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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

Rehabilitation Hospital Of Northern Indiana, Llc

Mishawaka, IN · CCN 153047 · Rates published

2,088 distinct procedures filed
14 distinct payers
22,272 rate rows
2026-03-17 last MRF observed
Data quality

4,675 of 22,272 rate rows are consumer-grade (21.0%)

17,597 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 17,006
per-diem day rate — not a per-procedure price 591
Data source & audit trail ↓ Download audit trail (JSON)
Source MRF file https://ernesthealth.com/pricing/2026/833605899_rehabilitation-hospital-of-northern-indiana_standard-charges.json
Found on page https://rhni.ernesthealth.com/price-transparency/
Discovered viaCMS hospital list
Last fetch success · 2026-08-14
Content fingerprint ee1067000364aea7… · 7,852,205 bytes · first seen 2026-05-05

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
B0404
HCPCS 		Traumatic Spinal Cord Injury M <31.50 And A <61.50- Tier Tier 1 10 $68,457.11 $68,457.11 $68,457.11 nat. median
$59,953
1.1× median
A0407
HCPCS 		Traumatic Spinal Cord Injury M <24.50 And A >=61.50- Tier None 10 $61,950.32 $61,950.32 $61,950.32 nat. median
$62,354
1.0× median
B0106
HCPCS 		Stroke M <41.50 And A <84.50- Tier Tier 1 10 $58,650.79 $58,650.79 $58,650.79 nat. median
$54,008
1.1× median
C1904
HCPCS 		Guillain-barré M <38.50- Tier Tier 2 10 $53,175.94 $53,175.94 $53,175.94 nat. median
$54,675
1.0× median
B2004
HCPCS 		Miscellaneous M <46.50 And A >=77.50- Tier Tier 1 10 $50,283.22 $50,283.22 $50,283.22 nat. median
$40,136
1.3× median
B1404
HCPCS 		Cardiac M <45.50- Tier Tier 1 10 $45,011.56 $54,583.03 $49,797.29 nat. median
$40,776
1.2× median
D1904
HCPCS 		Guillain-barré M <38.50- Tier Tier 3 10 $49,619.53 $49,619.53 $49,619.53 nat. median
$49,592
1.0× median
D1004
HCPCS 		Amputation Lower Extremity M <47.50- Tier Tier 3 10 $29,531.09 $63,553.71 $46,542.40 nat. median
$33,636
1.4× median
B0303
HCPCS 		Non-traumatic Brain Injury M >=42.50 And M <52.50- Tier Tier 1 10 $46,525.59 $46,525.59 $46,525.59 nat. median
$35,035
1.3× median
B0604
HCPCS 		Neurological M <43.50- Tier Tier 1 10 $46,491.21 $46,491.21 $46,491.21 nat. median
$46,532
1.0× median
B0904
HCPCS 		Other Orthopedic M <44.5- Tier Tier 1 10 $46,376.26 $46,376.26 $46,376.26 nat. median
$42,453
1.1× median
B1004
HCPCS 		Amputation Lower Extremity M <47.50- Tier Tier 1 10 $43,506.90 $48,761.04 $46,133.97 nat. median
$44,520
1.0× median
B0805
HCPCS 		Replacement Of Lower-extremity Joint M <42.50- Tier Tier 1 10 $45,823.76 $45,823.76 $45,823.76 nat. median
$39,820
1.2× median
B0305
HCPCS 		Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 1 10 $45,083.74 $45,083.74 $45,083.74 nat. median
$44,642
1.0× median
C0505
HCPCS 		Non-traumatic Spinal Cord Injury M <39.50- Tier Tier 2 10 $44,367.17 $44,367.17 $44,367.17 nat. median
$45,229
1.0× median
B0704
HCPCS 		Fracture Of Lower Extremity M <41.50- Tier Tier 1 10 $43,122.21 $44,002.26 $43,562.24 nat. median
$43,685
1.0× median
B2005
HCPCS 		Miscellaneous M <46.50 And A <77.50- Tier Tier 1 10 $41,996.23 $41,996.23 $41,996.23 nat. median
$41,996
1.0× median
C0105
HCPCS 		Stroke M <41.50 And A >=84.50- Tier Tier 2 10 $41,899.80 $41,899.80 $41,899.80 nat. median
$42,480
1.0× median
C0205
HCPCS 		Traumatic Brain Injury M <35.50- Tier Tier 2 10 $41,086.80 $41,086.80 $41,086.80 nat. median
$41,257
1.0× median
D0106
HCPCS 		Stroke M <41.50 And A <84.50- Tier Tier 3 10 $37,207.38 $43,550.38 $40,378.88 nat. median
$43,248
0.9× median
D0505
HCPCS 		Non-traumatic Spinal Cord Injury M <39.50- Tier Tier 3 10 $35,584.11 $41,914.93 $38,749.52 nat. median
$42,129
0.9× median
A0505
HCPCS 		Non-traumatic Spinal Cord Injury M <39.50- Tier None 10 $38,625.11 $38,625.11 $38,625.11 nat. median
$39,053
1.0× median
C1705
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier Tier 2 10 $38,534.36 $38,534.36 $38,534.36 nat. median
$38,430
1.0× median
B0104
HCPCS 		Stroke M >=41.50 And M <50.50- Tier Tier 1 10 $38,291.01 $38,291.01 $38,291.01 nat. median
$38,533
1.0× median
D0105
HCPCS 		Stroke M <41.50 And A >=84.50- Tier Tier 3 10 $37,522.80 $38,288.57 $37,905.68 nat. median
$38,441
1.0× median
C0805
HCPCS 		Replacement Of Lower-extremity Joint M <42.50- Tier Tier 2 10 $37,823.68 $37,823.68 $37,823.68 nat. median
$33,238
1.1× median
C1805
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 10 $36,547.23 $38,490.27 $37,518.75 nat. median
$37,575
1.0× median
B1703
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50… 10 $37,322.42 $37,322.42 $37,322.42 nat. median
$36,783
1.0× median
C0304
HCPCS 		Non-traumatic Brain Injury M <42.50 And A >=78.50- Tier Tier 2 10 $36,077.61 $36,077.61 $36,077.61 nat. median
$32,729
1.1× median
C0305
HCPCS 		Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 2 10 $36,068.88 $36,068.88 $36,068.88 nat. median
$35,676
1.0× median
D1705
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier Tier 3 10 $35,675.90 $35,675.90 $35,675.90 nat. median
$70
outlier · 509.7×
A0205
HCPCS 		Traumatic Brain Injury M <35.50- Tier None 10 $35,290.66 $35,290.66 $35,290.66 nat. median
$35,382
1.0× median
C0604
HCPCS 		Neurological M <43.50- Tier Tier 2 10 $35,252.10 $35,252.10 $35,252.10 nat. median
$35,373
1.0× median
B0903
HCPCS 		Other Orthopedic M >=44.50 And M <51.50- Tier Tier 1 10 $33,792.48 $33,792.48 $33,792.48 nat. median
$35,350
1.0× median
C2005
HCPCS 		Miscellaneous M <46.50 And A <77.50- Tier Tier 2 10 $33,544.80 $33,544.80 $33,544.80 nat. median
$33,711
1.0× median
B1403
HCPCS 		Cardiac M >=45.50 And M <55.50- Tier Tier 1 10 $33,109.94 $33,109.94 $33,109.94 nat. median
$32,913
1.0× median
B2003
HCPCS 		Miscellaneous M >=46.50 And M <55.50- Tier Tier 1 10 $32,880.51 $32,880.51 $32,880.51 nat. median
$33,140
1.0× median
C1704
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50… 10 $32,835.79 $32,835.79 $32,835.79 nat. median
$33,120
1.0× median
D2005
HCPCS 		Miscellaneous M <46.50 And A <77.50- Tier Tier 3 10 $23,944.94 $41,438.78 $32,691.86 nat. median
$31,386
1.0× median
A1805
HCPCS 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 10 $32,492.60 $32,492.60 $32,492.60 nat. median
$33,150
1.0× median
A0106
HCPCS 		Stroke M <41.50 And A <84.50- Tier None 10 $23,406.27 $41,502.76 $32,454.51 nat. median
$41,164
0.8× median
C0904
HCPCS 		Other Orthopedic M <44.5- Tier Tier 2 10 $32,431.18 $32,431.18 $32,431.18 nat. median
$32,429
1.0× median
A1705
HCPCS 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier None 10 $32,376.35 $32,376.35 $32,376.35 nat. median
$32,762
1.0× median
A0105
HCPCS 		Stroke M <41.50 And A >=84.50- Tier None 10 $28,082.70 $36,417.92 $32,250.31 nat. median
$36,651
0.9× median
C2004
HCPCS 		Miscellaneous M <46.50 And A >=77.50- Tier Tier 2 10 $31,824.26 $31,824.26 $31,824.26 nat. median
$32,130
1.0× median
C1404
HCPCS 		Cardiac M <45.50- Tier Tier 2 10 $31,650.21 $31,960.39 $31,805.30 nat. median
$32,640
1.0× median
D0704
HCPCS 		Fracture Of Lower Extremity M <41.50- Tier Tier 3 10 $31,239.54 $32,244.00 $31,741.77 nat. median
$30,260
1.0× median
A0305
HCPCS 		Non-traumatic Brain Injury M <42.50 And A <78.50- Tier None 10 $31,228.69 $31,228.69 $31,228.69 nat. median
$31,310
1.0× median
A0704
HCPCS 		Fracture Of Lower Extremity M <41.50- Tier None 10 $30,208.47 $30,208.47 $30,208.47 nat. median
$30,213
1.0× median
D0504
HCPCS 		Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50- Tier Tier 3 10 $30,164.23 $30,164.23 $30,164.23 nat. median
$30,000
1.0× median

Other procedures at this hospital

Browse this hospital's 2,088 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
             
00350 HCPCS Anesth Neck Vessel Surgery 0 0 — — — — — 2026-03-17
00921 HCPCS Anesth Vasectomy 0 0 — — — — — 2026-03-17
0110 RC Room & Board - Private (One Bed) - General Classification 1 1 — — $1,375.00 $1,375.00 $1,375.00 2026-03-17
0111 RC Room & Board - Private (One Bed) - Medical/Surgical/GYN 1 1 — — $1,420.00 $1,420.00 $1,420.00 2026-03-17
0118 RC Room & Board - Private (One Bed) - Rehabilitation 17 8 — — $667.00 $1,108.50 $1,108.50 2026-03-17
0120 RC Room & Board - Semi-private (Two Beds) - General Classification 1 1 — — $1,375.00 $1,375.00 $1,375.00 2026-03-17
0128 RC Room & Board - Semi-private (Two Beds) - Rehabilitation 16 7 — — $1,375.00 $1,375.00 $1,375.00 2026-03-17
0138 RC Room & Board - Three And Four Beds - Rehabilitation 18 7 — — $1,375.00 $1,375.00 $1,375.00 2026-03-17
0148 RC Room & Board - Deluxe Private - Rehabilitation 18 7 — — $1,375.00 $1,375.00 $1,375.00 2026-03-17
0158 RC Room & Board - Ward - Rehabilitation 18 7 — — $1,375.00 $1,375.00 $1,375.00 2026-03-17
0200 RC Intensive Care Unit - General Classification 1 1 — — $1,420.00 $1,420.00 $1,420.00 2026-03-17
0206 RC Intensive Care Unit - Intermediate ICU 1 1 — — $1,420.00 $1,420.00 $1,420.00 2026-03-17
0420 RC Physical Therapy - General Classification 54 14 — — $70.00 $75.07 $75.07 2026-03-17
0421 RC Physical Therapy - Visit Charge 54 14 — — $70.00 $75.07 $75.07 2026-03-17
0422 RC Physical Therapy - Hourly Charge 3 2 — — $70.00 $70.00 $70.00 2026-03-17
0423 RC Physical Therapy - Group Rate 3 2 — — $70.00 $70.00 $70.00 2026-03-17
0424 RC Physical Therapy - Evaluation Or Re-evaluation 54 14 — — $70.00 $76.92 $76.92 2026-03-17
0429 RC Physical Therapy - Other 3 2 — — $70.00 $70.00 $70.00 2026-03-17
0430 RC Occupational Therapy - General Classification 54 14 — — $61.00 $70.57 $70.57 2026-03-17
0431 RC Occupational Therapy - Visit Charge 3 2 — — $61.00 $70.57 $70.57 2026-03-17
0432 RC Occupational Therapy - Hourly Charge 3 2 — — $61.00 $61.00 $61.00 2026-03-17
0433 RC Occupational Therapy - Group Rate 3 2 — — $61.00 $61.00 $61.00 2026-03-17
0434 RC Occupational Therapy - Evaluation Or Reevaluation 54 14 — — $61.00 $72.42 $72.42 2026-03-17
0439 RC Occupational Therapy - Other 3 2 — — $61.00 $61.00 $61.00 2026-03-17
0440 RC Speech Therapy - Language Pathology - General Classification 54 14 — — $56.00 $68.07 $68.07 2026-03-17
0441 RC Speech Therapy - Language Pathology - Visit Charge 3 2 — — $56.00 $68.07 $68.07 2026-03-17
0442 RC Speech Therapy - Language Pathology - Hourly Charge 3 2 — — $56.00 $56.00 $56.00 2026-03-17
0443 RC Speech Therapy - Language Pathology - Group Rate 3 2 — — $56.00 $56.00 $56.00 2026-03-17
0444 RC Speech Therapy - Language Pathology - Evaluation Or Reevaluation 52 14 — — $56.00 $69.92 $69.92 2026-03-17
0449 RC Speech Therapy - Language Pathology - Other 3 2 — — $56.00 $56.00 $56.00 2026-03-17
0460 RC Pulmonary Function - General Classification 3 2 — — $81.00 $81.00 $81.00 2026-03-17
0469 RC Pulmonary Function - Other 3 2 — — $81.00 $81.00 $81.00 2026-03-17
0771 RC Preventive Care Services - Vaccine Administration 1 1 — — $20.50 $20.50 $20.50 2026-03-17
0801 RC Inpatient Renal Dialysis - Hemodialysis 1 1 — — $525.00 $525.00 $525.00 2026-03-17
0802 RC Inpatient Renal Dialysis - Peritoneal Dialysis (non-capd) 1 1 — — $450.00 $450.00 $450.00 2026-03-17
0803 RC Inpatient Renal Dialysis - Continuous Ambulatory Peritoneal Dialysis (capd) 1 1 — — $450.00 $450.00 $450.00 2026-03-17
0804 RC Inpatient Renal Dialysis - Continuous Cycling Peritoneal Dialysis (ccpd) 1 1 — — $450.00 $450.00 $450.00 2026-03-17
0805 RC Inpatient Renal Dialysis - Treatment 1 1 — — $450.00 $450.00 $450.00 2026-03-17
0806 RC Inpatient Renal Dialysis - Continuation 1 1 — — $450.00 $450.00 $450.00 2026-03-17
0807 RC Inpatient Renal Dialysis - Observation/Hourly 1 1 — — $450.00 $450.00 $450.00 2026-03-17
0808 RC Inpatient Renal Dialysis - Other 1 1 — — $450.00 $450.00 $450.00 2026-03-17
0809 RC Inpatient Renal Dialysis - Other 1 1 — — $450.00 $450.00 $450.00 2026-03-17
10005 HCPCS Fna Bx W/us Gdn 1st Les 0 0 — — — — — 2026-03-17
10060 HCPCS I&d Abscess Simple/single 0 0 — — — — — 2026-03-17
12032 HCPCS Intmd Rpr S/a/t/ext 2.6-7.5 0 0 — — — — — 2026-03-17
14000 HCPCS Tis Trnfr Trunk 10 Sq Cm/< 0 0 — — — — — 2026-03-17
14020 HCPCS Tis Trnfr S/a/l 10 Sq Cm/< 0 0 — — — — — 2026-03-17
15771 HCPCS Grfg Autol Fat Lipo 50 Cc/< 0 0 — — — — — 2026-03-17
15772 HCPCS Grfg Autol Fat Lipo Ea Addl 0 0 — — — — — 2026-03-17
15853 HCPCS Removal Sutr/stapl Xreq Anes 0 0 — — — — — 2026-03-17
22224 HCPCS Osteot Dsc Ant 1vrt Sgm Lmbr 0 0 — — — — — 2026-03-17
22513 HCPCS Perq Vertebral Augmentation 0 0 — — — — — 2026-03-17
22514 HCPCS Perq Vertebral Augmentation 0 0 — — — — — 2026-03-17
22515 HCPCS Perq Vertebral Augmentation 0 0 — — — — — 2026-03-17
22548 HCPCS Arthrd Ant Toral/xoral C1-c2 0 0 — — — — — 2026-03-17
22552 HCPCS Arthrd Ant Ntrbd Cervical Ea 0 0 — — — — — 2026-03-17
23412 HCPCS Repair Rotator Cuff Chronic 0 0 — — — — — 2026-03-17
23515 HCPCS Optx Clavicular Fx W/int Fix 0 0 — — — — — 2026-03-17
23650 HCPCS Cltx Sho Dslc W/mnpj Wo Anes 0 0 — — — — — 2026-03-17
24344 HCPCS Reconstruct Elbow Lat Ligmnt 0 0 — — — — — 2026-03-17
24430 HCPCS Repair Of Humerus 0 0 — — — — — 2026-03-17
24516 HCPCS Treat Humerus Fracture 0 0 — — — — — 2026-03-17
24615 HCPCS Treat Elbow Dislocation 0 0 — — — — — 2026-03-17
31257 HCPCS Nsl/sins Ndsc Tot W/sphendt 0 0 — — — — — 2026-03-17
31259 HCPCS Nsl/sins Ndsc Sphn Tiss Rmvl 0 0 — — — — — 2026-03-17
31267 HCPCS Endoscopy Maxillary Sinus 0 0 — — — — — 2026-03-17
31276 HCPCS Nsl/sins Ndsc Frnt Tiss Rmvl 0 0 — — — — — 2026-03-17
31288 HCPCS Nasal/sinus Endoscopy Surg 0 0 — — — — — 2026-03-17
31500 HCPCS Insert Emergency Airway 0 0 — — — — — 2026-03-17
32408 HCPCS Core Ndl Bx Lng/med Perq 0 0 — — — — — 2026-03-17
32555 HCPCS Aspirate Pleura With Imaging 0 0 — — — — — 2026-03-17
33207 HCPCS Insert Heart Pm Ventricular 0 0 — — — — — 2026-03-17
33227 HCPCS Remove&replace Pm Gen Singl 0 0 — — — — — 2026-03-17
33228 HCPCS Remv&replc Pm Gen Dual Lead 0 0 — — — — — 2026-03-17
36012 HCPCS Place Catheter In Vein 0 0 — — — — — 2026-03-17
36200 HCPCS Place Catheter In Aorta 0 0 — — — — — 2026-03-17
36225 HCPCS Place Cath Subclavian Art 0 0 — — — — — 2026-03-17
36247 HCPCS Ins Cath Abd/l-ext Art 3rd 0 0 — — — — — 2026-03-17
36248 HCPCS Ins Cath Abd/l-ext Art Addl 0 0 — — — — — 2026-03-17
36415 HCPCS Routine Venipuncture 0 0 — — — — — 2026-03-17
36430 HCPCS Transfusion Bld/bld Compnt 0 0 — — — — — 2026-03-17
36460 HCPCS Intrauterine Transfusion Ftl 0 0 — — — — — 2026-03-17
36514 HCPCS Apheresis Plasma 0 0 — — — — — 2026-03-17
36556 HCPCS Insert Non-tunnel Cv Cath 0 0 — — — — — 2026-03-17
36558 HCPCS Insert Tunneled Cv Cath 0 0 — — — — — 2026-03-17
36561 HCPCS Insert Tunneled Cv Cath 0 0 — — — — — 2026-03-17
36569 HCPCS Insj Picc 5 Yr+ Without Imaging 0 0 — — — — — 2026-03-17
36573 HCPCS Insj Picc Rs&i 5 Yr+ 0 0 — — — — — 2026-03-17
36589 HCPCS Removal Tunneled Cv Cath 0 0 — — — — — 2026-03-17
50590 HCPCS Fragmenting Of Kidney Stone 0 0 — — — — — 2026-03-17
50949 HCPCS Unlisted Laps Px Ureter 0 0 — — — — — 2026-03-17
51102 HCPCS Drain Bl W/cath Insertion 0 0 — — — — — 2026-03-17
51702 HCPCS Insert Temp Bladder Cath 0 0 — — — — — 2026-03-17
51798 HCPCS US Urine Capacity Measure 0 0 — — — — — 2026-03-17
52204 HCPCS Cystoscopy W/biopsy(s) 0 0 — — — — — 2026-03-17
52224 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-03-17
52234 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-03-17
52235 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-03-17
52240 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-03-17
52310 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-03-17
52317 HCPCS Remove Bladder Stone 0 0 — — — — — 2026-03-17
52332 HCPCS Cystoscopy And Treatment 0 0 — — — — — 2026-03-17
52356 HCPCS Cysto/uretero W/lithotripsy 0 0 — — — — — 2026-03-17
52601 HCPCS Prostatectomy (turp) 0 0 — — — — — 2026-03-17
53445 HCPCS Insert Uro/ves Nck Sphincter 0 0 — — — — — 2026-03-17
54161 HCPCS Circum 28 Days Or Older 0 0 — — — — — 2026-03-17
55040 HCPCS Removal Of Hydrocele 0 0 — — — — — 2026-03-17
55700 HCPCS Biopsy Of Prostate 0 0 — — — — — 2026-03-17
55880 HCPCS Abltj Mal Prst8 Tiss Hifu 0 0 — — — — — 2026-03-17
57260 HCPCS Cmbn Ant Pst Colprhy 0 0 — — — — — 2026-03-17
57288 HCPCS Repair Bladder Defect 0 0 — — — — — 2026-03-17
57461 HCPCS Conz Of Cervix W/scope Leep 0 0 — — — — — 2026-03-17
57522 HCPCS Conization Of Cervix 0 0 — — — — — 2026-03-17
58120 HCPCS Dilation And Curettage 0 0 — — — — — 2026-03-17
58301 HCPCS Remove Intrauterine Device 0 0 — — — — — 2026-03-17
58550 HCPCS Laparo-asst Vag Hysterectomy 0 0 — — — — — 2026-03-17
58552 HCPCS Laparo-vag Hyst Incl T/o 0 0 — — — — — 2026-03-17
58554 HCPCS Laparo-vag Hyst W/t/o Compl 0 0 — — — — — 2026-03-17
58558 HCPCS Hysteroscopy Biopsy 0 0 — — — — — 2026-03-17
58561 HCPCS Hysteroscopy Remove Myoma 0 0 — — — — — 2026-03-17
58563 HCPCS Hysteroscopy Ablation 0 0 — — — — — 2026-03-17
58570 HCPCS Tlh Uterus 250 G Or Less 0 0 — — — — — 2026-03-17
58571 HCPCS Tlh W/t/o 250 G Or Less 0 0 — — — — — 2026-03-17
58661 HCPCS Laparoscopy Remove Adnexa 0 0 — — — — — 2026-03-17
58662 HCPCS Laparoscopy Excise Lesions 0 0 — — — — — 2026-03-17
59012 HCPCS Fetal Cord Puncture Prenatal 0 0 — — — — — 2026-03-17
59025 HCPCS Fetal Non-stress Test 0 0 — — — — — 2026-03-17
59820 HCPCS Care Of Miscarriage 0 0 — — — — — 2026-03-17
59897 HCPCS Unlisted Fetal Invas Px W/us 0 0 — — — — — 2026-03-17
60220 HCPCS Partial Removal Of Thyroid 0 0 — — — — — 2026-03-17
61782 HCPCS Scan Proc Cranial Extra 0 0 — — — — — 2026-03-17
62270 HCPCS Dx Lmbr Spi Pnxr 0 0 — — — — — 2026-03-17
62328 HCPCS Dx Lmbr Spi Pnxr W/fluor/ct 0 0 — — — — — 2026-03-17
64450 HCPCS Njx Aa&/strd Other Pn/branch 0 0 — — — — — 2026-03-17
64718 HCPCS Revise Ulnar Nerve At Elbow 0 0 — — — — — 2026-03-17
64721 HCPCS Carpal Tunnel Surgery 0 0 — — — — — 2026-03-17
65426 HCPCS Removal Of Eye Lesion 0 0 — — — — — 2026-03-17
65730 HCPCS Corneal Transplant 0 0 — — — — — 2026-03-17
65755 HCPCS Corneal Transplant 0 0 — — — — — 2026-03-17
65756 HCPCS Corneal Trnspl Endothelial 0 0 — — — — — 2026-03-17
65820 HCPCS Relieve Inner Eye Pressure 0 0 — — — — — 2026-03-17
66170 HCPCS Glaucoma Surgery 0 0 — — — — — 2026-03-17
66180 HCPCS Aqueous Shunt Eye W/graft 0 0 — — — — — 2026-03-17
92507 HCPCS Speech/hearing Therapy 54 14 — — $56.00 $56.00 $56.00 2026-03-17
92521 HCPCS Evaluation Of Speech Fluency 1 1 — — $56.00 $56.00 $56.00 2026-03-17
92522 HCPCS Evaluate Speech Production 52 14 — — $56.00 $56.00 $56.00 2026-03-17
92523 HCPCS Speech Sound Lang Comprehen 54 14 — — $56.00 $56.00 $56.00 2026-03-17
92524 HCPCS Behavral Qualit Analys Voice 52 14 — — $56.00 $56.00 $56.00 2026-03-17
92526 HCPCS Oral Function Therapy 54 14 — — $56.00 $56.00 $56.00 2026-03-17
92597 HCPCS Oral Speech Device Eval 1 1 — — $56.00 $56.00 $56.00 2026-03-17
92605 HCPCS Ex For Nonspeech Device Rx 1 1 — — $56.00 $56.00 $56.00 2026-03-17
92606 HCPCS Non-speech Device Service 1 1 — — $56.00 $56.00 $56.00 2026-03-17
92607 HCPCS Ex For Speech Device Rx 1hr 52 14 — — $56.00 $56.00 $56.00 2026-03-17
96105 HCPCS Assessment Of Aphasia 52 14 — — $56.00 $56.00 $56.00 2026-03-17
97032 HCPCS Appl Modality 1+estim Ea 15 49 12 — — $70.00 $70.00 $70.00 2026-03-17
97110 HCPCS Therapeutic Exercises 54 14 — — $61.00 $61.00 $61.00 2026-03-17
97112 HCPCS Neuromuscular Reeducation 54 14 — — $70.00 $70.00 $70.00 2026-03-17
97113 HCPCS Aquatic Therapy/exercises 52 14 — — $70.00 $70.00 $70.00 2026-03-17
97116 HCPCS Gait Training Therapy 54 14 — — $61.00 $61.00 $61.00 2026-03-17
97124 HCPCS Massage Therapy 52 14 — — $70.00 $70.00 $70.00 2026-03-17
97129 HCPCS Ther Ivntj 1st 15 Min 52 14 — — $70.00 $70.00 $70.00 2026-03-17
97140 HCPCS Manual Therapy 1/> Regions 52 14 — — $70.00 $70.00 $70.00 2026-03-17
97161 HCPCS Pt Eval Low Complex 20 Min 54 14 — — $70.00 $70.00 $70.00 2026-03-17
97162 HCPCS Pt Eval Mod Complex 30 Min 54 14 — — $70.00 $70.00 $70.00 2026-03-17
97163 HCPCS Pt Eval High Complex 45 Min 54 14 — — $70.00 $70.00 $70.00 2026-03-17
97164 HCPCS Pt Re-eval Est Plan Care 54 14 — — $70.00 $70.00 $70.00 2026-03-17
97165 HCPCS Ot Eval Low Complex 30 Min 54 14 — — $61.00 $61.00 $61.00 2026-03-17
97166 HCPCS Ot Eval Mod Complex 45 Min 54 14 — — $61.00 $61.00 $61.00 2026-03-17
97167 HCPCS Ot Eval High Complex 60 Min 52 14 — — $61.00 $61.00 $61.00 2026-03-17
97168 HCPCS Ot Re-eval Est Plan Care 52 14 — — $61.00 $61.00 $61.00 2026-03-17
97530 HCPCS Therapeutic Activities 54 14 — — $61.00 $61.00 $61.00 2026-03-17
97535 HCPCS Self Care Mngment Training 54 14 — — $61.00 $61.00 $61.00 2026-03-17
97537 HCPCS Community/work Reintegration 52 14 — — $61.00 $61.00 $61.00 2026-03-17
A0102 HCPCS Stroke M >=63.50 And M <72.50- Tier None 22 10 — — $13,054.44 $17,740.44 $15,397.44 2026-03-17
A0103 HCPCS Stroke M >=50.50 And M <63.50- Tier None 22 10 — — $11,574.07 $22,864.24 $17,219.15 2026-03-17
A0104 HCPCS Stroke M >=41.50 And M <50.50- Tier None 22 10 — — $29,181.06 $29,181.06 $29,181.06 2026-03-17
A0105 HCPCS Stroke M <41.50 And A >=84.50- Tier None 22 10 — — $28,082.70 $36,417.92 $32,250.31 2026-03-17
A0106 HCPCS Stroke M <41.50 And A <84.50- Tier None 22 10 — — $23,406.27 $41,502.76 $32,454.51 2026-03-17
A0203 HCPCS Traumatic Brain Injury M >=49.50 And M <61.50- Tier None 22 10 — — $22,115.52 $22,115.52 $22,115.52 2026-03-17
A0204 HCPCS Traumatic Brain Injury M >=35.50 And M <49.50- Tier None 22 10 — — $27,430.28 $27,430.28 $27,430.28 2026-03-17
A0205 HCPCS Traumatic Brain Injury M <35.50- Tier None 22 10 — — $35,290.66 $35,290.66 $35,290.66 2026-03-17
A0302 HCPCS Non-traumatic Brain Injury M >=52.50 And M <65.50- Tier None 22 10 — — $20,296.66 $20,296.66 $20,296.66 2026-03-17
A0305 HCPCS Non-traumatic Brain Injury M <42.50 And A <78.50- Tier None 22 10 — — $31,228.69 $31,228.69 $31,228.69 2026-03-17
A0404 HCPCS Traumatic Spinal Cord Injury M <31.50 And A <61.50- Tier None 22 10 — — $6,878.12 $6,878.12 $6,878.12 2026-03-17
A0407 HCPCS Traumatic Spinal Cord Injury M <24.50 And A >=61.50- Tier None 22 10 — — $61,950.32 $61,950.32 $61,950.32 2026-03-17
A0505 HCPCS Non-traumatic Spinal Cord Injury M <39.50- Tier None 22 10 — — $38,625.11 $38,625.11 $38,625.11 2026-03-17
A0602 HCPCS Neurological M >=52.50 And M <64.50- Tier None 22 10 — — $20,084.91 $20,084.91 $20,084.91 2026-03-17
A0603 HCPCS Neurological M >=43.50 And M <52.50- Tier None 22 10 — — $11,406.36 $23,665.89 $17,536.12 2026-03-17
A0604 HCPCS Neurological M <43.50- Tier None 22 10 — — $8,938.89 $29,680.21 $19,309.55 2026-03-17
A0703 HCPCS Fracture Of Lower Extremity M >=41.50 And M <52.50- Tier None 22 10 — — $24,386.25 $24,386.25 $24,386.25 2026-03-17
A0704 HCPCS Fracture Of Lower Extremity M <41.50- Tier None 22 10 — — $30,208.47 $30,208.47 $30,208.47 2026-03-17
A0803 HCPCS Replacement Of Lower-extremity Joint M >=51.50 And M <57.50- Tier None 22 10 — — $19,782.20 $19,782.20 $19,782.20 2026-03-17
A0804 HCPCS Replacement Of Lower-extremity Joint M >=42.50 And M <51.50- Tier None 22 10 — — $22,172.24 $22,172.24 $22,172.24 2026-03-17
A0805 HCPCS Replacement Of Lower-extremity Joint M <42.50- Tier None 22 10 — — $4,748.70 $26,592.70 $15,670.70 2026-03-17
A0902 HCPCS Other Orthopedic M >=51.50 And M <63.50- Tier None 22 10 — — $19,489.95 $19,489.95 $19,489.95 2026-03-17
A0903 HCPCS Other Orthopedic M >=44.50 And M <51.50- Tier None 22 10 — — $23,081.67 $23,081.67 $23,081.67 2026-03-17
A0904 HCPCS Other Orthopedic M <44.5- Tier None 22 10 — — $23,855.49 $27,657.16 $25,756.33 2026-03-17
A1004 HCPCS Amputation Lower Extremity M <47.50- Tier None 22 10 — — $7,179.57 $7,179.57 $7,179.57 2026-03-17
A1404 HCPCS Cardiac M <45.50- Tier None 22 10 — — $27,343.30 $27,906.49 $27,624.90 2026-03-17
A1702 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=50.50 And M <57.50… 22 10 — — $24,747.91 $24,747.91 $24,747.91 2026-03-17
A1703 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50… 22 10 — — $5,831.94 $24,376.80 $15,104.37 2026-03-17
A1705 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier None 22 10 — — $32,376.35 $32,376.35 $32,376.35 2026-03-17
A1805 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 22 10 — — $32,492.60 $32,492.60 $32,492.60 2026-03-17
A2002 HCPCS Miscellaneous M >=55.50 And M <66.50- Tier None 22 10 — — $14,028.56 $19,117.99 $16,573.28 2026-03-17
A2003 HCPCS Miscellaneous M >=46.50 And M <55.50- Tier None 22 10 — — $16,780.87 $22,631.68 $19,706.28 2026-03-17
A2004 HCPCS Miscellaneous M <46.50 And A >=77.50- Tier None 22 10 — — $27,059.70 $27,059.70 $27,059.70 2026-03-17
A2005 HCPCS Miscellaneous M <46.50 And A <77.50- Tier None 22 10 — — $26,007.18 $26,007.18 $26,007.18 2026-03-17
B0104 HCPCS Stroke M >=41.50 And M <50.50- Tier Tier 1 22 10 — — $38,291.01 $38,291.01 $38,291.01 2026-03-17
B0105 HCPCS Stroke M <41.50 And A >=84.50- Tier Tier 1 22 10 — — $5,490.12 $5,490.12 $5,490.12 2026-03-17
B0106 HCPCS Stroke M <41.50 And A <84.50- Tier Tier 1 22 10 — — $58,650.79 $58,650.79 $58,650.79 2026-03-17
B0303 HCPCS Non-traumatic Brain Injury M >=42.50 And M <52.50- Tier Tier 1 22 10 — — $46,525.59 $46,525.59 $46,525.59 2026-03-17
B0305 HCPCS Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 1 22 10 — — $45,083.74 $45,083.74 $45,083.74 2026-03-17
B0404 HCPCS Traumatic Spinal Cord Injury M <31.50 And A <61.50- Tier Tier 1 22 10 — — $68,457.11 $68,457.11 $68,457.11 2026-03-17
B0603 HCPCS Neurological M >=43.50 And M <52.50- Tier Tier 1 22 10 — — $28,346.69 $28,346.69 $28,346.69 2026-03-17
B0604 HCPCS Neurological M <43.50- Tier Tier 1 22 10 — — $46,491.21 $46,491.21 $46,491.21 2026-03-17
B0704 HCPCS Fracture Of Lower Extremity M <41.50- Tier Tier 1 22 10 — — $43,122.21 $44,002.26 $43,562.24 2026-03-17
B0805 HCPCS Replacement Of Lower-extremity Joint M <42.50- Tier Tier 1 22 10 — — $45,823.76 $45,823.76 $45,823.76 2026-03-17
B0903 HCPCS Other Orthopedic M >=44.50 And M <51.50- Tier Tier 1 22 10 — — $33,792.48 $33,792.48 $33,792.48 2026-03-17
B0904 HCPCS Other Orthopedic M <44.5- Tier Tier 1 22 10 — — $46,376.26 $46,376.26 $46,376.26 2026-03-17
B1004 HCPCS Amputation Lower Extremity M <47.50- Tier Tier 1 22 10 — — $43,506.90 $48,761.04 $46,133.97 2026-03-17
B1403 HCPCS Cardiac M >=45.50 And M <55.50- Tier Tier 1 22 10 — — $33,109.94 $33,109.94 $33,109.94 2026-03-17
B1404 HCPCS Cardiac M <45.50- Tier Tier 1 22 10 — — $45,011.56 $54,583.03 $49,797.29 2026-03-17
B1703 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50… 22 10 — — $37,322.42 $37,322.42 $37,322.42 2026-03-17
B2002 HCPCS Miscellaneous M >=55.50 And M <66.50- Tier Tier 1 22 10 — — $27,266.42 $27,827.32 $27,546.87 2026-03-17
B2003 HCPCS Miscellaneous M >=46.50 And M <55.50- Tier Tier 1 22 10 — — $32,880.51 $32,880.51 $32,880.51 2026-03-17
B2004 HCPCS Miscellaneous M <46.50 And A >=77.50- Tier Tier 1 22 10 — — $50,283.22 $50,283.22 $50,283.22 2026-03-17
B2005 HCPCS Miscellaneous M <46.50 And A <77.50- Tier Tier 1 22 10 — — $41,996.23 $41,996.23 $41,996.23 2026-03-17
C0105 HCPCS Stroke M <41.50 And A >=84.50- Tier Tier 2 22 10 — — $41,899.80 $41,899.80 $41,899.80 2026-03-17
C0203 HCPCS Traumatic Brain Injury M >=49.50 And M <61.50- Tier Tier 2 22 10 — — $25,862.89 $25,862.89 $25,862.89 2026-03-17
C0204 HCPCS Traumatic Brain Injury M >=35.50 And M <49.50- Tier Tier 2 22 10 — — $24,332.19 $24,332.19 $24,332.19 2026-03-17
C0205 HCPCS Traumatic Brain Injury M <35.50- Tier Tier 2 22 10 — — $41,086.80 $41,086.80 $41,086.80 2026-03-17
C0303 HCPCS Non-traumatic Brain Injury M >=42.50 And M <52.50- Tier Tier 2 22 10 — — $28,207.35 $28,207.35 $28,207.35 2026-03-17
C0304 HCPCS Non-traumatic Brain Injury M <42.50 And A >=78.50- Tier Tier 2 22 10 — — $36,077.61 $36,077.61 $36,077.61 2026-03-17
C0305 HCPCS Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 2 22 10 — — $36,068.88 $36,068.88 $36,068.88 2026-03-17
C0504 HCPCS Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50- Tier Tier 2 22 10 — — $27,575.96 $31,928.25 $29,752.10 2026-03-17
C0505 HCPCS Non-traumatic Spinal Cord Injury M <39.50- Tier Tier 2 22 10 — — $44,367.17 $44,367.17 $44,367.17 2026-03-17
C0604 HCPCS Neurological M <43.50- Tier Tier 2 22 10 — — $35,252.10 $35,252.10 $35,252.10 2026-03-17
C0703 HCPCS Fracture Of Lower Extremity M >=41.50 And M <52.50- Tier Tier 2 22 10 — — $27,305.98 $27,305.98 $27,305.98 2026-03-17
C0805 HCPCS Replacement Of Lower-extremity Joint M <42.50- Tier Tier 2 22 10 — — $37,823.68 $37,823.68 $37,823.68 2026-03-17
C0904 HCPCS Other Orthopedic M <44.5- Tier Tier 2 22 10 — — $32,431.18 $32,431.18 $32,431.18 2026-03-17
C1402 HCPCS Cardiac M >=55.50 And M <68.50- Tier Tier 2 22 10 — — $21,763.46 $21,763.46 $21,763.46 2026-03-17
C1404 HCPCS Cardiac M <45.50- Tier Tier 2 22 10 — — $31,650.21 $31,960.39 $31,805.30 2026-03-17
C1704 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50… 22 10 — — $32,835.79 $32,835.79 $32,835.79 2026-03-17
C1705 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier Tier 2 22 10 — — $38,534.36 $38,534.36 $38,534.36 2026-03-17
C1801 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=67.50- Tier Tier 2 22 10 — — $14,246.26 $14,246.26 $14,246.26 2026-03-17
C1805 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50- T… 22 10 — — $36,547.23 $38,490.27 $37,518.75 2026-03-17
C1904 HCPCS Guillain-barré M <38.50- Tier Tier 2 22 10 — — $53,175.94 $53,175.94 $53,175.94 2026-03-17
C2002 HCPCS Miscellaneous M >=55.50 And M <66.50- Tier Tier 2 22 10 — — $22,227.07 $23,571.09 $22,899.08 2026-03-17
C2003 HCPCS Miscellaneous M >=46.50 And M <55.50- Tier Tier 2 22 10 — — $26,617.27 $31,776.08 $29,196.67 2026-03-17
C2004 HCPCS Miscellaneous M <46.50 And A >=77.50- Tier Tier 2 22 10 — — $31,824.26 $31,824.26 $31,824.26 2026-03-17
C2005 HCPCS Miscellaneous M <46.50 And A <77.50- Tier Tier 2 22 10 — — $33,544.80 $33,544.80 $33,544.80 2026-03-17
D0102 HCPCS Stroke M >=63.50 And M <72.50- Tier Tier 3 22 10 — — $13,993.85 $18,613.94 $16,303.90 2026-03-17
D0103 HCPCS Stroke M >=50.50 And M <63.50- Tier Tier 3 22 10 — — $11,730.67 $23,992.98 $17,861.83 2026-03-17
D0104 HCPCS Stroke M >=41.50 And M <50.50- Tier Tier 3 22 10 — — $21,237.43 $30,619.89 $25,928.66 2026-03-17
D0105 HCPCS Stroke M <41.50 And A >=84.50- Tier Tier 3 22 10 — — $37,522.80 $38,288.57 $37,905.68 2026-03-17
D0106 HCPCS Stroke M <41.50 And A <84.50- Tier Tier 3 22 10 — — $37,207.38 $43,550.38 $40,378.88 2026-03-17
D0202 HCPCS Traumatic Brain Injury M >=61.50 And M <73.50- Tier Tier 3 22 10 — — $18,861.62 $18,861.62 $18,861.62 2026-03-17
D0203 HCPCS Traumatic Brain Injury M >=49.50 And M <61.50- Tier Tier 3 22 10 — — $16,594.79 $23,490.06 $20,042.42 2026-03-17
D0204 HCPCS Traumatic Brain Injury M >=35.50 And M <49.50- Tier Tier 3 22 10 — — $29,133.80 $29,133.80 $29,133.80 2026-03-17
D0302 HCPCS Non-traumatic Brain Injury M >=52.50 And M <65.50- Tier Tier 3 22 10 — — $17,061.06 $21,535.07 $19,298.06 2026-03-17
D0303 HCPCS Non-traumatic Brain Injury M >=42.50 And M <52.50- Tier Tier 3 22 10 — — $6,163.49 $25,912.04 $16,037.76 2026-03-17
D0304 HCPCS Non-traumatic Brain Injury M <42.50 And A >=78.50- Tier Tier 3 22 10 — — $30,043.22 $30,043.22 $30,043.22 2026-03-17
D0305 HCPCS Non-traumatic Brain Injury M <42.50 And A <78.50- Tier Tier 3 22 10 — — $24,909.00 $33,132.63 $29,020.81 2026-03-17
D0502 HCPCS Non-traumatic Spinal Cord Injury M >=53.50 And M <60.50- Tier Tier 3 22 10 — — $22,048.12 $22,048.12 $22,048.12 2026-03-17
D0503 HCPCS Non-traumatic Spinal Cord Injury M >=48.50 And M <53.50- Tier Tier 3 22 10 — — $25,375.08 $25,375.08 $25,375.08 2026-03-17
D0504 HCPCS Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50- Tier Tier 3 22 10 — — $30,164.23 $30,164.23 $30,164.23 2026-03-17
D0505 HCPCS Non-traumatic Spinal Cord Injury M <39.50- Tier Tier 3 22 10 — — $35,584.11 $41,914.93 $38,749.52 2026-03-17
D0602 HCPCS Neurological M >=52.50 And M <64.50- Tier Tier 3 22 10 — — $22,050.02 $22,050.02 $22,050.02 2026-03-17
D0603 HCPCS Neurological M >=43.50 And M <52.50- Tier Tier 3 22 10 — — $26,241.03 $26,241.03 $26,241.03 2026-03-17
D0604 HCPCS Neurological M <43.50- Tier Tier 3 22 10 — — $20,018.49 $32,909.52 $26,464.01 2026-03-17
D0702 HCPCS Fracture Of Lower Extremity M >=52.50 And M <61.50- Tier Tier 3 22 10 — — $20,998.57 $20,998.57 $20,998.57 2026-03-17
D0703 HCPCS Fracture Of Lower Extremity M >=41.50 And M <52.50- Tier Tier 3 22 10 — — $24,841.77 $26,394.17 $25,617.97 2026-03-17
D0704 HCPCS Fracture Of Lower Extremity M <41.50- Tier Tier 3 22 10 — — $31,239.54 $32,244.00 $31,741.77 2026-03-17
D0803 HCPCS Replacement Of Lower-extremity Joint M >=51.50 And M <57.50- Tier Tier 3 22 10 — — $21,219.33 $21,219.33 $21,219.33 2026-03-17
D0804 HCPCS Replacement Of Lower-extremity Joint M >=42.50 And M <51.50- Tier Tier 3 22 10 — — $23,773.66 $23,773.66 $23,773.66 2026-03-17
D0805 HCPCS Replacement Of Lower-extremity Joint M <42.50- Tier Tier 3 22 10 — — $24,100.67 $28,511.76 $26,306.22 2026-03-17
D0901 HCPCS Other Orthopedic M >=63.50- Tier Tier 3 22 10 — — $16,961.47 $16,961.47 $16,961.47 2026-03-17
D0902 HCPCS Other Orthopedic M >=51.50 And M <63.50- Tier Tier 3 22 10 — — $20,217.63 $21,124.79 $20,671.21 2026-03-17
D0903 HCPCS Other Orthopedic M >=44.50 And M <51.50- Tier Tier 3 22 10 — — $14,848.96 $25,350.21 $20,099.58 2026-03-17
D0904 HCPCS Other Orthopedic M <44.5- Tier Tier 3 22 10 — — $21,647.14 $30,228.51 $25,937.83 2026-03-17
D1002 HCPCS Amputation Lower Extremity M >=55.50 And M <64.50- Tier Tier 3 22 10 — — $19,582.09 $21,366.83 $20,474.46 2026-03-17
D1003 HCPCS Amputation Lower Extremity M >=47.50 And M <55.50- Tier Tier 3 22 10 — — $25,673.82 $25,673.82 $25,673.82 2026-03-17
D1004 HCPCS Amputation Lower Extremity M <47.50- Tier Tier 3 22 10 — — $29,531.09 $63,553.71 $46,542.40 2026-03-17
D1402 HCPCS Cardiac M >=55.50 And M <68.50- Tier Tier 3 22 10 — — $16,050.00 $19,820.21 $17,935.10 2026-03-17
D1403 HCPCS Cardiac M >=45.50 And M <55.50- Tier Tier 3 22 10 — — $20,972.20 $24,252.01 $22,612.10 2026-03-17
D1404 HCPCS Cardiac M <45.50- Tier Tier 3 22 10 — — $29,716.13 $29,716.13 $29,716.13 2026-03-17
D1503 HCPCS Pulmonary M >=45.50 And M <56.50- Tier Tier 3 22 10 — — $26,505.72 $26,505.72 $26,505.72 2026-03-17
D1701 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=57.50- Tier Tier 3 22 10 — — $18,412.02 $18,412.02 $18,412.02 2026-03-17
D1702 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=50.50 And M <57.50… 22 10 — — $16,058.92 $22,610.88 $19,334.90 2026-03-17
D1703 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50… 22 10 — — $26,868.74 $26,868.74 $26,868.74 2026-03-17
D1704 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50… 22 10 — — $18,712.39 $30,410.02 $24,561.21 2026-03-17
D1705 HCPCS Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50- Tier Tier 3 22 10 — — $35,675.90 $35,675.90 $35,675.90 2026-03-17
D1806 HCPCS Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50- Tier Tier 3 22 10 — — $28,288.18 $28,288.18 $28,288.18 2026-03-17
D1904 HCPCS Guillain-barré M <38.50- Tier Tier 3 22 10 — — $49,619.53 $49,619.53 $49,619.53 2026-03-17
D2001 HCPCS Miscellaneous M >=66.50- Tier Tier 3 22 10 — — $16,485.27 $16,485.27 $16,485.27 2026-03-17
D2002 HCPCS Miscellaneous M >=55.50 And M <66.50- Tier Tier 3 22 10 — — $18,208.50 $20,763.67 $19,486.08 2026-03-17
D2003 HCPCS Miscellaneous M >=46.50 And M <55.50- Tier Tier 3 22 10 — — $24,522.79 $25,397.70 $24,960.24 2026-03-17
D2004 HCPCS Miscellaneous M <46.50 And A >=77.50- Tier Tier 3 22 10 — — $27,398.22 $29,729.37 $28,563.79 2026-03-17
D2005 HCPCS Miscellaneous M <46.50 And A <77.50- Tier Tier 3 22 10 — — $23,944.94 $41,438.78 $32,691.86 2026-03-17
G0008 HCPCS Admin Influenza Virus Vac 3 2 — — $20.50 $20.50 $20.50 2026-03-17
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