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California (Northern and Southern)
Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates View ASC Fee Schedule Updates below. July 2016 Updates per CMS CR 9668 CBSA 5 – Rest of California CBSA 11244 - Santa Ana-Anaheim-Irvine, CA; Orange County CBSA 12540 – Bakersfield, CA; Kern County CBSA 17020 – Chico, CA; Butte County CBSA 20940 – El Centro, CA; Imperial County CBSA 23420 - Fresno, CA; Fresno County CBSA 25260 - Hanford-Corcoran and Kings Counties CBSA 31084 - Los Angeles-Long Beach-Glendale, Los Angeles County CBSA 31460 - Madera, Madera County CBSA 32900 - Merced, Merced County CBSA 33700 - Modesto, Stanislaus County CBSA 34900 - Napa, Napa County CBSA 36084 - Oakland-Freemont-Hayward, Alameda County, Contra Costa County CBSA 37100 - Oxnard-Thousand Oaks-Ventura, Ventura County CBSA 39820 - Redding, Shasta County CBSA 40140 - Riverside-San Bernardino-Ontario, Riverside County, San Bernardino County CBSA 40900 - Sacramento-Arden-Arcade-Roseville, El Dorado County, Placer County, Sacramento County, Yolo County CBSA 41500 - Salinas, Monterey County CBSA 41740 - San Diego-Carlsbad-San Marcos, San Diego County CBSA 41884 - San Francisco-San Mateo-Redwood City, Marin County, San Francisco County, San Mateo County CBSA 41940 - San Jose-Sunnyvale-Santa Clara, San Benito County, Santa Clara County CBSA 42020 - San Luis Obispo-Paso Robles, San Luis Obispo County CBSA 42034 - San Francisco-San Mateo-Redwood City, Marin County, San Francisco County, San Mateo County, San Rafael County CBSA 42100 - Santa Cruz-Watsonville, Santa Cruz County CBSA 42200 - Santa Barbara-Santa Maria-Goleta, Santa Barbara County CBSA 42220 - Santa Rosa-Petaluma, Sonoma County CBSA 44700 - Stockton, San Joaquin County CBSA 46700 - Vallejo-Fairfield, Solano County CBSA 47300 - Visalia-Porterville, Tulare County CBSA 49700 - Yuba City, Sutter County, Yuba County CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 1 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates July - For Dates of Service on/after 7/1/16 and processed on/after 7/5/16 CBSA 5: 0438T S $1,460.96 FC HCPCS Modifier Amount $0.00 0440T S $906.84 $0.00 $0.00 $888.75 $0.00 $0.00 0441T S $906.84 $0.00 $0.00 $888.75 $0.00 $0.00 0442T S $906.84 $0.00 $0.00 $888.75 $0.00 $0.00 0443T S $980.98 $0.00 $0.00 $961.41 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount FB HCPCS Modifier Amount $0.00 $1,431.83 $0.00 $0.00 Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 11244: Procedure Indicator Amount 0438T S $1,367.06 FC HCPCS Modifier Amount $0.00 $1,339.80 $0.00 $0.00 0440T S $848.55 $0.00 $0.00 $831.63 $0.00 $0.00 0441T S $848.55 $0.00 $0.00 $831.63 $0.00 $0.00 0442T S $848.55 $0.00 $0.00 $831.63 $0.00 $0.00 0443T S $917.93 $0.00 $0.00 $899.61 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,364.82 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 12540: Procedure Indicator Amount 0438T S $1,392.59 FC HCPCS Modifier Amount $0.00 0440T S $864.40 $0.00 $0.00 $847.16 $0.00 $0.00 0441T S $864.40 $0.00 $0.00 $847.16 $0.00 $0.00 0442T S $864.40 $0.00 $0.00 $847.16 $0.00 $0.00 0443T S $935.07 $0.00 $0.00 $916.41 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 2 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 17020: $1,355.21 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,328.18 $0.00 $0.00 S $841.19 $0.00 $0.00 $824.41 $0.00 $0.00 0441T S $841.19 $0.00 $0.00 $824.41 $0.00 $0.00 0442T S $841.19 $0.00 $0.00 $824.41 $0.00 $0.00 0443T S $909.97 $0.00 $0.00 $891.81 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 Procedure Indicator Amount 0438T S 0440T CBSA HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 20940: Procedure Indicator Amount 0438T S $1,154.67 FC HCPCS Modifier Amount $0.00 $1,131.64 $0.00 $0.00 0440T S $716.72 $0.00 $0.00 $702.42 $0.00 $0.00 0441T S $716.72 $0.00 $0.00 $702.42 $0.00 $0.00 0442T S $716.72 $0.00 $0.00 $702.42 $0.00 $0.00 0443T S $775.32 $0.00 $0.00 $759.85 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,291.54 $0.00 $0.00 CBSA HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 23420: Procedure Indicator Amount 0438T S $1,317.82 FC HCPCS Modifier Amount $0.00 0440T S $817.99 $0.00 $0.00 $801.67 $0.00 $0.00 0441T S $817.99 $0.00 $0.00 $801.67 $0.00 $0.00 0442T S $817.99 $0.00 $0.00 $801.67 $0.00 $0.00 0443T S $884.87 $0.00 $0.00 $867.21 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 3 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 25260: 0438T S $1,327.92 FC HCPCS Modifier Amount $0.00 0440T S $824.25 $0.00 $0.00 $807.82 $0.00 $0.00 0441T S $824.25 $0.00 $0.00 $807.82 $0.00 $0.00 0442T S $824.25 $0.00 $0.00 $807.82 $0.00 $0.00 0443T S $891.65 $0.00 $0.00 $873.86 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount FB HCPCS Modifier Amount $0.00 $1,301.44 $0.00 $0.00 Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 31084: Procedure Indicator Amount 0438T S $1,421.63 FC HCPCS Modifier Amount $0.00 $1,393.28 $0.00 $0.00 0440T S $882.42 $0.00 $0.00 $864.82 $0.00 $0.00 0441T S $882.42 $0.00 $0.00 $864.82 $0.00 $0.00 0442T S $882.42 $0.00 $0.00 $864.82 $0.00 $0.00 0443T S $954.57 $0.00 $0.00 $935.52 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,075.27 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 31460: 0438T S $1,097.15 FC HCPCS Modifier Amount $0.00 0440T S $681.01 $0.00 $0.00 $667.43 $0.00 $0.00 0441T S $681.01 $0.00 $0.00 $667.43 $0.00 $0.00 0442T S $681.01 $0.00 $0.00 $667.43 $0.00 $0.00 0443T S $736.69 $0.00 $0.00 $721.99 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 4 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 32900: $1,477.46 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,447.99 $0.00 $0.00 S $917.07 $0.00 $0.00 $898.79 $0.00 $0.00 0441T S $917.07 $0.00 $0.00 $898.79 $0.00 $0.00 0442T S $917.07 $0.00 $0.00 $898.79 $0.00 $0.00 0443T S $992.06 $0.00 $0.00 $972.26 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount 0438T S 0440T Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 33700: $1,457.14 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,428.08 $0.00 $0.00 $904.46 $0.00 $0.00 $886.42 $0.00 $0.00 S $904.46 $0.00 $0.00 $886.42 $0.00 $0.00 0442T S $904.46 $0.00 $0.00 $886.42 $0.00 $0.00 0443T S $978.41 $0.00 $0.00 $958.89 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,586.25 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount 0438T S 0440T S 0441T Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 34900: Procedure Indicator Amount 0438T S $1,618.53 FC HCPCS Modifier Amount $0.00 0440T S $1,004.64 $0.00 $0.00 $984.60 $0.00 $0.00 0441T S $1,004.64 $0.00 $0.00 $984.60 $0.00 $0.00 0442T S $1,004.64 $0.00 $0.00 $984.60 $0.00 $0.00 0443T S $1,086.78 $0.00 $0.00 $1,065.10 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 5 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 36084: $1,731.13 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,696.60 $0.00 $0.00 S $1,074.53 $0.00 $0.00 $1,053.10 $0.00 $0.00 0441T S $1,074.53 $0.00 $0.00 $1,053.10 $0.00 $0.00 0442T S $1,074.53 $0.00 $0.00 $1,053.10 $0.00 $0.00 0443T S $1,162.39 $0.00 $0.00 $1,139.19 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount 0438T S 0440T Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 37100: Procedure Indicator Amount 0438T S $1,424.52 FC HCPCS Modifier Amount $0.00 $1,396.11 $0.00 $0.00 0440T S $884.21 $0.00 $0.00 $866.58 $0.00 $0.00 0441T S $884.21 $0.00 $0.00 $866.58 $0.00 $0.00 0442T S $884.21 $0.00 $0.00 $866.58 $0.00 $0.00 0443T S $956.51 $0.00 $0.00 $937.42 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,528.83 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 39820: Procedure Indicator Amount 0438T S $1,559.95 FC HCPCS Modifier Amount $0.00 0440T S $968.27 $0.00 $0.00 $948.96 $0.00 $0.00 0441T S $968.27 $0.00 $0.00 $948.96 $0.00 $0.00 0442T S $968.27 $0.00 $0.00 $948.96 $0.00 $0.00 0443T S $1,047.44 $0.00 $0.00 $1,026.54 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 6 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 40140: $1,360.16 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,333.03 $0.00 $0.00 S $844.27 $0.00 $0.00 $827.43 $0.00 $0.00 0441T S $844.27 $0.00 $0.00 $827.43 $0.00 $0.00 0442T S $844.27 $0.00 $0.00 $827.43 $0.00 $0.00 0443T S $913.30 $0.00 $0.00 $895.07 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount 0438T S 0440T Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 40900: Procedure Indicator Amount 0438T S $1,650.59 FC HCPCS Modifier Amount $0.00 $1,617.67 $0.00 $0.00 0440T S $1,024.54 $0.00 $0.00 $1,004.10 $0.00 $0.00 0441T S $1,024.54 $0.00 $0.00 $1,004.10 $0.00 $0.00 0442T S $1,024.54 $0.00 $0.00 $1,004.10 $0.00 $0.00 0443T S $1,108.31 $0.00 $0.00 $1,086.19 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,611.46 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 41500: Procedure Indicator Amount 0438T S $1,644.25 FC HCPCS Modifier Amount $0.00 0440T S $1,020.60 $0.00 $0.00 $1,000.25 $0.00 $0.00 0441T S $1,020.60 $0.00 $0.00 $1,000.25 $0.00 $0.00 0442T S $1,020.60 $0.00 $0.00 $1,000.25 $0.00 $0.00 0443T S $1,104.05 $0.00 $0.00 $1,082.02 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 7 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 41740: $1,383.75 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,356.15 $0.00 $0.00 S $858.91 $0.00 $0.00 $841.78 $0.00 $0.00 0441T S $858.91 $0.00 $0.00 $841.78 $0.00 $0.00 0442T S $858.91 $0.00 $0.00 $841.78 $0.00 $0.00 0443T S $929.13 $0.00 $0.00 $910.59 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount 0438T S 0440T Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 41884: Procedure Indicator Amount 0438T S $1,715.82 FC HCPCS Modifier Amount $0.00 $1,681.60 $0.00 $0.00 0440T S $1,065.03 $0.00 $0.00 $1,043.79 $0.00 $0.00 0441T S $1,065.03 $0.00 $0.00 $1,043.79 $0.00 $0.00 0442T S $1,065.03 $0.00 $0.00 $1,043.79 $0.00 $0.00 0443T S $1,152.11 $0.00 $0.00 $1,129.12 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,708.53 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 41940: Procedure Indicator Amount 0438T S $1,743.29 FC HCPCS Modifier Amount $0.00 0440T S $1,082.08 $0.00 $0.00 $1,060.50 $0.00 $0.00 0441T S $1,082.08 $0.00 $0.00 $1,060.50 $0.00 $0.00 0442T S $1,082.08 $0.00 $0.00 $1,060.50 $0.00 $0.00 0443T S $1,170.56 $0.00 $0.00 $1,147.20 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 8 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 42020: $1,464.73 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,435.51 $0.00 $0.00 S $909.17 $0.00 $0.00 $891.04 $0.00 $0.00 0441T S $909.17 $0.00 $0.00 $891.04 $0.00 $0.00 0442T S $909.17 $0.00 $0.00 $891.04 $0.00 $0.00 0443T S $983.51 $0.00 $0.00 $963.88 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount 0438T S 0440T Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 42034: Procedure Indicator Amount 0438T S $1,719.84 FC HCPCS Modifier Amount $0.00 $1,685.54 $0.00 $0.00 0440T S $1,067.52 $0.00 $0.00 $1,046.23 $0.00 $0.00 0441T S $1,067.52 $0.00 $0.00 $1,046.23 $0.00 $0.00 0442T S $1,067.52 $0.00 $0.00 $1,046.23 $0.00 $0.00 0443T S $1,154.81 $0.00 $0.00 $1,131.76 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,755.92 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 42100: Procedure Indicator Amount 0438T S $1,791.66 FC HCPCS Modifier Amount $0.00 0440T S $1,112.10 $0.00 $0.00 $1,089.92 $0.00 $0.00 0441T S $1,112.10 $0.00 $0.00 $1,089.92 $0.00 $0.00 0442T S $1,112.10 $0.00 $0.00 $1,089.92 $0.00 $0.00 0443T S $1,203.03 $0.00 $0.00 $1,179.02 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 9 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 42200: $1,457.45 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,428.38 $0.00 $0.00 S $904.65 $0.00 $0.00 $886.61 $0.00 $0.00 0441T S $904.65 $0.00 $0.00 $886.61 $0.00 $0.00 0442T S $904.65 $0.00 $0.00 $886.61 $0.00 $0.00 0443T S $978.62 $0.00 $0.00 $959.09 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount 0438T S 0440T Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 42220: Procedure Indicator Amount 0438T S $1,699.83 FC HCPCS Modifier Amount $0.00 $1,665.92 $0.00 $0.00 0440T S $1,055.10 $0.00 $0.00 $1,034.06 $0.00 $0.00 0441T S $1,055.10 $0.00 $0.00 $1,034.06 $0.00 $0.00 0442T S $1,055.10 $0.00 $0.00 $1,034.06 $0.00 $0.00 0443T S $1,141.37 $0.00 $0.00 $1,118.59 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,430.72 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 44700: Procedure Indicator Amount 0438T S $1,459.83 FC HCPCS Modifier Amount $0.00 0440T S $906.13 $0.00 $0.00 $888.06 $0.00 $0.00 0441T S $906.13 $0.00 $0.00 $888.06 $0.00 $0.00 0442T S $906.13 $0.00 $0.00 $888.06 $0.00 $0.00 0443T S $980.22 $0.00 $0.00 $960.66 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 10 Jurisdiction E Medicare Ambulatory Surgical Center (ASC) Fee Updates CBSA 46700: $1,679.63 FC HCPCS Modifier Amount $0.00 FB HCPCS Modifier Amount $0.00 $1,646.13 $0.00 $0.00 S $1,042.56 $0.00 $0.00 $1,021.77 $0.00 $0.00 0441T S $1,042.56 $0.00 $0.00 $1,021.77 $0.00 $0.00 0442T S $1,042.56 $0.00 $0.00 $1,021.77 $0.00 $0.00 0443T S $1,127.81 $0.00 $0.00 $1,105.30 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 HCPCS / CPT Code HCPCS Modifier Procedure Indicator Amount 0438T S 0440T Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 47300: Procedure Indicator Amount 0438T S $1,230.69 FC HCPCS Modifier Amount $0.00 $1,206.15 $0.00 $0.00 0440T S $763.90 $0.00 $0.00 $748.67 $0.00 $0.00 0441T S $763.90 $0.00 $0.00 $748.67 $0.00 $0.00 0442T S $763.90 $0.00 $0.00 $748.67 $0.00 $0.00 0443T S $826.36 $0.00 $0.00 $809.87 $0.00 $0.00 FB HCPCS Modifier Amount $0.00 $1,351.11 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CBSA 49700: Procedure Indicator Amount 0438T S $1,378.60 FC HCPCS Modifier Amount $0.00 0440T S $855.71 $0.00 $0.00 $838.65 $0.00 $0.00 0441T S $855.71 $0.00 $0.00 $838.65 $0.00 $0.00 0442T S $855.71 $0.00 $0.00 $838.65 $0.00 $0.00 0443T S $925.68 $0.00 $0.00 $907.21 $0.00 $0.00 HCPCS / CPT Code HCPCS Modifier Penalty Price FC Mod Penalty Price FB Mod Penalty Price CPT codes, descriptors and other data are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. .© Noridian Healthcare Solutions, LLC Page | 11
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