CPT Codes,Modifiers,Non Facility Amount,Facility Amount
10060,,,
10061,,,
10120,,,
10140,,,
11055,,,
11056,,,
11100,,,
11101,,,
11102,,,
11103,,,
11104,,,
11105,,,
11106,,,
11107,,,
11200,,,
11201,,,
11300,,,
11301,,,
11302,,,
11303,,,
11305,,,
11306,,,
11307,,,
11308,,,
11310,,,
11311,,,
11312,,,
11313,,,
11400,,,
11401,,,
11402,,,
11403,,,
11404,,,
11406,,,
11420,,,
11421,,,
11422,,,
11423,,,
11424,,,
11426,,,
11440,,,
11441,,,
11442,,,
11443,,,
11444,,,
11446,,,
11600,,,
11601,,,
11602,,,
11603,,,
11604,,,
11606,,,
11620,,,
11621,,,
11622,,,
11623,,,
11624,,,
11626,,,
11640,,,
11641,,,
11642,,,
11643,,,
11644,,,
11646,,,
11730,,,
11750,,,
11755,,,
11900,,,
11901,,,
12001,,,
12002,,,
12004,,,
12005,,,
12006,,,
12007,,,
12011,,,
12013,,,
12014,,,
12015,,,
12016,,,
12017,,,
12018,,,
12020,,,
12021,,,
12031,,,
12032,,,
12034,,,
12035,,,
12036,,,
12037,,,
12041,,,
12042,,,
12044,,,
12045,,,
12046,,,
12047,,,
12051,,,
12052,,,
12053,,,
12054,,,
12055,,,
12056,,,
12057,,,
13100,,,
13101,,,
13102,,,
13120,,,
13121,,,
13122,,,
13131,,,
13132,,,
13133,,,
13150,,,
13151,,,
13152,,,
13153,,,
13160,,,
14000,,,
14001,,,
14020,,,
14021,,,
14040,,,
14041,,,
14060,,,
14061,,,
14300,,,
15200,,,
15201,,,
15220,,,
15221,,,
15240,,,
15241,,,
15260,,,
15261,,,
15740,,,
17000,,,
17003,,,
17004,,,
17110,,,
17111,,,
17250,,,
17260,,,
17261,,,
17262,,,
17263,,,
17264,,,
17266,,,
17270,,,
17271,,,
17272,,,
17273,,,
17274,,,
17276,,,
17280,,,
17281,,,
17282,,,
17283,,,
17284,,,
17286,,,
17311,,,
17312,,,
17313,,,
17314,,,
17315,,,
40490,,,
46924,,,
54050,,,
54065,,,
54100,,,
56501,,,
56515,,,
67810,,,
69100,,,
81000,,,
81001,,,
81015,,,
81025,,,
87070,,,
87220,,,
88304,,,
88305,,,
95044,,,
96567,,,
96570,,,
96571,,,
96573,,,
96574,,,
96910,,,
96912,,,
99201,,,
99202,,,
99203,,,
99204,,,
99205,,,
99211,,,
99212,,,
99213,,,
99214,,,
99215,,,
J3301,,,
J9040,,,
J3490,,,
J7345,,,