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Hospital facility prices. What the hospital charges for the facility side of care — the surgeon’s and anesthesiologist’s fees are billed separately and are not included. How we scope prices →

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Hospital

Mountain Valley Regional Rehabilitation Hospital

Prescott Valley, AZ · CCN 033036 · Rates published

2,161 distinct procedures filed
17 distinct payers
48,542 rate rows
2026-08-10 last MRF observed
Data quality

8,938 of 48,542 rate rows are consumer-grade (18.4%)

39,604 rows are marked excluded from the consumer medians — these stay visible in the raw drill-down with the same reason shown here, so nothing is silently hidden.

Excluded — reasonRows
no usable negotiated amount (only an out-of-band fallback) — excluded from medians 38,928
per-diem day rate — not a per-procedure price 676
Data source & audit trail ↓ Download audit trail (JSON)
Source MRF file https://ernesthealth.com/wp-content/uploads/2025/01/pricing/Mountain%20Valley%20Regional%20Rehabilitation%20Hospital/203166972_Mountain-Valley-Regional-Rehabilitation-Hospital_Standard-Charges.json
Found on page https://mvrrh.ernesthealth.com/price-transparency/
Discovered viaDiscovered by HANK
Last fetch success · 2026-10-22
Content fingerprint e59d06477dd41480… · 9,644,744 bytes · first seen 2026-09-21

Top 50 most expensive offerings

Outliers are flagged where this hospital's filed rate is ≥2× or ≤0.5× the national median for the same code.

Code Description Payers Min $ Max $ Avg median vs national
C1806
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50- Tier Tier 2 11 $52,482.74 $52,482.74 $52,482.74 nat. median
$53,054
1.0× median
D1904
HCPCS 		Guillain-barré M <38.50- Tier Tier 3 11 $50,173.28 $50,173.28 $50,173.28 nat. median
$49,620
1.0× median
D1806
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50- Tier Tier 3 11 $49,825.34 $49,825.34 $49,825.34 nat. median
$49,816
1.0× median
A1904
HCPCS 		Guillain-barré M <38.50- Tier None 11 $49,305.33 $49,305.33 $49,305.33 nat. median
$49,305
1.0× median
D0404
HCPCS 		Traumatic Spinal Cord Injury M <31.50 And A <61.50- Tier Tier 3 11 $48,920.82 $48,920.82 $48,920.82 nat. median
$48,664
1.0× median
B0105
HCPCS 		Stroke M <41.50 And A >=84.50- Tier Tier 1 11 $48,852.23 $48,852.23 $48,852.23 nat. median
$47,997
1.0× median
B0604
HCPCS 		Neurological M <43.50- Tier Tier 1 11 $46,457.54 $46,457.54 $46,457.54 nat. median
$46,491
1.0× median
A1806
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50- Tier None 11 $46,196.74 $46,196.74 $46,196.74 nat. median
$47,794
1.0× median
C0505
HCPCS 		Non-traumatic Spinal Cord Injury M <39.50- Tier Tier 2 11 $44,862.30 $44,862.30 $44,862.30 nat. median
$45,226
1.0× median
D0106
HCPCS 		Stroke M <41.50 And A <84.50- Tier Tier 3 11 $43,155.68 $44,036.41 $43,596.04 nat. median
$43,154
1.0× median
B2005
HCPCS 		Miscellaneous M <46.50 And A <77.50- Tier Tier 1 11 $42,800.15 $42,800.15 $42,800.15 nat. median
$41,981
1.0× median
D0505
HCPCS 		Non-traumatic Spinal Cord Injury M <39.50- Tier Tier 3 11 $42,382.70 $42,382.70 $42,382.70 nat. median
$42,098
1.0× median
B1404
HCPCS 		Cardiac M <45.50- Tier Tier 1 11 $41,023.41 $41,023.41 $41,023.41 nat. median
$40,776
1.0× median
B0904
HCPCS 		Other Orthopedic M <44.5- Tier Tier 1 11 $40,943.11 $40,943.11 $40,943.11 nat. median
$42,433
1.0× median
B0104
HCPCS 		Stroke M >=41.50 And M <50.50- Tier Tier 1 11 $39,067.64 $39,067.64 $39,067.64 nat. median
$38,537
1.0× median
A0505
HCPCS 		Non-traumatic Spinal Cord Injury M <39.50- Tier None 11 $39,035.10 $39,056.17 $39,045.64 nat. median
$39,049
1.0× median
C1705
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier Tier 2 11 $38,964.40 $38,964.40 $38,964.40 nat. median
$38,430
1.0× median
D0105
HCPCS 		Stroke M <41.50 And A >=84.50- Tier Tier 3 11 $38,715.87 $38,715.87 $38,715.87 nat. median
$38,427
1.0× median
C1805
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 11 $36,955.10 $39,247.34 $38,101.22 nat. median
$37,575
1.0× median
A0105
HCPCS 		Stroke M <41.50 And A >=84.50- Tier None 11 $36,159.79 $36,897.74 $36,528.76 nat. median
$36,596
1.0× median
C0305
HCPCS 		Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 2 11 $36,471.41 $36,471.41 $36,471.41 nat. median
$35,651
1.0× median
D1705
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier Tier 3 11 $36,085.23 $36,085.23 $36,085.23 nat. median
$71
outlier · 511.6×
C1004
HCPCS 		Amputation Lower Extremity M <47.50- Tier Tier 2 11 $35,655.80 $35,655.80 $35,655.80 nat. median
$36,992
1.0× median
C0604
HCPCS 		Neurological M <43.50- Tier Tier 2 11 $35,645.51 $35,645.51 $35,645.51 nat. median
$35,373
1.0× median
A0205
HCPCS 		Traumatic Brain Injury M <35.50- Tier None 11 $35,526.98 $35,526.98 $35,526.98 nat. median
$35,382
1.0× median
D1805
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 11 $35,083.45 $35,083.45 $35,083.45 nat. median
$35,077
1.0× median
B1803
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=45.50 And M <55.50- T… 11 $34,940.06 $34,940.06 $34,940.06 nat. median
$34,068
1.0× median
C0704
HCPCS 		Fracture Of Lower Extremity M <41.50- Tier Tier 2 11 $34,418.14 $34,783.41 $34,600.78 nat. median
$34,601
1.0× median
C2005
HCPCS 		Miscellaneous M <46.50 And A <77.50- Tier Tier 2 11 $33,919.16 $33,919.16 $33,919.16 nat. median
$33,749
1.0× median
D0305
HCPCS 		Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 3 11 $33,502.39 $33,502.39 $33,502.39 nat. median
$32,729
1.0× median
D0604
HCPCS 		Neurological M <43.50- Tier Tier 3 11 $33,276.79 $33,276.79 $33,276.79 nat. median
$107
outlier · 311.8×
A1903
HCPCS 		Guillain-barré M >=38.50 And M <51.50- Tier None 11 $32,819.00 $32,819.00 $32,819.00 nat. median
$32,819
1.0× median
C0304
HCPCS 		Non-traumatic Brain Injury M <42.50 And A >=78.50- Tier Tier 2 11 $32,408.91 $33,070.32 $32,739.62 nat. median
$32,700
1.0× median
C0403
HCPCS 		Traumatic Spinal Cord Injury M >=41.50 And M <47.50- Tier Tier 2 11 $32,521.33 $32,521.33 $32,521.33 nat. median
$31,134
1.0× median
C0904
HCPCS 		Other Orthopedic M <44.5- Tier Tier 2 11 $32,137.25 $32,793.11 $32,465.18 nat. median
$32,428
1.0× median
B1303
HCPCS 		Rheumatoid Other Arthritis M >=44.50 And M <51.50 And A >=64.50- Tier Tier 1 11 $32,420.31 $32,420.31 $32,420.31 nat. median
$33,607
1.0× median
A1705
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier None 11 $32,082.92 $32,737.67 $32,410.29 nat. median
$32,738
1.0× median
C1404
HCPCS 		Cardiac M <45.50- Tier Tier 2 11 $32,317.07 $32,317.07 $32,317.07 nat. median
$32,577
1.0× median
D0704
HCPCS 		Fracture Of Lower Extremity M <41.50- Tier Tier 3 11 $31,951.76 $32,603.84 $32,277.80 nat. median
$30,260
1.1× median
C2004
HCPCS 		Miscellaneous M <46.50 And A >=77.50- Tier Tier 2 11 $32,179.42 $32,179.42 $32,179.42 nat. median
$32,081
1.0× median
C0504
HCPCS 		Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50- Tier Tier 2 11 $31,638.88 $32,284.57 $31,961.72 nat. median
$32,166
1.0× median
C0805
HCPCS 		Replacement Of Lower-extremity Joint M <42.50- Tier Tier 2 11 $31,621.18 $31,621.18 $31,621.18 nat. median
$33,238
1.0× median
D2005
HCPCS 		Miscellaneous M <46.50 And A <77.50- Tier Tier 3 11 $31,282.70 $31,921.12 $31,601.91 nat. median
$31,377
1.0× median
A0305
HCPCS 		Non-traumatic Brain Injury M <42.50 And A <78.50- Tier None 11 $31,577.20 $31,577.20 $31,577.20 nat. median
$31,269
1.0× median
D1004
HCPCS 		Amputation Lower Extremity M <47.50- Tier Tier 3 11 $28,574.76 $34,490.91 $31,532.83 nat. median
$33,575
0.9× median
D1704
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50… 11 $30,749.39 $30,749.39 $30,749.39 nat. median
$90
outlier · 343.0×
D0904
HCPCS 		Other Orthopedic M <44.5- Tier Tier 3 11 $29,954.54 $31,127.73 $30,541.13 nat. median
$30,444
1.0× median
D0304
HCPCS 		Non-traumatic Brain Injury M <42.50 And A >=78.50- Tier Tier 3 11 $30,378.51 $30,378.51 $30,378.51 nat. median
$30,379
1.0× median
D1404
HCPCS 		Cardiac M <45.50- Tier Tier 3 11 $30,047.76 $30,325.02 $30,186.39 nat. median
$30,122
1.0× median
D1804
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=40.50 And M <45.50- T… 11 $30,094.40 $30,094.40 $30,094.40 nat. median
$29,518
1.0× median

Other procedures at this hospital

Browse this hospital's 2,161 published procedures. Use the slice to choose what to show, then sort or filter any column.

Slice
Sortable, filterable data table. Use the column headers to sort, the filter row to narrow results.
Code Type Description Rate rows Payers Gross Cash Min $ Max $ Avg median Last observed
             
00410 HCPCS Anesth Correct Heart Rhythm 0 0 — — — — — 2026-08-10
0118 RC Room & Board - Private (One Bed) - Rehabilitation 16 5 — — $1,011.49 $1,675.00 $1,675.00 2026-08-10
0128 RC Room & Board - Semi-private (Two Beds) - Rehabilitation 16 5 — — $1,011.49 $1,665.00 $1,665.00 2026-08-10
0138 RC Room & Board - Three And Four Beds - Rehabilitation 16 5 — — $1,675.00 $1,675.00 $1,675.00 2026-08-10
0148 RC Room & Board - Deluxe Private - Rehabilitation 16 5 — — $1,675.00 $1,675.00 $1,675.00 2026-08-10
0158 RC Room & Board - Ward - Rehabilitation 16 5 — — $1,675.00 $1,675.00 $1,675.00 2026-08-10
0420 RC Physical Therapy - General Classification 102 16 — — $70.00 $503.04 $503.04 2026-08-10
0421 RC Physical Therapy - Visit Charge 98 15 — — $70.00 $113.00 $91.50 2026-08-10
0422 RC Physical Therapy - Hourly Charge 42 9 — — $70.00 $113.00 $91.50 2026-08-10
0423 RC Physical Therapy - Group Rate 42 9 — — $70.00 $113.00 $91.50 2026-08-10
0424 RC Physical Therapy - Evaluation Or Re-evaluation 100 16 — — $70.00 $150.00 $110.00 2026-08-10
0425 RC Physical Therapy - Treatment 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0426 RC Physical Therapy - Continuation 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0427 RC Physical Therapy - Observation/Hourly 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0428 RC Physical Therapy - Other 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0429 RC Physical Therapy - Other 24 6 — — $70.00 $113.00 $91.50 2026-08-10
0430 RC Occupational Therapy - General Classification 100 16 — — $70.00 $503.04 $503.04 2026-08-10
0431 RC Occupational Therapy - Visit Charge 40 7 — — $70.00 $113.00 $91.50 2026-08-10
0432 RC Occupational Therapy - Hourly Charge 40 7 — — $70.00 $113.00 $91.50 2026-08-10
0433 RC Occupational Therapy - Group Rate 40 7 — — $70.00 $113.00 $91.50 2026-08-10
0434 RC Occupational Therapy - Evaluation Or Reevaluation 96 16 — — $70.00 $503.04 $503.04 2026-08-10
0435 RC Occupational Therapy - Treatment 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0436 RC Occupational Therapy - Continuation 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0437 RC Occupational Therapy - Observation/Hourly 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0438 RC Occupational Therapy - Other 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0439 RC Occupational Therapy - Other 24 6 — — $70.00 $113.00 $91.50 2026-08-10
0440 RC Speech Therapy - Language Pathology - General Classification 98 16 — — $70.00 $503.04 $503.04 2026-08-10
0441 RC Speech Therapy - Language Pathology - Visit Charge 40 7 — — $70.00 $113.00 $91.50 2026-08-10
0442 RC Speech Therapy - Language Pathology - Hourly Charge 40 7 — — $70.00 $113.00 $91.50 2026-08-10
0443 RC Speech Therapy - Language Pathology - Group Rate 40 7 — — $70.00 $113.00 $91.50 2026-08-10
0444 RC Speech Therapy - Language Pathology - Evaluation Or Reevaluation 86 15 — — $70.00 $150.00 $110.00 2026-08-10
0445 RC Speech-language Pathology - Treatment 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0446 RC Speech-language Pathology - Continuation 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0447 RC Speech-language Pathology - Observation/Hourly 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0448 RC Speech-language Pathology - Other 18 5 — — $70.00 $70.00 $70.00 2026-08-10
0449 RC Speech Therapy - Language Pathology - Other 24 6 — — $70.00 $113.00 $91.50 2026-08-10
0850 RC Continuous Cycling Peritoneal Dialysis (ccpd) - Outpatient Or Home - General Cla… 6 1 — — $650.00 $650.00 $650.00 2026-08-10
0851 RC Continuous Cycling Peritoneal Dialysis (ccpd) - Outpatient Or Home - CCPD/Compos… 6 1 — — $650.00 $650.00 $650.00 2026-08-10
0940 RC Other Therapeutic Services - General Classification 18 5 — — $147.00 $147.00 $147.00 2026-08-10
10061 HCPCS I&d Abscess Comp/multiple 0 0 — — — — — 2026-08-10
11045 HCPCS Dbrdmt Subq Tiss Each Addl 0 0 — — — — — 2026-08-10
11406 HCPCS Exc Tr-ext B9+marg >4.0 Cm 0 0 — — — — — 2026-08-10
15771 HCPCS Grfg Autol Fat Lipo 50 Cc/< 0 0 — — — — — 2026-08-10
15772 HCPCS Grfg Autol Fat Lipo Ea Addl 0 0 — — — — — 2026-08-10
15853 HCPCS Removal Sutr/stapl Xreq Anes 0 0 — — — — — 2026-08-10
16020 HCPCS Dress/debrid P-thick Burn S 0 0 — — — — — 2026-08-10
19081 HCPCS Bx Breast 1st Lesion Strtctc 0 0 — — — — — 2026-08-10
19083 HCPCS Bx Breast 1st Lesion US Imag 0 0 — — — — — 2026-08-10
22548 HCPCS Arthrd Ant Toral/xoral C1-c2 0 0 — — — — — 2026-08-10
22552 HCPCS Arthrd Ant Ntrbd Cervical Ea 0 0 — — — — — 2026-08-10
23412 HCPCS Repair Rotator Cuff Chronic 0 0 — — — — — 2026-08-10
23515 HCPCS Optx Clavicular Fx W/int Fix 0 0 — — — — — 2026-08-10
23650 HCPCS Cltx Sho Dslc W/mnpj Wo Anes 0 0 — — — — — 2026-08-10
24344 HCPCS Reconstruct Elbow Lat Ligmnt 0 0 — — — — — 2026-08-10
24430 HCPCS Repair Of Humerus 0 0 — — — — — 2026-08-10
24516 HCPCS Treat Humerus Fracture 0 0 — — — — — 2026-08-10
24615 HCPCS Treat Elbow Dislocation 0 0 — — — — — 2026-08-10
24685 HCPCS Treat Ulnar Fracture 0 0 — — — — — 2026-08-10
25607 HCPCS Treat Fx Rad Extra-articul 0 0 — — — — — 2026-08-10
25608 HCPCS Treat Fx Rad Intra-articul 0 0 — — — — — 2026-08-10
31288 HCPCS Nasal/sinus Endoscopy Surg 0 0 — — — — — 2026-08-10
31500 HCPCS Insert Emergency Airway 0 0 — — — — — 2026-08-10
32408 HCPCS Core Ndl Bx Lng/med Perq 0 0 — — — — — 2026-08-10
32555 HCPCS Aspirate Pleura With Imaging 0 0 — — — — — 2026-08-10
33207 HCPCS Insert Heart Pm Ventricular 0 0 — — — — — 2026-08-10
33227 HCPCS Remove&replace Pm Gen Singl 0 0 — — — — — 2026-08-10
33228 HCPCS Remv&replc Pm Gen Dual Lead 0 0 — — — — — 2026-08-10
36012 HCPCS Place Catheter In Vein 0 0 — — — — — 2026-08-10
36200 HCPCS Place Catheter In Aorta 0 0 — — — — — 2026-08-10
36225 HCPCS Place Cath Subclavian Art 0 0 — — — — — 2026-08-10
36247 HCPCS Ins Cath Abd/l-ext Art 3rd 0 0 — — — — — 2026-08-10
36248 HCPCS Ins Cath Abd/l-ext Art Addl 0 0 — — — — — 2026-08-10
36415 HCPCS Routine Venipuncture 0 0 — — — — — 2026-08-10
36430 HCPCS Transfusion Bld/bld Compnt 0 0 — — — — — 2026-08-10
36460 HCPCS Intrauterine Transfusion Ftl 0 0 — — — — — 2026-08-10
36514 HCPCS Apheresis Plasma 0 0 — — — — — 2026-08-10
36556 HCPCS Insert Non-tunnel Cv Cath 0 0 — — — — — 2026-08-10
36558 HCPCS Insert Tunneled Cv Cath 0 0 — — — — — 2026-08-10
36561 HCPCS Insert Tunneled Cv Cath 0 0 — — — — — 2026-08-10
36569 HCPCS Insj Picc 5 Yr+ Without Imaging 0 0 — — — — — 2026-08-10
36573 HCPCS Insj Picc Rs&i 5 Yr+ 0 0 — — — — — 2026-08-10
36589 HCPCS Removal Tunneled Cv Cath 0 0 — — — — — 2026-08-10
36590 HCPCS Removal Tunneled Cv Cath 0 0 — — — — — 2026-08-10
36597 HCPCS Reposition Venous Catheter 0 0 — — — — — 2026-08-10
36600 HCPCS Withdrawal Of Arterial Blood 0 0 — — — — — 2026-08-10
52224 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-08-10
52234 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-08-10
52235 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-08-10
52240 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-08-10
52310 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-08-10
52317 HCPCS Remove Bladder Stone 0 0 — — — — — 2026-08-10
52332 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-08-10
52356 HCPCS Cysto/uretero W/lithotripsy 0 0 — — — — — 2026-08-10
52601 HCPCS Prostatectomy (turp) 0 0 — — — — — 2026-08-10
53445 HCPCS Insert Uro/ves Nck Sphincter 0 0 — — — — — 2026-08-10
54161 HCPCS Circum 28 Days Or Older 0 0 — — — — — 2026-08-10
55040 HCPCS Removal Of Hydrocele 0 0 — — — — — 2026-08-10
55700 HCPCS Biopsy Of Prostate 0 0 — — — — — 2026-08-10
55880 HCPCS Abltj Mal Prst8 Tiss Hifu 0 0 — — — — — 2026-08-10
57260 HCPCS Cmbn Ant Pst Colprhy 0 0 — — — — — 2026-08-10
57288 HCPCS Repair Bladder Defect 0 0 — — — — — 2026-08-10
57461 HCPCS Conz Of Cervix W/scope Leep 0 0 — — — — — 2026-08-10
57522 HCPCS Conization Of Cervix 0 0 — — — — — 2026-08-10
58120 HCPCS Dilation And Curettage 0 0 — — — — — 2026-08-10
58301 HCPCS Remove Intrauterine Device 0 0 — — — — — 2026-08-10
58550 HCPCS Laparo-asst Vag Hysterectomy 0 0 — — — — — 2026-08-10
58552 HCPCS Laparo-vag Hyst Incl T/o 0 0 — — — — — 2026-08-10
58554 HCPCS Laparo-vag Hyst W/t/o Compl 0 0 — — — — — 2026-08-10
58558 HCPCS Hysteroscopy Biopsy 0 0 — — — — — 2026-08-10
58561 HCPCS Hysteroscopy Remove Myoma 0 0 — — — — — 2026-08-10
58563 HCPCS Hysteroscopy Ablation 0 0 — — — — — 2026-08-10
58570 HCPCS Tlh Uterus 250 G Or Less 0 0 — — — — — 2026-08-10
58571 HCPCS Tlh W/t/o 250 G Or Less 0 0 — — — — — 2026-08-10
58661 HCPCS Laparoscopy Remove Adnexa 0 0 — — — — — 2026-08-10
58662 HCPCS Laparoscopy Excise Lesions 0 0 — — — — — 2026-08-10
59012 HCPCS Fetal Cord Puncture Prenatal 0 0 — — — — — 2026-08-10
59025 HCPCS Fetal Non-stress Test 0 0 — — — — — 2026-08-10
59820 HCPCS Care Of Miscarriage 0 0 — — — — — 2026-08-10
59897 HCPCS Unlisted Fetal Invas Px W/us 0 0 — — — — — 2026-08-10
60220 HCPCS Partial Removal Of Thyroid 0 0 — — — — — 2026-08-10
61782 HCPCS Scan Proc Cranial Extra 0 0 — — — — — 2026-08-10
62270 HCPCS Dx Lmbr Spi Pnxr 0 0 — — — — — 2026-08-10
62328 HCPCS Dx Lmbr Spi Pnxr W/fluor/ct 0 0 — — — — — 2026-08-10
64450 HCPCS Njx Aa&/strd Other Pn/branch 0 0 — — — — — 2026-08-10
64718 HCPCS Revise Ulnar Nerve At Elbow 0 0 — — — — — 2026-08-10
64721 HCPCS Carpal Tunnel Surgery 0 0 — — — — — 2026-08-10
65426 HCPCS Removal Of Eye Lesion 0 0 — — — — — 2026-08-10
65730 HCPCS Corneal Transplant 0 0 — — — — — 2026-08-10
65755 HCPCS Corneal Transplant 0 0 — — — — — 2026-08-10
65756 HCPCS Corneal Trnspl Endothelial 0 0 — — — — — 2026-08-10
65820 HCPCS Relieve Inner Eye Pressure 0 0 — — — — — 2026-08-10
66170 HCPCS Glaucoma Surgery 0 0 — — — — — 2026-08-10
66180 HCPCS Aqueous Shunt Eye W/graft 0 0 — — — — — 2026-08-10
66250 HCPCS Follow-up Surgery Of Eye 0 0 — — — — — 2026-08-10
66500 HCPCS Incision Of Iris 0 0 — — — — — 2026-08-10
66625 HCPCS Removal Of Iris 0 0 — — — — — 2026-08-10
92507 HCPCS Speech/hearing Therapy 86 15 — — $26.64 $95.00 $60.82 2026-08-10
92521 HCPCS Evaluation Of Speech Fluency 10 2 — — $95.00 $150.00 $95.00 2026-08-10
92522 HCPCS Evaluate Speech Production 66 12 — — $95.00 $150.00 $122.50 2026-08-10
92523 HCPCS Speech Sound Lang Comprehen 80 14 — — $95.00 $220.64 $157.82 2026-08-10
92524 HCPCS Behavral Qualit Analys Voice 66 12 — — $95.00 $150.00 $122.50 2026-08-10
92526 HCPCS Oral Function Therapy 86 15 — — $85.00 $95.00 $90.00 2026-08-10
92597 HCPCS Oral Speech Device Eval 10 2 — — $90.00 $95.00 $95.00 2026-08-10
92605 HCPCS Ex For Nonspeech Device Rx 10 2 — — $90.00 $95.00 $95.00 2026-08-10
92606 HCPCS Non-speech Device Service 10 2 — — $90.00 $95.00 $95.00 2026-08-10
92607 HCPCS Ex For Speech Device Rx 1hr 66 12 — — $90.00 $95.00 $92.50 2026-08-10
96105 HCPCS Assessment Of Aphasia 66 12 — — $66.70 $150.00 $108.35 2026-08-10
97032 HCPCS Appl Modality 1+estim Ea 15 58 11 — — $90.00 $95.00 $92.50 2026-08-10
97035 HCPCS App Mdlty 1+ultrasound Ea 15 56 10 — — $9.89 $9.89 $9.89 2026-08-10
97110 HCPCS Therapeutic Exercises 56 10 — — $13.83 $95.00 $53.94 2026-08-10
97112 HCPCS Neuromuscular Reeducation 90 15 — — $19.91 $95.00 $57.45 2026-08-10
97113 HCPCS Aquatic Therapy/exercises 76 13 — — $85.00 $154.80 $119.90 2026-08-10
97116 HCPCS Gait Training Therapy 90 15 — — $17.57 $95.00 $56.28 2026-08-10
97124 HCPCS Massage Therapy 76 13 — — $58.52 $95.00 $76.76 2026-08-10
97129 HCPCS Ther Ivntj 1st 15 Min 76 13 — — $13.34 $95.00 $54.17 2026-08-10
97130 HCPCS Ther Ivntj Ea Addl 15 Min 56 10 — — $38.82 $38.82 $38.82 2026-08-10
97140 HCPCS Manual Therapy 1/> Regions 76 13 — — $18.61 $95.00 $56.80 2026-08-10
97161 HCPCS Pt Eval Low Complex 20 Min 90 15 — — $58.38 $150.00 $104.19 2026-08-10
97162 HCPCS Pt Eval Mod Complex 30 Min 90 15 — — $85.00 $150.00 $117.50 2026-08-10
97163 HCPCS Pt Eval High Complex 45 Min 90 15 — — $85.00 $150.00 $117.50 2026-08-10
97164 HCPCS Pt Re-eval Est Plan Care 90 15 — — $85.00 $150.00 $117.50 2026-08-10
97165 HCPCS Ot Eval Low Complex 30 Min 90 15 — — $85.00 $510.54 $510.54 2026-08-10
97166 HCPCS Ot Eval Mod Complex 45 Min 90 15 — — $58.77 $497.42 $150.00 2026-08-10
97167 HCPCS Ot Eval High Complex 60 Min 76 13 — — $85.00 $510.54 $510.54 2026-08-10
97168 HCPCS Ot Re-eval Est Plan Care 76 13 — — $85.00 $510.54 $510.54 2026-08-10
97530 HCPCS Therapeutic Activities 88 15 — — $30.65 $95.00 $63.78 2026-08-10
97533 HCPCS Sensory Integration 64 11 — — $85.00 $90.00 $87.50 2026-08-10
97535 HCPCS Self Care Mngment Training 88 15 — — $21.15 $95.00 $58.08 2026-08-10
97537 HCPCS Community/work Reintegration 74 13 — — $85.00 $95.00 $90.00 2026-08-10
97542 HCPCS Wheelchair Mngment Training 64 11 — — $85.00 $90.00 $87.50 2026-08-10
A0102 HCPCS Stroke M >=63.50 And M <72.50- Tier None 40 11 — — $17,938.42 $17,938.42 $17,938.42 2026-08-10
A0103 HCPCS Stroke M >=50.50 And M <63.50- Tier None 40 11 — — $20,024.33 $23,329.35 $21,676.84 2026-08-10
A0104 HCPCS Stroke M >=41.50 And M <50.50- Tier None 40 11 — — $28,916.59 $29,506.72 $29,211.65 2026-08-10
A0105 HCPCS Stroke M <41.50 And A >=84.50- Tier None 40 11 — — $36,159.79 $36,897.74 $36,528.76 2026-08-10
A0106 HCPCS Stroke M <41.50 And A <84.50- Tier None 40 11 — — $2,682.17 $41,965.93 $22,324.05 2026-08-10
A0201 HCPCS Traumatic Brain Injury M >=73.50- Tier None 40 11 — — $13,730.55 $13,730.55 $13,730.55 2026-08-10
A0202 HCPCS Traumatic Brain Injury M >=61.50 And M <73.50- Tier None 40 11 — — $17,957.54 $17,957.54 $17,957.54 2026-08-10
A0203 HCPCS Traumatic Brain Injury M >=49.50 And M <61.50- Tier None 40 11 — — $22,362.33 $22,362.33 $22,362.33 2026-08-10
A0204 HCPCS Traumatic Brain Injury M >=35.50 And M <49.50- Tier None 40 11 — — $27,736.40 $27,736.40 $27,736.40 2026-08-10
A0205 HCPCS Traumatic Brain Injury M <35.50- Tier None 40 11 — — $35,526.98 $35,526.98 $35,526.98 2026-08-10
A0303 HCPCS Non-traumatic Brain Injury M >=42.50 And M <52.50- Tier None 40 11 — — $24,200.83 $24,694.72 $24,447.78 2026-08-10
A0304 HCPCS Non-traumatic Brain Injury M <42.50 And A >=78.50- Tier None 40 11 — — $28,633.03 $28,633.03 $28,633.03 2026-08-10
A0305 HCPCS Non-traumatic Brain Injury M <42.50 And A <78.50- Tier None 40 11 — — $31,577.20 $31,577.20 $31,577.20 2026-08-10
A0504 HCPCS Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50- Tier None 40 11 — — $28,107.29 $28,107.29 $28,107.29 2026-08-10
A0505 HCPCS Non-traumatic Spinal Cord Injury M <39.50- Tier None 40 11 — — $39,035.10 $39,056.17 $39,045.64 2026-08-10
A0601 HCPCS Neurological M >=64.50- Tier None 40 11 — — $16,013.24 $16,013.24 $16,013.24 2026-08-10
A0602 HCPCS Neurological M >=52.50 And M <64.50- Tier None 40 11 — — $20,309.05 $20,309.05 $20,309.05 2026-08-10
A0603 HCPCS Neurological M >=43.50 And M <52.50- Tier None 40 11 — — $23,930.00 $23,930.00 $23,930.00 2026-08-10
A0604 HCPCS Neurological M <43.50- Tier None 40 11 — — $30,011.44 $30,011.44 $30,011.44 2026-08-10
A0701 HCPCS Fracture Of Lower Extremity M >=61.50- Tier None 40 11 — — $16,473.36 $16,473.36 $16,473.36 2026-08-10
A0702 HCPCS Fracture Of Lower Extremity M >=52.50 And M <61.50- Tier None 40 11 — — $20,050.96 $20,362.87 $20,206.92 2026-08-10
A0703 HCPCS Fracture Of Lower Extremity M >=41.50 And M <52.50- Tier None 40 11 — — $24,165.23 $24,658.40 $24,411.81 2026-08-10
A0704 HCPCS Fracture Of Lower Extremity M <41.50- Tier None 40 11 — — $19,753.68 $30,122.32 $24,938.00 2026-08-10
A0802 HCPCS Replacement Of Lower-extremity Joint M >=57.50 And M <63.50- Tier None 40 11 — — $10,223.36 $10,223.36 $10,223.36 2026-08-10
A0804 HCPCS Replacement Of Lower-extremity Joint M >=42.50 And M <51.50- Tier None 40 11 — — $22,419.68 $22,419.68 $22,419.68 2026-08-10
A0805 HCPCS Replacement Of Lower-extremity Joint M <42.50- Tier None 40 11 — — $26,889.47 $26,889.47 $26,889.47 2026-08-10
A0902 HCPCS Other Orthopedic M >=51.50 And M <63.50- Tier None 40 11 — — $19,544.33 $19,544.33 $19,544.33 2026-08-10
A0903 HCPCS Other Orthopedic M >=44.50 And M <51.50- Tier None 40 11 — — $23,339.26 $23,582.85 $23,461.06 2026-08-10
A0904 HCPCS Other Orthopedic M <44.5- Tier None 40 11 — — $27,406.49 $27,965.81 $27,686.15 2026-08-10
A1002 HCPCS Amputation Lower Extremity M >=55.50 And M <64.50- Tier None 40 11 — — $20,229.35 $20,229.35 $20,229.35 2026-08-10
A1004 HCPCS Amputation Lower Extremity M <47.50- Tier None 40 11 — — $29,180.76 $29,180.76 $29,180.76 2026-08-10
A1402 HCPCS Cardiac M >=55.50 And M <68.50- Tier None 40 11 — — $6,454.43 $6,454.43 $6,454.43 2026-08-10
A1403 HCPCS Cardiac M >=45.50 And M <55.50- Tier None 40 11 — — $22,806.88 $22,806.88 $22,806.88 2026-08-10
A1404 HCPCS Cardiac M <45.50- Tier None 40 11 — — $28,455.39 $28,455.39 $28,455.39 2026-08-10
A1701 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=57.50- Tier None 40 11 — — $16,361.83 $16,361.83 $16,361.83 2026-08-10
A1703 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50… 40 11 — — $24,648.84 $24,648.84 $24,648.84 2026-08-10
A1704 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50… 40 11 — — $27,896.99 $27,896.99 $27,896.99 2026-08-10
A1705 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier None 40 11 — — $32,082.92 $32,737.67 $32,410.29 2026-08-10
A1803 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=45.50 And M <55.50- T… 40 11 — — $24,536.04 $24,536.04 $24,536.04 2026-08-10
A1804 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=40.50 And M <45.50- T… 40 11 — — $28,246.40 $28,246.40 $28,246.40 2026-08-10
A1805 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 40 11 — — $2,128.51 $32,529.28 $17,328.90 2026-08-10
A1806 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50- Tier None 40 11 — — $46,196.74 $46,196.74 $46,196.74 2026-08-10
A1903 HCPCS Guillain-barré M >=38.50 And M <51.50- Tier None 40 11 — — $32,819.00 $32,819.00 $32,819.00 2026-08-10
A1904 HCPCS Guillain-barré M <38.50- Tier None 40 11 — — $49,305.33 $49,305.33 $49,305.33 2026-08-10
A2001 HCPCS Miscellaneous M >=66.50- Tier None 40 11 — — $15,701.26 $15,701.26 $15,701.26 2026-08-10
A2002 HCPCS Miscellaneous M >=55.50 And M <66.50- Tier None 40 11 — — $19,110.35 $19,110.35 $19,110.35 2026-08-10
A2003 HCPCS Miscellaneous M >=46.50 And M <55.50- Tier None 40 11 — — $22,884.25 $22,884.25 $22,884.25 2026-08-10
A2004 HCPCS Miscellaneous M <46.50 And A >=77.50- Tier None 40 11 — — $27,361.68 $27,361.68 $27,361.68 2026-08-10
A2005 HCPCS Miscellaneous M <46.50 And A <77.50- Tier None 40 11 — — $2,884.14 $28,841.42 $15,862.78 2026-08-10
B0104 HCPCS Stroke M >=41.50 And M <50.50- Tier Tier 1 40 11 — — $39,067.64 $39,067.64 $39,067.64 2026-08-10
B0105 HCPCS Stroke M <41.50 And A >=84.50- Tier Tier 1 40 11 — — $48,852.23 $48,852.23 $48,852.23 2026-08-10
B0604 HCPCS Neurological M <43.50- Tier Tier 1 40 11 — — $46,457.54 $46,457.54 $46,457.54 2026-08-10
B0904 HCPCS Other Orthopedic M <44.5- Tier Tier 1 40 11 — — $40,943.11 $40,943.11 $40,943.11 2026-08-10
B1303 HCPCS Rheumatoid Other Arthritis M >=44.50 And M <51.50 And A >=64.50- Tier Tier 1 40 11 — — $32,420.31 $32,420.31 $32,420.31 2026-08-10
B1404 HCPCS Cardiac M <45.50- Tier Tier 1 40 11 — — $41,023.41 $41,023.41 $41,023.41 2026-08-10
B1803 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=45.50 And M <55.50- T… 40 11 — — $34,940.06 $34,940.06 $34,940.06 2026-08-10
B2005 HCPCS Miscellaneous M <46.50 And A <77.50- Tier Tier 1 40 11 — — $42,800.15 $42,800.15 $42,800.15 2026-08-10
C0106 HCPCS Stroke M <41.50 And A <84.50- Tier Tier 2 40 11 — — $7,027.54 $7,027.54 $7,027.54 2026-08-10
C0204 HCPCS Traumatic Brain Injury M >=35.50 And M <49.50- Tier Tier 2 40 11 — — $17,087.22 $17,087.22 $17,087.22 2026-08-10
C0205 HCPCS Traumatic Brain Injury M <35.50- Tier Tier 2 40 11 — — $10,043.56 $41,923.56 $25,983.56 2026-08-10
C0303 HCPCS Non-traumatic Brain Injury M >=42.50 And M <52.50- Tier Tier 2 40 11 — — $27,951.71 $28,522.15 $28,236.93 2026-08-10
C0304 HCPCS Non-traumatic Brain Injury M <42.50 And A >=78.50- Tier Tier 2 40 11 — — $32,408.91 $33,070.32 $32,739.62 2026-08-10
C0305 HCPCS Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 2 40 11 — — $36,471.41 $36,471.41 $36,471.41 2026-08-10
C0403 HCPCS Traumatic Spinal Cord Injury M >=41.50 And M <47.50- Tier Tier 2 40 11 — — $32,521.33 $32,521.33 $32,521.33 2026-08-10
C0503 HCPCS Non-traumatic Spinal Cord Injury M >=48.50 And M <53.50- Tier Tier 2 40 11 — — $27,365.93 $27,365.93 $27,365.93 2026-08-10
C0504 HCPCS Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50- Tier Tier 2 40 11 — — $31,638.88 $32,284.57 $31,961.72 2026-08-10
C0505 HCPCS Non-traumatic Spinal Cord Injury M <39.50- Tier Tier 2 40 11 — — $44,862.30 $44,862.30 $44,862.30 2026-08-10
C0603 HCPCS Neurological M >=43.50 And M <52.50- Tier Tier 2 40 11 — — $28,422.73 $28,422.73 $28,422.73 2026-08-10
C0604 HCPCS Neurological M <43.50- Tier Tier 2 40 11 — — $35,645.51 $35,645.51 $35,645.51 2026-08-10
C0703 HCPCS Fracture Of Lower Extremity M >=41.50 And M <52.50- Tier Tier 2 40 11 — — $28,174.20 $28,174.20 $28,174.20 2026-08-10
C0704 HCPCS Fracture Of Lower Extremity M <41.50- Tier Tier 2 40 11 — — $34,418.14 $34,783.41 $34,600.78 2026-08-10
C0805 HCPCS Replacement Of Lower-extremity Joint M <42.50- Tier Tier 2 40 11 — — $31,621.18 $31,621.18 $31,621.18 2026-08-10
C0904 HCPCS Other Orthopedic M <44.5- Tier Tier 2 40 11 — — $32,137.25 $32,793.11 $32,465.18 2026-08-10
C1004 HCPCS Amputation Lower Extremity M <47.50- Tier Tier 2 40 11 — — $35,655.80 $35,655.80 $35,655.80 2026-08-10
C1404 HCPCS Cardiac M <45.50- Tier Tier 2 40 11 — — $32,317.07 $32,317.07 $32,317.07 2026-08-10
C1705 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier Tier 2 40 11 — — $38,964.40 $38,964.40 $38,964.40 2026-08-10
C1805 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 40 11 — — $36,955.10 $39,247.34 $38,101.22 2026-08-10
C1806 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50- Tier Tier 2 40 11 — — $52,482.74 $52,482.74 $52,482.74 2026-08-10
C2003 HCPCS Miscellaneous M >=46.50 And M <55.50- Tier Tier 2 40 11 — — $26,914.32 $26,914.32 $26,914.32 2026-08-10
C2004 HCPCS Miscellaneous M <46.50 And A >=77.50- Tier Tier 2 40 11 — — $32,179.42 $32,179.42 $32,179.42 2026-08-10
C2005 HCPCS Miscellaneous M <46.50 And A <77.50- Tier Tier 2 40 11 — — $33,919.16 $33,919.16 $33,919.16 2026-08-10
D0102 HCPCS Stroke M >=63.50 And M <72.50- Tier Tier 3 40 11 — — $19,159.25 $19,159.25 $19,159.25 2026-08-10
D0103 HCPCS Stroke M >=50.50 And M <63.50- Tier Tier 3 40 11 — — $23,775.53 $24,260.74 $24,018.13 2026-08-10
D0104 HCPCS Stroke M >=41.50 And M <50.50- Tier Tier 3 40 11 — — $28,609.13 $30,961.60 $29,785.37 2026-08-10
D0105 HCPCS Stroke M <41.50 And A >=84.50- Tier Tier 3 40 11 — — $38,715.87 $38,715.87 $38,715.87 2026-08-10
D0106 HCPCS Stroke M <41.50 And A <84.50- Tier Tier 3 40 11 — — $43,155.68 $44,036.41 $43,596.04 2026-08-10
D0203 HCPCS Traumatic Brain Injury M >=49.50 And M <61.50- Tier Tier 3 40 11 — — $23,277.17 $23,752.21 $23,514.69 2026-08-10
D0204 HCPCS Traumatic Brain Injury M >=35.50 And M <49.50- Tier Tier 3 40 11 — — $28,869.75 $29,458.93 $29,164.34 2026-08-10
D0205 HCPCS Traumatic Brain Injury M <35.50- Tier Tier 3 40 11 — — $19,319.60 $37,735.11 $28,527.35 2026-08-10
D0301 HCPCS Non-traumatic Brain Injury M >=65.50- Tier Tier 3 40 11 — — $16,506.10 $16,842.96 $16,674.53 2026-08-10
D0302 HCPCS Non-traumatic Brain Injury M >=52.50 And M <65.50- Tier Tier 3 40 11 — — $21,775.40 $21,775.40 $21,775.40 2026-08-10
D0303 HCPCS Non-traumatic Brain Injury M >=42.50 And M <52.50- Tier Tier 3 40 11 — — $25,677.20 $26,201.22 $25,939.21 2026-08-10
D0304 HCPCS Non-traumatic Brain Injury M <42.50 And A >=78.50- Tier Tier 3 40 11 — — $30,378.51 $30,378.51 $30,378.51 2026-08-10
D0305 HCPCS Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 3 40 11 — — $33,502.39 $33,502.39 $33,502.39 2026-08-10
D0402 HCPCS Traumatic Spinal Cord Injury M >=47.50 And M <56.50- Tier Tier 3 40 11 — — $25,669.74 $25,669.74 $25,669.74 2026-08-10
D0404 HCPCS Traumatic Spinal Cord Injury M <31.50 And A <61.50- Tier Tier 3 40 11 — — $48,920.82 $48,920.82 $48,920.82 2026-08-10
D0502 HCPCS Non-traumatic Spinal Cord Injury M >=53.50 And M <60.50- Tier Tier 3 40 11 — — $22,385.27 $22,385.27 $22,385.27 2026-08-10
D0503 HCPCS Non-traumatic Spinal Cord Injury M >=48.50 And M <53.50- Tier Tier 3 40 11 — — $25,658.27 $25,658.27 $25,658.27 2026-08-10
D0505 HCPCS Non-traumatic Spinal Cord Injury M <39.50- Tier Tier 3 40 11 — — $42,382.70 $42,382.70 $42,382.70 2026-08-10
D0601 HCPCS Neurological M >=64.50- Tier Tier 3 40 11 — — $17,754.89 $17,754.89 $17,754.89 2026-08-10
D0602 HCPCS Neurological M >=52.50 And M <64.50- Tier Tier 3 40 11 — — $22,483.72 $22,483.72 $22,483.72 2026-08-10
D0603 HCPCS Neurological M >=43.50 And M <52.50- Tier Tier 3 40 11 — — $26,533.88 $26,533.88 $26,533.88 2026-08-10
D0604 HCPCS Neurological M <43.50- Tier Tier 3 40 11 — — $33,276.79 $33,276.79 $33,276.79 2026-08-10
D0702 HCPCS Fracture Of Lower Extremity M >=52.50 And M <61.50- Tier Tier 3 40 11 — — $22,282.47 $22,282.47 $22,282.47 2026-08-10
D0703 HCPCS Fracture Of Lower Extremity M >=41.50 And M <52.50- Tier Tier 3 40 11 — — $26,688.73 $26,688.73 $26,688.73 2026-08-10
D0704 HCPCS Fracture Of Lower Extremity M <41.50- Tier Tier 3 40 11 — — $31,951.76 $32,603.84 $32,277.80 2026-08-10
D0803 HCPCS Replacement Of Lower-extremity Joint M >=51.50 And M <57.50- Tier Tier 3 40 11 — — $21,456.13 $21,456.13 $21,456.13 2026-08-10
D0804 HCPCS Replacement Of Lower-extremity Joint M >=42.50 And M <51.50- Tier Tier 3 40 11 — — $24,038.98 $24,457.51 $24,248.24 2026-08-10
D0805 HCPCS Replacement Of Lower-extremity Joint M <42.50- Tier Tier 3 40 11 — — $28,253.35 $30,462.07 $29,357.71 2026-08-10
D0901 HCPCS Other Orthopedic M >=63.50- Tier Tier 3 40 11 — — $17,148.70 $17,148.70 $17,148.70 2026-08-10
D0902 HCPCS Other Orthopedic M >=51.50 And M <63.50- Tier Tier 3 40 11 — — $21,360.54 $21,360.54 $21,360.54 2026-08-10
D0903 HCPCS Other Orthopedic M >=44.50 And M <51.50- Tier Tier 3 40 11 — — $25,509.15 $25,509.15 $25,509.15 2026-08-10
D0904 HCPCS Other Orthopedic M <44.5- Tier Tier 3 40 11 — — $29,954.54 $31,127.73 $30,541.13 2026-08-10
D1004 HCPCS Amputation Lower Extremity M <47.50- Tier Tier 3 40 11 — — $28,574.76 $34,490.91 $31,532.83 2026-08-10
D1203 HCPCS Osteoarthritis M <49.50 And A >=74.50- Tier Tier 3 40 11 — — $28,378.76 $28,378.76 $28,378.76 2026-08-10
D1402 HCPCS Cardiac M >=55.50 And M <68.50- Tier Tier 3 40 11 — — $20,041.40 $20,041.40 $20,041.40 2026-08-10
D1403 HCPCS Cardiac M >=45.50 And M <55.50- Tier Tier 3 40 11 — — $24,522.66 $24,522.66 $24,522.66 2026-08-10
D1404 HCPCS Cardiac M <45.50- Tier Tier 3 40 11 — — $30,047.76 $30,325.02 $30,186.39 2026-08-10
D1702 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=50.50 And M <57.50… 40 11 — — $6,668.44 $6,668.44 $6,668.44 2026-08-10
D1703 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50… 40 11 — — $27,168.59 $27,168.59 $27,168.59 2026-08-10
D1704 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50… 40 11 — — $30,749.39 $30,749.39 $30,749.39 2026-08-10
D1705 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier Tier 3 40 11 — — $36,085.23 $36,085.23 $36,085.23 2026-08-10
D1804 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=40.50 And M <45.50- T… 40 11 — — $30,094.40 $30,094.40 $30,094.40 2026-08-10
D1805 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 40 11 — — $35,083.45 $35,083.45 $35,083.45 2026-08-10
D1806 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50- Tier Tier 3 40 11 — — $49,825.34 $49,825.34 $49,825.34 2026-08-10
D1904 HCPCS Guillain-barré M <38.50- Tier Tier 3 40 11 — — $50,173.28 $50,173.28 $50,173.28 2026-08-10
D2002 HCPCS Miscellaneous M >=55.50 And M <66.50- Tier Tier 3 40 11 — — $20,995.39 $20,995.39 $20,995.39 2026-08-10
D2003 HCPCS Miscellaneous M >=46.50 And M <55.50- Tier Tier 3 40 11 — — $25,142.08 $25,142.08 $25,142.08 2026-08-10
D2004 HCPCS Miscellaneous M <46.50 And A >=77.50- Tier Tier 3 40 11 — — $30,061.15 $30,061.15 $30,061.15 2026-08-10
D2005 HCPCS Miscellaneous M <46.50 And A <77.50- Tier Tier 3 40 11 — — $31,282.70 $31,921.12 $31,601.91 2026-08-10
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