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First Choice Health Network Physician, Nurse Practitioner and Physician Assistant Fee Schedule Sample Reimbursement Rates Non- CPT Facility Code Rate 99201 $58.43 99202 $99.75 99203 $144.40 99204 $220.40 99205 $276.45 99211 $26 .60 99212 $57.95 99213 $97 .38 99214 $143.45 99215 $193 .33 99217 $97.38 99218 $133.48 99219 $181.45 99220 $247.95 99221 $135.85 99222 $183.35 Non- CPT Facility Code Rate 10060 $157.70 11100 $138.70 17110 $148.68 20550 $79.33 20610 $81.23 25605 $739.10 29075 $117.80 29881 $740.53 42820 $401.38 43239 $535.80 45300 $166.25 45330 $225.15 49505 $715.83 52000 $275.50 54150 $208.05 55250 $518.23 57454 $205 .68 FCHN-PRO-102013 Sch B-RBRVS Effective January 1, 2017 EVALUATION AND MANAGEMENT SERVICES Non-Non- Facility CPT Facility Facility CPT Facility Facility Rate Code Rate Rate Code Rate Rate $35.63 99223 $271.23 $271.23 99315 $97.85 $97.85 $67.45 99231 $52.73 $52.73 99316 $141.55 $141.55 $103.08 99232 $96.43 $96.43 99381 $147.25 $102.60 $174.33 99233 $139.18 $139.18 99382 $153.90 $109.25 $226.58 99234 $179.08 $179.08 99383 $160.55 $116.38 $12.35 99235 $226.10 $226.10 99384 $181.45 $136.80 $33.73 99236 $291.18 $291.18 99385 $175 .28 $131.10 $68.40 99238 $96.90 $96 .90 99386 $203 .78 $159.60 $104 .98 99239 $143.45 $143.45 99387 $220.88 $171.48 $148.68 99281 $28 .50 $28.50 99391 $132.53 $93.58 $97.38 99282 $55.58 $55.58 99392 $141.55 $102.60 $133.48 99283 $83.13 $83.13 99393 $141.08 $102.60 $181.45 99284 $157.70 $157.70 99394 $154.85 $116.38 $247.95 99285 $232.75 $232.75 99395 $158.18 $119.70 $135.85 99291 $368.13 $299.73 99396 $168.63 $130.15 $183.35 99292 $164.35 $150.10 99397 $181.45 $136.80 MEDICAL/ SURGICAL SERVICES Non-Non- Facility CPT Facility Facility CPT Facility Facility Rate Code Rate Rate Code Rate Rate $131.10 58100 $146.78 $118.28 82977 $12.83 $12.83 $66.50 59025 $65.55 $65.55 83540 $11.88 $11.88 $94.53 59400 $2,858.08 $2,858.08 85014 $4.28 $4.28 $57.00 69210 $66.50 $44.65 85025 $14.25 $14.25 $62.70 69436 $219 .93 $219.93 86403 $18.53 $18.53 $695.88 70210 $39.43 $39.43 87081 $11.88 $11.88 $85 .03 70220 $49 .88 $49.88 87086 $14 .73 $14 .73 $740.53 70450 $155 .33 $155 .33 88150 $19.00 $19 .00 $401.38 71020 $37 .05 $37.05 88305 $98.33 $98.33 $200.93 72040 $44.18 $44.18 90837 $170.05 $168.63 $74.10 72050 $59.85 $59.85 92004 $198.55 $133.95 $77.43 73030 $38.48 $38.48 92014 $165.30 $107.35 $715.83 73140 $41.80 $41.80 92015 $26.60 $26.13 $172.43 73610 $41.33 $41.33 93000 $22.80 $22.80 $133.48 76805 $191.43 $191.43 93015 $102.13 $102.13 $309 .70 81000 $5 .70 $5 .70 94010 $48.45 $48.45 $183 .35 82270 $5 .70 $5.70 95165 $17.10 $4.28 Page 2