Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100...

95
Updated: May 1, 2015 Note: Modifier List Proc Code Description Mod Rate 10021 FNA W/O IMAGE TC 13.94 10021 FNA W/O IMAGE 26 51.76 10021 FNA W/O IMAGE 65.97 10022 FNA W/IMAGE TC 18.5 10022 FNA W/IMAGE 26 49.34 10022 FNA W/IMAGE 67.85 10040 ACNE SURGERY 48.54 10060 DRAINAGE OF SKIN ABSCESS 53.64 10061 DRAINAGE OF SKIN ABSCESS 111.57 10080 DRAINAGE OF PILONIDAL CYST 55.24 10081 DRAINAGE OF PILONIDAL CYST 116.93 10120 REMOVE FOREIGN BODY 46.13 10121 REMOVE FOREIGN BODY 131.68 10140 DRAINAGE OF HEMATOMA/FLUID 71.07 10160 PUNCTURE DRAINAGE OF LESION 48 10180 COMPLEX DRAINAGE WOUND 105.93 11000 DEBRIDE INFECTED SKIN 24.4 11001 DEBRIDE INFECTED SKIN ADD-ON 11.8 11010 DEBRIDE SKIN AT FX SITE 186.39 11011 DEBRIDE SKIN MUSC AT FX SITE 225.55 11012 DEB SKIN BONE AT FX SITE 335.51 11042 DEB SUBQ TISSUE 20 SQ CM/< 46.93 11043 DEB MUSC/FASCIA 20 SQ CM/< 111.57 11044 DEB BONE 20 SQ CM/< 145.36 CPT codes, descriptions and other data only are copyright © 2008 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. CPT is a registered trademark ® of the American Medical Association. Provider Type 21 Podiatrist Reimbursement Rates The information contained in the schedule is made available to provide information and is not a guarantee by the State or the Department or its employees as to the present accuracy of the information contained herein. For example, coverage as well as an actual rate may have been revised or updated and may no longer be the same as posted on the website. Procedure codes with a rate of $0.00 are reimbursed at 62% of Usual and Customary charges unless noted otherwise in Nevada Medicaid policy. "J" and "Q" codes with a rate of $0.00 and that do not require an NDC number when billed are reimbursed at 85% of AWP unless noted otherwise in Nevada Medicaid policy. 1/95

Transcript of Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100...

Page 1: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Updated: May 1, 2015

Note:

Modifier List

Proc Code Description Mod Rate

10021 FNA W/O IMAGE TC 13.94

10021 FNA W/O IMAGE 26 51.76

10021 FNA W/O IMAGE 65.97

10022 FNA W/IMAGE TC 18.5

10022 FNA W/IMAGE 26 49.34

10022 FNA W/IMAGE 67.85

10040 ACNE SURGERY 48.54

10060 DRAINAGE OF SKIN ABSCESS 53.64

10061 DRAINAGE OF SKIN ABSCESS 111.57

10080 DRAINAGE OF PILONIDAL CYST 55.24

10081 DRAINAGE OF PILONIDAL CYST 116.93

10120 REMOVE FOREIGN BODY 46.13

10121 REMOVE FOREIGN BODY 131.68

10140 DRAINAGE OF HEMATOMA/FLUID 71.07

10160 PUNCTURE DRAINAGE OF LESION 48

10180 COMPLEX DRAINAGE WOUND 105.93

11000 DEBRIDE INFECTED SKIN 24.4

11001 DEBRIDE INFECTED SKIN ADD-ON 11.8

11010 DEBRIDE SKIN AT FX SITE 186.39

11011 DEBRIDE SKIN MUSC AT FX SITE 225.55

11012 DEB SKIN BONE AT FX SITE 335.51

11042 DEB SUBQ TISSUE 20 SQ CM/< 46.93

11043 DEB MUSC/FASCIA 20 SQ CM/< 111.57

11044 DEB BONE 20 SQ CM/< 145.36

CPT codes, descriptions and other data only are copyright © 2008 American Medical Association. All rights

reserved. Applicable FARS/DFARS apply. CPT is a registered trademark ® of the American Medical

Association.

Provider Type 21 Podiatrist

Reimbursement Rates

The information contained in the schedule is made available to provide information and is not

a guarantee by the State or the Department or its employees as to the present accuracy of the

information contained herein. For example, coverage as well as an actual rate may have been

revised or updated and may no longer be the same as posted on the website.

Procedure codes with a rate of $0.00 are reimbursed at 62% of Usual and Customary charges unless

noted otherwise in Nevada Medicaid policy.

"J" and "Q" codes with a rate of $0.00 and that do not require an NDC number when billed are

reimbursed at 85% of AWP unless noted otherwise in Nevada Medicaid policy.

1/95

Page 2: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

11055 TRIM SKIN LESION 17.43

11056 TRIM SKIN LESIONS 2 TO 4 24.67

11057 TRIM SKIN LESIONS OVER 4 32.18

11100 BIOPSY SKIN LESION 33.79

11101 BIOPSY SKIN ADD-ON 17.16

11200 REMOVAL OF SKIN TAGS <W/15 30.84

11201 REMOVE SKIN TAGS ADD-ON 11.8

11300 SHAVE SKIN LESION 0.5 CM/< 20.91

11301 SHAVE SKIN LESION 0.6-1.0 CM 35.13

11302 SHAVE SKIN LESION 1.1-2.0 CM 43.44

11303 SHAVE SKIN LESION >2.0 CM 50.68

11305 SHAVE SKIN LESION 0.5 CM/< 27.35

11306 SHAVE SKIN LESION 0.6-1.0 CM 40.49

11307 SHAVE SKIN LESION 1.1-2.0 CM 46.66

11308 SHAVE SKIN LESION >2.0 CM 57.66

11310 SHAVE SKIN LESION 0.5 CM/< 30.57

11311 SHAVE SKIN LESION 0.6-1.0 CM 44.25

11312 SHAVE SKIN LESION 1.1-2.0 CM 50.42

11313 SHAVE SKIN LESION >2.0 CM 67.31

11400 EXC TR-EXT B9+MARG 0.5 CM< 36.47

11401 EXC TR-EXT B9+MARG 0.6-1 CM 53.37

11402 EXC TR-EXT B9+MARG 1.1-2 CM 74.55

11403 EXC TR-EXT B9+MARG 2.1-3CM/< 88.23

11404 EXC TR-EXT B9+MARG 3.1-4 CM 98.42

11406 EXC TR-EXT B9+MARG >4.0 CM 121.76

11420 EXC H-F-NK-SP B9+MARG 0.5/< 43.44

11421 EXC H-F-NK-SP B9+MARG 0.6-1 62.75

11422 EXC H-F-NK-SP B9+MARG 1.1-2 82.06

11423 EXC H-F-NK-SP B9+MARG 2.1-3 99.23

11424 EXC H-F-NK-SP B9+MARG 3.1-4 117.2

11426 EXC H-F-NK-SP B9+MARG >4 CM 165.47

11440 EXC FACE-MM B9+MARG 0.5 CM/< 48.27

11441 EXC FACE-MM B9+MARG 0.6-1 CM 67.58

11442 EXC FACE-MM B9+MARG 1.1-2 CM 91.18

11443 EXC FACE-MM B9+MARG 2.1-3 CM 118.54

11444 EXC FACE-MM B9+MARG 3.1-4 CM 158.23

11446 EXC FACE-MM B9+MARG >4 CM 202.75

11450 REMOVAL SWEAT GLAND LESION 110.76

11451 REMOVAL SWEAT GLAND LESION 156.09

11462 REMOVAL SWEAT GLAND LESION 102.45

11463 REMOVAL SWEAT GLAND LESION 166.01

11470 REMOVAL SWEAT GLAND LESION 132.49

11471 REMOVAL SWEAT GLAND LESION 180.23

11600 EXC TR-EXT MAL+MARG 0.5 CM/< 71.07

11601 EXC TR-EXT MAL+MARG 0.6-1 CM 93.87

2/95

Page 3: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

11602 EXC TR-EXT MAL+MARG 1.1-2 CM 99.5

11603 EXC TR-EXT MAL+MARG 2.1-3 CM 109.96

11604 EXC TR-EXT MAL+MARG 3.1-4 CM 118.81

11606 EXC TR-EXT MAL+MARG >4 CM 153.14

11620 EXC H-F-NK-SP MAL+MARG 0.5/< 69.46

11621 EXC S/N/H/F/G MAL+MRG 0.6-1 96.28

11622 EXC S/N/H/F/G MAL+MRG 1.1-2 112.64

11623 EXC S/N/H/F/G MAL+MRG 2.1-3 137.31

11624 EXC S/N/H/F/G MAL+MRG 3.1-4 158.5

11626 EXC S/N/H/F/G MAL+MRG >4 CM 198.73

11640 EXC F/E/E/N/L MAL+MRG 0.5CM< 80.46

11641 EXC F/E/E/N/L MAL+MRG 0.6-1 120.15

11642 EXC F/E/E/N/L MAL+MRG 1.1-2 141.34

11643 EXC F/E/E/N/L MAL+MRG 2.1-3 166.82

11644 EXC F/E/E/N/L MAL+MRG 3.1-4 215.63

11646 EXC F/E/E/N/L MAL+MRG >4 CM 280.26

11719 TRIM NAIL(S) ANY NUMBER 6.97

11720 DEBRIDE NAIL 1-5 12.87

11721 DEBRIDE NAIL 6 OR MORE 21.99

11730 REMOVAL OF NAIL PLATE 46.13

11732 REMOVE NAIL PLATE ADD-ON 23.6

11740 DRAIN BLOOD FROM UNDER NAIL 14.75

11750 REMOVAL OF NAIL BED 76.97

11752 REMOVE NAIL BED/TIP 131.95

11755 BIOPSY NAIL UNIT 53.9

11760 REPAIR OF NAIL BED 83.67

11762 RECONSTRUCTION OF NAIL BED 142.68

11765 EXCISION OF NAIL FOLD TOE 34.32

11770 REMOVE PILONIDAL CYST SIMPLE 113.18

11771 REMOVE PILONIDAL CYST EXTEN 284.56

11772 REMOVE PILONIDAL CYST COMPL 333.9

11900 INJECT SKIN LESIONS </W 7 21.18

11901 INJECT SKIN LESIONS >7 33.25

11950 TX CONTOUR DEFECTS 1 CC/< 37.81

11951 TX CONTOUR DEFECTS 1.1-5.0CC 49.08

11952 TX CONTOUR DEFECTS 5.1-10CC 68.92

11954 TX CONTOUR DEFECTS >10.0 CC 83.14

11960 INSERT TISSUE EXPANDER(S) 594.86

11970 REPLACE TISSUE EXPANDER 358.85

11971 REMOVE TISSUE EXPANDER(S) 177.54

11976 REMOVE CONTRACEPTIVE CAPSULE 72.68

11981 INSERT DRUG IMPLANT DEVICE 60.88

11982 REMOVE DRUG IMPLANT DEVICE 73.21

11983 REMOVE/INSERT DRUG IMPLANT 135.7

12001 RPR S/N/AX/GEN/TRNK 2.5CM/< 62.22

3/95

Page 4: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

12002 RPR S/N/AX/GEN/TRNK2.6-7.5CM 81.53

12004 RPR S/N/AX/GEN/TRK7.6-12.5CM 95.74

12005 RPR S/N/A/GEN/TRK12.6-20.0CM 119.34

12006 RPR S/N/A/GEN/TRK20.1-30.0CM 153.41

12007 RPR S/N/AX/GEN/TRNK >30.0 CM 174.59

12011 RPR F/E/E/N/L/M 2.5 CM/< 64.63

12013 RPR F/E/E/N/L/M 2.6-5.0 CM 86.36

12014 RPR F/E/E/N/L/M 5.1-7.5 CM 102.98

12015 RPR F/E/E/N/L/M 7.6-12.5 CM 130.34

12016 RPR FE/E/EN/L/M 12.6-20.0 CM 160.38

12017 RPR FE/E/EN/L/M 20.1-30.0 CM 193.37

12018 RPR F/E/E/N/L/M >30.0 CM 224.75

12020 CLOSURE OF SPLIT WOUND 118.54

12021 CLOSURE OF SPLIT WOUND 84.21

12031 INTMD RPR S/A/T/EXT 2.5 CM/< 85.28

12032 INTMD RPR S/A/T/EXT 2.6-7.5 109.42

12034 INTMD RPR S/TR/EXT 7.6-12.5 127.66

12035 INTMD RPR S/A/T/EXT 12.6-20 150.46

12036 INTMD RPR S/A/T/EXT 20.1-30 192.03

12037 INTMD RPR S/TR/EXT >30.0 CM 221.53

12041 INTMD RPR N-HF/GENIT 2.5CM/< 93.6

12042 INTMD RPR N-HF/GENIT2.6-7.5 120.95

12044 INTMD RPR N-HF/GENIT7.6-12.5 138.92

12045 INTMD RPR N-HF/GENIT12.6-20 162.79

12046 INTMD RPR N-HF/GENIT20.1-30 200.61

12047 INTMD RPR N-HF/GENIT >30.0CM 218.31

12051 INTMD RPR FACE/MM 2.5 CM/< 113.18

12052 INTMD RPR FACE/MM 2.6-5.0 CM 121.22

12053 INTMD RPR FACE/MM 5.1-7.5 CM 135.97

12054 INTMD RPR FACE/MM 7.6-12.5CM 149.38

12055 INTMD RPR FACE/MM 12.6-20 CM 193.9

12056 INTMD RPR FACE/MM 20.1-30.0 245.93

12057 INTMD RPR FACE/MM >30.0 CM 278.92

13100 CMPLX RPR TRUNK 1.1-2.5 CM 144.55

13101 CMPLX RPR TRUNK 2.6-7.5 CM 179.42

13102 CMPLX RPR TRUNK ADDL 5CM/< 53.37

13120 CMPLX RPR S/A/L 1.1-2.5 CM 150.72

13121 CMPLX RPR S/A/L 2.6-7.5 CM 194.98

13122 CMPLX RPR S/A/L ADDL 5 CM/> 61.41

13131 CMPLX RPR F/C/C/M/N/AX/G/H/F 174.33

13132 CMPLX RPR F/C/C/M/N/AX/G/H/F 264.98

13133 CMPLX RPR F/C/C/M/N/AX/G/H/F 94.67

13151 CMPLX RPR E/N/E/L 1.1-2.5 CM 218.04

13152 CMPLX RPR E/N/E/L 2.6-7.5 CM 298.23

13153 CMPLX RPR E/N/E/L ADDL 5CM/< 103.52

4/95

Page 5: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

13160 LATE CLOSURE OF WOUND 501.26

14000 TIS TRNFR TRUNK 10 SQ CM/< 308.16

14001 TIS TRNFR TRUNK 10.1-30SQCM 421.61

14020 TIS TRNFR S/A/L 10 SQ CM/< 348.66

14021 TIS TRNFR S/A/L 10.1-30 SQCM 499.12

14040 TIS TRNFR F/C/C/M/N/A/G/H/F 403.9

14041 TIS TRNFR F/C/C/M/N/A/G/H/F 559.46

14060 TIS TRNFR E/N/E/L 10 SQ CM/< 446.82

14061 TIS TRNFR E/N/E/L10.1-30SQCM 608.54

14350 FILLETED FINGER/TOE FLAP 474.98

15002 WOUND PREP TRK/ARM/LEG 148.1

15003 WOUND PREP ADDL 100 CM 30.27

15004 WOUND PREP F/N/HF/G 183.28

15005 WND PREP F/N/HF/G ADDL CM 60.55

15050 SKIN PINCH GRAFT 245.67

15100 SKIN SPLT GRFT TRNK/ARM/LEG 448.96

15101 SKIN SPLT GRFT T/A/L ADD-ON 73.48

15120 SKN SPLT A-GRFT FAC/NCK/HF/G 487.31

15121 SKN SPLT A-GRFT F/N/HF/G ADD 115.05

15200 SKIN FULL GRAFT TRUNK 397.2

15201 SKIN FULL GRAFT TRUNK ADD-ON 59

15220 SKIN FULL GRAFT SCLP/ARM/LEG 414.36

15221 SKIN FULL GRAFT ADD-ON 52.56

15240 SKIN FULL GRFT FACE/GENIT/HF 471.22

15241 SKIN FULL GRAFT ADD-ON 82.06

15260 SKIN FULL GRAFT EEN & LIPS 507.16

15261 SKIN FULL GRAFT ADD-ON 97.89

15275 Skin sub graft face/nk/hf/g 83.34

15276 SKIN SUB GRAFT F/N/HF/G ADDL 20.19

15277 Skn sub grft f/n/hf/g child 176.5

15278 SKN SUB GRFT F/N/HF/G CH ADD 44.68

15570 SKIN PEDICLE FLAP TRUNK 457.01

15572 SKIN PEDICLE FLAP ARMS/LEGS 456.74

15574 PEDCLE FH/CH/CH/M/N/AX/G/H/F 495.09

15576 PEDICLE E/N/E/L/NTRORAL 440.11

15600 DELAY FLAP TRUNK 127.66

15610 DELAY FLAP ARMS/LEGS 147.77

15620 DELAY FLAP F/C/C/N/AX/G/H/F 186.93

15630 DELAY FLAP EYE/NOS/EAR/LIP 203.83

15650 TRANSFER SKIN PEDICLE FLAP 229.84

15731 FOREHEAD FLAP W/VASC PEDICLE 644.83

15732 MUSCLE-SKIN GRAFT HEAD/NECK 853.68

15734 MUSCLE-SKIN GRAFT TRUNK 861.72

15736 MUSCLE-SKIN GRAFT ARM 806.74

15738 MUSCLE-SKIN GRAFT LEG 865.74

5/95

Page 6: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

15740 ISLAND PEDICLE FLAP GRAFT 496.97

15750 NEUROVASCULAR PEDICLE FLAP 579.31

15756 FREE MYO/SKIN FLAP MICROVASC 1677.32

15757 FREE SKIN FLAP MICROVASC 1686.97

15758 FREE FASCIAL FLAP MICROVASC 1694.21

15760 COMPOSITE SKIN GRAFT 451.91

15770 DERMA-FAT-FASCIA GRAFT 399.08

15786 ABRASION LESION SINGLE 94.13

15787 ABRASION LESIONS ADD-ON 14.48

15792 CHEMICAL PEEL NONFACIAL 98.69

15793 CHEMICAL PEEL NONFACIAL 212.41

15820 REVISION OF LOWER EYELID 347.31

15821 REVISION OF LOWER EYELID 368.77

15822 REVISION OF UPPER EYELID 310.3

15823 REVISION OF UPPER EYELID 412.22

15840 NERVE PALSY FASCIAL GRAFT 676.13

15841 NERVE PALSY MUSCLE GRAFT 1121.88

15842 NERVE PALSY MICROSURG GRAFT 1788.08

15845 SKIN AND MUSCLE REPAIR FACE 610.15

15850 REMOVE SUTURES SAME SURGEON 30.84

15851 REMOVE SUTURES DIFF SURGEON 34.59

15852 DRESSING CHANGE NOT FOR BURN 35.4

15860 TEST FOR BLOOD FLOW IN GRAFT 80.19

15920 REMOVAL OF TAIL BONE ULCER 405.51

15922 REMOVAL OF TAIL BONE ULCER 517.89

15931 REMOVE SACRUM PRESSURE SORE 443.87

15933 REMOVE SACRUM PRESSURE SORE 561.34

15934 REMOVE SACRUM PRESSURE SORE 622.22

15935 REMOVE SACRUM PRESSURE SORE 725.21

15936 REMOVE SACRUM PRESSURE SORE 621.95

15937 REMOVE SACRUM PRESSURE SORE 731.64

15940 REMOVE HIP PRESSURE SORE 455.4

15941 REMOVE HIP PRESSURE SORE 638.85

15944 REMOVE HIP PRESSURE SORE 592.45

15945 REMOVE HIP PRESSURE SORE 657.89

15946 REMOVE HIP PRESSURE SORE 1064.75

15950 REMOVE THIGH PRESSURE SORE 380.57

15951 REMOVE THIGH PRESSURE SORE 550.88

15952 REMOVE THIGH PRESSURE SORE 564.56

15953 REMOVE THIGH PRESSURE SORE 642.6

15956 REMOVE THIGH PRESSURE SORE 770

15958 REMOVE THIGH PRESSURE SORE 783.14

16000 INITIAL TREATMENT OF BURN(S) 33.52

16020 DRESS/DEBRID P-THICK BURN S 31.11

16025 DRESS/DEBRID P-THICK BURN M 74.29

6/95

Page 7: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

16030 DRESS/DEBRID P-THICK BURN L 89.04

16035 INCISION OF BURN SCAB INITI 156.09

16036 ESCHAROTOMY ADDL INCISION 61.14

17000 DESTRUCT PREMALG LESION 24.94

17003 DESTRUCT PREMALG LES 2-14 6.43

17004 DESTROY PREMAL LESIONS 15/> 115.32

17106 DESTRUCTION OF SKIN LESIONS 212.95

17107 DESTRUCTION OF SKIN LESIONS 411.15

17108 DESTRUCTION OF SKIN LESIONS 587.08

17110 DESTRUCT B9 LESION 1-14 26.01

17111 DESTRUCT LESION 15 OR MORE 37.54

17250 CHEMICAL CAUTERY TISSUE 20.65

17260 DESTRUCTION OF SKIN LESIONS 36.74

17261 DESTRUCTION OF SKIN LESIONS 48.81

17262 DESTRUCTION OF SKIN LESIONS 65.97

17263 DESTRUCTION OF SKIN LESIONS 74.02

17264 DESTRUCTION OF SKIN LESIONS 79.11

17266 DESTRUCTION OF SKIN LESIONS 96.01

17270 DESTRUCTION OF SKIN LESIONS 54.17

17271 DESTRUCTION OF SKIN LESIONS 62.22

17272 DESTRUCTION OF SKIN LESIONS 74.02

17273 DESTRUCTION OF SKIN LESIONS 85.28

17274 DESTRUCTION OF SKIN LESIONS 106.74

17276 DESTRUCTION OF SKIN LESIONS 142.41

17280 DESTRUCTION OF SKIN LESIONS 48.27

17281 DESTRUCTION OF SKIN LESIONS 71.87

17282 DESTRUCTION OF SKIN LESIONS 85.55

17283 DESTRUCTION OF SKIN LESIONS 109.15

17284 DESTRUCTION OF SKIN LESIONS 133.02

17286 DESTRUCTION OF SKIN LESIONS 197.12

20005 I&D ABSCESS SUBFASCIAL 164.94

20100 EXPLORE WOUND NECK 418.66

20101 EXPLORE WOUND CHEST 140.26

20102 EXPLORE WOUND ABDOMEN 169.23

20103 EXPLORE WOUND EXTREMITY 245.13

20150 EXCISE EPIPHYSEAL BAR 671.03

20200 MUSCLE BIOPSY 62.22

20205 DEEP MUSCLE BIOPSY 98.16

20206 NEEDLE BIOPSY MUSCLE 38.62

20220 BONE BIOPSY TROCAR/NEEDLE 119.34

20225 BONE BIOPSY TROCAR/NEEDLE 139.19

20240 BONE BIOPSY EXCISIONAL 213.48

20245 BONE BIOPSY EXCISIONAL 416.51

20250 OPEN BONE BIOPSY 273.56

20251 OPEN BONE BIOPSY 310.84

7/95

Page 8: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

20500 INJECTION OF SINUS TRACT 145.36

20501 INJECT SINUS TRACT FOR X-RAY 28.96

20520 REMOVAL OF FOREIGN BODY 156.36

20525 REMOVAL OF FOREIGN BODY 229.84

20526 THER INJECTION CARP TUNNEL 35.93

20550 INJ TENDON SHEATH/LIGAMENT 32.98

20551 INJ TENDON ORIGIN/INSERTION 35.93

20552 INJ TRIGGER POINT 1/2 MUSCL 35.93

20553 INJECT TRIGGER POINTS 3/> 35.93

20600 DRAIN/INJ JOINT/BURSA W/O US 30.03

20605 DRAIN/INJ JOINT/BURSA W/O US 30.84

20610 DRAIN/INJ JOINT/BURSA W/O US 36.2

20612 ASPIRATE/INJ GANGLION CYST 28.69

20615 TREATMENT OF BONE CYST 137.85

20650 INSERT AND REMOVE BONE PIN 157.96

20670 REMOVAL OF SUPPORT IMPLANT 149.65

20680 REMOVAL OF SUPPORT IMPLANT 245.67

20690 APPLY BONE FIXATION DEVICE 163.33

20692 APPLY BONE FIXATION DEVICE 291.8

20693 ADJUST BONE FIXATION DEVICE 547.12

20694 REMOVE BONE FIXATION DEVICE 306.28

20802 REPLANTATION ARM COMPLETE 2104.29

20805 REPLANT FOREARM COMPLETE 2554.87

20808 REPLANTATION HAND COMPLETE 3443.95

20816 REPLANTATION DIGIT COMPLETE 2310.81

20822 REPLANTATION DIGIT COMPLETE 2070.23

20824 REPLANTATION THUMB COMPLETE 2315.1

20827 REPLANTATION THUMB COMPLETE 2087.93

20838 REPLANTATION FOOT COMPLETE 2025.44

20900 REMOVAL OF BONE FOR GRAFT 341.68

20902 REMOVAL OF BONE FOR GRAFT 486.24

20910 REMOVE CARTILAGE FOR GRAFT 353.48

20912 REMOVE CARTILAGE FOR GRAFT 403.1

20920 REMOVAL OF FASCIA FOR GRAFT 312.18

20922 REMOVAL OF FASCIA FOR GRAFT 381.64

20924 REMOVAL OF TENDON FOR GRAFT 397.2

20926 REMOVAL OF TISSUE FOR GRAFT 355.09

20930 SP BONE ALGRFT MORSEL ADD-ON 70.8

20931 SP BONE ALGRFT STRUCT ADD-ON 87.16

20936 SP BONE AGRFT LOCAL ADD-ON 74.55

20937 SP BONE AGRFT MORSEL ADD-ON 131.95

20938 SP BONE AGRFT STRUCT ADD-ON 144.02

20950 FLUID PRESSURE MUSCLE 98.96

20955 FIBULA BONE GRAFT MICROVASC 2048.51

20956 ILIAC BONE GRAFT MICROVASC 2030.81

8/95

Page 9: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

20957 MT BONE GRAFT MICROVASC 1886.78

20962 OTHER BONE GRAFT MICROVASC 2021.95

20969 BONE/SKIN GRAFT MICROVASC 2252.88

20970 BONE/SKIN GRAFT ILIAC CREST 2149.35

20972 BONE/SKIN GRAFT METATARSAL 1863.45

20973 BONE/SKIN GRAFT GREAT TOE 2234.64

20974 ELECTRICAL BONE STIMULATION 29.23

20975 ELECTRICAL BONE STIMULATION 123.37

20979 US BONE STIMULATION 24.94

27600 DECOMPRESSION OF LOWER LEG 388.08

27601 DECOMPRESSION OF LOWER LEG 388.35

27602 DECOMPRESSION OF LOWER LEG 450.84

27603 DRAIN LOWER LEG LESION 444.94

27604 DRAIN LOWER LEG BURSA 374.13

27605 INCISION OF ACHILLES TENDON 192.03

27606 INCISION OF ACHILLES TENDON 271.68

27607 TREAT LOWER LEG BONE LESION 605.86

27610 EXPLORE/TREAT ANKLE JOINT 552.76

27612 EXPLORATION OF ANKLE JOINT 462.1

27613 BIOPSY LOWER LEG SOFT TISSUE 146.16

27614 BIOPSY LOWER LEG SOFT TISSUE 372.52

27615 RESECT LEG/ANKLE TUM < 5 CM 859.31

27618 EXC LEG/ANKLE TUM < 3 CM 341.95

27619 EXC LEG/ANKLE TUM DEEP <5 CM 525.4

27620 EXPLORE/TREAT ANKLE JOINT 416.51

27625 REMOVE ANKLE JOINT LINING 528.08

27626 REMOVE ANKLE JOINT LINING 569.65

27630 REMOVAL OF TENDON LESION 340.34

27635 REMOVE LOWER LEG BONE LESION 554.1

27637 REMOVE/GRAFT LEG BONE LESION 654.67

27638 REMOVE/GRAFT LEG BONE LESION 682.3

27640 PARTIAL REMOVAL OF TIBIA 870.84

27641 PARTIAL REMOVAL OF FIBULA 749.08

27645 RESECT TIBIA TUMOR 969.54

27646 RESECT FIBULA TUMOR 907.05

27647 RESECT TALUS/CALCANEUS TUM 698.39

27648 INJECTION FOR ANKLE X-RAY 37.54

27650 REPAIR ACHILLES TENDON 572.6

27652 REPAIR/GRAFT ACHILLES TENDON 601.3

27654 REPAIR OF ACHILLES TENDON 603.98

27656 REPAIR LEG FASCIA DEFECT 335.51

27658 REPAIR OF LEG TENDON EACH 410.88

27659 REPAIR OF LEG TENDON EACH 492.41

27664 REPAIR OF LEG TENDON EACH 399.61

27665 REPAIR OF LEG TENDON EACH 419.19

9/95

Page 10: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

27675 REPAIR LOWER LEG TENDONS 462.64

27676 REPAIR LOWER LEG TENDONS 535.05

27680 RELEASE OF LOWER LEG TENDON 411.15

27681 RELEASE OF LOWER LEG TENDONS 461.03

27685 REVISION OF LOWER LEG TENDON 440.11

27686 REVISE LOWER LEG TENDONS 510.65

27687 REVISION OF CALF TENDON 439.04

27690 REVISE LOWER LEG TENDON 542.03

27691 REVISE LOWER LEG TENDON 623.29

27692 REVISE ADDITIONAL LEG TENDON 86.36

27695 REPAIR OF ANKLE LIGAMENT 461.03

27696 REPAIR OF ANKLE LIGAMENTS 526.47

27698 REPAIR OF ANKLE LIGAMENT 565.63

27700 REVISION OF ANKLE JOINT 512.26

27702 RECONSTRUCT ANKLE JOINT 793.6

27703 RECONSTRUCTION ANKLE JOINT 871.38

27704 REMOVAL OF ANKLE IMPLANT 487.05

27705 INCISION OF TIBIA 648.23

27707 INCISION OF FIBULA 373.6

27709 INCISION OF TIBIA & FIBULA 633.22

27712 REALIGNMENT OF LOWER LEG 836.78

27715 REVISION OF LOWER LEG 876.74

27720 REPAIR OF TIBIA 752.56

27722 REPAIR/GRAFT OF TIBIA 747.2

27724 REPAIR/GRAFT OF TIBIA 1040.07

27725 REPAIR OF LOWER LEG 926.89

27727 REPAIR OF LOWER LEG 839.46

27730 REPAIR OF TIBIA EPIPHYSIS 508.77

27732 REPAIR OF FIBULA EPIPHYSIS 365.02

27734 REPAIR LOWER LEG EPIPHYSES 558.12

27740 REPAIR OF LEG EPIPHYSES 564.02

27742 REPAIR OF LEG EPIPHYSES 586.28

27745 REINFORCE TIBIA 639.38

27750 TREATMENT OF TIBIA FRACTURE 211.34

27752 TREATMENT OF TIBIA FRACTURE 355.9

27756 TREATMENT OF TIBIA FRACTURE 515.21

27758 TREATMENT OF TIBIA FRACTURE 704.29

27759 TREATMENT OF TIBIA FRACTURE 808.62

27760 CLTX MEDIAL ANKLE FX 201.68

27762 CLTX MED ANKLE FX W/MNPJ 324.79

27766 OPTX MEDIAL ANKLE FX 493.48

27767 Cltx post ankle fx 168.92

27768 Cltx post ankle fx w/mnpj 260.01

27769 Optx post ankle fx 446.64

27780 TREATMENT OF FIBULA FRACTURE 185.05

10/95

Page 11: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

27781 TREATMENT OF FIBULA FRACTURE 265.78

27784 TREATMENT OF FIBULA FRACTURE 463.98

27786 TREATMENT OF ANKLE FRACTURE 193.9

27788 TREATMENT OF ANKLE FRACTURE 268.46

27792 TREATMENT OF ANKLE FRACTURE 469.08

27808 TREATMENT OF ANKLE FRACTURE 214.02

27810 TREATMENT OF ANKLE FRACTURE 320.49

27814 TREATMENT OF ANKLE FRACTURE 640.99

27816 TREATMENT OF ANKLE FRACTURE 216.7

27818 TREATMENT OF ANKLE FRACTURE 336.05

27822 TREATMENT OF ANKLE FRACTURE 705.63

27823 TREATMENT OF ANKLE FRACTURE 804.86

27824 TREAT LOWER LEG FRACTURE 215.9

27825 TREAT LOWER LEG FRACTURE 370.65

27826 TREAT LOWER LEG FRACTURE 599.69

27827 TREAT LOWER LEG FRACTURE 860.38

27828 TREAT LOWER LEG FRACTURE 929.84

27829 TREAT LOWER LEG JOINT 414.63

27830 TREAT LOWER LEG DISLOCATION 237.89

27831 TREAT LOWER LEG DISLOCATION 280.26

27832 TREAT LOWER LEG DISLOCATION 429.12

27840 TREAT ANKLE DISLOCATION 311.64

27842 TREAT ANKLE DISLOCATION 338.2

27846 TREAT ANKLE DISLOCATION 599.42

27848 TREAT ANKLE DISLOCATION 678.27

27860 FIXATION OF ANKLE JOINT 178.35

27870 FUSION OF ANKLE JOINT OPEN 821.49

27871 FUSION OF TIBIOFIBULAR JOINT 596.47

27880 AMPUTATION OF LOWER LEG 697.05

27881 AMPUTATION OF LOWER LEG 758.73

27882 AMPUTATION OF LOWER LEG 640.19

27884 AMPUTATION FOLLOW-UP SURGERY 552.49

27886 AMPUTATION FOLLOW-UP SURGERY 601.57

27888 AMPUTATION OF FOOT AT ANKLE 610.95

27889 AMPUTATION OF FOOT AT ANKLE 598.89

27892 DECOMPRESSION OF LEG 461.3

27893 DECOMPRESSION OF LEG 466.39

27894 DECOMPRESSION OF LEG 604.52

28001 DRAINAGE OF BURSA OF FOOT 169.77

28002 TREATMENT OF FOOT INFECTION 260.15

28003 TREATMENT OF FOOT INFECTION 556.24

28005 TREAT FOOT BONE LESION 556.78

28008 INCISION OF FOOT FASCIA 315.93

28010 INCISION OF TOE TENDON 238.96

28011 INCISION OF TOE TENDONS 319.69

11/95

Page 12: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

28020 EXPLORATION OF FOOT JOINT 345.44

28022 EXPLORATION OF FOOT JOINT 320.49

28024 EXPLORATION OF TOE JOINT 319.42

28035 DECOMPRESSION OF TIBIA NERVE 309.23

28039 EXC FOOT/TOE TUM SC 1.5 CM/> 232.82

28041 EXC FOOT/TOE TUM DEP 1.5CM/> 306.31

28043 EXC FOOT/TOE TUM SC < 1.5 CM 248.35

28045 EXC FOOT/TOE TUM DEEP <1.5CM 309.23

28046 RESECT FOOT/TOE TUMOR < 3 CM 628.12

28047 RESECT FOOT/TOE TUMOR 3 CM/> 643.35

28050 BIOPSY OF FOOT JOINT LINING 302.52

28052 BIOPSY OF FOOT JOINT LINING 283.21

28054 BIOPSY OF TOE JOINT LINING 260.95

28055 NEURECTOMY FOOT 272.07

28060 PARTIAL REMOVAL FOOT FASCIA 344.63

28062 REMOVAL OF FOOT FASCIA 394.79

28070 REMOVAL OF FOOT JOINT LINING 330.15

28072 REMOVAL OF FOOT JOINT LINING 330.15

28080 REMOVAL OF FOOT LESION 266.32

28086 EXCISE FOOT TENDON SHEATH 348.39

28088 EXCISE FOOT TENDON SHEATH 305.47

28090 REMOVAL OF FOOT LESION 294.48

28092 REMOVAL OF TOE LESIONS 282.41

28100 REMOVAL OF ANKLE/HEEL LESION 391.84

28102 REMOVE/GRAFT FOOT LESION 490.53

28103 REMOVE/GRAFT FOOT LESION 397.2

28104 REMOVAL OF FOOT LESION 348.66

28106 REMOVE/GRAFT FOOT LESION 420

28107 REMOVE/GRAFT FOOT LESION 372.52

28108 REMOVAL OF TOE LESIONS 278.39

28110 PART REMOVAL OF METATARSAL 317.28

28111 PART REMOVAL OF METATARSAL 369.84

28112 PART REMOVAL OF METATARSAL 348.66

28113 PART REMOVAL OF METATARSAL 348.12

28114 REMOVAL OF METATARSAL HEADS 610.42

28116 REVISION OF FOOT 420

28118 REMOVAL OF HEEL BONE 388.08

28119 REMOVAL OF HEEL SPUR 340.61

28120 PART REMOVAL OF ANKLE/HEEL 441.72

28122 PARTIAL REMOVAL OF FOOT BONE 492.41

28124 PARTIAL REMOVAL OF TOE 362.87

28126 PARTIAL REMOVAL OF TOE 299.04

28130 REMOVAL OF ANKLE BONE 498.85

28140 REMOVAL OF METATARSAL 434.21

28150 REMOVAL OF TOE 323.98

12/95

Page 13: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

28153 PARTIAL REMOVAL OF TOE 287.77

28160 PARTIAL REMOVAL OF TOE 318.62

28171 RESECT TARSAL TUMOR 525.94

28173 RESECT METATARSAL TUMOR 518.43

28175 RESECT PHALANX OF TOE TUMOR 382.18

28190 REMOVAL OF FOOT FOREIGN BODY 156.36

28192 REMOVAL OF FOOT FOREIGN BODY 293.41

28193 REMOVAL OF FOOT FOREIGN BODY 360.72

28200 REPAIR OF FOOT TENDON 319.15

28202 REPAIR/GRAFT OF FOOT TENDON 402.56

28208 REPAIR OF FOOT TENDON 304.94

28210 REPAIR/GRAFT OF FOOT TENDON 373.87

28220 RELEASE OF FOOT TENDON 321.03

28222 RELEASE OF FOOT TENDONS 365.02

28225 RELEASE OF FOOT TENDON 270.07

28226 RELEASE OF FOOT TENDONS 327.74

28230 INCISION OF FOOT TENDON(S) 323.71

28232 INCISION OF TOE TENDON 288.85

28234 INCISION OF FOOT TENDON 275.97

28238 REVISION OF FOOT TENDON 455.13

28240 RELEASE OF BIG TOE 315.67

28250 REVISION OF FOOT FASCIA 384.33

28260 RELEASE OF MIDFOOT JOINT 474.71

28261 REVISION OF FOOT TENDON 638.58

28262 REVISION OF FOOT AND ANKLE 919.12

28264 RELEASE OF MIDFOOT JOINT 632.41

28270 RELEASE OF FOOT CONTRACTURE 356.97

28272 RELEASE OF TOE JOINT EACH 272.49

28280 FUSION OF TOES 351.87

28285 REPAIR OF HAMMERTOE 332.83

28286 REPAIR OF HAMMERTOE 331.76

28288 PARTIAL REMOVAL OF FOOT BONE 372.26

28289 REPAIR HALLUX RIGIDUS 492.68

28290 CORRECTION OF BUNION 423.75

28292 CORRECTION OF BUNION 435.82

28293 CORRECTION OF BUNION 511.72

28294 CORRECTION OF BUNION 499.65

28296 CORRECTION OF BUNION 529.96

28297 CORRECTION OF BUNION 575.55

28298 CORRECTION OF BUNION 486.51

28299 CORRECTION OF BUNION 581.99

28300 INCISION OF HEEL BONE 562.41

28302 INCISION OF ANKLE BONE 551.68

28304 INCISION OF MIDFOOT BONES 498.85

28305 INCISE/GRAFT MIDFOOT BONES 581.45

13/95

Page 14: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

28306 INCISION OF METATARSAL 365.55

28307 INCISION OF METATARSAL 409.27

28308 INCISION OF METATARSAL 322.64

28309 INCISION OF METATARSALS 706.43

28310 REVISION OF BIG TOE 364.21

28312 REVISION OF TOE 362.07

28313 REPAIR DEFORMITY OF TOE 409.54

28315 REMOVAL OF SESAMOID BONE 314.59

28320 REPAIR OF FOOT BONES 539.88

28322 REPAIR OF METATARSALS 496.17

28340 RESECT ENLARGED TOE TISSUE 394.79

28341 RESECT ENLARGED TOE 456.74

28344 REPAIR EXTRA TOE(S) 269.8

28345 REPAIR WEBBED TOE(S) 398

28360 RECONSTRUCT CLEFT FOOT 761.15

28400 TREATMENT OF HEEL FRACTURE 199.8

28405 TREATMENT OF HEEL FRACTURE 307.08

28406 TREATMENT OF HEEL FRACTURE 440.38

28415 TREAT HEEL FRACTURE 941.11

28420 TREAT/GRAFT HEEL FRACTURE 967.12

28430 TREATMENT OF ANKLE FRACTURE 183.71

28435 TREATMENT OF ANKLE FRACTURE 234.13

28436 TREATMENT OF ANKLE FRACTURE 367.43

28445 TREAT ANKLE FRACTURE 851.26

28446 Osteochondral talus autogrft 771.15

28450 TREAT MIDFOOT FRACTURE EACH 172.72

28455 TREAT MIDFOOT FRACTURE EACH 234.94

28456 TREAT MIDFOOT FRACTURE 258.54

28465 TREAT MIDFOOT FRACTURE EACH 447.08

28470 TREAT METATARSAL FRACTURE 157.16

28475 TREAT METATARSAL FRACTURE 215.36

28476 TREAT METATARSAL FRACTURE 292.87

28485 TREAT METATARSAL FRACTURE 407.12

28490 TREAT BIG TOE FRACTURE 95.21

28495 TREAT BIG TOE FRACTURE 113.18

28496 TREAT BIG TOE FRACTURE 200.88

28505 TREAT BIG TOE FRACTURE 306.82

28510 TREATMENT OF TOE FRACTURE 95.74

28515 TREATMENT OF TOE FRACTURE 108.88

28525 TREAT TOE FRACTURE 275.44

28530 TREAT SESAMOID BONE FRACTURE 113.98

28531 TREAT SESAMOID BONE FRACTURE 205.97

28540 TREAT FOOT DISLOCATION 167.35

28545 TREAT FOOT DISLOCATION 209.46

28546 TREAT FOOT DISLOCATION 277.05

14/95

Page 15: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

28555 REPAIR FOOT DISLOCATION 431.26

28570 TREAT FOOT DISLOCATION 154.21

28575 TREAT FOOT DISLOCATION 248.35

28576 TREAT FOOT DISLOCATION 321.57

28585 REPAIR FOOT DISLOCATION 483.83

28600 TREAT FOOT DISLOCATION 167.08

28605 TREAT FOOT DISLOCATION 207.05

28606 TREAT FOOT DISLOCATION 351.61

28615 REPAIR FOOT DISLOCATION 508.23

28630 TREAT TOE DISLOCATION 116.93

28635 TREAT TOE DISLOCATION 128.73

28636 TREAT TOE DISLOCATION 177.01

28645 REPAIR TOE DISLOCATION 253.44

28660 TREAT TOE DISLOCATION 109.15

28665 TREAT TOE DISLOCATION 128.46

28666 TREAT TOE DISLOCATION 167.62

28675 REPAIR OF TOE DISLOCATION 228.5

28705 FUSION OF FOOT BONES 1012.45

28715 FUSION OF FOOT BONES 763.02

28725 FUSION OF FOOT BONES 685.78

28730 FUSION OF FOOT BONES 638.85

28735 FUSION OF FOOT BONES 632.68

28737 REVISION OF FOOT BONES 555.97

28740 FUSION OF FOOT BONES 501.8

28750 FUSION OF BIG TOE JOINT 484.63

28755 FUSION OF BIG TOE JOINT 328

28760 FUSION OF BIG TOE JOINT 461.57

28800 AMPUTATION OF MIDFOOT 500.99

28805 AMPUTATION THRU METATARSAL 508.5

28810 AMPUTATION TOE & METATARSAL 412.22

28820 AMPUTATION OF TOE 334.98

28825 PARTIAL AMPUTATION OF TOE 304.4

28899 FOOT/TOES SURGERY PROCEDURE 0

29305 APPLICATION OF HIP CAST 108.62

29325 APPLICATION OF HIP CASTS 122.56

29345 APPLICATION OF LONG LEG CAST 72.41

29355 APPLICATION OF LONG LEG CAST 78.58

29358 APPLY LONG LEG CAST BRACE 74.55

29365 APPLICATION OF LONG LEG CAST 62.49

29405 APPLY SHORT LEG CAST 45.59

29425 APPLY SHORT LEG CAST 50.68

29435 APPLY SHORT LEG CAST 61.95

29440 ADDITION OF WALKER TO CAST 24.94

29445 APPLY RIGID LEG CAST 82.6

29450 APPLICATION OF LEG CAST 91.18

15/95

Page 16: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

29505 APPLICATION LONG LEG SPLINT 33.79

29515 APPLICATION LOWER LEG SPLINT 35.4

29520 STRAPPING OF HIP 27.35

29530 STRAPPING OF KNEE 26.82

29540 STRAPPING OF ANKLE AND/OR FT 23.86

29550 STRAPPING OF TOES 22.26

29580 APPLICATION OF PASTE BOOT 27.08

29581 APPLY MULTLAY COMPRS LWR LEG 22.53

29582 Apply multlay comprs upr leg 12.25

29700 REMOVAL/REVISION OF CAST 25.47

29705 REMOVAL/REVISION OF CAST 34.59

29710 REMOVAL/REVISION OF CAST 60.07

29720 REPAIR OF BODY CAST 31.64

29730 WINDOWING OF CAST 33.52

29740 WEDGING OF CAST 47.73

29750 WEDGING OF CLUBFOOT CAST 56.32

29800 JAW ARTHROSCOPY/SURGERY 455.4

29804 JAW ARTHROSCOPY/SURGERY 484.1

29805 SHOULDER ARTHROSCOPY DX 275.7

29806 SHOULDER ARTHROSCOPY/SURGERY 768.12

29807 SHOULDER ARTHROSCOPY/SURGERY 748

29819 SHOULDER ARTHROSCOPY/SURGERY 513.6

29820 SHOULDER ARTHROSCOPY/SURGERY 488.66

29821 SHOULDER ARTHROSCOPY/SURGERY 517.35

29822 SHOULDER ARTHROSCOPY/SURGERY 505.55

29823 SHOULDER ARTHROSCOPY/SURGERY 540.15

29824 SHOULDER ARTHROSCOPY/SURGERY 468.54

29825 SHOULDER ARTHROSCOPY/SURGERY 512.79

29826 SHOULDER ARTHROSCOPY/SURGERY 579.84

29827 ARTHROSCOP ROTATOR CUFF REPR 796.28

29828 Arthroscopy biceps tenodesis 596.36

29830 ELBOW ARTHROSCOPY 351.87

29834 ELBOW ARTHROSCOPY/SURGERY 390.49

29835 ELBOW ARTHROSCOPY/SURGERY 396.93

29836 ELBOW ARTHROSCOPY/SURGERY 450.3

29837 ELBOW ARTHROSCOPY/SURGERY 419.73

29838 ELBOW ARTHROSCOPY/SURGERY 457.81

29840 WRIST ARTHROSCOPY 405.25

29843 WRIST ARTHROSCOPY/SURGERY 430.99

29844 WRIST ARTHROSCOPY/SURGERY 449.23

29845 WRIST ARTHROSCOPY/SURGERY 496.43

29846 WRIST ARTHROSCOPY/SURGERY 535.86

29847 WRIST ARTHROSCOPY/SURGERY 550.61

29848 WRIST ENDOSCOPY/SURGERY 405.78

29850 KNEE ARTHROSCOPY/SURGERY 453.52

16/95

Page 17: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

29851 KNEE ARTHROSCOPY/SURGERY 746.13

29855 TIBIAL ARTHROSCOPY/SURGERY 628.92

29856 TIBIAL ARTHROSCOPY/SURGERY 794.14

29860 HIP ARTHROSCOPY DX 478.2

29861 HIP ARTHRO W/FB REMOVAL 531.3

29862 HIP ARTHR0 W/DEBRIDEMENT 583.6

29863 HIP ARTHR0 W/SYNOVECTOMY 599.42

29870 KNEE ARTHROSCOPY DX 333.1

29871 KNEE ARTHROSCOPY/DRAINAGE 438.5

29873 KNEE ARTHROSCOPY/SURGERY 368.23

29874 KNEE ARTHROSCOPY/SURGERY 445.21

29875 KNEE ARTHROSCOPY/SURGERY 413.02

29876 KNEE ARTHROSCOPY/SURGERY 505.55

29877 KNEE ARTHROSCOPY/SURGERY 462.64

29879 KNEE ARTHROSCOPY/SURGERY 495.09

29880 KNEE ARTHROSCOPY/SURGERY 517.08

29881 KNEE ARTHROSCOPY/SURGERY 482.22

29882 KNEE ARTHROSCOPY/SURGERY 519.5

29883 KNEE ARTHROSCOPY/SURGERY 631.07

29884 KNEE ARTHROSCOPY/SURGERY 478.2

29885 KNEE ARTHROSCOPY/SURGERY 560.8

29886 KNEE ARTHROSCOPY/SURGERY 488.12

29887 KNEE ARTHROSCOPY/SURGERY 558.66

29888 KNEE ARTHROSCOPY/SURGERY 786.09

29889 KNEE ARTHROSCOPY/SURGERY 881.84

29891 ANKLE ARTHROSCOPY/SURGERY 512.79

29892 ANKLE ARTHROSCOPY/SURGERY 535.32

29893 SCOPE PLANTAR FASCIOTOMY 319.69

29894 ANKLE ARTHROSCOPY/SURGERY 451.11

29895 ANKLE ARTHROSCOPY/SURGERY 443.06

29897 ANKLE ARTHROSCOPY/SURGERY 469.61

29898 ANKLE ARTHROSCOPY/SURGERY 506.09

29899 ANKLE ARTHROSCOPY/SURGERY 732.99

29900 MCP JOINT ARTHROSCOPY DX 332.29

29901 MCP JOINT ARTHROSCOPY SURG 366.36

29902 MCP JOINT ARTHROSCOPY SURG 393.44

29904 Subtalar arthro w/fb rmvl 400.22

29905 Subtalar arthro w/exc 431.52

29906 Subtalar arthro w/deb 454.52

29907 Subtalar arthro w/fusion 556.42

69990 MICROSURGERY ADD-ON 163.87

73500 X-RAY EXAM OF HIP TC 15.62

73500 X-RAY EXAM OF HIP 26 7.97

73500 X-RAY EXAM OF HIP 23.59

73510 X-RAY EXAM OF HIP TC 19.12

17/95

Page 18: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

73510 X-RAY EXAM OF HIP 26 9.88

73510 X-RAY EXAM OF HIP 29.01

73520 X-RAY EXAM OF HIPS TC 21.99

73520 X-RAY EXAM OF HIPS 26 12.11

73520 X-RAY EXAM OF HIPS 34.11

73525 CONTRAST X-RAY OF HIP TC 69.81

73525 CONTRAST X-RAY OF HIP 26 25.18

73525 CONTRAST X-RAY OF HIP 95

73530 X-RAY EXAM OF HIP TC 17.21

73530 X-RAY EXAM OF HIP 26 13.07

73530 X-RAY EXAM OF HIP 30.28

73540 X-RAY EXAM OF PELVIS & HIPS TC 19.12

73540 X-RAY EXAM OF PELVIS & HIPS 26 9.56

73540 X-RAY EXAM OF PELVIS & HIPS 28.69

73550 X-RAY EXAM OF THIGH TC 19.12

73550 X-RAY EXAM OF THIGH 26 7.97

73550 X-RAY EXAM OF THIGH 26.77

73560 X-RAY EXAM OF KNEE 1 OR 2 TC 17.21

73560 X-RAY EXAM OF KNEE 1 OR 2 26 8.28

73560 X-RAY EXAM OF KNEE 1 OR 2 25.5

73562 X-RAY EXAM OF KNEE 3 TC 19.12

73562 X-RAY EXAM OF KNEE 3 26 8.6

73562 X-RAY EXAM OF KNEE 3 27.41

73564 X-RAY EXAM KNEE 4 OR MORE TC 20.72

73564 X-RAY EXAM KNEE 4 OR MORE 26 10.52

73564 X-RAY EXAM KNEE 4 OR MORE 31.24

73565 X-RAY EXAM OF KNEES TC 16.25

73565 X-RAY EXAM OF KNEES 26 8.6

73565 X-RAY EXAM OF KNEES 24.86

73580 CONTRAST X-RAY OF KNEE JOINT TC 87.03

73580 CONTRAST X-RAY OF KNEE JOINT 26 24.86

73580 CONTRAST X-RAY OF KNEE JOINT 111.89

73590 X-RAY EXAM OF LOWER LEG TC 17.21

73590 X-RAY EXAM OF LOWER LEG 26 7.97

73590 X-RAY EXAM OF LOWER LEG 25.18

73592 X-RAY EXAM OF LEG INFANT TC 16.25

73592 X-RAY EXAM OF LEG INFANT 26 7.65

73592 X-RAY EXAM OF LEG INFANT 23.91

73600 X-RAY EXAM OF ANKLE TC 16.25

73600 X-RAY EXAM OF ANKLE 26 7.65

73600 X-RAY EXAM OF ANKLE 23.91

73610 X-RAY EXAM OF ANKLE TC 17.53

73610 X-RAY EXAM OF ANKLE 26 7.97

73610 X-RAY EXAM OF ANKLE 25.5

73615 CONTRAST X-RAY OF ANKLE TC 69.81

18/95

Page 19: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

73615 CONTRAST X-RAY OF ANKLE 26 24.86

73615 CONTRAST X-RAY OF ANKLE 94.36

73620 X-RAY EXAM OF FOOT TC 16.25

73620 X-RAY EXAM OF FOOT 26 7.65

73620 X-RAY EXAM OF FOOT 23.91

73630 X-RAY EXAM OF FOOT TC 17.53

73630 X-RAY EXAM OF FOOT 26 7.97

73630 X-RAY EXAM OF FOOT 25.5

73650 X-RAY EXAM OF HEEL TC 15.62

73650 X-RAY EXAM OF HEEL 26 7.65

73650 X-RAY EXAM OF HEEL 23.27

73660 X-RAY EXAM OF TOE(S) TC 13.7

73660 X-RAY EXAM OF TOE(S) 26 6.05

73660 X-RAY EXAM OF TOE(S) 19.76

73700 CT LOWER EXTREMITY W/O DYE TC 164.18

73700 CT LOWER EXTREMITY W/O DYE 26 49.41

73700 CT LOWER EXTREMITY W/O DYE 213.59

73701 CT LOWER EXTREMITY W/DYE TC 195.74

73701 CT LOWER EXTREMITY W/DYE 26 52.6

73701 CT LOWER EXTREMITY W/DYE 248.66

73702 CT LWR EXTREMITY W/O&W/DYE TC 245.79

73702 CT LWR EXTREMITY W/O&W/DYE 26 55.15

73702 CT LWR EXTREMITY W/O&W/DYE 301.26

73706 CT ANGIO LWR EXTR W/O&W/DYE TC 245.79

73706 CT ANGIO LWR EXTR W/O&W/DYE 26 88.3

73706 CT ANGIO LWR EXTR W/O&W/DYE 334.1

73718 MRI LOWER EXTREMITY W/O DYE TC 364.7

73718 MRI LOWER EXTREMITY W/O DYE 26 60.25

73718 MRI LOWER EXTREMITY W/O DYE 425.27

73719 MRI LOWER EXTREMITY W/DYE TC 437.71

73719 MRI LOWER EXTREMITY W/DYE 26 72.36

73719 MRI LOWER EXTREMITY W/DYE 510.08

73720 MRI LWR EXTREMITY W/O&W/DYE TC 810.07

73720 MRI LWR EXTREMITY W/O&W/DYE 26 96.91

73720 MRI LWR EXTREMITY W/O&W/DYE 906.66

73721 MRI JNT OF LWR EXTRE W/O DYE TC 364.7

73721 MRI JNT OF LWR EXTRE W/O DYE 26 60.25

73721 MRI JNT OF LWR EXTRE W/O DYE 425.27

73722 MRI JOINT OF LWR EXTR W/DYE TC 437.71

73722 MRI JOINT OF LWR EXTR W/DYE 26 73

73722 MRI JOINT OF LWR EXTR W/DYE 510.71

73723 MRI JOINT LWR EXTR W/O&W/DYE TC 810.07

73723 MRI JOINT LWR EXTR W/O&W/DYE 26 96.27

73723 MRI JOINT LWR EXTR W/O&W/DYE 906.34

73725 MR ANG LWR EXT W OR W/O DYE TC 371.4

19/95

Page 20: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

73725 MR ANG LWR EXT W OR W/O DYE 26 82.56

73725 MR ANG LWR EXT W OR W/O DYE 453.97

76000 FLUOROSCOPE EXAMINATION TC 43.35

76000 FLUOROSCOPE EXAMINATION 26 8.28

76000 FLUOROSCOPE EXAMINATION 51.64

76001 FLUOROSCOPE EXAM EXTENSIVE TC 87.03

76001 FLUOROSCOPE EXAM EXTENSIVE 26 30.6

76001 FLUOROSCOPE EXAM EXTENSIVE 117.63

76010 X-RAY NOSE TO RECTUM TC 17.21

76010 X-RAY NOSE TO RECTUM 26 8.28

76010 X-RAY NOSE TO RECTUM 25.5

76080 X-RAY EXAM OF FISTULA TC 35.06

76080 X-RAY EXAM OF FISTULA 26 24.22

76080 X-RAY EXAM OF FISTULA 59.29

76098 X-RAY EXAM BREAST SPECIMEN TC 13.7

76098 X-RAY EXAM BREAST SPECIMEN 26 7.65

76098 X-RAY EXAM BREAST SPECIMEN 21.04

76100 X-RAY EXAM OF BODY SECTION TC 41.44

76100 X-RAY EXAM OF BODY SECTION 26 26.46

76100 X-RAY EXAM OF BODY SECTION 67.9

76101 COMPLEX BODY SECTION X-RAY TC 47.5

76101 COMPLEX BODY SECTION X-RAY 26 26.46

76101 COMPLEX BODY SECTION X-RAY 73.64

76102 COMPLEX BODY SECTION X-RAYS TC 57.7

76102 COMPLEX BODY SECTION X-RAYS 26 26.46

76102 COMPLEX BODY SECTION X-RAYS 84.16

76120 CINE/VIDEO X-RAYS TC 35.06

76120 CINE/VIDEO X-RAYS 26 17.53

76120 CINE/VIDEO X-RAYS 52.6

76125 CINE/VIDEO X-RAYS ADD-ON TC 26.14

76125 CINE/VIDEO X-RAYS ADD-ON 26 12.43

76125 CINE/VIDEO X-RAYS ADD-ON 38.25

76140 X-RAY CONSULTATION 61.52

76380 CAT SCAN FOLLOW-UP STUDY TC 115.72

76380 CAT SCAN FOLLOW-UP STUDY 26 44.31

76380 CAT SCAN FOLLOW-UP STUDY 160.03

76390 MR SPECTROSCOPY TC 371.4

76390 MR SPECTROSCOPY 26 63.76

76390 MR SPECTROSCOPY 435.16

76497 CT PROCEDURE TC 0

76497 CT PROCEDURE 26 0

76497 CT PROCEDURE 0

76499 RADIOGRAPHIC PROCEDURE TC 0

76499 RADIOGRAPHIC PROCEDURE 26 0

76499 RADIOGRAPHIC PROCEDURE 0

20/95

Page 21: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

76885 US EXAM INFANT HIPS DYNAMIC TC 50.68

76885 US EXAM INFANT HIPS DYNAMIC 26 33.47

76885 US EXAM INFANT HIPS DYNAMIC 84.16

76886 US EXAM INFANT HIPS STATIC TC 47.5

76886 US EXAM INFANT HIPS STATIC 26 28.37

76886 US EXAM INFANT HIPS STATIC 75.87

76930 ECHO GUIDE CARDIOCENTESIS TC 50.68

76930 ECHO GUIDE CARDIOCENTESIS 26 31.24

76930 ECHO GUIDE CARDIOCENTESIS 81.93

76932 ECHO GUIDE FOR HEART BIOPSY TC 50.68

76932 ECHO GUIDE FOR HEART BIOPSY 26 31.24

76932 ECHO GUIDE FOR HEART BIOPSY 81.93

76936 ECHO GUIDE FOR ARTERY REPAIR TC 208.81

76936 ECHO GUIDE FOR ARTERY REPAIR 26 91.17

76936 ECHO GUIDE FOR ARTERY REPAIR 299.99

76941 ECHO GUIDE FOR TRANSFUSION TC 50.68

76941 ECHO GUIDE FOR TRANSFUSION 26 62.8

76941 ECHO GUIDE FOR TRANSFUSION 113.49

76942 ECHO GUIDE FOR BIOPSY TC 50.68

76942 ECHO GUIDE FOR BIOPSY 26 30.6

76942 ECHO GUIDE FOR BIOPSY 81.29

76945 ECHO GUIDE VILLUS SAMPLING TC 50.68

76945 ECHO GUIDE VILLUS SAMPLING 26 30.6

76945 ECHO GUIDE VILLUS SAMPLING 81.29

76946 ECHO GUIDE FOR AMNIOCENTESIS TC 50.68

76946 ECHO GUIDE FOR AMNIOCENTESIS 26 17.53

76946 ECHO GUIDE FOR AMNIOCENTESIS 68.22

76948 ECHO GUIDE OVA ASPIRATION TC 50.68

76948 ECHO GUIDE OVA ASPIRATION 26 17.21

76948 ECHO GUIDE OVA ASPIRATION 67.9

76965 ECHO GUIDANCE RADIOTHERAPY TC 184.58

76965 ECHO GUIDANCE RADIOTHERAPY 26 60.89

76965 ECHO GUIDANCE RADIOTHERAPY 245.47

76970 ULTRASOUND EXAM FOLLOW-UP TC 35.06

76970 ULTRASOUND EXAM FOLLOW-UP 26 18.17

76970 ULTRASOUND EXAM FOLLOW-UP 53.23

76975 GI ENDOSCOPIC ULTRASOUND TC 50.68

76975 GI ENDOSCOPIC ULTRASOUND 26 36.66

76975 GI ENDOSCOPIC ULTRASOUND 87.35

76977 US BONE DENSITY MEASURE TC 27.41

76977 US BONE DENSITY MEASURE 26 2.55

76977 US BONE DENSITY MEASURE 29.96

76999 ECHO EXAMINATION PROCEDURE TC 0

76999 ECHO EXAMINATION PROCEDURE 0

77071 X-RAY STRESS VIEW 24.81

21/95

Page 22: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

77072 X-RAYS FOR BONE AGE TC 11.99

77072 X-RAYS FOR BONE AGE 26 7.43

77072 X-RAYS FOR BONE AGE 19.42

77073 X-RAYS BONE LENGTH STUDIES TC 25.64

77073 X-RAYS BONE LENGTH STUDIES 26 10.99

77073 X-RAYS BONE LENGTH STUDIES 36.64

77074 X-RAYS BONE SURVEY LIMITED TC 36.96

77074 X-RAYS BONE SURVEY LIMITED 26 18.44

77074 X-RAYS BONE SURVEY LIMITED 55.4

77075 X-RAYS BONE SURVEY COMPLETE TC 55.28

77075 X-RAYS BONE SURVEY COMPLETE 26 22.32

77075 X-RAYS BONE SURVEY COMPLETE 77.59

77076 X-RAYS BONE SURVEY INFANT TC 34.3

77076 X-RAYS BONE SURVEY INFANT 26 28.45

77076 X-RAYS BONE SURVEY INFANT 62.75

77077 JOINT SURVEY SINGLE VIEW TC 34.3

77077 JOINT SURVEY SINGLE VIEW 26 12.94

77077 JOINT SURVEY SINGLE VIEW 47.24

77078 CT BONE DENSITY AXIAL TC 66.93

77078 CT BONE DENSITY AXIAL 26 10.03

77078 CT BONE DENSITY AXIAL 76.95

77080 DXA BONE DENSITY AXIAL TC 66.93

77080 DXA BONE DENSITY AXIAL 26 9.08

77080 DXA BONE DENSITY AXIAL 76.01

77081 DXA BONE DENSITY/PERIPHERAL TC 25.64

77081 DXA BONE DENSITY/PERIPHERAL 26 9.39

77081 DXA BONE DENSITY/PERIPHERAL 35.03

77084 MAGNETIC IMAGE BONE MARROW TC 258.71

77084 MAGNETIC IMAGE BONE MARROW 26 65.33

77084 MAGNETIC IMAGE BONE MARROW 324.04

80048 METABOLIC PANEL TOTAL CA TC 5.92

80048 METABOLIC PANEL TOTAL CA 5.92

80050 GENERAL HEALTH PANEL TC 19.65

80050 GENERAL HEALTH PANEL 26 4.91

80050 GENERAL HEALTH PANEL 24.56

80051 ELECTROLYTE PANEL TC 4.91

80051 ELECTROLYTE PANEL 4.91

80053 COMPREHEN METABOLIC PANEL TC 7.39

80053 COMPREHEN METABOLIC PANEL 7.39

80061 LIPID PANEL TC 9.36

80061 LIPID PANEL 9.36

80069 RENAL FUNCTION PANEL TC 6.07

80069 RENAL FUNCTION PANEL 6.07

80074 ACUTE HEPATITIS PANEL TC 33.28

80074 ACUTE HEPATITIS PANEL 33.28

22/95

Page 23: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

80076 HEPATIC FUNCTION PANEL TC 5.72

80076 HEPATIC FUNCTION PANEL 5.72

80150 ASSAY OF AMIKACIN TC 10.53

80150 ASSAY OF AMIKACIN 10.53

80156 ASSAY CARBAMAZEPINE TOTAL TC 10.18

80156 ASSAY CARBAMAZEPINE TOTAL 10.18

80157 ASSAY CARBAMAZEPINE FREE TC 9.27

80157 ASSAY CARBAMAZEPINE FREE 9.27

80158 ASSAY OF CYCLOSPORINE TC 12.62

80158 ASSAY OF CYCLOSPORINE 12.62

80162 ASSAY OF DIGOXIN TOTAL TC 9.28

80162 ASSAY OF DIGOXIN TOTAL 9.28

80164 ASSAY DIPROPYLACETIC ACD TOT TC 9.47

80164 ASSAY DIPROPYLACETIC ACD TOT 9.47

80168 ASSAY OF ETHOSUXIMIDE TC 11.42

80168 ASSAY OF ETHOSUXIMIDE 11.42

80170 ASSAY OF GENTAMICIN TC 11.45

80170 ASSAY OF GENTAMICIN 11.45

80173 ASSAY OF HALOPERIDOL TC 10.18

80173 ASSAY OF HALOPERIDOL 10.18

80176 ASSAY OF LIDOCAINE TC 10.27

80176 ASSAY OF LIDOCAINE 10.27

80178 ASSAY OF LITHIUM TC 4.62

80178 ASSAY OF LITHIUM 4.62

80184 ASSAY OF PHENOBARBITAL TC 8.01

80184 ASSAY OF PHENOBARBITAL 8.01

80185 ASSAY OF PHENYTOIN TOTAL TC 9.27

80185 ASSAY OF PHENYTOIN TOTAL 9.27

80186 ASSAY OF PHENYTOIN FREE TC 9.62

80186 ASSAY OF PHENYTOIN FREE 9.62

80188 ASSAY OF PRIMIDONE TC 11.58

80188 ASSAY OF PRIMIDONE 11.58

80190 ASSAY OF PROCAINAMIDE TC 11.71

80190 ASSAY OF PROCAINAMIDE 11.71

80192 ASSAY OF PROCAINAMIDE TC 11.71

80192 ASSAY OF PROCAINAMIDE 11.71

80194 ASSAY OF QUINIDINE TC 10.2

80194 ASSAY OF QUINIDINE 10.2

80197 ASSAY OF TACROLIMUS TC 9.59

80197 ASSAY OF TACROLIMUS 9.59

80198 ASSAY OF THEOPHYLLINE TC 9.89

80198 ASSAY OF THEOPHYLLINE 9.89

80200 ASSAY OF TOBRAMYCIN TC 11.27

80200 ASSAY OF TOBRAMYCIN 11.27

80201 ASSAY OF TOPIRAMATE TC 8.33

23/95

Page 24: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

80201 ASSAY OF TOPIRAMATE 8.33

80202 ASSAY OF VANCOMYCIN TC 9.47

80202 ASSAY OF VANCOMYCIN 9.47

80299 QUANTITATIVE ASSAY DRUG TC 9.57

80299 QUANTITATIVE ASSAY DRUG 9.57

80400 ACTH STIMULATION PANEL TC 22.79

80400 ACTH STIMULATION PANEL 22.79

80402 ACTH STIMULATION PANEL TC 60.73

80402 ACTH STIMULATION PANEL 60.73

80406 ACTH STIMULATION PANEL TC 54.67

80406 ACTH STIMULATION PANEL 54.67

80408 ALDOSTERONE SUPPRESSION EVAL TC 87.67

80408 ALDOSTERONE SUPPRESSION EVAL 87.67

80410 CALCITONIN STIMUL PANEL TC 56.12

80410 CALCITONIN STIMUL PANEL 56.12

80412 CRH STIMULATION PANEL TC 230.25

80412 CRH STIMULATION PANEL 230.25

80414 TESTOSTERONE RESPONSE TC 36.09

80414 TESTOSTERONE RESPONSE 36.09

80415 ESTRADIOL RESPONSE PANEL TC 39.05

80415 ESTRADIOL RESPONSE PANEL 39.05

80416 RENIN STIMULATION PANEL TC 92.2

80416 RENIN STIMULATION PANEL 92.2

80417 RENIN STIMULATION PANEL TC 30.73

80417 RENIN STIMULATION PANEL 30.73

80418 PITUITARY EVALUATION PANEL TC 404.89

80418 PITUITARY EVALUATION PANEL 404.89

80420 DEXAMETHASONE PANEL TC 50.32

80420 DEXAMETHASONE PANEL 50.32

80422 GLUCAGON TOLERANCE PANEL TC 32.19

80422 GLUCAGON TOLERANCE PANEL 32.19

80424 GLUCAGON TOLERANCE PANEL TC 35.28

80424 GLUCAGON TOLERANCE PANEL 35.28

80426 GONADOTROPIN HORMONE PANEL TC 103.7

80426 GONADOTROPIN HORMONE PANEL 103.7

80428 GROWTH HORMONE PANEL TC 46.59

80428 GROWTH HORMONE PANEL 46.59

80430 GROWTH HORMONE PANEL TC 54.8

80430 GROWTH HORMONE PANEL 54.8

80432 INSULIN SUPPRESSION PANEL TC 94.37

80432 INSULIN SUPPRESSION PANEL 94.37

80434 INSULIN TOLERANCE PANEL TC 70.66

80434 INSULIN TOLERANCE PANEL 70.66

80435 INSULIN TOLERANCE PANEL TC 71.93

80435 INSULIN TOLERANCE PANEL 71.93

24/95

Page 25: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

80436 METYRAPONE PANEL TC 63.69

80436 METYRAPONE PANEL 63.69

80438 TRH STIMULATION PANEL TC 35.21

80438 TRH STIMULATION PANEL 35.21

80439 TRH STIMULATION PANEL TC 46.94

80439 TRH STIMULATION PANEL 46.94

80500 LAB PATHOLOGY CONSULTATION TC 2.06

80500 LAB PATHOLOGY CONSULTATION 26 8.24

80500 LAB PATHOLOGY CONSULTATION 10.3

80502 LAB PATHOLOGY CONSULTATION TC 5.15

80502 LAB PATHOLOGY CONSULTATION 26 20.6

80502 LAB PATHOLOGY CONSULTATION 25.75

81000 URINALYSIS NONAUTO W/SCOPE TC 2.22

81000 URINALYSIS NONAUTO W/SCOPE 2.22

81001 URINALYSIS AUTO W/SCOPE TC 2.22

81001 URINALYSIS AUTO W/SCOPE 2.22

81002 URINALYSIS NONAUTO W/O SCOPE TC 1.79

81002 URINALYSIS NONAUTO W/O SCOPE 1.79

81003 URINALYSIS AUTO W/O SCOPE TC 1.58

81003 URINALYSIS AUTO W/O SCOPE 1.58

81005 URINALYSIS TC 1.52

81005 URINALYSIS 1.52

81007 URINE SCREEN FOR BACTERIA TC 0.68

81007 URINE SCREEN FOR BACTERIA 0.68

81015 MICROSCOPIC EXAM OF URINE TC 2.12

81015 MICROSCOPIC EXAM OF URINE 2.12

81020 URINALYSIS GLASS TEST TC 2.58

81020 URINALYSIS GLASS TEST 2.58

81025 URINE PREGNANCY TEST TC 4.43

81025 URINE PREGNANCY TEST 4.43

81050 URINALYSIS VOLUME MEASURE TC 2.1

81050 URINALYSIS VOLUME MEASURE 2.1

82009 TEST FOR ACETONE/KETONES TC 3.16

82009 TEST FOR ACETONE/KETONES 3.16

82010 ACETONE ASSAY TC 5.72

82010 ACETONE ASSAY 5.72

82013 ACETYLCHOLINESTERASE ASSAY TC 7.81

82013 ACETYLCHOLINESTERASE ASSAY 7.81

82016 ACYLCARNITINES QUAL TC 9.69

82016 ACYLCARNITINES QUAL 9.69

82017 ACYLCARNITINES QUANT TC 11.79

82017 ACYLCARNITINES QUANT 11.79

82024 ASSAY OF ACTH TC 26.99

82024 ASSAY OF ACTH 26.99

82030 ASSAY OF ADP & AMP TC 18.03

25/95

Page 26: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

82030 ASSAY OF ADP & AMP 18.03

82040 ASSAY OF SERUM ALBUMIN TC 3.47

82040 ASSAY OF SERUM ALBUMIN 3.47

82042 ASSAY OF URINE ALBUMIN TC 3.62

82042 ASSAY OF URINE ALBUMIN 3.62

82043 MICROALBUMIN QUANTITATIVE TC 4.05

82043 MICROALBUMIN QUANTITATIVE 4.05

82044 MICROALBUMIN SEMIQUANT TC 3.2

82044 MICROALBUMIN SEMIQUANT 3.2

82075 ASSAY OF BREATH ETHANOL TC 8.43

82075 ASSAY OF BREATH ETHANOL 8.43

82085 ASSAY OF ALDOLASE TC 6.79

82085 ASSAY OF ALDOLASE 6.79

82088 ASSAY OF ALDOSTERONE TC 28.47

82088 ASSAY OF ALDOSTERONE 28.47

82103 ALPHA-1-ANTITRYPSIN TOTAL TC 9.39

82103 ALPHA-1-ANTITRYPSIN TOTAL 9.39

82104 ALPHA-1-ANTITRYPSIN PHENO TC 10.11

82104 ALPHA-1-ANTITRYPSIN PHENO 10.11

82105 ALPHA-FETOPROTEIN SERUM TC 11.7

82105 ALPHA-FETOPROTEIN SERUM 11.7

82106 ALPHA-FETOPROTEIN AMNIOTIC TC 11.7

82106 ALPHA-FETOPROTEIN AMNIOTIC 11.7

82108 ASSAY OF ALUMINUM TC 17.8

82108 ASSAY OF ALUMINUM 17.8

82120 AMINES VAGINAL FLUID QUAL TC 2.63

82120 AMINES VAGINAL FLUID QUAL 2.63

82127 AMINO ACID SINGLE QUAL TC 9.69

82127 AMINO ACID SINGLE QUAL 9.69

82128 AMINO ACIDS MULT QUAL TC 9.69

82128 AMINO ACIDS MULT QUAL 9.69

82131 AMINO ACIDS SINGLE QUANT TC 11.79

82131 AMINO ACIDS SINGLE QUANT 11.79

82135 ASSAY AMINOLEVULINIC ACID TC 11.5

82135 ASSAY AMINOLEVULINIC ACID 11.5

82136 AMINO ACIDS QUANT 2-5 TC 11.79

82136 AMINO ACIDS QUANT 2-5 11.79

82139 AMINO ACIDS QUAN 6 OR MORE TC 11.79

82139 AMINO ACIDS QUAN 6 OR MORE 11.79

82140 ASSAY OF AMMONIA TC 10.19

82140 ASSAY OF AMMONIA 10.19

82143 AMNIOTIC FLUID SCAN TC 4.81

82143 AMNIOTIC FLUID SCAN 4.81

82150 ASSAY OF AMYLASE TC 4.54

82150 ASSAY OF AMYLASE 4.54

26/95

Page 27: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

82154 ANDROSTANEDIOL GLUCURONIDE TC 20.15

82154 ANDROSTANEDIOL GLUCURONIDE 20.15

82157 ASSAY OF ANDROSTENEDIONE TC 20.46

82157 ASSAY OF ANDROSTENEDIONE 20.46

82160 ASSAY OF ANDROSTERONE TC 17.47

82160 ASSAY OF ANDROSTERONE 17.47

82163 ASSAY OF ANGIOTENSIN II TC 14.35

82163 ASSAY OF ANGIOTENSIN II 14.35

82164 ANGIOTENSIN I ENZYME TEST TC 10.2

82164 ANGIOTENSIN I ENZYME TEST 10.2

82172 ASSAY OF APOLIPOPROTEIN TC 10.83

82172 ASSAY OF APOLIPOPROTEIN 10.83

82175 ASSAY OF ARSENIC TC 13.26

82175 ASSAY OF ARSENIC 13.26

82180 ASSAY OF ASCORBIC ACID TC 6.91

82180 ASSAY OF ASCORBIC ACID 6.91

82190 ATOMIC ABSORPTION TC 10.42

82190 ATOMIC ABSORPTION 10.42

82232 ASSAY OF BETA-2 PROTEIN TC 11.31

82232 ASSAY OF BETA-2 PROTEIN 11.31

82239 BILE ACIDS TOTAL TC 11.98

82239 BILE ACIDS TOTAL 11.98

82240 BILE ACIDS CHOLYLGLYCINE TC 18.57

82240 BILE ACIDS CHOLYLGLYCINE 18.57

82247 BILIRUBIN TOTAL TC 3.51

82247 BILIRUBIN TOTAL 3.51

82248 BILIRUBIN DIRECT TC 3.51

82248 BILIRUBIN DIRECT 3.51

82252 FECAL BILIRUBIN TEST TC 3.18

82252 FECAL BILIRUBIN TEST 3.18

82261 ASSAY OF BIOTINIDASE TC 11.79

82261 ASSAY OF BIOTINIDASE 11.79

82270 OCCULT BLOOD FECES TC 2.27

82270 OCCULT BLOOD FECES 2.27

82274 ASSAY TEST FOR BLOOD FECAL TC 11.11

82274 ASSAY TEST FOR BLOOD FECAL 11.11

82286 ASSAY OF BRADYKININ TC 4.81

82286 ASSAY OF BRADYKININ 4.81

82300 ASSAY OF CADMIUM TC 16.17

82300 ASSAY OF CADMIUM 16.17

82306 VITAMIN D 25 HYDROXY TC 20.47

82306 VITAMIN D 25 HYDROXY 20.47

82308 ASSAY OF CALCITONIN TC 18.71

82308 ASSAY OF CALCITONIN 18.71

82310 ASSAY OF CALCIUM TC 3.6

27/95

Page 28: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

82310 ASSAY OF CALCIUM 3.6

82330 ASSAY OF CALCIUM TC 9.55

82330 ASSAY OF CALCIUM 9.55

82331 CALCIUM INFUSION TEST TC 3.62

82331 CALCIUM INFUSION TEST 3.62

82340 ASSAY OF CALCIUM IN URINE TC 4.22

82340 ASSAY OF CALCIUM IN URINE 4.22

82355 CALCULUS ANALYSIS QUAL TC 8.09

82355 CALCULUS ANALYSIS QUAL 8.09

82360 CALCULUS ASSAY QUANT TC 9

82360 CALCULUS ASSAY QUANT 9

82365 CALCULUS SPECTROSCOPY TC 9.01

82365 CALCULUS SPECTROSCOPY 9.01

82370 X-RAY ASSAY CALCULUS TC 8.76

82370 X-RAY ASSAY CALCULUS 8.76

82373 ASSAY C-D TRANSFER MEASURE TC 12.62

82373 ASSAY C-D TRANSFER MEASURE 12.62

82374 ASSAY BLOOD CARBON DIOXIDE TC 3.42

82374 ASSAY BLOOD CARBON DIOXIDE 3.42

82376 ASSAY CARBOXYHB QUAL TC 4.1

82376 ASSAY CARBOXYHB QUAL 4.1

82378 CARCINOEMBRYONIC ANTIGEN TC 13.26

82378 CARCINOEMBRYONIC ANTIGEN 13.26

82379 ASSAY OF CARNITINE TC 11.79

82379 ASSAY OF CARNITINE 11.79

82380 ASSAY OF CAROTENE TC 6.45

82380 ASSAY OF CAROTENE 6.45

82382 ASSAY URINE CATECHOLAMINES TC 12.02

82382 ASSAY URINE CATECHOLAMINES 12.02

82383 ASSAY BLOOD CATECHOLAMINES TC 17.51

82383 ASSAY BLOOD CATECHOLAMINES 17.51

82384 ASSAY THREE CATECHOLAMINES TC 17.64

82384 ASSAY THREE CATECHOLAMINES 17.64

82387 ASSAY OF CATHEPSIN-D TC 14.54

82387 ASSAY OF CATHEPSIN-D 14.54

82390 ASSAY OF CERULOPLASMIN TC 7.51

82390 ASSAY OF CERULOPLASMIN 7.51

82397 CHEMILUMINESCENT ASSAY TC 9.87

82397 CHEMILUMINESCENT ASSAY 9.87

82415 ASSAY OF CHLORAMPHENICOL TC 8.86

82415 ASSAY OF CHLORAMPHENICOL 8.86

82435 ASSAY OF BLOOD CHLORIDE TC 3.22

82435 ASSAY OF BLOOD CHLORIDE 3.22

82436 ASSAY OF URINE CHLORIDE TC 3.51

82436 ASSAY OF URINE CHLORIDE 3.51

28/95

Page 29: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

82438 ASSAY OTHER FLUID CHLORIDES TC 3.42

82438 ASSAY OTHER FLUID CHLORIDES 3.42

82441 TEST FOR CHLOROHYDROCARBONS TC 4.2

82441 TEST FOR CHLOROHYDROCARBONS 4.2

82465 ASSAY BLD/SERUM CHOLESTEROL TC 3.04

82465 ASSAY BLD/SERUM CHOLESTEROL 3.04

82480 ASSAY SERUM CHOLINESTERASE TC 5.51

82480 ASSAY SERUM CHOLINESTERASE 5.51

82482 ASSAY RBC CHOLINESTERASE TC 5.37

82482 ASSAY RBC CHOLINESTERASE 5.37

82485 ASSAY CHONDROITIN SULFATE TC 14.43

82485 ASSAY CHONDROITIN SULFATE 14.43

82486 GAS/LIQUID CHROMATOGRAPHY TC 12.62

82486 GAS/LIQUID CHROMATOGRAPHY 12.62

82487 PAPER CHROMATOGRAPHY TC 11.15

82487 PAPER CHROMATOGRAPHY 11.15

82488 PAPER CHROMATOGRAPHY TC 14.93

82488 PAPER CHROMATOGRAPHY 14.93

82489 THIN LAYER CHROMATOGRAPHY TC 12.93

82489 THIN LAYER CHROMATOGRAPHY 12.93

82491 CHROMOTOGRAPHY QUANT SING TC 12.62

82491 CHROMOTOGRAPHY QUANT SING 12.62

82492 CHROMOTOGRAPHY QUANT MULT TC 12.62

82492 CHROMOTOGRAPHY QUANT MULT 12.62

82495 ASSAY OF CHROMIUM TC 14.18

82495 ASSAY OF CHROMIUM 14.18

82507 ASSAY OF CITRATE TC 19.43

82507 ASSAY OF CITRATE 19.43

82523 COLLAGEN CROSSLINKS TC 13.06

82523 COLLAGEN CROSSLINKS 13.06

82525 ASSAY OF COPPER TC 8.68

82525 ASSAY OF COPPER 8.68

82528 ASSAY OF CORTICOSTERONE TC 15.73

82528 ASSAY OF CORTICOSTERONE 15.73

82530 CORTISOL FREE TC 11.68

82530 CORTISOL FREE 11.68

82533 TOTAL CORTISOL TC 11.4

82533 TOTAL CORTISOL 11.4

82540 ASSAY OF CREATINE TC 3.25

82540 ASSAY OF CREATINE 3.25

82541 COLUMN CHROMOTOGRAPHY QUAL TC 12.62

82541 COLUMN CHROMOTOGRAPHY QUAL 12.62

82542 COLUMN CHROMOTOGRAPHY QUANT TC 12.62

82542 COLUMN CHROMOTOGRAPHY QUANT 12.62

82543 COLUMN CHROMOTOGRAPH/ISOTOPE TC 12.62

29/95

Page 30: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

82543 COLUMN CHROMOTOGRAPH/ISOTOPE 12.62

82544 COLUMN CHROMOTOGRAPH/ISOTOPE TC 12.62

82544 COLUMN CHROMOTOGRAPH/ISOTOPE 12.62

82550 ASSAY OF CK (CPK) TC 4.56

82550 ASSAY OF CK (CPK) 4.56

82552 ASSAY OF CPK IN BLOOD TC 9.36

82552 ASSAY OF CPK IN BLOOD 9.36

82553 CREATINE MB FRACTION TC 8.07

82553 CREATINE MB FRACTION 8.07

82554 CREATINE ISOFORMS TC 8.29

82554 CREATINE ISOFORMS 8.29

82565 ASSAY OF CREATININE TC 3.58

82565 ASSAY OF CREATININE 3.58

82570 ASSAY OF URINE CREATININE TC 3.62

82570 ASSAY OF URINE CREATININE 3.62

82575 CREATININE CLEARANCE TEST TC 6.6

82575 CREATININE CLEARANCE TEST 6.6

82585 ASSAY OF CRYOFIBRINOGEN TC 5.99

82585 ASSAY OF CRYOFIBRINOGEN 5.99

82595 ASSAY OF CRYOGLOBULIN TC 4.52

82595 ASSAY OF CRYOGLOBULIN 4.52

82600 ASSAY OF CYANIDE TC 13.56

82600 ASSAY OF CYANIDE 13.56

82607 VITAMIN B-12 TC 10.53

82607 VITAMIN B-12 10.53

82608 B-12 BINDING CAPACITY TC 10.01

82608 B-12 BINDING CAPACITY 10.01

82615 TEST FOR URINE CYSTINES TC 5.71

82615 TEST FOR URINE CYSTINES 5.71

82626 DEHYDROEPIANDROSTERONE TC 17.66

82626 DEHYDROEPIANDROSTERONE 17.66

82627 DEHYDROEPIANDROSTERONE TC 15.54

82627 DEHYDROEPIANDROSTERONE 15.54

82633 DESOXYCORTICOSTERONE TC 21.64

82633 DESOXYCORTICOSTERONE 21.64

82634 DEOXYCORTISOL TC 20.46

82634 DEOXYCORTISOL 20.46

82638 ASSAY OF DIBUCAINE NUMBER TC 8.56

82638 ASSAY OF DIBUCAINE NUMBER 8.56

82652 VIT D 1 25-DIHYDROXY TC 26.89

82652 VIT D 1 25-DIHYDROXY 26.89

82657 ENZYME CELL ACTIVITY TC 12.62

82657 ENZYME CELL ACTIVITY 12.62

82658 ENZYME CELL ACTIVITY RA TC 12.62

82658 ENZYME CELL ACTIVITY RA 12.62

30/95

Page 31: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

82664 ELECTROPHORETIC TEST TC 24

82664 ELECTROPHORETIC TEST 24

82668 ASSAY OF ERYTHROPOIETIN TC 13.14

82668 ASSAY OF ERYTHROPOIETIN 13.14

82670 ASSAY OF ESTRADIOL TC 19.53

82670 ASSAY OF ESTRADIOL 19.53

82671 ASSAY OF ESTROGENS TC 22.57

82671 ASSAY OF ESTROGENS 22.57

82672 ASSAY OF ESTROGEN TC 15.15

82672 ASSAY OF ESTROGEN 15.15

82677 ASSAY OF ESTRIOL TC 16.9

82677 ASSAY OF ESTRIOL 16.9

82679 ASSAY OF ESTRONE TC 17.45

82679 ASSAY OF ESTRONE 17.45

82693 ASSAY OF ETHYLENE GLYCOL TC 10.41

82693 ASSAY OF ETHYLENE GLYCOL 10.41

82696 ASSAY OF ETIOCHOLANOLONE TC 16.48

82696 ASSAY OF ETIOCHOLANOLONE 16.48

82705 FATS/LIPIDS FECES QUAL TC 3.56

82705 FATS/LIPIDS FECES QUAL 3.56

82710 FATS/LIPIDS FECES QUANT TC 11.74

82710 FATS/LIPIDS FECES QUANT 11.74

82715 ASSAY OF FECAL FAT TC 12.03

82715 ASSAY OF FECAL FAT 12.03

82725 ASSAY OF BLOOD FATTY ACIDS TC 9.31

82725 ASSAY OF BLOOD FATTY ACIDS 9.31

82726 LONG CHAIN FATTY ACIDS TC 12.62

82726 LONG CHAIN FATTY ACIDS 12.62

82728 ASSAY OF FERRITIN TC 9.52

82728 ASSAY OF FERRITIN 9.52

82731 ASSAY OF FETAL FIBRONECTIN TC 25.96

82731 ASSAY OF FETAL FIBRONECTIN 25.96

82735 ASSAY OF FLUORIDE TC 12.96

82735 ASSAY OF FLUORIDE 12.96

82746 ASSAY OF FOLIC ACID SERUM TC 10.28

82746 ASSAY OF FOLIC ACID SERUM 10.28

82747 ASSAY OF FOLIC ACID RBC TC 12.11

82747 ASSAY OF FOLIC ACID RBC 12.11

82759 ASSAY OF RBC GALACTOKINASE TC 15.01

82759 ASSAY OF RBC GALACTOKINASE 15.01

82760 ASSAY OF GALACTOSE TC 7.83

82760 ASSAY OF GALACTOSE 7.83

82775 ASSAY GALACTOSE TRANSFERASE TC 14.72

82775 ASSAY GALACTOSE TRANSFERASE 14.72

82776 GALACTOSE TRANSFERASE TEST TC 5.86

31/95

Page 32: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

82776 GALACTOSE TRANSFERASE TEST 5.86

82784 ASSAY IGA/IGD/IGG/IGM EACH TC 4.68

82784 ASSAY IGA/IGD/IGG/IGM EACH 4.68

82785 ASSAY OF IGE TC 11.51

82785 ASSAY OF IGE 11.51

82787 IGG 1 2 3 OR 4 EACH TC 5.6

82787 IGG 1 2 3 OR 4 EACH 5.6

82800 BLOOD PH TC 5.92

82800 BLOOD PH 5.92

82803 BLOOD GASES ANY COMBINATION TC 13.53

82803 BLOOD GASES ANY COMBINATION 13.53

82805 BLOOD GASES W/O2 SATURATION TC 19.83

82805 BLOOD GASES W/O2 SATURATION 19.83

82810 BLOOD GASES O2 SAT ONLY TC 6.1

82810 BLOOD GASES O2 SAT ONLY 6.1

82820 HEMOGLOBIN-OXYGEN AFFINITY TC 6.63

82820 HEMOGLOBIN-OXYGEN AFFINITY 6.63

82938 GASTRIN TEST TC 12.36

82938 GASTRIN TEST 12.36

82941 ASSAY OF GASTRIN TC 12.32

82941 ASSAY OF GASTRIN 12.32

82943 ASSAY OF GLUCAGON TC 9.99

82943 ASSAY OF GLUCAGON 9.99

82945 GLUCOSE OTHER FLUID TC 2.75

82945 GLUCOSE OTHER FLUID 2.75

82946 GLUCAGON TOLERANCE TEST TC 10.53

82946 GLUCAGON TOLERANCE TEST 10.53

82947 ASSAY GLUCOSE BLOOD QUANT TC 2.75

82947 ASSAY GLUCOSE BLOOD QUANT 2.75

82948 REAGENT STRIP/BLOOD GLUCOSE TC 2.22

82948 REAGENT STRIP/BLOOD GLUCOSE 2.22

82950 GLUCOSE TEST TC 3.32

82950 GLUCOSE TEST 3.32

82951 GLUCOSE TOLERANCE TEST (GTT) TC 7.29

82951 GLUCOSE TOLERANCE TEST (GTT) 7.29

82952 GTT-ADDED SAMPLES TC 2.75

82952 GTT-ADDED SAMPLES 2.75

82955 ASSAY OF G6PD ENZYME TC 6.78

82955 ASSAY OF G6PD ENZYME 6.78

82960 TEST FOR G6PD ENZYME TC 4.24

82960 TEST FOR G6PD ENZYME 4.24

82962 GLUCOSE BLOOD TEST TC 1.27

82962 GLUCOSE BLOOD TEST 1.27

82963 ASSAY OF GLUCOSIDASE TC 15.01

82963 ASSAY OF GLUCOSIDASE 15.01

32/95

Page 33: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

82965 ASSAY OF GDH ENZYME TC 5.41

82965 ASSAY OF GDH ENZYME 5.41

82977 ASSAY OF GGT TC 5.04

82977 ASSAY OF GGT 5.04

82978 ASSAY OF GLUTATHIONE TC 9.96

82978 ASSAY OF GLUTATHIONE 9.96

82979 ASSAY RBC GLUTATHIONE TC 4.81

82979 ASSAY RBC GLUTATHIONE 4.81

82985 ASSAY OF GLYCATED PROTEIN TC 10.53

82985 ASSAY OF GLYCATED PROTEIN 10.53

83001 ASSAY OF GONADOTROPIN (FSH) TC 12.99

83001 ASSAY OF GONADOTROPIN (FSH) 12.99

83002 ASSAY OF GONADOTROPIN (LH) TC 12.94

83002 ASSAY OF GONADOTROPIN (LH) 12.94

83003 ASSAY GROWTH HORMONE (HGH) TC 11.65

83003 ASSAY GROWTH HORMONE (HGH) 11.65

83010 ASSAY OF HAPTOGLOBIN QUANT TC 8.79

83010 ASSAY OF HAPTOGLOBIN QUANT 8.79

83012 ASSAY OF HAPTOGLOBINS TC 12.02

83012 ASSAY OF HAPTOGLOBINS 12.02

83013 H PYLORI (C-13) BREATH TC 47.06

83013 H PYLORI (C-13) BREATH 47.06

83014 H PYLORI DRUG ADMIN TC 5.49

83014 H PYLORI DRUG ADMIN 5.49

83015 HEAVY METAL SCREEN TC 13.16

83015 HEAVY METAL SCREEN 13.16

83018 QUANTITATIVE SCREEN METALS TC 15.35

83018 QUANTITATIVE SCREEN METALS 15.35

83020 HEMOGLOBIN ELECTROPHORESIS TC 4.23

83020 HEMOGLOBIN ELECTROPHORESIS 26 4.77

83020 HEMOGLOBIN ELECTROPHORESIS 9

83021 HEMOGLOBIN CHROMOTOGRAPHY TC 12.62

83021 HEMOGLOBIN CHROMOTOGRAPHY 12.62

83026 HEMOGLOBIN COPPER SULFATE TC 1.65

83026 HEMOGLOBIN COPPER SULFATE 1.65

83030 FETAL HEMOGLOBIN CHEMICAL TC 5.79

83030 FETAL HEMOGLOBIN CHEMICAL 5.79

83033 FETAL HEMOGLOBIN ASSAY QUAL TC 4.17

83033 FETAL HEMOGLOBIN ASSAY QUAL 4.17

83036 GLYCOSYLATED HEMOGLOBIN TEST TC 6.79

83036 GLYCOSYLATED HEMOGLOBIN TEST 6.79

83045 BLOOD METHEMOGLOBIN TEST TC 3.47

83045 BLOOD METHEMOGLOBIN TEST 3.47

83050 BLOOD METHEMOGLOBIN ASSAY TC 5.12

83050 BLOOD METHEMOGLOBIN ASSAY 5.12

33/95

Page 34: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

83051 ASSAY OF PLASMA HEMOGLOBIN TC 5.11

83051 ASSAY OF PLASMA HEMOGLOBIN 5.11

83060 BLOOD SULFHEMOGLOBIN ASSAY TC 5.79

83060 BLOOD SULFHEMOGLOBIN ASSAY 5.79

83065 ASSAY OF HEMOGLOBIN HEAT TC 4.81

83065 ASSAY OF HEMOGLOBIN HEAT 4.81

83068 HEMOGLOBIN STABILITY SCREEN TC 5.92

83068 HEMOGLOBIN STABILITY SCREEN 5.92

83069 ASSAY OF URINE HEMOGLOBIN TC 2.76

83069 ASSAY OF URINE HEMOGLOBIN 2.76

83070 ASSAY OF HEMOSIDERIN QUAL TC 3.32

83070 ASSAY OF HEMOSIDERIN QUAL 3.32

83080 ASSAY OF B HEXOSAMINIDASE TC 11.79

83080 ASSAY OF B HEXOSAMINIDASE 11.79

83088 ASSAY OF HISTAMINE TC 20.63

83088 ASSAY OF HISTAMINE 20.63

83090 ASSAY OF HOMOCYSTINE TC 11.79

83090 ASSAY OF HOMOCYSTINE 11.79

83150 ASSAY OF HOMOVANILLIC ACID TC 13.53

83150 ASSAY OF HOMOVANILLIC ACID 13.53

83491 ASSAY OF CORTICOSTEROIDS 17 TC 12.24

83491 ASSAY OF CORTICOSTEROIDS 17 12.24

83497 ASSAY OF 5-HIAA TC 9.01

83497 ASSAY OF 5-HIAA 9.01

83498 ASSAY OF PROGESTERONE 17-D TC 18.98

83498 ASSAY OF PROGESTERONE 17-D 18.98

83499 ASSAY OF PROGESTERONE 20- TC 17.62

83499 ASSAY OF PROGESTERONE 20- 17.62

83500 ASSAY FREE HYDROXYPROLINE TC 15.83

83500 ASSAY FREE HYDROXYPROLINE 15.83

83505 ASSAY TOTAL HYDROXYPROLINE TC 16.98

83505 ASSAY TOTAL HYDROXYPROLINE 16.98

83516 IMMUNOASSAY NONANTIBODY TC 8.07

83516 IMMUNOASSAY NONANTIBODY 8.07

83518 IMMUNOASSAY DIPSTICK TC 5.93

83518 IMMUNOASSAY DIPSTICK 5.93

83519 RIA NONANTIBODY TC 9.44

83519 RIA NONANTIBODY 9.44

83520 IMMUNOASSAY QUANT NOS NONAB TC 9.05

83520 IMMUNOASSAY QUANT NOS NONAB 9.05

83525 ASSAY OF INSULIN TC 7.99

83525 ASSAY OF INSULIN 7.99

83527 ASSAY OF INSULIN TC 9.05

83527 ASSAY OF INSULIN 9.05

83528 ASSAY OF INTRINSIC FACTOR TC 11.11

34/95

Page 35: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

83528 ASSAY OF INTRINSIC FACTOR 11.11

83540 ASSAY OF IRON TC 3.99

83540 ASSAY OF IRON 3.99

83550 IRON BINDING TEST TC 4.89

83550 IRON BINDING TEST 4.89

83570 ASSAY OF IDH ENZYME TC 6.18

83570 ASSAY OF IDH ENZYME 6.18

83582 ASSAY OF KETOGENIC STEROIDS TC 9.9

83582 ASSAY OF KETOGENIC STEROIDS 9.9

83586 ASSAY 17- KETOSTEROIDS TC 8.95

83586 ASSAY 17- KETOSTEROIDS 8.95

83593 FRACTIONATION KETOSTEROIDS TC 18.38

83593 FRACTIONATION KETOSTEROIDS 18.38

83605 ASSAY OF LACTIC ACID TC 7.47

83605 ASSAY OF LACTIC ACID 7.47

83615 LACTATE (LD) (LDH) ENZYME TC 4.22

83615 LACTATE (LD) (LDH) ENZYME 4.22

83625 ASSAY OF LDH ENZYMES TC 8.94

83625 ASSAY OF LDH ENZYMES 8.94

83632 PLACENTAL LACTOGEN TC 14.12

83632 PLACENTAL LACTOGEN 14.12

83633 TEST URINE FOR LACTOSE TC 3.85

83633 TEST URINE FOR LACTOSE 3.85

83655 ASSAY OF LEAD TC 8.46

83655 ASSAY OF LEAD 8.46

83661 L/S RATIO FETAL LUNG TC 15.36

83661 L/S RATIO FETAL LUNG 15.36

83662 FOAM STABILITY FETAL LUNG TC 13.22

83662 FOAM STABILITY FETAL LUNG 13.22

83663 FLUORO POLARIZE FETAL LUNG TC 13.22

83663 FLUORO POLARIZE FETAL LUNG 13.22

83664 LAMELLAR BDY FETAL LUNG TC 13.22

83664 LAMELLAR BDY FETAL LUNG 13.22

83670 ASSAY OF LAP ENZYME TC 6.41

83670 ASSAY OF LAP ENZYME 6.41

83690 ASSAY OF LIPASE TC 4.81

83690 ASSAY OF LIPASE 4.81

83718 ASSAY OF LIPOPROTEIN TC 5.72

83718 ASSAY OF LIPOPROTEIN 5.72

83719 ASSAY OF BLOOD LIPOPROTEIN TC 8.14

83719 ASSAY OF BLOOD LIPOPROTEIN 8.14

83721 ASSAY OF BLOOD LIPOPROTEIN TC 6.67

83721 ASSAY OF BLOOD LIPOPROTEIN 6.67

83727 ASSAY OF LRH HORMONE TC 12.02

83727 ASSAY OF LRH HORMONE 12.02

35/95

Page 36: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

83735 ASSAY OF MAGNESIUM TC 4.68

83735 ASSAY OF MAGNESIUM 4.68

83775 ASSAY MALATE DEHYDROGENASE TC 5.16

83775 ASSAY MALATE DEHYDROGENASE 5.16

83785 ASSAY OF MANGANESE TC 17.19

83785 ASSAY OF MANGANESE 17.19

83788 MASS SPECTROMETRY QUAL TC 12.62

83788 MASS SPECTROMETRY QUAL 12.62

83789 MASS SPECTROMETRY QUANT TC 12.62

83789 MASS SPECTROMETRY QUANT 12.62

83825 ASSAY OF MERCURY TC 11.36

83825 ASSAY OF MERCURY 11.36

83835 ASSAY OF METANEPHRINES TC 11.84

83835 ASSAY OF METANEPHRINES 11.84

83857 ASSAY OF METHEMALBUMIN TC 7.51

83857 ASSAY OF METHEMALBUMIN 7.51

83864 MUCOPOLYSACCHARIDES TC 13.91

83864 MUCOPOLYSACCHARIDES 13.91

83872 ASSAY SYNOVIAL FLUID MUCIN TC 4.1

83872 ASSAY SYNOVIAL FLUID MUCIN 4.1

83873 ASSAY OF CSF PROTEIN TC 12.03

83873 ASSAY OF CSF PROTEIN 12.03

83874 ASSAY OF MYOGLOBIN TC 9.03

83874 ASSAY OF MYOGLOBIN 9.03

83880 ASSAY OF NATRIURETIC PEPTIDE TC 23.72

83880 ASSAY OF NATRIURETIC PEPTIDE 23.72

83883 ASSAY NEPHELOMETRY NOT SPEC TC 9.5

83883 ASSAY NEPHELOMETRY NOT SPEC 9.5

83885 ASSAY OF NICKEL TC 17.12

83885 ASSAY OF NICKEL 17.12

83915 ASSAY OF NUCLEOTIDASE TC 7.79

83915 ASSAY OF NUCLEOTIDASE 7.79

83916 OLIGOCLONAL BANDS TC 14.05

83916 OLIGOCLONAL BANDS 14.05

83918 ORGANIC ACIDS TOTAL QUANT TC 11.5

83918 ORGANIC ACIDS TOTAL QUANT 11.5

83919 ORGANIC ACIDS QUAL EACH TC 11.5

83919 ORGANIC ACIDS QUAL EACH 11.5

83921 ORGANIC ACID SINGLE QUANT TC 11.5

83921 ORGANIC ACID SINGLE QUANT 11.5

83930 ASSAY OF BLOOD OSMOLALITY TC 4.62

83930 ASSAY OF BLOOD OSMOLALITY 4.62

83935 ASSAY OF URINE OSMOLALITY TC 4.77

83935 ASSAY OF URINE OSMOLALITY 4.77

83937 ASSAY OF OSTEOCALCIN TC 20.86

36/95

Page 37: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

83937 ASSAY OF OSTEOCALCIN 20.86

83945 ASSAY OF OXALATE TC 9

83945 ASSAY OF OXALATE 9

83950 ONCOPROTEIN HER-2/NEU TC 25.96

83950 ONCOPROTEIN HER-2/NEU 25.96

83970 ASSAY OF PARATHORMONE TC 28.84

83970 ASSAY OF PARATHORMONE 28.84

83986 ASSAY PH BODY FLUID NOS TC 2.5

83986 ASSAY PH BODY FLUID NOS 2.5

83992 ASSAY FOR PHENCYCLIDINE TC 8.91

83992 ASSAY FOR PHENCYCLIDINE 8.91

84030 ASSAY OF BLOOD PKU TC 3.85

84030 ASSAY OF BLOOD PKU 3.85

84035 ASSAY OF PHENYLKETONES TC 2.56

84035 ASSAY OF PHENYLKETONES 2.56

84060 ASSAY ACID PHOSPHATASE TC 5.16

84060 ASSAY ACID PHOSPHATASE 5.16

84061 PHOSPHATASE FORENSIC EXAM TC 5.54

84061 PHOSPHATASE FORENSIC EXAM 5.54

84066 ASSAY PROSTATE PHOSPHATASE TC 6.75

84066 ASSAY PROSTATE PHOSPHATASE 6.75

84075 ASSAY ALKALINE PHOSPHATASE TC 3.62

84075 ASSAY ALKALINE PHOSPHATASE 3.62

84078 ASSAY ALKALINE PHOSPHATASE TC 4.68

84078 ASSAY ALKALINE PHOSPHATASE 4.68

84080 ASSAY ALKALINE PHOSPHATASES TC 10.33

84080 ASSAY ALKALINE PHOSPHATASES 10.33

84081 ASSAY PHOSPHATIDYLGLYCEROL TC 11.55

84081 ASSAY PHOSPHATIDYLGLYCEROL 11.55

84085 ASSAY OF RBC PG6D ENZYME TC 4.72

84085 ASSAY OF RBC PG6D ENZYME 4.72

84087 ASSAY PHOSPHOHEXOSE ENZYMES TC 7.22

84087 ASSAY PHOSPHOHEXOSE ENZYMES 7.22

84100 ASSAY OF PHOSPHORUS TC 3.32

84100 ASSAY OF PHOSPHORUS 3.32

84105 ASSAY OF URINE PHOSPHORUS TC 3.62

84105 ASSAY OF URINE PHOSPHORUS 3.62

84106 TEST FOR PORPHOBILINOGEN TC 3

84106 TEST FOR PORPHOBILINOGEN 3

84110 ASSAY OF PORPHOBILINOGEN TC 5.91

84110 ASSAY OF PORPHOBILINOGEN 5.91

84119 TEST URINE FOR PORPHYRINS TC 6.02

84119 TEST URINE FOR PORPHYRINS 6.02

84120 ASSAY OF URINE PORPHYRINS TC 10.28

84120 ASSAY OF URINE PORPHYRINS 10.28

37/95

Page 38: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

84126 ASSAY OF FECES PORPHYRINS TC 17.8

84126 ASSAY OF FECES PORPHYRINS 17.8

84132 ASSAY OF SERUM POTASSIUM TC 3.22

84132 ASSAY OF SERUM POTASSIUM 3.22

84133 ASSAY OF URINE POTASSIUM TC 3.01

84133 ASSAY OF URINE POTASSIUM 3.01

84134 ASSAY OF PREALBUMIN TC 10.19

84134 ASSAY OF PREALBUMIN 10.19

84135 ASSAY OF PREGNANEDIOL TC 13.37

84135 ASSAY OF PREGNANEDIOL 13.37

84138 ASSAY OF PREGNANETRIOL TC 13.23

84138 ASSAY OF PREGNANETRIOL 13.23

84140 ASSAY OF PREGNENOLONE TC 14.45

84140 ASSAY OF PREGNENOLONE 14.45

84143 ASSAY OF 17-HYDROXYPREGNENO TC 15.95

84143 ASSAY OF 17-HYDROXYPREGNENO 15.95

84144 ASSAY OF PROGESTERONE TC 14.58

84144 ASSAY OF PROGESTERONE 14.58

84146 ASSAY OF PROLACTIN TC 13.54

84146 ASSAY OF PROLACTIN 13.54

84150 ASSAY OF PROSTAGLANDIN TC 17.45

84150 ASSAY OF PROSTAGLANDIN 17.45

84152 ASSAY OF PSA COMPLEXED TC 12.86

84152 ASSAY OF PSA COMPLEXED 12.86

84153 ASSAY OF PSA TOTAL TC 12.86

84153 ASSAY OF PSA TOTAL 12.86

84154 ASSAY OF PSA FREE TC 12.86

84154 ASSAY OF PSA FREE 12.86

84155 ASSAY OF PROTEIN SERUM TC 2.56

84155 ASSAY OF PROTEIN SERUM 2.56

84160 ASSAY OF PROTEIN ANY SOURCE TC 3.62

84160 ASSAY OF PROTEIN ANY SOURCE 3.62

84165 PROTEIN E-PHORESIS SERUM TC 3.27

84165 PROTEIN E-PHORESIS SERUM 26 4.24

84165 PROTEIN E-PHORESIS SERUM 7.51

84181 WESTERN BLOT TEST TC 6.52

84181 WESTERN BLOT TEST 26 5.38

84181 WESTERN BLOT TEST 11.9

84182 PROTEIN WESTERN BLOT TEST TC 6.86

84182 PROTEIN WESTERN BLOT TEST 26 5.72

84182 PROTEIN WESTERN BLOT TEST 12.58

84202 ASSAY RBC PROTOPORPHYRIN TC 10.03

84202 ASSAY RBC PROTOPORPHYRIN 10.03

84203 TEST RBC PROTOPORPHYRIN TC 6.02

84203 TEST RBC PROTOPORPHYRIN 6.02

38/95

Page 39: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

84206 ASSAY OF PROINSULIN TC 12.45

84206 ASSAY OF PROINSULIN 12.45

84207 ASSAY OF VITAMIN B-6 TC 19.63

84207 ASSAY OF VITAMIN B-6 19.63

84210 ASSAY OF PYRUVATE TC 7.59

84210 ASSAY OF PYRUVATE 7.59

84220 ASSAY OF PYRUVATE KINASE TC 6.6

84220 ASSAY OF PYRUVATE KINASE 6.6

84228 ASSAY OF QUININE TC 8.14

84228 ASSAY OF QUININE 8.14

84233 ASSAY OF ESTROGEN TC 25.96

84233 ASSAY OF ESTROGEN 25.96

84234 ASSAY OF PROGESTERONE TC 21.89

84234 ASSAY OF PROGESTERONE 21.89

84235 ASSAY OF ENDOCRINE HORMONE TC 36.57

84235 ASSAY OF ENDOCRINE HORMONE 36.57

84238 ASSAY NONENDOCRINE RECEPTOR TC 25.55

84238 ASSAY NONENDOCRINE RECEPTOR 25.55

84244 ASSAY OF RENIN TC 15.37

84244 ASSAY OF RENIN 15.37

84252 ASSAY OF VITAMIN B-2 TC 14.15

84252 ASSAY OF VITAMIN B-2 14.15

84255 ASSAY OF SELENIUM TC 17.84

84255 ASSAY OF SELENIUM 17.84

84260 ASSAY OF SEROTONIN TC 21.64

84260 ASSAY OF SEROTONIN 21.64

84270 ASSAY OF SEX HORMONE GLOBUL TC 15.19

84270 ASSAY OF SEX HORMONE GLOBUL 15.19

84275 ASSAY OF SIALIC ACID TC 9.39

84275 ASSAY OF SIALIC ACID 9.39

84285 ASSAY OF SILICA TC 16.46

84285 ASSAY OF SILICA 16.46

84295 ASSAY OF SERUM SODIUM TC 3.36

84295 ASSAY OF SERUM SODIUM 3.36

84300 ASSAY OF URINE SODIUM TC 3.4

84300 ASSAY OF URINE SODIUM 3.4

84302 ASSAY OF SWEAT SODIUM TC 3.4

84302 ASSAY OF SWEAT SODIUM 3.4

84305 ASSAY OF SOMATOMEDIN TC 14.86

84305 ASSAY OF SOMATOMEDIN 14.86

84307 ASSAY OF SOMATOSTATIN TC 12.78

84307 ASSAY OF SOMATOSTATIN 12.78

84311 SPECTROPHOTOMETRY TC 4.89

84311 SPECTROPHOTOMETRY 4.89

84315 BODY FLUID SPECIFIC GRAVITY TC 1.75

39/95

Page 40: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

84315 BODY FLUID SPECIFIC GRAVITY 1.75

84375 CHROMATOGRAM ASSAY SUGARS TC 13.7

84375 CHROMATOGRAM ASSAY SUGARS 13.7

84376 SUGARS SINGLE QUAL TC 3.85

84376 SUGARS SINGLE QUAL 3.85

84377 SUGARS MULTIPLE QUAL TC 3.85

84377 SUGARS MULTIPLE QUAL 3.85

84378 SUGARS SINGLE QUANT TC 8.06

84378 SUGARS SINGLE QUANT 8.06

84379 SUGARS MULTIPLE QUANT TC 8.06

84379 SUGARS MULTIPLE QUANT 8.06

84392 ASSAY OF URINE SULFATE TC 3.32

84392 ASSAY OF URINE SULFATE 3.32

84402 ASSAY OF FREE TESTOSTERONE TC 17.79

84402 ASSAY OF FREE TESTOSTERONE 17.79

84403 ASSAY OF TOTAL TESTOSTERONE TC 18.05

84403 ASSAY OF TOTAL TESTOSTERONE 18.05

84425 ASSAY OF VITAMIN B-1 TC 14.84

84425 ASSAY OF VITAMIN B-1 14.84

84430 ASSAY OF THIOCYANATE TC 8.14

84430 ASSAY OF THIOCYANATE 8.14

84432 ASSAY OF THYROGLOBULIN TC 11.23

84432 ASSAY OF THYROGLOBULIN 11.23

84436 ASSAY OF TOTAL THYROXINE TC 4.81

84436 ASSAY OF TOTAL THYROXINE 4.81

84437 ASSAY OF NEONATAL THYROXINE TC 4.52

84437 ASSAY OF NEONATAL THYROXINE 4.52

84439 ASSAY OF FREE THYROXINE TC 6.31

84439 ASSAY OF FREE THYROXINE 6.31

84442 ASSAY OF THYROID ACTIVITY TC 10.33

84442 ASSAY OF THYROID ACTIVITY 10.33

84443 ASSAY THYROID STIM HORMONE TC 11.74

84443 ASSAY THYROID STIM HORMONE 11.74

84445 ASSAY OF TSI GLOBULIN TC 35.53

84445 ASSAY OF TSI GLOBULIN 35.53

84446 ASSAY OF VITAMIN E TC 9.91

84446 ASSAY OF VITAMIN E 9.91

84449 ASSAY OF TRANSCORTIN TC 12.58

84449 ASSAY OF TRANSCORTIN 12.58

84450 TRANSFERASE (AST) (SGOT) TC 3.61

84450 TRANSFERASE (AST) (SGOT) 3.61

84460 ALANINE AMINO (ALT) (SGPT) TC 3.71

84460 ALANINE AMINO (ALT) (SGPT) 3.71

84466 ASSAY OF TRANSFERRIN TC 8.93

84466 ASSAY OF TRANSFERRIN 8.93

40/95

Page 41: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

84478 ASSAY OF TRIGLYCERIDES TC 4.02

84478 ASSAY OF TRIGLYCERIDES 4.02

84479 ASSAY OF THYROID (T3 OR T4) TC 4.52

84479 ASSAY OF THYROID (T3 OR T4) 4.52

84480 ASSAY TRIIODOTHYRONINE (T3) TC 9.91

84480 ASSAY TRIIODOTHYRONINE (T3) 9.91

84481 FREE ASSAY (FT-3) TC 11.84

84481 FREE ASSAY (FT-3) 11.84

84482 T3 REVERSE TC 11.02

84482 T3 REVERSE 11.02

84484 ASSAY OF TROPONIN QUANT TC 6.88

84484 ASSAY OF TROPONIN QUANT 6.88

84485 ASSAY DUODENAL FLUID TRYPSIN TC 5.25

84485 ASSAY DUODENAL FLUID TRYPSIN 5.25

84488 TEST FECES FOR TRYPSIN TC 5.1

84488 TEST FECES FOR TRYPSIN 5.1

84490 ASSAY OF FECES FOR TRYPSIN TC 5.32

84490 ASSAY OF FECES FOR TRYPSIN 5.32

84510 ASSAY OF TYROSINE TC 7.27

84510 ASSAY OF TYROSINE 7.27

84512 ASSAY OF TROPONIN QUAL TC 5.39

84512 ASSAY OF TROPONIN QUAL 5.39

84520 ASSAY OF UREA NITROGEN TC 2.76

84520 ASSAY OF UREA NITROGEN 2.76

84525 UREA NITROGEN SEMI-QUANT TC 2.63

84525 UREA NITROGEN SEMI-QUANT 2.63

84540 ASSAY OF URINE/UREA-N TC 3.32

84540 ASSAY OF URINE/UREA-N 3.32

84545 UREA-N CLEARANCE TEST TC 4.62

84545 UREA-N CLEARANCE TEST 4.62

84550 ASSAY OF BLOOD/URIC ACID TC 3.16

84550 ASSAY OF BLOOD/URIC ACID 3.16

84560 ASSAY OF URINE/URIC ACID TC 3.32

84560 ASSAY OF URINE/URIC ACID 3.32

84577 ASSAY OF FECES/UROBILINOGEN TC 8.72

84577 ASSAY OF FECES/UROBILINOGEN 8.72

84578 TEST URINE UROBILINOGEN TC 2.27

84578 TEST URINE UROBILINOGEN 2.27

84580 ASSAY OF URINE UROBILINOGEN TC 4.97

84580 ASSAY OF URINE UROBILINOGEN 4.97

84583 ASSAY OF URINE UROBILINOGEN TC 3.51

84583 ASSAY OF URINE UROBILINOGEN 3.51

84585 ASSAY OF URINE VMA TC 10.83

84585 ASSAY OF URINE VMA 10.83

84586 ASSAY OF VIP TC 24.69

41/95

Page 42: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

84586 ASSAY OF VIP 24.69

84588 ASSAY OF VASOPRESSIN TC 23.72

84588 ASSAY OF VASOPRESSIN 23.72

84590 ASSAY OF VITAMIN A TC 8.11

84590 ASSAY OF VITAMIN A 8.11

84591 ASSAY OF NOS VITAMIN TC 8.11

84591 ASSAY OF NOS VITAMIN 8.11

84597 ASSAY OF VITAMIN K TC 9.58

84597 ASSAY OF VITAMIN K 9.58

84600 ASSAY OF VOLATILES TC 11.23

84600 ASSAY OF VOLATILES 11.23

84620 XYLOSE TOLERANCE TEST TC 8.28

84620 XYLOSE TOLERANCE TEST 8.28

84630 ASSAY OF ZINC TC 7.96

84630 ASSAY OF ZINC 7.96

84681 ASSAY OF C-PEPTIDE TC 14.54

84681 ASSAY OF C-PEPTIDE 14.54

84702 CHORIONIC GONADOTROPIN TEST TC 9.82

84702 CHORIONIC GONADOTROPIN TEST 9.82

84703 CHORIONIC GONADOTROPIN ASSAY TC 5.25

84703 CHORIONIC GONADOTROPIN ASSAY 5.25

84830 OVULATION TESTS TC 7.02

84830 OVULATION TESTS 7.02

85002 BLEEDING TIME TEST TC 3.15

85002 BLEEDING TIME TEST 3.15

85004 AUTOMATED DIFF WBC COUNT TC 4.52

85004 AUTOMATED DIFF WBC COUNT 4.52

85007 BL SMEAR W/DIFF WBC COUNT TC 2.41

85007 BL SMEAR W/DIFF WBC COUNT 2.41

85008 BL SMEAR W/O DIFF WBC COUNT TC 2.41

85008 BL SMEAR W/O DIFF WBC COUNT 2.41

85009 MANUAL DIFF WBC COUNT B-COAT TC 2.6

85009 MANUAL DIFF WBC COUNT B-COAT 2.6

85013 SPUN MICROHEMATOCRIT TC 1.66

85013 SPUN MICROHEMATOCRIT 1.66

85014 HEMATOCRIT TC 1.66

85014 HEMATOCRIT 1.66

85018 HEMOGLOBIN TC 1.66

85018 HEMOGLOBIN 1.66

85025 COMPLETE CBC W/AUTO DIFF WBC TC 5.43

85025 COMPLETE CBC W/AUTO DIFF WBC 5.43

85027 COMPLETE CBC AUTOMATED TC 4.52

85027 COMPLETE CBC AUTOMATED 4.52

85032 MANUAL CELL COUNT EACH TC 3.01

85032 MANUAL CELL COUNT EACH 3.01

42/95

Page 43: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

85041 AUTOMATED RBC COUNT TC 2.1

85041 AUTOMATED RBC COUNT 2.1

85044 MANUAL RETICULOCYTE COUNT TC 3.01

85044 MANUAL RETICULOCYTE COUNT 3.01

85045 AUTOMATED RETICULOCYTE COUNT TC 2.8

85045 AUTOMATED RETICULOCYTE COUNT 2.8

85046 RETICYTE/HGB CONCENTRATE TC 3.91

85046 RETICYTE/HGB CONCENTRATE 3.91

85048 AUTOMATED LEUKOCYTE COUNT TC 1.78

85048 AUTOMATED LEUKOCYTE COUNT 1.78

85049 AUTOMATED PLATELET COUNT TC 3.13

85049 AUTOMATED PLATELET COUNT 3.13

85060 BLOOD SMEAR INTERPRETATION TC 2.46

85060 BLOOD SMEAR INTERPRETATION 26 9.86

85060 BLOOD SMEAR INTERPRETATION 12.32

85097 BONE MARROW INTERPRETATION TC 8.5

85097 BONE MARROW INTERPRETATION 26 34.02

85097 BONE MARROW INTERPRETATION 42.53

85130 CHROMOGENIC SUBSTRATE ASSAY TC 8.32

85130 CHROMOGENIC SUBSTRATE ASSAY 8.32

85170 BLOOD CLOT RETRACTION TC 2.53

85170 BLOOD CLOT RETRACTION 2.53

85175 BLOOD CLOT LYSIS TIME TC 3.18

85175 BLOOD CLOT LYSIS TIME 3.18

85210 CLOT FACTOR II PROTHROM SPEC TC 9.07

85210 CLOT FACTOR II PROTHROM SPEC 9.07

85220 BLOOC CLOT FACTOR V TEST TC 12.33

85220 BLOOC CLOT FACTOR V TEST 12.33

85230 CLOT FACTOR VII PROCONVERTIN TC 12.52

85230 CLOT FACTOR VII PROCONVERTIN 12.52

85240 CLOT FACTOR VIII AHG 1 STAGE TC 12.52

85240 CLOT FACTOR VIII AHG 1 STAGE 12.52

85244 CLOT FACTOR VIII RELTD ANTGN TC 14.27

85244 CLOT FACTOR VIII RELTD ANTGN 14.27

85245 CLOT FACTOR VIII VW RISTOCTN TC 16.04

85245 CLOT FACTOR VIII VW RISTOCTN 16.04

85246 CLOT FACTOR VIII VW ANTIGEN TC 16.04

85246 CLOT FACTOR VIII VW ANTIGEN 16.04

85247 CLOT FACTOR VIII MULTIMETRIC TC 16.04

85247 CLOT FACTOR VIII MULTIMETRIC 16.04

85250 CLOT FACTOR IX PTC/CHRSTMAS TC 13.31

85250 CLOT FACTOR IX PTC/CHRSTMAS 13.31

85260 CLOT FACTOR X STUART-POWER TC 12.52

85260 CLOT FACTOR X STUART-POWER 12.52

85270 CLOT FACTOR XI PTA TC 12.52

43/95

Page 44: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

85270 CLOT FACTOR XI PTA 12.52

85280 CLOT FACTOR XII HAGEMAN TC 13.53

85280 CLOT FACTOR XII HAGEMAN 13.53

85290 CLOT FACTOR XIII FIBRIN STAB TC 11.42

85290 CLOT FACTOR XIII FIBRIN STAB 11.42

85291 CLOT FACTOR XIII FIBRIN SCRN TC 6.22

85291 CLOT FACTOR XIII FIBRIN SCRN 6.22

85292 CLOT FACTOR FLETCHER FACT TC 13.23

85292 CLOT FACTOR FLETCHER FACT 13.23

85293 CLOT FACTOR WGHT KININOGEN TC 13.23

85293 CLOT FACTOR WGHT KININOGEN 13.23

85300 ANTITHROMBIN III ACTIVITY TC 8.28

85300 ANTITHROMBIN III ACTIVITY 8.28

85301 ANTITHROMBIN III ANTIGEN TC 7.56

85301 ANTITHROMBIN III ANTIGEN 7.56

85302 CLOT INHIBIT PROT C ANTIGEN TC 8.4

85302 CLOT INHIBIT PROT C ANTIGEN 8.4

85303 CLOT INHIBIT PROT C ACTIVITY TC 9.66

85303 CLOT INHIBIT PROT C ACTIVITY 9.66

85305 CLOT INHIBIT PROT S TOTAL TC 8.11

85305 CLOT INHIBIT PROT S TOTAL 8.11

85306 CLOT INHIBIT PROT S FREE TC 10.71

85306 CLOT INHIBIT PROT S FREE 10.71

85307 ASSAY ACTIVATED PROTEIN C TC 10.71

85307 ASSAY ACTIVATED PROTEIN C 10.71

85335 FACTOR INHIBITOR TEST TC 9

85335 FACTOR INHIBITOR TEST 9

85337 THROMBOMODULIN TC 4.95

85337 THROMBOMODULIN 4.95

85345 COAGULATION TIME LEE & WHITE TC 3.01

85345 COAGULATION TIME LEE & WHITE 3.01

85347 COAGULATION TIME ACTIVATED TC 2.98

85347 COAGULATION TIME ACTIVATED 2.98

85348 COAGULATION TIME OTR METHOD TC 2.6

85348 COAGULATION TIME OTR METHOD 2.6

85360 EUGLOBULIN LYSIS TC 5.87

85360 EUGLOBULIN LYSIS 5.87

85362 FIBRIN DEGRADATION PRODUCTS TC 3.98

85362 FIBRIN DEGRADATION PRODUCTS 3.98

85366 FIBRINOGEN TEST TC 5.86

85366 FIBRINOGEN TEST 5.86

85370 FIBRINOGEN TEST TC 7.94

85370 FIBRINOGEN TEST 7.94

85378 FIBRIN DEGRADE SEMIQUANT TC 4.99

85378 FIBRIN DEGRADE SEMIQUANT 4.99

44/95

Page 45: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

85379 FIBRIN DEGRADATION QUANT TC 7.12

85379 FIBRIN DEGRADATION QUANT 7.12

85384 FIBRINOGEN ACTIVITY TC 5.94

85384 FIBRINOGEN ACTIVITY 5.94

85385 FIBRINOGEN ANTIGEN TC 5.94

85385 FIBRINOGEN ANTIGEN 5.94

85390 FIBRINOLYSINS SCREEN I&R TC 0.98

85390 FIBRINOLYSINS SCREEN I&R 26 2.63

85390 FIBRINOLYSINS SCREEN I&R 3.61

85400 FIBRINOLYTIC PLASMIN TC 6.18

85400 FIBRINOLYTIC PLASMIN 6.18

85410 FIBRINOLYTIC ANTIPLASMIN TC 5.39

85410 FIBRINOLYTIC ANTIPLASMIN 5.39

85415 FIBRINOLYTIC PLASMINOGEN TC 12.02

85415 FIBRINOLYTIC PLASMINOGEN 12.02

85420 FIBRINOLYTIC PLASMINOGEN TC 4.57

85420 FIBRINOLYTIC PLASMINOGEN 4.57

85421 FIBRINOLYTIC PLASMINOGEN TC 7.12

85421 FIBRINOLYTIC PLASMINOGEN 7.12

85441 HEINZ BODIES DIRECT TC 2.95

85441 HEINZ BODIES DIRECT 2.95

85445 HEINZ BODIES INDUCED TC 4.77

85445 HEINZ BODIES INDUCED 4.77

85460 HEMOGLOBIN FETAL TC 5.41

85460 HEMOGLOBIN FETAL 5.41

85461 HEMOGLOBIN FETAL TC 4.64

85461 HEMOGLOBIN FETAL 4.64

85475 HEMOLYSIN ACID TC 6.2

85475 HEMOLYSIN ACID 6.2

85520 HEPARIN ASSAY TC 9.15

85520 HEPARIN ASSAY 9.15

85525 HEPARIN NEUTRALIZATION TC 8.28

85525 HEPARIN NEUTRALIZATION 8.28

85530 HEPARIN-PROTAMINE TOLERANCE TC 9.91

85530 HEPARIN-PROTAMINE TOLERANCE 9.91

85536 IRON STAIN PERIPHERAL BLOOD TC 4.52

85536 IRON STAIN PERIPHERAL BLOOD 4.52

85540 WBC ALKALINE PHOSPHATASE TC 6.02

85540 WBC ALKALINE PHOSPHATASE 6.02

85547 RBC MECHANICAL FRAGILITY TC 6.02

85547 RBC MECHANICAL FRAGILITY 6.02

85549 MURAMIDASE TC 13.11

85549 MURAMIDASE 13.11

85555 RBC OSMOTIC FRAGILITY TC 4.68

85555 RBC OSMOTIC FRAGILITY 4.68

45/95

Page 46: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

85557 RBC OSMOTIC FRAGILITY TC 9.33

85557 RBC OSMOTIC FRAGILITY 9.33

85576 BLOOD PLATELET AGGREGATION TC 8.92

85576 BLOOD PLATELET AGGREGATION 26 6.09

85576 BLOOD PLATELET AGGREGATION 15.01

85597 PHOSPHOLIPID PLTLT NEUTRALIZ TC 12.57

85597 PHOSPHOLIPID PLTLT NEUTRALIZ 12.57

85610 PROTHROMBIN TIME TC 2.75

85610 PROTHROMBIN TIME 2.75

85611 PROTHROMBIN TEST TC 2.76

85611 PROTHROMBIN TEST 2.76

85612 VIPER VENOM PROTHROMBIN TIME TC 6.69

85612 VIPER VENOM PROTHROMBIN TIME 6.69

85613 RUSSELL VIPER VENOM DILUTED TC 6.69

85613 RUSSELL VIPER VENOM DILUTED 6.69

85635 REPTILASE TEST TC 6.89

85635 REPTILASE TEST 6.89

85651 RBC SED RATE NONAUTOMATED TC 2.49

85651 RBC SED RATE NONAUTOMATED 2.49

85652 RBC SED RATE AUTOMATED TC 1.89

85652 RBC SED RATE AUTOMATED 1.89

85660 RBC SICKLE CELL TEST TC 3.86

85660 RBC SICKLE CELL TEST 3.86

85670 THROMBIN TIME PLASMA TC 4.04

85670 THROMBIN TIME PLASMA 4.04

85675 THROMBIN TIME TITER TC 4.79

85675 THROMBIN TIME TITER 4.79

85705 THROMBOPLASTIN INHIBITION TC 6.73

85705 THROMBOPLASTIN INHIBITION 6.73

85730 THROMBOPLASTIN TIME PARTIAL TC 4.2

85730 THROMBOPLASTIN TIME PARTIAL 4.2

85732 THROMBOPLASTIN TIME PARTIAL TC 4.52

85732 THROMBOPLASTIN TIME PARTIAL 4.52

85810 BLOOD VISCOSITY EXAMINATION TC 8.16

85810 BLOOD VISCOSITY EXAMINATION 8.16

86000 AGGLUTININS FEBRILE ANTIGEN TC 4.88

86000 AGGLUTININS FEBRILE ANTIGEN 4.88

86001 ALLERGEN SPECIFIC IGG TC 3.66

86001 ALLERGEN SPECIFIC IGG 3.66

86003 ALLERGEN SPECIFIC IGE TC 3.66

86003 ALLERGEN SPECIFIC IGE 3.66

86005 ALLERGEN SPECIFIC IGE TC 5.58

86005 ALLERGEN SPECIFIC IGE 5.58

86021 WBC ANTIBODY IDENTIFICATION TC 7.93

86021 WBC ANTIBODY IDENTIFICATION 7.93

46/95

Page 47: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86022 PLATELET ANTIBODIES TC 12.83

86022 PLATELET ANTIBODIES 12.83

86023 IMMUNOGLOBULIN ASSAY TC 5.54

86023 IMMUNOGLOBULIN ASSAY 5.54

86038 ANTINUCLEAR ANTIBODIES TC 8.45

86038 ANTINUCLEAR ANTIBODIES 8.45

86039 ANTINUCLEAR ANTIBODIES (ANA) TC 7.81

86039 ANTINUCLEAR ANTIBODIES (ANA) 7.81

86060 ANTISTREPTOLYSIN O TITER TC 5.1

86060 ANTISTREPTOLYSIN O TITER 5.1

86063 ANTISTREPTOLYSIN O SCREEN TC 4.04

86063 ANTISTREPTOLYSIN O SCREEN 4.04

86077 PHYS BLOOD BANK SERV XMATCH TC 4.12

86077 PHYS BLOOD BANK SERV XMATCH 26 16.48

86077 PHYS BLOOD BANK SERV XMATCH 20.6

86078 PHYS BLOOD BANK SERV REACTJ TC 4.12

86078 PHYS BLOOD BANK SERV REACTJ 26 16.48

86078 PHYS BLOOD BANK SERV REACTJ 20.6

86140 C-REACTIVE PROTEIN TC 3.62

86140 C-REACTIVE PROTEIN 3.62

86141 C-REACTIVE PROTEIN HS TC 9.05

86141 C-REACTIVE PROTEIN HS 9.05

86146 BETA-2 GLYCOPROTEIN ANTIBODY TC 17.78

86146 BETA-2 GLYCOPROTEIN ANTIBODY 17.78

86147 CARDIOLIPIN ANTIBODY EA IG TC 17.78

86147 CARDIOLIPIN ANTIBODY EA IG 17.78

86148 ANTI-PHOSPHOLIPID ANTIBODY TC 11.23

86148 ANTI-PHOSPHOLIPID ANTIBODY 11.23

86155 CHEMOTAXIS ASSAY TC 11.17

86155 CHEMOTAXIS ASSAY 11.17

86156 COLD AGGLUTININ SCREEN TC 4.68

86156 COLD AGGLUTININ SCREEN 4.68

86157 COLD AGGLUTININ TITER TC 5.64

86157 COLD AGGLUTININ TITER 5.64

86160 COMPLEMENT ANTIGEN TC 8.4

86160 COMPLEMENT ANTIGEN 8.4

86161 COMPLEMENT/FUNCTION ACTIVITY TC 8.4

86161 COMPLEMENT/FUNCTION ACTIVITY 8.4

86162 COMPLEMENT TOTAL (CH50) TC 14.2

86162 COMPLEMENT TOTAL (CH50) 14.2

86171 COMPLEMENT FIXATION EACH TC 7

86171 COMPLEMENT FIXATION EACH 7

86185 COUNTERIMMUNOELECTROPHORESIS TC 6.25

86185 COUNTERIMMUNOELECTROPHORESIS 6.25

86215 DEOXYRIBONUCLEASE ANTIBODY TC 9.26

47/95

Page 48: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86215 DEOXYRIBONUCLEASE ANTIBODY 9.26

86225 DNA ANTIBODY NATIVE TC 9.61

86225 DNA ANTIBODY NATIVE 9.61

86226 DNA ANTIBODY SINGLE STRAND TC 8.47

86226 DNA ANTIBODY SINGLE STRAND 8.47

86235 NUCLEAR ANTIGEN ANTIBODY TC 11.7

86235 NUCLEAR ANTIGEN ANTIBODY 11.7

86243 FC RECEPTOR TC 14.35

86243 FC RECEPTOR 14.35

86255 FLUORESCENT ANTIBODY SCREEN TC 3.82

86255 FLUORESCENT ANTIBODY SCREEN 26 4.61

86255 FLUORESCENT ANTIBODY SCREEN 8.43

86256 FLUORESCENT ANTIBODY TITER TC 3.82

86256 FLUORESCENT ANTIBODY TITER 26 4.61

86256 FLUORESCENT ANTIBODY TITER 8.43

86277 GROWTH HORMONE ANTIBODY TC 11

86277 GROWTH HORMONE ANTIBODY 11

86280 HEMAGGLUTINATION INHIBITION TC 5.72

86280 HEMAGGLUTINATION INHIBITION 5.72

86294 IMMUNOASSAY TUMOR QUAL TC 13.71

86294 IMMUNOASSAY TUMOR QUAL 13.71

86300 IMMUNOASSAY TUMOR CA 15-3 TC 14.54

86300 IMMUNOASSAY TUMOR CA 15-3 14.54

86301 IMMUNOASSAY TUMOR CA 19-9 TC 14.54

86301 IMMUNOASSAY TUMOR CA 19-9 14.54

86304 IMMUNOASSAY TUMOR CA 125 TC 14.54

86304 IMMUNOASSAY TUMOR CA 125 14.54

86308 HETEROPHILE ANTIBODY SCREEN TC 3.62

86308 HETEROPHILE ANTIBODY SCREEN 3.62

86309 HETEROPHILE ANTIBODY TITER TC 4.52

86309 HETEROPHILE ANTIBODY TITER 4.52

86310 HETEROPHILE ANTIBODY ABSRBJ TC 5.16

86310 HETEROPHILE ANTIBODY ABSRBJ 5.16

86316 IMMUNOASSAY TUMOR OTHER TC 14.54

86316 IMMUNOASSAY TUMOR OTHER 14.54

86317 IMMUNOASSAY INFECTIOUS AGENT TC 10.48

86317 IMMUNOASSAY INFECTIOUS AGENT 10.48

86318 IMMUNOASSAY INFECTIOUS AGENT TC 9.05

86318 IMMUNOASSAY INFECTIOUS AGENT 9.05

86320 SERUM IMMUNOELECTROPHORESIS TC 9.56

86320 SERUM IMMUNOELECTROPHORESIS 26 6.1

86320 SERUM IMMUNOELECTROPHORESIS 15.66

86325 OTHER IMMUNOELECTROPHORESIS TC 9.63

86325 OTHER IMMUNOELECTROPHORESIS 26 5.99

86325 OTHER IMMUNOELECTROPHORESIS 15.62

48/95

Page 49: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86327 IMMUNOELECTROPHORESIS ASSAY TC 9.12

86327 IMMUNOELECTROPHORESIS ASSAY 26 6.74

86327 IMMUNOELECTROPHORESIS ASSAY 15.86

86329 IMMUNODIFFUSION NES TC 9.82

86329 IMMUNODIFFUSION NES 9.82

86331 IMMUNODIFFUSION OUCHTERLONY TC 8.38

86331 IMMUNODIFFUSION OUCHTERLONY 8.38

86332 IMMUNE COMPLEX ASSAY TC 17.03

86332 IMMUNE COMPLEX ASSAY 17.03

86334 IMMUNOFIX E-PHORESIS SERUM TC 9.48

86334 IMMUNOFIX E-PHORESIS SERUM 26 6.13

86334 IMMUNOFIX E-PHORESIS SERUM 15.61

86337 INSULIN ANTIBODIES TC 14.97

86337 INSULIN ANTIBODIES 14.97

86340 INTRINSIC FACTOR ANTIBODY TC 10.53

86340 INTRINSIC FACTOR ANTIBODY 10.53

86341 ISLET CELL ANTIBODY TC 13.83

86341 ISLET CELL ANTIBODY 13.83

86343 LEUKOCYTE HISTAMINE RELEASE TC 8.71

86343 LEUKOCYTE HISTAMINE RELEASE 8.71

86344 LEUKOCYTE PHAGOCYTOSIS TC 5.58

86344 LEUKOCYTE PHAGOCYTOSIS 5.58

86353 LYMPHOCYTE TRANSFORMATION TC 34.25

86353 LYMPHOCYTE TRANSFORMATION 34.25

86359 T CELLS TOTAL COUNT TC 26.36

86359 T CELLS TOTAL COUNT 26.36

86360 T CELL ABSOLUTE COUNT/RATIO TC 32.83

86360 T CELL ABSOLUTE COUNT/RATIO 32.83

86361 T CELL ABSOLUTE COUNT TC 12.65

86361 T CELL ABSOLUTE COUNT 12.65

86376 MICROSOMAL ANTIBODY EACH TC 10.17

86376 MICROSOMAL ANTIBODY EACH 10.17

86378 MIGRATION INHIBITORY FACTOR TC 13.76

86378 MIGRATION INHIBITORY FACTOR 13.76

86382 NEUTRALIZATION TEST VIRAL TC 11.82

86382 NEUTRALIZATION TEST VIRAL 11.82

86384 NITROBLUE TETRAZOLIUM DYE TC 7.96

86384 NITROBLUE TETRAZOLIUM DYE 7.96

86403 PARTICLE AGGLUT ANTBDY SCRN TC 7.12

86403 PARTICLE AGGLUT ANTBDY SCRN 7.12

86406 PARTICLE AGGLUT ANTBDY TITR TC 7.44

86406 PARTICLE AGGLUT ANTBDY TITR 7.44

86430 RHEUMATOID FACTOR TEST QUAL TC 3.97

86430 RHEUMATOID FACTOR TEST QUAL 3.97

86431 RHEUMATOID FACTOR QUANT TC 3.97

49/95

Page 50: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86431 RHEUMATOID FACTOR QUANT 3.97

86485 SKIN TEST CANDIDA TC 2.1

86485 SKIN TEST CANDIDA 26 8.42

86485 SKIN TEST CANDIDA 10.52

86490 COCCIDIOIDOMYCOSIS SKIN TEST TC 2.1

86490 COCCIDIOIDOMYCOSIS SKIN TEST 26 8.42

86490 COCCIDIOIDOMYCOSIS SKIN TEST 10.52

86510 HISTOPLASMOSIS SKIN TEST TC 2.1

86510 HISTOPLASMOSIS SKIN TEST 26 8.42

86510 HISTOPLASMOSIS SKIN TEST 10.52

86580 TB INTRADERMAL TEST TC 2.66

86580 TB INTRADERMAL TEST 26 10.67

86580 TB INTRADERMAL TEST 13.33

86590 STREPTOKINASE ANTIBODY TC 7.71

86590 STREPTOKINASE ANTIBODY 7.71

86592 SYPHILIS TEST NON-TREP QUAL TC 2.99

86592 SYPHILIS TEST NON-TREP QUAL 2.99

86593 SYPHILIS TEST NON-TREP QUANT TC 3.08

86593 SYPHILIS TEST NON-TREP QUANT 3.08

86602 ANTINOMYCES ANTIBODY TC 7.12

86602 ANTINOMYCES ANTIBODY 7.12

86603 ADENOVIRUS ANTIBODY TC 8.99

86603 ADENOVIRUS ANTIBODY 8.99

86606 ASPERGILLUS ANTIBODY TC 10.52

86606 ASPERGILLUS ANTIBODY 10.52

86609 BACTERIUM ANTIBODY TC 9

86609 BACTERIUM ANTIBODY 9

86611 BARTONELLA ANTIBODY TC 7.12

86611 BARTONELLA ANTIBODY 7.12

86612 BLASTOMYCES ANTIBODY TC 9.02

86612 BLASTOMYCES ANTIBODY 9.02

86615 BORDETELLA ANTIBODY TC 9.22

86615 BORDETELLA ANTIBODY 9.22

86617 LYME DISEASE ANTIBODY TC 10.82

86617 LYME DISEASE ANTIBODY 10.82

86618 LYME DISEASE ANTIBODY TC 11.9

86618 LYME DISEASE ANTIBODY 11.9

86619 BORRELIA ANTIBODY TC 9.35

86619 BORRELIA ANTIBODY 9.35

86622 BRUCELLA ANTIBODY TC 6.24

86622 BRUCELLA ANTIBODY 6.24

86625 CAMPYLOBACTER ANTIBODY TC 9.17

86625 CAMPYLOBACTER ANTIBODY 9.17

86628 CANDIDA ANTIBODY TC 8.4

86628 CANDIDA ANTIBODY 8.4

50/95

Page 51: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86631 CHLAMYDIA ANTIBODY TC 8.27

86631 CHLAMYDIA ANTIBODY 8.27

86632 CHLAMYDIA IGM ANTIBODY TC 8.87

86632 CHLAMYDIA IGM ANTIBODY 8.87

86635 COCCIDIOIDES ANTIBODY TC 8.02

86635 COCCIDIOIDES ANTIBODY 8.02

86638 Q FEVER ANTIBODY TC 8.48

86638 Q FEVER ANTIBODY 8.48

86641 CRYPTOCOCCUS ANTIBODY TC 10.07

86641 CRYPTOCOCCUS ANTIBODY 10.07

86644 CMV ANTIBODY TC 10.06

86644 CMV ANTIBODY 10.06

86645 CMV ANTIBODY IGM TC 11.78

86645 CMV ANTIBODY IGM 11.78

86648 DIPHTHERIA ANTIBODY TC 10.63

86648 DIPHTHERIA ANTIBODY 10.63

86651 ENCEPHALITIS CALIFORN ANTBDY TC 9.22

86651 ENCEPHALITIS CALIFORN ANTBDY 9.22

86652 ENCEPHALTIS EAST EQNE ANBDY TC 9.22

86652 ENCEPHALTIS EAST EQNE ANBDY 9.22

86653 ENCEPHALTIS ST LOUIS ANTBODY TC 9.22

86653 ENCEPHALTIS ST LOUIS ANTBODY 9.22

86654 ENCEPHALTIS WEST EQNE ANTBDY TC 9.22

86654 ENCEPHALTIS WEST EQNE ANTBDY 9.22

86658 ENTEROVIRUS ANTIBODY TC 9.11

86658 ENTEROVIRUS ANTIBODY 9.11

86663 EPSTEIN-BARR ANTIBODY TC 9.17

86663 EPSTEIN-BARR ANTIBODY 9.17

86664 EPSTEIN-BARR NUCLEAR ANTIGEN TC 10.69

86664 EPSTEIN-BARR NUCLEAR ANTIGEN 10.69

86665 EPSTEIN-BARR CAPSID VCA TC 12.68

86665 EPSTEIN-BARR CAPSID VCA 12.68

86666 EHRLICHIA ANTIBODY TC 7.12

86666 EHRLICHIA ANTIBODY 7.12

86668 FRANCISELLA TULARENSIS TC 7.27

86668 FRANCISELLA TULARENSIS 7.27

86671 FUNGUS NES ANTIBODY TC 8.57

86671 FUNGUS NES ANTIBODY 8.57

86674 GIARDIA LAMBLIA ANTIBODY TC 10.28

86674 GIARDIA LAMBLIA ANTIBODY 10.28

86677 HELICOBACTER PYLORI ANTIBODY TC 10.15

86677 HELICOBACTER PYLORI ANTIBODY 10.15

86682 HELMINTH ANTIBODY TC 9.09

86682 HELMINTH ANTIBODY 9.09

86684 HEMOPHILUS INFLUENZA ANTIBDY TC 11.07

51/95

Page 52: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86684 HEMOPHILUS INFLUENZA ANTIBDY 11.07

86687 HTLV-I ANTIBODY TC 5.87

86687 HTLV-I ANTIBODY 5.87

86688 HTLV-II ANTIBODY TC 9.79

86688 HTLV-II ANTIBODY 9.79

86689 HTLV/HIV CONFIRMJ ANTIBODY TC 13.53

86689 HTLV/HIV CONFIRMJ ANTIBODY 13.53

86692 HEPATITIS DELTA AGENT ANTBDY TC 11.99

86692 HEPATITIS DELTA AGENT ANTBDY 11.99

86694 HERPES SIMPLEX NES ANTBDY TC 10.06

86694 HERPES SIMPLEX NES ANTBDY 10.06

86695 HERPES SIMPLEX TYPE 1 TEST TC 9.22

86695 HERPES SIMPLEX TYPE 1 TEST 9.22

86696 HERPES SIMPLEX TYPE 2 TEST TC 13.53

86696 HERPES SIMPLEX TYPE 2 TEST 13.53

86698 HISTOPLASMA ANTIBODY TC 8.73

86698 HISTOPLASMA ANTIBODY 8.73

86701 HIV-1ANTIBODY TC 6.21

86701 HIV-1ANTIBODY 6.21

86702 HIV-2 ANTIBODY TC 9.44

86702 HIV-2 ANTIBODY 9.44

86703 HIV-1/HIV-2 1 RESULT ANTBDY TC 9.59

86703 HIV-1/HIV-2 1 RESULT ANTBDY 9.59

86704 HEP B CORE ANTIBODY TOTAL TC 8.43

86704 HEP B CORE ANTIBODY TOTAL 8.43

86705 HEP B CORE ANTIBODY IGM TC 8.23

86705 HEP B CORE ANTIBODY IGM 8.23

86706 HEP B SURFACE ANTIBODY TC 7.51

86706 HEP B SURFACE ANTIBODY 7.51

86707 HEPATITIS BE ANTIBODY TC 8.08

86707 HEPATITIS BE ANTIBODY 8.08

86708 HEPATITIS A TOTAL ANTIBODY TC 8.66

86708 HEPATITIS A TOTAL ANTIBODY 8.66

86709 HEPATITIS A IGM ANTIBODY TC 7.87

86709 HEPATITIS A IGM ANTIBODY 7.87

86710 INFLUENZA VIRUS ANTIBODY TC 9.48

86710 INFLUENZA VIRUS ANTIBODY 9.48

86713 LEGIONELLA ANTIBODY TC 10.7

86713 LEGIONELLA ANTIBODY 10.7

86717 LEISHMANIA ANTIBODY TC 8.57

86717 LEISHMANIA ANTIBODY 8.57

86720 LEPTOSPIRA ANTIBODY TC 9.22

86720 LEPTOSPIRA ANTIBODY 9.22

86723 LISTERIA MONOCYTOGENES TC 9.22

86723 LISTERIA MONOCYTOGENES 9.22

52/95

Page 53: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86727 LYMPH CHORIOMENINGITIS AB TC 8.99

86727 LYMPH CHORIOMENINGITIS AB 8.99

86729 LYMPHO VENEREUM ANTIBODY TC 8.35

86729 LYMPHO VENEREUM ANTIBODY 8.35

86732 MUCORMYCOSIS ANTIBODY TC 9.22

86732 MUCORMYCOSIS ANTIBODY 9.22

86735 MUMPS ANTIBODY TC 9.12

86735 MUMPS ANTIBODY 9.12

86738 MYCOPLASMA ANTIBODY TC 9.26

86738 MYCOPLASMA ANTIBODY 9.26

86741 NEISSERIA MENINGITIDIS TC 9.22

86741 NEISSERIA MENINGITIDIS 9.22

86744 NOCARDIA ANTIBODY TC 9.22

86744 NOCARDIA ANTIBODY 9.22

86747 PARVOVIRUS ANTIBODY TC 10.5

86747 PARVOVIRUS ANTIBODY 10.5

86750 MALARIA ANTIBODY TC 9.22

86750 MALARIA ANTIBODY 9.22

86753 PROTOZOA ANTIBODY NOS TC 8.66

86753 PROTOZOA ANTIBODY NOS 8.66

86756 RESPIRATORY VIRUS ANTIBODY TC 9.01

86756 RESPIRATORY VIRUS ANTIBODY 9.01

86757 RICKETTSIA ANTIBODY TC 13.53

86757 RICKETTSIA ANTIBODY 13.53

86759 ROTAVIRUS ANTIBODY TC 9.22

86759 ROTAVIRUS ANTIBODY 9.22

86762 RUBELLA ANTIBODY TC 10.06

86762 RUBELLA ANTIBODY 10.06

86765 RUBEOLA ANTIBODY TC 9

86765 RUBEOLA ANTIBODY 9

86768 SALMONELLA ANTIBODY TC 9.22

86768 SALMONELLA ANTIBODY 9.22

86771 SHIGELLA ANTIBODY TC 9.22

86771 SHIGELLA ANTIBODY 9.22

86774 TETANUS ANTIBODY TC 10.35

86774 TETANUS ANTIBODY 10.35

86777 TOXOPLASMA ANTIBODY TC 10.06

86777 TOXOPLASMA ANTIBODY 10.06

86778 TOXOPLASMA ANTIBODY IGM TC 10.07

86778 TOXOPLASMA ANTIBODY IGM 10.07

86784 TRICHINELLA ANTIBODY TC 8.78

86784 TRICHINELLA ANTIBODY 8.78

86787 VARICELLA-ZOSTER ANTIBODY TC 9

86787 VARICELLA-ZOSTER ANTIBODY 9

86790 VIRUS ANTIBODY NOS TC 9

53/95

Page 54: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86790 VIRUS ANTIBODY NOS 9

86793 YERSINIA ANTIBODY TC 9.22

86793 YERSINIA ANTIBODY 9.22

86800 THYROGLOBULIN ANTIBODY TC 11.11

86800 THYROGLOBULIN ANTIBODY 11.11

86803 HEPATITIS C AB TEST TC 9.98

86803 HEPATITIS C AB TEST 9.98

86804 HEP C AB TEST CONFIRM TC 10.82

86804 HEP C AB TEST CONFIRM 10.82

86805 LYMPHOCYTOTOXICITY ASSAY TC 36.53

86805 LYMPHOCYTOTOXICITY ASSAY 36.53

86806 LYMPHOCYTOTOXICITY ASSAY TC 33.25

86806 LYMPHOCYTOTOXICITY ASSAY 33.25

86807 CYTOTOXIC ANTIBODY SCREENING TC 17.88

86807 CYTOTOXIC ANTIBODY SCREENING 17.88

86808 CYTOTOXIC ANTIBODY SCREENING TC 17.88

86808 CYTOTOXIC ANTIBODY SCREENING 17.88

86812 HLA TYPING A B OR C TC 18.04

86812 HLA TYPING A B OR C 18.04

86813 HLA TYPING A B OR C TC 29.25

86813 HLA TYPING A B OR C 29.25

86816 HLA TYPING DR/DQ TC 19.46

86816 HLA TYPING DR/DQ 19.46

86817 HLA TYPING DR/DQ TC 29.25

86817 HLA TYPING DR/DQ 29.25

86821 LYMPHOCYTE CULTURE MIXED TC 29.25

86821 LYMPHOCYTE CULTURE MIXED 29.25

86822 LYMPHOCYTE CULTURE PRIMED TC 25.54

86822 LYMPHOCYTE CULTURE PRIMED 25.54

86850 RBC ANTIBODY SCREEN TC 2.47

86850 RBC ANTIBODY SCREEN 26 9.88

86850 RBC ANTIBODY SCREEN 12.36

86860 RBC ANTIBODY ELUTION TC 6.18

86860 RBC ANTIBODY ELUTION 26 24.72

86860 RBC ANTIBODY ELUTION 30.9

86870 RBC ANTIBODY IDENTIFICATION TC 5.15

86870 RBC ANTIBODY IDENTIFICATION 26 20.6

86870 RBC ANTIBODY IDENTIFICATION 25.75

86880 COOMBS TEST DIRECT TC 3.75

86880 COOMBS TEST DIRECT 3.75

86885 COOMBS TEST INDIRECT QUAL TC 4

86885 COOMBS TEST INDIRECT QUAL 4

86886 COOMBS TEST INDIRECT TITER TC 3.62

86886 COOMBS TEST INDIRECT TITER 3.62

86890 AUTOLOGOUS BLOOD PROCESS TC 10.3

54/95

Page 55: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86890 AUTOLOGOUS BLOOD PROCESS 26 41.2

86890 AUTOLOGOUS BLOOD PROCESS 51.5

86891 AUTOLOGOUS BLOOD OP SALVAGE TC 22.26

86891 AUTOLOGOUS BLOOD OP SALVAGE 26 89.06

86891 AUTOLOGOUS BLOOD OP SALVAGE 111.33

86900 BLOOD TYPING SEROLOGIC ABO TC 2.09

86900 BLOOD TYPING SEROLOGIC ABO 2.09

86901 BLOOD TYPING SEROLOGIC RH(D) TC 1.56

86901 BLOOD TYPING SEROLOGIC RH(D) 26 6.26

86901 BLOOD TYPING SEROLOGIC RH(D) 7.82

86904 BLOOD TYPING PATIENT SERUM TC 6.64

86904 BLOOD TYPING PATIENT SERUM 6.64

86905 BLOOD TYPING RBC ANTIGENS TC 2.68

86905 BLOOD TYPING RBC ANTIGENS 2.68

86906 BLD TYPING SEROLOGIC RH PHNT TC 5.42

86906 BLD TYPING SEROLOGIC RH PHNT 5.42

86920 COMPATIBILITY TEST SPIN TC 4.12

86920 COMPATIBILITY TEST SPIN 26 16.48

86920 COMPATIBILITY TEST SPIN 20.6

86927 PLASMA FRESH FROZEN TC 2.47

86927 PLASMA FRESH FROZEN 26 9.88

86927 PLASMA FRESH FROZEN 12.36

86930 FROZEN BLOOD PREP TC 7.21

86930 FROZEN BLOOD PREP 26 28.84

86930 FROZEN BLOOD PREP 36.05

86931 FROZEN BLOOD THAW TC 9.27

86931 FROZEN BLOOD THAW 26 37.08

86931 FROZEN BLOOD THAW 46.35

86932 FROZEN BLOOD FREEZE/THAW TC 9.27

86932 FROZEN BLOOD FREEZE/THAW 26 37.08

86932 FROZEN BLOOD FREEZE/THAW 46.35

86940 HEMOLYSINS/AGGLUTININS AUTO TC 5.74

86940 HEMOLYSINS/AGGLUTININS AUTO 5.74

86941 HEMOLYSINS/AGGLUTININS TC 8.47

86941 HEMOLYSINS/AGGLUTININS 8.47

86945 BLOOD PRODUCT/IRRADIATION TC 1.03

86945 BLOOD PRODUCT/IRRADIATION 26 4.12

86945 BLOOD PRODUCT/IRRADIATION 5.15

86950 LEUKACYTE TRANSFUSION TC 9.77

86950 LEUKACYTE TRANSFUSION 26 39.11

86950 LEUKACYTE TRANSFUSION 48.89

86965 POOLING BLOOD PLATELETS TC 2.46

86965 POOLING BLOOD PLATELETS 26 9.86

86965 POOLING BLOOD PLATELETS 12.32

86970 RBC PRETX INCUBATJ W/CHEMICL TC 1.23

55/95

Page 56: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

86970 RBC PRETX INCUBATJ W/CHEMICL 26 4.94

86970 RBC PRETX INCUBATJ W/CHEMICL 6.18

86971 RBC PRETX INCUBATJ W/ENZYMES TC 1.23

86971 RBC PRETX INCUBATJ W/ENZYMES 26 4.94

86971 RBC PRETX INCUBATJ W/ENZYMES 6.18

86972 RBC PRETX INCUBATJ W/DENSITY TC 1.23

86972 RBC PRETX INCUBATJ W/DENSITY 26 4.94

86972 RBC PRETX INCUBATJ W/DENSITY 6.18

86975 RBC SERUM PRETX INCUBJ DRUGS TC 1.23

86975 RBC SERUM PRETX INCUBJ DRUGS 26 4.94

86975 RBC SERUM PRETX INCUBJ DRUGS 6.18

86976 RBC SERUM PRETX ID DILUTION TC 1.23

86976 RBC SERUM PRETX ID DILUTION 26 4.94

86976 RBC SERUM PRETX ID DILUTION 6.18

86977 RBC SERUM PRETX INCUBJ/INHIB TC 1.23

86977 RBC SERUM PRETX INCUBJ/INHIB 26 4.94

86977 RBC SERUM PRETX INCUBJ/INHIB 6.18

86978 RBC PRETREATMENT SERUM TC 1.23

86978 RBC PRETREATMENT SERUM 26 4.94

86978 RBC PRETREATMENT SERUM 6.18

86985 SPLIT BLOOD OR PRODUCTS TC 1.03

86985 SPLIT BLOOD OR PRODUCTS 26 4.12

86985 SPLIT BLOOD OR PRODUCTS 5.15

87003 SMALL ANIMAL INOCULATION TC 11.77

87003 SMALL ANIMAL INOCULATION 11.77

87015 SPECIMEN INFECT AGNT CONCNTJ TC 4.67

87015 SPECIMEN INFECT AGNT CONCNTJ 4.67

87040 BLOOD CULTURE FOR BACTERIA TC 7.22

87040 BLOOD CULTURE FOR BACTERIA 7.22

87045 FECES CULTURE AEROBIC BACT TC 6.6

87045 FECES CULTURE AEROBIC BACT 6.6

87046 STOOL CULTR AEROBIC BACT EA TC 6.6

87046 STOOL CULTR AEROBIC BACT EA 6.6

87070 CULTURE OTHR SPECIMN AEROBIC TC 6.02

87070 CULTURE OTHR SPECIMN AEROBIC 6.02

87071 CULTURE AEROBIC QUANT OTHER TC 6.6

87071 CULTURE AEROBIC QUANT OTHER 6.6

87073 CULTURE BACTERIA ANAEROBIC TC 6.6

87073 CULTURE BACTERIA ANAEROBIC 6.6

87075 CULTR BACTERIA EXCEPT BLOOD TC 6.62

87075 CULTR BACTERIA EXCEPT BLOOD 6.62

87076 CULTURE ANAEROBE IDENT EACH TC 5.65

87076 CULTURE ANAEROBE IDENT EACH 5.65

87077 CULTURE AEROBIC IDENTIFY TC 5.65

87077 CULTURE AEROBIC IDENTIFY 5.65

56/95

Page 57: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

87081 CULTURE SCREEN ONLY TC 4.64

87081 CULTURE SCREEN ONLY 4.64

87084 CULTURE OF SPECIMEN BY KIT TC 6.02

87084 CULTURE OF SPECIMEN BY KIT 6.02

87086 URINE CULTURE/COLONY COUNT TC 5.64

87086 URINE CULTURE/COLONY COUNT 5.64

87088 URINE BACTERIA CULTURE TC 5.66

87088 URINE BACTERIA CULTURE 5.66

87101 SKIN FUNGI CULTURE TC 5.39

87101 SKIN FUNGI CULTURE 5.39

87102 FUNGUS ISOLATION CULTURE TC 5.87

87102 FUNGUS ISOLATION CULTURE 5.87

87103 BLOOD FUNGUS CULTURE TC 6.31

87103 BLOOD FUNGUS CULTURE 6.31

87106 FUNGI IDENTIFICATION YEAST TC 7.22

87106 FUNGI IDENTIFICATION YEAST 7.22

87107 FUNGI IDENTIFICATION MOLD TC 7.22

87107 FUNGI IDENTIFICATION MOLD 7.22

87109 MYCOPLASMA TC 10.75

87109 MYCOPLASMA 10.75

87110 CHLAMYDIA CULTURE TC 13.69

87110 CHLAMYDIA CULTURE 13.69

87116 MYCOBACTERIA CULTURE TC 7.56

87116 MYCOBACTERIA CULTURE 7.56

87118 MYCOBACTERIC IDENTIFICATION TC 7.65

87118 MYCOBACTERIC IDENTIFICATION 7.65

87140 CULTURE TYPE IMMUNOFLUORESC TC 3.9

87140 CULTURE TYPE IMMUNOFLUORESC 3.9

87143 CULTURE TYPING GLC/HPLC TC 8.76

87143 CULTURE TYPING GLC/HPLC 8.76

87147 CULTURE TYPE IMMUNOLOGIC TC 3.51

87147 CULTURE TYPE IMMUNOLOGIC 3.51

87149 DNA/RNA DIRECT PROBE TC 14.02

87149 DNA/RNA DIRECT PROBE 14.02

87152 CULTURE TYPE PULSE FIELD GEL TC 3.66

87152 CULTURE TYPE PULSE FIELD GEL 3.66

87158 CULTURE TYPING ADDED METHOD TC 3.66

87158 CULTURE TYPING ADDED METHOD 3.66

87164 DARK FIELD EXAMINATION TC 3.34

87164 DARK FIELD EXAMINATION 26 4.17

87164 DARK FIELD EXAMINATION 7.51

87166 DARK FIELD EXAMINATION TC 7.89

87166 DARK FIELD EXAMINATION 7.89

87168 MACROSCOPIC EXAM ARTHROPOD TC 2.99

87168 MACROSCOPIC EXAM ARTHROPOD 2.99

57/95

Page 58: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

87169 MACROSCOPIC EXAM PARASITE TC 2.99

87169 MACROSCOPIC EXAM PARASITE 2.99

87172 PINWORM EXAM TC 2.99

87172 PINWORM EXAM 2.99

87176 TISSUE HOMOGENIZATION CULTR TC 4.12

87176 TISSUE HOMOGENIZATION CULTR 4.12

87177 OVA AND PARASITES SMEARS TC 6.22

87177 OVA AND PARASITES SMEARS 6.22

87181 MICROBE SUSCEPTIBLE DIFFUSE TC 1.17

87181 MICROBE SUSCEPTIBLE DIFFUSE 1.17

87184 MICROBE SUSCEPTIBLE DISK TC 4.82

87184 MICROBE SUSCEPTIBLE DISK 4.82

87185 MICROBE SUSCEPTIBLE ENZYME TC 1.17

87185 MICROBE SUSCEPTIBLE ENZYME 1.17

87186 MICROBE SUSCEPTIBLE MIC TC 6.04

87186 MICROBE SUSCEPTIBLE MIC 6.04

87187 MICROBE SUSCEPTIBLE MLC TC 7.24

87187 MICROBE SUSCEPTIBLE MLC 7.24

87188 MICROBE SUSCEPT MACROBROTH TC 4.64

87188 MICROBE SUSCEPT MACROBROTH 4.64

87190 MICROBE SUSCEPT MYCOBACTERI TC 3.51

87190 MICROBE SUSCEPT MYCOBACTERI 3.51

87197 BACTERICIDAL LEVEL SERUM TC 10.5

87197 BACTERICIDAL LEVEL SERUM 10.5

87205 SMEAR GRAM STAIN TC 2.99

87205 SMEAR GRAM STAIN 2.99

87206 SMEAR FLUORESCENT/ACID STAI TC 3.75

87206 SMEAR FLUORESCENT/ACID STAI 3.75

87207 SMEAR SPECIAL STAIN TC 1.21

87207 SMEAR SPECIAL STAIN 26 2.98

87207 SMEAR SPECIAL STAIN 4.19

87210 SMEAR WET MOUNT SALINE/INK TC 2.99

87210 SMEAR WET MOUNT SALINE/INK 2.99

87220 TISSUE EXAM FOR FUNGI TC 2.99

87220 TISSUE EXAM FOR FUNGI 2.99

87230 ASSAY TOXIN OR ANTITOXIN TC 13.8

87230 ASSAY TOXIN OR ANTITOXIN 13.8

87250 VIRUS INOCULATE EGGS/ANIMAL TC 13.66

87250 VIRUS INOCULATE EGGS/ANIMAL 13.66

87252 VIRUS INOCULATION TISSUE TC 18.21

87252 VIRUS INOCULATION TISSUE 18.21

87253 VIRUS INOCULATE TISSUE ADDL TC 14.11

87253 VIRUS INOCULATE TISSUE ADDL 14.11

87254 VIRUS INOCULATION SHELL VIA TC 13.66

87254 VIRUS INOCULATION SHELL VIA 13.66

58/95

Page 59: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

87255 GENET VIRUS ISOLATE HSV TC 23.66

87255 GENET VIRUS ISOLATE HSV 23.66

87260 ADENOVIRUS AG IF TC 8.39

87260 ADENOVIRUS AG IF 8.39

87265 PERTUSSIS AG IF TC 8.39

87265 PERTUSSIS AG IF 8.39

87270 CHLAMYDIA TRACHOMATIS AG IF TC 8.39

87270 CHLAMYDIA TRACHOMATIS AG IF 8.39

87272 CRYPTOSPORIDIUM AG IF TC 8.39

87272 CRYPTOSPORIDIUM AG IF 8.39

87273 HERPES SIMPLEX 2 AG IF TC 8.39

87273 HERPES SIMPLEX 2 AG IF 8.39

87274 HERPES SIMPLEX 1 AG IF TC 8.39

87274 HERPES SIMPLEX 1 AG IF 8.39

87275 INFLUENZA B AG IF TC 8.39

87275 INFLUENZA B AG IF 8.39

87276 INFLUENZA A AG IF TC 8.39

87276 INFLUENZA A AG IF 8.39

87277 LEGIONELLA MICDADEI AG IF TC 8.39

87277 LEGIONELLA MICDADEI AG IF 8.39

87278 LEGION PNEUMOPHILIA AG IF TC 8.39

87278 LEGION PNEUMOPHILIA AG IF 8.39

87279 PARAINFLUENZA AG IF TC 8.39

87279 PARAINFLUENZA AG IF 8.39

87280 RESPIRATORY SYNCYTIAL AG IF TC 8.39

87280 RESPIRATORY SYNCYTIAL AG IF 8.39

87281 PNEUMOCYSTIS CARINII AG IF TC 8.39

87281 PNEUMOCYSTIS CARINII AG IF 8.39

87283 RUBEOLA AG IF TC 8.39

87283 RUBEOLA AG IF 8.39

87285 TREPONEMA PALLIDUM AG IF TC 8.39

87285 TREPONEMA PALLIDUM AG IF 8.39

87290 VARICELLA ZOSTER AG IF TC 8.39

87290 VARICELLA ZOSTER AG IF 8.39

87299 ANTIBODY DETECTION NOS IF TC 8.39

87299 ANTIBODY DETECTION NOS IF 8.39

87300 AG DETECTION POLYVAL IF TC 8.39

87300 AG DETECTION POLYVAL IF 8.39

87301 ADENOVIRUS AG EIA TC 8.39

87301 ADENOVIRUS AG EIA 8.39

87320 CHYLMD TRACH AG EIA TC 8.39

87320 CHYLMD TRACH AG EIA 8.39

87324 CLOSTRIDIUM AG EIA TC 8.39

87324 CLOSTRIDIUM AG EIA 8.39

87327 CRYPTOCOCCUS NEOFORM AG EIA TC 8.39

59/95

Page 60: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

87327 CRYPTOCOCCUS NEOFORM AG EIA 8.39

87328 CRYPTOSPORIDIUM AG EIA TC 8.39

87328 CRYPTOSPORIDIUM AG EIA 8.39

87332 CYTOMEGALOVIRUS AG EIA TC 8.39

87332 CYTOMEGALOVIRUS AG EIA 8.39

87335 E COLI 0157 AG EIA TC 8.39

87335 E COLI 0157 AG EIA 8.39

87336 ENTAMOEB HIST DISPR AG EIA TC 8.39

87336 ENTAMOEB HIST DISPR AG EIA 8.39

87337 ENTAMOEB HIST GROUP AG EIA TC 8.39

87337 ENTAMOEB HIST GROUP AG EIA 8.39

87338 HPYLORI STOOL EIA TC 8.39

87338 HPYLORI STOOL EIA 8.39

87339 H PYLORI AG EIA TC 8.39

87339 H PYLORI AG EIA 8.39

87340 HEPATITIS B SURFACE AG EIA TC 7.22

87340 HEPATITIS B SURFACE AG EIA 7.22

87341 HEPATITIS B SURFACE AG EIA TC 7.22

87341 HEPATITIS B SURFACE AG EIA 7.22

87350 HEPATITIS BE AG EIA TC 8.06

87350 HEPATITIS BE AG EIA 8.06

87380 HEPATITIS DELTA AG EIA TC 11.48

87380 HEPATITIS DELTA AG EIA 11.48

87385 HISTOPLASMA CAPSUL AG EIA TC 8.39

87385 HISTOPLASMA CAPSUL AG EIA 8.39

87390 HIV-1 AG EIA TC 12.33

87390 HIV-1 AG EIA 12.33

87391 HIV-2 AG EIA TC 12.33

87391 HIV-2 AG EIA 12.33

87400 INFLUENZA A/B AG EIA TC 8.39

87400 INFLUENZA A/B AG EIA 8.39

87420 RESP SYNCYTIAL AG EIA TC 8.39

87420 RESP SYNCYTIAL AG EIA 8.39

87425 ROTAVIRUS AG EIA TC 8.39

87425 ROTAVIRUS AG EIA 8.39

87427 SHIGA-LIKE TOXIN AG EIA TC 8.39

87427 SHIGA-LIKE TOXIN AG EIA 8.39

87430 STREP A AG EIA TC 8.39

87430 STREP A AG EIA 8.39

87449 AG DETECT NOS EIA MULT TC 8.39

87449 AG DETECT NOS EIA MULT 8.39

87450 AG DETECT NOS EIA SINGLE TC 6.7

87450 AG DETECT NOS EIA SINGLE 6.7

87451 AG DETECT POLYVAL EIA MULT TC 6.7

87451 AG DETECT POLYVAL EIA MULT 6.7

60/95

Page 61: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

87470 BARTONELLA DNA DIR PROBE TC 14.02

87470 BARTONELLA DNA DIR PROBE 14.02

87471 BARTONELLA DNA AMP PROBE TC 24.53

87471 BARTONELLA DNA AMP PROBE 24.53

87472 BARTONELLA DNA QUANT TC 29.93

87472 BARTONELLA DNA QUANT 29.93

87475 LYME DIS DNA DIR PROBE TC 14.02

87475 LYME DIS DNA DIR PROBE 14.02

87476 LYME DIS DNA AMP PROBE TC 24.53

87476 LYME DIS DNA AMP PROBE 24.53

87477 LYME DIS DNA QUANT TC 29.93

87477 LYME DIS DNA QUANT 29.93

87480 CANDIDA DNA DIR PROBE TC 14.02

87480 CANDIDA DNA DIR PROBE 14.02

87481 CANDIDA DNA AMP PROBE TC 24.53

87481 CANDIDA DNA AMP PROBE 24.53

87482 CANDIDA DNA QUANT TC 29.17

87482 CANDIDA DNA QUANT 29.17

87485 CHYLMD PNEUM DNA DIR PROBE TC 14.02

87485 CHYLMD PNEUM DNA DIR PROBE 14.02

87486 CHYLMD PNEUM DNA AMP PROBE TC 24.53

87486 CHYLMD PNEUM DNA AMP PROBE 24.53

87487 CHYLMD PNEUM DNA QUANT TC 29.93

87487 CHYLMD PNEUM DNA QUANT 29.93

87490 CHYLMD TRACH DNA DIR PROBE TC 14.02

87490 CHYLMD TRACH DNA DIR PROBE 14.02

87491 CHYLMD TRACH DNA AMP PROBE TC 24.53

87491 CHYLMD TRACH DNA AMP PROBE 24.53

87492 CHYLMD TRACH DNA QUANT TC 24.43

87492 CHYLMD TRACH DNA QUANT 24.43

87495 CYTOMEG DNA DIR PROBE TC 14.02

87495 CYTOMEG DNA DIR PROBE 14.02

87496 CYTOMEG DNA AMP PROBE TC 24.53

87496 CYTOMEG DNA AMP PROBE 24.53

87497 CYTOMEG DNA QUANT TC 29.93

87497 CYTOMEG DNA QUANT 29.93

87510 GARDNER VAG DNA DIR PROBE TC 14.02

87510 GARDNER VAG DNA DIR PROBE 14.02

87511 GARDNER VAG DNA AMP PROBE TC 24.53

87511 GARDNER VAG DNA AMP PROBE 24.53

87512 GARDNER VAG DNA QUANT TC 29.17

87512 GARDNER VAG DNA QUANT 29.17

87515 HEPATITIS B DNA DIR PROBE TC 14.02

87515 HEPATITIS B DNA DIR PROBE 14.02

87516 HEPATITIS B DNA AMP PROBE TC 24.53

61/95

Page 62: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

87516 HEPATITIS B DNA AMP PROBE 24.53

87517 HEPATITIS B DNA QUANT TC 29.93

87517 HEPATITIS B DNA QUANT 29.93

87520 HEPATITIS C RNA DIR PROBE TC 14.02

87520 HEPATITIS C RNA DIR PROBE 14.02

87521 HEPATITIS C PROBE&RVRS TRNSC TC 24.53

87521 HEPATITIS C PROBE&RVRS TRNSC 24.53

87522 HEPATITIS C REVRS TRNSCRPJ TC 29.93

87522 HEPATITIS C REVRS TRNSCRPJ 29.93

87525 HEPATITIS G DNA DIR PROBE TC 14.02

87525 HEPATITIS G DNA DIR PROBE 14.02

87526 HEPATITIS G DNA AMP PROBE TC 24.53

87526 HEPATITIS G DNA AMP PROBE 24.53

87527 HEPATITIS G DNA QUANT TC 29.17

87527 HEPATITIS G DNA QUANT 29.17

87528 HSV DNA DIR PROBE TC 14.02

87528 HSV DNA DIR PROBE 14.02

87529 HSV DNA AMP PROBE TC 24.53

87529 HSV DNA AMP PROBE 24.53

87530 HSV DNA QUANT TC 29.93

87530 HSV DNA QUANT 29.93

87531 HHV-6 DNA DIR PROBE TC 14.02

87531 HHV-6 DNA DIR PROBE 14.02

87532 HHV-6 DNA AMP PROBE TC 24.53

87532 HHV-6 DNA AMP PROBE 24.53

87533 HHV-6 DNA QUANT TC 29.17

87533 HHV-6 DNA QUANT 29.17

87534 HIV-1 DNA DIR PROBE TC 14.02

87534 HIV-1 DNA DIR PROBE 14.02

87535 HIV-1 PROBE&REVERSE TRNSCRPJ TC 24.53

87535 HIV-1 PROBE&REVERSE TRNSCRPJ 24.53

87536 HIV-1 QUANT&REVRSE TRNSCRPJ TC 59.45

87536 HIV-1 QUANT&REVRSE TRNSCRPJ 59.45

87537 HIV-2 DNA DIR PROBE TC 14.02

87537 HIV-2 DNA DIR PROBE 14.02

87538 HIV-2 PROBE&REVRSE TRNSCRIPJ TC 24.53

87538 HIV-2 PROBE&REVRSE TRNSCRIPJ 24.53

87539 HIV-2 QUANT&REVRSE TRNSCRIPJ TC 29.93

87539 HIV-2 QUANT&REVRSE TRNSCRIPJ 29.93

87540 LEGION PNEUMO DNA DIR PROB TC 14.02

87540 LEGION PNEUMO DNA DIR PROB 14.02

87541 LEGION PNEUMO DNA AMP PROB TC 24.53

87541 LEGION PNEUMO DNA AMP PROB 24.53

87542 LEGION PNEUMO DNA QUANT TC 29.17

87542 LEGION PNEUMO DNA QUANT 29.17

62/95

Page 63: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

87550 MYCOBACTERIA DNA DIR PROBE TC 14.02

87550 MYCOBACTERIA DNA DIR PROBE 14.02

87551 MYCOBACTERIA DNA AMP PROBE TC 24.53

87551 MYCOBACTERIA DNA AMP PROBE 24.53

87552 MYCOBACTERIA DNA QUANT TC 29.93

87552 MYCOBACTERIA DNA QUANT 29.93

87555 M.TUBERCULO DNA DIR PROBE TC 14.02

87555 M.TUBERCULO DNA DIR PROBE 14.02

87556 M.TUBERCULO DNA AMP PROBE TC 24.53

87556 M.TUBERCULO DNA AMP PROBE 24.53

87557 M.TUBERCULO DNA QUANT TC 29.93

87557 M.TUBERCULO DNA QUANT 29.93

87560 M.AVIUM-INTRA DNA DIR PROB TC 14.02

87560 M.AVIUM-INTRA DNA DIR PROB 14.02

87561 M.AVIUM-INTRA DNA AMP PROB TC 24.53

87561 M.AVIUM-INTRA DNA AMP PROB 24.53

87562 M.AVIUM-INTRA DNA QUANT TC 29.93

87562 M.AVIUM-INTRA DNA QUANT 29.93

87580 M.PNEUMON DNA DIR PROBE TC 14.02

87580 M.PNEUMON DNA DIR PROBE 14.02

87581 M.PNEUMON DNA AMP PROBE TC 24.53

87581 M.PNEUMON DNA AMP PROBE 24.53

87582 M.PNEUMON DNA QUANT TC 29.17

87582 M.PNEUMON DNA QUANT 29.17

87590 N.GONORRHOEAE DNA DIR PROB TC 14.02

87590 N.GONORRHOEAE DNA DIR PROB 14.02

87591 N.GONORRHOEAE DNA AMP PROB TC 24.53

87591 N.GONORRHOEAE DNA AMP PROB 24.53

87592 N.GONORRHOEAE DNA QUANT TC 29.93

87592 N.GONORRHOEAE DNA QUANT 29.93

87650 STREP A DNA DIR PROBE TC 14.02

87650 STREP A DNA DIR PROBE 14.02

87651 STREP A DNA AMP PROBE TC 24.53

87651 STREP A DNA AMP PROBE 24.53

87652 STREP A DNA QUANT TC 29.17

87652 STREP A DNA QUANT 29.17

87797 DETECT AGENT NOS DNA DIR TC 14.02

87797 DETECT AGENT NOS DNA DIR 14.02

87798 DETECT AGENT NOS DNA AMP TC 24.53

87798 DETECT AGENT NOS DNA AMP 24.53

87799 DETECT AGENT NOS DNA QUANT TC 29.93

87799 DETECT AGENT NOS DNA QUANT 29.93

87800 DETECT AGNT MULT DNA DIREC TC 28.02

87800 DETECT AGNT MULT DNA DIREC 28.02

87801 DETECT AGNT MULT DNA AMPLI TC 49.04

63/95

Page 64: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

87801 DETECT AGNT MULT DNA AMPLI 49.04

87802 STREP B ASSAY W/OPTIC TC 8.39

87802 STREP B ASSAY W/OPTIC 8.39

87803 CLOSTRIDIUM TOXIN A W/OPTIC TC 8.39

87803 CLOSTRIDIUM TOXIN A W/OPTIC 8.39

87804 INFLUENZA ASSAY W/OPTIC TC 8.39

87804 INFLUENZA ASSAY W/OPTIC 8.39

87810 CHYLMD TRACH ASSAY W/OPTIC TC 8.39

87810 CHYLMD TRACH ASSAY W/OPTIC 8.39

87850 N. GONORRHOEAE ASSAY W/OPTIC TC 8.39

87850 N. GONORRHOEAE ASSAY W/OPTIC 8.39

87880 STREP A ASSAY W/OPTIC TC 8.39

87880 STREP A ASSAY W/OPTIC 8.39

87899 AGENT NOS ASSAY W/OPTIC TC 8.39

87899 AGENT NOS ASSAY W/OPTIC 8.39

87901 GENOTYPE DNA HIV REVERSE T TC 179.85

87901 GENOTYPE DNA HIV REVERSE T 179.85

87902 GENOTYPE DNA/RNA HEP C TC 179.85

87902 GENOTYPE DNA/RNA HEP C 179.85

87903 PHENOTYPE DNA HIV W/CULTURE TC 341.36

87903 PHENOTYPE DNA HIV W/CULTURE 341.36

87904 PHENOTYPE DNA HIV W/CLT ADD TC 91.06

87904 PHENOTYPE DNA HIV W/CLT ADD 91.06

88104 CYTOPATH FL NONGYN SMEARS TC 6.18

88104 CYTOPATH FL NONGYN SMEARS 26 37.2

88104 CYTOPATH FL NONGYN SMEARS 46.5

88106 CYTOPATH FL NONGYN FILTER TC 6.18

88106 CYTOPATH FL NONGYN FILTER 26 37.2

88106 CYTOPATH FL NONGYN FILTER 46.5

88108 CYTOPATH CONCENTRATE TECH TC 13.95

88108 CYTOPATH CONCENTRATE TECH 26 55.8

88108 CYTOPATH CONCENTRATE TECH 69.75

88125 FORENSIC CYTOPATHOLOGY TC 5.15

88125 FORENSIC CYTOPATHOLOGY 26 69.75

88125 FORENSIC CYTOPATHOLOGY 77.5

88130 SEX CHROMATIN IDENTIFICATION TC 10.52

88130 SEX CHROMATIN IDENTIFICATION 10.52

88140 SEX CHROMATIN IDENTIFICATION TC 5.59

88140 SEX CHROMATIN IDENTIFICATION 5.59

88141 CYTOPATH C/V INTERPRET TC 6.44

88141 CYTOPATH C/V INTERPRET 26 25.77

88141 CYTOPATH C/V INTERPRET 32.22

88142 CYTOPATH C/V THIN LAYER TC 14.16

88142 CYTOPATH C/V THIN LAYER 14.16

88143 CYTOPATH C/V THIN LAYER REDO TC 14.16

64/95

Page 65: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

88143 CYTOPATH C/V THIN LAYER REDO 14.16

88147 CYTOPATH C/V AUTOMATED TC 7.95

88147 CYTOPATH C/V AUTOMATED 7.95

88148 CYTOPATH C/V AUTO RESCREEN TC 10.62

88148 CYTOPATH C/V AUTO RESCREEN 10.62

88150 CYTOPATH C/V MANUAL TC 7.39

88150 CYTOPATH C/V MANUAL 7.39

88152 CYTOPATH C/V AUTO REDO TC 7.39

88152 CYTOPATH C/V AUTO REDO 7.39

88153 CYTOPATH C/V REDO TC 7.39

88153 CYTOPATH C/V REDO 7.39

88154 CYTOPATH C/V SELECT TC 7.39

88154 CYTOPATH C/V SELECT 7.39

88155 CYTOPATH C/V INDEX ADD-ON TC 4.19

88155 CYTOPATH C/V INDEX ADD-ON 4.19

88160 CYTOPATH SMEAR OTHER SOURCE TC 4.12

88160 CYTOPATH SMEAR OTHER SOURCE 26 31

88160 CYTOPATH SMEAR OTHER SOURCE 37.2

88161 CYTOPATH SMEAR OTHER SOURCE TC 9.3

88161 CYTOPATH SMEAR OTHER SOURCE 26 37.2

88161 CYTOPATH SMEAR OTHER SOURCE 46.5

88162 CYTOPATH SMEAR OTHER SOURCE TC 21.7

88162 CYTOPATH SMEAR OTHER SOURCE 26 86.8

88162 CYTOPATH SMEAR OTHER SOURCE 108.5

88164 CYTOPATH TBS C/V MANUAL TC 7.39

88164 CYTOPATH TBS C/V MANUAL 7.39

88165 CYTOPATH TBS C/V REDO TC 7.39

88165 CYTOPATH TBS C/V REDO 7.39

88166 CYTOPATH TBS C/V AUTO REDO TC 7.39

88166 CYTOPATH TBS C/V AUTO REDO 7.39

88167 CYTOPATH TBS C/V SELECT TC 7.39

88167 CYTOPATH TBS C/V SELECT 7.39

88172 CYTP DX EVAL FNA 1ST EA SITE TC 4.65

88172 CYTP DX EVAL FNA 1ST EA SITE 26 18.6

88172 CYTP DX EVAL FNA 1ST EA SITE 23.25

88173 CYTOPATH EVAL FNA REPORT TC 7.44

88173 CYTOPATH EVAL FNA REPORT 26 29.76

88173 CYTOPATH EVAL FNA REPORT 37.2

88182 CELL MARKER STUDY TC 12.37

88182 CELL MARKER STUDY 26 49.5

88182 CELL MARKER STUDY 61.87

88230 TISSUE CULTURE LYMPHOCYTE TC 81.39

88230 TISSUE CULTURE LYMPHOCYTE 81.39

88233 TISSUE CULTURE SKIN/BIOPSY TC 98.32

88233 TISSUE CULTURE SKIN/BIOPSY 98.32

65/95

Page 66: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

88235 TISSUE CULTURE PLACENTA TC 102.88

88235 TISSUE CULTURE PLACENTA 102.88

88237 TISSUE CULTURE BONE MARROW TC 88.24

88237 TISSUE CULTURE BONE MARROW 88.24

88239 TISSUE CULTURE TUMOR TC 103.06

88239 TISSUE CULTURE TUMOR 103.06

88240 CELL CRYOPRESERVE/STORAGE TC 7.06

88240 CELL CRYOPRESERVE/STORAGE 7.06

88241 FROZEN CELL PREPARATION TC 7.06

88241 FROZEN CELL PREPARATION 7.06

88245 CHROMOSOME ANALYSIS 20-25 TC 103.99

88245 CHROMOSOME ANALYSIS 20-25 103.99

88248 CHROMOSOME ANALYSIS 50-100 TC 120.99

88248 CHROMOSOME ANALYSIS 50-100 120.99

88249 CHROMOSOME ANALYSIS 100 TC 120.99

88249 CHROMOSOME ANALYSIS 100 120.99

88261 CHROMOSOME ANALYSIS 5 TC 123.47

88261 CHROMOSOME ANALYSIS 5 123.47

88262 CHROMOSOME ANALYSIS 15-20 TC 87.07

88262 CHROMOSOME ANALYSIS 15-20 87.07

88263 CHROMOSOME ANALYSIS 45 TC 104.99

88263 CHROMOSOME ANALYSIS 45 104.99

88264 CHROMOSOME ANALYSIS 20-25 TC 87.07

88264 CHROMOSOME ANALYSIS 20-25 87.07

88267 CHROMOSOME ANALYS PLACENTA TC 125.59

88267 CHROMOSOME ANALYS PLACENTA 125.59

88269 CHROMOSOME ANALYS AMNIOTIC TC 116.2

88269 CHROMOSOME ANALYS AMNIOTIC 116.2

88271 CYTOGENETICS DNA PROBE TC 14.97

88271 CYTOGENETICS DNA PROBE 14.97

88272 CYTOGENETICS 3-5 TC 18.71

88272 CYTOGENETICS 3-5 18.71

88273 CYTOGENETICS 10-30 TC 22.45

88273 CYTOGENETICS 10-30 22.45

88274 CYTOGENETICS 25-99 TC 24.32

88274 CYTOGENETICS 25-99 24.32

88275 CYTOGENETICS 100-300 TC 28.06

88275 CYTOGENETICS 100-300 28.06

88280 CHROMOSOME KARYOTYPE STUDY TC 17.54

88280 CHROMOSOME KARYOTYPE STUDY 17.54

88283 CHROMOSOME BANDING STUDY TC 35.01

88283 CHROMOSOME BANDING STUDY 35.01

88285 CHROMOSOME COUNT ADDITIONAL TC 13.28

88285 CHROMOSOME COUNT ADDITIONAL 13.28

88289 CHROMOSOME STUDY ADDITIONAL TC 10

66/95

Page 67: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

88289 CHROMOSOME STUDY ADDITIONAL 10

88291 CYTO/MOLECULAR REPORT TC 1.71

88291 CYTO/MOLECULAR REPORT 26 6.86

88291 CYTO/MOLECULAR REPORT 8.58

88300 SURGICAL PATH GROSS TC 3.09

88300 SURGICAL PATH GROSS 26 18.6

88300 SURGICAL PATH GROSS 23.25

88302 TISSUE EXAM BY PATHOLOGIST TC 5.15

88302 TISSUE EXAM BY PATHOLOGIST 26 54.25

88302 TISSUE EXAM BY PATHOLOGIST 62

88304 TISSUE EXAM BY PATHOLOGIST TC 6.18

88304 TISSUE EXAM BY PATHOLOGIST 26 68.2

88304 TISSUE EXAM BY PATHOLOGIST 77.5

88305 TISSUE EXAM BY PATHOLOGIST TC 10.3

88305 TISSUE EXAM BY PATHOLOGIST 26 93

88305 TISSUE EXAM BY PATHOLOGIST 108.5

88307 TISSUE EXAM BY PATHOLOGIST TC 10.3

88307 TISSUE EXAM BY PATHOLOGIST 26 139.5

88307 TISSUE EXAM BY PATHOLOGIST 155

88309 TISSUE EXAM BY PATHOLOGIST TC 10.3

88309 TISSUE EXAM BY PATHOLOGIST 26 139.5

88309 TISSUE EXAM BY PATHOLOGIST 155

88311 DECALCIFY TISSUE TC 1.03

88311 DECALCIFY TISSUE 26 10.85

88311 DECALCIFY TISSUE 12.4

88312 SPECIAL STAINS GROUP 1 TC 5.27

88312 SPECIAL STAINS GROUP 1 26 21.08

88312 SPECIAL STAINS GROUP 1 26.35

88313 SPECIAL STAINS GROUP 2 TC 2.48

88313 SPECIAL STAINS GROUP 2 26 9.92

88313 SPECIAL STAINS GROUP 2 12.4

88314 HISTOCHEMICAL STAINS ADD-ON TC 2.48

88314 HISTOCHEMICAL STAINS ADD-ON 26 9.92

88314 HISTOCHEMICAL STAINS ADD-ON 12.4

88319 ENZYME HISTOCHEMISTRY TC 2.48

88319 ENZYME HISTOCHEMISTRY 26 9.92

88319 ENZYME HISTOCHEMISTRY 12.4

88321 MICROSLIDE CONSULTATION 26 124

88321 MICROSLIDE CONSULTATION 124

88323 MICROSLIDE CONSULTATION TC 9.27

88323 MICROSLIDE CONSULTATION 26 55.8

88323 MICROSLIDE CONSULTATION 69.75

88325 COMPREHENSIVE REVIEW OF DATA 26 100.75

88325 COMPREHENSIVE REVIEW OF DATA 100.75

88329 PATH CONSULT INTROP 26 62

67/95

Page 68: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

88329 PATH CONSULT INTROP 62

88331 PATH CONSULT INTRAOP 1 BLOC TC 10.3

88331 PATH CONSULT INTRAOP 1 BLOC 26 77.5

88331 PATH CONSULT INTRAOP 1 BLOC 93

88332 PATH CONSULT INTRAOP ADDL TC 13.95

88332 PATH CONSULT INTRAOP ADDL 26 31

88332 PATH CONSULT INTRAOP ADDL 69.75

88342 IMMUNOHISTOCHEMISTRY TC 13.95

88342 IMMUNOHISTOCHEMISTRY 26 55.8

88342 IMMUNOHISTOCHEMISTRY 69.75

88346 IMMUNOFLUORESCENT STUDY TC 24.8

88346 IMMUNOFLUORESCENT STUDY 26 99.2

88346 IMMUNOFLUORESCENT STUDY 124

88347 IMMUNOFLUORESCENT STUDY TC 24.8

88347 IMMUNOFLUORESCENT STUDY 26 99.2

88347 IMMUNOFLUORESCENT STUDY 124

88348 ELECTRON MICROSCOPY TC 77.5

88348 ELECTRON MICROSCOPY 26 310

88348 ELECTRON MICROSCOPY 387.5

88355 ANALYSIS SKELETAL MUSCLE TC 39.92

88355 ANALYSIS SKELETAL MUSCLE 26 159.68

88355 ANALYSIS SKELETAL MUSCLE 199.6

88356 ANALYSIS NERVE TC 62.88

88356 ANALYSIS NERVE 26 251.55

88356 ANALYSIS NERVE 314.44

88358 ANALYSIS TUMOR TC 56.87

88358 ANALYSIS TUMOR 26 227.51

88358 ANALYSIS TUMOR 284.39

88362 NERVE TEASING PREPARATIONS TC 45.82

88362 NERVE TEASING PREPARATIONS 26 183.29

88362 NERVE TEASING PREPARATIONS 229.12

88365 INSITU HYBRIDIZATION (FISH) TC 18.56

88365 INSITU HYBRIDIZATION (FISH) 26 74.26

88365 INSITU HYBRIDIZATION (FISH) 92.82

88371 PROTEIN WESTERN BLOT TISSUE TC 6.36

88371 PROTEIN WESTERN BLOT TISSUE 26 3.96

88371 PROTEIN WESTERN BLOT TISSUE 10.32

88372 PROTEIN ANALYSIS W/PROBE TC 9.68

88372 PROTEIN ANALYSIS W/PROBE 26 6.22

88372 PROTEIN ANALYSIS W/PROBE 15.9

89050 BODY FLUID CELL COUNT TC 3.31

89050 BODY FLUID CELL COUNT 3.31

89051 BODY FLUID CELL COUNT TC 3.85

89051 BODY FLUID CELL COUNT 3.85

89055 LEUKOCYTE ASSESSMENT FECAL TC 2.99

68/95

Page 69: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

89055 LEUKOCYTE ASSESSMENT FECAL 2.99

89060 EXAM SYNOVIAL FLUID CRYSTALS TC 1.62

89060 EXAM SYNOVIAL FLUID CRYSTALS 26 3.38

89060 EXAM SYNOVIAL FLUID CRYSTALS 5

89125 SPECIMEN FAT STAIN TC 2.42

89125 SPECIMEN FAT STAIN 2.42

89160 EXAM FECES FOR MEAT FIBERS TC 2.58

89160 EXAM FECES FOR MEAT FIBERS 2.58

89190 NASAL SMEAR FOR EOSINOPHILS TC 3.32

89190 NASAL SMEAR FOR EOSINOPHILS 3.32

89310 SEMEN ANALYSIS W/COUNT TC 6.02

89310 SEMEN ANALYSIS W/COUNT 6.02

90471 IMMUNIZATION ADMIN 7.8

90471 IMMUNIZATION ADMIN 7.8

90472 IMMUNIZATION ADMIN EACH ADD 7.8

90472 IMMUNIZATION ADMIN EACH ADD 7.8

90473 IMMUNE ADMIN ORAL/NASAL 7.8

90473 IMMUNE ADMIN ORAL/NASAL 7.8

90474 IMMUNE ADMIN ORAL/NASAL ADDL 7.8

90474 IMMUNE ADMIN ORAL/NASAL ADDL 7.8

90476 ADENOVIRUS VACCINE TYPE 4 0

90477 ADENOVIRUS VACCINE TYPE 7 0

90581 ANTHRAX VACCINE SC OR IM 113.17

90585 BCG VACCINE PERCUT 124.53

90586 BCG VACCINE INTRAVESICAL 148.66

90633 HEP A VACC PED/ADOL 2 DOSE 21.11

90634 HEP A VACC PED/ADOL 3 DOSE 21.11

90645 HIB VACCINE HBOC IM 17.32

90646 HIB VACCINE PRP-D IM 18.94

90647 HIB VACCINE PRP-OMP IM 16.13

90648 HIB VACCINE PRP-T IM 21.1

90656 FLU VACCINE NO PRESERV 3 & > 10.47

90657 FLU VACCINE 3 YRS IM 7.03

90658 FLU VACCINE 3 YRS & > IM 13.74

90660 FLU VACCINE NASAL 9.34

90669 PNEUMOCOCCAL VACC 7 VAL IM 16.3

90675 RABIES VACCINE IM 99.62

90676 RABIES VACCINE ID 67.39

90680 ROTOVIRUS VACC 3 DOSE ORAL 55.71

90688 FLU VACC 4 VAL 3 YRS PLUS IM 13.74

90690 TYPHOID VACCINE ORAL 20.87

90691 TYPHOID VACCINE IM 29.18

90692 TYPHOID VACCINE H-P SC/ID 2.09

90693 TYPHOID VACCINE AKD SC 0

90700 DTAP VACCINE < 7 YRS IM 12.75

69/95

Page 70: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

90702 DT VACCINE < 7 YRS IM 6.64

90703 TETANUS VACCINE IM 5.93

90704 MUMPS VACCINE SC 12.81

90705 MEASLES VACCINE SC 9.96

90706 RUBELLA VACCINE SC 11.39

90707 MMR VACCINE SC 25.62

90708 MEASLES-RUBELLA VACCINE SC 22.07

90710 MMRV VACCINE SC 99.16

90712 ORAL POLIOVIRUS VACCINE 13.76

90713 POLIOVIRUS IPV SC/IM 9.96

90716 CHICKEN POX VACCINE SC 44.12

90717 YELLOW FEVER VACCINE SC 40.8

90719 DIPHTHERIA VACCINE IM 0

90720 DTP/HIB VACCINE IM 26.8

90721 DTAP/HIB VACCINE IM 23.4

90723 DTAP-HEP B-IPV VACCINE IM 32.75

90725 CHOLERA VACCINE INJECTABLE 8.65

90727 PLAGUE VACCINE IM 0

90732 PNEUMOCOCCAL VACC 23 VAL IM 11.12

90733 MENINGOCOCCAL VACCINE SC 46.73

90735 ENCEPHALITIS VACCINE SC 55.27

90740 HEPB VACC ILL PAT 3 DOSE IM 79.22

90743 HEP B VACC ADOL 2 DOSE IM 17.32

90744 HEPB VACC PED/ADOL 3 DOSE IM 17.32

90747 HEPB VACC ILL PAT 4 DOSE IM 79.22

90748 HEP B/HIB VACCINE IM 35.11

90901 BIOFEEDBACK TRAIN ANY METH 30.6

90911 BIOFEEDBACK PERI/URO/RECTAL 43.88

92950 HEART/LUNG RESUSCITATION CPR 135.68

92953 TEMPORARY EXTERNAL PACING 11.39

92960 CARDIOVERSION ELECTRIC EXT 110.77

92961 CARDIOVERSION ELECTRIC INT 160.11

93922 UPR/L XTREMITY ART 2 LEVELS TC 30.12

93922 UPR/L XTREMITY ART 2 LEVELS 26 8.78

93922 UPR/L XTREMITY ART 2 LEVELS 38.66

93923 UPR/LXTR ART STDY 3+ LVLS TC 56.45

93923 UPR/LXTR ART STDY 3+ LVLS 26 15.89

93923 UPR/LXTR ART STDY 3+ LVLS 72.35

93924 LWR XTR VASC STDY BILAT TC 61.43

93924 LWR XTR VASC STDY BILAT 26 17.79

93924 LWR XTR VASC STDY BILAT 79.22

93925 LOWER EXTREMITY STUDY TC 95.83

93925 LOWER EXTREMITY STUDY 26 20.16

93925 LOWER EXTREMITY STUDY 115.99

93926 LOWER EXTREMITY STUDY TC 63.81

70/95

Page 71: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

93926 LOWER EXTREMITY STUDY 26 13.52

93926 LOWER EXTREMITY STUDY 77.56

93930 UPPER EXTREMITY STUDY TC 101.76

93930 UPPER EXTREMITY STUDY 26 15.66

93930 UPPER EXTREMITY STUDY 117.65

93931 UPPER EXTREMITY STUDY TC 67.6

93931 UPPER EXTREMITY STUDY 26 10.67

93931 UPPER EXTREMITY STUDY 78.28

93965 EXTREMITY STUDY TC 28.46

93965 EXTREMITY STUDY 26 12.1

93965 EXTREMITY STUDY 40.56

93970 EXTREMITY STUDY TC 106.03

93970 EXTREMITY STUDY 26 23.48

93970 EXTREMITY STUDY 129.75

93971 EXTREMITY STUDY TC 70.69

93971 EXTREMITY STUDY 26 15.42

93971 EXTREMITY STUDY 86.1

95860 MUSCLE TEST ONE LIMB TC 18.5

95860 MUSCLE TEST ONE LIMB 26 34.87

95860 MUSCLE TEST ONE LIMB 53.37

95861 MUSCLE TEST 2 LIMBS TC 18.74

95861 MUSCLE TEST 2 LIMBS 26 55.98

95861 MUSCLE TEST 2 LIMBS 74.48

95863 MUSCLE TEST 3 LIMBS TC 23.48

95863 MUSCLE TEST 3 LIMBS 26 67.84

95863 MUSCLE TEST 3 LIMBS 91.08

95864 MUSCLE TEST 4 LIMBS TC 44.59

95864 MUSCLE TEST 4 LIMBS 26 72.11

95864 MUSCLE TEST 4 LIMBS 116.7

95867 MUSCLE TEST CRAN NERV UNILAT TC 14.47

95867 MUSCLE TEST CRAN NERV UNILAT 26 28.7

95867 MUSCLE TEST CRAN NERV UNILAT 43.17

95868 MUSCLE TEST CRAN NERVE BILAT TC 17.32

95868 MUSCLE TEST CRAN NERVE BILAT 26 43.41

95868 MUSCLE TEST CRAN NERVE BILAT 60.72

95869 MUSCLE TEST THOR PARASPINAL TC 5.46

95869 MUSCLE TEST THOR PARASPINAL 26 13.28

95869 MUSCLE TEST THOR PARASPINAL 18.74

95870 MUSCLE TEST NONPARASPINAL TC 5.46

95870 MUSCLE TEST NONPARASPINAL 26 13.28

95870 MUSCLE TEST NONPARASPINAL 18.74

95872 MUSCLE TEST ONE FIBER TC 15.18

95872 MUSCLE TEST ONE FIBER 26 53.61

95872 MUSCLE TEST ONE FIBER 68.79

95875 LIMB EXERCISE TEST TC 23.48

71/95

Page 72: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

95875 LIMB EXERCISE TEST 26 39.38

95875 LIMB EXERCISE TEST 62.86

95921 AUTONOMIC NRV PARASYM INERVJ TC 9.49

95921 AUTONOMIC NRV PARASYM INERVJ 26 30.6

95921 AUTONOMIC NRV PARASYM INERVJ 40.09

95922 AUTONOMIC NRV ADRENRG INERVJ TC 9.49

95922 AUTONOMIC NRV ADRENRG INERVJ 26 34.39

95922 AUTONOMIC NRV ADRENRG INERVJ 43.88

95923 AUTONOMIC NRV SYST FUNJ TEST TC 54.08

95923 AUTONOMIC NRV SYST FUNJ TEST 26 32.26

95923 AUTONOMIC NRV SYST FUNJ TEST 86.34

95925 SOMATOSENSORY TESTING TC 22.53

95925 SOMATOSENSORY TESTING 26 19.45

95925 SOMATOSENSORY TESTING 41.98

95926 SOMATOSENSORY TESTING TC 22.53

95926 SOMATOSENSORY TESTING 26 19.69

95926 SOMATOSENSORY TESTING 42.22

95927 SOMATOSENSORY TESTING TC 22.53

95927 SOMATOSENSORY TESTING 26 20.4

95927 SOMATOSENSORY TESTING 42.93

95930 VISUAL EVOKED POTENTIAL TEST TC 17.08

95930 VISUAL EVOKED POTENTIAL TEST 26 12.57

95930 VISUAL EVOKED POTENTIAL TEST 29.65

95933 BLINK REFLEX TEST TC 19.69

95933 BLINK REFLEX TEST 26 21.35

95933 BLINK REFLEX TEST 41.04

95937 NEUROMUSCULAR JUNCTION TEST TC 8.54

95937 NEUROMUSCULAR JUNCTION TEST 26 23.01

95937 NEUROMUSCULAR JUNCTION TEST 31.55

96000 MOTION ANALYSIS VIDEO/3D 61.2

96001 MOTION TEST W/FT PRESS MEAS 73.06

96002 DYNAMIC SURFACE EMG 14.23

96003 DYNAMIC FINE WIRE EMG 13.28

96004 PHYS REVIEW OF MOTION TESTS 62.86

96567 PHOTODYNAMIC TX SKIN 41.04

96570 PHOTODYNMC TX 30 MIN ADD-ON 38.66

96571 PHOTODYNAMIC TX ADDL 15 MIN 19.21

97001 PT EVALUATION 45.31

97002 PT RE-EVALUATION 24.19

97003 OT EVALUATION 46.97

97004 OT RE-EVALUATION 31.78

97010 HOT OR COLD PACKS THERAPY 3.38

97022 WHIRLPOOL THERAPY 13.85

97032 ELECTRICAL STIMULATION 14.77

97035 ULTRASOUND THERAPY 9.54

72/95

Page 73: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

97110 THERAPEUTIC EXERCISES 17.79

97112 NEUROMUSCULAR REEDUCATION 18.5

97116 GAIT TRAINING THERAPY 19.69

97150 GROUP THERAPEUTIC PROCEDURES 11.86

97535 SELF CARE MNGMENT TRAINING 19.92

97602 WOUND(S) CARE NON-SELECTIVE 11.15

97760 ORTHOTIC MGMT AND TRAINING 20.02

97761 PROSTHETIC TRAINING 18.27

97762 C/O FOR ORTHOTIC/PROSTH USE 16.97

98925 OSTEOPATH MANJ 1-2 REGIONS 20.4

98926 OSTEOPATH MANJ 3-4 REGIONS 26.8

98927 OSTEOPATH MANJ 5-6 REGIONS 34.39

98928 OSTEOPATH MANJ 7-8 REGIONS 39.85

98929 OSTEOPATH MANJ 9-10 REGIONS 45.54

99024 POSTOP FOLLOW-UP VISIT 0

99058 OFFICE EMERGENCY CARE 15.18

99070 SPECIAL SUPPLIES PHYS/QHP 15.5

99090 COMPUTER DATA ANALYSIS 85.92

99170 ANOGENITAL EXAM CHILD W IMAG 93.46

99175 INDUCTION OF VOMITING 34.87

99183 HYPERBARIC OXYGEN THERAPY 78.28

99195 PHLEBOTOMY 10.91

99199 SPECIAL SERVICE/PROC/REPORT 0

99201 OFFICE/OUTPATIENT VISIT NEW 22.77

99202 OFFICE/OUTPATIENT VISIT NEW 41.27

99203 OFFICE/OUTPATIENT VISIT NEW 61.91

99204 OFFICE/OUTPATIENT VISIT NEW 87.76

99205 OFFICE/OUTPATIENT VISIT NEW 111.48

99211 OFFICE/OUTPATIENT VISIT EST 13.76

99212 OFFICE/OUTPATIENT VISIT EST 24.43

99213 OFFICE/OUTPATIENT VISIT EST 33.92

99214 OFFICE/OUTPATIENT VISIT EST 52.9

99215 OFFICE/OUTPATIENT VISIT EST 77.8

99221 INITIAL HOSPITAL CARE 43.64

99222 INITIAL HOSPITAL CARE 72.35

99223 INITIAL HOSPITAL CARE 100.81

99231 SUBSEQUENT HOSPITAL CARE 21.82

99232 SUBSEQUENT HOSPITAL CARE 35.82

99233 SUBSEQUENT HOSPITAL CARE 51

99238 HOSPITAL DISCHARGE DAY 44.12

99239 HOSPITAL DISCHARGE DAY 60.72

99241 OFFICE CONSULTATION 31.78

99242 OFFICE CONSULTATION 58.83

99243 OFFICE CONSULTATION 77.8

99244 OFFICE CONSULTATION 110.3

73/95

Page 74: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

99245 OFFICE CONSULTATION 142.79

99251 INPATIENT CONSULTATION 23.25

99252 INPATIENT CONSULTATION 46.73

99253 INPATIENT CONSULTATION 63.81

99254 INPATIENT CONSULTATION 91.56

99255 INPATIENT CONSULTATION 125.95

99281 EMERGENCY DEPT VISIT 10.67

99282 EMERGENCY DEPT VISIT 17.55

99283 EMERGENCY DEPT VISIT 39.85

99284 EMERGENCY DEPT VISIT 61.91

99285 EMERGENCY DEPT VISIT 96.78

99291 CRITICAL CARE FIRST HOUR 139.47

99292 CRITICAL CARE ADDL 30 MIN 72.35

99315 NURSING FAC DISCHARGE DAY 46.25

99316 NURSING FAC DISCHARGE DAY 60.72

99341 HOME VISIT NEW PATIENT 39.38

99342 HOME VISIT NEW PATIENT 59.06

99343 HOME VISIT NEW PATIENT 88

99344 HOME VISIT NEW PATIENT 113.86

99345 HOME VISIT NEW PATIENT 139.71

99347 HOME VISIT EST PATIENT 31.07

99348 HOME VISIT EST PATIENT 49.34

99349 HOME VISIT EST PATIENT 76.38

99350 HOME VISIT EST PATIENT 111.25

99354 PROLONGED SERVICE OFFICE 79.94

99355 PROLONGED SERVICE OFFICE 74.48

99356 PROLONGED SERVICE INPATIENT 57.4

99357 PROLONGED SERVICE INPATIENT 58.11

99360 PHYSICIAN STANDBY SERVICES 70.21

99374 HOME HEALTH CARE SUPERVISION 63.57

99375 HOME HEALTH CARE SUPERVISION 81.6

99377 HOSPICE CARE SUPERVISION 63.57

99378 HOSPICE CARE SUPERVISION 91.56

99379 NURSING FAC CARE SUPERVISION 63.33

99380 NURSING FAC CARE SUPERVISION 85.15

A4221 MAINT DRUG INFUS CATH PER WK 22.26

A4222 INFUSION SUPPLIES WITH PUMP 44.17

A4253 BLOOD GLUCOSE/REAGENT STRIPS NU 33.76

A4255 GLUCOSE MONITOR PLATFORMS 4.11

A4256 CALIBRATOR SOLUTION/CHIPS 9.72

A4257 REPLACE LENSSHIELD CARTRIDGE 12.75

A4258 LANCET DEVICE EACH 17.75

A4259 LANCETS PER BOX 12.74

A4265 PARAFFIN 3.39

A4280 BRST PRSTHS ADHSV ATTCHMNT 4.84

74/95

Page 75: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

A4310 INSERT TRAY W/O BAG/CATH 7.72

A4311 CATHETER W/O BAG 2-WAY LATEX 14.84

A4312 CATH W/O BAG 2-WAY SILICONE 18.04

A4313 CATHETER W/BAG 3-WAY 18.52

A4314 CATH W/DRAINAGE 2-WAY LATEX 21.5

A4315 CATH W/DRAINAGE 2-WAY SILCNE 26.39

A4316 CATH W/DRAINAGE 3-WAY 28.4

A4320 IRRIGATION TRAY 5.33

A4322 IRRIGATION SYRINGE 3.04

A4326 MALE EXTERNAL CATHETER 10.79

A4327 FEM URINARY COLLECT DEV CUP 42.27

A4328 FEM URINARY COLLECT POUCH 10.45

A4330 STOOL COLLECTION POUCH 7.15

A4331 EXTENSION DRAINAGE TUBING 3.18

A4332 LUBE STERILE PACKET 0.12

A4333 URINARY CATH ANCHOR DEVICE 2.2

A4334 URINARY CATH LEG STRAP 4.93

A4338 INDWELLING CATHETER LATEX 12.26

A4340 INDWELLING CATHETER SPECIAL 26.99

A4344 CATH INDW FOLEY 2 WAY SILICN 16.02

A4346 CATH INDW FOLEY 3 WAY 19.25

A4351 STRAIGHT TIP URINE CATHETER 1.81

A4352 COUDE TIP URINARY CATHETER 6.42

A4353 INTERMITTENT URINARY CATH 7

A4354 CATH INSERTION TRAY W/BAG 11.8

A4355 BLADDER IRRIGATION TUBING 7.86

A4356 EXT URETH CLMP OR COMPR DVC 39.33

A4357 BEDSIDE DRAINAGE BAG 9.7

A4358 URINARY LEG OR ABDOMEN BAG 6.63

A4361 OSTOMY FACE PLATE 18.37

A4362 SOLID SKIN BARRIER 3.46

A4364 ADHESIVE, LIQUID OR EQUAL 2.93

A4367 OSTOMY BELT 7.35

A4368 OSTOMY FILTER 0.26

A4369 SKIN BARRIER LIQUID PER OZ 2.06

A4371 SKIN BARRIER POWDER PER OZ 3.6

A4372 SKIN BARRIER SOLID 4X4 EQUIV 4.18

A4373 SKIN BARRIER WITH FLANGE 6.28

A4375 DRAINABLE PLASTIC PCH W FCPL 17.18

A4376 DRAINABLE RUBBER PCH W FCPLT 47.58

A4377 DRAINABLE PLSTIC PCH W/O FP 4.29

A4378 DRAINABLE RUBBER PCH W/O FP 30.75

A4379 URINARY PLASTIC POUCH W FCPL 15.02

A4380 URINARY RUBBER POUCH W FCPLT 37.33

A4381 URINARY PLASTIC POUCH W/O FP 4.61

75/95

Page 76: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

A4382 URINARY HVY PLSTC PCH W/O FP 24.62

A4383 URINARY RUBBER POUCH W/O FP 28.19

A4384 OSTOMY FACEPLT/SILICONE RING 9.62

A4385 OST SKN BARRIER SLD EXT WEAR 5.1

A4388 DRAINABLE PCH W EX WEAR BARR 4.36

A4389 DRAINABLE PCH W ST WEAR BARR 6.22

A4390 DRAINABLE PCH EX WEAR CONVEX 9.61

A4391 URINARY POUCH W EX WEAR BARR 7.07

A4392 URINARY POUCH W ST WEAR BARR 8.18

A4393 URINE PCH W EX WEAR BAR CONV 9.04

A4394 OSTOMY POUCH LIQ DEODORANT 2.58

A4395 OSTOMY POUCH SOLID DEODORANT 0.05

A4396 PERISTOMAL HERNIA SUPPRT BLT 40.48

A4397 IRRIGATION SUPPLY SLEEVE 4.07

A4398 OSTOMY IRRIGATION BAG 13.81

A4399 OSTOMY IRRIG CONE/CATH W BRS 12.26

A4400 OSTOMY IRRIGATION SET 48.87

A4402 LUBRICANT PER OUNCE 1.6

A4404 OSTOMY RING EACH 1.63

A4405 NONPECTIN BASED OSTOMY PASTE 3.4

A4406 PECTIN BASED OSTOMY PASTE 5.74

A4407 EXT WEAR OST SKN BARR <=4SQ� 8.76

A4408 EXT WEAR OST SKN BARR >4SQ� 9.87

A4409 OST SKN BARR CONVEX <=4 SQ I 6.22

A4410 OST SKN BARR EXTND >4 SQ 9.04

A4413 2 PC DRAINABLE OST POUCH 5.5

A4414 OST SKNBAR W/O CONV<=4 SQ IN 4.93

A4415 OST SKN BARR W/O CONV >4 SQI 6

A4422 OST POUCH ABSORBENT MATERIAL 0.12

A4450 NON-WATERPROOF TAPE 0.09

A4452 WATERPROOF TAPE 0.36

A4455 ADHESIVE REMOVER PER OUNCE 1.22

A4481 TRACHEOSTOMA FILTER 0.38

A4550 SURGICAL TRAYS 34.14

A4556 ELECTRODES, PAIR 12.14

A4557 LEAD WIRES, PAIR 17.94

A4558 CONDUCTIVE GEL OR PASTE 5.45

A4570 SPLINT 20.13

A4580 CAST SUPPLIES (PLASTER) 0

A4590 SPECIAL CASTING MATERIAL 45.29

A4595 TENS SUPPL 2 LEAD PER MONTH 28.35

A4608 TRANSTRACHEAL OXYGEN CATH 58.15

A4612 BATTERY CABLES UE 60.95

A4612 BATTERY CABLES RR 8.14

A4612 BATTERY CABLES NU 79.93

76/95

Page 77: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

A4614 HAND-HELD PEFR METER 23.78

A4619 FACE TENT 1.21

A4623 TRACHEOSTOMY INNER CANNULA 5.57

A4624 TRACHEAL SUCTION TUBE NU 2.63

A4625 TRACH CARE KIT FOR NEW TRACH 6.58

A4626 TRACHEOSTOMY CLEANING BRUSH 2.78

A4628 OROPHARYNGEAL SUCTION CATH NU 3.65

A4629 TRACHEOSTOMY CARE KIT 4.61

A4630 REPL BAT T.E.N.S. OWN BY PT NU 6.19

A4633 UVL REPLACEMENT BULB NU 41.04

A4639 INFRARED HT SYS REPLCMNT PAD NU 287.21

A4640 ALTERNATING PRESSURE PAD UE 38.13

A4640 ALTERNATING PRESSURE PAD RR 6.45

A4640 ALTERNATING PRESSURE PAD NU 53.82

A5051 POUCH CLSD W BARR ATTACHED 2.07

A5052 CLSD OSTOMY POUCH W/O BARR 1.49

A5053 CLSD OSTOMY POUCH FACEPLATE 1.48

A5054 CLSD OSTOMY POUCH W/FLANGE 1.79

A5055 STOMA CAP 1.44

A5061 POUCH DRAINABLE W BARRIER AT 3.52

A5062 DRNBLE OSTOMY POUCH W/O BARR 2.09

A5063 DRAIN OSTOMY POUCH W/FLANGE 2.17

A5071 URINARY POUCH W/BARRIER 6.01

A5072 URINARY POUCH W/O BARRIER 3.43

A5073 URINARY POUCH ON BARR W/FLNG 3.18

A5081 STOMA PLUG OR SEAL, ANY TYPE 2.81

A5082 CONTINENT STOMA CATHETER 10.11

A5093 OSTOMY ACCESSORY CONVEX INSE 1.95

A5102 BEDSIDE DRAIN BTL W/WO TUBE 20.69

A5105 URINARY SUSPENSORY 40.76

A5112 URINARY LEG BAG 34.62

A5113 LATEX LEG STRAP 4.7

A5114 FOAM/FABRIC LEG STRAP 8.94

A5121 SOLID SKIN BARRIER 6X6 6.72

A5122 SOLID SKIN BARRIER 8X8 12.85

A5126 DISK/FOAM PAD +OR- ADHESIVE 1.32

A5131 APPLIANCE CLEANER 13.76

A5200 PERCUTANEOUS CATHETER ANCHOR 11.29

A5500 DIAB SHOE FOR DENSITY INSERT 59.36

A5501 DIABETIC CUSTOM MOLDED SHOE 178.04

A5503 DIABETIC SHOE W/ROLLER/ROCKR 26.4

A5504 DIABETIC SHOE WITH WEDGE 26.4

A5505 DIAB SHOE W/METATARSAL BAR 26.4

A5506 DIABETIC SHOE W/OFF SET HEEL 26.4

A5507 MODIFICATION DIABETIC SHOE 26.4

77/95

Page 78: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

A5508 DIABETIC DELUXE SHOE 0

A5510 COMPRESSION FORM SHOE INSERT 0

A5512 MULTI DEN INSERT DIRECT FORM 24.22

A5513 MULTI DEN INSERT CUSTOM MOLD 36.14

A6010 COLLAGEN BASED WOUND FILLER 30.96

A6011 COLLAGEN GEL/PASTE WOUND FIL 2.28

A6021 COLLAGEN DRESSING <=16 SQ IN 21.02

A6022 COLLAGEN DRSG>16<=48 SQ IN 21.02

A6023 COLLAGEN DRESSING >48 SQ IN 190.3

A6024 COLLAGEN DSG WOUND FILLER 6.19

A6154 WOUND POUCH EACH 14.36

A6196 ALGINATE DRESSING <=16 SQ IN 7.35

A6197 ALGINATE DRSG >16 <=48 SQ IN 16.44

A6199 ALGINATE DRSG WOUND FILLER 5.29

A6203 COMPOSITE DRSG <= 16 SQ IN 3.35

A6204 COMPOSITE DRSG >16<=48 SQ IN 6.23

A6207 CONTACT LAYER >16<= 48 SQ IN 7.34

A6209 FOAM DRSG <=16 SQ IN W/O BDR 7.48

A6210 FOAM DRG >16<=48 SQ IN W/O B 19.92

A6211 FOAM DRG > 48 SQ IN W/O BRDR 29.37

A6212 FOAM DRG <=16 SQ IN W/BORDER 9.7

A6214 FOAM DRG > 48 SQ IN W/BORDER 10.29

A6216 NON-STERILE GAUZE<=16 SQ IN 0.05

A6219 GAUZE <= 16 SQ IN W/BORDER 0.95

A6220 GAUZE >16 <=48 SQ IN W/BORDR 2.58

A6222 GAUZE <=16 IN NO W/SAL W/O B 2.13

A6223 GAUZE >16<=48 NO W/SAL W/O B 2.42

A6224 GAUZE > 48 IN NO W/SAL W/O B 3.61

A6229 GAUZE >16<=48 SQ IN WATR/SAL 3.61

A6231 HYDROGEL DSG<=16 SQ IN 4.68

A6232 HYDROGEL DSG>16<=48 SQ IN 6.88

A6233 HYDROGEL DRESSING >48 SQ IN 19.19

A6234 HYDROCOLLD DRG <=16 W/O BDR 6.54

A6235 HYDROCOLLD DRG >16<=48 W/O B 16.82

A6236 HYDROCOLLD DRG > 48 IN W/O B 27.25

A6237 HYDROCOLLD DRG <=16 IN W/BDR 7.91

A6238 HYDROCOLLD DRG >16<=48 W/BDR 22.79

A6240 HYDROCOLLD DRG FILLER PASTE 12.24

A6241 HYDROCOLLOID DRG FILLER DRY 2.57

A6242 HYDROGEL DRG <=16 IN W/O BDR 6.07

A6243 HYDROGEL DRG >16<=48 W/O BDR 12.31

A6244 HYDROGEL DRG >48 IN W/O BDR 39.28

A6245 HYDROGEL DRG <= 16 IN W/BDR 7.27

A6246 HYDROGEL DRG >16<=48 IN W/B 9.92

A6247 HYDROGEL DRG > 48 SQ IN W/B 23.78

78/95

Page 79: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

A6248 HYDROGEL DRSG GEL FILLER 16.24

A6251 ABSORPT DRG <=16 SQ IN W/O B 1.99

A6252 ABSORPT DRG >16 <=48 W/O BDR 3.25

A6253 ABSORPT DRG > 48 SQ IN W/O B 6.34

A6254 ABSORPT DRG <=16 SQ IN W/BDR 1.21

A6255 ABSORPT DRG >16<=48 IN W/BDR 3.03

A6257 TRANSPARENT FILM <= 16 SQ IN 1.53

A6258 TRANSPARENT FILM >16<=48 IN 4.3

A6259 TRANSPARENT FILM > 48 SQ IN 10.94

A6266 IMPREG GAUZE NO H20/SAL/YARD 1.92

A6402 STERILE GAUZE <= 16 SQ IN 0.12

A6403 STERILE GAUZE>16 <= 48 SQ IN 0.43

A6410 STERILE EYE PAD 0.39

A7000 DISPOSABLE CANISTER FOR PUMP NU 9.54

A7001 NONDISPOSABLE PUMP CANISTER NU 33.08

A7002 TUBING USED W SUCTION PUMP NU 3.83

A7003 NEBULIZER ADMINISTRATION SET NU 2.74

A7004 DISPOSABLE NEBULIZER SML VOL NU 1.8

A7005 NONDISPOSABLE NEBULIZER SET NU 30.83

A7006 FILTERED NEBULIZER ADMIN SET NU 9.54

A7007 LG VOL NEBULIZER DISPOSABLE NU 4.61

A7008 DISPOSABLE NEBULIZER PREFILL NU 11

A7009 NEBULIZER RESERVOIR BOTTLE NU 42.04

A7010 DISPOSABLE CORRUGATED TUBING NU 23.59

A7012 NEBULIZER WATER COLLEC DEVIC NU 3.78

A7013 DISPOSABLE COMPRESSOR FILTER NU 0.83

A7014 COMPRESSOR NONDISPOS FILTER NU 4.49

A7015 AEROSOL MASK USED W NEBULIZE NU 1.88

A7016 NEBULIZER DOME & MOUTHPIECE NU 7.25

A7017 NEBULIZER NOT USED W OXYGEN UE 100.52

A7017 NEBULIZER NOT USED W OXYGEN RR 13.4

A7017 NEBULIZER NOT USED W OXYGEN NU 134.04

A7018 WATER DISTILLED W/NEBULIZER 0.38

A7020 INTERFACE, COUGH STIM DEVICE INTER 2.75

A7025 REPLACE CHEST COMPRESS VEST NU 434.94

A7026 REPLACE CHST CMPRSS SYS HOSE NU 28.75

A7030 CPAP FULL FACE MASK NU 188.64

A7031 REPLACEMENT FACEMASK INTERFA NU 69.77

A7032 REPLACEMENT NASAL CUSHION NU 40.53

A7033 REPLACEMENT NASAL PILLOWS NU 28.41

A7034 NASAL APPLICATION DEVICE NU 117.64

A7035 POS AIRWAY PRESS HEADGEAR NU 39.75

A7036 POS AIRWAY PRESS CHINSTRAP NU 18.2

A7037 POS AIRWAY PRESSURE TUBING NU 41.02

A7038 POS AIRWAY PRESSURE FILTER NU 5.39

79/95

Page 80: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

A7039 FILTER, NON DISPOSABLE W PAP NU 15.33

A7044 PAP ORAL INTERFACE NU 120.91

A7501 TRACHEOSTOMA VALVE W DIAPHRA 105.03

A7502 REPLACEMENT DIAPHRAGM/FPLATE 49.91

A7503 HMES FILTER HOLDER OR CAP 11.33

A7504 TRACHEOSTOMA HMES FILTER 0.67

A7505 HMES OR TRACH VALVE HOUSING 4.68

A7506 HMES/TRACHVALVE ADHESIVEDISK 0.33

A7507 INTEGRATED FILTER & HOLDER 2.49

A7508 HOUSING & INTEGRATED ADHESIV 2.87

A7509 HEAT & MOISTURE EXCHANGE SYS 1.41

E0110 CRUTCH FOREARM PAIR UE 49.45

E0110 CRUTCH FOREARM PAIR RR 15.99

E0110 CRUTCH FOREARM PAIR NU 65.95

E0111 CRUTCH FOREARM EACH UE 34.94

E0111 CRUTCH FOREARM EACH RR 8.43

E0111 CRUTCH FOREARM EACH NU 45.27

E0112 CRUTCH UNDERARM PAIR WOOD UE 24.85

E0112 CRUTCH UNDERARM PAIR WOOD RR 9.93

E0112 CRUTCH UNDERARM PAIR WOOD NU 33.11

E0113 CRUTCH UNDERARM EACH WOOD UE 13.48

E0113 CRUTCH UNDERARM EACH WOOD RR 5.15

E0113 CRUTCH UNDERARM EACH WOOD NU 17.96

E0114 CRUTCH UNDERARM PAIR NO WOOD UE 30.32

E0114 CRUTCH UNDERARM PAIR NO WOOD RR 8.57

E0114 CRUTCH UNDERARM PAIR NO WOOD NU 40.11

E0116 CRUTCH UNDERARM EACH NO WOOD UE 17.75

E0116 CRUTCH UNDERARM EACH NO WOOD RR 5.4

E0116 CRUTCH UNDERARM EACH NO WOOD NU 23.58

E0117 UNDERARM SPRINGASSIST CRUTCH UE 144.55

E0117 UNDERARM SPRINGASSIST CRUTCH RR 19.26

E0117 UNDERARM SPRINGASSIST CRUTCH NU 192.71

E0118 CRUTCH SUBSTITUTE RR 33.4

E0118 CRUTCH SUBSTITUTE NU 334

J1050 Medroxyprogesterone acetate 0

J1741 Ibuprofen injection 0

J1930 LANREOTIDE INJECTION 0

J3530 NASAL VACCINE INHALATION 0

J3570 LAETRILE AMYGDALIN VIT B17 0

J7315 OPHTHALMIC MITOMYCIN 0

J7316 Inj ocriplasmin 0.125 mg 0

J7508 Tacrolimus ex rel oral 0.1mg 0

J7665 MANNITOL FOR INHALER 0

L0120 CERV FLEX N/ADJ FOAM PRE OTS 26.63

L0130 FLEX THERMOPLASTIC COLLAR MO 133.02

80/95

Page 81: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L0140 CERVICAL SEMI-RIGID ADJUSTAB 48.19

L0150 CERV SEMI-RIG ADJ MOLDED CHN 108.46

L0160 CERV SR WIRE OCC/MAN PRE OTS 133.06

L0170 CERVICAL COLLAR MOLDED TO PT 641.8

L0172 CERV COL SR FOAM 2PC PRE OTS 119.82

L0174 CERV SR 2PC THOR EXT PRE OTS 275.72

L0180 CER POST COL OCC/MAN SUP ADJ 357.44

L0190 CERV COLLAR SUPP ADJ CERV BA 497.18

L0200 CERV COL SUPP ADJ BAR & THOR 518.3

L0220 THOR RIB BELT CUSTOM FABRICA 92.19

L0450 TLSO FLEX TRUNK/THOR PRE OTS 174.44

L0452 TLSO FLEX CUSTOM FAB THORACI 330.85

L0454 TLSO TRNK SJ-T9 PRE CST 350.83

L0456 TLSO FLEX TRNK SJ-SS PRE CST 350.83

L0458 TLSO 2MOD SYMPHIS-XIPHO PRE 547.13

L0460 TLSO 2 SHL SYMPHYS-STERN CST 547.13

L0462 TLSO 3MOD SACRO-SCAP PRE 547.13

L0464 TLSO 4MOD SACRO-SCAP PRE 547.13

L0466 TLSO R FRAM SOFT ANT PRE CST 374.99

L0468 TLSO RIG FRAM PELVIC PRE CST 454.5

L0470 TLSO RIGID FRAME PRE SUBCLAV 639.9

L0472 TLSO RIGID FRAME HYPEREX PRE 405.83

L0480 TLSO RIGID PLASTIC CUSTOM FA 1217.79

L0482 TLSO RIGID LINED CUSTOM FAB 1388.76

L0484 TLSO RIGID PLASTIC CUST FAB 1562.86

L0486 TLSO RIGIDLINED CUST FAB TWO 1692.61

L0488 TLSO RIGID LINED PRE ONE PIE 1212.41

L0490 TLSO RIGID PLASTIC PRE ONE 1124.43

L0700 CTLSO A-P-L CONTROL MOLDED 2029.13

L0710 CTLSO A-P-L CONTROL W/ INTER 2096.18

L0810 HALO CERVICAL INTO JCKT VEST 2588.89

L0820 HALO CERVICAL INTO BODY JACK 2040.86

L0830 HALO CERV INTO MILWAUKEE TYP 3147.31

L0970 TLSO CORSET FRONT 114.71

L0972 LSO CORSET FRONT 103.29

L0974 TLSO FULL CORSET 173.7

L0976 LSO FULL CORSET 122.61

L0978 AXILLARY CRUTCH EXTENSION 193.2

L0980 PERONEAL STRAPS PAIR PRE OTS 13.14

L0982 STOCKING SUP GRIPS 4 PRE OTS 13.03

L0984 PROTECT BODY SOCK EA PRE OTS 51.46

L1000 CTLSO MILWAUKE INITIAL MODEL 2037.7

L1005 TENSION BASED SCOLIOSIS ORTH 2514.93

L1010 CTLSO AXILLA SLING 57.18

L1020 KYPHOSIS PAD 86.75

81/95

Page 82: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L1025 KYPHOSIS PAD FLOATING 116.87

L1030 LUMBAR BOLSTER PAD 50.16

L1040 LUMBAR OR LUMBAR RIB PAD 78.3

L1050 STERNAL PAD 83.56

L1060 THORACIC PAD 95.99

L1070 TRAPEZIUS SLING 90.31

L1080 OUTRIGGER 48.04

L1085 OUTRIGGER BIL W/ VERT EXTENS 154.49

L1090 LUMBAR SLING 92

L1100 RING FLANGE PLASTIC/LEATHER 159.61

L1110 RING FLANGE PLAS/LEATHER MOL 256.33

L1120 COVERS FOR UPRIGHT EACH 39.86

L1200 FURNSH INITIAL ORTHOSIS ONLY 1572.58

L1210 LATERAL THORACIC EXTENSION 262.62

L1220 ANTERIOR THORACIC EXTENSION 222.35

L1230 MILWAUKEE TYPE SUPERSTRUCTUR 446.81

L1240 LUMBAR DEROTATION PAD 77.93

L1250 ANTERIOR ASIS PAD 61.81

L1260 ANTERIOR THORACIC DEROTATION 67.6

L1270 ABDOMINAL PAD 77.76

L1280 RIB GUSSET (ELASTIC) EACH 86.58

L1290 LATERAL TROCHANTERIC PAD 78.89

L1300 BODY JACKET MOLD TO PATIENT 1676.57

L1310 POST-OPERATIVE BODY JACKET 1575.53

L1499 SPINAL ORTHOSIS NOS 1906.45

L1600 HO FLEX FREJKA W/COV PRE CST 123.26

L1610 HO FREJKA COV ONLY PRE CST 44.06

L1620 HO FLEX PAVLIK HARNS PRE CST 125.04

L1630 ABDUCT CONTROL HIP SEMI-FLEX 138.76

L1640 PELV BAND/SPREAD BAR THIGH C 347.34

L1650 HO ABDUCTION HIP ADJUSTABLE 203.36

L1652 HO BI THIGHCUFFS W SPRDR BAR 280.1

L1660 HO ABDUCTION STATIC PLASTIC 128.82

L1680 PELVIC & HIP CONTROL THIGH C 1222.9

L1685 POST-OP HIP ABDUCT CUSTOM FA 1193.85

L1686 HO POST-OP HIP ABDUCTION 915.55

L1690 COMBINATION BILATERAL HO 1519.45

L1700 LEG PERTHES ORTH TORONTO TYP 1532.72

L1710 LEGG PERTHES ORTH NEWINGTON 1794.22

L1720 LEGG PERTHES ORTHOSIS TRILAT 1322.56

L1730 LEGG PERTHES ORTH SCOTTISH R 1135.95

L1755 LEGG PERTHES PATTEN BOTTOM T 1580.97

L1810 KO ELASTIC WITH JOINTS 97.8

L1820 KO ELAS W/ CONDYLE PADS & JO 119.08

L1830 KO IMMOB CANVAS LONG PRE OTS 87.8

82/95

Page 83: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L1832 KO ADJ JNT POS R SUP PRE CST 546.47

L1834 KO W/0 JOINT RIGID MOLDED TO 736.39

L1836 KO RIGID W/O JOINTS PRE OTS 104.84

L1840 KO DEROT ANT CRUCIATE CUSTOM 922.86

L1843 KO SINGLE UPRIGHT PRE CST 705.03

L1844 KO W/ADJ JT ROT CNTRL MOLDED 1595.91

L1845 KO DOUBLE UPRIGHT PRE CST 615.27

L1846 KO W ADJ FLEX/EXT ROTAT MOLD 1065.6

L1847 KO DBL UPRIGHT W/AIR PRE CST 451.94

L1850 KO SWEDISH TYPE PRE OTS 288.9

L1860 KO SUPRACONDYLAR SOCKET MOLD 1077

L1900 AFO SPRNG WIR DRSFLX CALF BD 229.71

L1902 AFO ANKLE GAUNTLET PRE OTS 68.86

L1904 AFO MOLDED ANKLE GAUNTLET 471.98

L1906 AFO MULTILIG ANK SUP PRE OTS 120.7

L1910 AFO SING BAR CLASP ATTACH SH 268.41

L1920 AFO SING UPRIGHT W/ ADJUST S 274.43

L1930 AFO PLASTIC 237.44

L1940 AFO MOLDED TO PATIENT PLASTI 496.37

L1945 AFO MOLDED PLAS RIG ANT TIB 929.1

L1950 AFO SPIRAL MOLDED TO PT PLAS 747.58

L1960 AFO POS SOLID ANK PLASTIC MO 556.33

L1970 AFO PLASTIC MOLDED W/ANKLE J 581.72

L1980 AFO SING SOLID STIRRUP CALF 368.36

L1990 AFO DOUB SOLID STIRRUP CALF 447.39

L2000 KAFO SING FRE STIRR THI/CALF 1018.01

L2010 KAFO SNG SOLID STIRRUP W/O J 928.01

L2020 KAFO DBL SOLID STIRRUP BAND/ 1171.94

L2030 KAFO DBL SOLID STIRRUP W/O J 1016.77

L2034 KAFO PLA SIN UP W/WO K/A CUS 1574.25

L2035 KAFO PLASTIC PEDIATRIC SIZE 136.11

L2036 KAFO PLAS DOUB FREE KNEE MOL 1669.84

L2037 KAFO PLAS SING FREE KNEE MOL 1671.72

L2038 KAFO W/O JOINT MULTI-AXIS AN 1228.47

L2040 HKAFO TORSION BIL ROT STRAPS 133.65

L2050 HKAFO TORSION CABLE HIP PELV 478.11

L2060 HKAFO TORSION BALL BEARING J 582.72

L2070 HKAFO TORSION UNILAT ROT STR 111.6

L2080 HKAFO UNILAT TORSION CABLE 361

L2090 HKAFO UNILAT TORSION BALL BR 440.1

L2106 AFO TIB FX CAST PLASTER MOLD 682.41

L2108 AFO TIB FX CAST MOLDED TO PT 991.76

L2112 AFO TIBIAL FRACTURE SOFT 432.04

L2114 AFO TIB FX SEMI-RIGID 582.57

L2116 AFO TIBIAL FRACTURE RIGID 714.52

83/95

Page 84: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L2126 KAFO FEM FX CAST THERMOPLAS 1031.23

L2128 KAFO FEM FX CAST MOLDED TO P 1619.84

L2132 KAFO FEMORAL FX CAST SOFT 625.79

L2134 KAFO FEM FX CAST SEMI-RIGID 970.73

L2136 KAFO FEMORAL FX CAST RIGID 1186.95

L2180 PLAS SHOE INSERT W ANK JOINT 117.53

L2182 DROP LOCK KNEE 80.46

L2184 LIMITED MOTION KNEE JOINT 93.25

L2186 ADJ MOTION KNEE JNT LERMAN T 113.33

L2188 QUADRILATERAL BRIM 225.44

L2190 WAIST BELT 65.74

L2192 PELVIC BAND & BELT THIGH FLA 357.87

L2200 LIMITED ANKLE MOTION EA JNT 47.72

L2210 DORSIFLEXION ASSIST EACH JOI 67.47

L2220 DORSI & PLANTAR FLEX ASS/RES 82.19

L2230 SPLIT FLAT CALIPER STIRR & P 77.01

L2240 ROUND CALIPER AND PLATE ATTA 83.93

L2250 FOOT PLATE MOLDED STIRRUP AT 356.64

L2260 REINFORCED SOLID STIRRUP 201.2

L2265 LONG TONGUE STIRRUP 118.2

L2270 VARUS/VALGUS STRAP PADDED/LI 53.9

L2275 PLASTIC MOD LOW EXT PAD/LINE 117.73

L2280 MOLDED INNER BOOT 454.48

L2300 ABDUCTION BAR JOINTED ADJUST 270.23

L2310 ABDUCTION BAR-STRAIGHT 123.47

L2320 NON-MOLDED LACER 206.5

L2330 LACER MOLDED TO PATIENT MODE 394.1

L2335 ANTERIOR SWING BAND 228.01

L2340 PRE-TIBIAL SHELL MOLDED TO P 448.58

L2350 PROSTHETIC TYPE SOCKET MOLDE 894.32

L2360 EXTENDED STEEL SHANK 51.36

L2370 PATTEN BOTTOM 257.65

L2375 TORSION ANK & HALF SOLID STI 113.41

L2380 TORSION STRAIGHT KNEE JOINT 123.56

L2385 STRAIGHT KNEE JOINT HEAVY DU 134.43

L2390 OFFSET KNEE JOINT EACH 109.86

L2395 OFFSET KNEE JOINT HEAVY DUTY 143.93

L2397 SUSPENSION SLEEVE LOWER EXT 99.48

L2405 KNEE JOINT DROP LOCK EA JNT 68.5

L2415 KNEE JOINT CAM LOCK EACH JOI 95.43

L2425 KNEE DISC/DIAL LOCK/ADJ FLEX 112.64

L2430 KNEE JNT RATCHET LOCK EA JNT 112.64

L2492 KNEE LIFT LOOP DROP LOCK RIN 88.98

L2500 THI/GLUT/ISCHIA WGT BEARING 316.63

L2510 TH/WGHT BEAR QUAD-LAT BRIM M 729.05

84/95

Page 85: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L2520 TH/WGHT BEAR QUAD-LAT BRIM C 462.37

L2525 TH/WGHT BEAR NAR M-L BRIM MO 1142.09

L2526 TH/WGHT BEAR NAR M-L BRIM CU 637.51

L2530 THIGH/WGHT BEAR LACER NON-MO 235.82

L2540 THIGH/WGHT BEAR LACER MOLDED 424.34

L2550 THIGH/WGHT BEAR HIGH ROLL CU 288.26

L2570 HIP CLEVIS TYPE 2 POSIT JNT 478.06

L2580 PELVIC CONTROL PELVIC SLING 465.81

L2600 HIP CLEVIS/THRUST BEARING FR 206.13

L2610 HIP CLEVIS/THRUST BEARING LO 243.74

L2620 PELVIC CONTROL HIP HEAVY DUT 268.36

L2622 HIP JOINT ADJUSTABLE FLEXION 307.79

L2624 HIP ADJ FLEX EXT ABDUCT CONT 332.36

L2627 PLASTIC MOLD RECIPRO HIP & C 1290.44

L2628 METAL FRAME RECIPRO HIP & CA 1261.16

L2630 PELVIC CONTROL BAND & BELT U 248.53

L2640 PELVIC CONTROL BAND & BELT B 337.29

L2650 PELV & THOR CONTROL GLUTEAL 100.65

L2660 THORACIC CONTROL THORACIC BA 187.06

L2670 THORAC CONT PARASPINAL UPRIG 153.51

L2680 THORAC CONT LAT SUPPORT UPRI 142.52

L2750 PLATING CHROME/NICKEL PR BAR 62.92

L2755 CARBON GRAPHITE LAMINATION 102.68

L2760 EXTENSION PER EXTENSION PER 60.98

L2768 ORTHO SIDEBAR DISCONNECT 102.38

L2780 NON-CORROSIVE FINISH 67.92

L2785 DROP LOCK RETAINER EACH 31.81

L2795 KNEE CONTROL FULL KNEECAP 85.28

L2800 KNEE CAP MEDIAL OR LATERAL P 107.06

L2810 KNEE CONTROL CONDYLAR PAD 78.39

L2820 SOFT INTERFACE BELOW KNEE SE 87.16

L2830 SOFT INTERFACE ABOVE KNEE SE 94.3

L2840 TIBIAL LENGTH SOCK FX OR EQU 32.89

L2850 FEMORAL LGTH SOCK FX OR EQUA 56.34

L2999 LOWER EXTREMITY ORTHOSIS NOS 0

L3140 ABDUCTION ROTATION BAR SHOE 33

L3150 ABDUCT ROTATION BAR W/O SHOE 33

L3160 SHOE STYLED POSITIONING DEV 11.86

L3170 FOOT PLAS HEEL STABI PRE OTS 39.99

L3260 AMBULATORY SURGICAL BOOT EAC 15.42

L3265 PLASTAZOTE SANDAL EACH 17

L3650 SO 8 ABD RESTRAINT PRE OTS 58.25

L3660 SO 8 AB RSTR CAN/WEB PRE OTS 89.62

L3670 SO ACRO/CLAV CAN WEB PRE OTS 111.06

L3675 SO VEST CANVAS/WEB PRE OTS 125.49

85/95

Page 86: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L3677 SO HARD PLAS STABILI PRE CST 67.87

L3710 EO ELAS W/METAL JNTS PRE OTS 101.95

L3720 FOREARM/ARM CUFFS FREE MOTIO 642.4

L3730 FOREARM/ARM CUFFS EXT/FLEX A 885.36

L3740 CUFFS ADJ LOCK W/ ACTIVE CON 1049.67

L3760 EO WITHJOINT, PREFABRICATED 357.62

L3762 EO RIGID W/O JOINTS PRE OTS 76.89

L3807 WHFO W/O JOINTS PRE CST 178.81

L3900 HINGE EXTENSION/FLEX WRIST/F 1166.95

L3901 HINGE EXT/FLEX WRIST FINGER 1436.4

L3904 WHFO ELECTRIC CUSTOM FITTED 2876.16

L3906 WHO W/O JOINTS CF 388.08

L3908 WHO COCK-UP NONMOLDE PRE OTS 58.85

L3912 HFO FLEXION GLOVE PRE OTS 93.14

L3916 Who nontorsion jnts pre ots 115.14

L3918 Metacarp fx orthosis pre ots 76.97

L3923 HFO WITHOUT JOINTS PRE CST 27.82

L3924 Hfo without joints pre ots 97.42

L3930 Hfo nontorsion jnts pre ots 53.5

L3956 ADD JOINT UPPER EXT ORTHOSIS 721.81

L3960 SEWHO AIRPLAN DESIG ABDU POS 721.81

L3962 SEWHO ERBS PALSEY DESIGN ABD 704.68

L3980 UP EXT FX ORTHOS HUMERAL NOS 303.63

L3982 UPPER EXT FX ORTHOSIS RAD/UL 366.65

L3984 UPPER EXT FX ORTHOSIS WRIST 338.05

L3995 SOCK FRACTURE OR EQUAL EACH 28.06

L3999 UPPER LIMB ORTHOSIS NOS 1279.73

L4000 REPL GIRDLE MILWAUKEE ORTH 8

L4010 REPLACE TRILATERAL SOCKET BR 673.59

L4020 REPLACE QUADLAT SOCKET BRIM 864.49

L4030 REPLACE SOCKET BRIM CUST FIT 506.74

L4040 REPLACE MOLDED THIGH LACER 409.7

L4045 REPLACE NON-MOLDED THIGH LAC 329.24

L4050 REPLACE MOLDED CALF LACER 414.36

L4055 REPLACE NON-MOLDED CALF LACE 268.31

L4060 REPLACE HIGH ROLL CUFF 318.97

L4070 REPLACE PROX & DIST UPRIGHT 282.46

L4080 REPL MET BAND KAFO-AFO PROX 86.99

L4090 REPL MET BAND KAFO-AFO CALF/ 82.84

L4100 REPL LEATH CUFF KAFO PROX TH 104.69

L4110 REPL LEATH CUFF KAFO-AFO CAL 85.11

L4130 REPLACE PRETIBIAL SHELL 497.96

L4205 ORTHO DVC REPAIR PER 15 MIN 8

L4210 ORTH DEV REPAIR/REPL MINOR P 8

L4350 ANKLE CONTROL ORTHO PRE OTS 89.72

86/95

Page 87: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L4360 PNEUMAT WALKING BOOT PRE CST 243.17

L4370 PNEUM FULL LEG SPLNT PRE OTS 142.11

L4386 NON-PNEUM WALK BOOT PRE CST 124.58

L4392 REPLACE AFO SOFT INTERFACE 18.19

L4394 REPLACE FOOT DROP SPINT 13.25

L4396 STATIC OR DYNAMI AFO PRE CST 129.66

L4398 FOOT DROP SPLINT PRE OTS 59.69

L4631 AFO, WALK BOOT TYPE, CUS FAB ANKLE 1661.65

L5000 SHO INSERT W ARCH TOE FILLER 481.95

L5010 MOLD SOCKET ANK HGT W/ TOE F 1082

L5020 TIBIAL TUBERCLE HGT W/ TOE F 2119.07

L5050 ANK SYMES MOLD SCKT SACH FT 2135.36

L5060 SYMES MET FR LEATH SOCKET AR 2953.39

L5100 MOLDED SOCKET SHIN SACH FOOT 2156.06

L5105 PLAST SOCKET JTS/THGH LACER 3714.66

L5150 MOLD SCKT EXT KNEE SHIN SACH 3755.02

L5160 MOLD SOCKET BENT KNEE SHIN S 4084.26

L5200 KNE SING AXIS FRIC SHIN SACH 3218.43

L5210 NO KNEE/ANKLE JOINTS W/ FT B 2374.61

L5220 NO KNEE JOINT WITH ARTIC ALI 2949.37

L5230 FEM FOCAL DEFIC CONSTANT FRI 4067.77

L5250 HIP CANAD SING AXI CONS FRIC 5548.07

L5270 TILT TABLE LOCKING HIP SING 5499.47

L5280 HEMIPELVECT CANAD SING AXIS 5444.47

L5301 BK MOLD SOCKET SACH FT ENDO 0

L5321 AK OPEN END SACH 3514.44

L5331 HIP DISART CANADIAN SACH FT 4670.41

L5341 HEMIPELVECTOMY CANADIAN SACH 5404.15

L5400 POSTOP DRESS & 1 CAST CHG BK 1272.55

L5410 POSTOP DSG BK EA ADD CAST CH 335.08

L5420 POSTOP DSG & 1 CAST CHG AK/D 1625.34

L5430 POSTOP DSG AK EA ADD CAST CH 452.99

L5450 POSTOP APP NON-WGT BEAR DSG 326.73

L5460 POSTOP APP NON-WGT BEAR DSG 437.3

L5500 INIT BK PTB PLASTER DIRECT 1367.68

L5505 INIT AK ISCHAL PLSTR DIRECT 1859.84

L5510 PREP BK PTB PLASTER MOLDED 1410.83

L5520 PERP BK PTB THERMOPLS DIRECT 1536.75

L5530 PREP BK PTB THERMOPLS MOLDED 1846.92

L5535 PREP BK PTB OPEN END SOCKET 1813.31

L5540 PREP BK PTB LAMINATED SOCKET 1934.1

L5560 PREP AK ISCHIAL PLAST MOLDED 1885.32

L5570 PREP AK ISCHIAL DIRECT FORM 2066.95

L5580 PREP AK ISCHIAL THERMO MOLD 2508.74

L5585 PREP AK ISCHIAL OPEN END 2221.79

87/95

Page 88: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L5590 PREP AK ISCHIAL LAMINATED 2570.51

L5595 HIP DISARTIC SACH THERMOPLS 4305.5

L5600 HIP DISART SACH LAMINAT MOLD 4754.56

L5610 ABOVE KNEE HYDRACADENCE 1965.23

L5611 AK 4 BAR LINK W/FRIC SWING 1589.32

L5613 AK 4 BAR LING W/HYDRAUL SWIG 2620.51

L5614 4-BAR LINK ABOVE KNEE W/SWNG 1328.51

L5616 AK UNIV MULTIPLEX SYS FRICT 1131.75

L5617 AK/BK SELF-ALIGNING UNIT EA 440.5

L5618 TEST SOCKET SYMES 231.58

L5620 TEST SOCKET BELOW KNEE 234.56

L5622 TEST SOCKET KNEE DISARTICULA 304.02

L5624 TEST SOCKET ABOVE KNEE 333.46

L5626 TEST SOCKET HIP DISARTICULAT 438.06

L5628 TEST SOCKET HEMIPELVECTOMY 387.67

L5629 BELOW KNEE ACRYLIC SOCKET 254.87

L5630 SYME TYP EXPANDABL WALL SCKT 441.86

L5631 AK/KNEE DISARTIC ACRYLIC SOC 352.37

L5632 SYMES TYPE PTB BRIM DESIGN S 189.51

L5634 SYMES TYPE POSTER OPENING SO 325.26

L5636 SYMES TYPE MEDIAL OPENING SO 204.34

L5637 BELOW KNEE TOTAL CONTACT 307.69

L5638 BELOW KNEE LEATHER SOCKET 520.39

L5639 BELOW KNEE WOOD SOCKET 1198.87

L5640 KNEE DISARTICULAT LEATHER SO 622.22

L5642 ABOVE KNEE LEATHER SOCKET 496.87

L5643 HIP FLEX INNER SOCKET EXT FR 1248.22

L5644 ABOVE KNEE WOOD SOCKET 473.68

L5645 BK FLEX INNER SOCKET EXT FRA 724.32

L5646 BELOW KNEE CUSHION SOCKET 439.41

L5647 BELOW KNEE SUCTION SOCKET 850.58

L5648 ABOVE KNEE CUSHION SOCKET 528

L5649 ISCH CONTAINMT/NARROW M-L SO 1536.84

L5650 TOT CONTACT AK/KNEE DISART S 522.01

L5651 AK FLEX INNER SOCKET EXT FRA 963.1

L5652 SUCTION SUSP AK/KNEE DISART 349.64

L5653 KNEE DISART EXPAND WALL SOCK 522.47

L5654 SOCKET INSERT SYMES 326.77

L5655 SOCKET INSERT BELOW KNEE 283.62

L5656 SOCKET INSERT KNEE ARTICULAT 396.66

L5658 SOCKET INSERT ABOVE KNEE 301.88

L5661 MULTI-DUROMETER SYMES 603.22

L5665 MULTI-DUROMETER BELOW KNEE 547.51

L5666 BELOW KNEE CUFF SUSPENSION 74.85

L5668 BK MOLDED DISTAL CUSHION 107.98

88/95

Page 89: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L5670 BK MOLDED SUPRACONDYLAR SUSP 290.15

L5671 BK/AK LOCKING MECHANISM 531.87

L5672 BK REMOVABLE MEDIAL BRIM SUS 252.77

L5676 BK KNEE JOINTS SINGLE AXIS P 387.48

L5677 BK KNEE JOINTS POLYCENTRIC P 527.22

L5678 BK JOINT COVERS PAIR 42.46

L5680 BK THIGH LACER NON-MOLDED 255.75

L5682 BK THIGH LACER GLUT/ISCHIA M 668.73

L5684 BK FORK STRAP 51.46

L5686 BK BACK CHECK 49.79

L5688 BK WAIST BELT WEBBING 65.31

L5690 BK WAIST BELT PADDED AND LIN 104.63

L5692 AK PELVIC CONTROL BELT LIGHT 142.08

L5694 AK PELVIC CONTROL BELT PAD/L 193.98

L5695 AK SLEEVE SUSP NEOPRENE/EQUA 174.38

L5696 AK/KNEE DISARTIC PELVIC JOIN 197.84

L5697 AK/KNEE DISARTIC PELVIC BAND 85.84

L5698 AK/KNEE DISARTIC SILESIAN BA 110.02

L5699 SHOULDER HARNESS 199.37

L5700 REPLACE SOCKET BELOW KNEE 2928.3

L5701 REPLACE SOCKET ABOVE KNEE 3635.72

L5702 REPLACE SOCKET HIP 4645.7

L5703 SYMES ANKLE W/O (SACH) FOOT 1930.5

L5704 CUSTOM SHAPE COVER BK 489.05

L5705 CUSTOM SHAPE COVER AK 802.86

L5706 CUSTOM SHAPE CVR KNEE DISART 795.73

L5707 CUSTOM SHAPE CVR HIP DISART 1131.18

L5710 KNE-SHIN EXO SNG AXI MNL LOC 384.58

L5711 KNEE-SHIN EXO MNL LOCK ULTRA 558.34

L5712 KNEE-SHIN EXO FRICT SWG & ST 460.75

L5714 KNEE-SHIN EXO VARIABLE FRICT 400.43

L5716 KNEE-SHIN EXO MECH STANCE PH 779.34

L5718 KNEE-SHIN EXO FRCT SWG & STA 974.09

L5722 KNEE-SHIN PNEUM SWG FRCT EXO 870.17

L5724 KNEE-SHIN EXO FLUID SWING PH 1546.65

L5726 KNEE-SHIN EXT JNTS FLD SWG E 1581.69

L5728 KNEE-SHIN FLUID SWG & STANCE 2544.37

L5780 KNEE-SHIN PNEUM/HYDRA PNEUM 1224.24

L5781 LOWER LIMB PROS VACUUM PUMP 3150.08

L5785 EXOSKELETAL BK ULTRALT MATER 440.52

L5790 EXOSKELETAL AK ULTRA-LIGHT M 709.25

L5795 EXOSKEL HIP ULTRA-LIGHT MATE 894.98

L5810 ENDOSKEL KNEE-SHIN MNL LOCK 520.6

L5811 ENDO KNEE-SHIN MNL LCK ULTRA 779.85

L5812 ENDO KNEE-SHIN FRCT SWG & ST 604.46

89/95

Page 90: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L5814 ENDO KNEE-SHIN HYDRAL SWG PH 2923.91

L5816 ENDO KNEE-SHIN POLYC MCH STA 909.37

L5818 ENDO KNEE-SHIN FRCT SWG & ST 1026.87

L5822 ENDO KNEE-SHIN PNEUM SWG FRC 1365.67

L5824 ENDO KNEE-SHIN FLUID SWING P 1639.82

L5826 MINIATURE KNEE JOINT 2458.64

L5828 ENDO KNEE-SHIN FLUID SWG/STA 2933.64

L5830 ENDO KNEE-SHIN PNEUM/SWG PHA 2029.01

L5840 MULTI-AXIAL KNEE/SHIN SYSTEM 3236.89

L5845 KNEE-SHIN SYS STANCE FLEXION 1411.11

L5848 KNEE-SHIN SYS HYDRAUL STANCE 846.6

L5850 ENDO AK/HIP KNEE EXTENS ASSI 102.59

L5855 MECH HIP EXTENSION ASSIST 330.23

L5910 ENDO BELOW KNEE ALIGNABLE SY 290.45

L5920 ENDO AK/HIP ALIGNABLE SYSTEM 425.51

L5925 ABOVE KNEE MANUAL LOCK 349.76

L5930 HIGH ACTIVITY KNEE FRAME 2649.95

L5940 ENDO BK ULTRA-LIGHT MATERIAL 427.54

L5950 ENDO AK ULTRA-LIGHT MATERIAL 623.94

L5960 ENDO HIP ULTRA-LIGHT MATERIA 773.13

L5962 BELOW KNEE FLEX COVER SYSTEM 628.52

L5964 ABOVE KNEE FLEX COVER SYSTEM 904.8

L5966 HIP FLEXIBLE COVER SYSTEM 1173.04

L5968 MULTIAXIAL ANKLE W DORSIFLEX 2860.96

L5970 FOOT EXTERNAL KEEL SACH FOOT 204.9

L5971 SACH FOOT, REPLACEMENT 204.9

L5972 FLEXIBLE KEEL FOOT 376.85

L5974 FOOT SINGLE AXIS ANKLE/FOOT 249.17

L5975 COMBO ANKLE/FOOT PROSTHESIS 364.98

L5976 ENERGY STORING FOOT 598.83

L5978 FT PROSTH MULTIAXIAL ANKL/FT 312.05

L5979 MULTI-AXIAL ANKLE/FT PROSTH 2417.33

L5980 FLEX FOOT SYSTEM 3384.57

L5981 FLEX-WALK SYS LOW EXT PROSTH 2626.94

L5982 EXOSKELETAL AXIAL ROTATION U 618.17

L5984 ENDOSKELETAL AXIAL ROTATION 609.15

L5985 LWR EXT DYNAMIC PROSTH PYLON 222.32

L5986 MULTI-AXIAL ROTATION UNIT 677.59

L5987 SHANK FT W VERT LOAD PYLON 5663.57

L5988 VERTICAL SHOCK REDUCING PYLO 1572.78

L5990 USER ADJUSTABLE HEEL HEIGHT 1428.31

L5999 LOWR EXTREMITY PROSTHES NOS 1420.76

L6010 PART HAND LITTLE/RING 1581.07

L6020 PART HAND NO FINGERS 1474.1

L6050 WRST MLD SCK FLX HNG TRI PAD 2024.81

90/95

Page 91: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L6055 WRST MOLD SOCK W/EXP INTERFA 2596.73

L6100 ELB MOLD SOCK FLEX HINGE PAD 1685

L6110 ELBOW MOLD SOCK SUSPENSION T 2182.18

L6120 ELBOW MOLD DOUB SPLT SOC STE 2477.81

L6130 ELBOW STUMP ACTIVATED LOCK H 2768.09

L6200 ELBOW MOLD OUTSID LOCK HINGE 2917.12

L6205 ELBOW MOLDED W/ EXPAND INTER 3560.93

L6250 ELBOW INTER LOC ELBOW FORARM 2871.42

L6300 SHLDER DISART INT LOCK ELBOW 3983.78

L6310 SHOULDER PASSIVE RESTOR COMP 3244.87

L6320 SHOULDER PASSIVE RESTOR CAP 1827.35

L6350 THORACIC INTERN LOCK ELBOW 4156.76

L6360 THORACIC PASSIVE RESTOR COMP 3405.88

L6370 THORACIC PASSIVE RESTOR CAP 2171.81

L6380 POSTOP DSG CAST CHG WRST/ELB 1037.38

L6382 POSTOP DSG CAST CHG ELB DIS/ 1305.03

L6384 POSTOP DSG CAST CHG SHLDER/T 1692.25

L6386 POSTOP EA CAST CHG & REALIGN 429.41

L6388 POSTOP APPLICAT RIGID DSG ON 438.41

L6400 BELOW ELBOW PROSTH TISS SHAP 2481.18

L6450 ELB DISART PROSTH TISS SHAP 3024.44

L6500 ABOVE ELBOW PROSTH TISS SHAP 2749.48

L6550 SHLDR DISAR PROSTH TISS SHAP 4077.47

L6570 SCAP THORAC PROSTH TISS SHAP 4680.15

L6580 WRIST/ELBOW BOWDEN CABLE MOL 1433.23

L6582 WRIST/ELBOW BOWDEN CBL DIR F 1103.75

L6584 ELBOW FAIR LEAD CABLE MOLDED 1791.95

L6586 ELBOW FAIR LEAD CABLE DIR FO 1524.3

L6588 SHDR FAIR LEAD CABLE MOLDED 2593.27

L6590 SHDR FAIR LEAD CABLE DIRECT 2278.38

L6600 POLYCENTRIC HINGE PAIR 200.57

L6605 SINGLE PIVOT HINGE PAIR 198.05

L6610 FLEXIBLE METAL HINGE PAIR 178.02

L6615 DISCONNECT LOCKING WRIST UNI 146.93

L6616 DISCONNECT INSERT LOCKING WR 52.02

L6620 FLEXION/EXTENSION WRIST UNIT 306.47

L6623 SPRING-ASS ROT WRST W/ LATCH 514.43

L6625 ROTATION WRST W/ CABLE LOCK 568.71

L6628 QUICK DISCONN HOOK ADAPTER O 384.18

L6629 LAMINATION COLLAR W/ COUPLIN 140.43

L6630 STAINLESS STEEL ANY WRIST 172.84

L6632 LATEX SUSPENSION SLEEVE EACH 52.1

L6635 LIFT ASSIST FOR ELBOW 188.33

L6637 NUDGE CONTROL ELBOW LOCK 343.89

L6638 ELEC LOCK ON MANUAL PW ELBOW 1968.81

91/95

Page 92: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L6640 SHOULDER ABDUCTION JOINT PAI 224.64

L6641 EXCURSION AMPLIFIER PULLEY T 161.11

L6642 EXCURSION AMPLIFIER LEVER TY 208.95

L6645 SHOULDER FLEXION-ABDUCTION J 341.35

L6646 MULTIPO LOCKING SHOULDER JNT 2483.11

L6647 SHOULDER LOCK ACTUATOR 408.79

L6648 EXT PWRD SHLDER LOCK/UNLOCK 2560.98

L6650 SHOULDER UNIVERSAL JOINT 361.94

L6655 STANDARD CONTROL CABLE EXTRA 80.32

L6660 HEAVY DUTY CONTROL CABLE 98.15

L6665 TEFLON OR EQUAL CABLE LINING 39.77

L6670 HOOK TO HAND CABLE ADAPTER 51.28

L6672 HARNESS CHEST/SHLDER SADDLE 180.3

L6675 HARNESS FIGURE OF 8 SING CON 122.42

L6676 HARNESS FIGURE OF 8 DUAL CON 129.68

L6680 TEST SOCK WRIST DISART/BEL E 248.09

L6682 TEST SOCK ELBW DISART/ABOVE 247.03

L6684 TEST SOCKET SHLDR DISART/THO 372.73

L6686 SUCTION SOCKET 631.27

L6687 FRAME TYP SOCKET BEL ELBOW/W 467.87

L6688 FRAME TYP SOCK ABOVE ELB/DIS 506.84

L6689 FRAME TYP SOCKET SHOULDER DI 577.97

L6690 FRAME TYP SOCK INTERSCAP-THO 669.54

L6691 REMOVABLE INSERT EACH 368.41

L6692 SILICONE GEL INSERT OR EQUAL 597.98

L6693 LOCKINGELBOW FOREARM CNTRBAL 2235.13

L6715 "Term device multi art digit" 342.54

L6805 TERM DEV MODIFIER WRIST UNIT 339.57

L6810 TERM DEV PRECISION PINCH DEV 174.55

L6880 Elec hand ind art digits 494.41

L6881 TERM DEV AUTO GRASP FEATURE 3218.65

L6882 MICROPROCESSOR CONTROL UPLMB 2441.49

L6890 PREFAB GLOVE FOR TERM DEVICE 181.87

L6895 CUSTOM GLOVE FOR TERM DEVICE 447.81

L6900 HAND RESTORAT THUMB/1 FINGER 1608.83

L6905 HAND RESTORATION MULTIPLE FI 1569.94

L6910 HAND RESTORATION NO FINGERS 1529.45

L6915 HAND RESTORATION REPLACMNT G 647.52

L7360 SIX VOLT BAT OTTO BOCK/EQ EA 194.82

L7362 BATTERY CHRGR SIX VOLT OTTO 207.03

L7364 TWELVE VOLT BATTERY UTAH/EQU 380.92

L7366 BATTERY CHRGR 12 VOLT UTAH/E 492.16

L7367 REPLACEMNT LITHIUM IONBATTER 306.51

L7368 LITHIUM ION BATTERY CHARGER 397.34

L7499 UPPER EXTREMITY PROSTHES NOS 426.3

92/95

Page 93: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L7510 PROSTHETIC DEVICE REPAIR REP 8

L7520 REPAIR PROSTHESIS PER 15 MIN 8

L8000 MASTECTOMY BRA 39.04

L8001 BREAST PROSTHESIS BRA & FORM 98.74

L8002 BRST PRSTH BRA & BILAT FORM 129.88

L8010 MASTECTOMY SLEEVE 47.19

L8015 EXT BREASTPROSTHESIS GARMENT 47.19

L8020 MASTECTOMY FORM 167.64

L8030 BREAST PROSTHES W/O ADHESIVE 306.28

L8035 CUSTOM BREAST PROSTHESIS 2884.35

L8039 BREAST PROSTHESIS NOS 0

L8040 NASAL PROSTHESIS KN 824.92

L8040 NASAL PROSTHESIS 2062.29

L8041 MIDFACIAL PROSTHESIS KN 994.4

L8041 MIDFACIAL PROSTHESIS KM 2361.57

L8041 MIDFACIAL PROSTHESIS 2485.87

L8042 ORBITAL PROSTHESIS KN 1117.25

L8042 ORBITAL PROSTHESIS KM 2653.46

L8042 ORBITAL PROSTHESIS 2793.11

L8043 UPPER FACIAL PROSTHESIS KN 1251.3

L8043 UPPER FACIAL PROSTHESIS KM 2971.85

L8043 UPPER FACIAL PROSTHESIS 3128.29

L8044 HEMI-FACIAL PROSTHESIS KN 1385.38

L8044 HEMI-FACIAL PROSTHESIS KM 3290.28

L8044 HEMI-FACIAL PROSTHESIS 3463.45

L8045 AURICULAR PROSTHESIS KN 870.74

L8045 AURICULAR PROSTHESIS KM 2068.01

L8045 AURICULAR PROSTHESIS 2176.85

L8046 PARTIAL FACIAL PROSTHESIS KN 893.79

L8046 PARTIAL FACIAL PROSTHESIS KM 2122.77

L8046 PARTIAL FACIAL PROSTHESIS 2234.49

L8047 NASAL SEPTAL PROSTHESIS KN 458.08

L8047 NASAL SEPTAL PROSTHESIS KM 1087.91

L8047 NASAL SEPTAL PROSTHESIS 1145.16

L8049 REPAIR MAXILLOFACIAL PROSTH 8

L8300 TRUSS SINGLE W/ STANDARD PAD 90.2

L8310 TRUSS DOUBLE W/ STANDARD PAD 142.41

L8320 TRUSS ADDITION TO STD PAD WA 57.16

L8330 TRUSS ADD TO STD PAD SCROTAL 52.79

L8400 SHEATH BELOW KNEE 16.83

L8410 SHEATH ABOVE KNEE 21.72

L8415 SHEATH UPPER LIMB 19.2

L8417 PROS SHEATH/SOCK W GEL CUSHN 59.2

L8420 PROSTHETIC SOCK MULTI PLY BK 20.8

L8430 PROSTHETIC SOCK MULTI PLY AK 22.32

93/95

Page 94: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

L8435 PROS SOCK MULTI PLY UPPER LM 20.72

L8440 SHRINKER BELOW KNEE 44.72

L8460 SHRINKER ABOVE KNEE 71.27

L8465 SHRINKER UPPER LIMB 39.12

L8470 PROS SOCK SINGLE PLY BK 7.14

L8480 PROS SOCK SINGLE PLY AK 8.51

L8485 PROS SOCK SINGLE PLY UPPER L 11.53

L8499 UNLISTED MISC PROSTHETIC SER 0

L8500 ARTIFICIAL LARYNX 529.27

L8501 TRACHEOSTOMY SPEAKING VALVE 96.88

L8507 TRACH-ESOPH VOICE PROS PT IN 32.98

L8509 TRACH-ESOPH VOICE PROS MD IN 85.98

L8600 IMPLANT BREAST SILICONE/EQ 545.82

L8603 COLLAGEN IMP URINARY 2.5 ML 351.66

L8606 SYNTHETIC IMPLNT URINARY 1ML 182.61

L8610 OCULAR IMPLANT 469.4

L8612 AQUEOUS SHUNT PROSTHESIS 638.02

L8613 OSSICULAR IMPLANT 236.84

L8614 COCHLEAR DEVICE 15819.35

L8619 COCH IMP EXT PROC/CONTR RPLC 6791.15

L8630 METACARPOPHALANGEAL IMPLANT 270.19

L8641 METATARSAL JOINT IMPLANT 283.93

L8642 HALLUX IMPLANT 277.8

L8658 INTERPHALANGEAL JOINT SPACER 244.76

L8670 VASCULAR GRAFT, SYNTHETIC 446.41

L9900 O&P SUPPLY/ACCESSORY/SERVICE 0

Q4001 CAST SUP BODY CAST PLASTER 161.73

Q4002 CAST SUP BODY CAST FIBERGLAS 343.6

Q4003 CAST SUP SHOULDER CAST PLSTR 87.7

Q4004 CAST SUP SHOULDER CAST FBRGL 186.17

Q4005 CAST SUP LONG ARM ADULT PLST 48.16

Q4006 CAST SUP LONG ARM ADULT FBRG 102.43

Q4007 CAST SUP LONG ARM PED PLSTER 24.08

Q4008 CAST SUP LONG ARM PED FBRGLS 51.04

Q4009 CAST SUP SHT ARM ADULT PLSTR 37.02

Q4010 CAST SUP SHT ARM ADULT FBRGL 79.43

Q4011 CAST SUP SHT ARM PED PLASTER 18.69

Q4012 CAST SUP SHT ARM PED FBRGLAS 39.54

Q4013 CAST SUP GAUNTLET PLASTER 34.86

Q4014 CAST SUP GAUNTLET FIBERGLASS 74.76

Q4015 CAST SUP GAUNTLET PED PLSTER 17.61

Q4016 CAST SUP GAUNTLET PED FBRGLS 37.38

Q4017 CAST SUP LNG ARM SPLINT PLST 30.55

Q4018 CAST SUP LNG ARM SPLINT FBRG 65.05

Q4019 CAST SUP LNG ARM SPLNT PED P 15.45

94/95

Page 95: Modifier Listdhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/... · 2015. 7. 7. · 11100 biopsy skin lesion 33.79 11101 biopsy skin add-on 17.16 11200 removal of skin tags

Proc Code Description Mod Rate

Q4020 CAST SUP LNG ARM SPLNT PED F 32.71

Q4021 CAST SUP SHT ARM SPLINT PLST 30.55

Q4022 CAST SUP SHT ARM SPLINT FBRG 65.05

Q4023 CAST SUP SHT ARM SPLNT PED P 15.45

Q4024 CAST SUP SHT ARM SPLNT PED F 32.71

Q4025 CAST SUP HIP SPICA PLASTER 135.86

Q4026 CAST SUP HIP SPICA FIBERGLAS 288.97

Q4027 CAST SUP HIP SPICA PED PLSTR 67.93

Q4028 CAST SUP HIP SPICA PED FBRGL 144.48

Q4029 CAST SUP LONG LEG PLASTER 66.85

Q4030 CAST SUP LONG LEG FIBERGLASS 142.33

Q4031 CAST SUP LNG LEG PED PLASTER 33.43

Q4032 CAST SUP LNG LEG PED FBRGLS 71.16

Q4033 CAST SUP LNG LEG CYLINDER PL 57.15

Q4034 CAST SUP LNG LEG CYLINDER FB 121.12

Q4035 CAST SUP LNGLEG CYLNDR PED P 28.39

Q4036 CAST SUP LNGLEG CYLNDR PED F 60.38

Q4037 CAST SUP SHRT LEG PLASTER 76.55

Q4038 CAST SUP SHRT LEG FIBERGLASS 163.17

Q4039 CAST SUP SHRT LEG PED PLSTER 38.1

Q4040 CAST SUP SHRT LEG PED FBRGLS 81.59

Q4041 CAST SUP LNG LEG SPLNT PLSTR 43.85

Q4042 CAST SUP LNG LEG SPLNT FBRGL 93.09

Q4043 CAST SUP LNG LEG SPLNT PED P 21.92

Q4044 CAST SUP LNG LEG SPLNT PED F 46.72

Q4045 CAST SUP SHT LEG SPLNT PLSTR 28.39

Q4046 CAST SUP SHT LEG SPLNT FBRGL 60.38

Q4047 CAST SUP SHT LEG SPLNT PED P 14.02

Q4048 CAST SUP SHT LEG SPLNT PED F 30.19

Q4049 FINGER SPLINT, STATIC 37.38

Q4050 CAST SUPPLIES UNLISTED 0

Q4051 SPLINT SUPPLIES MISC 0

Q4101 APLIGRAF 31.39

Q4102 OASIS WOUND MATRIX 4.35

Q4105 INTEGRA DRT 11.87

Q4106 DERMAGRAFT 38.45

Q4116 ALLODERM 34.3

Q4141 Alloskin ac 1 cm 0

95/95