
TC |
$1,775.91
|
$1,775.91
|
|
| 93528 |
|
$2,253.37
|
$2,253.37
|
|
| 93528 |
TC |
$1,775.91
|
$1,775.91
|
|
| 93529 |
|
$2,034.79
|
$2,034.79
|
|
| 93529 |
TC |
$1,775.91
|
$1,775.91
|
|
| 93530 |
|
$860.68
|
$860.68
|
|
| 93530 |
TC |
$638.16
|
$638.16
|
|
| 93531 |
|
$2,258.67
|
$2,258.67
|
|
| 93531 |
TC |
$1,824.85
|
$1,824.85
|
|
| 93555 |
|
$276.13
|
$276.13
|
|
| 93555 |
TC |
$234.98
|
$234.98
|
|
| 93556 |
|
$411.88
|
$411.88
|
|
| 93556 |
TC |
$369.62
|
$369.62
|
|
| 93561 |
|
$44.05
|
$44.05
|
|
| 93561 |
TC |
$20.61
|
$20.61
|
|
| 93562 |
|
$20.23
|
$20.23
|
|
| 93562 |
TC |
$12.79
|
$12.79
|
|
| 93571 |
|
$260.94
|
$260.94
|
Y
|
| 93571 |
TC |
$170.46
|
$170.46
|
Y
|
| 93572 |
|
IC
|
IC
|
Y
|
| 93572 |
TC |
IC
|
IC
|
Y
|
| 93600 |
|
$184.17
|
$184.17
|
|
| 93600 |
TC |
$74.11
|
$74.11
|
|
| 93602 |
|
$151.91
|
$151.91
|
|
| 93602 |
TC |
$41.84
|
$41.84
|
|
| 93603 |
|
$173.55
|
$173.55
|
|
| 93603 |
TC |
$63.47
|
$63.47
|
|
| 93609 |
|
$361.82
|
$361.82
|
|
| 93609 |
TC |
$102.82
|
$102.82
|
|
| 93610 |
|
$207.49
|
$207.49
|
|
| 93610 |
TC |
$51.43
|
$51.43
|
|
| 93612 |
|
$217.07
|
$217.07
|
|
| 93612 |
TC |
$61.00
|
$61.00
|
|
| 93615 |
|
$58.55
|
$58.55
|
|
| 93615 |
TC |
$12.05
|
$12.05
|
|
| 93618 |
|
$370.06
|
$370.06
|
|
| 93618 |
TC |
$149.25
|
$149.25
|
|
| 93619 |
|
$677.18
|
$677.18
|
|
| 93619 |
TC |
$290.35
|
$290.35
|
|
| 93623 |
|
$222.65
|
$222.65
|
|
| 93623 |
TC |
$75.17
|
$75.17
|
|
| 93624 |
|
$332.66
|
$332.66
|
|
| 93624 |
TC |
$75.17
|
$75.17
|
|
| 94642 |
|
$12.05
|
$12.05
|
|
| 95951 |
|
$871.59
|
$871.59
|
|
| 95951 |
TC |
$572.85
|
$572.85
|
|
| 96020 |
|
IC
|
IC
|
|
| 96020 |
TC |
IC
|
IC
|
|
|
HCPCS Code
|
Modifier
|
Non-Facility
|
Facility
|
Fees Subject to OPPS Payment Caps
|
| R0070 |
|
$124.06
|
$124.06
|
|
| R0075 |
|
$124.06
|
$124.06
|
|
- IC - Payment will be determined on an individual consideration basis
- Inclusion or exclusion of a fee does not warrant coverage
* CPT codes and modifiers begin with a numeric character and HCPCS codes and modifiers begin with a alph character.