Policy source
The recorded policy does not contain a public text excerpt. Read the official source for details.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 0598T | HCPCS | Covered |
| 0599T | HCPCS | Covered |
| 0602T | HCPCS | Covered |
| 0603T | HCPCS | Covered |
| 0604T | HCPCS | Covered |
| 0605T | HCPCS | Covered |
| 0606T | HCPCS | Covered |
| 0607T | HCPCS | Covered |
| 0608T | HCPCS | Covered |
| 0609T | HCPCS | Covered |
| 0610T | HCPCS | Covered |
| 0611T | HCPCS | Covered |
| 0615T | HCPCS | Covered |
| 0633T | HCPCS | Covered |
| 0634T | HCPCS | Covered |
| 0635T | HCPCS | Covered |
| 0636T | HCPCS | Covered |
| 0637T | HCPCS | Covered |
| 0638T | HCPCS | Covered |
| 0648T | HCPCS | Covered |
| 0650T | HCPCS | Covered |
| 0651T | HCPCS | Covered |
| 0652T | HCPCS | Covered |
| 0658T | HCPCS | Covered |
| 0659T | HCPCS | Covered |
| 0689T | HCPCS | Covered |
| 0690T | HCPCS | Covered |
| 0691T | HCPCS | Covered |
| 0693T | HCPCS | Covered |
| 0697T | HCPCS | Covered |
| 0698T | HCPCS | Covered |
| 0721T | HCPCS | Covered |
| 0722T | HCPCS | Covered |
| 0723T | HCPCS | Covered |
| 0724T | HCPCS | Covered |
| 10004 | HCPCS | Covered |
| 10005 | HCPCS | Covered |
| 10006 | HCPCS | Covered |
| 10007 | HCPCS | Covered |
| 10008 | HCPCS | Covered |
| 10009 | HCPCS | Covered |
| 10010 | HCPCS | Covered |
| 10011 | HCPCS | Covered |
| 10012 | HCPCS | Covered |
| 11102 | HCPCS | Covered |
| 11103 | HCPCS | Covered |
| 11104 | HCPCS | Covered |
| 11105 | HCPCS | Covered |
| 11106 | HCPCS | Covered |
| 11107 | HCPCS | Covered |
| 19000 | HCPCS | Covered |
| 19001 | HCPCS | Covered |
| 19030 | HCPCS | Covered |
| 19081 | HCPCS | Covered |
| 19082 | HCPCS | Covered |
| 19083 | HCPCS | Covered |
| 19084 | HCPCS | Covered |
| 19085 | HCPCS | Covered |
| 19086 | HCPCS | Covered |
| 23350 | HCPCS | Covered |
| 24220 | HCPCS | Covered |
| 25246 | HCPCS | Covered |
| 27093 | HCPCS | Covered |
| 27095 | HCPCS | Covered |
| 27096 | HCPCS | Covered |
| 27369 | HCPCS | Covered |
| 27648 | HCPCS | Covered |
| 31253 | HCPCS | Covered |
| 36005 | HCPCS | Covered |
| 38505 | HCPCS | Covered |
| 42975 | HCPCS | Covered |
| 50430 | HCPCS | Covered |
| 50431 | HCPCS | Covered |
| 51600 | HCPCS | Covered |
| 51725 | HCPCS | Covered |
| 51726 | HCPCS | Covered |
| 51727 | HCPCS | Covered |
| 51728 | HCPCS | Covered |
| 51729 | HCPCS | Covered |
| 51736 | HCPCS | Covered |
| 51741 | HCPCS | Covered |
| 51784 | HCPCS | Covered |
| 51785 | HCPCS | Covered |
| 51792 | HCPCS | Covered |
| 51797 | HCPCS | Covered |
| 51798 | HCPCS | Covered |
| 54240 | HCPCS | Covered |
| 54250 | HCPCS | Covered |
| 58340 | HCPCS | Covered |
| 62302 | HCPCS | Covered |
| 62303 | HCPCS | Covered |
| 62304 | HCPCS | Covered |
| 62305 | HCPCS | Covered |
| 62328 | HCPCS | Covered |
| 70010 | HCPCS | Covered |
| 70015 | HCPCS | Covered |
| 70030 | HCPCS | Covered |
| 70100 | HCPCS | Covered |
| 70110 | HCPCS | Covered |
| 70120 | HCPCS | Covered |
| 70130 | HCPCS | Covered |
| 70134 | HCPCS | Covered |
| 70140 | HCPCS | Covered |
| 70150 | HCPCS | Covered |
| 70160 | HCPCS | Covered |
| 70170 | HCPCS | Covered |
| 70190 | HCPCS | Covered |
| 70200 | HCPCS | Covered |
| 70210 | HCPCS | Covered |
| 70220 | HCPCS | Covered |
| 70240 | HCPCS | Covered |
| 70250 | HCPCS | Covered |
| 70260 | HCPCS | Covered |
| 70300 | HCPCS | Covered |
| 70310 | HCPCS | Covered |
| 70320 | HCPCS | Covered |
| 70328 | HCPCS | Covered |
| 70330 | HCPCS | Covered |
| 70332 | HCPCS | Covered |
| 70336 | HCPCS | Covered |
| 70350 | HCPCS | Covered |
| 70355 | HCPCS | Covered |
| 70360 | HCPCS | Covered |
| 70370 | HCPCS | Covered |
| 70371 | HCPCS | Covered |
| 70380 | HCPCS | Covered |
| 70390 | HCPCS | Covered |
| 70450 | HCPCS | Covered |
| 70460 | HCPCS | Covered |
| 70470 | HCPCS | Covered |
| 70471 | HCPCS | Covered |
| 70480 | HCPCS | Covered |
| 70481 | HCPCS | Covered |
| 70482 | HCPCS | Covered |
| 70486 | HCPCS | Covered |
| 70487 | HCPCS | Covered |
| 70488 | HCPCS | Covered |
| 70490 | HCPCS | Covered |
| 70491 | HCPCS | Covered |
| 70492 | HCPCS | Covered |
| 70496 | HCPCS | Covered |
| 70498 | HCPCS | Covered |
| 70540 | HCPCS | Covered |
| 70542 | HCPCS | Covered |
| 70543 | HCPCS | Covered |
| 70544 | HCPCS | Covered |
| 70545 | HCPCS | Covered |
| 70546 | HCPCS | Covered |
| 70547 | HCPCS | Covered |
| 70548 | HCPCS | Covered |
| 70549 | HCPCS | Covered |
| 70551 | HCPCS | Covered |
| 70552 | HCPCS | Covered |
| 70553 | HCPCS | Covered |
| 70554 | HCPCS | Covered |
| 70555 | HCPCS | Covered |
| 71045 | HCPCS | Covered |
| 71046 | HCPCS | Covered |
| 71047 | HCPCS | Covered |
| 71048 | HCPCS | Covered |
| 71100 | HCPCS | Covered |
| 71101 | HCPCS | Covered |
| 71110 | HCPCS | Covered |
| 71111 | HCPCS | Covered |
| 71120 | HCPCS | Covered |
| 71130 | HCPCS | Covered |
| 71250 | HCPCS | Covered |
| 71260 | HCPCS | Covered |
| 71270 | HCPCS | Covered |
| 71271 | HCPCS | Covered |
| 71275 | HCPCS | Covered |
| 71550 | HCPCS | Covered |
| 71551 | HCPCS | Covered |
| 71552 | HCPCS | Covered |
| 71555 | HCPCS | Covered |
| 72020 | HCPCS | Covered |
| 72040 | HCPCS | Covered |
| 72050 | HCPCS | Covered |
| 72052 | HCPCS | Covered |
| 72070 | HCPCS | Covered |
| 72072 | HCPCS | Covered |
| 72074 | HCPCS | Covered |
| 72080 | HCPCS | Covered |
| 72081 | HCPCS | Covered |
| 72082 | HCPCS | Covered |
| 72083 | HCPCS | Covered |
| 72084 | HCPCS | Covered |
| 72100 | HCPCS | Covered |
| 72110 | HCPCS | Covered |
| 72114 | HCPCS | Covered |
| 72120 | HCPCS | Covered |
| 72125 | HCPCS | Covered |
| 72126 | HCPCS | Covered |
| 72127 | HCPCS | Covered |
| 72128 | HCPCS | Covered |
| 72129 | HCPCS | Covered |
| 72130 | HCPCS | Covered |
| 72131 | HCPCS | Covered |
| 72132 | HCPCS | Covered |
| 72133 | HCPCS | Covered |
| 72141 | HCPCS | Covered |
| 72142 | HCPCS | Covered |
| 72146 | HCPCS | Covered |
| 72147 | HCPCS | Covered |
| 72148 | HCPCS | Covered |
| 72149 | HCPCS | Covered |
| 72156 | HCPCS | Covered |
| 72157 | HCPCS | Covered |
| 72158 | HCPCS | Covered |
| 72159 | HCPCS | Covered |
| 72170 | HCPCS | Covered |
| 72190 | HCPCS | Covered |
| 72191 | HCPCS | Covered |
| 72192 | HCPCS | Covered |
| 72193 | HCPCS | Covered |
| 72194 | HCPCS | Covered |
| 72195 | HCPCS | Covered |
| 72196 | HCPCS | Covered |
| 72197 | HCPCS | Covered |
| 72198 | HCPCS | Covered |
| 72200 | HCPCS | Covered |
| 72202 | HCPCS | Covered |
| 72220 | HCPCS | Covered |
| 72240 | HCPCS | Covered |
| 72255 | HCPCS | Covered |
| 72265 | HCPCS | Covered |
| 72270 | HCPCS | Covered |
| 72285 | HCPCS | Covered |
| 72295 | HCPCS | Covered |
| 73000 | HCPCS | Covered |
| 73010 | HCPCS | Covered |
| 73020 | HCPCS | Covered |
| 73030 | HCPCS | Covered |
| 73040 | HCPCS | Covered |
| 73050 | HCPCS | Covered |
| 73060 | HCPCS | Covered |
| 73070 | HCPCS | Covered |
| 73080 | HCPCS | Covered |
| 73085 | HCPCS | Covered |
| 73090 | HCPCS | Covered |
| 73092 | HCPCS | Covered |
| 73100 | HCPCS | Covered |
| 73110 | HCPCS | Covered |
| 73115 | HCPCS | Covered |
| 73120 | HCPCS | Covered |
| 73130 | HCPCS | Covered |
| 73140 | HCPCS | Covered |
| 73200 | HCPCS | Covered |
| 73201 | HCPCS | Covered |
| 73202 | HCPCS | Covered |
| 73206 | HCPCS | Covered |
| 73218 | HCPCS | Covered |
| 73219 | HCPCS | Covered |
| 73220 | HCPCS | Covered |
| 73221 | HCPCS | Covered |
| 73222 | HCPCS | Covered |
| 73223 | HCPCS | Covered |
| 73225 | HCPCS | Covered |
| 73501 | HCPCS | Covered |
| 73502 | HCPCS | Covered |
| 73503 | HCPCS | Covered |
| 73521 | HCPCS | Covered |
| 73522 | HCPCS | Covered |
| 73523 | HCPCS | Covered |
| 73525 | HCPCS | Covered |
| 73551 | HCPCS | Covered |
| 73552 | HCPCS | Covered |
| 73560 | HCPCS | Covered |
| 73562 | HCPCS | Covered |
| 73564 | HCPCS | Covered |
| 73565 | HCPCS | Covered |
| 73580 | HCPCS | Covered |
| 73590 | HCPCS | Covered |
| 73592 | HCPCS | Covered |
| 73600 | HCPCS | Covered |
| 73610 | HCPCS | Covered |
| 73615 | HCPCS | Covered |
| 73620 | HCPCS | Covered |
| 73630 | HCPCS | Covered |
| 73650 | HCPCS | Covered |
| 73660 | HCPCS | Covered |
| 73700 | HCPCS | Covered |
| 73701 | HCPCS | Covered |
| 73702 | HCPCS | Covered |
| 73706 | HCPCS | Covered |
| 73718 | HCPCS | Covered |
| 73719 | HCPCS | Covered |
| 73720 | HCPCS | Covered |
| 73721 | HCPCS | Covered |
| 73722 | HCPCS | Covered |
| 73723 | HCPCS | Covered |
| 73725 | HCPCS | Covered |
| 74018 | HCPCS | Covered |
| 74019 | HCPCS | Covered |
| 74021 | HCPCS | Covered |
| 74022 | HCPCS | Covered |
| 74150 | HCPCS | Covered |
| 74160 | HCPCS | Covered |
| 74170 | HCPCS | Covered |
| 74174 | HCPCS | Covered |
| 74175 | HCPCS | Covered |
| 74176 | HCPCS | Covered |
| 74177 | HCPCS | Covered |
| 74178 | HCPCS | Covered |
| 74181 | HCPCS | Covered |
| 74182 | HCPCS | Covered |
| 74183 | HCPCS | Covered |
| 74185 | HCPCS | Covered |
| 74190 | HCPCS | Covered |
| 74210 | HCPCS | Covered |
| 74220 | HCPCS | Covered |
| 74221 | HCPCS | Covered |
| 74230 | HCPCS | Covered |
| 74240 | HCPCS | Covered |
| 74246 | HCPCS | Covered |
| 74248 | HCPCS | Covered |
| 74250 | HCPCS | Covered |
| 74251 | HCPCS | Covered |
| 74261 | HCPCS | Covered |
| 74262 | HCPCS | Covered |
| 74270 | HCPCS | Covered |
| 74280 | HCPCS | Covered |
| 74290 | HCPCS | Covered |
| 74400 | HCPCS | Covered |
| 74410 | HCPCS | Covered |
| 74415 | HCPCS | Covered |
| 74420 | HCPCS | Covered |
| 74425 | HCPCS | Covered |
| 74430 | HCPCS | Covered |
| 74440 | HCPCS | Covered |
| 74445 | HCPCS | Covered |
| 74450 | HCPCS | Covered |
| 74455 | HCPCS | Covered |
| 74470 | HCPCS | Covered |
| 74712 | HCPCS | Covered |
| 74713 | HCPCS | Covered |
| 74740 | HCPCS | Covered |
| 74742 | HCPCS | Covered |
| 74775 | HCPCS | Covered |
| 75557 | HCPCS | Covered |
| 75559 | HCPCS | Covered |
| 75561 | HCPCS | Covered |
| 75563 | HCPCS | Covered |
| 75565 | HCPCS | Covered |
| 75572 | HCPCS | Covered |
| 75573 | HCPCS | Covered |
| 75574 | HCPCS | Covered |
| 75577 | HCPCS | Covered |
| 75580 | HCPCS | Covered |
| 75600 | HCPCS | Covered |
| 75605 | HCPCS | Covered |
| 75625 | HCPCS | Covered |
| 75630 | HCPCS | Covered |
| 75635 | HCPCS | Covered |
| 75705 | HCPCS | Covered |
| 75710 | HCPCS | Covered |
| 75716 | HCPCS | Covered |
| 75726 | HCPCS | Covered |
| 75731 | HCPCS | Covered |
| 75733 | HCPCS | Covered |
| 75736 | HCPCS | Covered |
| 75741 | HCPCS | Covered |
| 75743 | HCPCS | Covered |
| 75746 | HCPCS | Covered |
| 75756 | HCPCS | Covered |
| 75774 | HCPCS | Covered |
| 75801 | HCPCS | Covered |
| 75803 | HCPCS | Covered |
| 75807 | HCPCS | Covered |
| 75809 | HCPCS | Covered |
| 75810 | HCPCS | Covered |
| 75820 | HCPCS | Covered |
| 75822 | HCPCS | Covered |
| 75825 | HCPCS | Covered |
| 75827 | HCPCS | Covered |
| 75831 | HCPCS | Covered |
| 75833 | HCPCS | Covered |
| 75840 | HCPCS | Covered |
| 75860 | HCPCS | Covered |
| 75870 | HCPCS | Covered |
| 75872 | HCPCS | Covered |
| 75880 | HCPCS | Covered |
| 75885 | HCPCS | Covered |
| 75887 | HCPCS | Covered |
| 75889 | HCPCS | Covered |
| 75891 | HCPCS | Covered |
| 75893 | HCPCS | Covered |
| 76000 | HCPCS | Covered |
| 76010 | HCPCS | Covered |
| 76014 | HCPCS | Covered |
| 76015 | HCPCS | Covered |
| 76016 | HCPCS | Covered |
| 76017 | HCPCS | Covered |
| 76018 | HCPCS | Covered |
| 76019 | HCPCS | Covered |
| 76080 | HCPCS | Covered |
| 76098 | HCPCS | Covered |
| 76120 | HCPCS | Covered |
| 76125 | HCPCS | Covered |
| 76140 | HCPCS | Covered |
| 76376 | HCPCS | Covered |
| 76377 | HCPCS | Covered |
| 76380 | HCPCS | Covered |
| 76390 | HCPCS | Covered |
| 76506 | HCPCS | Covered |
| 76510 | HCPCS | Covered |
| 76511 | HCPCS | Covered |
| 76512 | HCPCS | Covered |
| 76513 | HCPCS | Covered |
| 76514 | HCPCS | Covered |
| 76516 | HCPCS | Covered |
| 76519 | HCPCS | Covered |
| 76529 | HCPCS | Covered |
| 76536 | HCPCS | Covered |
| 76604 | HCPCS | Covered |
| 76641 | HCPCS | Covered |
| 76642 | HCPCS | Covered |
| 76700 | HCPCS | Covered |
| 76705 | HCPCS | Covered |
| 76706 | HCPCS | Covered |
| 76770 | HCPCS | Covered |
| 76775 | HCPCS | Covered |
| 76776 | HCPCS | Covered |
| 76800 | HCPCS | Covered |
| 76801 | HCPCS | Covered |
| 76802 | HCPCS | Covered |
| 76805 | HCPCS | Covered |
| 76810 | HCPCS | Covered |
| 76811 | HCPCS | Covered |
| 76812 | HCPCS | Covered |
| 76813 | HCPCS | Covered |
| 76814 | HCPCS | Covered |
| 76815 | HCPCS | Covered |
| 76816 | HCPCS | Covered |
| 76817 | HCPCS | Covered |
| 76818 | HCPCS | Covered |
| 76819 | HCPCS | Covered |
| 76820 | HCPCS | Covered |
| 76821 | HCPCS | Covered |
| 76825 | HCPCS | Covered |
| 76826 | HCPCS | Covered |
| 76827 | HCPCS | Covered |
| 76828 | HCPCS | Covered |
| 76830 | HCPCS | Covered |
| 76831 | HCPCS | Covered |
| 76856 | HCPCS | Covered |
| 76857 | HCPCS | Covered |
| 76870 | HCPCS | Covered |
| 76872 | HCPCS | Covered |
| 76873 | HCPCS | Covered |
| 76881 | HCPCS | Covered |
| 76882 | HCPCS | Covered |
| 76885 | HCPCS | Covered |
| 76886 | HCPCS | Covered |
| 76937 | HCPCS | Covered |
| 76942 | HCPCS | Covered |
| 77002 | HCPCS | Covered |
| 77046 | HCPCS | Covered |
| 77047 | HCPCS | Covered |
| 77048 | HCPCS | Covered |
| 77049 | HCPCS | Covered |
| 77053 | HCPCS | Covered |
| 77054 | HCPCS | Covered |
| 77063 | HCPCS | Covered |
| 77065 | HCPCS | Covered |
| 77066 | HCPCS | Covered |
| 77067 | HCPCS | Covered |
| 77072 | HCPCS | Covered |
| 77074 | HCPCS | Covered |
| 77075 | HCPCS | Covered |
| 77076 | HCPCS | Covered |
| 77077 | HCPCS | Covered |
| 77078 | HCPCS | Covered |
| 77080 | HCPCS | Covered |
| 77081 | HCPCS | Covered |
| 77084 | HCPCS | Covered |
| 77085 | HCPCS | Covered |
| 77086 | HCPCS | Covered |
| 78012 | HCPCS | Covered |
| 78013 | HCPCS | Covered |
| 78014 | HCPCS | Covered |
| 78015 | HCPCS | Covered |
| 78016 | HCPCS | Covered |
| 78018 | HCPCS | Covered |
| 78020 | HCPCS | Covered |
| 78070 | HCPCS | Covered |
| 78071 | HCPCS | Covered |
| 78072 | HCPCS | Covered |
| 78075 | HCPCS | Covered |
| 78102 | HCPCS | Covered |
| 78103 | HCPCS | Covered |
| 78104 | HCPCS | Covered |
| 78110 | HCPCS | Covered |
| 78111 | HCPCS | Covered |
| 78120 | HCPCS | Covered |
| 78121 | HCPCS | Covered |
| 78122 | HCPCS | Covered |
| 78130 | HCPCS | Covered |
| 78140 | HCPCS | Covered |
| 78185 | HCPCS | Covered |
| 78191 | HCPCS | Covered |
| 78195 | HCPCS | Covered |
| 78201 | HCPCS | Covered |
| 78202 | HCPCS | Covered |
| 78215 | HCPCS | Covered |
| 78216 | HCPCS | Covered |
| 78226 | HCPCS | Covered |
| 78227 | HCPCS | Covered |
| 78230 | HCPCS | Covered |
| 78231 | HCPCS | Covered |
| 78232 | HCPCS | Covered |
| 78258 | HCPCS | Covered |
| 78261 | HCPCS | Covered |
| 78262 | HCPCS | Covered |
| 78264 | HCPCS | Covered |
| 78265 | HCPCS | Covered |
| 78266 | HCPCS | Covered |
| 78267 | HCPCS | Covered |
| 78278 | HCPCS | Covered |
| 78282 | HCPCS | Covered |
| 78290 | HCPCS | Covered |
| 78291 | HCPCS | Covered |
| 78300 | HCPCS | Covered |
| 78305 | HCPCS | Covered |
| 78306 | HCPCS | Covered |
| 78315 | HCPCS | Covered |
| 78414 | HCPCS | Covered |
| 78428 | HCPCS | Covered |
| 78429 | HCPCS | Covered |
| 78430 | HCPCS | Covered |
| 78431 | HCPCS | Covered |
| 78432 | HCPCS | Covered |
| 78433 | HCPCS | Covered |
| 78434 | HCPCS | Covered |
| 78445 | HCPCS | Covered |
| 78451 | HCPCS | Covered |
| 78452 | HCPCS | Covered |
| 78453 | HCPCS | Covered |
| 78454 | HCPCS | Covered |
| 78456 | HCPCS | Covered |
| 78457 | HCPCS | Covered |
| 78458 | HCPCS | Covered |
| 78459 | HCPCS | Covered |
| 78466 | HCPCS | Covered |
| 78468 | HCPCS | Covered |
| 78469 | HCPCS | Covered |
| 78472 | HCPCS | Covered |
| 78473 | HCPCS | Covered |
| 78481 | HCPCS | Covered |
| 78483 | HCPCS | Covered |
| 78491 | HCPCS | Covered |
| 78492 | HCPCS | Covered |
| 78494 | HCPCS | Covered |
| 78496 | HCPCS | Covered |
| 78579 | HCPCS | Covered |
| 78580 | HCPCS | Covered |
| 78582 | HCPCS | Covered |
| 78597 | HCPCS | Covered |
| 78598 | HCPCS | Covered |
| 78600 | HCPCS | Covered |
| 78601 | HCPCS | Covered |
| 78605 | HCPCS | Covered |
| 78606 | HCPCS | Covered |
| 78608 | HCPCS | Covered |
| 78609 | HCPCS | Covered |
| 78610 | HCPCS | Covered |
| 78630 | HCPCS | Covered |
| 78635 | HCPCS | Covered |
| 78645 | HCPCS | Covered |
| 78650 | HCPCS | Covered |
| 78660 | HCPCS | Covered |
| 78700 | HCPCS | Covered |
| 78701 | HCPCS | Covered |
| 78707 | HCPCS | Covered |
| 78708 | HCPCS | Covered |
| 78709 | HCPCS | Covered |
| 78725 | HCPCS | Covered |
| 78730 | HCPCS | Covered |
| 78740 | HCPCS | Covered |
| 78761 | HCPCS | Covered |
| 78800 | HCPCS | Covered |
| 78801 | HCPCS | Covered |
| 78802 | HCPCS | Covered |
| 78803 | HCPCS | Covered |
| 78804 | HCPCS | Covered |
| 78811 | HCPCS | Covered |
| 78812 | HCPCS | Covered |
| 78813 | HCPCS | Covered |
| 78814 | HCPCS | Covered |
| 78815 | HCPCS | Covered |
| 78816 | HCPCS | Covered |
| 78830 | HCPCS | Covered |
| 78831 | HCPCS | Covered |
| 78832 | HCPCS | Covered |
| 78835 | HCPCS | Covered |
| 91010 | HCPCS | Covered |
| 91013 | HCPCS | Covered |
| 91020 | HCPCS | Covered |
| 91022 | HCPCS | Covered |
| 91030 | HCPCS | Covered |
| 91034 | HCPCS | Covered |
| 91035 | HCPCS | Covered |
| 91037 | HCPCS | Covered |
| 91038 | HCPCS | Covered |
| 91040 | HCPCS | Covered |
| 91065 | HCPCS | Covered |
| 91113 | HCPCS | Covered |
| 91117 | HCPCS | Covered |
| 91132 | HCPCS | Covered |
| 91133 | HCPCS | Covered |
| 92060 | HCPCS | Covered |
| 92081 | HCPCS | Covered |
| 92082 | HCPCS | Covered |
| 92083 | HCPCS | Covered |
| 92132 | HCPCS | Covered |
| 92133 | HCPCS | Covered |
| 92134 | HCPCS | Covered |
| 92136 | HCPCS | Covered |
| 92137 | HCPCS | Covered |
| 92227 | HCPCS | Covered |
| 92228 | HCPCS | Covered |
| 92229 | HCPCS | Covered |
| 92235 | HCPCS | Covered |
| 92240 | HCPCS | Covered |
| 92242 | HCPCS | Covered |
| 92250 | HCPCS | Covered |
| 92260 | HCPCS | Covered |
| 92265 | HCPCS | Covered |
| 92270 | HCPCS | Covered |
| 92274 | HCPCS | Covered |
| 92283 | HCPCS | Covered |
| 92284 | HCPCS | Covered |
| 92285 | HCPCS | Covered |
| 92286 | HCPCS | Covered |
| 92516 | HCPCS | Covered |
| 92517 | HCPCS | Covered |
| 92518 | HCPCS | Covered |
| 92519 | HCPCS | Covered |
| 92520 | HCPCS | Covered |
| 92541 | HCPCS | Covered |
| 92542 | HCPCS | Covered |
| 92544 | HCPCS | Covered |
| 92545 | HCPCS | Covered |
| 92546 | HCPCS | Covered |
| 92547 | HCPCS | Covered |
| 92548 | HCPCS | Covered |
| 92549 | HCPCS | Covered |
| 92550 | HCPCS | Covered |
| 92552 | HCPCS | Covered |
| 92553 | HCPCS | Covered |
| 92555 | HCPCS | Covered |
| 92556 | HCPCS | Covered |
| 92557 | HCPCS | Covered |
| 92562 | HCPCS | Covered |
| 92563 | HCPCS | Covered |
| 92565 | HCPCS | Covered |
| 92567 | HCPCS | Covered |
| 92568 | HCPCS | Covered |
| 92571 | HCPCS | Covered |
| 92572 | HCPCS | Covered |
| 92575 | HCPCS | Covered |
| 92576 | HCPCS | Covered |
| 92577 | HCPCS | Covered |
| 92579 | HCPCS | Covered |
| 92582 | HCPCS | Covered |
| 92583 | HCPCS | Covered |
| 92584 | HCPCS | Covered |
| 92587 | HCPCS | Covered |
| 92588 | HCPCS | Covered |
| 92596 | HCPCS | Covered |
| 92650 | HCPCS | Covered |
| 92651 | HCPCS | Covered |
| 92652 | HCPCS | Covered |
| 92653 | HCPCS | Covered |
| 93000 | HCPCS | Covered |
| 93005 | HCPCS | Covered |
| 93010 | HCPCS | Covered |
| 93015 | HCPCS | Covered |
| 93016 | HCPCS | Covered |
| 93017 | HCPCS | Covered |
| 93018 | HCPCS | Covered |
| 93024 | HCPCS | Covered |
| 93025 | HCPCS | Covered |
| 93040 | HCPCS | Covered |
| 93041 | HCPCS | Covered |
| 93042 | HCPCS | Covered |
| 93224 | HCPCS | Covered |
| 93225 | HCPCS | Covered |
| 93226 | HCPCS | Covered |
| 93227 | HCPCS | Covered |
| 93228 | HCPCS | Covered |
| 93229 | HCPCS | Covered |
| 93241 | HCPCS | Covered |
| 93242 | HCPCS | Covered |
| 93243 | HCPCS | Covered |
| 93244 | HCPCS | Covered |
| 93245 | HCPCS | Covered |
| 93246 | HCPCS | Covered |
| 93247 | HCPCS | Covered |
| 93248 | HCPCS | Covered |
| 93260 | HCPCS | Covered |
| 93261 | HCPCS | Covered |
| 93264 | HCPCS | Covered |
| 93268 | HCPCS | Covered |
| 93270 | HCPCS | Covered |
| 93271 | HCPCS | Covered |
| 93272 | HCPCS | Covered |
| 93278 | HCPCS | Covered |
| 93293 | HCPCS | Covered |
| 93294 | HCPCS | Covered |
| 93295 | HCPCS | Covered |
| 93296 | HCPCS | Covered |
| 93297 | HCPCS | Covered |
| 93298 | HCPCS | Covered |
| 93303 | HCPCS | Covered |
| 93304 | HCPCS | Covered |
| 93306 | HCPCS | Covered |
| 93307 | HCPCS | Covered |
| 93308 | HCPCS | Covered |
| 93312 | HCPCS | Covered |
| 93313 | HCPCS | Covered |
| 93314 | HCPCS | Covered |
| 93315 | HCPCS | Covered |
| 93316 | HCPCS | Covered |
| 93317 | HCPCS | Covered |
| 93319 | HCPCS | Covered |
| 93320 | HCPCS | Covered |
| 93321 | HCPCS | Covered |
| 93325 | HCPCS | Covered |
| 93350 | HCPCS | Covered |
| 93351 | HCPCS | Covered |
| 93352 | HCPCS | Covered |
| 93356 | HCPCS | Covered |
| 93701 | HCPCS | Covered |
| 93770 | HCPCS | Covered |
| 93784 | HCPCS | Covered |
| 93786 | HCPCS | Covered |
| 93788 | HCPCS | Covered |
| 93790 | HCPCS | Covered |
| 93880 | HCPCS | Covered |
| 93882 | HCPCS | Covered |
| 93886 | HCPCS | Covered |
| 93888 | HCPCS | Covered |
| 93892 | HCPCS | Covered |
| 93893 | HCPCS | Covered |
| 93895 | HCPCS | Covered |
| 93896 | HCPCS | Covered |
| 93897 | HCPCS | Covered |
| 93898 | HCPCS | Covered |
| 93922 | HCPCS | Covered |
| 93923 | HCPCS | Covered |
| 93924 | HCPCS | Covered |
| 93925 | HCPCS | Covered |
| 93926 | HCPCS | Covered |
| 93930 | HCPCS | Covered |
| 93931 | HCPCS | Covered |
| 93970 | HCPCS | Covered |
| 93971 | HCPCS | Covered |
| 93975 | HCPCS | Covered |
| 93976 | HCPCS | Covered |
| 93978 | HCPCS | Covered |
| 93979 | HCPCS | Covered |
| 93980 | HCPCS | Covered |
| 93981 | HCPCS | Covered |
| 93985 | HCPCS | Covered |
| 93986 | HCPCS | Covered |
| 93990 | HCPCS | Covered |
| 94010 | HCPCS | Covered |
| 94014 | HCPCS | Covered |
| 94015 | HCPCS | Covered |
| 94016 | HCPCS | Covered |
| 94060 | HCPCS | Covered |
| 94070 | HCPCS | Covered |
| 94150 | HCPCS | Covered |
| 94200 | HCPCS | Covered |
| 94375 | HCPCS | Covered |
| 94450 | HCPCS | Covered |
| 94452 | HCPCS | Covered |
| 94453 | HCPCS | Covered |
| 94617 | HCPCS | Covered |
| 94618 | HCPCS | Covered |
| 94619 | HCPCS | Covered |
| 94621 | HCPCS | Covered |
| 94680 | HCPCS | Covered |
| 94681 | HCPCS | Covered |
| 94690 | HCPCS | Covered |
| 94726 | HCPCS | Covered |
| 94727 | HCPCS | Covered |
| 94728 | HCPCS | Covered |
| 94729 | HCPCS | Covered |
| 94760 | HCPCS | Covered |
| 94761 | HCPCS | Covered |
| 94762 | HCPCS | Covered |
| 94772 | HCPCS | Covered |
| 95700 | HCPCS | Covered |
| 95705 | HCPCS | Covered |
| 95706 | HCPCS | Covered |
| 95707 | HCPCS | Covered |
| 95708 | HCPCS | Covered |
| 95709 | HCPCS | Covered |
| 95710 | HCPCS | Covered |
| 95711 | HCPCS | Covered |
| 95712 | HCPCS | Covered |
| 95713 | HCPCS | Covered |
| 95714 | HCPCS | Covered |
| 95715 | HCPCS | Covered |
| 95716 | HCPCS | Covered |
| 95717 | HCPCS | Covered |
| 95718 | HCPCS | Covered |
| 95719 | HCPCS | Covered |
| 95720 | HCPCS | Covered |
| 95721 | HCPCS | Covered |
| 95722 | HCPCS | Covered |
| 95723 | HCPCS | Covered |
| 95724 | HCPCS | Covered |
| 95725 | HCPCS | Covered |
| 95726 | HCPCS | Covered |
| 95800 | HCPCS | Covered |
| 95801 | HCPCS | Covered |
| 95805 | HCPCS | Covered |
| 95806 | HCPCS | Covered |
| 95807 | HCPCS | Covered |
| 95808 | HCPCS | Covered |
| 95810 | HCPCS | Covered |
| 95811 | HCPCS | Covered |
| 95812 | HCPCS | Covered |
| 95813 | HCPCS | Covered |
| 95816 | HCPCS | Covered |
| 95819 | HCPCS | Covered |
| 95822 | HCPCS | Covered |
| 95830 | HCPCS | Covered |
| 95836 | HCPCS | Covered |
| 95860 | HCPCS | Covered |
| 95861 | HCPCS | Covered |
| 95863 | HCPCS | Covered |
| 95864 | HCPCS | Covered |
| 95867 | HCPCS | Covered |
| 95868 | HCPCS | Covered |
| 95869 | HCPCS | Covered |
| 95870 | HCPCS | Covered |
| 95872 | HCPCS | Covered |
| 95875 | HCPCS | Covered |
| 95885 | HCPCS | Covered |
| 95886 | HCPCS | Covered |
| 95887 | HCPCS | Covered |
| 95905 | HCPCS | Covered |
| 95907 | HCPCS | Covered |
| 95908 | HCPCS | Covered |
| 95909 | HCPCS | Covered |
| 95910 | HCPCS | Covered |
| 95911 | HCPCS | Covered |
| 95912 | HCPCS | Covered |
| 95913 | HCPCS | Covered |
| 95921 | HCPCS | Covered |
| 95922 | HCPCS | Covered |
| 95923 | HCPCS | Covered |
| 95924 | HCPCS | Covered |
| 95925 | HCPCS | Covered |
| 95926 | HCPCS | Covered |
| 95927 | HCPCS | Covered |
| 95928 | HCPCS | Covered |
| 95929 | HCPCS | Covered |
| 95930 | HCPCS | Covered |
| 95933 | HCPCS | Covered |
| 95937 | HCPCS | Covered |
| 95938 | HCPCS | Covered |
| 95939 | HCPCS | Covered |
| 95957 | HCPCS | Covered |
| 95958 | HCPCS | Covered |
| 95965 | HCPCS | Covered |
| 95966 | HCPCS | Covered |
| 95967 | HCPCS | Covered |
| 95976 | HCPCS | Covered |
| 95977 | HCPCS | Covered |
| 95983 | HCPCS | Covered |
| 95984 | HCPCS | Covered |
| 96105 | HCPCS | Covered |
| 96110 | HCPCS | Covered |
| 96116 | HCPCS | Covered |
| 99151 | HCPCS | Covered |
| 99152 | HCPCS | Covered |
| 99153 | HCPCS | Covered |
| 99155 | HCPCS | Covered |
| 99156 | HCPCS | Covered |
| 99157 | HCPCS | Covered |
| 99202 | HCPCS | Covered |
| 99211 | HCPCS | Covered |
| 99453 | HCPCS | Covered |
| 99454 | HCPCS | Covered |
| 99457 | HCPCS | Covered |
| 99458 | HCPCS | Covered |
| G0130 | HCPCS | Covered |
| G0279 | HCPCS | Covered |
| G0288 | HCPCS | Covered |
| G0398 | HCPCS | Covered |
| G0399 | HCPCS | Covered |
| G0400 | HCPCS | Covered |
| G0500 | HCPCS | Covered |
| G2010 | HCPCS | Covered |