Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ......

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Revised 03-11-08 Page 1 Physician Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION HCPCS CPT–4 or HCPCS Procedure Code Note Special billing information applies to the code. A Professional and Technical components are each reimbursed at 50% of the state maximum. To bill quantities: Number of tests performed on a single date of service should be billed using the days/units field. When the quantity exceeds 5, the claim must be submitted on paper and must be accompanied by supporting documentation. B Professional and technical components are each reimbursed at 50% of the state maximum, rounded to the nearest cent. To bill quantities: For bilateral, submit the procedure code, use modifier 50, and show quantity “1” in days/units field. For multiples that are not bilateral, claims must be submitted on paper. Submit the procedure code on one service section, and in the next service section submit the unlisted procedure code for any quantity beyond the first, listing total # and name of additional tests in the description field, and attaching documentation of all tests performed. C Reimbursement for professional and technical components split at a rate other than 50%. To bill quantities: Claims for multiple quantities must be submitted on paper. Submit the procedure code on one service section, and in the next service section submit the unlisted procedure code for any quantity beyond the first, listing total # and name of additional tests in the description field and attaching documentation of all test performed. D Code is billable by encounter rate clinic only. E Vaccine is supplied through the Vaccines For Children (VFC) program. The department reimburses for the administration of the vaccine only. F Vaccine is not available the VFC; the department reimburses for the vaccine when it is medically necessary. G Vaccine is supplied for children but not adults through the VFC. The department reimburses for the administration (as shown in the Unit Price column) for children, and for adults (as shown in the State Max column) when medically necessary.

Transcript of Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ......

Page 1: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Revised 03-11-08 Page 1

Physician Fee Schedule Key

COLUMN HEADING

COLUMN DESCRIPTION

HCPCS CPT–4 or HCPCS Procedure Code Note Special billing information applies to the code.

A Professional and Technical components are each reimbursed at 50% of the state maximum. To bill quantities: Number of tests performed on a single date of service should be billed using the days/units field. When the quantity exceeds 5, the claim must be submitted on paper and must be accompanied by supporting documentation.

B Professional and technical components are each reimbursed at 50% of the state maximum, rounded to the nearest cent. To bill quantities: For bilateral, submit the procedure code, use modifier 50, and show quantity “1” in days/units field. For multiples that are not bilateral, claims must be submitted on paper. Submit the procedure code on one service section, and in the next service section submit the unlisted procedure code for any quantity beyond the first, listing total # and name of additional tests in the description field, and attaching documentation of all tests performed.

C Reimbursement for professional and technical components split at a rate other than 50%. To bill quantities: Claims for multiple quantities must be submitted on paper. Submit the procedure code on one service section, and in the next service section submit the unlisted procedure code for any quantity beyond the first, listing total # and name of additional tests in the description field and attaching documentation of all test performed.

D Code is billable by encounter rate clinic only. E Vaccine is supplied through the Vaccines For Children

(VFC) program. The department reimburses for the administration of the vaccine only.

F Vaccine is not available the VFC; the department reimburses for the vaccine when it is medically necessary.

G Vaccine is supplied for children but not adults through the VFC. The department reimburses for the administration (as shown in the Unit Price column) for children, and for adults (as shown in the State Max column) when medically necessary.

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H CLIA “A” rage for the full test. I CLIA “W” rate for the waived test J Covered only for blood lead draws as a Healthy Kids

service for client ages 0-20 years and must be billed with the U1 modifier as documentation that the service meets this description.

K Prior approval required for surgeon and assistant surgeon. Anesthesia services for these codes must be billed using the anesthesia five-digit procedure code.

L Number of eyes tested should be billed using the days/units field; maximum quantity is 2.

M Age restricted to 9-26 years. Vaccine is supplied through the VFC Program for ages 9-20 years. The department reimburses VFC-enrolled providers for administration as shown in the unit price column. The department reimburses for adults, ages 21-26 years, and ages 9-26 years for non-VFC providers as shown in the State Max column. Additional information is provided at http://www.hfs.illinois.gov/physicians/ .

Prog Cov Program Coverage

02-Title XIX coverage only (limited Transitional Assistance coverage) 04-Medicaid covered services 09–Qualified Medicare Beneficiary (QMB) coverage only.

Eff Date Effective Date

Effective date of codes added on or after 01/01/07.

HP Hand Price Indicator

If “Y”, special pricing methodology is applied. Anesthesia: Claims may be submitted electronically or on paper following the billing guidelines posted on our website at http://www.hfs.illinois.gov/assets/101006_physician.pdf Medical/surgical procedure: Claims must be submitted on paper. The name of the procedure and total number of times performed must be submitted in the description field and the procedure note must be attached. To bill quantities: The number listed in the days/units field must be “1” and the actual quantity must be included in the description/note field. Drugs: May be submitted electronically or on paper. The claim must contain the name of the drug, strength of the drug, and the amount given in the description/note field and must be billed according to NDC billing guidelines available on our website at http://www.hfs.illinois.gov/assets/ncd_112107.pdf To bill quantities: The number listed in the days/units field must be “1” and the actual quantity must be included in the description/note field.

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APL Ambulatory Procedure Listing

“Y” indicates the procedure is on the APL listing. APL rates are listed in a separate fee schedule on our website at http://www.hfs.illinois.gov/reimbursement/apl.html . Hospital claims billed fee-for-service will be rejected.

NDC Ind NDC Indicator

If “Y”, must be billed according to NDC billing guidelines available on our website at http://www.hfs.illinois.gov/assets/ncd_112107.pdf

Surg Ind Surgery Indicator

If “M”, reimbursement for procedure includes 30-day postoperative care.

M1(26) Modifier 1 (26)

Rate paid for the professional component of the code.

M2 (TC) Modifier 2 (TC)

Rate paid for the technical component of the code.

Unit Price Price for each unit when multiple quantities are billable. Max Qty Maximum

Quantity The maximum quantity payable for the code.

State Max State Maximum

The maximum allowable reimbursement (reflects combined professional and technical components where applicable).

Surg Add-on

Surgical Add-on

The additional amount paid beyond the state maximum when the procedure is performed in the practitioner’s office.

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MODIFIERS RECOGNIZED IN PROCESSING ILLINOIS HEALTHCARE AND FAMILY SERVICE CLAIMS

MODIFIER DESCRIPTION HOW PAYMENT IS AFFECTED

26 Professional componentPays professional component only (*see physician fee schedule, Notes A, B, C)

50 Bilateral procedure

Bill procedure code one time with modifier and quantity "1" to indicate bilaterals performed (*see physician fee schedule, Note B)

51 Multiple proceduresApplies only to billing multiple NDCs (**see Informational Notice to Physicians dated 12-21-07)

52 Reduced services Goes to hand pricing, requires attachment of additional information

53 Discontinued procedure Not payable; bill only for services completed59 Distinct procedural service Applies to Medicare crossovers only62 Two surgeons Each surgeon is paid at 50% state maximum73 Discontinued outpatient procedure prior to anesthesia administration Not payable; bill only for services completed74 Discontinued outpatient procedure after anesthesia administration Not payable; bill only for services completed

76 Repeat procedure by same physicianApplies only to billing multiple NDCs (**see Informational Notice to Physicians dated 12-21-07)

80 Assistant surgeon Payment is based on minutes billed81 Minimum assistant surgeon Payment is based on minutes billed82 Assistant surgeon when qualified resident surgeon not available Payment is based on minutes billed90 Reference (outside) laboratory Not payable for APL or inpatient procedures91 Repeat clinical diagnostic laboratory test Applies to Medicare crossovers onlyAH Clinical psychologist Billable only by FQHC and RHCAJ Clinical social worker Billable only by FQHC and RHC

ASPhysician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery Payment is based on minutes billed

AT Acute Treatment Sterilization permit not required when procedure performed for acute reason and not for sterilization purposes

E1 Upper left eyelidProcesses separately from same CPT with different eyelid modifier

E2 Lower left eyelidProcesses separately from same CPT with different eyelid modifier

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E3 Upper right eyelidProcesses separately from same CPT with different eyelid modifier

E4 Lower right eyelidProcesses separately from same CPT with different eyelid modifier

EPService provided as part of medicaid early periodic screening diagnosis and treatment (EPSDT) program Service is processed as a Healthy Kids service

F1 Left hand, second digit Processes separately from same CPT with different digit modifier

F2 Left hand, third digit Processes separately from same CPT with different digit modifier

F3 Left hand, fourth digit Processes separately from same CPT with different digit modifier

F4 Left hand, fifth digit Processes separately from same CPT with different digit modifier

F5 Right hand, thumb Processes separately from same CPT with different digit modifier

F6 Right hand, second digit Processes separately from same CPT with different digit modifier

F7 Right hand, third digit Processes separately from same CPT with different digit modifier

F8 Right hand, fourth digit Processes separately from same CPT with different digit modifier

F9 Right hand, fifth digit Processes separately from same CPT with different digit modifier

FA Left hand, thumb Processes separately from same CPT with different digit modifierFP Service provided as part of family planning program Service is processed as a family planning serviceGN Outpatient speech therapy See Therapists Provider Notice dated 061605GO Outpatient occupational therapy See Therapists Provider Notice dated 061605GP Outpatient physical therapy See Therapists Provider Notice dated 061605GZ Item or service expected to be denied as not reasonable and necessary Not payable HD Pregnant/parenting women's program Service is processed as a postpartum depression screening

HE Mental health program

Inpatient/outpatient psychiatric consultation or inpatient psychiatric subsequent care rate (**see Physician Provider Notice dated 102903)

HO Masters degree level; added 060108 effective 10/22/07 Billable only by FQHC and RHC

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LC Left circumflex coronary arteryProcesses separately from same CPT with different coronary artery modifier

LD Left anterior descending coronary arteryProcesses separately from same CPT with different coronary artery modifier

LT Left side Processes separately from same CPT with RT modifierNU New equipment Processes as PurchaseP1 Normal, healthy patient Anesthesia converts to modifying units "0"P2 Patient with mild systemic disease Anesthesia converts to modifying units "1"P3 Patient with severe systemic disease Anesthesia converts to modifying units "2"P4 Patient with severe systemic disease that is a constant threat to life Anesthesia converts to modifying units "3"P5 Moribund patient not expected to survive without the operation Anesthesia converts to modifying units "4"

P6Declared brain-dead patient whose organs are being removed for donor purposes Anesthesia converts to modifying units "0"

QL Patient pronounced dead after ambulance called Not payableQM Ambulance service provided under arrangement by a provider of services Not payable

QW CLIA waived testProcesses at the waived CLIA rate (*see physician fee schedule, Note I)

RC Right coronary arteryProcesses separately from same CPT with different coronary artery modifier

RR Rental Processes as rentalRT Right side Processes separately from same CPT with LT modifier

SL State supplied vaccineProcesses HPV vaccine to Obstetricians not enrolled with VFC (**see Physician Provider Notice dated 061507)

T1 Left foot, second digit Processes separately from same CPT with different digit modifier

T2 Left foot, third digit Processes separately from same CPT with different digit modifier

T3 Left foot, fourth digit Processes separately from same CPT with different digit modifier

T4 Left foot, fifth digit Processes separately from same CPT with different digit modifier

T5 Right foot, great toe Processes separately from same CPT with different digit modifier

T6 Right foot, second digit Processes separately from same CPT with different digit modifier

T7 Right foot, third digit Processes separately from same CPT with different digit modifier

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T8 Right foot, fourth digit Processes separately from same CPT with different digit modifier

T9 Right foot, fifth digit Processes separately from same CPT with different digit modifier

TA Left foot, great toe Processes separately from same CPT with different digit modifier

TC Technical componentPays technical component only (*see physician fee schedule, Notes A, B, C)

TT Individualized service provided to more than one patient in same settingProcesses as coincident visit Long Term care(**see Physician Provider Notice dated 102903)

U1 Local modifier-Blood lead drawBlood specimen drawn for lead analysis as part of Healthy Kids program (***see Chapter HK-200 Section 202.1)

U2 Local modifier-Home Health nursing assessment visitProcesses as assessment visit only (***see Home Health Handbook Section R-203.1)

U4 Local modifier-Pregnancy resulting from rape Claim requires abortion payment application HFS form 2390

U6 Local modifier-Service provided within 60 days of hospital dischargeProcesses as therapy visit within 60 days of hospital discharge(***see Therapy Providers Handbook Section J-211)

U7 Local modifier-Pregnancy resulting from incest Claim requires abortion payment application HFS form 2390U8 Local modifier-Pregnancy threatening the mother's life Claim requires abortion payment application HFS form 2390

* Physician Fee Schedule is posted on our website at http://www.hfs.illinois.gov/feeschedule/**Provider Informational Notices are posted on our website at http://www.hfs.illinois.gov/releases/***Provider Handbooks are posted on our website at http://www.hfs.illinois.gov/handbooks/

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2008 HCPCS Codes HealthCare and Family Services Updated 6/1/2008

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00102 04 MY

00103 04 MY

00104 02 N 44.40N

00120 04 MY

00124 04 IY

00126 04 IY

00140 04 MY

00142 04 MY

00144 04 MY

00145 04 MY

00147 04 MY

00148 04 IY

00160 04 MY

00162 04 MY

00164 04 IY

00170 04 IY

00172 04 MY

00174 04 MY

Wednesday, June 18, 2008 Page 1 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00176 04 MY

0017T 04 MYY

00190 04 MY

00192 04 MY

0019T 04 IYY

00210 04 MY

00212 04 MY

00214 04 MY

00215 04 MY

00216 04 MY

00218 04 MY

00220 04 MY

00222 04 MY

0026T B 04 NY

0027T 04 M 444.30YN

0028T B 04 N 49.05 49.05 98.10YN

0029T 04 NYY

00300 04 MY

0030T 04 NY

0031T 04 I 37.40N

00320 04 MY

Wednesday, June 18, 2008 Page 2 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00322 04 MY

00326 04 MY

00350 04 MY

00352 04 MY

00400 04 IY

00402 04 MY

00404 04 MY

00406 04 MY

00410 04 I 112.40N

0041T 04 NY

0042T B 04 N 141.22 141.22 282.45YN

0043T 04 NY

00450 04 MY

00452 04 MY

00454 04 IY

00470 04 MY

00472 04 MY

00474 04 MY

0048T 04 MY

00500 04 MY

0051T 04 MY

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00520 04 MY

00522 04 IY

00524 04 MY

00528 04 MY

00529 04 NY

0052T 04 MY

00530 04 MY

00532 04 IY

00534 04 MY

00537 04 IY

00539 04 MY

0053T 04 MY

00540 04 MY

00541 04 MY

00542 04 MY

00546 04 MY

00548 04 MY

00550 04 MY

00560 04 MY

00561 04 MY

00562 04 MY

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00563 04 MY

00566 04 MY

00580 04 MY

00600 04 MY

00604 04 MY

0060T 04 NYY

0061T 04 MYY

00620 04 MY

00622 04 MY

00625 04 1/1/2007 MY

00626 04 1/1/2007 NY

0062T 04 M 509.95YN

00630 04 MY

00632 04 MY

00634 04 MY

00635 04 IY

0063T 04 MYY

00640 04 MY

00670 04 MY

00700 04 MY

00702 04 IY

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00730 04 MY

0073T 04 N 364.51YN

00740 04 MY

00750 04 MY

00752 04 MY

00754 04 MY

00756 04 MY

0075T 04 I 83.00YN

0076T 04 I 83.00YN

00770 04 MY

0077T 04 M 449.50YN

0078T 04 M 1,148.60N

00790 04 MY

00792 04 MY

00794 04 MY

00796 04 MY

00797 04 MY

0079T 04 MY

00800 04 MY

00802 04 MY

0080T 04 NY

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00810 04 MY

0081T 04 MYY

00820 04 MY

00830 04 MY

00832 04 MY

00834 04 MY

00836 04 MY

00840 04 MY

00842 04 IY

00844 04 MY

00846 04 MY

00848 04 MY

0084T 04 I 118.20YN

00851 04 MY

00860 04 MY

00862 04 MY

00864 04 MY

00865 04 MY

00866 04 MY

00868 04 MY

00870 04 MY

Wednesday, June 18, 2008 Page 7 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00872 04 MY

00873 04 MY

00880 04 MY

00882 04 MY

00902 04 MY

00904 04 MY

00906 04 MY

00908 04 MY

0090T 04 MYY

00910 04 MY

00912 04 MY

00914 04 MY

00916 04 MY

00918 04 MY

00920 04 MY

00921 04 MY

00922 04 MY

00924 04 MY

00926 04 MY

00928 04 MY

00930 04 MY

Wednesday, June 18, 2008 Page 8 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

00932 04 MY

00934 04 MY

00936 04 MY

00938 04 MY

0093T 04 MYY

00940 04 IY

00942 04 MY

00944 04 MY

00948 04 IY

00950 04 IY

00952 04 IY

0095T 04 MYY

0096T 04 MYY

0101T 04 MYY

0102T 04 MYY

01112 04 IY

01120 04 MY

01130 04 IY

01140 04 MY

01150 04 MY

01160 04 MY

Wednesday, June 18, 2008 Page 9 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

01170 04 MY

01173 04 MY

01180 04 MY

01190 04 MY

01200 04 MY

01202 04 MY

01210 04 MY

01212 04 MY

01214 04 MY

01215 04 IY

01220 04 MY

01230 04 MY

01232 04 MY

01234 04 MY

0123T 04 MYY

0124T 04 MYY

01250 04 MY

01260 04 MY

01270 04 MY

01272 04 MY

01274 04 MY

Wednesday, June 18, 2008 Page 10 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

01320 04 MY

01340 04 MY

01360 04 MY

0137T 04 IYY

01380 04 MY

01382 04 MY

01390 04 MY

01392 04 MY

01400 04 MY

01402 04 MY

01404 04 MY

01420 04 IY

01430 04 MY

01432 04 MY

0143T 04 NY

01440 04 MY

01442 04 MY

01444 04 MY

01462 04 MY

01464 04 MY

01470 04 MY

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

01472 04 MY

01474 04 MY

0147T C 04 N 21.37 88.48 109.85N

01480 04 MY

01482 04 MY

01484 04 MY

01486 04 MY

01490 04 IY

01500 04 MY

01502 04 MY

01520 04 MY

01522 04 MY

01610 04 MY

01620 04 MY

01622 04 MY

01630 04 MY

01632 04 MY

01634 04 MY

01636 04 MY

01638 04 MY

01650 04 MY

Wednesday, June 18, 2008 Page 12 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

01652 04 MY

01654 04 MY

01656 04 MY

01670 04 MY

01680 04 IY

01682 04 IY

01710 04 MY

01712 04 MY

01714 04 MY

01716 04 MY

01730 04 MY

01732 04 MY

01740 04 MY

01742 04 MY

01744 04 MY

01756 04 MY

01758 04 MY

01760 04 MY

01770 04 MY

01772 04 MY

01780 04 MY

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

01782 04 MY

01810 04 MY

01820 04 MY

01829 04 M 356.10N

01830 04 MY

01832 04 MY

01840 04 MY

01842 04 MY

01844 04 MY

01850 04 MY

01852 04 MY

01860 04 MY

01916 04 IY

01920 04 MY

01922 04 IY

01924 04 MY

01925 04 MY

01926 04 IY

01930 04 MY

01931 04 MY

01932 04 MY

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

01933 04 MY

01935 04 1/1/2008 MY

01936 04 1/1/2008 MY

01951 04 IY

01952 04 IY

01953 04 IY

01958 04 MY

01960 09 MY

01961 04 MY

01962 04 MY

01963 04 MY

01965 04 MY

01967 04 MY

01968 04 MY

01969 04 MY

01991 04 IY

01992 04 IY

01996 04 I 14.25N

01999 04 MY

0500F 04 B 44.10N

0502F 04 B 44.10N

Wednesday, June 18, 2008 Page 15 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

0503F 04 B 50.15N

10021 04 I 49.80YN

10022 04 I 56.70YN

10040 04 I 35.20YN

10060 04 I 36.00YN

10061 04 I 66.50YN

10080 04 I 70.65.YN

10081 04 I 131.80YN

10120 04 I 39.05YN

10121 04 I 77.60YN

10140 04 I 41.50YN

10160 04 I 35.95YN

10180 04 I 130.55YN

11000 04 I 77.70YN

11001 04 I 20.85YN

11004 04 M 154.43YN

11005 04 M 154.43YN

11006 04 M 154.43YN

11008 04 M 154.43YN

11010 04 I 127.60YN

11011 04 I 157.90YN

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

11012 04 I 218.40YN

11040 04 I 34.10YN

11041 04 I 51.90YN

11042 04 I 70.55YN

11043 04 M 170.55YN

11044 04 M 219.35YN

11055 04 I 22.15YN

11056 04 IYY

11057 04 IYY

11100 04 I 50.20 17.00YN

11101 04 I 22.15YN

11200 04 I 35.65 17.00YN

11201 04 I 15.20YN

11300 04 I 21.10YN

11301 04 I 29.20YN

11302 04 I 37.50YN

11303 04 I 45.70YN

11305 04 I 22.25YN

11306 04 I 31.25YN

11307 04 I 37.50YN

11308 04 I 45.70YN

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

11310 04 I 32.40YN

11311 04 I 40.55YN

11312 04 I 48.80YN

11313 04 I 57.10YN

11400 04 I 39.05 17.00YN

11401 04 I 50.20 17.00YN

11402 04 I 64.80 17.00YN

11403 04 I 77.90 17.00YN

11404 04 I 92.40 17.00YN

11406 04 I 108.00 17.00YN

11420 04 I 38.30 17.00YN

11421 04 I 50.85 17.00YN

11422 04 I 64.80 17.00YN

11423 04 I 77.90 17.00YN

11424 04 I 92.40 17.00YN

11426 04 I 127.48 17.00YN

11440 04 I 54.15 17.00YN

11441 04 I 75.30 17.00YN

11442 04 I 96.40 17.00YN

11443 04 I 111.00 17.00YN

11444 04 I 117.55 17.00YN

Wednesday, June 18, 2008 Page 18 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

11446 04 I 146.37 17.00YN

11450 04 M 215.40 34.00YN

11451 04 M 244.10 34.00YN

11462 04 M 215.40 34.00YN

11463 04 M 232.20YN

11470 04 M 291.30YN

11471 04 M 297.00N

11600 04 I 54.15 17.00N

11601 04 I 75.30 17.00N

11602 04 I 96.40 17.00N

11603 04 I 117.55 17.00YN

11604 04 I 138.75 17.00YN

11606 04 M 185.52 17.00YN

11620 04 I 54.15 17.00N

11621 04 I 75.30 17.00N

11622 04 I 96.40 17.00YN

11623 04 I 117.55 17.00YN

11624 04 I 138.75 17.00YN

11626 04 M 185.52 17.00YN

11640 04 I 107.00 17.00YN

11641 04 I 149.25 17.00YN

Wednesday, June 18, 2008 Page 19 of 455

Page 27: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

11642 04 M 192.95 17.00YN

11643 04 M 235.20 17.00YN

11644 04 M 278.80 17.00YN

11646 04 M 294.77 17.00YN

11719 04 I 15.90N

11720 04 I 15.90N

11721 04 I 18.10N

11730 04 I 34.30 17.00N

11732 04 I 14.45N

11740 04 I 36.00N

11750 04 I 61.85 34.00N

11752 04 M 167.40 34.00YN

11755 04 I 38.80N

11760 04 I 60.80 17.00YN

11762 04 I 87.75 17.00YN

11765 04 I 38.40N

11770 04 M 215.40 34.00YN

11771 04 M 291.30YN

11772 04 M 341.25YN

11900 04 I 21.10 17.00N

11901 04 IY

Wednesday, June 18, 2008 Page 20 of 455

Page 28: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

11920 09 MY

11921 04 I 63.57N

11922 04 I 16.13N

11950 09 MY

11951 09 MY

11952 09 MY

11954 09 MY

11960 04 M 350.05YN

11970 04 M 475.70YN

11971 04 I 135.00YN

11975 04 I 108.00YN

11976 04 I 108.00YN

11977 04 I 108.00YN

11980 04 M 108.00YN

11981 04 I 72.30YN

11982 04 I 87.00YN

11983 04 I 108.00YN

12001 04 I 53.10 17.00YN

12002 04 I 58.40 17.00YN

12004 04 I 69.70 17.00YN

12005 04 I 100.40 17.00YN

Wednesday, June 18, 2008 Page 21 of 455

Page 29: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

12006 04 I 145.80 17.00YN

12007 04 MYY

12011 04 I 56.40 17.00YN

12013 04 I 64.00 17.00YN

12014 04 I 112.90 17.00YN

12015 04 I 125.50 17.00YN

12016 04 I 200.75 17.00YN

12017 04 M 259.20 17.00YN

12018 04 M 272.63YN

12020 04 I 139.30 17.00YN

12021 04 I 88.70 17.00YN

12031 04 I 64.70 17.00YN

12032 04 I 81.60 17.00YN

12034 04 I 106.65 17.00YN

12035 04 I 144.30 17.00YN

12036 04 M 194.50 17.00YN

12037 04 M 261.12YN

12041 04 I 72.10 17.00YN

12042 04 I 94.10 17.00YN

12044 04 I 119.20 17.00YN

12045 04 I 156.85 17.00YN

Wednesday, June 18, 2008 Page 22 of 455

Page 30: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

12046 04 M 207.10 17.00YN

12047 04 M 270.45YN

12051 04 I 74.70 17.00YN

12052 04 I 94.10 17.00YN

12053 04 I 112.90 17.00YN

12054 04 I 131.80 17.00YN

12055 04 I 169.40 17.00YN

12056 04 M 219.60 17.00YN

12057 04 M 305.68YN

13100 04 I 110.04YN

13101 04 I 127.57YN

13102 04 IY

13120 04 I 114.98YN

13121 04 I 138.55YN

13122 04 IY

13131 04 I 127.85YN

13132 04 I 178.18YN

13133 04 IYY

13150 04 I 150.67YN

13151 04 I 160.83YN

13152 04 I 205.55YN

Wednesday, June 18, 2008 Page 23 of 455

Page 31: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

13153 04 IY

13160 04 M 295.88YN

14000 04 M 224.25YN

14001 04 M 291.69YN

14020 04 M 244.40YN

14021 04 M 328.07YN

14040 04 M 277.07YN

14041 04 M 375.10YN

14060 04 M 299.29YN

14061 04 M 405.20YN

14300 04 M 389.59YN

14350 04 M 270.20YN

15002 04 1/1/2007 MYY

15003 04 1/1/2007 MYY

15004 04 1/1/2007 MYY

15005 04 1/1/2007 MYY

15040 04 M 71.01YN

15050 04 M 131.80YN

15100 04 M 263.55YN

15101 04 MYY

15110 04 M 71.01YN

Wednesday, June 18, 2008 Page 24 of 455

Page 32: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

15111 04 M 71.00YN

15115 04 M 382.21YN

15116 04 M 84.01YN

15120 04 M 307.90YN

15121 04 MYY

15130 04 M 297.44YN

15131 04 M 50.11YN

15135 04 M 414.03YN

15136 04 M 50.41YN

15150 04 M 330.87YN

15151 04 M 66.75YN

15152 04 M 83.39YN

15155 04 M 354.66YN

15156 04 M 92.48YN

15157 04 M 100.77YN

15170 04 M 167.63YN

15171 04 M 50.29YN

15175 04 M 249.07YN

15176 04 M 79.42YN

15200 04 M 318.60YN

15201 04 MYY

Wednesday, June 18, 2008 Page 25 of 455

Page 33: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

15220 04 M 307.90YN

15221 04 MYY

15240 04 M 308.96YN

15241 04 MYY

15260 04 M 332.72YN

15261 04 MYY

15300 04 M 141.69YN

15301 04 M 32.90YN

15320 04 M 165.11YN

15321 04 M 49.16YN

15330 04 M 141.50YN

15331 04 M 32.90YN

15335 04 M 158.29YN

15336 04 M 47.01YN

15340 04 M 143.60YN

15341 04 M 16.19YN

15360 04 M 153.62YN

15361 04 M 37.29YN

15365 04 M 162.56YN

15366 04 M 46.85YN

15400 04 M 165.30YN

Wednesday, June 18, 2008 Page 26 of 455

Page 34: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

15401 04 MYY

15420 04 M 183.07YN

15421 04 M 49.73YN

15430 04 M 267.39YN

15431 04 MYY

15570 04 M 298.24YN

15572 04 M 292.34YN

15574 04 M 466.61YN

15576 04 M 296.30YN

15600 04 M 259.81YN

15610 04 M 97.47YN

15620 04 M 158.26YN

15630 04 M 310.61YN

15650 04 M 168.27YN

15731 04 1/1/2007 M 168.27YN

15732 04 M 536.60YN

15734 04 M 569.25YN

15736 04 M 512.70YN

15738 04 M 520.25YN

15740 04 M 321.69YN

15750 04 M 339.54YN

Wednesday, June 18, 2008 Page 27 of 455

Page 35: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

15756 04 M 1,306.65YN

15757 04 M 1,306.65YN

15758 04 M 1,306.65YN

15760 04 M 300.05YN

15770 04 M 307.90YN

15775 09 MY

15776 09 MY

15780 09 MY

15781 09 MY

15782 09 MY

15783 09 MY

15786 09 IY

15787 09 MY

15819 04 M 274.36YN

15820 04 M 651.10YN

15821 04 M 651.10YN

15822 04 M 651.10YN

15823 04 M 651.10YN

15830 04 1/1/2007 MYY

15832 04 M 340.15YN

15833 04 M 306.75YN

Wednesday, June 18, 2008 Page 28 of 455

Page 36: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

15834 04 M 308.30YN

15835 04 M 319.10YN

15836 04 M 265.30YN

15837 04 M 255.00YN

15838 04 M 219.35YN

15839 04 M 237.80YN

15840 04 M 891.10YN

15841 04 M 663.96YN

15842 04 M 1,063.03YN

15845 04 M 355.83YN

15847 04 1/1/2007 MYY

15850 04 I 31.40YN

15851 04 I 48.60YN

15852 04 I 31.95YN

15860 04 I 55.50N

15876 04 MYY

15877 04 MYY

15878 04 MYY

15879 04 MY

15920 04 M 374.55YN

15922 04 M 449.50YN

Wednesday, June 18, 2008 Page 29 of 455

Page 37: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

15931 04 M 449.50YN

15933 04 M 674.20YN

15934 04 M 749.20YN

15935 04 M 749.20YN

15936 04 M 749.20YN

15937 04 M 749.20YN

15940 04 M 449.50YN

15941 04 M 524.40YN

15944 04 M 524.40YN

15945 04 M 600.00YN

15946 04 M 674.20YN

15950 04 M 449.50YN

15951 04 M 524.40YN

15952 04 M 524.40YN

15953 04 M 599.35YN

15956 04 M 727.40YN

15958 04 M 727.40YN

15962 04 MY

15963 04 MY

15999 04 MYY

16000 04 I 45.80N

Wednesday, June 18, 2008 Page 30 of 455

Page 38: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

16020 04 I 24.90 17.00YN

16025 04 I 49.50 34.00YN

16030 04 I 61.65 34.00YN

16035 04 M 92.79 34.00YN

16036 04 M 36.74YN

17000 04 I 52.70N

17003 04 I 8.85 13 115.05N

17004 04 I 86.59N

17106 04 I 125.35YN

17107 04 M 238.80YN

17108 04 M 372.30YN

17110 04 I 74.90N

17111 04 I 43.05N

17250 04 I 18.90N

17260 04 I 40.60YN

17261 04 I 60.70YN

17262 04 I 80.85YN

17263 04 I 100.90YN

17264 04 I 117.55YN

17266 04 M 162.00YN

17270 04 I 45.25YN

Wednesday, June 18, 2008 Page 31 of 455

Page 39: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

17271 04 I 64.50YN

17272 04 I 85.60YN

17273 04 I 106.75YN

17274 04 I 117.20YN

17276 04 M 162.00YN

17280 04 I 96.20YN

17281 04 I 127.70YN

17282 04 M 171.30YN

17283 04 M 213.60YN

17284 04 M 257.10YN

17286 04 IYY

17311 04 1/1/2007 M 216.00YN

17312 04 1/1/2007 MYY

17313 04 1/1/2007 MYY

17314 04 1/1/2007 MYY

17315 04 1/1/2007 MYY

17340 04 I 26.20N

17360 04 I 38.65N

17380 04 IY

17999 04 MY

19000 04 I 37.40N

Wednesday, June 18, 2008 Page 32 of 455

Page 40: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

19001 04 I 17.80N

19020 04 I 135.90YN

19030 04 I 102.50YN

19100 04 I 59.60YN

19101 04 M 192.85 34.00YN

19102 04 M 164.85 34.00YN

19103 04 M 324.90 34.00YN

19105 04 1/1/2007 MYY

19110 04 M 240.00 34.00YN

19112 04 M 240.00YN

19120 04 M 240.00 34.00YN

19125 04 M 240.00YN

19126 04 M 74.45YN

19260 04 M 430.64N

19271 04 M 534.45YN

19272 04 M 598.34YN

19290 04 I 59.40N

19291 04 I 27.00N

19295 04 I 63.10N

19296 04 I 109.01YN

19297 04 I 109.01YN

Wednesday, June 18, 2008 Page 33 of 455

Page 41: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

19298 04 I 109.01YN

19300 04 1/1/2007 M 374.55YN

19301 04 1/1/2007 M 310.80YN

19302 04 1/1/2007 M 601.45YN

19303 04 1/1/2007 M 461.95YN

19304 04 1/1/2007 M 574.35YN

19305 04 1/1/2007 M 787.95YN

19306 04 1/1/2007 M 948.90YN

19307 04 1/1/2007 M 738.10YN

19316 04 M 567.10YN

19318 04 M 374.60YN

19324 04 M 567.10YN

19325 04 M 567.10YN

19328 04 M 240.00YN

19330 04 M 240.00YN

19340 04 M 310.80YN

19342 04 M 354.20YN

19350 04 M 310.55YN

19355 04 M 275.00YN

19357 04 M 532.30YN

19361 04 M 609.80N

Wednesday, June 18, 2008 Page 34 of 455

Page 42: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

19364 04 M 558.15N

19366 04 M 558.15N

19367 04 M 755.20N

19368 04 M 1,306.65N

19369 04 M 852.25N

19370 04 M 242.70YN

19371 04 M 297.00YN

19380 04 M 280.40YN

19396 04 M 136.88N

19499 04 MYY

20000 04 I 59.80 17.00YN

20005 04 I 125.50 17.00YN

20100 04 M 372.65YN

20101 04 M 599.35YN

20102 04 M 480.00YN

20103 04 M 189.37 34.00N

20150 04 MYY

20200 04 I 113.60 17.00YN

20205 04 M 252.35 17.00YN

20206 04 I 53.50 17.00YN

20220 04 I 90.10YN

Wednesday, June 18, 2008 Page 35 of 455

Page 43: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

20225 04 I 187.30 34.00YN

20240 04 M 220.55YN

20245 04 M 289.90YN

20250 04 M 163.05YN

20251 04 M 277.50YN

20500 04 I 61.40YN

20501 04 I 105.90YN

20520 04 M 107.00 17.00YN

20525 04 M 167.80YN

20526 04 I 31.35N

20550 04 I 31.75N

20551 04 I 31.75N

20552 04 I 31.75N

20553 04 I 31.75N

20555 04 1/1/2008 I 176.10N

20600 04 I 30.40 17.00N

20605 04 I 33.00 17.00N

20610 04 I 31.80 17.00YN

20612 04 I 31.80N

20615 04 I 73.35YN

20650 04 I 141.50YN

Wednesday, June 18, 2008 Page 36 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

20660 04 M 192.85YN

20661 04 M 192.85YN

20662 04 I 203.85YN

20663 04 I 170.05YN

20664 04 M 271.45YN

20665 04 I 134.60YN

20670 04 I 134.60YN

20680 04 M 233.00YN

20690 04 I 172.80YN

20692 04 I 297.00YN

20693 04 I 243.00YN

20694 04 I 152.95YN

20802 04 MY

20805 04 MY

20808 04 MY

20816 04 MY

20822 04 MY

20824 04 MY

20827 04 MY

20838 04 MY

20900 04 M 224.70YN

Wednesday, June 18, 2008 Page 37 of 455

Page 45: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

20902 04 M 374.55YN

20910 04 MYY

20912 04 MYY

20920 04 M 168.10YN

20922 04 M 231.10YN

20924 04 M 212.90YN

20926 04 MYY

20930 09 MY

20931 09 MYY

20936 09 MY

20937 09 MY

20938 09 MY

20950 04 I 44.80YN

20955 04 MY

20956 04 MYY

20957 04 MYY

20962 04 MYY

20969 04 MYY

20970 04 MYY

20972 04 MYY

20973 04 MYY

Wednesday, June 18, 2008 Page 38 of 455

Page 46: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

20974 09 MY

20975 04 I 82.90YN

20979 04 I 176.70N

20982 04 M 220.57YN

20985 04 1/1/2008 M 83.23YN

20986 04 1/1/2008 MYY

20987 04 1/1/2008 MYY

20999 04 MY

21010 04 M 374.55YN

21015 04 M 224.36YN

21025 04 M 299.70YN

21026 04 M 299.70YN

21029 04 MYY

21030 04 M 299.70YN

21031 04 M 299.70YN

21032 04 M 299.70YN

21034 04 M 421.10YN

21040 04 M 299.70YN

21044 04 M 350.55YN

21045 04 M 1,678.65YN

21046 04 M 397.20YN

Wednesday, June 18, 2008 Page 39 of 455

Page 47: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21047 04 MYY

21048 04 MYY

21049 04 MYY

21050 04 M 524.40YN

21060 04 M 524.40YN

21070 04 M 299.70YN

21073 04 1/1/2008 M 188.93YN

21076 04 IY

21077 04 IY

21079 04 IY

21080 04 IY

21081 04 IY

21082 04 IY

21083 04 IY

21084 04 IY

21085 04 IY

21086 04 IY

21087 04 IY

21088 04 IY

21089 04 IY

21100 04 M 192.85YN

Wednesday, June 18, 2008 Page 40 of 455

Page 48: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21110 04 M 176.70YN

21116 04 I 73.20YN

21120 04 M 1,198.70YN

21121 04 M 1,198.70YN

21122 04 M 1,414.70YN

21123 04 M 1,522.70YN

21125 04 M 1,198.70YN

21127 04 M 1,306.65YN

21137 04 M 958.60YN

21138 04 M 1,198.70YN

21139 04 M 1,522.70YN

21141 04 M 1,198.70YN

21142 04 M 1,306.65YN

21143 04 M 1,414.70YN

21145 04 M 1,306.65YN

21146 04 M 1,522.70YN

21147 04 M 1,522.70YN

21150 04 M 1,306.65YN

21151 04 M 1,522.70YN

21154 04 M 1,306.65YN

21155 04 M 1,522.70YN

Wednesday, June 18, 2008 Page 41 of 455

Page 49: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21159 04 M 1,522.70YN

21160 04 M 1,522.70YN

21172 04 M 1,522.70YN

21175 04 M 1,522.70YN

21179 04 M 1,414.70YN

21180 04 M 1,522.70YN

21181 04 M 958.60YN

21182 04 M 1,522.70YN

21183 04 M 1,522.70YN

21184 04 M 1,630.70YN

21188 04 M 1,306.65YN

21193 04 M 1,198.70YN

21194 04 M 1,414.70YN

21195 04 M 1,198.70YN

21196 04 M 1,198.70YN

21198 04 M 958.60YN

21199 04 M 700.70YN

21206 04 M 1,198.70YN

21208 04 M 1,198.70YN

21209 04 M 1,198.70YN

21210 04 M 636.80YN

Wednesday, June 18, 2008 Page 42 of 455

Page 50: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21215 04 M 1,048.85YN

21230 04 M 957.25YN

21235 04 M 449.50YN

21240 04 M 599.35YN

21242 04 M 599.35YN

21243 04 M 1,198.70YN

21244 04 M 1,198.70YN

21245 04 M 1,198.70YN

21246 04 M 1,198.70YN

21247 04 M 1,306.65YN

21248 04 M 1,198.70YN

21249 04 M 1,198.70YN

21255 04 M 1,306.65YN

21256 04 M 1,306.65YN

21260 04 M 1,306.65YN

21261 04 M 1,522.70YN

21263 04 M 1,522.70YN

21267 04 M 1,306.65YN

21268 04 M 1,522.70YN

21270 04 M 1,048.85YN

21275 04 M 1,048.85YN

Wednesday, June 18, 2008 Page 43 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21280 04 M 359.30YN

21282 04 M 359.30YN

21295 04 M 449.50YN

21296 04 M 449.50YN

21299 04 MYY

21310 04 I 138.75YN

21315 04 M 176.20YN

21320 04 M 280.25YN

21325 04 M 337.10YN

21330 04 M 424.45YN

21335 04 M 571.60YN

21336 04 M 337.10YN

21337 04 M 224.70YN

21338 04 M 334.40YN

21339 04 M 457.70YN

21340 04 M 749.20YN

21343 04 M 898.95YN

21344 04 M 1,048.85YN

21345 04 M 749.20YN

21346 04 M 749.20YN

21347 04 M 766.90YN

Wednesday, June 18, 2008 Page 44 of 455

Page 52: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21348 04 M 954.20YN

21355 04 M 149.80YN

21356 04 M 539.65YN

21360 04 M 539.65YN

21365 04 M 689.50YN

21366 04 M 954.20YN

21385 04 M 599.35YN

21386 04 M 599.35YN

21387 04 M 749.20YN

21390 04 M 861.50YN

21395 04 M 861.50YN

21400 04 I 149.80YN

21401 04 M 224.70YN

21406 04 M 599.35YN

21407 04 M 749.20YN

21408 04 M 749.20YN

21421 04 M 457.70YN

21422 04 M 678.40YN

21423 04 M 828.20YN

21431 04 M 524.40YN

21432 04 M 749.20YN

Wednesday, June 18, 2008 Page 45 of 455

Page 53: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21433 04 M 898.95YN

21435 04 M 1,048.85YN

21436 04 M 1,048.85YN

21440 04 M 374.55YN

21445 04 M 599.35YN

21450 04 I 117.60YN

21451 04 M 498.10YN

21452 04 I 112.40YN

21453 04 M 498.10YN

21454 04 M 498.10YN

21461 04 M 706.15YN

21462 04 M 706.15YN

21465 04 M 498.10YN

21470 04 M 885.20YN

21480 04 M 240.00YN

21485 04 M 240.00YN

21490 04 M 749.20YN

21495 04 M 449.50YN

21497 04 M 149.80YN

21499 04 MYY

21501 04 I 115.30 17.00YN

Wednesday, June 18, 2008 Page 46 of 455

Page 54: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21502 04 M 224.70YN

21510 04 M 224.70YN

21550 04 I 99.10 17.00YN

21555 04 I 124.00 17.00YN

21556 04 I 158.50YN

21557 04 MYY

21600 04 M 299.70YN

21610 04 M 399.50YN

21615 04 M 449.50YN

21616 04 M 599.35YN

21620 04 M 250.40YN

21627 04 MYY

21630 04 M 749.20YN

21632 04 M 749.20YN

21685 04 M 491.50YN

21700 04 M 374.55YN

21705 04 M 449.50YN

21720 04 M 577.10YN

21725 04 M 599.35YN

21740 04 M 898.95YN

21742 04 M 898.95YN

Wednesday, June 18, 2008 Page 47 of 455

Page 55: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

21743 04 M 898.95YN

21750 04 M 368.20YN

21800 04 I 52.70YN

21805 04 I 111.00YN

21810 04 M 242.40YN

21820 04 I 74.90YN

21825 04 M 374.55YN

21899 04 MYY

21920 04 I 113.50 17.00YN

21925 04 M 180.20 17.00YN

21930 04 M 149.80YN

21935 04 MYY

22010 04 M 453.30YN

22015 04 M 449.25YN

22100 04 M 311.40YN

22101 04 M 315.50YN

22102 04 M 299.70YN

22103 04 MYY

22110 04 M 718.70YN

22112 04 M 718.70YN

22114 04 M 718.70YN

Wednesday, June 18, 2008 Page 48 of 455

Page 56: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

22116 04 MYY

22206 04 1/1/2008 M 1270.13YN

22207 04 1/1/2008 M 1253.30YN

22208 04 1/1/2008 M 325.80YN

22210 04 M 973.90YN

22212 04 M 973.90YN

22214 04 M 973.90YN

22216 04 MYY

22220 04 M 973.90YN

22222 04 M 973.90YN

22224 04 M 973.90YN

22226 04 MYY

22305 04 M 259.40YN

22310 04 I 98.80YN

22315 04 M 276.20YN

22318 04 M 1,417.20YN

22319 04 M 1,558.90YN

22325 04 M 599.35YN

22326 04 M 627.30YN

22327 04 M 608.50YN

22328 04 MYY

Wednesday, June 18, 2008 Page 49 of 455

Page 57: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

22505 04 I 149.80YN

22520 04 M 353.85YN

22521 04 M 331.90YN

22522 04 M 116.00N

22523 04 M 343.13N

22524 04 M 328.66N

22525 04 M 158.82N

22526 04 1/1/2007 M 509.95YN

22527 04 1/1/2007 MYY

22532 04 M 876.68YN

22533 04 M 816.43YN

22534 04 M 208.02YN

22548 04 M 1,642.15YN

22554 04 M 1,642.65YN

22556 04 M 1,642.65YN

22558 04 M 1,642.65YN

22585 04 MYY

22590 04 M 1,198.70YN

22595 04 M 1,198.70YN

22600 04 M 1,198.70YN

22610 04 M 1,198.70YN

Wednesday, June 18, 2008 Page 50 of 455

Page 58: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

22612 04 M 1,198.70YN

22614 04 MYY

22630 04 M 1,198.70YN

22632 04 MYY

22800 04 M 1,086.30YN

22802 04 M 1,086.30YN

22804 04 M 1,782.30YN

22808 04 M 1,086.30YN

22810 04 M 1,086.30YN

22812 04 M 1,086.30YN

22818 04 M 1,610.65YN

22819 04 M 1,610.65YN

22830 04 MYY

22840 04 M 1,872.90YN

22841 04 M 1,872.90YN

22842 04 M 1,872.90YN

22843 04 M 1,872.90YN

22844 04 M 1,872.90YN

22845 04 M 1,872.90YN

22846 04 M 1,872.90YN

22847 04 M 1,872.90YN

Wednesday, June 18, 2008 Page 51 of 455

Page 59: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

22848 04 M 351.00YN

22849 04 M 1,134.10YN

22850 04 M 449.50YN

22851 04 M 750.70YN

22852 04 M 449.50YN

22855 04 M 449.50YN

22857 04 1/1/2007 MYY

22862 04 1/1/2007 MYY

22865 04 1/1/2007 MYY

22899 04 MYY

22900 04 M 224.70YN

22999 04 MYY

23000 04 M 359.30YN

23020 04 M 299.70YN

23030 04 I 125.50 17.00YN

23031 04 I 99.10 17.00YN

23035 04 M 317.40YN

23040 04 M 599.35YN

23044 04 M 599.35YN

23065 04 I 113.60 17.00YN

23066 04 I 149.25 17.00YN

Wednesday, June 18, 2008 Page 52 of 455

Page 60: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

23075 04 M 224.70YN

23076 04 M 449.50YN

23077 04 MYY

23100 04 M 374.55YN

23101 04 M 599.35YN

23105 04 M 599.35YN

23106 04 M 599.35YN

23107 04 M 473.50YN

23120 04 M 362.00YN

23125 04 M 718.70YN

23130 04 M 362.00YN

23140 04 M 264.90YN

23145 04 M 480.00YN

23146 04 M 480.00YN

23150 04 M 275.80YN

23155 04 M 480.00YN

23156 04 M 480.00YN

23170 04 M 240.00YN

23172 04 M 240.00YN

23174 04 M 480.00YN

23180 04 M 299.70YN

Wednesday, June 18, 2008 Page 53 of 455

Page 61: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

23182 04 M 480.00YN

23184 04 M 480.00YN

23190 04 M 480.00YN

23195 04 M 599.35YN

23200 04 M 718.70YN

23210 04 M 718.70YN

23220 04 M 718.70YN

23221 04 M 839.35YN

23222 04 M 1,048.85YN

23330 04 I 17.00 107.00YN

23331 04 M 233.00YN

23332 04 MYY

23350 04 I 88.30YN

23395 04 M 501.35YN

23397 04 M 599.35YN

23400 04 M 839.35YN

23405 04 M 299.70YN

23406 04 M 449.50YN

23410 04 M 779.70YN

23412 04 M 779.70YN

23415 04 M 674.20YN

Wednesday, June 18, 2008 Page 54 of 455

Page 62: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

23420 04 M 674.20YN

23430 04 M 449.50YN

23440 04 M 449.50YN

23450 04 M 839.35YN

23455 04 M 839.35YN

23460 04 M 839.35YN

23462 04 M 839.35YN

23465 04 M 733.85YN

23466 04 M 584.40YN

23470 04 M 839.35YN

23472 04 M 1,498.30YN

23480 04 M 480.00YN

23485 04 M 486.90YN

23490 04 M 379.40YN

23491 04 M 464.45YN

23500 04 I 112.40YN

23505 04 M 187.30YN

23515 04 M 419.00YN

23520 04 I 112.40YN

23525 04 M 162.30YN

23530 04 M 720.00YN

Wednesday, June 18, 2008 Page 55 of 455

Page 63: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

23532 04 I 786.60YN

23540 04 I 112.40YN

23545 04 M 228.90YN

23550 04 M 503.60YN

23552 04 M 561.85YN

23570 04 I 79.60YN

23575 04 M 241.35YN

23585 04 M 449.50YN

23600 04 M 194.20YN

23605 04 M 277.50YN

23615 04 M 545.25YN

23616 04 M 975.25YN

23620 04 I 111.00YN

23625 04 M 163.70YN

23630 04 M 524.40YN

23650 04 M 178.90YN

23655 04 M 255.20YN

23660 04 M 419.00YN

23665 04 M 206.70YN

23670 04 M 842.10YN

23675 04 M 299.70YN

Wednesday, June 18, 2008 Page 56 of 455

Page 64: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

23680 04 M 599.35YN

23700 04 M 194.20YN

23800 04 M 839.35YN

23802 04 M 839.35YN

23900 04 M 1198.70YN

23920 04 M 1048.85YN

23921 04 M 224.70YN

23929 04 MYY

23930 04 M 179.70 17.00YN

23931 04 I 141.30 17.00YN

23935 04 M 240.00YN

24000 04 M 299.70YN

24006 04 M 380.15YN

24065 04 I 113.60 17.00YN

24066 04 M 264.25 17.00YN

24075 04 M 149.80YN

24076 04 M 224.70YN

24077 04 MYY

24100 04 M 299.70YN

24101 04 M 480.00YN

24102 04 M 524.40YN

Wednesday, June 18, 2008 Page 57 of 455

Page 65: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

24105 04 M 380.15YN

24110 04 M 527.20YN

24115 04 M 749.20YN

24116 04 M 749.20YN

24120 04 M 449.50YN

24125 04 M 749.20YN

24126 04 M 749.20YN

24130 04 M 492.55YN

24134 04 M 351.00YN

24136 04 M 262.80YN

24138 04 M 254.80YN

24140 04 M 480.00YN

24145 04 M 480.00YN

24147 04 M 480.00YN

24149 04 MYY

24150 04 M 1198.70YN

24151 04 M 1198.70YN

24152 04 M 958.60YN

24153 04 M 1048.85YN

24155 04 M 749.20YN

24160 04 M 299.70YN

Wednesday, June 18, 2008 Page 58 of 455

Page 66: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

24164 04 M 492.55YN

24200 04 M 169.30YN

24201 04 M 245.55YN

24220 04 I 105.15YN

24300 04 I 66.70YN

24301 04 M 453.70YN

24305 04 M 359.30YN

24310 04 M 188.70YN

24320 04 M 599.35YN

24330 04 M 599.35YN

24331 04 M 599.35YN

24332 04 M 326.30YN

24340 04 M 299.70YN

24341 04 M 274.20YN

24342 04 M 535.45YN

24343 04 M 430.15YN

24344 04 M 651.95YN

24345 04 M 430.15YN

24346 04 M 651.95YN

24357 04 1/1/2008 M 233.94YN

24358 04 1/1/2008 M 275.71YN

Wednesday, June 18, 2008 Page 59 of 455

Page 67: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

24359 04 1/1/2008 M 341.04YN

24360 04 M 718.70YN

24361 04 M 1123.70YN

24362 04 M 1123.70YN

24363 04 M 1123.70YN

24365 04 M 1123.70YN

24366 04 M 1123.70YN

24400 04 M 541.05YN

24410 04 M 481.65YN

24420 04 M 898.95YN

24430 04 M 636.80YN

24435 04 M 958.60YN

24470 04 M 374.55YN

24495 04 M 299.70YN

24498 04 M 491.50YN

24500 04 M 153.95YN

24505 04 M 295.50YN

24515 04 M 624.30YN

24516 04 M 624.30YN

24530 04 M 299.70YN

24535 04 M 334.40YN

Wednesday, June 18, 2008 Page 60 of 455

Page 68: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

24538 04 M 405.10YN

24545 04 M 718.70YN

24546 04 M 718.70YN

24560 04 M 199.75YN

24565 04 M 242.80YN

24566 04 M 257.30YN

24575 04 M 718.70YN

24576 04 M 188.70YN

24577 04 M 245.55YN

24579 04 M 718.70YN

24582 04 M 405.10YN

24586 04 M 480.65YN

24587 04 M 1123.70YN

24600 04 M 208.05YN

24605 04 M 242.80YN

24615 04 M 419.00YN

24620 04 M 259.40YN

24635 04 M 482.80YN

24640 04 M 180.30YN

24650 04 I 142.90YN

24655 04 M 208.05YN

Wednesday, June 18, 2008 Page 61 of 455

Page 69: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

24665 04 M 400.90YN

24666 04 M 449.50YN

24670 04 M 181.65YN

24675 04 M 206.70YN

24685 04 M 556.35YN

24800 04 M 718.70YN

24802 04 M 839.35YN

24900 04 M 313.50YN

24920 04 M 595.20YN

24925 04 M 262.20YN

24930 04 M 595.20YN

24931 04 M 674.20YN

24935 04 M 599.35YN

24940 04 M 621.10YN

24999 04 MYY

25000 04 M 351.00YN

25001 04 M 207.95YN

25020 04 M 388.50YN

25023 04 M 394.80YN

25024 04 M 458.20YN

25025 04 M 588.15YN

Wednesday, June 18, 2008 Page 62 of 455

Page 70: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

25028 04 I 179.25 17.00YN

25031 04 M 232.55 17.00YN

25035 04 M 287.60YN

25040 04 M 480.00YN

25065 04 I 113.60 17.00YN

25066 04 I 149.25 17.00YN

25075 04 M 149.80YN

25076 04 M 262.20YN

25077 04 MYY

25085 04 M 262.20YN

25100 04 M 419.00YN

25101 04 M 480.00YN

25105 04 M 480.00YN

25107 04 M 480.00YN

25109 04 1/1/2007 M 240.00YN

25110 04 M 217.80YN

25111 04 M 214.00 34.00YN

25112 04 M 214.00 34.00YN

25115 04 M 599.35YN

25116 04 M 599.35YN

25118 04 M 480.00YN

Wednesday, June 18, 2008 Page 63 of 455

Page 71: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

25119 04 M 659.00YN

25120 04 M 599.35YN

25125 04 M 674.20YN

25126 04 M 674.20YN

25130 04 M 299.70YN

25135 04 M 449.50YN

25136 04 M 449.50YN

25145 04 M 359.30YN

25150 04 M 359.30YN

25151 04 M 359.30YN

25170 04 MYY

25210 04 M 480.00YN

25215 04 M 480.00YN

25230 04 M 299.70YN

25240 04 M 359.30YN

25246 04 I 96.90YN

25248 04 M 181.25YN

25250 04 M 224.70YN

25251 04 M 339.50YN

25259 04 M 230.15YN

25260 04 M 283.50YN

Wednesday, June 18, 2008 Page 64 of 455

Page 72: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

25263 04 M 302.60YN

25265 04 M 484.20YN

25270 04 M 369.05YN

25272 04 M 256.85YN

25274 04 M 359.30YN

25275 04 M 442.50YN

25280 04 M 359.30YN

25290 04 M 302.40YN

25295 04 M 277.50YN

25300 04 M 359.30YN

25301 04 M 359.30YN

25310 04 M 480.00YN

25312 04 M 524.40YN

25315 04 M 480.00YN

25316 04 M 524.40YN

25320 04 M 449.50YN

25332 04 M 749.20YN

25335 04 M 749.20YN

25337 04 M 718.70YN

25350 04 M 374.55YN

25355 04 M 480.00YN

Wednesday, June 18, 2008 Page 65 of 455

Page 73: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

25360 04 M 316.10YN

25365 04 M 561.85YN

25370 04 M 480.00YN

25375 04 M 524.40YN

25390 04 M 599.35YN

25391 40 M 898.95YN

25392 04 M 898.95YN

25393 04 M 898.95YN

25394 04 M 514.80YN

25400 04 M 524.40YN

25405 04 M 599.35YN

25415 04 M 488.00YN

25420 04 M 839.35YN

25425 04 M 599.35YN

25426 04 M 749.20YN

25430 04 M 451.90YN

25431 04 M 449.10YN

25440 04 M 599.35YN

25441 04 M 659.00YN

25442 04 M 659.00YN

25443 04 M 749.20YN

Wednesday, June 18, 2008 Page 66 of 455

Page 74: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

25444 04 M 749.20YN

25445 04 M 749.20YN

25446 04 M 898.95YN

25447 04 MYY

25449 04 M 659.00YN

25450 04 M 299.70YN

25455 04 M 449.50YN

25490 04 M 356.50YN

25491 04 M 365.60YN

25492 04 M 459.05YN

25500 04 I 112.40YN

25505 04 M 210.90YN

25515 04 M 554.90YN

25520 04 M 267.80YN

25525 04 M 443.95YN

25526 04 M 592.40YN

25530 04 M 199.75YN

25535 04 M 240.00YN

25545 04 M 538.20YN

25560 04 M 176.20YN

25565 04 M 292.60YN

Wednesday, June 18, 2008 Page 67 of 455

Page 75: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

25574 04 M 538.20YN

25575 04 M 592.40YN

25600 04 M 155.35YN

25605 04 M 294.10YN

25606 04 1/1/2007 M 301.00YN

25607 04 1/1/2007 M 443.95YN

25608 04 1/1/2007 M 443.95YN

25609 04 1/1/2007 M 443.95YN

25622 04 I 147.10YN

25624 04 I 181.10YN

25628 04 M 335.70YN

25630 04 M 201.10YN

25635 04 I 174.60YN

25645 04 M 335.70YN

25650 04 I 126.90YN

25651 04 M 271.25YN

25652 04 M 374.00YN

25660 04 I 139.00YN

25670 04 M 266.70YN

25671 04 M 205.30YN

25675 04 I 168.25YN

Wednesday, June 18, 2008 Page 68 of 455

Page 76: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

25676 04 M 270.40YN

25680 04 M 240.00YN

25685 04 M 449.50YN

25690 04 I 188.65YN

25695 04 M 276.50YN

25800 04 M 718.70YN

25805 04 M 786.60YN

25810 04 M 839.35YN

25820 04 M 664.25YN

25825 04 M 718.70YN

25830 04 M 786.60YN

25900 04 M 359.30YN

25905 04 M 359.30YN

25907 04 M 290.30YN

25909 04 M 359.30YN

25915 04 M 1198.70YN

25920 04 M 359.30YN

25922 04 M 244.50YN

25924 04 M 359.30YN

25927 04 M 302.60YN

25929 04 M 236.30YN

Wednesday, June 18, 2008 Page 69 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

25931 04 M 285.80YN

25999 04 MYY

26010 04 I 76.25YN

26011 04 I 97.40YN

26020 04 M 191.80YN

26025 04 M 201.60YN

26030 04 M 237.15YN

26034 04 M 240.00YN

26035 04 M 321.65YN

26037 04 M 265.20YN

26040 04 M 264.90YN

26045 04 M 449.50YN

26055 04 M 235.80YN

26060 04 I 107.90YN

26070 04 M 224.70YN

26075 04 M 224.70YN

26080 04 M 187.30YN

26100 04 M 299.70YN

26105 04 M 262.20YN

26110 04 M 187.30YN

26115 04 M 149.80YN

Wednesday, June 18, 2008 Page 70 of 455

Page 78: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

26116 04 M 224.70YN

26117 04 MYY

26121 04 M 449.50YN

26123 04 M 524.40YN

26125 04 MYY

26130 04 M 374.55YN

26135 04 M 270.60YN

26140 04 M 245.35YN

26145 04 M 252.80YN

26160 04 M 210.10 34.00YN

26170 04 M 240.00YN

26180 04 M 240.00YN

26185 04 MYY

26200 04 M 299.70YN

26205 04 M 374.55YN

26210 04 M 224.70YN

26215 04 M 314.95YN

26230 04 M 299.70YN

26235 04 M 224.70YN

26236 04 M 204.05YN

26250 04 M 449.50YN

Wednesday, June 18, 2008 Page 71 of 455

Page 79: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

26255 04 M 524.40YN

26260 04 M 374.55YN

26261 04 M 449.50YN

26262 04 M 299.70YN

26320 04 M 233.00YN

26340 04 I 139.70YN

26350 04 M 274.40YN

26352 04 M 480.00YN

26356 04 M 359.30YN

26357 04 M 359.30YN

26358 04 M 599.35YN

26370 04 M 307.20YN

26372 04 M 480.00YN

26373 04 M 480.00YN

26390 04 M 480.00YN

26392 04 M 480.00YN

26410 04 M 222.00YN

26412 04 M 299.70YN

26415 04 M 306.95YN

26416 04 M 414.90YN

26418 04 M 201.65YN

Wednesday, June 18, 2008 Page 72 of 455

Page 80: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

26420 04 M 299.70YN

26426 04 M 480.00YN

26428 04 M 599.35YN

26432 04 M 359.30YN

26433 04 M 222.00YN

26434 04 M 359.30YN

26437 04 M 225.10YN

26440 04 M 417.60YN

26442 04 M 627.05YN

26445 04 M 240.00YN

26449 04 M 359.30YN

26450 04 M 240.00YN

26455 04 M 240.00YN

26460 04 M 240.00YN

26471 04 M 299.70YN

26474 04 M 359.30YN

26476 04 M 359.30YN

26477 04 M 359.30YN

26478 04 M 359.30YN

26479 04 M 359.30YN

26480 04 M 480.00YN

Wednesday, June 18, 2008 Page 73 of 455

Page 81: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

26483 04 M 480.00YN

26485 04 M 480.00YN

26489 04 M 561.85YN

26490 04 M 356.60YN

26492 04 M 449.50YN

26494 04 M 356.60YN

26496 04 MYY

26497 04 M 374.55YN

26498 04 M 693.70YN

26499 04 M 374.55YN

26500 04 M 226.50YN

26502 04 M 419.00YN

26508 04 M 232.55YN

26510 04 M 442.90YN

26514 04 IY

26516 04 M 255.00YN

26517 04 M 374.55YN

26518 04 M 416.20YN

26520 04 M 262.20YN

26525 04 M 262.20YN

26530 04 M 289.30YN

Wednesday, June 18, 2008 Page 74 of 455

Page 82: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

26531 04 M 337.10YN

26535 04 M 524.40YN

26536 04 M 524.40YN

26540 04 M 346.75YN

26541 04 M 374.55YN

26542 04 M 374.55YN

26545 04 M 299.70YN

26546 04 MYY

26548 04 M 299.70YN

26550 04 M 680.50YN

26551 04 MYY

26553 04 MYY

26554 04 MYY

26555 04 M 571.10YN

26556 04 MYY

26560 04 M 584.05YYN

26561 04 M 639.60YN

26562 04 M 898.95YN

26565 04 M 359.30YN

26567 04 M 359.30YN

26568 04 M 415.85YN

Wednesday, June 18, 2008 Page 75 of 455

Page 83: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

26580 04 M 579.05YN

26587 04 M 259.20YN

26590 04 M 587.40YN

26591 04 M 237.60YN

26593 04 M 259.20YN

26596 04 MYY

26600 04 I 93.70YN

26605 04 I 138.75YN

26607 04 M 299.70YN

26608 04 M 299.70YN

26615 04 M 299.70YN

26641 04 M 166.40YN

26645 04 M 166.40YN

26650 04 M 240.00YN

26665 04 M 374.55YN

26670 04 I 134.25YN

26675 04 I 181.55YN

26676 04 M 262.20YN

26685 04 M 233.30YN

26686 04 M 280.80YN

26700 04 I 107.00YN

Wednesday, June 18, 2008 Page 76 of 455

Page 84: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

26705 04 M 166.40YN

26706 04 M 237.85YN

26715 04 M 274.65YN

26720 04 I 97.05YN

26725 04 I 130.35YN

26727 04 M 171.00YN

26735 04 M 263.55YN

26740 04 I 97.05YN

26742 04 I 150.50YN

26746 04 M 263.55YN

26750 04 I 97.05YN

26755 04 I 104.10YN

26756 04 M 224.70YN

26765 04 M 285.80YN

26770 04 I 92.50YN

26775 04 I 132.45YN

26776 04 M 224.70YN

26785 04 I 148.60YN

26820 04 M 310.10YN

26841 04 M 299.70YN

26842 04 M 374.55YN

Wednesday, June 18, 2008 Page 77 of 455

Page 85: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

26843 04 M 299.70YN

26844 04 M 374.55YN

26850 04 M 262.20YN

26852 04 M 301.70YN

26860 04 M 200.65YN

26861 04 M 90.10YN

26862 04 M 274.60YN

26863 04 M 119.25YN

26910 04 M 271.90YN

26951 04 M 271.90YN

26952 04 M 259.40YN

26989 04 MYY

26990 04 I 262.45 17.00YN

26991 04 I 215.80 17.00YN

26992 04 M 418.80YN

27000 04 M 197.00YN

27001 04 M 202.20YN

27003 04 M 299.70YN

27005 04 M 274.65YN

27006 04 M 289.20YN

27025 04 M 374.55YN

Wednesday, June 18, 2008 Page 78 of 455

Page 86: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27030 04 M 524.40YN

27033 04 M 599.35YN

27035 04 M 599.35YN

27036 04 MYY

27040 04 I 113.60 17.00YN

27041 04 I 258.20 17.00YN

27047 04 M 224.70YN

27048 04 M 374.55YN

27049 04 MYY

27050 04 M 524.40YN

27052 04 M 524.40YN

27054 04 M 749.20YN

27060 04 M 277.50YN

27062 04 M 374.55YN

27065 04 M 599.35YN

27066 04 M 674.20YN

27067 04 M 749.20YN

27070 04 M 419.00YN

27071 04 M 480.00YN

27075 04 M 599.35YN

27076 04 M 681.10YN

Wednesday, June 18, 2008 Page 79 of 455

Page 87: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27077 04 M 723.20YN

27078 04 M 599.35YN

27079 04 M 599.35YN

27080 04 M 359.30YN

27086 04 I 107.00 17.00YN

27087 04 M 247.20 17.00YN

27090 04 M 412.00YN

27091 04 M 694.45YN

27093 04 I 106.70YN

27095 04 I 111.70YN

27096 04 I 172.50YN

27097 04 M 290.25YN

27098 04 M 345.70YN

27100 04 M 561.85YN

27105 04 M 636.80YN

27110 04 M 674.20YN

27111 04 M 674.20YN

27120 04 M 898.95YN

27122 04 M 954.50YN

27125 04 M 1026.65YN

27130 04 M 1749.50YN

Wednesday, June 18, 2008 Page 80 of 455

Page 88: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27132 04 M 1798.05YN

27134 04 M 1048.85YN

27137 04 M 1048.85YN

27138 04 M 1048.85YN

27140 04 M 718.70YN

27146 04 M 718.70YN

27147 04 M 839.35YN

27151 04 M 1011.40YN

27156 04 M 1123.70YN

27158 04 M 583.00YN

27161 04 M 749.20YN

27165 04 M 898.95YN

27170 04 M 898.95YN

27175 04 M 599.35YN

27176 04 M 599.35YN

27177 04 M 958.60YN

27178 04 M 958.60YN

27179 04 M 839.35YN

27181 04 M 958.60YN

27185 04 M 779.70YN

27187 04 M 950.50YN

Wednesday, June 18, 2008 Page 81 of 455

Page 89: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27193 04 I 170.80YN

27194 04 I 272.40YN

27200 04 M 149.80YN

27202 04 M 374.55YN

27215 04 M 674.20YN

27216 04 M 550.90YN

27217 04 M 599.35YN

27218 04 M 599.35YN

27220 04 M 412.00YN

27222 04 M 412.00YN

27226 04 M 930.90YN

27227 04 M 930.90YN

27228 04 M 1198.70YN

27230 04 I 179.15YN

27232 04 M 449.50YN

27235 04 M 674.20YN

27236 04 M 1019.70YN

27238 04 I 183.80YN

27240 04 M 449.50YN

27244 04 M 933.80YN

27245 04 M 933.80YN

Wednesday, June 18, 2008 Page 82 of 455

Page 90: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27246 04 I 167.00YN

27248 04 M 779.70YN

27250 04 M 242.80YN

27252 04 M 284.90YN

27253 04 M 599.35YN

27254 04 M 606.30YN

27256 04 M 208.05YN

27257 04 M 277.50YN

27258 04 M 733.85YN

27259 04 M 958.60YN

27265 04 M 242.80YN

27266 04 M 283.00YN

27267 04 1/1/2008 M 220.82YN

27268 04 1/1/2008 M 273.08YN

27269 04 1/1/2008 M 655.58YN

27275 04 M 240.00YN

27280 04 M 958.60YN

27282 04 M 958.60YN

27284 04 M 898.95YN

27286 04 M 1033.50YN

27290 04 M 1678.65YN

Wednesday, June 18, 2008 Page 83 of 455

Page 91: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27295 04 M 1198.70YN

27299 04 MYY

27301 04 M 242.10YN

27303 04 M 298.20YN

27305 04 M 374.55YN

27306 04 M 374.55YN

27307 04 M 561.85YN

27310 04 M 486.90YN

27323 04 I 113.60 17.00YN

27324 04 M 264.25 17.00YN

27325 04 1/1/2007 M 412.00YN

27326 04 1/1/2007 M 412.00YN

27327 04 I 156.30YN

27328 04 M 295.50YN

27329 04 MYY

27330 04 M 374.55YN

27331 04 M 599.35YN

27332 04 M 621.50YN

27333 04 M 621.50YN

27334 04 M 621.50YN

27335 04 M 621.50YN

Wednesday, June 18, 2008 Page 84 of 455

Page 92: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27340 04 M 240.00YN

27345 04 M 381.50YN

27347 04 M 381.50YN

27350 04 M 636.80YN

27355 04 M 599.35YN

27356 04 M 674.20YN

27357 04 M 674.20YN

27358 04 M 674.20YN

27360 04 M 480.00YN

27365 04 M 898.95YN

27370 04 I 101.10YN

27372 04 M 174.10YN

27380 04 M 412.00YN

27381 04 M 524.40YN

27385 04 M 419.00YN

27386 04 M 524.40YN

27390 04 M 359.30YN

27391 04 M 458.40YN

27392 04 M 661.15YN

27393 04 M 359.30YN

27394 04 M 458.40YN

Wednesday, June 18, 2008 Page 85 of 455

Page 93: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27395 04 M 661.15YN

27396 04 M 599.35YN

27397 04 M 550.90YN

27400 04 M 599.35YN

27403 04 M 621.50YN

27405 04 M 524.40YN

27407 04 M 524.40YN

27409 04 M 674.20YN

27412 04 M 621.50YN

27415 04 M 621.50YN

27416 04 1/1/2008 M 513.32YN

27418 04 M 486.10YN

27420 04 M 620.10YN

27422 04 M 620.10YN

27424 04 M 636.80YN

27425 04 M 561.85YN

27427 04 M 524.40YN

27428 04 M 621.10YN

27429 04 M 674.20YN

27430 04 M 561.85YN

27435 04 M 524.40YN

Wednesday, June 18, 2008 Page 86 of 455

Page 94: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27437 04 M 599.35YN

27438 04 M 958.60YN

27440 04 M 599.35YN

27441 04 M 599.35YN

27442 04 M 881.00YN

27443 04 M 881.00YN

27445 04 M 1473.35YN

27446 04 M 1473.35YN

27447 04 M 1473.35YN

27448 04 M 599.35YN

27450 04 M 689.50YN

27454 04 M 749.20YN

27455 04 M 524.40YN

27457 04 M 524.40YN

27465 04 M 749.20YN

27466 04 M 898.95YN

27468 04 M 1198.70YN

27470 04 M 839.35YN

27472 04 M 958.60YN

27475 04 M 659.00YN

27477 04 M 659.00YN

Wednesday, June 18, 2008 Page 87 of 455

Page 95: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27479 04 M 958.60YN

27485 04 M 561.85YN

27486 04 M 736.60YN

27487 04 M 1473.30YN

27488 04 M 524.65YN

27495 04 MYY

27496 04 M 374.55YN

27497 04 M 374.55YN

27498 04 M 383.45YN

27499 04 M 383.45YN

27500 04 M 257.40YN

27501 04 M 263.20YN

27502 04 M 338.50YN

27503 04 M 338.50YN

27506 04 M 910.10YN

27507 04 M 910.10YN

27508 04 M 209.00YN

27509 04 M 524.40YN

27510 04 M 524.40YN

27511 04 M 836.55YN

27513 04 M 826.30YN

Wednesday, June 18, 2008 Page 88 of 455

Page 96: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27514 04 M 836.55YN

27516 04 M 599.35YN

27517 04 M 599.35YN

27519 04 M 836.55YN

27520 04 M 191.50YN

27524 04 M 629.90YN

27530 04 M 288.50YN

27532 04 M 321.90YN

27535 04 M 839.35YN

27536 04 M 839.35YN

27538 04 M 213.65YN

27540 04 M 958.60YN

27550 04 M 194.25YN

27552 04 M 227.40YN

27556 04 M 656.20YN

27557 04 M 749.20YN

27558 04 M 749.20YN

27560 04 I 149.80YN

27562 04 M 187.80YN

27566 04 M 383.25YN

27570 04 I 66.70YN

Wednesday, June 18, 2008 Page 89 of 455

Page 97: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27580 04 M 1384.60YN

27590 04 M 649.25YN

27591 04 M 749.20YN

27592 04 M 574.35YN

27594 04 M 224.70YN

27596 04 M 574.35YN

27598 04 M 480.00YN

27599 04 MYY

27600 04 M 189.80YN

27601 04 M 190.20YN

27602 04 M 262.20YN

27603 04 M 211.60 17.00YN

27604 04 I 156.50 17.00YN

27605 04 M 359.30YN

27606 04 M 359.30YN

27607 04 M 292.30YN

27610 04 M 480.00YN

27612 04 M 374.55YN

27613 04 I 113.60 17.00YN

27614 04 I 264.25 17.00YN

27615 04 M 521.56YN

Wednesday, June 18, 2008 Page 90 of 455

Page 98: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27618 04 I 186.90YN

27619 04 M 268.40YN

27620 04 M 480.00YN

27625 04 M 480.00YN

27626 04 M 480.00YN

27630 04 M 188.65YN

27635 04 M 374.55YN

27637 04 M 599.35YN

27638 04 M 599.35YN

27640 04 M 407.80YN

27641 04 M 335.00YN

27645 04 M 599.35YN

27646 04 M 599.35YN

27647 04 M 449.50YN

27648 04 I 82.75YN

27650 04 M 359.30YN

27652 04 M 480.00YN

27654 04 M 449.50YN

27656 04 M 299.70YN

27658 04 M 224.70YN

27659 04 M 416.20YN

Wednesday, June 18, 2008 Page 91 of 455

Page 99: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27664 04 M 182.50YN

27665 04 M 302.40YN

27675 04 M 239.30YN

27676 04 M 313.20YN

27680 04 M 381.50YN

27681 04 M 231.00YN

27685 04 M 262.20YN

27686 04 M 257.00YN

27687 04 M 262.20YN

27690 04 M 299.70YN

27691 04 M 524.40YN

27692 04 M 149.80YN

27695 04 M 374.55YN

27696 04 M 561.85YN

27698 04 M 453.70YN

27700 04 M 718.70YN

27702 04 M 749.20YN

27703 04 MYY

27704 04 M 249.35YN

27705 04 M 412.00YN

27707 04 M 359.30YN

Wednesday, June 18, 2008 Page 92 of 455

Page 100: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27709 04 M 524.40YN

27712 04 M 674.20YN

27715 04 M 749.20YN

27720 04 M 629.90YN

27722 04 M 733.85YN

27724 04 M 840.75YN

27725 04 M 840.75YN

27726 04 1/1/2008 M 478.66YN

27727 04 M 648.10YN

27730 04 M 412.00YN

27732 04 M 314.95YN

27734 04 M 599.35YN

27740 04 M 839.35YN

27742 04 M 839.35YN

27745 04 M 378.05YN

27750 04 M 208.05YN

27752 04 M 320.45YN

27756 04 M 738.10YN

27758 04 M 839.35YN

27759 04 M 839.35YN

27760 04 M 166.40YN

Wednesday, June 18, 2008 Page 93 of 455

Page 101: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27762 04 M 235.80YN

27766 04 M 535.45YN

27767 04 1/1/2008 M 131.63YN

27768 04 1/1/2008 M 208.32YN

27769 04 1/1/2008 M 362.81YN

27780 04 M 152.60YN

27781 04 M 217.80YN

27784 04 M 416.20YN

27786 04 M 152.60YN

27788 04 M 222.00YN

27792 04 M 299.70YN

27808 04 M 208.05YN

27810 04 M 305.15YN

27814 04 M 610.45YN

27816 04 M 224.70YN

27818 04 M 369.05YN

27822 04 M 599.35YN

27823 04 M 599.35YN

27824 04 M 232.20YN

27825 04 M 286.20YN

27826 04 M 515.70YN

Wednesday, June 18, 2008 Page 94 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27827 04 M 638.00YN

27828 04 M 696.90YN

27829 04 M 412.00YN

27830 04 M 153.75YN

27831 04 M 224.70YN

27832 04 M 599.35YN

27840 04 M 138.20YN

27842 04 M 208.05YN

27846 04 M 378.70YN

27848 04 M 481.90YN

27860 04 I 77.10YN

27870 04 M 659.00YN

27871 04 M 659.00YN

27880 04 M 613.20YN

27881 04 M 674.20YN

27882 04 M 588.20YN

27884 04 M 252.65YN

27886 04 M 374.55YN

27888 04 M 599.35YN

27889 04 M 374.55YN

27892 04 M 220.40YN

Wednesday, June 18, 2008 Page 95 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

27893 04 M 212.80YN

27894 04 M 293.20YN

27899 04 MY

28001 04 M 136.05 17.00YN

28002 04 M 143.95YN

28003 04 M 246.85YN

28005 04 M 270.50YN

28008 04 I 147.95YN

28010 04 I 123.35YN

28011 04 MYY

28020 04 M 224.70YN

28022 04 M 153.65YN

28024 04 I 146.15YN

28035 04 M 524.40YN

28043 04 M 149.80YN

28045 04 M 224.70YN

28046 04 MYY

28050 04 M 299.70YN

28052 04 M 299.70YN

28054 04 M 224.70YN

28055 04 1/1/2007 M 302.40YN

Wednesday, June 18, 2008 Page 96 of 455

Page 104: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

28060 04 M 224.70YN

28062 04 MYY

28070 04 M 224.70YN

28072 04 M 161.90YN

28080 04 M 180.30YN

28086 04 M 184.50YN

28088 04 M 184.50YN

28090 04 M 175.75 34.00YN

28092 04 M 211.35 34.00YN

28100 04 M 224.70YN

28102 04 M 718.70YN

28103 04 M 718.70YN

28104 04 M 259.40YN

28106 04 M 449.50YN

28107 04 M 449.50YN

28108 04 M 259.40YN

28110 04 M 359.30YN

28111 04 M 359.30YN

28112 04 M 314.95YN

28113 04 M 314.95YN

28114 04 M 943.40YN

Wednesday, June 18, 2008 Page 97 of 455

Page 105: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

28116 04 M 346.75YN

28118 04 M 346.75YN

28119 04 M 264.90YN

28120 04 M 259.40YN

28122 04 M 253.90YN

28124 04 M 259.40YN

28126 04 M 209.40YN

28130 04 M 412.00YN

28140 04 M 394.00YN

28150 04 M 209.40YN

28153 04 M 144.70YN

28160 04 M 224.70YN

28171 04 MYY

28173 04 MYY

28175 04 MYY

28190 04 I 107.00 17.00YN

28192 04 M 159.80 17.00YN

28193 04 M 180.30YN

28200 04 M 353.75YN

28202 04 M 480.00YN

28208 04 M 299.70YN

Wednesday, June 18, 2008 Page 98 of 455

Page 106: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

28210 04 M 378.05YN

28220 04 M 212.30YN

28222 04 MYY

28225 04 M 212.30YN

28226 04 MYY

28230 04 M 173.40YN

28232 04 I 121.10YN

28234 04 I 121.05YN

28238 04 M 299.70YN

28240 04 M 140.75YN

28250 04 M 359.30YN

28260 04 M 299.70YN

28261 04 M 363.45YN

28262 04 M 524.40YN

28264 04 M 449.50YN

28270 04 M 299.70YN

28272 04 M 224.70YN

28280 04 M 162.35YN

28285 04 M 270.50YN

28286 04 M 337.10YN

28288 04 M 299.70YN

Wednesday, June 18, 2008 Page 99 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

28289 04 M 359.30YN

28290 04 M 424.45YN

28292 04 M 359.30YN

28293 04 M 359.30YN

28294 04 M 359.30YN

28296 04 M 419.00YN

28297 04 M 419.00YN

28298 04 M 359.30YN

28299 04 M 384.89YN

28300 04 M 374.55YN

28302 04 M 337.90YN

28304 04 M 283.60YN

28305 04 M 373.70YN

28306 04 M 262.20YN

28307 04 M 299.70YN

28308 04 M 202.50YN

28309 04 M 358.05YN

28310 04 M 262.20YN

28312 04 M 169.85YN

28313 04 M 167.10YN

28315 04 M 224.70YN

Wednesday, June 18, 2008 Page 100 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

28320 04 M 378.05YN

28322 04 M 244.90YN

28340 04 M 270.00YN

28341 04 M 307.90YN

28344 04 M 172.80YN

28345 04 M 216.00YN

28360 04 MYY

28400 04 I 114.20YN

28405 04 M 228.90YN

28406 04 M 231.65YN

28415 04 M 642.45YN

28420 04 M 671.85YN

28430 04 M 109.00YN

28435 04 M 215.05YN

28436 04 M 318.60YN

28445 04 M 718.70YN

28446 04 1/1/2008 M 626.74YN

28450 04 M 98.00YN

28455 04 M 277.50YN

28456 04 M 313.20YN

28465 04 M 599.35YN

Wednesday, June 18, 2008 Page 101 of 455

Page 109: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

28470 04 I 97.05YN

28475 04 M 173.40YN

28476 04 M 237.85YN

28485 04 M 301.00YN

28490 04 I 55.40YN

28495 04 I 69.30YN

28496 04 M 113.60YN

28505 04 M 230.80YN

28510 04 I 41.60YN

28515 04 I 97.05YN

28525 04 I 202.90YN

28530 04 I 57.30YN

28531 04 M 224.70YN

28540 04 I 138.75YN

28545 04 I 152.60YN

28546 04 I 134.60YN

28555 04 M 480.00YN

28570 04 I 113.65YN

28575 04 M 151.15YN

28576 04 M 262.20YN

28585 04 M 427.20YN

Wednesday, June 18, 2008 Page 102 of 455

Page 110: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

28600 04 M 299.70YN

28605 04 M 299.70YN

28606 04 M 299.70YN

28615 04 M 368.45YN

28630 04 I 112.40YN

28635 04 M 262.20YN

28636 04 M 262.20YN

28645 04 M 240.00YN

28660 04 I 104.10YN

28665 04 I 117.85YN

28666 04 M 133.35YN

28675 04 M 241.35YN

28705 04 M 599.35YN

28715 04 M 599.35YN

28725 04 M 480.00YN

28730 04 M 480.00YN

28735 04 M 599.35YN

28737 04 M 599.35YN

28740 04 M 337.10YN

28750 04 M 262.20YN

28755 04 M 169.10YN

Wednesday, June 18, 2008 Page 103 of 455

Page 111: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

28760 04 M 239.10YN

28800 04 M 485.50YN

28805 04 M 482.80YN

28810 04 M 419.00YN

28820 04 I 167.10YN

28825 04 I 145.60YN

28890 04 M 121.80YN

28899 04 MYY

29000 04 I 156.80YN

29010 04 I 141.50YN

29015 04 I 188.70YN

29020 04 I 205.30YN

29025 04 I 227.50YN

29035 04 I 152.60YN

29040 04 I 181.65YN

29044 04 I 173.40YN

29046 04 I 187.30YN

29049 04 I 66.10 34.00N

29055 04 I 115.80 34.00N

29058 04 I 79.30 34.00N

29065 04 I 59.45 34.00N

Wednesday, June 18, 2008 Page 104 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

29075 04 I 59.45 34.00N

29085 04 I 49.30 17.00N

29086 04 I 30.70N

29105 04 I 42.10 17.00N

29125 04 I 32.15 17.00YN

29126 04 I 39.30 17.00YN

29130 04 I 23.00 17.00N

29131 04 I 23.50 17.00N

29200 04 I 24.25N

29220 04 I 23.00N

29240 04 I 37.40N

29260 04 I 19.95N

29280 04 I 19.30N

29305 04 I 166.40N

29325 04 I 194.20N

29345 04 I 79.30 34.00N

29355 04 I 92.40 34.00N

29358 04 I 174.40 34.00N

29365 04 I 79.30 34.00N

29405 04 I 70.00 34.00N

29425 04 I 75.30 34.00N

Wednesday, June 18, 2008 Page 105 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

29435 04 I 79.30 34.00N

29440 04 I 29.80N

29445 04 I 91.65N

29450 04 I 43.50 17.00N

29505 04 I 43.50 17.00N

29515 04 I 35.85 17.00N

29520 04 I 21.40N

29530 04 I 21.80N

29540 04 I 15.40N

29550 04 I 14.20N

29580 04 I 27.00 17.00N

29590 04 I 22.15N

29700 04 I 24.15N

29705 04 I 25.60N

29710 04 I 56.80N

29715 04 I 94.30N

29720 04 I 59.60N

29730 04 I 36.00N

29740 04 I 46.55N

29750 04 I 44.30N

29799 04 IY

Wednesday, June 18, 2008 Page 106 of 455

Page 114: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

29800 04 M 374.55YN

29804 04 M 355.80YN

29805 04 M 325.20YN

29806 04 M 673.30YN

29807 04 M 673.30YN

29819 04 M 480.00YN

29820 04 M 480.00YN

29821 04 M 480.00YN

29822 04 M 480.00YN

29823 04 M 480.00YN

29824 04 M 526.45YN

29825 04 M 480.00YN

29826 04 M 480.00YN

29827 04 M 674.20YN

29828 04 1/1/2008 M 484.90YN

29830 04 M 394.50YN

29834 04 M 480.00YN

29835 04 M 480.00YN

29836 04 M 480.00YN

29837 04 M 480.00YN

29838 04 M 480.00YN

Wednesday, June 18, 2008 Page 107 of 455

Page 115: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

29840 04 M 356.10YN

29843 04 M 356.10YN

29844 04 M 480.00YN

29845 04 M 480.00YN

29846 04 M 356.10YN

29847 04 M 480.00YN

29848 04 M 456.00YN

29850 04 M 675.10YN

29851 04 M 958.60YN

29855 04 M 629.90YN

29856 04 M 839.35YN

29860 04 M 374.55YN

29861 04 M 486.90YN

29862 04 M 599.35YN

29863 04 M 599.35YN

29866 04 MYY

29867 04 MYY

29868 04 MYY

29870 04 M 374.55YN

29871 04 M 374.55YN

29873 04 M 374.55YN

Wednesday, June 18, 2008 Page 108 of 455

Page 116: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

29874 04 M 486.90YN

29875 04 M 599.35YN

29876 04 M 599.35YN

29877 04 M 599.35YN

29879 04 M 599.35YN

29880 04 M 621.50YN

29881 04 M 621.50YN

29882 04 M 621.50YN

29883 04 M 599.35YN

29884 04 M 599.35YN

29885 04 M 621.50YN

29886 04 M 599.35YN

29887 04 M 599.35YN

29888 04 M 621.50YN

29889 04 M 621.50YN

29891 04 M 480.00YN

29892 04 M 480.00YN

29893 04 M 171.90YN

29894 04 M 480.00YN

29895 04 M 480.00YN

29897 04 M 480.00YN

Wednesday, June 18, 2008 Page 109 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

29898 04 M 480.00YN

29899 04 M 659.00YN

29900 04 M 288.60YN

29901 04 M 318.80YN

29902 04 M 342.55YN

29904 04 1/1/2008 M 323.37YN

29905 04 1/1/2008 M 347.96YN

29906 04 1/1/2008 M 366.46YN

29907 04 1/1/2008 M 451.20YN

29999 04 MYY

30000 04 I 46.70 17.00YN

30020 04 I 47.80 17.00N

30100 04 I 55.40 17.00YN

30110 04 I 57.10 17.00YN

30115 04 M 156.80YN

30117 04 I 109.30YN

30118 04 I 299.35YN

30120 04 M 480.00YN

30124 04 I 89.10 17.00YN

30125 04 I 218.95YN

30130 04 M 180.30YN

Wednesday, June 18, 2008 Page 110 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

30140 04 M 180.30YN

30150 04 MYY

30160 04 MYY

30200 04 I 24.90YN

30210 04 I 34.80YN

30220 04 I 56.00YN

30300 04 I 39.05N

30310 04 I 74.90YN

30320 04 I 152.60YN

30400 04 M 749.20YN

30410 04 M 749.20YN

30420 04 M 980.85YN

30430 04 M 374.55YN

30435 04 MYY

30450 04 M 599.35YN

30460 04 M 599.35YN

30462 04 M 815.50YN

30465 04 M 547.60YN

30520 04 M 417.60YN

30540 04 M 524.40YN

30545 04 M 674.20YN

Wednesday, June 18, 2008 Page 111 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

30560 04 I 42.00YN

30580 04 M 374.55YN

30600 04 M 374.55YN

30620 04 M 524.40YN

30630 04 M 524.40YN

30801 04 I 50.05YN

30802 04 I 71.15YN

30901 04 I 74.90YN

30903 04 I 71.40 17.00YN

30905 04 I 80.75 17.00YN

30906 04 I 85.70 17.00YN

30915 04 M 359.30YN

30920 04 M 359.30YN

30930 04 I 90.10YN

30999 04 MYY

31000 04 I 39.35YN

31002 04 I 51.50YN

31020 04 M 180.30YN

31030 04 M 480.00YN

31032 04 M 718.70YN

31040 04 M 359.30YN

Wednesday, June 18, 2008 Page 112 of 455

Page 120: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

31050 04 M 412.00YN

31051 04 M 412.00YN

31070 04 M 180.30YN

31075 04 M 599.35YN

31080 04 M 898.95YN

31081 04 M 898.95YN

31084 04 M 898.95YN

31085 04 M 898.95YN

31086 04 M 898.95YN

31087 04 M 898.95YN

31090 04 M 718.70YN

31200 04 M 262.20YN

31201 04 M 449.50YN

31205 04 M 449.50YN

31225 04 M 898.95YN

31230 04 M 1,198.70YN

31231 04 I 107.00YN

31233 04 I 112.40YN

31235 04 I 107.00YN

31237 04 I 102.55YN

31238 04 I 113.10YN

Wednesday, June 18, 2008 Page 113 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

31239 04 MYY

31240 04 M 221.90YN

31254 04 M 262.20YN

31255 04 M 449.50YN

31256 04 M 180.30YN

31267 04 M 224.70YN

31276 04 M 253.30YN

31287 04 M 205.95YN

31288 04 M 412.00YN

31290 04 MYY

31291 04 MYY

31292 04 M 451.50YN

31293 04 M 492.15YN

31294 04 M 581.00YN

31299 04 MYY

31300 04 M 524.40YN

31320 04 M 299.70YN

31360 04 M 1,198.70YN

31365 04 M 1,537.15YN

31367 04 M 958.60YN

31368 04 M 1,537.15YN

Wednesday, June 18, 2008 Page 114 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

31370 04 M 958.60YN

31375 04 M 958.60YN

31380 04 M 958.60YN

31382 04 M 958.60YN

31390 04 M 1,537.15YN

31395 04 M 1,728.25YN

31400 04 M 749.20YN

31420 04 M 524.40YN

31500 04 I 55.50N

31502 04 I 28.50N

31505 04 I 37.40YN

31510 04 I 74.90YN

31511 04 I 202.50YN

31512 04 M 202.50YN

31513 04 M 235.80YN

31515 04 I 107.00 17.00YN

31520 04 I 112.40YN

31525 04 I 107.00 17.00YN

31526 04 I 192.95 17.00YN

31527 04 M 192.95 17.00YN

31528 04 I 192.95 17.00YN

Wednesday, June 18, 2008 Page 115 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

31529 04 I 192.95 17.00YN

31530 04 M 192.95 34.00YN

31531 04 M 224.60 34.00YN

31535 04 I 224.60 34.00YN

31536 04 I 224.60 34.00YN

31540 04 M 268.20 34.00YN

31541 04 M 268.20 34.00YN

31545 04 M 268.20YN

31546 04 M 577.16YN

31560 04 M 499.45 34.00YN

31561 04 M 499.45 34.00YN

31570 04 M 224.60 34.00YN

31571 04 M 224.60 34.00YN

31575 04 I 107.00 34.00YN

31576 04 I 224.60 34.00YN

31577 04 M 192.95 34.00YN

31578 04 M 268.20 34.00YN

31579 04 I 192.95YN

31580 04 M 524.35YN

31582 04 M 686.80YN

31584 04 M 591.60YN

Wednesday, June 18, 2008 Page 116 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

31587 04 M 524.35YN

31588 04 MYY

31590 04 M 839.35YN

31595 04 M 360.70YN

31599 04 MYY

31600 04 I 266.40YN

31601 04 I 284.40YN

31603 04 I 266.40YN

31605 04 I 266.40YN

31610 04 I 289.40YN

31611 04 M 374.60YN

31612 04 I 149.80YN

31613 04 M 208.05YN

31614 04 MYY

31615 04 I 107.00 17.00YN

31620 04 I 56.70YY

31622 04 I 235.20 56.70YN

31623 04 I 235.20YN

31624 04 I 270.50YN

31625 04 I 235.20 56.70YN

31628 04 I 246.95YN

Wednesday, June 18, 2008 Page 117 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

31629 04 I 235.20YN

31630 04 M 251.10YN

31631 04 M 251.10YN

31632 04 I 30.94YN

31633 04 I 38.51YN

31635 04 M 239.15 56.70YN

31636 04 M 251.10YN

31637 04 M 251.10YN

31638 04 M 251.10YN

31640 04 M 251.10YN

31641 04 M 251.10YN

31643 04 I 235.95YN

31645 04 I 219.35 56.70YN

31646 04 I 219.35 56.70YN

31656 04 I 270.50YN

31715 04 I 74.90YN

31717 04 I 230.25YN

31720 04 I 224.70N

31725 04 I 224.70N

31730 04 I 88.90YN

31750 04 M 713.50YN

Wednesday, June 18, 2008 Page 118 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

31755 04 M 527.50YN

31760 04 M 1,123.70YN

31766 04 M 1,198.70YN

31770 04 M 1,048.85YN

31775 04 M 1,123.70YN

31780 04 M 749.20YN

31781 04 M 1,123.70YN

31785 04 M 1,198.70YN

31786 04 M 1,198.70YN

31800 04 M 524.40YN

31805 04 M 749.20YN

31820 04 M 214.00 34.00YN

31825 04 M 374.55YN

31830 04 M 166.75YN

31899 04 MY

32035 04 M 524.40YN

32036 04 M 331.15YN

32095 04 M 419.00YN

32100 04 M 811.50YN

32110 04 M 811.50YN

32120 04 M 599.35YN

Wednesday, June 18, 2008 Page 119 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

32124 04 M 599.35YN

32140 04 M 599.35YN

32141 04 M 599.35YN

32150 04 M 599.35YN

32151 04 M 599.35YN

32160 04 M 374.55YN

32200 04 M 480.00YN

32201 04 M 434.45YN

32215 04 M 599.35YN

32220 04 M 749.20YN

32225 04 M 599.35YN

32310 04 M 958.60YN

32320 04 M 1,198.70YN

32400 04 I 71.40 34.00YN

32402 04 M 524.40YN

32405 04 I 107.00 34.00YN

32420 04 I 107.00 34.00YN

32421 04 1/1/2008 I 87.98YN

32422 04 1/1/2008 I 108.51YN

32440 04 M 1,198.70N

32442 04 M 1,414.70N

Wednesday, June 18, 2008 Page 120 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

32445 04 M 1,198.70N

32480 04 M 1,213.95N

32482 04 M 1,213.95N

32484 04 M 1,213.95N

32486 04 M 1,350.15N

32488 04 M 1,213.95N

32491 04 M 1,213.95N

32500 04 M 718.70N

32501 04 M 324.05N

32503 04 M 1,050.34YN

32504 04 M 1,203.13YN

32540 04 M 958.60YN

32550 04 1/1/2008 M 127.01 318.46YN

32551 04 1/1/2008 M 101.27YN

32560 04 1/1/2008 I 165.83YN

32601 04 I 167.20YN

32602 04 I 181.35YN

32603 04 I 302.40YN

32604 04 I 302.40YN

32605 04 I 314.95YN

32606 04 I 314.95YN

Wednesday, June 18, 2008 Page 121 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

32650 04 M 349.85YN

32651 04 M 426.10YN

32652 04 M 591.40YN

32653 04 M 418.50YN

32654 04 M 400.80YN

32655 04 M 838.95YN

32656 04 M 523.85YN

32657 04 M 523.85YN

32658 04 M 415.90YN

32659 04 M 415.55YN

32660 04 M 648.10YN

32661 04 M 523.85YN

32662 04 M 598.40YN

32663 04 M 1,213.85YN

32664 04 M 749.20YN

32665 04 M 1,082.10YN

32800 04 MYY

32810 04 M 398.40YN

32815 04 MYY

32820 04 MYY

32850 04 M 1,134.10N

Wednesday, June 18, 2008 Page 122 of 455

Page 130: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

32851 04 M 2,106.30N

32852 04 M 2,397.40N

32853 04 M 3,402.50N

32854 04 M 3,834.55N

32900 04 M 564.90YN

32905 04 M 749.20YN

32906 04 M 772.90YN

32940 04 M 571.55N

32960 04 I 299.70YN

32997 04 M 246.40YN

32998 04 1/1/2007 M 214.24YN

32999 04 MY

33010 04 I 61.25YN

33011 04 I 57.55YN

33015 04 I 204.05YN

33020 04 M 733.85YN

33025 04 M 839.35YN

33030 04 M 839.35N

33031 04 M 2,397.40N

33050 04 M 1,048.85N

33120 04 M 2,397.40N

Wednesday, June 18, 2008 Page 123 of 455

Page 131: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33130 04 M 749.20N

33140 04 MYY

33141 04 MYY

33202 04 1/1/2007 M 861.50YN

33203 04 1/1/2007 M 349.85YN

33206 04 M 861.50YN

33207 04 M 861.50YN

33208 04 M 861.50YN

33210 04 I 240.00YN

33211 04 I 240.00YN

33212 04 I 240.00YN

33213 04 I 240.00YN

33214 04 M 299.70YN

33215 04 M 299.70YN

33216 04 M 299.70YN

33217 04 M 299.70YN

33218 04 M 299.70YN

33220 04 M 245.65YN

33222 04 M 299.70YN

33223 04 M 299.70YN

33224 04 M 299.70YN

Wednesday, June 18, 2008 Page 124 of 455

Page 132: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33225 04 M 299.70YN

33226 04 M 299.70YN

33233 04 M 167.40YN

33234 04 M 351.00YN

33235 04 M 351.00YN

33236 04 M 419.00YN

33237 04 M 433.95YN

33238 04 M 452.80YN

33240 04 IYY

33241 04 IYY

33243 04 MYY

33244 04 IYY

33249 04 M 642.60YN

33250 04 M 1,798.10N

33251 04 M 2,397.40YN

33254 04 1/1/2007 M 2,397.40YN

33255 04 1/1/2007 M 2,397.40YN

33256 04 1/1/2007 M 2,397.40YN

33257 04 1/1/2008 M 327.74N

33258 04 1/1/2008 M 371.27N

33259 04 1/1/2008 M 489.48N

Wednesday, June 18, 2008 Page 125 of 455

Page 133: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33261 04 M 2,397.40N

33265 04 1/1/2007 M 2,397.40YN

33266 04 1/1/2007 M 2,397.40YN

33282 04 M 584.80YN

33284 04 M 444.05YN

33300 04 M 629.90N

33305 04 M 2,397.40N

33310 04 M 1,048.85YN

33315 04 M 2,397.40N

33320 04 M 749.20YN

33321 04 M 1,798.05N

33322 04 M 2,397.40N

33330 04 M 1,198.70N

33332 04 M 2,397.40N

33335 04 M 2,397.40N

33400 04 M 2,397.40N

33401 04 M 2,397.40N

33403 04 M 2,397.40N

33404 04 MY

33405 04 M 2,397.40N

33406 04 M 2,397.40N

Wednesday, June 18, 2008 Page 126 of 455

Page 134: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33410 04 M 2,397.40N

33411 04 M 2,397.40N

33412 04 M 2,397.40N

33413 04 M 2,397.40N

33414 04 MY

33415 04 M 1,198.70N

33416 04 M 2,397.40N

33417 04 MY

33420 04 M 1,048.85N

33422 04 M 2,397.40N

33425 04 M 2,397.40N

33426 04 M 2,397.40N

33427 04 M 2,397.40N

33430 04 M 2,397.40N

33460 04 M 2,397.40N

33463 04 M 2,397.40N

33464 04 M 2,397.40N

33465 04 M 2,397.40N

33468 04 M 2,397.40N

33470 04 M 749.20N

33471 04 M 1,198.70N

Wednesday, June 18, 2008 Page 127 of 455

Page 135: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33472 04 M 1,198.70N

33474 04 M 2,397.40N

33475 04 M 2,397.40N

33476 04 M 1,198.70N

33478 04 M 2,277.50N

33496 04 M 2,397.40N

33500 04 M 2,397.40N

33501 04 M 1,198.70N

33502 04 M 749.20YN

33503 04 M 2,397.40YN

33504 04 M 2,397.40N

33505 04 MY

33506 04 MY

33507 04 M 1,014.99YN

33508 04 M 17.04YN

33510 04 M 2,397.40N

33511 04 M 2,397.40N

33512 04 M 2,397.40N

33513 04 M 2,397.40N

33514 04 M 2,397.40N

33516 04 M 2,397.40N

Wednesday, June 18, 2008 Page 128 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33517 04 M 2,397.40N

33518 04 M 2,397.40N

33519 04 M 2,397.40N

33521 04 M 2,397.40N

33522 04 M 2,397.40N

33523 04 M 2,397.40N

33530 04 M 2,397.40N

33533 04 M 2,397.40N

33534 04 M 2,397.40N

33535 04 M 2,397.40N

33536 04 M 2,397.40N

33542 04 M 1,198.70N

33545 04 M 2,397.40N

33548 04 M 1,333.12YN

33572 04 M 2,397.40N

33600 04 MY

33602 04 MY

33606 04 MY

33608 04 MY

33610 04 MY

33611 04 MY

Wednesday, June 18, 2008 Page 129 of 455

Page 137: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33612 04 MY

33615 04 M 2,397.40N

33617 04 M 2,397.40N

33619 04 M 2,397.40N

33641 04 M 2,397.40N

33645 04 M 2,397.40N

33647 04 M 2,397.40N

33660 04 M 2,397.40N

33665 04 M 2,397.40N

33670 04 M 2,397.40N

33675 04 1/1/2007 M 2,397.40YN

33676 04 1/1/2007 M 2,397.40YN

33677 04 1/1/2007 M 2,397.40YN

33681 04 M 2,397.40N

33684 04 M 2,397.40N

33688 04 M 2,397.40N

33690 04 M 958.60N

33692 04 M 2,397.40N

33694 04 M 2,397.40N

33697 04 M 2,996.80N

33702 04 M 2,397.40N

Wednesday, June 18, 2008 Page 130 of 455

Page 138: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33710 04 M 2,397.40N

33720 04 M 2,397.40N

33722 04 MY

33724 04 1/1/2007 M 2,397.40YN

33726 04 1/1/2007 M 2,721.45YN

33730 04 M 2,721.45N

33732 04 M 2,397.40N

33735 04 M 1,198.70N

33736 04 M 2,397.40N

33737 04 M 2,397.40N

33750 04 M 1,079.30N

33755 04 M 1,079.30N

33762 04 M 1,079.30N

33764 04 M 1,198.70N

33766 04 M 1,079.30N

33767 04 M 2,397.40N

33768 04 M 255.00YN

33770 04 M 2,996.80N

33771 04 M 2,996.80N

33774 04 M 2,397.40N

33775 04 M 2,397.40N

Wednesday, June 18, 2008 Page 131 of 455

Page 139: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33776 04 M 2,996.60N

33777 04 M 2,996.60N

33778 04 M 2,397.40N

33779 04 M 2,397.40N

33780 04 M 2,996.60N

33781 04 M 2,996.60N

33786 04 M 2,397.40N

33788 04 M 2,057.80N

33800 04 M 1,123.70N

33802 04 M 1,123.70N

33803 04 M 1,501.75N

33813 04 M 1,797.95N

33814 04 M 2,397.40N

33820 04 M 839.35N

33822 04 M 839.35N

33824 04 M 1,079.30N

33840 04 M 1,198.70N

33845 04 M 1,198.70N

33851 04 M 1,198.70N

33852 04 M 2,397.40N

33853 04 M 2,397.40N

Wednesday, June 18, 2008 Page 132 of 455

Page 140: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33860 04 M 2,397.40N

33861 04 M 2,397.40N

33863 04 M 2,397.40N

33864 04 1/1/2008 M 1794.48N

33870 04 M 2,397.40N

33875 04 MY

33877 04 MY

33880 04 M 1,042.97YN

33881 04 M 894.71YN

33883 04 M 662.83YN

33884 04 M 249.09YN

33886 04 M 571.51YN

33889 04 M 499.99YN

33891 04 M 636.67YN

33910 04 M 2,397.40N

33915 04 MY

33916 04 M 2,397.40N

33917 04 M 2,397.40N

33920 04 M 2,397.40N

33922 04 M 2,397.40N

33924 04 M 324.05N

Wednesday, June 18, 2008 Page 133 of 455

Page 141: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

33925 04 M 1,037.68YN

33926 04 M 1,407.80YN

33930 04 M 1,306.65N

33935 04 M 4,104.60N

33940 04 M 1,198.70N

33945 04 M 2,894.30N

33960 04 I 453.70N

33961 04 I 295.60N

33967 04 I 230.20YN

33968 04 M 162.00YN

33970 04 M 689.50YN

33971 04 M 334.80YN

33973 04 M 689.50YN

33974 04 M 419.25YN

33975 04 M 1,350.15YN

33976 04 M 1,674.20YN

33977 04 M 1,215.15N

33978 04 M 1,458.20N

33979 04 M 730.85N

33980 04 M 787.90N

33999 04 MY

Wednesday, June 18, 2008 Page 134 of 455

Page 142: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

34001 04 M 718.70YN

34051 04 M 718.70YN

34101 04 M 718.70YN

34111 04 M 718.70YN

34151 04 M 718.70YN

34201 04 M 718.70YN

34203 04 M 718.70YN

34401 04 M 718.70YN

34421 04 M 718.70YN

34451 04 M 898.95YN

34471 04 M 599.35YN

34490 04 M 599.35YN

34501 04 M 480.00YN

34502 04 MYY

34510 04 M 480.00YN

34520 04 M 480.00YN

34530 04 M 599.35YN

34800 04 M 819.60YN

34802 04 M 904.75YN

34803 04 M 1,148.60YN

34804 04 M 904.75YN

Wednesday, June 18, 2008 Page 135 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

34805 04 M 669.46YN

34806 04 1/1/2008 M 59.78YN

34808 04 M 156.10YN

34812 04 M 255.70YN

34813 04 M 181.55YN

34820 04 M 369.05YN

34825 04 M 488.60YN

34826 04 M 156.10YN

34830 04 M 1,276.30YN

34831 04 M 1,379.95YN

34832 04 M 1,379.95YN

34833 04 M 488.60YN

34834 04 M 369.05YN

34900 04 M 488.60YN

35001 04 M 1,123.70YN

35002 04 M 1,306.65YN

35005 04 M 1,414.70YN

35011 04 M 898.95YN

35013 04 M 1,198.70YN

35021 04 M 1,198.70YN

35022 04 M 1,414.70YN

Wednesday, June 18, 2008 Page 136 of 455

Page 144: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35045 04 M 599.35YN

35081 04 M 1,198.70YN

35082 04 M 1,630.70YN

35091 04 M 1,198.70YN

35092 04 M 1,630.70YN

35102 04 M 1,198.70YN

35103 04 M 1,630.70YN

35111 04 M 1,198.70YN

35112 04 M 1,630.70YN

35121 04 M 1198.70YN

35122 04 M 1630.70YN

35131 04 M 958.60YN

35132 04 M 1,198.70YN

35141 04 M 958.60YN

35142 04 M 1,198.70YN

35151 04 M 958.60YN

35152 04 M 1,198.70YN

35180 04 M 1,198.70YN

35182 04 M 952.10YN

35184 04 M 599.35YN

35188 04 M 1,198.70YN

Wednesday, June 18, 2008 Page 137 of 455

Page 145: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35189 04 M 952.10YN

35190 04 M 599.35YN

35201 04 M 1,198.70YN

35206 04 M 599.35YN

35207 04 M 341.20YN

35211 04 M 1,498.30YN

35216 04 M 1,198.70YN

35221 04 M 1,198.70YN

35226 04 M 599.35YN

35231 04 M 599.35YN

35236 04 M 599.35YN

35241 04 M 1498.30YN

35246 04 M 1,198.70YN

35251 04 M 1198.70YN

35256 04 M 599.35YN

35261 04 M 599.35YN

35266 04 M 599.35YN

35271 04 M 1498.30YN

35276 04 M 1198.70YN

35281 04 M 1198.70YN

35286 04 M 599.35YN

Wednesday, June 18, 2008 Page 138 of 455

Page 146: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35301 04 M 1101.60YN

35302 04 1/1/2007 M 958.60YN

35303 04 1/1/2007 M 958.60YN

35304 04 1/1/2007 M 958.60YN

35305 04 1/1/2007 M 958.60YN

35306 04 1/1/2007 M 958.60YN

35311 04 M 749.20YN

35321 04 M 749.20YN

35331 04 M 1198.70YN

35341 04 M 958.60YN

35351 04 M 958.60YN

35355 04 M 958.60YN

35361 04 M 1,198.70YN

35363 04 M 1,198.70YN

35371 04 M 958.60YN

35372 04 M 1,021.15YN

35390 04 MYY

35400 04 IYY

35450 04 M 682.80YN

35452 04 M 682.80YN

35454 04 M 682.80YN

Wednesday, June 18, 2008 Page 139 of 455

Page 147: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35456 04 M 479.00YN

35458 04 M 479.00YN

35459 04 M 479.00YN

35460 04 M 479.00YN

35470 04 M 479.00YN

35471 04 M 479.00YN

35472 04 M 479.00YN

35473 04 M 479.00YN

35474 04 M 479.00YN

35475 04 M 479.00YN

35476 04 M 479.00YN

35480 04 M 1,101.20YN

35481 04 M 1,198.70YN

35482 04 M 958.60YN

35483 04 M 958.60YN

35484 04 M 749.20YN

35485 04 M 958.60YN

35490 04 M 1,024.15YN

35491 04 M 1,024.15YN

35492 04 M 1,024.15YN

35493 04 M 718.50YN

Wednesday, June 18, 2008 Page 140 of 455

Page 148: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35494 04 M 718.50YN

35495 04 M 718.50YN

35500 04 M 209.75YN

35501 04 M 839.35YN

35506 04 M 958.60YN

35508 04 M 958.60YN

35509 04 M 958.60YN

35510 04 M 708.05YN

35511 04 M 958.60YN

35512 04 M 694.72YN

35515 04 M 958.60YN

35516 04 M 958.60YN

35518 04 M 958.60YN

35521 04 M 1,198.70YN

35522 04 M 674.99YN

35523 04 1/1/2008 M 726.14YN

35525 04 M 644.91YN

35526 04 M 958.60YN

35531 04 M 958.60YN

35533 04 M 1,198.70YN

35536 04 M 958.60YN

Wednesday, June 18, 2008 Page 141 of 455

Page 149: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35537 04 1/1/2007 M 1,198.70YN

35538 04 1/1/2007 M 1,198.70YN

35539 04 1/1/2007 M 839.35YN

35540 04 1/1/2007 M 839.35YN

35548 04 M 839.35YN

35549 04 M 1,198.70YN

35551 04 M 1,198.70YN

35556 04 M 958.60YN

35558 04 M 1,079.30YN

35560 04 M 1,198.70YN

35563 04 M 1,198.70YN

35565 04 M 1,198.70YN

35566 04 M 958.60YN

35571 04 M 958.60YN

35572 04 M 209.75YN

35583 04 M 958.60YN

35585 04 M 958.60YN

35587 04 M 958.60YN

35600 04 M 192.75YN

35601 04 M 839.35YN

35606 04 M 958.60YN

Wednesday, June 18, 2008 Page 142 of 455

Page 150: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35612 04 M 958.60YN

35616 04 M 958.60YN

35621 04 M 1,198.70YN

35623 04 M 1,306.65YN

35626 04 M 958.60N

35631 04 M 1,198.70N

35636 04 M 1,079.30N

35637 04 1/1/2007 M 1,198.70YN

35638 04 1/1/2007 M 1,198.70YN

35642 04 M 958.60N

35645 04 M 958.60N

35646 04 M 1,198.70N

35647 04 M 1,053.80N

35650 04 M 1,079.30N

35651 04 M 1,198.70N

35654 04 M 1,198.70N

35656 04 M 958.60N

35661 04 M 1,079.30N

35663 04 M 1,198.70N

35665 04 M 1,198.70N

35666 04 M 958.60N

Wednesday, June 18, 2008 Page 143 of 455

Page 151: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35671 04 M 958.60N

35681 04 MY

35682 04 M 314.60N

35683 04 M 314.60N

35685 04 I 146.50N

35686 04 I 129.25N

35691 04 M 1,198.70YN

35693 04 M 1,198.70YN

35694 04 M 1,198.70YN

35695 04 M 1,198.70YN

35697 04 M 90.02YN

35700 04 MYY

35701 04 M 374.55YN

35721 04 M 299.70YN

35741 04 M 299.70YN

35761 04 MYY

35800 04 M 374.55YN

35820 04 M 524.40YN

35840 04 M 480.00N

35860 04 M 449.50YN

35870 04 MYY

Wednesday, June 18, 2008 Page 144 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

35875 04 M 449.50YN

35876 04 M 455.15YN

35879 04 M 599.35YN

35881 04 M 789.80YN

35883 04 1/1/2007 M 599.35YN

35884 04 1/1/2007 M 599.35YN

35901 04 M 599.35YN

35903 04 M 449.50YN

35905 04 M 811.50YN

35907 04 M 599.35YN

36000 09 IY

36002 04 IYY

36005 04 I 136.65YN

36010 04 I 224.70YN

36011 04 I 249.35YN

36012 04 I 264.80YN

36013 04 I 213.50YN

36014 04 I 213.50YN

36015 04 I 249.35YN

36100 04 I 213.65YN

36120 04 I 233.00YN

Wednesday, June 18, 2008 Page 145 of 455

Page 153: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

36140 04 I 188.70YN

36145 04 I 188.70YN

36160 04 I 202.50YN

36200 04 I 224.70YN

36215 04 I 198.90YN

36216 04 I 264.80YN

36217 04 I 281.00YN

36218 04 I 281.00YN

36245 04 I 213.50YN

36246 04 I 264.80YN

36247 04 I 281.00YN

36248 04 I 281.00YN

36260 04 MYY

36261 04 MYY

36262 04 MYY

36299 04 IYY

36400 04 I 16.65YN

36405 04 I 16.65YN

36406 04 I 16.65N

36410 04 I 16.65N

36415 J 04 I 4.10 1 4.10N

Wednesday, June 18, 2008 Page 146 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

36416 09 IY

36420 04 I 37.40YN

36425 04 I 37.40YN

36430 04 I 16.65YN

36440 04 I 28.80YN

36450 04 I 308.00YN

36455 04 I 338.50YN

36460 04 I 176.90YN

36470 04 I 17.00Y

36471 04 I 17.00Y

36475 04 M 213.52YN

36476 04 M 104.57YN

36478 04 M 213.52YN

36479 04 M 104.57YN

36481 04 I 264.80YN

36500 04 I 71.05N

36510 04 I 25.20N

36511 04 IYY

36512 04 IYY

36513 04 IYY

36514 04 IYY

Wednesday, June 18, 2008 Page 147 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

36515 04 IYY

36516 04 IYY

36522 04 M 599.30YN

36555 04 I 74.38YN

36556 04 I 67.13YN

36557 04 I 166.18YN

36558 04 I 158.02YN

36560 04 I 196.66YN

36561 04 I 190.09YN

36563 04 I 197.81YN

36565 04 I 190.09YN

36566 04 I 203.24YN

36568 04 I 55.01YN

36569 04 I 51.61YN

36570 04 I 171.97YN

36571 04 I 171.37YN

36575 04 I 33.10YN

36576 04 I 112.21YN

36578 04 I 126.75YN

36580 04 I 38.25YN

36581 04 I 118.78YN

Wednesday, June 18, 2008 Page 148 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

36582 04 I 171.77YN

36583 04 I 173.17YN

36584 04 I 38.64YN

36585 04 I 161.21YN

36589 04 I 78.73YN

36590 04 I 107.54YN

36593 04 1/1/2008 I 22.14YN

36595 04 I 107.23YN

36596 04 I 25.85YN

36597 04 I 34.37YN

36598 04 I 67.51YN

36600 09 IY

36620 04 I 37.40N

36625 04 I 52.70YN

36640 04 I 74.90YN

36660 04 I 37.40YN

36680 04 I 90.10YN

36800 04 M 424.45YN

36810 04 M 424.45YN

36815 04 I 112.40YN

36818 04 M 850.30YN

Wednesday, June 18, 2008 Page 149 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

36819 04 M 850.30YN

36820 04 M 541.15YN

36821 04 M 578.55YN

36822 04 M 599.30YN

36823 04 M 578.55YN

36825 04 M 578.55YN

36830 04 M 578.55YN

36831 04 M 578.55YN

36832 04 M 578.55YN

36833 04 M 578.55YN

36834 04 M 599.35YN

36835 04 M 578.55YN

36838 04 M 666.71YN

36860 04 I 112.40YN

36861 04 I 419.00YN

36870 04 M 884.80YN

37140 04 M 1198.70YN

37145 04 M 1079.30YN

37160 04 M 1079.30YN

37180 04 M 1079.30YN

37181 04 M 1079.30YN

Wednesday, June 18, 2008 Page 150 of 455

Page 158: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

37182 04 M 910.70YN

37183 04 I 429.07YN

37184 04 M 265.81YN

37185 04 I 97.64YN

37186 04 M 146.50YN

37187 04 M 247.12YN

37188 04 I 178.38YN

37195 04 M 472.40YN

37200 04 I 189.00YN

37201 04 I 472.40YN

37202 04 I 189.00YN

37203 04 M 682.80YN

37204 04 M 682.80YN

37205 04 M 910.70YN

37206 04 MYY

37207 04 M 910.70YN

37208 04 MYY

37209 04 M 213.50YN

37210 04 1/1/2007 M 682.80YN

37215 04 M 910.70YN

37216 04 M 910.70YN

Wednesday, June 18, 2008 Page 151 of 455

Page 159: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

37250 04 I 89.10YN

37251 04 I 57.65YN

37500 04 I 299.70YN

37501 04 IYY

37565 04 M 374.55YN

37600 04 M 374.55YN

37605 04 M 449.50YN

37606 04 M 449.50YN

37607 04 M 262.20YN

37609 04 I 112.40YN

37615 04 M 374.55YN

37616 04 M 524.40YN

37617 04 M 524.40YN

37618 04 M 262.20YN

37620 04 M 449.50YN

37650 04 M 374.55YN

37660 04 M 449.50YN

37700 04 M 203.95YN

37718 04 I 227.39YN

37722 04 I 275.02YN

37735 04 M 419.00YN

Wednesday, June 18, 2008 Page 152 of 455

Page 160: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

37760 04 M 299.70YN

37765 04 M 245.90YN

37766 04 M 298.81YN

37780 04 M 149.80YN

37785 04 I 131.25YN

37788 04 MYY

37790 04 MYY

37799 04 MYY

38100 04 M 770.00N

38101 04 M 770.00N

38102 04 MY

38115 04 M 770.00N

38120 04 M 770.00YN

38129 04 MYY

38200 04 I 66.50YN

38204 09 IY

38205 04 IY

38206 04 IY

38207 09 IY

38208 09 IY

38209 09 IY

Wednesday, June 18, 2008 Page 153 of 455

Page 161: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

38210 09 IY

38211 09 IY

38212 09 IY

38213 09 IY

38214 09 IY

38215 09 IY

38220 04 I 50.15YN

38221 04 I 78.45YN

38230 04 M 660.65YN

38240 04 M 220.20N

38241 04 M 220.20N

38242 04 I 80.55N

38300 04 I 71.40 17.00YN

38305 04 I 156.95 17.00YN

38308 04 MYY

38380 04 M 556.25YN

38381 04 M 811.60YN

38382 04 M 612.15YN

38500 04 I 85.70 17.00YN

38505 04 I 106.80 17.00YN

38510 04 I 127.70YN

Wednesday, June 18, 2008 Page 154 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

38520 04 I 157.90YN

38525 04 I 135.60YN

38530 04 I 189.25YN

38542 04 I 185.45YN

38550 04 M 224.70YN

38555 04 M 656.60YN

38562 04 M 480.00YN

38564 04 M 599.35YN

38570 04 M 302.40YN

38571 04 M 599.35YN

38572 04 M 599.35YN

38589 04 MYY

38700 04 M 786.60YN

38720 04 M 861.50YN

38724 04 M 645.45YN

38740 04 M 524.40YN

38745 04 M 524.40YN

38746 04 MYY

38747 04 MYY

38760 04 M 299.70YN

38765 04 M 918.40YN

Wednesday, June 18, 2008 Page 155 of 455

Page 163: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

38770 04 M 918.40YN

38780 04 M 998.80YN

38790 04 I 220.85YN

38792 04 I 105.40YN

38794 04 MYY

38999 04 MYY

39000 04 M 718.70YN

39010 04 M 718.70YN

39200 04 M 749.20YN

39220 04 M 749.20YN

39400 04 I 314.95YN

39499 04 MYY

39501 04 M 648.60YN

39502 04 M 826.50YN

39503 04 M 960.55N

39520 04 M 682.60N

39530 04 M 682.60N

39531 04 M 735.45N

39540 04 M 682.60N

39541 04 M 682.60N

39545 04 M 682.60N

Wednesday, June 18, 2008 Page 156 of 455

Page 164: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

39560 04 M 708.60N

39561 04 M 803.05N

39599 04 MYY

40490 04 I 46.25 17.00N

40500 04 M 165.10YN

40510 04 I 170.45YN

40520 04 M 524.40YN

40525 04 M 629.90YN

40527 04 M 718.70YN

40530 04 M 524.35YN

40650 04 M 629.90YN

40652 04 M 629.90YN

40654 04 M 629.90YN

40700 04 M 718.70YN

40701 04 M 958.60YN

40702 04 M 958.60YN

40720 04 M 718.70YN

40761 04 M 802.00YN

40799 04 MYY

40800 04 I 39.90 17.00YN

40801 04 I 76.15YN

Wednesday, June 18, 2008 Page 157 of 455

Page 165: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

40804 04 I 44.10 17.00YN

40805 04 I 89.10YN

40806 04 I 35.65 17.00YN

40808 04 I 50.20 17.00YN

40810 04 I 50.95 17.00YN

40812 04 I 73.70 17.00YN

40814 04 I 117.65YN

40816 04 I 142.70 34.00YN

40818 04 I 113.40YN

40819 04 M 149.80YN

40820 04 I 142.70 17.00YN

40830 04 I 107.00 17.00YN

40831 04 I 132.75 17.00YN

40840 04 M 252.00YN

40842 04 M 251.05YN

40843 04 M 347.20YN

40844 04 M 496.90YN

40845 04 M 629.10YN

40899 04 MYY

41000 04 I 44.65 17.00YN

41005 04 I 41.70 17.00YN

Wednesday, June 18, 2008 Page 158 of 455

Page 166: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

41006 04 I 93.60YN

41007 04 I 102.95 17.00YN

41008 04 I 92.70 17.00YN

41009 04 I 116.50YN

41010 04 I 42.45 17.00YN

41015 04 I 106.45 17.00YN

41016 04 I 130.40 17.00YN

41017 04 I 113.10 17.00YN

41018 04 I 154.95YN

41019 04 1/1/2008 I 259.65YN

41100 04 I 88.50 17.00YN

41105 04 I 181.00 17.00YN

41108 04 I 88.50 17.00YN

41110 04 M 214.00 17.00YN

41112 04 M 299.70YN

41113 04 M 299.70YN

41114 04 M 249.70YN

41115 04 M 224.70YN

41116 04 M 224.70YN

41120 04 M 524.40YN

41130 04 M 524.40YN

Wednesday, June 18, 2008 Page 159 of 455

Page 167: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

41135 04 M 861.50N

41140 04 M 735.65N

41145 04 M 1048.85N

41150 04 M 1498.30N

41153 04 M 1498.30N

41155 04 M 1798.05N

41250 04 I 71.40 34.00YN

41251 04 I 74.10 34.00YN

41252 04 I 95.25 34.00YN

41500 04 I 121.70YN

41510 04 M 374.55YN

41520 04 I 92.70YN

41599 04 MYY

41800 04 I 39.70 17.00YN

41805 04 I 42.30 17.00YN

41806 04 I 90.10YN

41820 04 I 99.05YN

41821 04 I 71.60YN

41822 04 I 90.10YN

41823 04 M 169.40YN

41825 04 I 76.95YN

Wednesday, June 18, 2008 Page 160 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

41826 04 M 224.70YN

41827 04 M 299.70YN

41828 04 I 110.35YN

41830 04 M 224.70YN

41850 04 I 41.25YN

41870 04 M 169.40YN

41872 04 M 169.40YN

41874 04 M 169.40YN

41899 04 MYY

42000 04 I 43.05 17.00YN

42100 04 I 50.20 34.00YN

42104 04 I 79.30 34.00YN

42106 04 M 480.00YN

42107 04 M 506.40YN

42120 04 M 647.90YN

42140 04 M 184.50YN

42145 04 M 359.30YN

42160 04 I 64.10 17.00YN

42180 04 M 149.80YN

42182 04 M 215.90YN

42200 04 M 718.70YN

Wednesday, June 18, 2008 Page 161 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

42205 04 M 718.70YN

42210 04 M 850.80YN

42215 04 M 491.50YN

42220 04 M 718.70YN

42225 04 M 986.35YN

42226 04 M 784.75YN

42227 04 M 784.75YN

42235 04 M 374.55YN

42260 04 M 718.70YN

42280 04 I 53.85N

42281 04 I 58.45YN

42299 04 MYY

42300 04 I 79.30 17.00YN

42305 04 I 164.90YN

42310 04 I 79.30 17.00YN

42320 04 I 113.60 17.00YN

42330 04 I 113.60 34.00YN

42335 04 M 240.00YN

42340 04 M 240.00YN

42400 04 I 113.60 17.00YN

42405 04 I 113.60 34.00YN

Wednesday, June 18, 2008 Page 162 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

42408 04 I 137.80 34.00YN

42409 04 I 113.60 34.00YN

42410 04 M 749.20YN

42415 04 M 754.65YN

42420 04 M 867.10YN

42425 04 M 892.00YN

42426 04 M 1079.30N

42440 04 M 480.00YN

42450 04 M 480.00YN

42500 04 M 359.30YN

42505 04 M 359.30YN

42507 04 M 767.60YN

42508 04 M 839.35YN

42509 04 M 1079.30YN

42510 04 M 839.35YN

42550 04 I 109.95YN

42600 04 M 359.30YN

42650 04 I 30.40 17.00YN

42660 04 I 34.30 17.00YN

42665 04 I 160.20YN

42699 04 MYY

Wednesday, June 18, 2008 Page 163 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

42700 04 I 79.30 34.00YN

42720 04 I 157.30YN

42725 04 I 291.90YN

42800 04 I 79.30 34.00YN

42802 04 I 79.30 34.00YN

42804 04 I 79.30 34.00YN

42806 04 I 79.30 34.00YN

42808 04 M 192.95 34.00YN

42809 04 M 202.50 34.00YN

42810 04 M 374.55YN

42815 04 M 431.40YN

42820 04 M 194.20YN

42821 04 M 202.50YN

42825 04 M 194.20YN

42826 04 M 202.50YN

42830 04 M 142.90YN

42831 04 M 142.90YN

42835 04 M 142.90YN

42836 04 M 142.90YN

42842 04 M 702.10YN

42844 04 M 810.10YN

Wednesday, June 18, 2008 Page 164 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

42845 04 M 918.15YN

42860 04 I 119.25 34.00YN

42870 04 I 156.65 34.00YN

42890 04 M 958.60YN

42892 04 M 912.80YN

42894 04 M 1188.20YN

42900 04 M 34.00YY

42950 04 M 939.50YN

42953 04 MYY

42955 04 M 266.40YN

42960 04 I 74.90 34.00YN

42961 04 M 150.80YN

42962 04 M 220.10YN

42970 04 I 131.20 34.00YN

42971 04 M 173.40YN

42972 04 M 206.40YN

42999 04 MYY

43020 04 M 480.00YN

43030 04 M 819.10YN

43045 04 M 839.35YN

43100 04 M 749.20YN

Wednesday, June 18, 2008 Page 165 of 455

Page 173: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

43101 04 M 749.20YN

43107 04 M 1467.80N

43108 04 M 1782.30N

43112 04 M 1467.80N

43113 04 M 1782.30N

43116 04 M 2106.30N

43117 04 M 1467.80N

43118 04 M 1782.30N

43121 04 M 1467.80N

43122 04 M 1467.80N

43123 04 M 1782.30N

43124 04 MY

43130 04 M 718.70N

43135 04 M 718.70N

43200 04 I 186.20 56.70YN

43201 04 I 113.55YN

43202 04 I 199.50 56.70YN

43204 04 M 256.60YN

43205 04 M 256.60YN

43215 04 I 244.50 56.70YN

43216 04 I 244.50YN

Wednesday, June 18, 2008 Page 166 of 455

Page 174: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

43217 04 I 244.50 56.70YN

43219 04 I 244.50 56.70YN

43220 04 I 142.70 56.70YN

43226 04 M 224.60 56.70YN

43227 04 I 235.20 56.70YN

43228 04 M 235.20 56.70YN

43231 04 I 158.20YN

43232 04 I 183.70YN

43234 04 I 159.35 56.70YN

43235 04 I 239.15 56.70YN

43236 04 I 239.15YN

43237 04 I 117.67YN

43238 04 I 145.34YN

43239 04 I 249.70 56.70YN

43240 04 I 201.55YN

43241 04 I 249.70 56.70YN

43242 04 I 201.55YN

43243 04 M 256.60YN

43244 04 M 256.60YN

43245 04 I 249.70 56.70YN

43246 04 I 249.70 56.70YN

Wednesday, June 18, 2008 Page 167 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

43247 04 M 249.70 56.70YN

43248 04 I 295.95YN

43249 04 I 113.40YN

43250 04 I 249.70YN

43251 04 I 249.70 56.70YN

43255 04 I 249.70 56.70YN

43256 04 M 159.35YN

43257 04 IYY

43258 04 M 249.70YN

43259 04 I 240.30YN

43260 04 I 264.25 56.70YN

43261 04 I 264.25YN

43262 04 M 390.10 56.70YN

43263 04 I 264.25 56.70YN

43264 04 M 390.10 56.70YN

43265 04 M 390.10YN

43267 04 I 264.25 56.70YN

43268 04 M 358.60 56.70YN

43269 04 M 358.60YN

43271 04 M 358.60 56.70YN

43272 04 M 390.10 56.70YN

Wednesday, June 18, 2008 Page 168 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

43280 04 M 682.60YN

43289 04 MYY

43300 04 M 786.60N

43305 04 M 1258.35N

43310 04 M 839.35N

43312 04 M 1258.35N

43313 04 M 1188.50N

43314 04 M 1564.90N

43320 04 M 958.60N

43324 04 M 682.60N

43325 04 M 749.20N

43326 04 M 749.20N

43330 04 M 1082.10YN

43331 04 M 1082.10YN

43340 04 M 1198.70YN

43341 04 M 1082.10YN

43350 04 M 839.35YN

43351 04 M 839.35YN

43352 04 M 839.35YN

43360 04 M 1467.80YN

43361 04 M 1782.30YN

Wednesday, June 18, 2008 Page 169 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

43400 04 M 480.00YN

43401 04 M 822.80YN

43405 04 MYY

43410 04 M 480.00YN

43415 04 M 839.35YN

43420 04 M 480.00YN

43425 04 M 839.35YN

43450 04 I 74.90YN

43453 04 I 74.90YN

43456 04 I 112.40YN

43458 04 I 142.70YN

43460 04 I 93.05YN

43496 04 M 1778.60YN

43499 04 MY

43500 04 M 599.35YN

43501 04 M 599.35YN

43502 04 M 658.90YN

43510 04 M 599.35YN

43520 04 M 599.35YN

43600 04 I 108.20YN

43605 04 M 599.35YN

Wednesday, June 18, 2008 Page 170 of 455

Page 178: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

43610 04 M 718.70YN

43611 04 MYY

43620 04 M 1011.40YN

43621 04 M 1011.40YN

43622 04 M 1173.40YN

43631 04 M 915.65YN

43632 04 M 915.65YN

43633 04 M 915.65YN

43634 04 M 1077.70YN

43635 04 M 1026.65YN

43640 04 M 812.90YN

43641 04 M 812.90YN

43644 K 04 M 942.28YN

43645 K 04 M 1017.05YN

43647 04 1/1/2007 M 399.59YN

43648 04 1/1/2007 M 399.50YN

43651 04 M 524.40YN

43652 04 M 524.40YN

43653 04 M 399.50N

43659 04 MY

43752 04 I 35.05YN

Wednesday, June 18, 2008 Page 171 of 455

Page 179: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

43760 04 I 35.65 17.00YN

43761 04 I 48.50YN

43770 K 04 I 565.47YN

43771 K 04 I 652.01YN

43772 K 04 I 497.20YN

43773 K 04 I 652.27YN

43774 K 04 I 497.78YN

43800 04 M 699.20YN

43810 04 M 718.70YN

43820 04 M 718.70YN

43825 04 M 898.95YN

43830 04 M 399.50YN

43831 04 M 399.50YN

43832 04 M 399.50YN

43840 04 M 678.40YN

43842 K 04 M 718.70YN

43843 K 04 M 718.70YN

43845 K 04 M 982.18N

43846 K 04 M 770.00N

43847 K 04 M 986.00N

43848 K 04 M 770.00N

Wednesday, June 18, 2008 Page 172 of 455

Page 180: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

43850 04 M 718.70N

43855 04 M 793.60N

43860 04 M 718.70N

43865 04 M 793.60N

43870 04 M 240.00YN

43880 04 M 958.60YN

43881 04 1/1/2007 M 599.35YN

43882 04 1/1/2007 M 599.35YN

43886 04 I 152.73YN

43887 04 I 151.56YN

43888 04 I 215.38YN

43999 04 MY

44005 04 M 643.65YN

44010 04 M 599.35YN

44015 04 M 399.50YN

44020 04 M 599.35YN

44021 04 M 599.35YN

44025 04 M 599.35YN

44050 04 M 599.35YN

44055 04 M 599.35YN

44100 04 I 108.20YN

Wednesday, June 18, 2008 Page 173 of 455

Page 181: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

44110 04 M 599.35YN

44111 04 M 599.35YN

44120 04 M 806.10N

44121 04 M 403.05N

44125 04 M 733.85N

44126 04 M 1039.70N

44127 04 M 1195.80N

44128 04 M 175.20N

44130 04 M 718.70N

44132 04 MY

44133 04 MY

44135 04 MY

44136 04 MY

44137 04 M 806.10N

44139 04 M 108.00N

44140 04 M 951.80N

44141 04 M 951.80N

44143 04 M 951.80N

44144 04 M 951.80N

44145 04 M 958.60N

44146 04 M 951.80N

Wednesday, June 18, 2008 Page 174 of 455

Page 182: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

44147 04 M 1198.70N

44150 04 M 1079.30N

44151 04 M 1079.10N

44155 04 M 1198.70N

44156 04 M 1198.70N

44157 04 1/1/2007 M 1198.70N

44158 04 1/1/2007 M 1198.70N

44160 04 M 1198.70N

44180 04 I 479.20YN

44186 04 I 335.80YN

44187 04 I 553.18YN

44188 04 I 607.88YN

44202 04 M 806.10YN

44203 04 M 191.80YN

44204 04 M 973.80YN

44205 04 M 861.80YN

44206 04 M 951.80YN

44207 04 M 958.60YN

44208 04 M 951.80YN

44210 04 M 1255.88YN

44211 04 M 1079.30YN

Wednesday, June 18, 2008 Page 175 of 455

Page 183: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

44212 04 M 1198.70YN

44213 04 I 110.46YN

44227 04 I 864.06YN

44238 04 MYY

44300 04 M 599.35YN

44310 04 M 629.90YN

44312 04 M 374.55YN

44314 04 M 599.35YN

44316 04 M 535.45YN

44320 04 M 535.45YN

44322 04 M 535.45YN

44340 04 M 299.70YN

44345 04 M 480.00YN

44346 04 M 951.80YN

44360 04 I 264.25 56.70YN

44361 04 I 285.40 56.70YN

44363 04 M 285.40 56.70YN

44364 04 M 356.70 56.70YN

44365 04 M 356.70YN

44366 04 M 285.40 56.70YN

44369 04 M 285.40 56.70YN

Wednesday, June 18, 2008 Page 176 of 455

Page 184: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

44370 04 M 158.30YN

44372 04 M 285.40YN

44373 04 M 356.70YN

44376 04 I 318.30YN

44377 04 I 318.30YN

44378 04 M 318.30YN

44379 04 M 258.55YN

44380 04 I 182.30 56.70YN

44382 04 I 218.00 56.70YN

44383 04 I 88.30YN

44385 04 I 182.30 56.70YN

44386 04 I 182.30 56.70YN

44388 04 I 192.85 56.70YN

44389 04 I 192.85 56.70YN

44390 04 I 192.85 56.70YN

44391 04 I 283.40 56.70YN

44392 04 M 230.80 56.70YN

44393 04 M 230.80 56.70YN

44394 04 M 318.30YN

44397 04 M 165.00YN

44500 04 I 99.10N

Wednesday, June 18, 2008 Page 177 of 455

Page 185: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

44602 04 M 599.35YN

44603 04 M 674.20YN

44604 04 M 599.35YN

44605 04 M 718.70YN

44615 04 M 599.35YN

44620 04 M 359.30YN

44625 04 M 729.70YN

44626 04 M 729.70YN

44640 04 M 480.00YN

44650 04 M 629.90YN

44660 04 M 958.60YN

44661 04 M 958.60YN

44680 04 M 599.35YN

44700 04 M 480.00YN

44701 04 I 72.34N

44799 04 MY

44800 04 M 480.00YN

44820 04 M 599.35YN

44850 04 M 480.00YN

44899 04 MYY

44900 04 M 310.80YN

Wednesday, June 18, 2008 Page 178 of 455

Page 186: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

44901 04 M 310.80YN

44950 04 M 374.55YN

44955 04 M 374.55N

44960 04 M 480.00YN

44970 04 M 374.55YN

44979 04 MYY

45000 04 M 170.65YN

45005 04 I 107.00 34.00YN

45020 04 I 134.00YN

45100 04 I 118.00YN

45108 04 M 262.20YN

45110 04 M 1079.30N

45111 04 M 1079.30N

45112 04 M 1079.30N

45113 04 M 1631.05N

45114 04 M 1138.70N

45116 04 M 1079.30N

45119 04 M 1630.70N

45120 04 M 1198.70N

45121 04 M 1450.40N

45123 04 MY

Wednesday, June 18, 2008 Page 179 of 455

Page 187: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

45126 04 MY

45130 04 M 383.70YN

45135 04 M 524.40YN

45136 04 M 1028.70YN

45150 04 IYY

45160 04 M 1138.70YN

45170 04 M 257.70YN

45190 04 I 240.00YN

45300 04 I 42.30 17.00YN

45303 04 I 42.30 17.00YN

45305 04 I 72.60 17.00YN

45307 04 M 72.60 17.00YN

45308 04 I 125.50YN

45309 04 I 125.50YN

45315 04 I 107.00 17.00YN

45317 04 I 76.85 17.00YN

45320 04 M 201.30 56.70YN

45321 04 I 125.50 17.00YN

45327 04 I 61.65YN

45330 04 I 107.00 34.00YN

45331 04 I 142.70 34.00YN

Wednesday, June 18, 2008 Page 180 of 455

Page 188: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

45332 04 I 125.50 34.00YN

45333 04 M 161.20 34.00YN

45334 04 I 142.70 34.00YN

45335 04 I 68.14N

45337 04 I 125.50 34.00YN

45338 04 M 161.20YN

45339 04 M 201.30YN

45340 04 I 42.30YN

45341 04 I 137.30YN

45342 04 I 158.60YN

45345 04 M 106.05YN

45355 04 I 112.40 56.70YN

45378 04 I 214.00 56.70YN

45379 04 M 214.00 56.70YN

45380 04 I 214.00 56.70YN

45381 04 I 184.28YN

45382 04 M 283.40 56.70YN

45383 04 M 285.40 56.70YN

45384 04 M 285.40YN

45385 04 M 285.40 56.70YN

45386 04 I 108.86YN

Wednesday, June 18, 2008 Page 181 of 455

Page 189: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

45387 04 M 215.35YN

45391 04 M 204.00YN

45392 04 I 214.00YN

45395 04 I 1015.28YN

45397 04 I 1103.45YN

45400 04 I 592.90YN

45402 04 I 805.75YN

45499 04 IYY

45500 04 M 419.00YN

45505 04 M 419.00YN

45520 04 I 74.90YN

45540 04 M 599.35YN

45541 04 M 599.35YN

45550 04 M 749.20YN

45560 04 M 227.70YN

45562 04 MYY

45563 04 MYY

45800 04 M 599.35YN

45805 04 M 674.20YN

45820 04 M 599.35YN

45825 04 M 674.20YN

Wednesday, June 18, 2008 Page 182 of 455

Page 190: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

45900 04 I 44.40YN

45905 04 I 58.05YN

45910 04 I 73.40YN

45915 04 I 77.60YN

45990 04 I 58.42YN

45999 04 MYY

46020 04 I 140.75YN

46030 04 I 71.40 34.00YN

46040 04 M 149.80YN

46045 04 M 149.80YN

46050 04 I 71.40 34.00YN

46060 04 M 471.70YN

46070 04 I 81.20YN

46080 04 I 119.25YN

46083 04 I 64.10 17.00YN

46200 04 M 262.20YN

46210 04 I 93.50 17.00YN

46211 04 I 129.45 17.00YN

46220 04 I 71.40 17.00YN

46221 04 I 107.00 17.00N

46230 04 I 84.65 17.00YN

Wednesday, June 18, 2008 Page 183 of 455

Page 191: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

46250 04 M 248.30 34.00YN

46255 04 M 342.65YN

46257 04 M 417.60YN

46258 04 M 471.70YN

46260 04 M 449.50YN

46261 04 M 524.40YN

46262 04 M 578.55YN

46270 04 M 471.70YN

46275 04 M 471.70YN

46280 04 M 471.70YN

46285 04 M 471.70YN

46288 04 M 471.70YN

46320 04 I 62.90 17.00YN

46500 04 I 51.50 17.00YN

46505 04 I 102.99YN

46600 04 I 19.80 17.00N

46604 04 I 34.10 17.00YN

46606 04 I 24.20 17.00YN

46608 04 I 49.85 17.00YN

46610 04 I 71.40 17.00YN

46611 04 I 71.40YN

Wednesday, June 18, 2008 Page 184 of 455

Page 192: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

46612 04 I 89.85 17.00YN

46614 04 I 62.00 17.00YN

46615 04 IYY

46700 04 M 299.70YN

46705 04 M 299.70YN

46706 04 I 62.32YN

46710 04 I 530.10YN

46712 04 I 1118.22YN

46715 04 M 449.50YN

46716 04 M 449.50YN

46730 04 M 571.25YN

46735 04 M 1079.30YN

46740 04 M 788.65YN

46742 04 M 1079.30YN

46744 04 M 918.15YN

46746 04 M 1139.40YN

46748 04 M 1139.40YN

46750 04 M 419.00YN

46751 04 M 419.00YN

46753 04 I 187.90YN

46754 04 I 134.60YN

Wednesday, June 18, 2008 Page 185 of 455

Page 193: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

46760 04 M 524.40YN

46761 04 M 524.40YN

46762 04 M 739.90YN

46900 04 I 62.70 17.00N

46910 04 I 108.30 17.00YN

46916 04 I 108.30 34.00YN

46917 04 I 108.30 34.00YN

46922 04 I 108.30 17.00YN

46924 04 M 181.00 17.00YN

46934 04 I 127.20 34.00YN

46935 04 I 107.00 34.00YN

46936 04 M 178.30 34.00YN

46937 04 I 96.95 34.00YN

46938 04 I 148.20 34.00YN

46940 04 I 68.50 17.00YN

46942 04 I 61.15 17.00YN

46945 04 I 72.45 17.00YN

46946 04 I 112.40YN

46947 04 M 342.65YN

46999 04 MYY

47000 04 I 106.80YN

Wednesday, June 18, 2008 Page 186 of 455

Page 194: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

47001 04 I 65.90YN

47010 04 M 599.35YN

47011 04 M 599.35YN

47015 04 M 480.00YN

47100 04 M 480.00YN

47120 04 M 682.60N

47122 04 M 1048.85N

47125 04 M 1048.85N

47130 04 M 1048.85N

47133 04 M 1048.85N

47135 04 M 3299.30N

47136 04 M 3299.30N

47140 04 M 1660.18YN

47141 04 M 2001.23YN

47142 04 M 2201.17YN

47300 04 M 718.70YN

47350 04 M 659.00YN

47360 04 M 697.90N

47361 04 M 810.10YN

47362 04 M 523.85YN

47370 04 M 761.10YN

Wednesday, June 18, 2008 Page 187 of 455

Page 195: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

47371 04 M 761.10YN

47379 04 MYY

47380 04 M 892.80YN

47381 04 M 892.80YN

47382 04 M 474.20YN

47399 04 MYY

47400 04 M 718.70YN

47420 04 M 647.90YN

47425 04 M 682.60YN

47460 04 M 463.80YN

47480 04 M 647.90YN

47490 04 M 599.35YN

47500 04 I 50.75YN

47505 04 I 127.50YN

47510 04 M 230.75YN

47511 04 M 284.60YN

47525 04 I 129.90YN

47530 04 M 199.80YN

47550 04 M 94.30YN

47552 04 I 135.70YN

47553 04 I 155.75YN

Wednesday, June 18, 2008 Page 188 of 455

Page 196: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

47554 04 I 220.30YN

47555 04 I 169.10YN

47556 04 I 187.90YN

47560 04 M 299.70YN

47561 04 M 317.60YN

47562 04 M 647.90YN

47563 04 M 699.20YN

47564 04 M 801.90YN

47570 04 M 685.40YN

47579 04 MYY

47600 04 M 647.90YN

47605 04 M 699.20YN

47610 04 M 801.90YN

47612 04 M 801.90YN

47620 04 M 801.90YN

47630 04 M 299.70YN

47700 04 M 449.50YN

47701 04 M 685.40YN

47711 04 M 801.90YN

47712 04 M 1198.70YN

47715 04 M 862.30YN

Wednesday, June 18, 2008 Page 189 of 455

Page 197: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

47720 04 M 685.40YN

47721 04 M 1044.70YN

47740 04 M 685.40YN

47741 04 M 1044.70YN

47760 04 M 685.40YN

47765 04 M 1438.70YN

47780 04 M 770.00YN

47785 04 M 1438.70YN

47800 04 M 770.00YN

47801 04 M 621.95YN

47802 04 M 948.90YN

47900 04 M 621.95YN

47999 04 MYY

48000 04 M 718.70YN

48001 04 M 801.90YN

48020 04 M 839.35YN

48100 04 M 480.00YN

48102 04 I 154.90YN

48105 04 1/1/2007 M 810.10YN

48120 04 M 599.35YN

48140 04 M 839.35YN

Wednesday, June 18, 2008 Page 190 of 455

Page 198: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

48145 04 M 1438.70YN

48146 04 M 1438.70YN

48148 04 M 859.00YN

48150 04 M 1438.70YN

48152 04 M 1438.70YN

48153 04 M 1438.70YN

48154 04 M 1438.70YN

48155 04 M 1438.70YN

48160 04 M 2397.40N

48400 04 I 47.30YN

48500 04 M 839.35YN

48510 04 M 839.35YN

48511 04 M 839.35YN

48520 04 M 839.35YN

48540 04 M 839.35YN

48545 04 M 599.35YN

48547 04 M 718.70YN

48548 04 1/1/2007 M 958.60YN

48550 04 M 599.35YN

48554 04 M 2397.40N

48556 04 M 599.35N

Wednesday, June 18, 2008 Page 191 of 455

Page 199: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

48999 04 MY

49000 04 M 480.00YN

49002 04 M 480.00YN

49010 04 M 480.00YN

49020 04 M 480.00YN

49021 04 M 314.60YN

49040 04 M 480.00YN

49041 04 M 480.00YN

49060 04 M 480.00YN

49061 04 M 480.00YN

49062 04 M 480.00YN

49080 04 I 71.40 34.00YN

49081 04 I 71.40 34.00YN

49180 04 I 106.80YN

49203 04 1/1/2008 M 617.99YN

49204 04 1/1/2008 M 789.45YN

49205 04 1/1/2008 M 904.11YN

49215 04 M 766.90YN

49220 04 M 998.80YN

49250 04 M 374.55YN

49255 04 M 599.35YN

Wednesday, June 18, 2008 Page 192 of 455

Page 200: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

49320 04 M 302.40YN

49321 04 M 302.40YN

49322 04 MYY

49323 04 M 480.00YN

49324 04 1/1/2007 M 480.00YN

49325 04 1/1/2007 M 480.00YN

49326 04 1/1/2007 M 480.00YN

49329 04 MYY

49400 04 I 47.00YN

49402 04 1/1/2007 MYY

49419 04 M 180.46YN

49420 04 I 74.90YN

49421 04 M 299.70YN

49422 04 M 240.00YN

49423 04 M 262.20YN

49424 04 I 20.95YN

49425 04 M 718.70YN

49426 04 MYY

49427 04 I 37.40YN

49428 04 MYY

49429 04 MYY

Wednesday, June 18, 2008 Page 193 of 455

Page 201: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

49435 04 1/1/2007 M 60.90YN

49436 04 1/1/2007 M 88.75YN

49440 04 1/1/2008 I 133.76 465.96YN

49441 04 1/1/2008 I 144.19 563.56YN

49442 04 1/1/2008 I 119.66 457.55YN

49446 04 1/1/2008 I 94.47 493.61YN

49450 04 1/1/2008 I 38.43 371.36YN

49451 04 1/1/2008 I 52.85 382.19YN

49452 04 1/1/2008 I 82.55 451.13YN

49460 04 1/1/2008 I 27.00 406.44YN

49465 04 1/1/2008 I 17.80 73.55YN

49491 04 M 433.70YN

49492 04 M 535.00YN

49495 04 M 362.00YN

49496 04 M 362.00YN

49500 04 M 362.00YN

49501 04 M 387.05YN

49505 04 M 387.05YN

49507 04 M 387.05YN

49520 04 M 409.20YN

49521 04 M 387.05YN

Wednesday, June 18, 2008 Page 194 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

49525 04 M 464.80YN

49540 04 M 337.10YN

49550 04 M 409.20YN

49553 04 M 409.20YN

49555 04 M 460.60YN

49557 04 M 460.60YN

49560 04 M 503.60YN

49561 04 M 503.60YN

49565 04 M 546.65YN

49566 04 M 572.50YN

49568 04 M 460.60YN

49570 04 M 345.50YN

49572 04 M 345.50YN

49580 04 M 342.65YN

49582 04 M 374.55YN

49585 04 M 374.55YN

49587 04 M 374.55YN

49590 04 M 374.55YN

49600 04 M 275.80YN

49605 04 M 573.10YN

49606 04 MYY

Wednesday, June 18, 2008 Page 195 of 455

Page 203: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

49610 04 M 599.35YN

49611 04 M 449.50YN

49650 04 M 387.05YN

49651 04 M 409.20YN

49659 04 MYY

49900 04 M 307.05YN

49904 04 M 617.40YN

49905 04 M 442.90YN

49906 04 M 1306.65YN

49999 04 MYY

50010 04 M 480.00YN

50020 04 M 398.35YN

50021 04 M 299.70YN

50040 04 M 775.60YN

50045 04 M 718.70YN

50060 04 M 718.70N

50065 04 M 599.35N

50070 04 M 749.20N

50075 04 M 749.20N

50080 04 M 434.20YN

50081 04 M 600.55YN

Wednesday, June 18, 2008 Page 196 of 455

Page 204: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

50100 04 M 767.20N

50120 04 M 839.35N

50125 04 M 839.35YN

50130 04 M 837.90YN

50135 04 MY

50200 04 I 112.40YN

50205 04 M 480.00YN

50220 04 M 933.80N

50225 04 M 933.80N

50230 04 M 1057.20N

50234 04 M 933.80N

50236 04 MY

50240 04 M 749.20N

50250 04 M 373.74N

50280 04 M 718.70YN

50290 04 M 718.70YN

50300 04 MY

50320 04 M 933.80N

50323 09 MY

50328 09 MY

50340 04 M 933.80N

Wednesday, June 18, 2008 Page 197 of 455

Page 205: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

50360 04 M 1366.60N

50365 04 M 1833.45N

50370 04 M 933.80N

50380 04 MY

50382 04 I 163.58YN

50384 04 I 148.92YN

50385 04 1/1/2008 M 137.81 572.99YN

50386 04 1/1/2008 M 104.23 356.14YN

50387 04 I 59.20YN

50389 04 I 32.75YN

50390 04 I 119.25YN

50391 04 I 117.95YN

50392 04 I 119.25YN

50393 04 I 119.25YN

50394 04 I 117.35YN

50395 04 I 119.25YN

50396 04 I 50.20 34.00YN

50398 04 I 36.70 34.00YN

50400 04 M 958.60YN

50405 04 M 958.60YN

50500 04 M 718.70YN

Wednesday, June 18, 2008 Page 198 of 455

Page 206: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

50520 04 M 480.00YN

50525 04 M 674.20YN

50526 04 M 674.20YN

50540 04 M 1198.70YN

50541 04 M 718.70YN

50542 04 M 718.70YN

50543 04 M 749.20YN

50544 04 M 958.60YN

50545 04 M 906.40YN

50546 04 M 933.80YN

50547 04 M 933.80N

50548 04 M 933.80YN

50549 04 MYY

50551 04 I 151.00 56.70YN

50553 04 I 245.35 56.70YN

50555 04 I 250.35 56.70YN

50557 04 I 294.80 56.70YN

50561 04 I 301.85 56.70YN

50562 04 M 301.95YN

50570 04 I 204.70YN

50572 04 I 268.20YN

Wednesday, June 18, 2008 Page 199 of 455

Page 207: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

50574 04 I 281.05YN

50575 04 I 365.15YN

50576 04 I 294.80YN

50580 04 I 269.70YN

50590 04 M 749.20YN

50592 04 I 214.22YN

50593 04 1/1/2008 M 267.81 2228.0YN

50600 04 M 718.70YN

50605 04 M 738.10YN

50610 04 M 738.10YN

50620 04 M 738.10YN

50630 04 M 738.10YN

50650 04 M 599.35YN

50660 04 M 599.35YN

50684 04 I 120.00 17.00YN

50686 04 I 64.10 34.00YN

50688 04 I 37.40 34.00YN

50690 04 I 129.70 17.00YN

50700 04 M 958.60YN

50715 04 M 749.20YN

50722 04 M 749.20YN

Wednesday, June 18, 2008 Page 200 of 455

Page 208: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

50725 04 M 958.60YN

50727 04 M 455.80YN

50728 04 M 567.10YN

50740 04 M 958.60YN

50750 04 M 958.60YN

50760 04 M 958.60YN

50770 04 M 958.60YN

50780 04 M 958.60YN

50782 04 M 945.15YN

50783 04 M 945.15YN

50785 04 M 958.60YN

50800 04 M 718.70YN

50810 04 M 718.70YN

50815 04 M 718.70YN

50820 04 M 718.70YN

50825 04 M 1438.70YN

50830 04 MYY

50840 04 M 718.70YN

50845 04 MYY

50860 04 M 958.60YN

50900 04 M 958.60YN

Wednesday, June 18, 2008 Page 201 of 455

Page 209: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

50920 04 M 480.00YN

50930 04 M 629.90YN

50940 04 M 934.70YN

50945 04 M 738.10YN

50947 04 M 973.55YN

50948 04 M 890.50YN

50949 04 MYY

50951 04 I 152.60 56.70YN

50953 04 I 251.25 56.70YN

50955 04 I 235.50 56.70YN

50957 04 I 236.20 56.70YN

50961 04 M 297.95 56.70YN

50970 04 I 187.70YN

50972 04 I 152.10YN

50974 04 I 243.40YN

50976 04 I 236.20YN

50980 04 M 262.20YN

51020 04 M 524.40YN

51030 04 M 524.40YN

51040 04 M 449.50YN

51045 04 M 449.50YN

Wednesday, June 18, 2008 Page 202 of 455

Page 210: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

51050 04 M 599.35YN

51060 04 M 738.10YN

51065 04 M 738.10YN

51080 04 M 599.35YN

51100 04 1/1/2008 I 22.55 13.02YN

51101 04 1/1/2008 I 30.11 41.49YN

51102 04 1/1/2008 I 141.08 47.69YN

51500 04 M 599.35YN

51520 04 M 480.00YN

51525 04 M 718.70YN

51530 04 M 599.35YN

51535 04 M 599.35YN

51550 04 M 599.35YN

51555 04 M 599.35YN

51565 04 M 958.60YN

51570 04 M 749.20YN

51575 04 M 1198.70YN

51580 04 M 1438.70YN

51585 04 M 1438.70YN

51590 04 M 1438.70YN

51595 04 M 1498.30YN

Wednesday, June 18, 2008 Page 203 of 455

Page 211: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

51596 04 M 1438.70YN

51597 04 M 1498.30N

51600 04 I 121.35 17.00YN

51605 04 I 121.35 17.00YN

51610 04 I 130.80 17.00YN

51700 04 I 44.60N

51701 04 I 24.02N

51702 04 I 24.02N

51703 04 I 26.18N

51705 04 I 38.85 17.00YN

51710 04 I 66.85 17.00YN

51715 04 I 295.95YN

51720 04 I 66.85 17.00YN

51725 04 I 44.40YN

51726 04 I 50.05YN

51736 04 I 17.30YN

51741 04 I 52.70YN

51772 04 I 45.00YN

51784 04 I 52.70YN

51785 04 I 52.70YN

51792 04 I 74.90YN

Wednesday, June 18, 2008 Page 204 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

51795 04 I 51.50YN

51797 04 I 45.00YN

51798 A 04 I 8.78 8.78 17.56YN

51800 04 M 599.35YN

51820 04 M 839.35YN

51840 04 M 631.25YN

51841 04 M 631.25YN

51845 04 M 631.25YN

51860 04 M 599.35YN

51865 04 M 599.35YN

51880 04 M 216.65YN

51900 04 M 958.60YN

51920 04 M 958.60YN

51925 04 M 958.60YN

51940 04 M 839.35YN

51960 04 M 1105.80YN

51980 04 M 449.50YN

51990 04 M 631.25YN

51992 04 M 631.25YN

51999 04 MYY

52000 04 I 85.90 56.70YN

Wednesday, June 18, 2008 Page 205 of 455

Page 213: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

52001 04 I 90.40YN

52005 04 I 118.90 56.70YN

52007 04 M 154.60 56.70YN

52010 04 I 118.90 56.70YN

52204 04 I 163.90 56.70N

52214 04 M 178.30 56.70YN

52224 04 M 295.95 56.70YN

52234 04 M 374.55YN

52235 04 M 374.55YN

52240 04 M 524.40YN

52250 04 I 141.30 56.70YN

52260 04 I 149.80YN

52265 04 I 142.70 56.70YN

52270 04 M 180.30YN

52275 04 M 194.20YN

52276 04 M 209.40YN

52277 04 M 180.30YN

52281 04 I 134.80 56.70YN

52282 04 I 204.10 56.70YN

52283 04 I 149.80YN

52285 04 I 135.70YN

Wednesday, June 18, 2008 Page 206 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

52290 04 M 184.50YN

52300 04 M 240.00YN

52301 04 M 240.00YN

52305 04 M 297.00YN

52310 04 I 180.30 56.70YN

52315 04 M 239.00 56.70YN

52317 04 M 342.15 56.70YN

52318 04 M 339.25 56.70YN

52320 04 M 249.70 56.70YN

52325 04 M 379.40YN

52327 04 I 295.95YN

52330 04 M 260.80 56.70YN

52332 04 I 138.90YN

52334 04 M 308.35YN

52341 04 M 224.45YN

52342 04 M 242.90YN

52343 04 M 269.10YN

52344 04 M 287.60YN

52345 04 M 306.60YN

52346 04 M 344.90YN

52351 04 I 178.30YN

Wednesday, June 18, 2008 Page 207 of 455

Page 215: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

52352 04 M 293.75YN

52353 04 M 262.20YN

52354 04 M 249.70YN

52355 04 M 337.00YN

52400 04 M 398.85YN

52402 04 M 537.15YN

52450 04 M 249.00YN

52500 04 M 480.00YN

52601 04 M 775.60YN

52606 04 M 374.55YN

52612 04 M 621.50YN

52614 04 M 430.05YN

52620 04 M 202.55YN

52630 04 M 599.35YN

52640 04 M 486.90YN

52647 04 M 599.35YN

52648 04 M 599.35YN

52649 04 1/1/2008 M 562.42YN

52700 04 M 314.95YN

53000 04 M 240.00YN

53010 04 M 314.95YN

Wednesday, June 18, 2008 Page 208 of 455

Page 216: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

53020 04 I 67.80 17.00YN

53025 04 I 58.60 17.00YN

53040 04 I 197.80 17.00YN

53060 04 I 95.30 17.00YN

53080 04 M 17.00YY

53085 04 MYY

53200 04 I 92.70 17.00YN

53210 04 M 449.50YN

53215 04 M 524.40YN

53220 04 M 449.50YN

53230 04 M 599.35YN

53235 04 M 599.35YN

53240 04 M 449.50YN

53250 04 M 34.00YY

53260 04 I 113.60 34.00YN

53265 04 I 115.00 34.00YN

53270 04 I 113.60 34.00YN

53275 04 I 122.20 34.00YN

53400 04 M 599.35YN

53405 04 M 599.35YN

53410 04 M 599.35YN

Wednesday, June 18, 2008 Page 209 of 455

Page 217: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

53415 04 M 745.30YN

53420 04 M 599.35YN

53425 04 M 449.50YN

53430 04 M 517.40YN

53431 04 M 709.95YN

53440 04 M 599.35YN

53442 04 M 449.50YN

53444 04 M 540.40YN

53445 04 MYY

53446 04 M 494.90YN

53447 04 M 449.50YN

53448 04 M 842.25YN

53449 04 MYY

53450 04 M 164.30YN

53460 04 M 224.70YN

53500 04 M 386.25YN

53502 04 MYY

53505 04 MYY

53510 04 MYY

53515 04 MYY

53520 04 M 314.95YN

Wednesday, June 18, 2008 Page 210 of 455

Page 218: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

53600 04 I 52.80YN

53601 04 I 47.80YN

53605 04 I 47.80YN

53620 04 I 75.10YN

53621 04 I 69.55YN

53660 04 I 41.80YN

53661 04 I 42.10YN

53665 04 I 36.00YN

53850 04 M 576.80YN

53852 04 M 576.80YN

53853 04 M 229.10YN

53899 04 MYY

54000 04 I 74.90 17.00YN

54001 04 I 87.85 17.00YN

54015 04 I 156.75 17.00YN

54050 04 I 52.70 17.00N

54055 04 I 72.10 17.00N

54056 04 I 71.40 17.00N

54057 04 I 71.40 17.00YN

54060 04 I 88.50 17.00YN

54065 04 I 107.00 34.00YN

Wednesday, June 18, 2008 Page 211 of 455

Page 219: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

54100 04 I 88.50 17.00YN

54105 04 I 114.25 17.00YN

54110 04 M 321.45YN

54111 04 M 585.75YN

54112 04 M 717.90YN

54115 04 MYY

54120 04 M 285.10YN

54125 04 M 449.50N

54130 04 M 749.20N

54135 04 M 749.20N

54150 04 I 77.50YN

54160 04 I 99.80YN

54161 04 I 146.70 34.00YN

54162 04 I 97.25YN

54163 04 I 137.40YN

54164 04 I 120.30YN

54200 04 I 38.60YN

54205 04 IYY

54220 04 M 299.70YN

54230 04 I 38.20YN

54231 04 I 118.80N

Wednesday, June 18, 2008 Page 212 of 455

Page 220: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

54235 04 I 37.40YN

54240 09 IY

54250 04 I 54.55N

54300 04 M 425.80YN

54304 04 M 670.10YN

54308 04 M 599.35YN

54312 04 M 670.10YN

54316 04 M 670.10YN

54318 04 M 670.10YN

54322 04 M 480.00YN

54324 04 M 538.00YN

54326 04 M 670.10YN

54328 04 M 958.60YN

54332 04 M 670.10YN

54336 04 M 958.60YN

54340 04 M 538.00YN

54344 04 M 670.10YN

54348 04 M 958.60YN

54352 04 MYY

54360 04 M 690.78YN

54380 04 M 386.30YN

Wednesday, June 18, 2008 Page 213 of 455

Page 221: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

54385 04 M 446.00YN

54390 04 M 600.70YN

54400 09 MY

54401 09 MY

54405 09 MY

54406 09 MY

54408 09 MY

54410 09 MY

54411 09 MY

54415 09 MY

54416 09 MY

54417 09 MY

54420 04 M 409.20YN

54430 04 M 409.20YN

54435 04 M 405.10YN

54440 04 M 224.70YN

54450 04 I 37.45N

54500 04 I 68.20 17.00YN

54505 04 I 113.60 17.00YN

54512 04 M 356.05YN

54520 04 M 351.00YN

Wednesday, June 18, 2008 Page 214 of 455

Page 222: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

54522 04 M 404.20YN

54530 04 M 958.60YN

54535 04 M 958.60YN

54550 04 M 359.30YN

54560 04 M 480.00YN

54600 04 M 359.30YN

54620 04 M 299.70YN

54640 04 M 504.90YN

54650 04 M 480.00YN

54660 09 MY

54670 04 MYY

54680 04 MYY

54690 04 M 351.00YN

54692 04 M 504.90YN

54699 04 MYY

54700 04 I 128.30 17.00YN

54800 04 I 119.25YN

54830 04 M 299.70YN

54840 04 M 299.70YN

54860 04 M 359.30YN

54861 04 M 480.00YN

Wednesday, June 18, 2008 Page 215 of 455

Page 223: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

54865 04 1/1/2007 M 179.47YN

54900 04 M 480.00YN

54901 04 M 599.35YN

55000 04 I 42.35 17.00YN

55040 04 M 299.70YN

55041 04 M 449.50YN

55060 04 M 259.40YN

55100 04 I 110.90 17.00YN

55110 04 MYY

55120 04 I 129.30 17.00YN

55150 04 I 206.10YN

55175 04 MYY

55180 04 MYY

55200 04 I 147.95 56.70YN

55250 04 I 147.95 56.70YN

55300 04 I 112.40YN

55400 04 MYY

55450 04 M 150.40 56.70YN

55500 04 M 359.30YN

55520 04 M 240.00YN

55530 04 M 359.30YN

Wednesday, June 18, 2008 Page 216 of 455

Page 224: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

55535 04 M 359.30YN

55540 04 M 480.00YN

55550 04 M 359.30YN

55559 04 MYY

55600 04 I 178.30YN

55605 04 M 223.60YN

55650 04 M 958.60YN

55680 04 I 299.70YN

55700 04 I 113.60 17.00YN

55705 04 M 187.30YN

55720 04 M 359.30YN

55725 04 M 359.30YN

55801 04 M 839.35YN

55810 04 M 1198.70YN

55812 04 M 1678.65YN

55815 04 M 1809.25YN

55821 04 M 958.60YN

55831 04 M 958.60YN

55840 04 M 1198.70YN

55842 04 M 1285.40YN

55845 04 M 1438.70N

Wednesday, June 18, 2008 Page 217 of 455

Page 225: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

55860 04 MYY

55862 04 MYY

55865 04 MYY

55866 04 MYY

55870 09 IY

55873 04 M 739.15YN

55875 04 1/1/2007 M 359.30YN

55876 04 1/1/2007 M 59.34YN

55899 04 MYY

55920 04 1/1/2008 M 246.06N

56405 04 I 95.05YN

56420 04 I 103.05 17.00YN

56440 04 M 202.50YN

56441 04 I 127.90YN

56442 04 1/1/2007 I 68.65YN

56501 04 I 52.70 17.00YN

56515 04 M 181.00 34.00YN

56605 04 I 108.30YN

56606 04 I 35.65YN

56620 04 M 335.70YN

56625 04 M 480.00YN

Wednesday, June 18, 2008 Page 218 of 455

Page 226: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

56630 04 M 524.40YN

56631 04 M 511.20YN

56632 04 M 599.65YN

56633 04 M 524.40YN

56634 04 M 599.35YN

56637 04 M 749.20YN

56640 04 M 749.20YN

56700 04 I 113.60N

56740 04 M 226.10YN

56800 04 I 119.25YN

56805 04 M 496.90YN

56810 04 M 190.00YN

56820 04 I 37.40N

56821 04 I 50.20N

57000 04 M 202.55YN

57010 04 M 224.70YN

57020 04 I 79.30 17.00YN

57022 04 I 109.50YN

57023 04 I 109.50YN

57061 04 I 45.40 17.00YN

57065 04 I 91.35YN

Wednesday, June 18, 2008 Page 219 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

57100 04 I 107.00 17.00N

57105 04 I 107.00 17.00YN

57106 04 M 299.70YN

57107 04 M 544.50YN

57109 04 M 782.80YN

57110 04 M 374.30YN

57111 04 M 782.80YN

57112 04 M 1022.80YN

57120 04 M 299.70YN

57130 04 M 180.30YN

57135 04 I 121.55 17.00YN

57150 04 I 18.25N

57155 04 I 257.40N

57160 04 I 27.65N

57170 04 I 28.60N

57180 04 I 48.75 17.00N

57200 04 M 188.90 34.00YN

57210 04 M 206.05 34.00YN

57220 04 M 355.10YN

57230 04 M 517.40YN

57240 04 M 355.10YN

Wednesday, June 18, 2008 Page 220 of 455

Page 228: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

57250 04 M 314.95YN

57260 04 M 525.80YN

57265 04 M 532.80YN

57267 04 M 167.79YN

57268 04 M 532.80YN

57270 04 M 480.00YN

57280 04 M 599.35YN

57282 04 M 480.00YN

57283 04 M 599.35YN

57284 04 M 532.80YN

57285 04 1/1/2008 M 352.36YN

57287 04 M 467.50YN

57288 04 M 631.25YN

57289 04 M 674.20YN

57291 04 MYY

57292 04 MYY

57295 04 M 269.31YN

57296 04 1/1/2007 M 481.19YN

57300 04 M 466.15YN

57305 04 M 1127.90YN

57307 04 M 1127.90YN

Wednesday, June 18, 2008 Page 221 of 455

Page 229: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

57308 04 M 728.35YN

57310 04 M 718.70YN

57311 04 M 799.70YN

57320 04 M 597.90YN

57330 04 M 524.40YN

57335 04 M 466.15YN

57400 04 I 111.00YN

57410 04 I 53.30YN

57415 04 I 111.00YN

57420 04 I 37.40N

57421 04 I 50.20N

57423 04 1/1/2008 M 497.75YN

57425 04 M 487.77YN

57452 04 I 37.40N

57454 04 I 50.20 34.00YN

57455 04 I 50.20YN

57456 04 I 50.20YN

57460 04 I 77.00 34.00YN

57461 04 I 172.05YN

57500 04 I 142.70 17.00N

57505 04 I 48.55YN

Wednesday, June 18, 2008 Page 222 of 455

Page 230: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

57510 04 I 60.60YN

57511 04 I 58.10YN

57513 04 I 131.10YN

57520 04 M 321.90YN

57522 04 M 305.80 34.00YN

57530 04 M 308.00YN

57531 04 M 1030.80YN

57540 04 M 599.35YN

57545 04 M 599.35YN

57550 04 M 599.35YN

57555 04 M 674.20YN

57556 04 M 674.20YN

57558 04 1/1/2007 I 149.80YN

57700 04 M 313.50YN

57720 04 M 559.30YN

57800 04 I 119.25YN

58100 04 I 52.90 34.00YN

58110 04 M 24.90YN

58120 04 M 206.85YN

58140 04 M 718.70YN

58145 04 M 718.70YN

Wednesday, June 18, 2008 Page 223 of 455

Page 231: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

58146 04 M 718.70YN

58150 04 M 772.70YN

58152 04 M 1096.05YN

58180 04 M 652.05YN

58200 04 M 772.70YN

58210 04 M 1030.80YN

58240 04 M 1423.45YN

58260 04 M 725.60YN

58262 04 M 725.60YN

58263 04 M 725.60YN

58267 04 M 856.00YN

58270 04 M 856.00YN

58275 04 M 875.40YN

58280 04 M 800.50YN

58285 04 M 950.30N

58290 04 M 725.60YN

58291 04 M 725.60YN

58292 04 M 725.60YN

58293 04 M 856.00YN

58294 04 M 856.00YN

58300 04 I 44.00N

Wednesday, June 18, 2008 Page 224 of 455

Page 232: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

58301 04 I 37.40N

58340 04 I 93.40N

58346 04 I 274.00YN

58350 04 I 37.50N

58353 04 I 150.60YN

58356 04 M 201.30YN

58400 04 M 449.50YN

58410 04 M 449.50YN

58520 04 M 480.00YN

58540 04 MYY

58541 04 1/1/2007 M 433.94YN

58542 04 1/1/2007 M 479.33YN

58543 04 1/1/2007 M 487.55YN

58544 04 1/1/2007 M 528.11YN

58545 04 M 480.00YN

58546 04 M 480.00YN

58548 04 1/1/2007 M 924.56YN

58550 04 M 725.60YN

58552 04 M 725.00YN

58553 04 M 725.00YN

58554 04 M 725.00YN

Wednesday, June 18, 2008 Page 225 of 455

Page 233: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

58555 04 I 95.75YN

58558 04 I 145.80YN

58559 04 I 160.80YN

58560 04 I 160.80YN

58561 04 M 361.85YN

58562 04 M 361.85YN

58563 04 I 300.43YN

58565 04 M 327.45YN

58570 04 1/1/2008 M 496.17YN

58571 04 1/1/2008 M 542.05YN

58572 04 1/1/2008 M 617.19YN

58573 04 1/1/2008 M 693.59YN

58578 04 MYY

58579 04 MYY

58600 04 M 327.45YN

58605 04 M 327.45YN

58611 04 M 97.30N

58615 04 M 327.45YN

58660 04 M 302.40YN

58661 04 M 480.00YN

58662 04 M 302.40YN

Wednesday, June 18, 2008 Page 226 of 455

Page 234: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

58670 04 M 363.45YN

58671 04 M 363.45YN

58672 09 MY

58673 04 M 480.00YN

58679 04 MYY

58700 04 M 481.90YN

58720 04 M 525.85YN

58740 04 M 480.00YN

58752 09 MY

58770 04 M 480.00YN

58800 04 M 359.30YN

58805 04 M 480.00YN

58820 04 M 240.00YN

58822 04 M 480.00YN

58823 04 M 302.90YN

58825 04 MYY

58900 04 M 480.00YN

58920 04 M 529.95YN

58925 04 M 524.40YN

58940 04 M 554.90YN

58943 04 M 958.60YN

Wednesday, June 18, 2008 Page 227 of 455

Page 235: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

58950 04 M 704.70YN

58951 04 M 898.95N

58952 04 M 958.60N

58953 04 M 1241.75YN

58954 04 M 1350.35N

58956 04 M 1241.75YN

58957 04 1/1/2007 M 749.43YN

58958 04 1/1/2007 M 830.11YN

58960 04 M 599.35YN

58999 04 MY

59000 04 I 58.35 34.00YN

59001 04 B 89.80YN

59012 04 I 115.00YN

59015 04 IYY

59020 C 04 I 7.90 25.80 33.70YN

59025 C 04 I 7.90 25.80 33.70YN

59030 04 I 79.00YN

59050 04 I 25.40N

59051 09 NY

59070 04 I 158.55YN

59074 04 I 158.55YN

Wednesday, June 18, 2008 Page 228 of 455

Page 236: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

59076 04 M 257.88YN

59100 04 M 540.00YN

59120 04 M 540.00YN

59121 04 M 540.00YN

59130 04 M 540.00YN

59135 04 M 696.15YN

59136 04 M 540.00YN

59140 04 M 540.00YN

59150 04 M 540.00YN

59151 04 M 540.00YN

59160 04 M 199.95YN

59200 04 B 27.80N

59300 04 B 74.95N

59320 04 M 282.45YN

59325 04 M 540.10YN

59350 04 M 540.00YN

59409 04 B 535.20N

59410 04 B 535.20N

59412 04 B 72.95YN

59414 04 B 67.50N

59430 04 B 50.15N

Wednesday, June 18, 2008 Page 229 of 455

Page 237: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

59510 09 NY

59514 04 B 681.20N

59515 04 B 681.20N

59525 04 M 299.30N

59610 09 NY

59612 04 B 535.20N

59614 04 B 535.20N

59618 09 BY

59620 04 B 681.20N

59622 04 B 681.20N

59812 04 M 298.70YN

59820 04 M 199.95YN

59821 04 M 298.70YN

59830 04 M 223.70YN

59840 04 M 199.95YN

59841 04 B 199.95YN

59850 04 M 199.95YN

59851 04 M 199.95N

59855 04 M 199.95N

59856 04 M 199.95YN

59857 04 M 199.95YN

Wednesday, June 18, 2008 Page 230 of 455

Page 238: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

59866 09 MY

59870 04 M 389.25YN

59871 04 I 66.95YN

59897 04 MYY

59898 09 BY

59899 04 BY

60000 04 I 113.60 17.00YN

60100 04 I 50.20 17.00YN

60200 04 M 360.70YN

60210 04 M 550.90YN

60212 04 M 718.70YN

60220 04 M 703.30YN

60225 04 M 703.30YN

60240 04 M 718.70YN

60252 04 M 1198.70YN

60254 04 M 1198.70YN

60260 04 M 718.70YN

60270 04 M 839.35YN

60271 04 M 749.20YN

60280 04 M 718.70YN

60281 04 M 718.70YN

Wednesday, June 18, 2008 Page 231 of 455

Page 239: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

60300 04 1/1/2008 I 27.75 27.05YN

60500 04 M 839.35YN

60502 04 M 839.35YN

60505 04 M 839.35YN

60512 04 M 135.00YN

60520 04 M 749.20YN

60521 04 M 839.35YN

60522 04 M 1198.70YN

60540 04 M 839.35YN

60545 04 M 958.60YN

60600 04 M 839.35YN

60605 04 M 839.35YN

60650 04 M 839.35YN

60659 04 MYY

60699 04 MYY

61000 04 I 112.40YN

61020 04 I 112.40YN

61026 04 M 62.15YN

61050 04 I 112.40YN

61055 04 M 157.50YN

61070 04 I 112.40YN

Wednesday, June 18, 2008 Page 232 of 455

Page 240: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

61105 04 M 359.30YN

61107 04 M 359.30YN

61108 04 M 599.35YN

61120 04 M 359.30YN

61140 04 M 510.30YN

61150 04 M 958.60YN

61151 04 I 330.80YN

61154 04 M 599.35YN

61156 04 M 599.35YN

61210 04 M 449.50YN

61215 04 M 449.50YN

61250 04 M 449.50YN

61253 04 M 449.50YN

61304 04 M 749.20N

61305 04 M 886.90N

61312 04 M 861.50N

61313 04 M 861.50N

61314 04 M 861.50N

61315 04 M 1198.70N

61316 04 MY

61320 04 M 1123.70N

Wednesday, June 18, 2008 Page 233 of 455

Page 241: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

61321 04 M 1123.70N

61322 04 M 1123.70N

61323 04 M 1123.70N

61330 04 M 973.90N

61332 04 M 973.90YN

61333 04 M 1198.70YN

61334 04 M 1198.70YN

61340 04 M 839.35YN

61343 04 M 1738.80N

61345 04 M 1198.70N

61440 04 M 839.35N

61450 04 M 839.35N

61458 04 M 893.25YN

61460 04 M 891.30N

61470 04 M 958.60N

61480 04 M 958.60N

61490 04 M 1198.70N

61500 04 M 1198.70YN

61501 04 M 1198.70YN

61510 04 M 1198.70N

61512 04 M 1198.70N

Wednesday, June 18, 2008 Page 234 of 455

Page 242: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

61514 04 M 1198.70N

61516 04 M 1198.70N

61517 04 I 49.85N

61518 04 M 1198.70N

61519 04 M 1271.10N

61520 04 M 1604.85N

61521 04 M 1351.20N

61522 04 M 1198.70N

61524 04 M 1198.70N

61526 04 M 1499.10N

61530 04 M 1327.00N

61531 04 M 1138.70YN

61533 04 M 1138.70YN

61534 04 M 1198.70YN

61535 04 MYY

61536 04 M 1198.70N

61537 04 M 939.13N

61538 04 M 1198.70N

61539 04 M 1198.70N

61540 04 M 1134.13N

61541 04 M 1701.95N

Wednesday, June 18, 2008 Page 235 of 455

Page 243: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

61542 04 M 1198.70N

61543 04 M 1198.70N

61544 04 M 1198.70N

61545 04 M 1283.15N

61546 04 M 1198.70N

61548 04 M 1198.70N

61550 04 M 898.95N

61552 04 M 1198.70N

61556 04 M 1144.65N

61557 04 M 1690.50N

61558 04 M 1689.90N

61559 04 M 1689.90N

61563 04 MYY

61564 04 MYY

61566 04 M 1116.28N

61567 04 M 1270.28N

61570 04 M 1198.70N

61571 04 M 1198.70N

61575 04 M 1198.70YN

61576 04 M 1630.70YN

61580 04 M 1198.70YN

Wednesday, June 18, 2008 Page 236 of 455

Page 244: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

61581 04 M 1630.70YN

61582 04 M 1198.70N

61583 04 M 1306.65N

61584 04 M 1306.65N

61585 04 M 1630.70N

61586 04 M 1306.65N

61590 04 M 1630.70N

61591 04 M 1630.70N

61592 04 M 1630.70N

61595 04 M 1414.70N

61596 04 M 1630.70N

61597 04 M 1630.70N

61598 04 M 1522.70N

61600 04 M 1198.70N

61601 04 M 1198.70N

61605 04 M 1138.70N

61606 04 M 1198.70N

61607 04 M 1198.70N

61608 04 M 1274.80N

61609 04 M 1198.70YN

61610 04 M 1306.65YN

Wednesday, June 18, 2008 Page 237 of 455

Page 245: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

61611 04 M 1198.70YN

61612 04 M 1306.65YN

61613 04 M 1244.80YN

61615 04 M 1198.70YN

61616 04 M 1306.65YN

61618 04 M 958.60YN

61619 04 MYY

61623 04 I 241.20YN

61624 04 M 682.80YN

61626 04 M 682.80YN

61630 04 MYY

61635 04 MYY

61640 04 MYY

61641 04 MYY

61642 04 MYY

61680 04 M 1048.85N

61682 04 M 1784.20N

61684 04 M 1231.20N

61686 04 M 1871.15N

61690 04 M 973.90N

61692 04 M 1480.90N

Wednesday, June 18, 2008 Page 238 of 455

Page 246: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

61697 04 M 2267.10N

61698 04 M 2182.15N

61700 04 M 1498.85N

61702 04 M 1481.20N

61703 04 M 718.70N

61705 04 M 1198.70N

61708 04 M 1198.70N

61710 04 M 787.40N

61711 04 M 1158.10N

61720 04 M 1198.70N

61735 04 M 1198.70N

61750 04 M 1306.65YN

61751 04 M 1198.70YN

61760 04 M 1138.70YN

61770 04 M 749.20YN

61790 04 M 749.20YN

61791 04 M 1198.70YN

61793 04 M 1198.70YN

61795 04 M 230.30N

61850 04 M 749.20YN

61860 04 M 1198.70YN

Wednesday, June 18, 2008 Page 239 of 455

Page 247: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

61863 04 M 574.19YN

61867 04 M 843.83YN

61870 04 M 958.60YN

61875 04 M 958.60YN

61880 04 M 749.20YN

61885 04 M 749.20YN

61886 04 M 749.20YN

61888 04 M 749.20YN

62000 04 M 789.30N

62005 04 M 1347.10N

62010 04 M 1347.10N

62100 04 M 1198.70N

62115 04 M 1296.20N

62116 04 M 1458.20N

62117 04 M 1458.20N

62120 04 M 698.40N

62121 04 M 1198.70N

62140 04 M 749.20YN

62141 04 M 1048.85YN

62142 04 M 749.20YN

62143 04 M 1048.85YN

Wednesday, June 18, 2008 Page 240 of 455

Page 248: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

62145 04 M 1198.70N

62146 04 M 1350.15YN

62147 04 M 1458.20YN

62148 04 M 105.00N

62160 04 M 156.52YN

62161 04 M 985.60YN

62162 04 M 1036.85YN

62163 04 M 861.50YN

62164 04 M 1198.70YN

62165 04 M 1198.70YN

62180 04 M 839.35YN

62190 04 M 839.35YN

62192 04 M 761.60YN

62194 04 M 599.35YN

62200 04 M 839.35YN

62201 04 M 1048.85YN

62220 04 M 839.35YN

62223 04 M 761.60YN

62225 04 M 374.55YN

62230 04 M 374.55YN

62252 04 I 54.20YN

Wednesday, June 18, 2008 Page 241 of 455

Page 249: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

62256 04 M 225.80YN

62258 04 M 599.35YN

62263 04 M 193.60YN

62264 04 M 193.60YN

62268 04 M 449.50YN

62269 04 M 449.50YN

62270 04 I 53.70YN

62272 04 I 59.10YN

62273 04 I 74.90YN

62280 04 I 158.20YN

62281 04 I 81.10YN

62282 04 I 158.20YN

62284 04 I 158.20N

62287 04 M 481.80YN

62290 04 I 158.20YN

62291 04 I 158.20YN

62292 04 M 852.05YN

62294 04 M 852.05YN

62310 04 I 85.90YN

62311 04 I 86.00YN

62318 04 MYY

Wednesday, June 18, 2008 Page 242 of 455

Page 250: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

62319 04 MYY

62350 04 M 545.10YN

62351 04 M 839.35YN

62355 04 M 180.30YN

62360 04 M 545.10YN

62361 04 M 545.10YN

62362 04 M 545.10YN

62365 04 M 162.00YN

62367 04 I 27.55N

62368 04 I 40.45N

63001 04 M 1102.95YN

63003 04 M 1102.95YN

63005 04 M 1102.95YN

63011 04 M 881.00YN

63012 04 M 1404.20YN

63015 04 M 1161.20YN

63016 04 M 1161.20YN

63017 04 M 1161.20YN

63020 04 MYY

63030 04 M 1129.30YN

63035 04 MYY

Wednesday, June 18, 2008 Page 243 of 455

Page 251: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

63040 04 M 1129.30YN

63042 04 M 1129.30YN

63043 04 MYY

63044 04 MYY

63045 04 M 1129.30YN

63046 04 M 1129.30YN

63047 04 M 1129.30YN

63048 04 MYY

63050 04 M 843.88YN

63051 04 M 947.11YN

63055 04 M 1291.70YN

63056 04 M 1291.70YN

63057 04 MY

63064 04 M 1198.70YN

63066 04 MY

63075 04 M 1198.70YN

63076 04 M 1198.70N

63077 04 M 1198.70YN

63078 04 M 1198.70N

63081 04 M 1291.70YN

63082 04 MYY

Wednesday, June 18, 2008 Page 244 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

63085 04 M 1291.70YN

63086 04 MYY

63087 04 M 1291.70YN

63088 04 MYY

63090 04 M 1291.70YN

63091 04 MYY

63101 04 M 1153.57YN

63102 04 M 1153.57YN

63103 04 MYY

63170 04 M 1291.70YN

63172 04 M 1198.70YN

63173 04 M 1393.75YN

63180 04 M 1198.70YN

63182 04 M 1198.70YN

63185 04 M 839.35N

63190 04 M 1079.30N

63191 04 MYY

63194 04 M 958.60N

63195 04 M 958.60N

63196 04 M 958.60N

63197 04 M 958.60N

Wednesday, June 18, 2008 Page 245 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

63198 04 M 1291.70N

63199 04 MY

63200 04 M 1198.70YN

63250 04 M 1198.70YN

63251 04 M 1198.70YN

63252 04 M 1224.30YN

63265 04 M 1198.70YN

63266 04 M 1198.70YN

63267 04 M 1198.70YN

63268 04 M 1198.70YN

63270 04 M 1198.70YN

63271 04 M 1198.70YN

63272 04 M 1198.70YN

63273 04 M 1198.70YN

63275 04 M 1198.70YN

63276 04 M 1198.70YN

63277 04 M 1198.70YN

63278 04 M 1198.70YN

63280 04 M 1198.70YN

63281 04 M 1198.70YN

63282 04 M 1198.70YN

Wednesday, June 18, 2008 Page 246 of 455

Page 254: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

63283 04 M 1198.70YN

63285 04 M 1198.70YN

63286 04 M 1198.70YN

63287 04 M 1198.70YN

63290 04 M 1198.70YN

63295 04 M 190.18YN

63300 04 M 1606.30YN

63301 04 M 1615.70YN

63302 04 M 1291.70YN

63303 04 M 1291.70YN

63304 04 M 1291.70YN

63305 04 M 1291.70YN

63306 04 M 1291.70YN

63307 04 M 1291.70YN

63308 04 MYY

63600 04 M 898.95YN

63610 04 M 599.35YN

63615 04 M 898.95YN

63650 04 M 524.40YN

63655 04 M 733.85YN

63660 04 M 374.55YN

Wednesday, June 18, 2008 Page 247 of 455

Page 255: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

63685 04 M 599.35YN

63688 04 M 374.55YN

63700 04 M 599.35YN

63702 04 M 599.35N

63704 04 M 630.10YN

63706 04 M 689.00N

63707 04 M 1198.70YN

63709 04 M 1198.70YN

63710 04 M 1102.95YN

63740 04 M 839.35YN

63741 04 M 324.05YN

63744 04 M 374.55YN

63746 04 M 194.05YN

64400 04 I 74.90YN

64402 04 I 74.90YN

64405 04 I 74.90YN

64408 04 I 52.40YN

64410 04 I 49.40YN

64412 04 I 46.65YN

64413 04 I 52.70YN

64415 04 I 52.70YN

Wednesday, June 18, 2008 Page 248 of 455

Page 256: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

64416 04 I 74.90YN

64417 04 I 48.40YN

64418 04 I 47.15YN

64420 04 I 43.25YN

64421 04 I 56.40YN

64425 04 I 52.65YN

64430 04 I 51.10YN

64435 04 I 50.55YN

64445 04 I 53.20YN

64446 04 I 74.90YN

64447 04 I 53.20YN

64448 04 I 74.90YN

64449 04 I 81.40YN

64450 04 I 38.95YN

64470 04 I 88.05YN

64472 04 I 74.90YN

64475 04 I 77.90YN

64476 04 I 74.90YN

64479 04 I 95.90YN

64480 04 I 85.75YN

64483 04 I 88.25YN

Wednesday, June 18, 2008 Page 249 of 455

Page 257: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

64484 04 I 83.20YN

64505 04 I 59.60YN

64508 04 I 59.60YN

64510 04 I 59.60YN

64517 04 I 64.40YN

64520 04 I 56.20YN

64530 04 I 58.70YN

64550 04 I 22.15N

64553 04 I 149.80YN

64555 04 I 60.80YN

64560 04 I 97.20YN

64561 04 M 171.50YN

64565 04 IYY

64573 04 M 599.35YN

64575 04 M 599.35YN

64577 04 M 599.35YN

64580 04 M 599.35YN

64581 04 M 332.00YN

64585 04 I 149.80YN

64590 04 M 599.35YN

64595 04 M 149.80YN

Wednesday, June 18, 2008 Page 250 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

64600 04 I 100.00YN

64605 04 I 140.65YN

64610 04 I 233.00YN

64612 04 I 71.15YN

64613 04 I 71.15YN

64614 04 I 27.10YN

64620 04 I 80.90YN

64622 04 I 99.70YN

64623 04 I 48.20YN

64626 04 I 113.40YN

64627 04 I 66.50YN

64630 04 I 88.50YN

64640 04 I 90.50YN

64650 04 I 22.42YN

64653 04 I 28.36YN

64680 04 M 224.70YN

64681 04 I 116.11YN

64702 04 M 524.40YN

64704 04 M 524.40YN

64708 04 M 524.40YN

64712 04 M 524.40YN

Wednesday, June 18, 2008 Page 251 of 455

Page 259: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

64713 04 M 647.90YN

64714 04 M 647.90YN

64716 04 MYY

64718 04 M 524.40YN

64719 04 M 524.40YN

64721 04 M 524.40YN

64722 04 M 524.40YN

64726 04 M 524.40YN

64727 04 M 524.40YN

64732 04 I 148.20YN

64734 04 M 158.30YN

64736 04 M 224.70YN

64738 04 M 374.55YN

64740 04 M 224.70YN

64742 04 M 224.70YN

64744 04 M 607.60YN

64746 04 I 181.05YN

64752 04 M 524.40YN

64755 04 M 524.40YN

64760 04 M 524.40YN

64761 04 M 299.70YN

Wednesday, June 18, 2008 Page 252 of 455

Page 260: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

64763 04 M 224.70YN

64766 04 M 374.55YN

64771 04 M 374.55YN

64772 04 M 374.55YN

64774 04 I 144.55 34.00YN

64776 04 M 180.30YN

64778 04 MYY

64782 04 M 240.00YN

64783 04 M 120.60YN

64784 04 M 359.30YN

64786 04 M 470.15YN

64787 04 M 124.70N

64788 04 I 139.60 34.00YN

64790 04 M 359.30YN

64792 04 MYY

64795 04 I 112.40YN

64802 04 M 480.00YN

64804 04 M 599.35YN

64809 04 M 749.20YN

64818 04 M 653.40YN

64820 04 MYY

Wednesday, June 18, 2008 Page 253 of 455

Page 261: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

64821 04 M 407.40YN

64822 04 M 407.40YN

64823 04 M 471.00YN

64831 04 M 252.45YN

64832 04 M 139.00YN

64834 04 M 299.70YN

64835 04 M 599.35YN

64836 04 M 599.35YN

64837 04 M 299.70YN

64840 04 M 449.50YN

64856 04 M 449.50YN

64857 04 M 449.50YN

64858 04 M 599.35YN

64859 04 M 229.70YN

64861 04 M 718.70YN

64862 04 M 718.70YN

64864 04 M 599.35YN

64865 04 M 861.50YN

64866 04 M 599.35YN

64868 04 M 599.35YN

64870 04 M 599.35YN

Wednesday, June 18, 2008 Page 254 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

64872 04 M 449.50YN

64874 04 M 749.20YN

64876 04 M 524.40YN

64885 04 M 507.15YN

64886 04 M 600.65YN

64890 04 M 455.90YN

64891 04 M 457.30YN

64892 04 M 557.45YN

64893 04 M 557.45YN

64895 04 M 551.10YN

64896 04 M 619.50YN

64897 04 M 665.50YN

64898 04 M 665.50YN

64901 04 M 316.55YN

64902 04 M 359.70YN

64905 04 MYY

64907 04 MYY

64910 04 1/1/2007 MYY

64911 04 1/1/2007 MYY

64999 04 MYY

65091 04 M 359.30YN

Wednesday, June 18, 2008 Page 255 of 455

Page 263: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

65093 04 M 480.00YN

65101 04 M 359.30YN

65103 04 M 480.00YN

65105 04 M 599.35YN

65110 04 M 898.95YN

65112 04 M 973.90YN

65114 04 M 1048.85YN

65125 04 MYY

65130 04 M 749.20YN

65135 04 M 449.50YN

65140 04 M 599.35YN

65150 04 M 524.40YN

65155 04 M 475.25YN

65175 04 M 236.70YN

65205 04 I 58.15N

65210 04 I 62.60N

65220 04 I 73.50N

65222 04 I 64.60N

65235 04 M 480.00YN

65260 04 M 480.00YN

65265 04 M 480.00YN

Wednesday, June 18, 2008 Page 256 of 455

Page 264: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

65270 04 M 107.00 17.00YN

65272 04 M 142.70 17.00YN

65273 04 M 224.70YN

65275 04 M 359.30YN

65280 04 M 599.35YN

65285 04 M 599.35YN

65286 04 M 359.30YN

65290 04 M 449.50YN

65400 04 M 323.30YN

65410 04 I 51.40 17.00YN

65420 04 M 273.30YN

65426 04 M 348.15YN

65430 04 I 78.50 17.00YN

65435 04 I 48.55YN

65436 04 I 125.25YN

65450 04 I 135.40YN

65600 04 M 240.00YN

65710 04 M 839.25YN

65730 04 M 1317.95YN

65750 04 M 1317.95YN

65755 04 M 1317.95YN

Wednesday, June 18, 2008 Page 257 of 455

Page 265: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

65760 04 M 1560.80YN

65765 04 M 1560.80YN

65767 04 M 1560.80YN

65770 04 MYY

65772 04 M 1252.00YN

65775 04 M 648.10YN

65780 04 M 403.90YN

65781 04 M 617.78YN

65782 04 M 532.61YN

65800 04 M 240.00YN

65805 04 M 299.70YN

65810 04 M 299.70YN

65815 04 M 480.00YN

65820 04 M 599.35YN

65850 04 M 599.35YN

65855 04 M 599.35YN

65860 04 M 299.70YN

65865 04 M 299.70YN

65870 04 M 297.00YN

65875 04 M 324.05YN

65880 04 M 299.70YN

Wednesday, June 18, 2008 Page 258 of 455

Page 266: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

65900 04 M 378.05YN

65920 04 MYY

65930 04 M 480.00YN

66020 04 M 180.30YN

66030 04 M 180.30YN

66130 04 M 273.30YN

66150 04 M 718.70YN

66155 04 M 718.70YN

66160 04 M 718.70YN

66165 04 M 599.35YN

66170 04 M 718.70YN

66172 04 M 810.10YN

66180 04 M 799.70YN

66185 04 M 351.00YN

66220 04 M 550.90YN

66225 04 M 675.10YN

66250 04 MYY

66500 04 M 149.80YN

66505 04 M 240.00YN

66600 04 M 581.30YN

66605 04 M 581.30YN

Wednesday, June 18, 2008 Page 259 of 455

Page 267: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

66625 04 M 581.30YN

66630 04 M 581.30YN

66635 04 M 581.30YN

66680 04 M 471.70YN

66682 04 M 471.70YN

66700 04 M 341.30YN

66710 04 M 341.30YN

66711 04 M 341.30YN

66720 04 M 341.30YN

66740 04 M 569.30YN

66761 04 M 449.50YN

66762 04 M 449.50YN

66770 04 M 374.55YN

66820 04 M 299.70YN

66821 04 M 299.70YN

66825 04 M 299.70YN

66830 04 M 374.55YN

66840 04 M 751.90YN

66850 04 M 751.90YN

66852 04 M 751.90YN

66920 04 M 751.90YN

Wednesday, June 18, 2008 Page 260 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

66930 04 M 751.90YN

66940 04 M 751.90YN

66982 04 M 587.60YN

66983 04 M 1051.60YN

66984 04 M 1051.60YN

66985 04 M 574.75YN

66986 04 M 546.00YN

66990 09 NY

66999 04 MYY

67005 04 M 749.20YN

67010 04 M 749.20YN

67015 04 M 861.50YN

67025 04 M 818.45YN

67027 04 M 524.35YN

67028 04 M 287.10YN

67030 04 M 818.45YN

67031 04 M 818.45YN

67036 04 M 1086.30YN

67039 04 M 1086.30YN

67040 04 M 1086.30YN

67041 04 1/1/2008 M 613.65YN

Wednesday, June 18, 2008 Page 261 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

67042 04 1/1/2008 M 703.00YN

67043 04 1/1/2008 M 737.55YN

67101 04 M 434.30YN

67105 04 M 457.20YN

67107 04 M 980.85YN

67108 04 M 1086.30YN

67110 04 M 434.30YN

67112 04 MYY

67113 04 1/1/2008 M 809.66N

67115 04 M 735.60YN

67120 04 M 958.60YN

67121 04 MYY

67141 04 M 443.95YN

67145 04 M 443.95YN

67208 04 M 443.95YN

67210 04 M 443.95YN

67218 04 M 486.10YN

67220 04 M 443.95YN

67221 04 M 225.30YN

67225 04 I 42.55YN

67227 04 M 443.95YN

Wednesday, June 18, 2008 Page 262 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

67228 04 M 466.15YN

67229 04 1/1/2008 M 532.19YN

67250 04 M 749.20YN

67255 04 M 898.95YN

67299 04 MYY

67311 04 M 511.90YN

67312 04 M 511.90YN

67314 04 M 511.90YN

67316 04 M 511.90YN

67318 04 M 550.90YN

67320 04 M 647.20YN

67331 04 M 374.55YN

67332 04 M 511.90YN

67334 04 M 511.90YN

67335 09 NY

67340 04 M 405.10YN

67343 04 M 399.60YN

67345 04 M 100.00YN

67346 04 1/1/2007 I 107.00YN

67399 04 MYY

67400 04 M 681.10YN

Wednesday, June 18, 2008 Page 263 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

67405 04 M 524.40YN

67412 04 M 839.35YN

67413 04 M 839.35YN

67414 04 M 797.40YN

67415 04 I 56.80 17.00YN

67420 04 M 1079.30YN

67430 04 M 1079.30YN

67440 04 M 681.10YN

67445 04 M 1025.40YN

67450 04 M 681.10YN

67500 04 I 78.20YN

67505 04 M 74.90YN

67515 04 I 74.90YN

67550 04 M 415.85YN

67560 04 M 340.90YN

67570 04 M 797.40YN

67599 04 MYY

67700 04 I 73.50YN

67710 04 M 224.70YN

67715 04 I 59.60YN

67800 04 I 77.20 17.00YN

Wednesday, June 18, 2008 Page 264 of 455

Page 272: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

67801 04 I 91.85 17.00YN

67805 04 M 99.05 17.00YN

67808 04 I 112.80YN

67810 04 I 68.10 17.00YN

67820 04 I 30.50N

67825 04 I 88.50N

67830 04 I 112.60N

67835 04 M 187.30YN

67840 04 I 93.30 17.00YN

67850 04 I 90.20YN

67875 04 M 187.30YN

67880 04 M 187.30YN

67882 04 M 231.50YN

67900 04 M 216.00YN

67901 04 M 685.40YN

67902 04 M 685.40YN

67903 04 M 685.40YN

67904 04 M 685.40YN

67906 04 M 749.20YN

67908 04 M 749.20YN

67909 04 M 749.20YN

Wednesday, June 18, 2008 Page 265 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

67911 04 M 749.20YN

67912 04 M 221.64YN

67914 04 M 359.30YN

67915 04 I 133.90YN

67916 04 M 299.70YN

67917 04 M 359.30YN

67921 04 M 359.30YN

67922 04 I 130.70YN

67923 04 M 299.70YN

67924 04 M 359.30YN

67930 04 M 189.00 17.00YN

67935 04 M 244.50 17.00YN

67938 04 I 80.90 17.00YN

67950 04 M 359.30YN

67961 04 M 324.05YN

67966 04 M 345.70YN

67971 04 M 449.50YN

67973 04 M 449.50YN

67974 04 M 449.50YN

67975 04 M 449.50YN

67999 04 MYY

Wednesday, June 18, 2008 Page 266 of 455

Page 274: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

68020 04 I 72.55 17.00YN

68040 04 I 71.40 17.00YN

68100 04 I 77.60 17.00YN

68110 04 M 180.30YN

68115 04 M 180.30YN

68130 04 M 224.70YN

68135 04 M 224.70YN

68200 04 I 56.60N

68320 04 M 449.50YN

68325 04 M 531.30YN

68326 04 M 531.30YN

68328 04 M 531.30YN

68330 04 M 299.70YN

68335 04 M 524.40YN

68340 04 M 299.70YN

68360 04 M 240.00YN

68362 04 M 359.30YN

68371 04 M 191.25YN

68399 04 MYY

68400 04 I 103.60 17.00YN

68420 04 I 117.70 17.00YN

Wednesday, June 18, 2008 Page 267 of 455

Page 275: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

68440 04 I 66.90 17.00YN

68500 04 M 599.35YN

68505 04 M 336.45YN

68510 04 I 191.40 17.00YN

68520 04 M 599.35YN

68525 04 I 124.50 17.00YN

68530 04 I 174.60 17.00YN

68540 04 M 599.35YN

68550 04 M 648.10YN

68700 04 M 359.30YN

68705 04 I 93.60YN

68720 04 M 839.35YN

68745 04 M 839.35YN

68750 04 M 858.70YN

68760 04 I 84.10YN

68761 04 I 75.50YN

68770 04 MYY

68801 04 I 71.70YN

68810 04 I 103.50YN

68811 04 I 115.10YN

68815 04 I 143.40YN

Wednesday, June 18, 2008 Page 268 of 455

Page 276: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

68816 04 1/1/2008 I 115.00 205.23YN

68840 04 I 83.30YN

68850 04 I 116.35YN

68899 04 MYY

69000 04 I 42.40 17.00YN

69005 04 I 64.10 17.00YN

69020 04 I 44.60 17.00YN

69100 04 I 31.15 17.00YN

69105 04 I 50.20 17.00YN

69110 04 M 209.40YN

69120 04 M 240.00YN

69140 04 M 480.00YN

69145 04 I 90.10YN

69150 04 M 718.70YN

69155 04 M 1198.70N

69200 04 I 26.60N

69205 04 I 74.90YN

69210 04 I 21.40N

69220 04 I 28.50YN

69222 04 I 57.30YN

69300 09 MY

Wednesday, June 18, 2008 Page 269 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

69310 04 M 694.40YN

69320 04 M 958.60YN

69399 04 MYY

69400 04 I 28.15YN

69401 04 I 22.15YN

69405 04 I 115.10YN

69420 04 I 43.80 17.00YN

69421 04 I 56.60YN

69424 04 I 30.35YN

69433 04 I 76.60 34.00YN

69436 04 I 80.50YN

69440 04 M 599.35YN

69450 04 I 191.10YN

69501 04 M 692.20YN

69502 04 M 692.20YN

69505 04 M 749.20YN

69511 04 M 839.35YN

69530 04 M 1198.70YN

69535 04 M 1198.70YN

69540 04 I 50.20 17.00YN

69550 04 I 363.60 17.00YN

Wednesday, June 18, 2008 Page 270 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

69552 04 M 674.20YN

69554 04 M 954.95YN

69601 04 M 695.05YN

69602 04 M 695.05YN

69603 04 M 695.05YN

69604 04 M 695.05YN

69605 04 M 695.05YN

69610 04 MYY

69620 04 MYY

69631 04 M 749.20YN

69632 04 M 749.20YN

69633 04 M 861.50YN

69635 04 M 749.20YN

69636 04 M 749.20YN

69637 04 M 861.50YN

69641 04 M 1048.85YN

69642 04 M 1048.85YN

69643 04 M 1048.85YN

69644 04 M 1048.85YN

69645 04 M 1048.85YN

69646 04 M 1048.85YN

Wednesday, June 18, 2008 Page 271 of 455

Page 279: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

69650 04 M 743.65YN

69660 04 M 749.20YN

69661 04 M 749.20YN

69662 04 M 749.20YN

69666 04 M 749.20YN

69667 04 M 749.20YN

69670 04 M 1079.30YN

69676 04 M 834.50YN

69700 04 M 299.70YN

69710 04 M 918.15YN

69711 04 M 550.90YN

69714 04 M 604.65YN

69715 04 M 765.85YN

69717 04 M 623.25YN

69718 04 M 775.20YN

69720 04 M 749.20YN

69725 04 M 749.20YN

69740 04 M 599.35YN

69745 04 M 947.20YN

69799 04 MYY

69801 04 M 749.20YN

Wednesday, June 18, 2008 Page 272 of 455

Page 280: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

69802 04 M 749.20YN

69805 04 M 749.20YN

69806 04 M 749.20YN

69820 04 M 749.20YN

69840 04 M 749.20YN

69905 04 M 1198.70YN

69910 04 M 1198.70YN

69915 04 M 1198.70YN

69930 04 M 1296.20YN

69949 04 MYY

69950 04 M 1079.30YN

69955 04 M 1079.30YN

69960 04 M 1198.70YN

69970 04 M 1188.20YN

69979 04 MYY

69990 09 NY

70010 04 I 28.70YN

70015 04 I 39.20YN

70030 A 04 N 10.75 10.75 21.50N

70100 A 04 N 11.40 11.40 22.80N

70110 A 04 N 15.65 15.65 31.30N

Wednesday, June 18, 2008 Page 273 of 455

Page 281: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

70120 A 04 N 11.40 11.40 22.80N

70130 A 04 N 15.65 15.65 31.30N

70134 A 04 N 20.25 20.25 40.50N

70140 A 04 N 14.35 14.35 28.70N

70150 A 04 N 17.62 15.62 35.25N

70160 A 04 N 10.47 10.47 20.95N

70170 04 I 18.30N

70190 A 04 N 11.40 11.40 22.80N

70200 A 04 N 17.62 17.62 35.25N

70210 A 04 N 11.10 11.10 22.20N

70220 A 04 N 14.35 14.35 28.70N

70240 A 04 N 11.40 11.40 22.80N

70250 A 04 N 10.75 10.75 21.50N

70260 A 04 N 17.62 17.62 35.25N

70300 A 04 N 5.90 5.90 11.80N

70310 A 04 N 7.17 7.17 14.35N

70320 A 04 N 14.35 14.35 28.70N

70328 A 04 N 14.35 14.35 28.70N

70330 A 04 N 14.35 14.35 28.70N

70332 04 I 23.30N

70336 B 04 N 148.30 148.30 296.60YN

Wednesday, June 18, 2008 Page 274 of 455

Page 282: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

70350 A 04 N 7.17 7.17 14.35N

70355 A 04 N 14.35 14.35 28.70N

70360 A 04 N 7.17 7.17 14.35N

70370 A 04 N 13.07 13.07 26.15N

70371 A 04 N 12.70 12.70 25.40YN

70373 04 I 20.20N

70380 A 04 N 11.10 11.10 22.20N

70390 04 I 22.20YN

70450 B 04 N 123.58 123.58 247.15YN

70460 B 04 N 141.23 141.22 282.45YN

70470 B 04 N 141.22 141.22 282.45YN

70480 B 04 N 31.35 31.35 62.70YN

70481 B 04 N 37.95 37.95 75.90YN

70482 B 04 N 54.92 54.92 109.95YN

70486 B 04 N 31.35 31.35 62.70YN

70487 B 04 N 37.95 37.95 75.90YN

70488 B 04 N 54.92 54.92 109.85YN

70490 B 04 N 31.35 31.35 62.70YN

70491 B 04 N 37.95 37.95 75.90YN

70492 B 04 N 54.92 54.92 109.85YN

70496 B 04 N 123.52 123.52 247.05YN

Wednesday, June 18, 2008 Page 275 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

70498 B 04 N 123.52 123.52 247.05YN

70540 B 04 N 148.30 148.30 296.60YN

70542 B 04 N 148.30 148.30 296.60YN

70543 B 04 N 223.93 223.92 447.85YN

70544 B 04 N 148.30 148.30 296.60YN

70545 B 04 N 148.30 148.30 296.60YN

70546 B 04 N 204.77 204.78 409.55YN

70547 B 04 N 148.30 148.30 296.60YN

70548 B 04 N 148.30 148.30 296.60YN

70549 B 04 N 204.77 204.78 409.55YN

70551 B 04 N 148.30 148.30 296.60YN

70552 B 04 N 148.30 148.30 296.60YN

70553 B 04 N 148.30 148.30 296.60YN

70554 C 04 1/1/2007 N 50.42 246.18 1 296.60YN

70555 04 1/1/2007 N 64.32YN

70557 04 M 79.06YN

70558 04 M 87.53YN

70559 04 N 88.02YN

71010 A 04 N 8.50 8.50 17.00N

71015 A 04 N 10.75 10.75 21.50N

71020 A 04 N 10.75 10.75 21.50N

Wednesday, June 18, 2008 Page 276 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

71021 A 04 N 10.75 10.75 21.50N

71022 A 04 N 10.75 10.75 21.50N

71023 A 04 N 10.75 10.75 21.50N

71030 A 04 N 14.35 14.35 28.70N

71034 A 04 N 14.35 14.35 28.70N

71035 A 04 N 14.35 14.35 28.70N

71040 04 I 32.70YN

71060 04 I 52.30YN

71090 04 I 103.30YN

71100 A 04 N 10.75 10.75 21.50N

71101 A 04 N 12.40 12.40 24.80N

71110 A 04 N 13.07 13.08 26.15N

71111 A 04 N 14.35 14.35 28.70N

71120 A 04 N 10.75 10.75 21.50N

71130 A 04 N 14.35 14.35 28.70N

71250 B 04 N 31.35 31.35 62.70YN

71260 B 04 N 37.95 37.95 75.90YN

71270 B 04 N 54.93 54.92 109.85YN

71275 B 04 N 132.50 132.50 265.00YN

71550 B 04 N 148.30 148.30 296.60YN

71551 B 04 N 148.30 148.30 296.60YN

Wednesday, June 18, 2008 Page 277 of 455

Page 285: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

71552 B 04 N 224.03 224.02 448.05YN

71555 B 04 N 148.30 148.30 296.60YN

72010 A 04 N 35.95 35.95 71.90N

72020 A 04 N 12.07 12.08 24.15N

72040 A 04 N 12.07 12.08 24.15N

72050 A 04 N 17.63 17.62 35.25N

72052 A 04 N 18.25 18.25 36.50N

72069 A 04 N 11.40 11.40 22.80N

72070 A 04 N 11.40 11.40 22.80N

72072 A 04 N 10.47 10.48 20.95N

72074 A 04 N 10.75 10.75 21.50N

72080 A 04 N 12.70 12.70 25.40N

72090 A 04 N 29.45 29.45 58.90N

72100 A 04 N 14.35 14.35 28.70N

72110 A 04 N 18.95 18.95 37.90N

72114 A 04 N 18.95 18.95 37.90N

72120 A 04 N 18.95 18.95 37.90N

72125 B 04 N 31.35 31.35 62.70YN

72126 B 04 N 37.95 37.95 75.90YN

72127 B 04 N 54.93 54.92 109.85YN

72128 B 04 N 31.35 31.35 62.70YN

Wednesday, June 18, 2008 Page 278 of 455

Page 286: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

72129 B 04 N 37.95 37.95 75.90YN

72130 B 04 N 54.93 54.92 109.85YN

72131 B 04 N 31.35 31.35 62.70YN

72132 B 04 N 37.95 37.95 75.90YN

72133 B 04 N 54.93 54.92 109.85YN

72141 B 04 N 148.30 148.30 296.60YN

72142 B 04 N 148.30 148.30 296.60YN

72146 B 04 N 148.30 148.30 296.60YN

72147 B 04 N 148.30 148.30 296.60YN

72148 B 04 N 148.30 148.30 296.60YN

72149 B 04 N 148.30 148.30 296.60YN

72156 B 04 N 148.30 148.30 296.60YN

72157 B 04 N 148.30 148.30 296.60YN

72158 B 04 N 148.30 148.30 296.60YN

72159 B 04 N 148.30 148.30 296.60YN

72170 A 04 N 7.85 7.85 15.70N

72190 A 04 N 17.63 17.62 35.25N

72191 B 04 N 128.30 128.30 256.60YN

72192 B 04 N 31.35 31.35 62.70YN

72193 B 04 N 37.95 37.95 75.90YN

72194 B 04 N 54.93 54.92 109.85YN

Wednesday, June 18, 2008 Page 279 of 455

Page 287: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

72195 B 04 N 148.30 148.30 296.60YN

72196 B 04 N 148.30 148.30 296.60YN

72197 B 04 N 226.15 226.15 452.30YN

72198 B 04 N 148.30 148.30 296.60YN

72200 A 04 N 10.75 10.75 21.50YN

72202 A 04 N 11.40 11.40 22.80YN

72220 A 04 N 10.75 10.75 21.50N

72240 04 I 65.35YN

72255 04 I 52.30YN

72265 04 N 52.30YN

72270 04 N 99.35YN

72275 04 I 57.45YN

72285 04 I 52.30N

72291 04 1/1/2007 I 78.05N

72292 04 1/1/2007 I 62.50N

72295 04 I 45.80N

73000 A 04 N 7.50 7.50 15.00N

73010 A 04 N 10.75 10.75 21.50N

73020 A 04 N 10.75 10.75 21.50N

73030 A 04 N 11.10 11.10 22.20N

73040 C 04 I 6.03 17.47 23.50YN

Wednesday, June 18, 2008 Page 280 of 455

Page 288: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

73050 A 04 N 10.07 10.08 20.15YN

73060 A 04 N 7.85 7.85 15.70N

73070 A 04 N 9.80 9.80 19.60N

73080 A 04 N 10.75 10.75 21.50N

73085 04 I 22.20YN

73090 A 04 N 9.15 9.15 18.30N

73092 A 04 N 7.17 7.18 14.35N

73100 A 04 N 10.75 10.75 21.50N

73110 A 04 N 11.10 11.10 22.20N

73115 04 I 30.10YN

73120 A 04 N 8.50 8.50 17.00N

73130 A 04 N 9.15 9.15 18.30N

73140 A 04 N 7.17 7.18 14.35N

73200 B 04 N 31.35 31.35 62.70YN

73201 B 04 N 37.95 37.95 75.90YN

73202 B 04 N 54.93 54.92 109.85YN

73206 B 04 N 115.55 115.55 231.10YN

73218 B 04 N 148.30 148.30 296.60YN

73219 B 04 N 148.30 148.30 296.60YN

73220 B 04 N 148.30 148.30 296.60YN

73221 B 04 N 148.30 148.30 296.60YN

Wednesday, June 18, 2008 Page 281 of 455

Page 289: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

73222 B 04 N 148.30 148.30 296.60YN

73223 B 04 N 223.92 223.92 447.85YN

73225 B 04 N 148.30 148.30 296.60YN

73500 A 04 N 10.75 10.75 21.50N

73510 A 04 N 14.35 14.35 28.70N

73520 A 04 N 19.60 19.60 39.20N

73525 C 04 I 14.02 38.28 52.30YN

73530 A 04 N 24.85 24.85 49.70N

73540 A 04 N 17.00 17.00 34.00N

73542 04 I 120.90YN

73550 A 04 N 10.75 10.75 21.50N

73560 A 04 N 9.80 9.80 19.60N

73562 A 04 N 10.10 10.10 20.20N

73564 A 04 N 11.10 11.10 22.20N

73565 A 04 N 16.70 16.70 33.40N

73580 04 I 37.90YN

73590 A 04 N 10.75 10.75 21.50N

73592 A 04 N 10.75 10.75 21.50N

73600 A 04 N 10.75 10.75 21.50N

73610 A 04 N 14.35 14.35 28.70N

73615 04 I 26.15N

Wednesday, June 18, 2008 Page 282 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

73620 A 04 N 8.50 8.50 17.00N

73630 A 04 N 10.75 10.75 21.50N

73650 A 04 N 8.50 8.50 17.00N

73660 A 04 N 7.17 7.17 14.35N

73700 B 04 N 31.35 31.35 62.70YN

73701 B 04 N 37.95 37.95 75.90YN

73702 B 04 N 54.92 54.92 109.85YN

73706 B 04 N 115.55 115.55 231.10YN

73718 B 04 N 148.30 148.30 296.60YN

73719 B 04 N 148.30 148.30 296.60YN

73720 B 04 N 148.30 148.30 296.60YN

73721 B 04 N 148.30 148.30 296.60YN

73722 B 04 N 148.30 148.30 296.60YN

73723 B 04 N 223.92 223.92 447.85YN

73725 B 04 N 148.30 148.30 296.60YN

74000 A 04 N 10.75 10.75 21.50N

74010 A 04 N 12.70 12.70 25.40N

74020 A 04 N 12.70 12.70 25.40N

74022 A 04 N 20.95 20.95 41.90N

74150 B 04 N 31.35 31.35 62.70YN

74160 B 04 N 37.95 37.95 75.90YN

Wednesday, June 18, 2008 Page 283 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

74170 B 04 N 54.92 54.92 109.85YN

74175 B 04 N 128.32 128.32 256.65YN

74181 B 04 N 148.30 148.30 296.60YN

74182 B 04 N 148.30 148.30 296.60YN

74183 B 04 N 226.15 226.15 452.30YN

74185 B 04 N 148.30 148.30 296.60YN

74190 04 I 21.50YN

74210 A 04 N 14.35 14.35 28.70N

74220 A 04 N 14.35 14.35 28.70N

74230 A 04 N 12.70 12.70 25.40N

74235 04 I 122.40YN

74240 B 04 N 24.85 24.85 49.70N

74241 B 04 N 25.50 25.50 51.00N

74245 B 04 N 32.02 32.02 64.05N

74246 B 04 N 26.15 26.15 52.30N

74247 B 04 N 26.80 26.80 53.60N

74249 B 04 N 32.02 32.02 64.05N

74250 B 04 N 21.57 21.57 43.15N

74251 B 04 N 29.45 29.45 58.90N

74260 B 04 N 18.25 18.25 36.50N

74270 B 04 N 24.85 24.85 49.70N

Wednesday, June 18, 2008 Page 284 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

74280 B 04 N 29.45 29.45 58.90N

74283 B 04 N 29.45 29.45 58.90N

74290 B 04 N 17.62 17.62 35.25YN

74291 B 04 N 17.62 17.62 35.25YN

74300 04 I 35.25YN

74301 04 IY

74305 04 I 35.25YN

74320 04 I 57.55YN

74327 04 I 168.65YN

74328 04 I 64.05YN

74329 04 I 92.80YN

74330 04 I 100.65YN

74340 04 I 51.00YN

74355 04 I 118.60YN

74360 04 I 44.90YN

74363 04 I 170.00YN

74400 B 04 N 24.85 24.85 49.70YN

74410 B 04 N 28.77 28.77 57.55YN

74415 B 04 N 28.77 28.77 57.55YN

74420 B 04 N 14.35 14.35 28.70YN

74425 04 I 28.70YN

Wednesday, June 18, 2008 Page 285 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

74430 04 I 23.50YN

74440 04 I 32.70YN

74445 04 I 28.70YN

74450 04 I 26.15YN

74455 04 I 26.15YN

74470 04 I 18.30YN

74475 04 I 14.35YN

74480 04 I 71.90YN

74485 04 I 28.50YN

74710 B 04 N 22.90 22.90 45.80YN

74740 C 04 I 10.65 28.55 39.20YN

74742 04 I 39.20YN

74775 04 N 71.20YN

75557 C 04 1/1/2008 N 68.87 230.81 299.68YY

75558 04 1/1/2008 NYY

75559 C 04 1/1/2008 N 87.60 344.24 431.84YY

75560 04 1/1/2008 NYY

75561 C 04 1/1/2008 N 76.18 325.65 401.83YN

75562 04 1/1/2008 NYY

75563 C 04 1/1/2008 N 90.99 404.09 495.08YY

75564 04 1/1/2008 NYY

Wednesday, June 18, 2008 Page 286 of 455

Page 294: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

75600 04 I 109.85YN

75605 04 I 77.20YN

75625 04 I 98.10YN

75630 04 I 130.80YN

75635 C 04 I 51.14 230.26 281.40YN

75650 04 I 163.40YN

75658 04 I 78.45YN

75660 04 I 84.90YN

75662 04 I 130.80YN

75665 04 I 98.10YN

75671 04 I 130.80YN

75676 04 I 78.45YN

75680 04 I 104.60YN

75685 04 I 78.45YN

75705 04 I 98.10YN

75710 04 I 78.45YN

75716 04 I 111.10YN

75722 04 I 78.45YN

75724 04 I 111.10YN

75726 04 I 91.45YN

75731 04 I 91.45YN

Wednesday, June 18, 2008 Page 287 of 455

Page 295: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

75733 04 I 115.10YN

75736 04 I 91.45YN

75741 04 I 91.45YN

75743 04 I 117.60YN

75746 04 I 65.35YN

75756 04 I 39.20YN

75774 04 I 25.10YN

75790 04 I 84.90YN

75801 04 I 35.25YN

75803 04 I 75.90YN

75805 04 I 77.20YN

75807 04 I 91.45YN

75809 04 I 77.20YN

75810 04 I 91.45YN

75820 04 I 45.80YN

75822 04 I 65.35YN

75825 04 I 78.45YN

75827 04 I 100.65YN

75831 04 I 91.45YN

75833 04 I 111.10YN

75840 04 I 57.55YN

Wednesday, June 18, 2008 Page 288 of 455

Page 296: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

75842 04 I 91.45YN

75860 04 I 78.45YN

75870 04 I 52.30YN

75872 04 I 130.80YN

75880 04 I 28.70YN

75885 04 I 64.30YN

75887 04 I 54.60YN

75889 04 I 128.20YN

75891 04 I 93.40YN

75893 04 I 98.10N

75894 04 I 64.05YN

75896 04 I 64.05YN

75898 04 I 56.20YN

75900 04 I 201.20YN

75901 04 I 66.60YN

75902 04 I 66.60YN

75940 04 I 66.60YN

75945 04 I 64.05YN

75946 04 I 49.40YN

75952 04 I 162.85YN

75953 04 I 68.30YN

Wednesday, June 18, 2008 Page 289 of 455

Page 297: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

75954 04 I 83.00YN

75956 04 M 221.10N

75957 04 M 189.42N

75958 04 M 126.26N

75959 04 M 110.52N

75960 04 I 83.00YN

75961 04 I 62.15YN

75962 04 I 83.00YN

75964 04 I 83.00YN

75966 04 I 83.00YN

75968 04 I 83.00YN

75970 04 I 78.90YN

75978 04 I 65.35YN

75980 04 I 83.00YN

75982 04 I 41.90YN

75984 04 I 53.60YN

75989 04 I 84.90YN

75992 04 I 83.00YN

75993 04 IYY

75994 04 I 83.00YN

75995 04 I 83.00YN

Wednesday, June 18, 2008 Page 290 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

75996 04 IYY

76000 04 I 32.70N

76001 04 I 56.45N

76010 A 04 N 16.20 16.20 32.40N

76080 04 I 26.15N

76098 A 04 N 6.20 6.20 12.40N

76100 A 04 N 24.85 24.85 49.70N

76101 A 04 N 17.62 17.62 35.25N

76102 A 04 N 24.85 24.85 49.70N

76120 A 04 N 10.47 10.47 20.95N

76125 A 04 N 24.85 24.85 49.70N

76140 04 N 19.60N

76150 B 04 NY

76350 B 04 NY

76376 C 04 I 6.18 66.99 1 73.17YN

76377 C 04 I 24.33 72.94 1 97.27YN

76380 04 N 59.55YN

76390 B 04 I 148.30 148.30 296.60YN

76496 A 04 IYY

76497 B 04 IYY

76498 B 04 IYY

Wednesday, June 18, 2008 Page 291 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

76499 04 NY

76506 B 04 N 32.02 32.02 64.05YN

76510 A 04 N 32.67 32.67 65.35N

76511 A 04 N 24.85 24.85 49.70YN

76512 A 04 N 32.67 32.67 65.35YN

76513 A 04 N 32.67 32.67 65.35YN

76514 C 04 N 5.20 1.37 1 6.57YN

76516 A 04 N 24.85 24.85 49.70YN

76519 A 04 N 24.90 24.90 49.80YN

76529 A 04 N 32.67 32.67 65.35YN

76536 B 04 N 34.00 34.00 68.00YN

76604 B 04 N 31.35 31.35 62.70YN

76645 B 04 N 31.35 31.35 62.70YN

76700 B 04 N 37.95 37.95 75.90YN

76705 B 04 N 31.35 31.35 62.70YN

76770 B 04 N 37.95 37.95 75.90YN

76775 B 04 N 31.35 31.35 62.70YN

76776 C 04 1/1/2007 N 53.13 22.77 1 75.90YN

76800 B 04 N 37.95 37.95 75.90YN

76801 B 04 N 35.95 35.95 71.90YN

76802 B 04 N 22.52 22.52 45.05YN

Wednesday, June 18, 2008 Page 292 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

76805 B 04 N 35.95 35.95 71.90YN

76810 B 04 N 22.52 22.52 45.05YN

76811 B 04 N 35.95 35.95 71.90YN

76812 B 04 N 22.52 22.52 45.05YN

76813 C 04 1/1/2007 N 32.36 39.54 1 71.90YN

76814 C 04 1/1/2007 N 25.23 19.82 1 45.05YN

76815 B 04 N 35.95 35.95 71.90YN

76816 B 04 N 35.95 35.95 71.90YN

76817 B 04 N 35.95 35.95 71.90YN

76818 B 04 N 31.97 31.97 63.95YN

76819 B 04 N 15.55 15.55 31.10YN

76820 B 04 N 35.95 35.95 71.90YN

76821 B 04 N 35.95 35.95 71.90YN

76825 B 04 N 35.95 35.95 71.90YN

76826 B 04 N 35.95 35.95 71.90YN

76827 B 04 N 35.95 35.95 71.90YN

76828 B 04 N 35.95 35.95 71.90YN

76830 B 04 N 35.95 35.95 71.90YN

76831 B 04 N 35.95 35.90 71.90YN

76856 B 04 N 35.95 35.95 71.90YN

76857 B 04 N 35.95 35.95 71.90YN

Wednesday, June 18, 2008 Page 293 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

76870 B 04 N 24.85 24.85 49.70YN

76872 B 04 N 35.95 35.95 71.90YN

76873 B 04 N 71.35 71.35 142.70YN

76880 B 04 N 24.85 24.85 49.70YN

76885 B 04 N 35.95 35.95 71.90YN

76886 B 04 N 35.95 35.95 71.90YN

76930 04 I 56.20YN

76932 04 I 65.35YN

76936 04 I 56.20YN

76937 C 04 I 9.21 9.60 1 18.81YN

76940 C 04 I 55.84 35.48 1 91.32YN

76941 04 I 56.20YN

76942 04 I 60.10YN

76945 04 I 49.70YN

76946 04 I 51.00YN

76950 B 04 N 31.35 31.35 62.70YN

76965 B 04 N 24.85 24.85 49.70YN

76970 A 04 NYY

76975 04 I 51.00YN

76977 B 04 N 17.25 17.25 34.50YN

76998 04 1/1/2007 N 33.37YN

Wednesday, June 18, 2008 Page 294 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

76999 04 NY

77001 C 04 1/1/2007 N 8.75 29.29 1 38.04N

77002 C 04 1/1/2007 N 13.27 24.63 1 37.90N

77003 C 04 1/1/2007 N 20.40 31.90 1 52.30N

77011 C 04 1/1/2007 N 7.31 48.89 1 56.20YN

77012 C 04 1/1/2007 N 10.12 46.08 1 56.20N

77013 04 N 233.70YN

77014 C 04 1/1/2007 N 14.05 42.15 1 56.20YN

77021 C 04 1/1/2007 N 53.61 281.44 1 335.05N

77022 C 04 1/1/2007 N 53.61 281.44 1 335.05YN

77031 C 04 1/1/2007 N 26.08 9.17 1 35.25N

77032 C 04 1/1/2007 N 13.75 21.50 1 35.25N

77051 C 04 1/1/2007 N 1.89 8.07 1 9.96N

77052 C 04 1/1/2007 N 1.89 8.07 1 9.96N

77053 C 04 1/1/2007 N 9.18 41.82 1 51.00N

77054 C 04 1/1/2007 N 11.44 60.06 1 71.50N

77055 C 04 1/1/2007 N 17.64 21.56 1 39.20N

77056 C 04 1/1/2007 N 31.64 40.26 1 71.90N

77057 C 04 1/1/2007 N 30.20 41.70 1 71.90N

77058 C 04 1/1/2007 N 29.66 266.94 1 296.60YN

77059 C 04 1/1/2007 N 23.73 272.87 1 296.60YN

Wednesday, June 18, 2008 Page 295 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

77071 04 1/1/2007 N 15.53N

77072 C 04 1/1/2007 N 8.81 12.69 1 21.50N

77073 C 04 1/1/2007 N 9.18 19.52 1 28.70N

77074 C 04 1/1/2007 N 20.72 36.83 1 57.55N

77075 C 04 1/1/2007 N 30.41 67.69 1 98.10N

77076 C 04 1/1/2007 N 16.92 18.33 1 35.25N

77077 C 04 1/1/2007 N 12.57 29.33 1 41.90YN

77078 C 04 1/1/2007 N 3.20 32.40 1 35.60YN

77079 C 04 1/1/2007 N 3.92 31.68 1 35.60YN

77080 C 04 1/1/2007 N 9.81 88.29 1 98.10YN

77081 C 04 1/1/2007 N 28.45 69.65 1 98.10YN

77082 C 04 1/1/2007 N 24.53 73.57 1 98.10YN

77083 C 04 1/1/2007 N 30.10 73.70 1 103.80YN

77084 C 04 1/1/2007 N 48.83 238.43 1 287.26YN

77261 09 NY

77262 09 NY

77263 09 IY

77280 09 NY

77285 09 NY

77290 09 NY

77295 09 NY

Wednesday, June 18, 2008 Page 296 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

77299 09 NY

77300 09 NY

77301 09 NY

77305 09 NY

77310 09 NY

77315 09 NY

77321 09 NY

77326 09 NY

77327 09 NY

77328 09 NY

77331 09 NY

77332 09 NY

77333 09 NY

77334 09 NY

77336 09 NY

77370 09 NY

77371 04 1/1/2007 N 574.13YN

77372 04 1/1/2007 N 435.96YN

77373 04 1/1/2007 N 812.27YN

77399 09 N 1Y

77401 B 04 N 12.07 12.07 24.15YN

Wednesday, June 18, 2008 Page 297 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

77402 B 04 N 12.07 12.07 24.15YN

77403 B 04 N 13.00 13.00 26.00YN

77404 B 04 N 13.85 13.85 27.70YN

77406 B 04 N 15.05 15.05 30.10YN

77407 B 04 N 19.47 19.47 38.95YN

77408 B 04 N 21.00 21.00 42.00YN

77409 B 04 N 22.90 22.90 45.80YN

77411 B 04 N 23.70 23.70 47.40YN

77412 B 04 N 21.00 21.00 42.00YN

77413 B 04 N 21.80 21.80 43.60YN

77414 B 04 N 22.90 22.90 45.80YN

77416 B 04 N 24.55 24.55 49.10YN

77417 09 NY

77418 B 04 N 123.25 123.25 246.50YN

77421 C 04 I 11.99 69.33 81.32YN

77422 04 I 35.73YN

77423 04 I 46.14YN

77427 04 N 70.85N

77431 04 N 35.65N

77432 04 I 254.60N

77435 04 1/1/2007 N 350.19N

Wednesday, June 18, 2008 Page 298 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

77470 04 N 240.10N

77499 04 NY

77520 B 04 N 35.42 35.42 70.85YN

77522 04 NYY

77523 B 04 N 44.87 44.87 89.75YN

77525 04 NYY

77600 04 N 21.30YN

77605 04 N 28.45YN

77610 04 N 58.80YN

77615 B 04 N 35.30 35.30 70.60YN

77620 04 N 74.10YN

77750 04 N 141.30YN

77761 04 I 256.30YN

77762 04 I 256.30YN

77763 04 I 256.30YN

77776 04 I 156.85YN

77777 04 I 183.10YN

77778 04 I 209.25YN

77781 04 NYY

77782 04 NYY

77783 04 NYY

Wednesday, June 18, 2008 Page 299 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

77784 04 NYY

77789 04 N 96.70YN

77790 04 NY

77799 04 NY

78000 B 04 N 10.75 10.75 21.50YN

78001 B 04 N 14.35 14.35 28.70YN

78003 B 04 N 15.05 15.05 30.10YN

78006 B 04 N 32.67 32.67 65.35YN

78007 B 04 N 32.67 32.67 65.35YN

78010 B 04 N 32.67 32.67 65.35YN

78011 B 04 N 35.30 35.30 70.60YN

78015 B 04 N 39.22 39.22 78.45YN

78016 B 04 N 49.05 49.05 98.10YN

78018 04 N 84.90YN

78020 04 N 78.45YN

78070 B 04 N 29.45 29.45 58.90YN

78075 B 04 N 32.67 32.67 65.35YN

78099 04 NYY

78102 B 04 N 42.45 42.45 84.90YN

78103 B 04 N 58.80 58.80 117.60YN

78104 B 04 N 58.80 58.80 117.60YN

Wednesday, June 18, 2008 Page 300 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

78110 B 04 N 10.47 10.47 20.95YN

78111 B 04 N 16.35 16.35 32.70YN

78120 B 04 N 16.35 16.35 32.70YN

78121 B 04 N 28.77 28.77 57.55YN

78122 A 04 N 28.77 28.77 57.55YN

78130 B 04 N 32.67 32.67 65.35YN

78135 B 04 N 39.22 39.22 78.45YN

78140 B 04 N 21.57 21.57 43.15YN

78185 B 04 N 49.05 49.05 98.10YN

78190 04 NYY

78191 04 N 18.65YN

78195 B 04 N 49.05 49.05 98.10YN

78199 04 NYY

78201 B 04 N 65.40 65.40 130.80YN

78202 B 04 N 65.40 65.40 130.80YN

78205 B 04 N 65.40 65.40 130.80YN

78206 B 04 N 65.40 65.40 130.80YN

78215 B 04 N 65.40 65.40 130.80YN

78216 B 04 N 65.40 65.40 130.80YN

78220 B 04 N 32.67 32.67 65.35YN

78223 B 04 N 35.30 35.30 70.60YN

Wednesday, June 18, 2008 Page 301 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

78230 B 04 N 16.35 16.35 32.70YN

78231 04 N 28.70YN

78232 04 N 14.25YN

78258 B 04 N 35.30 35.30 70.60YN

78261 04 N 28.70YN

78262 04 N 28.70YN

78264 04 N 41.90YN

78267 04 NYY

78268 B 04 N 30.58 30.58 61.17YN

78270 B 04 N 16.35 16.35 32.70YN

78271 B 04 N 16.35 16.35 32.70YN

78272 B 04 N 16.35 16.35 32.70YN

78278 C 04 N 9.64 32.26 41.90YN

78282 B 04 N 22.90 22.90 45.80YN

78290 B 04 N 49.05 49.05 98.10YN

78291 B 04 N 12.45 12.45 24.90YN

78299 04 NYY

78300 B 04 N 39.22 39.22 78.45YN

78305 B 04 N 58.80 58.80 117.60YN

78306 B 04 N 58.80 58.80 117.60YN

78315 B 04 N 17.62 17.62 35.25YN

Wednesday, June 18, 2008 Page 302 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

78320 B 04 N 33.67 33.67 67.35YN

78350 B 04 N 62.25 62.25 124.50YN

78351 B 04 N 74.75 74.75 149.50YN

78399 04 NYY

78414 04 N 49.70YN

78428 04 N 49.70YN

78445 B 04 N 24.85 24.85 49.70YN

78456 B 04 N 70.85 70.85 141.70YN

78457 04 N 60.10YN

78458 04 N 84.90YN

78459 B 04 N 65.40 65.40 130.80YN

78460 B 04 N 24.85 24.85 49.70YN

78461 B 04 N 32.67 32.67 65.35YN

78464 B 04 N 65.40 65.40 130.80YN

78465 B 04 N 65.40 65.40 130.80YN

78466 B 04 N 24.85 24.85 49.70YN

78468 B 04 N 24.85 24.85 49.70YN

78469 B 04 N 65.40 65.40 130.80YN

78472 B 04 N 32.67 32.67 65.35YN

78473 B 04 N 37.20 37.20 74.40YN

78478 B 04 N 23.60 23.60 47.20YN

Wednesday, June 18, 2008 Page 303 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

78480 B 04 N 23.60 23.60 47.20YN

78481 B 04 N 24.85 24.85 49.70YN

78483 B 04 N 31.07 31.07 62.15YN

78491 B 04 I 65.40 65.40 130.80YN

78492 B 04 I 65.40 65.40 130.80YN

78494 B 04 N 31.07 31.07 62.15YN

78496 B 04 N 31.07 31.07 62.15YN

78499 04 NYY

78580 B 04 N 32.67 32.67 65.35YN

78584 B 04 N 35.30 35.30 70.60YN

78585 B 04 N 35.30 35.30 70.60YN

78586 B 04 N 32.67 32.67 65.35YN

78587 B 04 N 32.67 32.67 65.35YN

78588 B 04 N 32.67 32.67 65.35YN

78591 B 04 N 32.67 32.67 65.35YN

78593 B 04 N 32.67 32.67 65.35YN

78594 B 04 N 35.95 35.95 71.90YN

78596 B 04 N 35.95 35.95 71.90YN

78599 A 04 NYY

78600 B 04 N 49.05 49.05 98.10YN

78601 B 04 N 65.40 65.40 130.80YN

Wednesday, June 18, 2008 Page 304 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

78605 B 04 N 49.05 49.05 98.10YN

78606 B 04 N 65.40 65.40 130.80YN

78607 B 04 N 65.40 65.40 130.80YN

78608 B 04 N 65.40 65.40 130.80YN

78609 B 04 N 65.40 65.40 130.80YN

78610 B 04 N 65.40 65.40 130.80YN

78630 B 04 N 49.05 49.05 98.10YN

78635 B 04 N 49.05 49.05 98.10YN

78645 B 04 N 20.95 20.95 41.90YN

78647 B 04 N 24.85 24.85 49.70YN

78650 B 04 N 20.95 20.95 41.90YN

78660 B 04 N 16.35 16.35 32.70YN

78699 04 NYY

78700 B 04 N 39.22 39.22 78.45YN

78701 B 04 N 39.22 39.22 78.45YN

78707 B 04 N 42.45 42.45 84.90YN

78708 B 04 N 47.20 47.20 94.40YN

78709 B 04 N 47.20 47.20 94.40YN

78710 B 04 N 39.22 39.22 78.45YN

78725 B 04 N 39.22 39.22 78.45YN

78730 04 N 28.70YN

Wednesday, June 18, 2008 Page 305 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

78740 B 04 N 17.62 17.62 35.25YN

78761 B 04 N 24.85 24.85 49.70YN

78799 04 NYY

78800 B 04 N 32.02 32.02 64.05YN

78801 B 04 N 35.95 35.95 71.90YN

78802 B 04 N 42.45 42.45 84.90YN

78803 B 04 N 32.02 32.02 64.05YN

78804 C 04 N 29.65 86.89 116.54YN

78805 B 04 N 32.02 32.02 64.05YN

78806 B 04 N 42.45 42.45 84.90YN

78807 B 04 N 32.02 32.02 64.05YN

78811 B 04 N 65.40 65.40 130.80YN

78812 B 04 N 65.40 65.40 130.80YN

78813 B 04 N 65.40 65.40 130.80YN

78814 B 04 N 65.40 65.40 130.80YN

78815 B 04 N 65.40 65.40 130.80YN

78816 B 04 N 65.40 65.40 130.80YN

78890 B 04 N 10.47 10.47 20.95N

78891 B 04 N 10.47 10.47 20.95YN

78999 04 NYY

79005 04 N 52.50YN

Wednesday, June 18, 2008 Page 306 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

79101 04 N 57.30YN

79200 C 04 N 61.51 56.11 117.62YN

79300 B 04 N 70.60 70.60 141.20YN

79403 C 04 N 65.05 82.93 147.98YN

79440 B 04 N 52.95 52.95 105.90YN

79445 04 NYY

79999 04 NYY

80047 04 1/1/2008 N 18.31N

80048 B 04 N 5.52 5.52 11.05N

80051 A 04 N 4.57 4.57 9.15N

80053 B 04 N 6.90 6.90 13.80N

80055 B 04 N 20.95 20.95 41.90N

80061 B 04 N 4.15 4.15 8.30N

80069 B 04 N 5.67 5.67 11.35N

80074 B 04 N 25.65 25.65 51.30N

80076 B 04 N 5.32 5.32 10.65N

80100 09 NY

80101 B 04 N 8.95 8.95 17.90N

80102 09 NY

80103 A 09 NY

80150 A 04 N 3.60 3.60 7.20N

Wednesday, June 18, 2008 Page 307 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

80152 A 04 N 7.00 7.00 14.00N

80154 A 04 N 5.00 5.00 10.00N

80156 A 04 N 5.90 5.90 11.80N

80157 A 04 N 5.20 5.20 10.40N

80158 A 04 N 8.42 8.42 16.85N

80160 A 04 N 5.27 5.27 10.55N

80162 A 04 N 8.65 8.65 17.30N

80164 A 04 N 5.90 5.90 11.80N

80166 A 04 N 8.95 8.95 17.90N

80168 A 04 N 7.55 7.55 15.10N

80170 A 04 N 3.92 3.92 7.85N

80172 A 04 N 6.42 6.42 12.85N

80173 A 04 N 7.60 7.60 15.20N

80174 A 04 N 7.00 7.00 14.00N

80176 A 04 N 1.15 1.15 2.30N

80178 A 04 N 4.30 4.30 8.60N

80182 A 04 N 5.90 5.90 11.80N

80184 A 04 N 5.90 5.90 11.80N

80185 A 04 N 8.65 8.65 17.30N

80186 A 04 N 9.00 9.00 18.00N

80188 A 04 N 7.30 7.30 14.60N

Wednesday, June 18, 2008 Page 308 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

80190 A 04 N 6.15 6.15 12.30N

80192 A 04 N 6.15 6.15 12.30N

80194 A 04 N 7.00 7.00 14.00N

80195 04 N 11.50N

80196 A 04 N 3.60 3.60 7.20N

80197 A 04 N 7.00 7.00 14.00N

80198 A 04 N 6.15 6.15 12.30N

80200 A 04 N 5.85 5.85 11.70N

80201 A 04 N 7.55 7.55 15.10N

80202 A 04 N 8.85 8.85 17.70N

80299 A 04 NY

80400 B 04 N 17.97 17.97 35.95N

80402 B 04 N 29.72 29.72 59.45N

80406 B 04 N 30.30 30.30 60.60N

80408 B 04 N 81.90 81.90 163.80N

80410 B 04 N 16.80 16.80 33.60N

80412 B 04 N 107.85 107.85 215.70N

80414 B 04 N 33.70 33.70 67.40N

80415 B 04 N 13.60 13.60 27.20N

80416 B 04 N 86.15 86.15 172.30N

80417 B 04 N 28.72 28.72 57.45N

Wednesday, June 18, 2008 Page 309 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

80418 B 04 NY

80420 B 04 N 39.35 39.35 78.70N

80422 B 04 N 26.65 26.65 53.30N

80424 B 04 N 20.20 20.20 40.40N

80426 B 04 N 80.15 80.15 160.30N

80428 B 04 N 23.52 23.52 47.05N

80430 B 04 N 32.52 32.52 65.05N

80432 B 04 N 63.62 63.62 127.25N

80434 B 04 N 59.95 59.95 119.90N

80435 B 04 N 44.40 44.40 88.80N

80436 B 04 N 38.70 38.70 77.40N

80438 B 04 N 32.90 32.90 65.80N

80439 B 04 N 43.85 43.85 87.70N

80440 B 04 N 26.97 26.97 53.95N

80500 04 N 12.40N

80502 04 N 49.80N

81000 A 04 N 1.75 1.75 3.50N

81001 A 04 N 1.90 1.90 3.80N

81002 A 04 N 1.30 1.30 2.60N

81003 A 04 N 1.45 1.45 2.90N

81005 A 04 N 1.15 1.15 2.30N

Wednesday, June 18, 2008 Page 310 of 455

Page 318: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

81007 A 04 N 1.67 1.67 3.35N

81015 A 04 N 1.75 1.75 3.50N

81020 A 04 N 1.85 1.85 3.70N

81025 A 04 N 1.72 1.72 3.45N

81050 A 04 N 1.70 1.70 3.40N

81099 A 04 NY

82000 A 04 N 5.27 5.27 10.55N

82003 A 04 N 5.27 5.27 10.55N

82009 A 04 N 1.15 1.15 2.30N

82010 A 04 N 1.15 1.15 2.30N

82013 A 04 N 3.60 3.60 7.20N

82016 A 04 N 3.40 3.40 6.80N

82017 A 04 N 7.75 7.75 15.50N

82024 A 04 N 8.95 8.95 17.90N

82030 B 04 N 5.90 5.90 11.80N

82040 A 04 N 3.00 3.00 6.00N

82042 A 04 N 3.00 3.00 6.00N

82043 A 04 N 2.62 2.62 5.25N

82044 A 04 N 2.62 2.62 5.25N

82045 A 04 NY

82055 A 04 N 5.75 5.75 11.50N

Wednesday, June 18, 2008 Page 311 of 455

Page 319: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82075 A 04 N 3.35 3.35 6.70N

82085 B 04 N 4.20 4.20 8.40N

82088 A 04 N 26.60 26.60 53.20N

82101 A 04 N 11.80 11.80 23.60N

82103 B 04 N 5.90 5.90 11.80N

82104 B 04 N 4.77 4.77 9.55N

82105 B 04 N 10.95 10.95 21.90N

82106 B 04 N 4.15 4.15 8.30N

82107 B 04 N 19.62 19.62 39.24N

82108 A 04 N 3.35 3.35 6.70N

82120 A 04 N 2.45 2.45 4.90N

82127 A 04 N 3.40 3.40 6.80N

82128 A 04 N 3.40 3.40 6.80N

82131 A 04 N 7.75 7.75 15.50N

82135 B 04 N 5.90 5.90 11.80N

82136 A 04 N 7.75 7.75 15.50N

82139 A 04 N 7.75 7.75 15.50N

82140 A 04 N 4.77 4.77 9.55N

82143 A 04 N 4.47 4.77 8.95N

82145 A 04 N 7.00 7.00 14.00N

82150 A 04 N 4.25 4.25 8.50N

Wednesday, June 18, 2008 Page 312 of 455

Page 320: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82154 B 04 N 11.20 11.20 22.40N

82157 B 04 N 11.20 11.20 22.40N

82160 A 04 N 3.60 3.60 7.20N

82163 B 04 N 5.00 5.00 10.00N

82164 B 04 N 4.77 4.77 9.55N

82172 A 04 N 8.00 8.00 16.00N

82175 A 04 N 5.90 5.90 11.80N

82180 B 04 N 3.35 3.35 6.70N

82190 A 04 N 9.75 9.75 19.50N

82205 A 04 N 5.90 5.90 11.80N

82232 A 04 N 5.27 5.27 10.55N

82239 B 04 N 11.17 11.17 22.35N

82240 B 04 N 8.50 8.50 17.00N

82247 A 04 N 3.10 3.10 6.20N

82248 A 04 N 3.10 3.10 6.20N

82252 A 04 N 1.75 1.75 3.50N

82261 B 04 N 11.00 11.00 22.00N

82270 A 04 N 1.65 1.65 3.30N

82271 A 04 N 1.36 1.36 2.72N

82272 A 04 N 1.36 1.36 2.72N

82274 A 04 N 6.66 6.66 13.33N

Wednesday, June 18, 2008 Page 313 of 455

Page 321: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82286 A 04 N 2.67 2.67 5.35N

82300 A 04 N 4.45 4.45 8.90N

82306 04 N 11.80N

82307 04 N 23.60N

82308 A 04 N 4.20 4.20 8.40N

82310 A 04 N 3.10 3.10 6.20N

82330 A 04 N 8.90 8.90 17.80N

82331 A 04 N 2.77 2.77 5.55N

82340 A 04 N 3.60 3.60 7.20N

82355 A 04 N 3.10 3.10 6.20N

82360 A 04 N 6.05 6.05 12.10N

82365 A 04 N 3.10 3.10 6.20N

82370 A 04 N 3.10 3.10 6.20N

82373 A 04 N 3.75 3.75 7.50N

82374 A 04 N 3.20 3.20 6.40N

82375 A 04 N 3.10 3.10 6.20N

82376 A 04 N 3.10 3.10 6.20N

82378 B 04 N 8.95 8.95 17.90N

82379 A 04 N 7.75 7.75 15.50N

82380 A 04 N 3.10 3.10 6.20N

82382 B 04 N 10.10 10.10 20.20N

Wednesday, June 18, 2008 Page 314 of 455

Page 322: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82383 B 04 N 10.10 10.10 20.20N

82384 B 04 N 10.10 10.10 20.20N

82387 B 04 N 7.65 7.65 15.30N

82390 B 04 N 5.90 5.90 11.80N

82397 A 04 N 9.22 9.22 18.45N

82415 A 04 N 5.90 5.90 11.80N

82435 A 04 N 3.00 3.00 6.00N

82436 A 04 N 3.10 3.10 6.20N

82438 A 04 N 3.20 3.20 6.40N

82441 A 04 N 2.85 2.85 5.70N

82465 A 04 N 2.82 2.82 5.65N

82480 A 04 N 4.77 4.77 9.55N

82482 A 04 N 1.75 1.75 3.50N

82485 A 04 N 6.72 6.72 13.45N

82486 B 04 N 4.77 4.77 9.55N

82487 B 04 N 5.62 5.62 11.25N

82488 B 04 N 8.55 8.55 17.10N

82489 B 04 N 2.25 2.25 4.50N

82491 B 04 N 8.12 8.12 16.25N

82492 B 04 N 8.12 8.12 16.25N

82495 A 04 N 8.95 8.95 17.90N

Wednesday, June 18, 2008 Page 315 of 455

Page 323: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82507 A 04 N 3.60 3.60 7.20N

82520 A 04 N 4.77 4.77 9.55N

82523 09 NY

82525 A 04 N 7.40 7.40 14.80N

82528 B 04 N 11.80 11.80 23.60N

82530 A 04 N 8.95 8.95 17.90N

82533 A 04 N 8.95 8.95 17.90N

82540 A 04 N 3.00 3.00 6.00N

82541 B 04 N 4.77 4.77 9.55N

82542 B 04 N 8.12 8.12 16.25N

82543 B 04 N 8.12 8.12 16.25N

82544 B 04 N 8.12 8.12 16.25N

82550 A 04 N 4.05 4.05 8.10N

82552 A 04 N 4.20 4.20 8.40N

82553 A 04 N 4.95 4.95 9.90N

82554 A 04 N 4.10 4.10 8.20N

82565 A 04 N 3.10 3.10 6.20N

82570 A 04 N 3.10 3.10 6.20N

82575 B 04 N 6.15 6.15 12.30N

82585 B 04 N 5.60 5.60 11.20N

82595 B 04 N 3.10 3.10 6.20N

Wednesday, June 18, 2008 Page 316 of 455

Page 324: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82600 A 04 N 4.45 4.45 8.90N

82607 B 04 N 8.01 8.01 16.02N

82608 B 04 N 8.01 8.01 16.02N

82610 04 1/1/2008 N 11.40N

82615 A 04 N 4.20 4.20 8.40N

82626 B 04 N 5.90 5.90 11.80N

82627 B 04 N 5.30 5.30 10.60N

82633 B 04 N 6.72 6.72 13.45N

82634 A 04 N 10.35 10.35 20.70N

82638 A 04 N 4.77 4.77 9.55N

82646 A 04 N 2.35 2.35 4.70N

82649 A 04 N 5.90 5.90 11.80N

82651 B 04 N 13.45 13.45 26.90N

82652 04 N 21.40N

82654 B 04 N 2.25 2.25 4.50N

82656 A 04 N 4.83 4.83 9.67N

82657 A 04 N 8.12 8.12 16.25N

82658 A 04 N 8.12 8.12 16.25N

82664 B 04 N 18.03 18.03 36.07N

82666 B 04 N 5.90 5.90 11.80N

82668 B 04 N 6.95 6.95 13.90N

Wednesday, June 18, 2008 Page 317 of 455

Page 325: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82670 A 04 N 6.75 6.75 13.50N

82671 B 04 N 11.80 11.80 23.60N

82672 B 04 N 11.80 11.80 23.60N

82677 B 04 N 6.75 6.75 13.50N

82679 B 04 N 6.75 6.75 13.50N

82690 A 04 N 5.62 5.62 11.25N

82693 A 04 N 9.75 9.75 19.50N

82696 B 04 N 6.72 6.72 13.45N

82705 A 04 N 1.70 1.70 3.40N

82710 A 04 N 2.05 2.05 4.10N

82715 A 04 N 2.15 2.15 4.30N

82725 A 04 N 1.75 1.75 3.50N

82726 B 04 N 8.12 8.12 16.25N

82728 A 04 N 4.77 4.77 9.55N

82731 B 04 N 24.52 24.52 49.05N

82735 A 04 N 4.77 4.77 9.55N

82742 A 04 N 4.77 4.77 9.55N

82746 B 04 N 7.64 7.64 15.29N

82747 B 04 N 8.85 8.85 17.70N

82757 A 04 N 5.30 5.30 10.60N

82759 A 04 N 3.10 3.10 6.20N

Wednesday, June 18, 2008 Page 318 of 455

Page 326: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82760 A 04 N 3.10 3.10 6.20N

82775 A 04 N 8.95 8.95 17.90N

82776 A 04 N 3.35 3.35 6.70N

82784 A 04 N 6.05 6.05 12.10N

82785 A 04 N 4.77 4.77 9.55N

82787 A 04 N 5.25 5.25 10.50N

82800 A 04 N 3.10 3.10 6.20N

82803 A 04 N 7.25 7.25 14.50N

82805 A 04 N 7.25 7.25 14.50N

82810 A 04 N 3.80 3.80 7.60N

82820 A 04 N 6.52 6.52 13.05N

82926 A 04 N 3.55 3.55 7.10N

82928 A 04 N 2.35 2.35 4.70N

82938 04 N 22.40N

82941 B 04 N 5.27 5.27 10.55N

82943 A 04 N 4.67 4.67 9.35N

82945 A 04 N 2.05 2.05 4.10N

82946 B 04 N 7.00 7.00 14.00N

82947 A 04 N 2.55 2.55 5.10N

82948 A 04 N 1.15 1.15 2.30N

82950 A 04 N 3.10 3.10 6.20N

Wednesday, June 18, 2008 Page 319 of 455

Page 327: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

82951 B 04 N 8.40 8.40 16.80N

82952 A 04 N 2.55 2.55 5.10N

82953 A 04 N 3.10 3.10 6.20N

82955 A 04 N 5.75 5.75 11.50N

82960 A 04 N 3.95 3.95 7.90N

82962 A 04 N 1.12 1.12 2.25N

82963 B 04 N 8.42 8.42 16.85N

82965 A 04 N 4.77 4.77 9.55N

82975 B 04 N 3.60 3.60 7.20N

82977 A 04 N 3.60 3.60 7.20N

82978 A 04 N 6.40 6.40 12.80N

82979 A 04 N 2.35 2.35 4.70N

82980 A 04 N 4.10 4.10 8.20N

82985 B 04 N 8.95 8.95 17.90N

83001 A 04 N 12.12 12.12 24.25N

83002 A 04 N 5.90 5.90 11.80N

83003 A 04 N 5.90 5.90 11.80N

83008 A 04 N 7.50 7.50 15.00N

83009 A 04 N 28.23 28.23 56.47N

83010 A 04 N 5.90 5.90 11.80N

83012 A 04 N 4.45 4.45 8.90N

Wednesday, June 18, 2008 Page 320 of 455

Page 328: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

83013 B 04 N 5.75 5.75 11.50N

83014 B 04 N 5.10 5.10 10.20N

83015 B 04 N 12.30 12.30 24.60N

83018 A 04 N 3.10 3.10 6.20N

83020 B 04 N 5.75 5.75 11.50N

83021 B 04 N 8.12 8.12 16.25N

83026 A 04 N 1.52 1.52 3.05N

83030 A 04 N 2.15 2.15 4.30N

83033 A 04 N 3.90 3.90 7.80N

83036 B 04 N 4.20 4.20 8.40N

83037 04 N 1.96N

83045 A 04 N 3.10 3.10 6.20N

83050 A 04 N 2.00 2.00 4.00N

83051 A 04 N 2.15 2.15 4.30N

83055 A 04 N 2.15 2.15 4.30N

83060 A 04 N 2.15 2.15 4.30N

83065 A 04 N 2.15 2.15 4.30N

83068 A 04 N 2.15 2.15 4.30N

83069 A 04 N 1.02 1.02 2.05N

83070 A 04 N 1.75 1.75 3.50N

83071 A 04 N 2.15 2.15 4.30N

Wednesday, June 18, 2008 Page 321 of 455

Page 329: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

83080 B 04 N 7.75 7.75 15.50N

83088 04 N 23.60N

83090 04 N 17.60N

83150 B 04 N 7.30 7.30 14.60N

83491 B 04 N 4.77 4.72 9.55N

83497 B 04 N 8.42 8.42 16.85N

83498 B 04 N 5.90 5.90 11.80N

83499 B 04 N 10.70 10.70 21.40N

83500 B 04 N 9.52 9.52 19.05N

83505 B 04 N 11.80 11.80 23.60N

83516 A 04 N 5.85 5.85 11.70N

83518 A 04 N 5.52 5.52 11.05N

83519 A 04 N 8.80 8.80 17.60N

83520 A 04 N 8.45 8.45 16.90N

83525 A 04 N 5.90 5.90 11.80N

83527 A 04 N 5.90 5.90 11.80N

83528 A 04 N 5.30 5.30 10.60N

83540 A 04 N 4.25 4.25 8.50N

83550 A 04 N 5.70 5.70 11.40N

83570 A 04 N 4.77 4.77 9.55N

83582 B 04 N 8.12 8.12 16.25N

Wednesday, June 18, 2008 Page 322 of 455

Page 330: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

83586 B 04 N 4.37 4.37 8.75N

83593 B 04 N 10.35 10.35 20.70N

83605 A 04 N 5.90 5.90 11.80N

83615 A 04 N 3.95 3.95 7.90N

83625 B 04 N 6.95 6.95 13.90N

83630 04 N 9.62N

83631 B 04 I 8.22 8.22 16.45N

83632 B 04 N 5.90 5.90 11.80N

83633 A 04 N 3.60 3.60 7.20N

83634 A 04 N 3.95 3.95 7.90N

83655 B 04 N 7.90 7.90 15.80N

83661 B 04 N 8.95 8.95 17.90N

83662 B 04 N 8.27 8.27 16.55N

83663 B 04 N 4.90 4.90 9.80N

83664 B 04 N 2.47 2.47 4.95N

83670 B 04 N 4.20 4.20 8.40N

83690 A 04 N 4.47 4.47 8.95N

83695 B 04 N 5.42 5.42 10.85N

83698 04 N 11.89 11.89 23.78N

83700 04 I 4.71 4.71 9.43N

83701 04 N 10.40 10.40 20.80N

Wednesday, June 18, 2008 Page 323 of 455

Page 331: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

83704 04 I 13.22 13.22 26.44N

83718 B 04 N 5.35 5.35 10.70N

83719 B 04 N 7.60 7.60 15.20N

83721 B 04 N 6.22 6.22 12.45N

83727 A 04 N 5.90 5.90 11.80N

83735 A 04 N 4.37 4.37 8.75N

83775 A 04 N 3.70 3.70 7.40N

83785 A 04 N 0.85 0.85 1.70N

83788 A 04 N 4.77 4.77 9.55N

83789 A 04 N 4.77 4.77 9.55N

83805 A 04 N 4.70 4.70 9.40N

83825 A 04 N 5.27 5.27 10.55N

83835 B 04 N 8.95 8.95 17.90N

83840 A 04 N 5.90 5.90 11.80N

83857 A 04 N 1.75 1.75 3.50N

83858 A 04 N 5.27 5.27 10.55N

83864 B 04 N 7.00 7.00 14.00N

83866 B 04 N 5.95 5.95 11.90N

83872 A 04 N 1.75 1.75 3.50N

83873 B 04 N 6.42 6.42 12.85N

83874 B 04 N 8.42 8.42 16.85N

Wednesday, June 18, 2008 Page 324 of 455

Page 332: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

83880 B 04 N 9.91 9.91 19.82N

83883 A 04 N 6.96 6.96 13.93N

83885 A 04 N 5.27 5.27 10.55N

83887 A 04 N 4.45 4.45 8.90N

83890 B 04 N 2.62 2.62 5.25N

83891 B 04 N 2.62 2.62 5.25N

83892 B 04 N 2.52 2.52 5.05N

83893 B 04 N 2.62 2.62 5.25N

83894 B 04 N 2.52 2.52 5.05N

83896 B 04 N 2.62 2.62 5.25N

83897 B 04 N 2.62 2.62 5.25N

83898 B 04 N 10.95 10.95 21.90N

83900 B 04 N 14.05 14.05 28.10N

83901 B 04 N 10.95 10.95 21.90N

83902 B 04 N 9.25 9.25 18.50N

83903 B 04 N 10.95 10.95 21.90N

83904 B 04 N 10.95 10.95 21.90N

83905 B 04 N 10.95 10.95 21.90N

83906 B 04 N 10.95 10.95 21.90N

83907 B 04 N 5.59 5.59 11.19N

83908 B 04 N 7.02 7.02 14.05N

Wednesday, June 18, 2008 Page 325 of 455

Page 333: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

83909 B 04 N 7.02 7.02 14.05N

83912 B 04 N 2.62 2.62 5.25N

83913 B 04 1/1/2007 N 5.60 5.60 11.20N

83914 B 04 N 7.02 7.02 14.05N

83915 B 04 N 3.60 3.60 7.20N

83916 B 04 N 4.45 4.45 8.90N

83918 B 04 N 10.75 10.75 21.50N

83919 B 04 N 10.75 10.75 21.50N

83921 B 04 N 8.60 8.60 17.20N

83925 A 04 N 11.30 11.30 22.60N

83930 A 04 N 3.10 3.10 6.20N

83935 A 04 N 3.10 3.10 6.20N

83937 04 N 17.90N

83945 A 04 N 2.05 2.05 4.10N

83950 B 04 N 30.55 30.55 61.10N

83970 B 04 N 20.75 20.75 41.50N

83986 A 04 N 2.35 2.35 4.70N

83992 A 04 N 3.10 3.10 6.20N

83993 04 1/1/2008 N 16.45N

84022 A 04 N 3.60 3.60 7.20N

84030 A 04 N 3.50 3.50 7.00N

Wednesday, June 18, 2008 Page 326 of 455

Page 334: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

84035 A 04 N 1.15 1.15 2.30N

84060 A 04 N 4.77 4.77 9.55N

84061 A 04 N 4.20 4.20 8.40N

84066 A 04 N 2.05 2.05 4.10N

84075 A 04 N 3.35 3.35 6.70N

84078 A 04 N 4.77 4.77 9.55N

84080 A 04 N 5.90 5.90 11.80N

84081 A 04 N 1.67 1.67 3.35N

84085 A 04 N 2.35 2.35 4.70N

84087 A 04 N 3.70 3.70 7.40N

84100 A 04 N 3.10 3.10 6.20N

84105 A 04 N 1.50 1.50 3.00N

84106 A 04 N 2.80 2.80 5.60N

84110 A 04 N 3.10 3.10 6.20N

84119 B 04 N 5.62 5.62 11.25N

84120 B 04 N 8.95 8.95 17.90N

84126 B 04 N 14.60 14.60 29.20N

84127 B 04 N 7.30 7.30 14.60N

84132 A 04 N 3.00 3.00 6.00N

84133 A 04 N 2.80 2.80 5.60N

84134 A 04 N 3.72 3.72 7.45N

Wednesday, June 18, 2008 Page 327 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

84135 B 04 N 5.27 5.27 10.55N

84138 B 04 N 5.90 5.90 11.80N

84140 04 N 11.80N

84143 04 N 12.30N

84144 A 04 N 6.15 6.15 12.30N

84146 A 04 N 8.95 8.95 17.90N

84150 A 04 N 2.35 2.35 4.70N

84152 B 40 N 9.60 9.60 19.20N

84153 B 04 N 8.80 8.80 17.60N

84154 B 04 N 8.80 8.80 17.60N

84155 A 04 N 2.40 2.40 4.80N

84156 B 04 N 1.53 1.53 3.07N

84157 B 04 N 1.53 1.53 3.07N

84160 A 04 N 1.75 1.75 3.50N

84163 04 N 12.78N

84165 B 04 N 7.00 7.00 14.00N

84166 04 N 14.95N

84181 B 04 N 11.10 11.10 22.21N

84182 B 04 N 11.73 11.73 23.47N

84202 A 04 N 2.35 2.35 4.70N

84203 A 04 N 1.75 1.75 3.50N

Wednesday, June 18, 2008 Page 328 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

84206 B 04 N 4.77 4.77 9.55N

84207 B 04 N 8.00 8.00 16.00N

84210 A 04 N 4.77 4.77 9.55N

84220 A 04 N 3.10 3.10 6.20N

84228 A 04 N 7.00 7.00 14.00N

84233 B 04 N 22.00 22.00 44.00N

84234 B 04 N 3.60 3.60 7.20N

84235 A 04 N 3.60 3.60 7.20N

84238 B 04 N 13.35 13.35 26.70N

84244 A 04 N 14.35 14.35 28.70N

84252 B 04 N 1.75 1.75 3.50N

84255 A 04 N 3.20 3.20 6.40N

84260 A 04 N 3.35 3.35 6.70N

84270 B 04 N 10.92 10.92 21.85N

84275 A 04 N 2.35 2.35 4.70N

84285 A 04 N 2.40 2.40 4.80N

84295 A 04 N 3.10 3.10 6.20N

84300 A 04 N 2.82 2.82 5.65N

84302 B 04 N 1.70 1.70 3.40N

84305 B 04 N 10.05 10.05 20.10N

84307 B 04 N 10.05 10.05 20.10N

Wednesday, June 18, 2008 Page 329 of 455

Page 337: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

84311 A 04 N 4.58 4.58 9.16N

84315 A 04 N 1.62 1.62 3.25N

84375 A 04 N 3.10 3.10 6.20N

84376 A 04 N 3.60 3.60 7.20N

84377 A 04 N 3.60 3.60 7.20N

84378 A 04 N 3.95 3.95 7.90N

84379 A 04 N 3.95 3.95 7.90N

84392 A 04 N 3.10 3.10 6.20N

84402 A 04 N 12.22 12.22 24.45N

84403 A 04 N 16.85 16.85 33.70N

84425 B 04 N 8.55 8.55 17.10N

84430 B 04 N 4.77 4.77 9.55N

84432 B 04 N 10.47 10.47 20.95N

84436 B 04 N 4.47 4.47 8.95N

84437 B 04 N 4.25 4.25 8.50N

84439 B 04 N 5.90 5.90 11.80N

84442 B 04 N 5.90 5.90 11.80N

84443 B 04 N 10.95 10.95 21.90N

84445 B 04 N 17.97 17.97 35.95N

84446 B 04 N 5.90 5.90 11.80N

84449 04 N 17.90N

Wednesday, June 18, 2008 Page 330 of 455

Page 338: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

84450 A 04 N 3.35 3.35 6.70N

84460 A 04 N 3.45 3.45 6.90N

84466 A 04 N 5.85 5.85 11.70N

84478 B 04 N 3.60 3.60 7.20N

84479 B 04 N 8.50N

84480 B 04 N 6.37 6.37 12.75N

84481 B 04 N 6.75 6.75 13.50N

84482 B 04 N 4.55 4.55 9.10N

84484 A 04 N 4.95 4.95 9.90N

84485 A 04 N 3.60 3.60 7.20N

84488 B 04 N 3.60 3.60 7.20N

84490 B 04 N 3.60 3.60 7.20N

84510 B 04 N 6.80 6.80 13.60N

84512 A 04 N 4.95 4.95 9.90N

84520 A 04 N 2.57 2.57 5.15N

84525 A 04 N 1.15 1.15 2.30N

84540 A 04 N 2.35 2.35 4.70N

84545 A 04 N 2.67 2.67 5.35N

84550 A 04 N 2.95 2.95 5.90N

84560 A 04 N 1.75 1.75 3.50N

84577 A 04 N 3.60 3.60 7.20N

Wednesday, June 18, 2008 Page 331 of 455

Page 339: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

84578 A 04 N 1.15 1.15 2.30N

84580 A 04 N 2.67 2.67 5.35N

84583 A 04 N 1.75 1.75 3.50N

84585 B 04 N 10.10 10.10 20.20N

84586 B 04 N 4.65 4.65 9.30N

84588 B 04 N 3.10 3.10 6.20N

84590 B 04 N 3.10 3.10 6.20N

84591 B 04 N 6.05 6.05 12.10N

84597 B 04 N 3.35 3.35 6.70N

84600 A 04 N 2.35 2.35 4.70N

84620 A 04 N 5.00 5.00 10.00N

84630 B 04 N 6.72 6.72 13.45N

84681 B 04 N 8.55 8.55 17.10N

84702 B 04 N 5.90 5.90 11.80N

84703 B 04 N 4.77 4.77 9.55N

84704 04 1/1/2008 N 12.62N

84999 A 04 NY

85002 A 04 N 1.15 1.15 2.30N

85004 A 04 N 2.26 2.26 4.52N

85007 A 04 N 1.75 1.75 3.50N

85008 A 04 N 2.25 2.25 4.50N

Wednesday, June 18, 2008 Page 332 of 455

Page 340: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

85009 A 04 N 1.75 1.75 3.50N

85013 A 04 N 1.55 1.55 3.10N

85014 A 04 N 1.55 1.55 3.10N

85018 A 04 N 1.55 1.55 3.10N

85025 A 04 N 3.82 3.82 7.65N

85027 A 04 N 3.82 3.82 7.65N

85032 A 04 N 1.50 1.50 3.01N

85041 A 04 N 1.15 1.15 2.30N

85044 A 04 N 1.75 1.75 3.50N

85045 A 04 N 1.75 1.75 3.50N

85046 A 04 N 3.65 3.65 7.30N

85048 A 04 N 1.15 1.15 2.30N

85049 A 04 N 1.56 1.56 3.13N

85055 A 04 N 5.66 5.66 11.32N

85060 04 N 4.50N

85097 04 N 22.40N

85130 B 04 N 7.75 7.75 15.50N

85170 A 04 N 1.15 1.15 2.30N

85175 A 04 N 2.97 2.97 5.95N

85210 B 04 N 5.90 5.90 11.80N

85220 B 04 N 5.90 5.90 11.80N

Wednesday, June 18, 2008 Page 333 of 455

Page 341: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

85230 B 04 N 5.90 5.90 11.80N

85240 B 04 N 5.90 5.90 11.80N

85244 B 04 N 4.77 4.77 9.55N

85245 B 04 N 4.80 4.80 9.60N

85246 B 04 N 4.80 4.80 9.60N

85247 B 04 N 9.25 9.25 18.50N

85250 B 04 N 5.90 5.90 11.80N

85260 B 04 N 5.90 5.90 11.80N

85270 B 04 N 5.90 5.90 11.80N

85280 B 04 N 5.90 5.90 11.80N

85290 B 04 N 5.90 5.90 11.80N

85291 B 04 N 5.80 5.80 11.60N

85292 B 04 N 7.50 7.50 15.00N

85293 B 04 N 7.50 7.50 15.00N

85300 B 04 N 5.90 5.90 11.80N

85301 B 04 N 7.05 7.05 14.10N

85302 B 04 N 7.85 7.85 15.70N

85303 B 04 N 7.80 7.80 15.60N

85305 B 04 N 7.55 7.55 15.10N

85306 B 04 N 7.80 7.80 15.60N

85307 B 04 N 8.00 8.00 16.00N

Wednesday, June 18, 2008 Page 334 of 455

Page 342: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

85335 A 04 N 7.05 7.05 14.10N

85337 A 04 N 6.80 6.80 13.60N

85345 A 04 N 2.00 2.00 4.00N

85347 A 04 N 1.75 1.75 3.50N

85348 A 04 N 2.45 2.45 4.90N

85360 A 04 N 3.95 3.95 7.90N

85362 A 04 N 1.75 1.75 3.50N

85366 A 04 N 3.65 3.65 7.30N

85370 A 04 N 3.65 3.65 7.30N

85378 B 04 N 4.65 4.65 9.30N

85379 B 04 N 5.00 5.00 10.00N

85380 B 04 N 3.55 3.55 7.11N

85384 A 04 N 3.50 3.50 7.00N

85385 A 04 N 3.50 3.50 7.00N

85390 A 04 N 1.62 1.62 3.25N

85396 A 04 N 5.84 5.84 11.69N

85400 A 04 N 3.10 3.10 6.20N

85410 A 04 N 3.10 3.10 6.20N

85415 A 04 N 5.75 5.75 11.50N

85420 A 04 N 3.10 3.10 6.20N

85421 A 04 N 4.30 4.30 8.60N

Wednesday, June 18, 2008 Page 335 of 455

Page 343: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

85441 A 04 N 2.72 2.72 5.45N

85445 A 04 N 1.15 1.15 2.30N

85460 A 04 N 2.15 2.15 4.30N

85461 A 04 N 2.10 2.10 4.20N

85475 A 04 N 5.80 5.80 11.60N

85520 B 04 N 4.20 4.20 8.40N

85525 B 04 N 7.17 7.17 14.35N

85530 B 04 N 4.20 4.20 8.40N

85536 A 04 N 3.37 3.37 6.75N

85540 A 04 N 2.35 2.35 4.70N

85547 A 04 N 1.52 1.52 3.05N

85549 A 04 N 4.77 4.77 9.55N

85555 A 04 N 3.10 3.10 6.20N

85557 A 04 N 3.10 3.10 6.20N

85576 A 04 N 3.40 3.40 6.80N

85597 A 04 N 3.65 3.65 7.30N

85610 A 04 N 2.55 2.55 5.10N

85611 A 04 N 2.57 2.57 5.15N

85612 B 04 N 3.70 3.70 7.40N

85613 B 04 N 4.67 4.67 9.35N

85635 B 04 N 1.75 1.75 3.50N

Wednesday, June 18, 2008 Page 336 of 455

Page 344: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

85651 A 04 N 2.30 2.30 4.60N

85652 A 04 N 1.75 1.75 3.50N

85660 A 04 N 3.10 3.10 6.20N

85670 A 04 N 3.10 3.10 6.20N

85675 A 04 N 4.25 4.25 8.50N

85705 A 04 N 5.80 5.80 11.60N

85730 A 04 N 3.92 3.92 7.85N

85732 A 04 N 4.25 4.25 8.50N

85810 A 04 N 3.60 3.60 7.20N

85999 A 04 NY

86000 A 04 N 3.70 3.70 7.40N

86001 A 04 N 2.72 2.72 5.45N

86003 A 04 N 0.57 0.57 1.15N

86005 A 04 N 5.20 5.20 10.40N

86021 A 04 N 3.10 3.10 6.20N

86022 A 04 N 9.52 9.52 19.05N

86023 B 04 N 4.70 4.70 9.40N

86038 B 04 N 7.90 7.90 15.80N

86039 B 04 N 5.35 5.35 10.70N

86060 B 04 N 4.30 4.30 8.60N

86063 B 04 N 3.77 3.77 7.55N

Wednesday, June 18, 2008 Page 337 of 455

Page 345: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86077 04 N 39.30N

86078 04 N 16.85N

86079 04 N 20.35N

86140 B 04 N 2.35 2.35 4.70N

86141 B 04 N 8.45 8.45 16.90N

86146 B 04 N 13.30 13.30 26.60N

86147 B 04 N 6.35 6.35 12.70N

86148 B 04 N 6.35 6.35 12.70N

86155 A 04 N 4.30 4.30 8.60N

86156 B 04 N 2.62 2.62 5.25N

86157 B 04 N 3.30 3.30 6.60N

86160 A 04 N 4.62 4.62 9.25N

86161 A 04 N 5.15 5.15 10.30N

86162 B 04 N 8.95 8.95 17.90N

86171 09 NY

86185 04 N 4.20 4.20 8.40N

86200 04 N 5.42 5.42 10.85N

86215 B 04 N 5.90 5.90 11.80N

86225 B 04 N 5.90 5.90 11.80N

86226 B 04 N 6.67 6.67 13.35N

86235 A 04 N 5.90 5.90 11.80N

Wednesday, June 18, 2008 Page 338 of 455

Page 346: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86243 A 04 N 5.90 5.90 11.80N

86255 A 04 N 3.60 3.60 7.20N

86256 A 04 N 5.90 5.90 11.80N

86277 A 04 N 10.27 10.27 20.55N

86280 A 04 N 4.10 4.10 8.20N

86294 A 04 NY

86300 B 04 N 10.85 10.85 21.70N

86301 B 04 N 10.85 10.85 21.70N

86304 B 04 N 10.85 10.85 21.70N

86308 B 04 N 2.40 2.40 4.80N

86309 B 04 N 4.25 4.25 8.50N

86310 B 04 N 4.82 4.82 9.65N

86316 A 04 N 5.05 5.05 10.10N

86317 09 Y

86318 A 04 N 8.45 8.45 16.90N

86320 B 04 N 10.65 10.65 21.30N

86325 B 04 N 5.90 5.90 11.80N

86327 B 04 N 7.00 7.00 14.00N

86329 A 04 N 9.15 9.15 18.30N

86331 A 04 N 5.90 5.90 11.80N

86332 B 04 N 9.40 9.40 18.80N

Wednesday, June 18, 2008 Page 339 of 455

Page 347: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86334 B 04 N 13.95 13.95 27.90N

86335 A 04 N 12.30 12.30 24.60N

86336 B 04 N 10.87 10.87 21.75N

86337 B 04 N 5.90 5.90 11.80N

86340 A 04 N 5.90 5.90 11.80N

86341 04 N 11.80N

86343 B 04 N 8.07 8.07 16.15N

86344 A 04 N 1.15 1.15 2.30N

86353 B 04 N 5.90 5.90 11.80N

86355 04 N 15.81 15.81 31.62N

86356 04 1/1/2008 N 11.33N

86357 04 N 15.81 15.81 31.62N

86359 B 04 N 3.82 3.82 7.65N

86360 B 04 N 4.85 4.85 9.70N

86361 B 04 N 4.85 4.85 9.70N

86367 04 N 15.81 15.81 31.62N

86376 A 04 N 4.20 4.20 8.40N

86378 B 04 N 6.95 6.95 13.90N

86382 A 04 N 3.60 3.60 7.20N

86384 A 04 N 2.35 2.35 4.70N

86403 A 04 N 3.00 3.00 6.00N

Wednesday, June 18, 2008 Page 340 of 455

Page 348: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86406 A 04 N 5.90 5.90 11.80N

86430 B 04 N 3.10 3.10 6.20N

86431 B 04 N 3.62 3.62 7.25N

86480 04 N 25.97 25.97 51.95N

86485 B 04 N 2.00 2.00 4.00N

86486 04 1/1/2008 NY

86490 B 04 N 2.57 2.57 5.15N

86510 B 04 N 2.57 2.57 5.15N

86580 04 N 4.00N

86590 B 04 N 5.90 5.90 11.80N

86592 B 04 N 2.00 2.00 4.00N

86593 B 04 N 2.00 2.00 4.00N

86602 B 04 N 5.10 5.10 10.20N

86603 A 04 N 7.40 7.40 14.80N

86606 B 04 N 5.10 5.10 10.20N

86609 B 04 N 5.12 5.12 10.25N

86611 B 04 N 5.30 5.30 10.60N

86612 B 04 N 5.10 5.10 10.20N

86615 B 04 N 5.95 5.95 11.90N

86617 B 04 N 10.10 10.10 20.20N

86618 B 04 N 11.10 11.10 22.20N

Wednesday, June 18, 2008 Page 341 of 455

Page 349: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86619 B 04 N 5.10 5.10 10.20N

86622 B 04 N 5.10 5.10 10.20N

86625 B 04 N 4.85 4.85 9.70N

86628 B 04 N 5.10 5.10 10.20N

86631 B 04 N 7.70 7.70 15.40N

86632 B 04 N 8.27 8.27 16.55N

86635 B 04 N 5.10 5.10 10.20N

86638 B 04 N 5.10 5.10 10.20N

86641 B 04 N 5.10 5.10 10.20N

86644 B 04 N 6.67 6.67 13.35N

86645 B 04 N 9.12 9.12 18.25N

86648 B 04 N 9.60 9.60 19.20N

86651 B 04 N 8.00 8.00 16.00N

86652 B 04 N 8.00 8.00 16.00N

86653 B 04 N 7.80 7.80 15.60N

86654 B 04 N 8.00 8.00 16.00N

86658 B 04 N 8.50 8.50 17.00N

86663 B 04 N 8.57 8.57 17.15N

86664 B 04 N 8.80 8.80 17.60N

86665 B 04 N 9.60 9.60 19.20N

86666 B 04 N 5.30 5.30 10.60N

Wednesday, June 18, 2008 Page 342 of 455

Page 350: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86668 B 04 N 5.10 5.10 10.20N

86671 B 04 N 8.01 8.01 16.02N

86674 B 04 N 5.10 5.10 10.20N

86677 B 04 N 7.50 7.50 15.00N

86682 B 04 NY

86684 B 04 N 9.60 9.60 19.20N

86687 B 04 N 5.10 5.10 10.20N

86688 B 04 N 6.72 6.72 13.45N

86689 B 04 N 11.19 11.19 22.39N

86692 B 04 N 5.05 5.05 10.10N

86694 B 04 N 6.67 6.67 13.35N

86695 B 04 N 7.65 7.65 15.30N

86696 B 04 N 10.10 10.10 20.20N

86698 B 04 N 8.15 8.15 16.30N

86701 B 04 N 5.80 5.80 11.60N

86702 B 04 N 5.10 5.10 10.20N

86703 B 04 N 8.95 8.95 17.90N

86704 B 04 N 7.85 7.85 15.70N

86705 B 04 N 7.70 7.70 15.40N

86706 B 04 N 7.00 7.00 14.00N

86707 B 04 N 4.77 4.77 9.55N

Wednesday, June 18, 2008 Page 343 of 455

Page 351: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86708 B 04 N 4.77 4.77 9.55N

86709 B 04 N 2.77 2.77 5.55N

86710 B 04 N 8.85 8.85 17.70N

86713 B 04 N 2.62 2.62 5.25N

86717 B 04 N 5.10 5.10 10.20N

86720 B 04 N 5.10 5.10 10.20N

86723 B 04 N 8.32 8.32 16.65N

86727 B 04 N 7.80 7.80 15.60N

86729 B 04 N 7.65 7.65 15.30N

86732 B 04 N 5.10 5.10 10.20N

86735 B 04 N 6.35 6.35 12.70N

86738 B 04 N 5.10 5.10 10.20N

86741 B 04 N 5.10 5.10 10.20N

86744 B 04 N 5.10 5.10 10.20N

86747 B 04 N 9.80 9.80 19.60N

86750 B 04 N 5.10 5.10 10.20N

86753 B 04 N 8.08 8.08 16.17N

86756 B 04 N 8.42 8.42 16.85N

86757 B 04 N 10.10 10.10 20.20N

86759 B 04 N 8.40 8.40 16.80N

86762 B 04 N 4.10 4.10 8.20N

Wednesday, June 18, 2008 Page 344 of 455

Page 352: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86765 B 04 N 4.10 4.10 8.20N

86768 B 04 N 5.10 5.10 10.20N

86771 B 04 N 5.10 5.10 10.20N

86774 B 04 N 9.65 9.65 19.30N

86777 B 04 N 6.35 6.35 12.70N

86778 B 04 N 9.40 9.40 18.80N

86781 B 04 N 8.64 8.64 17.29N

86784 B 04 N 5.10 5.10 10.20N

86787 B 04 N 7.50 7.50 15.00N

86788 B 04 1/1/2007 N 7.06 7.06 14.12N

86789 B 04 1/1/2007 N 6.03 6.03 12.07N

86790 B 04 N 8.42 8.42 16.85N

86793 B 04 N 5.10 5.10 10.20N

86800 B 04 N 5.90 5.90 11.80N

86803 B 04 N 8.42 8.42 16.85N

86804 B 04 N 6.20 6.20 12.40N

86805 B 04 N 23.90 23.90 47.80N

86806 B 04 N 21.72 21.72 43.45N

86807 B 04 N 18.05 18.05 36.10N

86808 B 04 N 13.55 13.55 27.10N

86812 B 04 N 3.10 3.10 6.20N

Wednesday, June 18, 2008 Page 345 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86813 B 04 N 8.42 8.42 16.85N

86816 B 04 N 7.50 7.50 15.00N

86817 B 04 N 14.00 14.00 28.00N

86821 B 04 N 28.05 28.05 56.10N

86822 B 04 N 13.35 13.35 26.70N

86849 A 04 NY

86850 A 04 N 2.82 2.82 5.65N

86860 A 04 N 5.95 5.95 11.90N

86870 A 04 N 7.17 7.17 14.35N

86880 A 04 N 2.90 2.90 5.80N

86885 A 04 N 3.05 3.05 6.10N

86886 A 04 N 3.10 3.10 6.20N

86890 04 N 40.40N

86891 04 N 101.80N

86900 A 04 N 1.75 1.75 3.50N

86901 A 04 N 2.35 2.35 4.70N

86903 A 04 N 6.15 6.15 12.30N

86904 A 04 N 6.20 6.20 12.40N

86905 A 04 N 2.47 2.47 4.95N

86906 A 04 N 2.30 2.30 4.60N

86910 A 04 N 12.02 12.02 24.05N

Wednesday, June 18, 2008 Page 346 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86911 A 04 N 3.40 3.40 6.80N

86920 A 04 N 2.35 2.35 4.70N

86921 A 04 N 4.70 4.70 9.40N

86922 A 04 N 4.70 4.70 9.40N

86927 09 NY

86930 09 NY

86931 09 NY

86932 09 NY

86940 A 04 N 2.77 2.77 5.55N

86941 A 04 N 2.35 2.35 4.70N

86945 04 N 6.60N

86950 04 N 25.70YN

86965 04 N 5.05N

86970 04 N 10.10N

86971 04 N 8.20N

86972 04 N 8.20N

86975 04 N 8.20N

86976 04 N 8.20N

86977 04 N 8.20N

86978 04 N 10.10N

86985 A 04 N 4.10 4.10 8.20N

Wednesday, June 18, 2008 Page 347 of 455

Page 355: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

86999 A 04 NY

87001 B 04 N 8.60 8.60 17.20N

87003 B 04 N 8.95 8.95 17.90N

87015 A 04 N 3.60 3.60 7.20N

87040 B 04 N 6.75 6.75 13.50N

87045 B 04 N 6.15 6.15 12.30N

87046 B 04 N 1.20 1.20 2.40N

87070 B 04 N 3.10 3.10 6.20N

87071 09 NY

87073 09 NY

87075 B 04 N 6.17 6.17 12.35N

87076 09 NY

87077 09 NY

87081 B 04 N 2.90 2.90 5.80N

87084 B 04 N 3.00 3.00 6.00N

87086 B 04 N 5.25 5.25 10.50N

87088 09 Y 6.20N

87101 B 04 N 3.10 3.10 6.20N

87102 B 04 N 3.10 3.10 6.20N

87103 B 04 N 3.10 3.10 6.20N

87106 09 NY

Wednesday, June 18, 2008 Page 348 of 455

Page 356: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87107 09 NY

87109 B 04 N 4.77 4.77 9.55N

87110 B 04 N 8.42 8.42 16.85N

87116 B 04 N 5.85 5.85 11.70N

87118 09 NY

87140 B 04 N 0.57 0.57 1.15N

87143 B 04 N 3.60 3.60 7.20N

87147 B 04 N 1.60 1.60 3.20N

87149 09 NY

87152 09 NY

87158 B 04 N 0.57 0.57 1.15N

87164 04 N 14.00N

87166 04 N 14.75N

87168 B 04 N 2.25 2.25 4.50N

87169 B 04 N 2.25 2.25 4.50N

87172 A 04 N 2.25 2.25 4.50N

87176 A 04 N 3.85 3.85 7.70N

87177 A 04 N 3.60 3.60 7.20N

87181 B 04 6.20N

87184 B 04 N 4.50 4.50 9.00N

87185 A 04 N 2.47 2.47 4.95N

Wednesday, June 18, 2008 Page 349 of 455

Page 357: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87186 B 04 N 5.65 5.65 11.30N

87187 B 04 N 4.30 4.30 8.60N

87188 B 04 N 4.32 4.32 8.65N

87190 04 N 7.40N

87197 B 04 N 6.40 6.40 12.80N

87205 B 04 N 1.75 1.75 3.50N

87206 B 04 N 2.10 2.10 4.20N

87207 B 04 N 1.75 1.75 3.50N

87209 B 04 N 7.53 7.53 15.06N

87210 B 04 N 2.35 2.35 4.70N

87220 B 04 N 2.35 2.35 4.70N

87230 B 04 N 7.50 7.50 15.00N

87250 04 N 12.80N

87252 B 04 N 6.40 6.40 12.80N

87253 B 04 N 7.50 7.50 15.00N

87254 A 04 N 3.20 3.20 6.40N

87255 A 04 N 11.83 11.83 23.66N

87260 B 04 N 7.85 7.85 15.70N

87265 B 04 N 7.85 7.85 15.70N

87267 B 04 N 4.19 4.19 8.38N

87269 B 04 N 5.02 5.02 10.05N

Wednesday, June 18, 2008 Page 350 of 455

Page 358: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87270 B 04 N 7.85 7.85 15.70N

87271 B 04 N 4.19 4.19 8.38N

87272 B 04 N 7.85 7.85 15.70N

87273 B 04 N 6.25 6.25 12.50N

87274 B 04 N 7.85 7.85 15.70N

87275 B 04 N 6.25 6.25 12.50N

87276 B 04 N 7.85 7.85 15.70N

87277 B 04 N 6.25 6.25 12.50N

87278 B 04 N 7.85 7.85 15.70N

87279 A 04 N 6.25 6.25 12.50N

87280 B 04 N 7.85 7.85 15.70N

87281 B 04 N 6.25 6.25 12.50N

87283 B 04 N 6.25 6.25 12.50N

87285 B 04 N 7.85 7.85 15.70N

87290 B 04 N 7.85 7.85 15.70N

87299 A 04 NY

87300 A 04 N 3.10 3.10 6.20N

87301 B 04 N 7.85 7.85 15.70N

87305 B 04 N 7.85 7.85 15.70N

87320 B 04 N 7.85 7.85 15.70N

87324 B 04 N 7.85 7.85 15.70N

Wednesday, June 18, 2008 Page 351 of 455

Page 359: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87327 B 04 N 6.25 6.25 12.50N

87328 B 04 N 7.85 7.85 15.70N

87329 B 04 N 5.02 5.02 10.05N

87332 B 04 N 7.85 7.85 15.70N

87335 B 04 N 7.85 7.85 15.70N

87336 B 04 N 6.25 6.25 12.50N

87337 B 04 N 6.25 6.25 12.50N

87338 B 04 N 9.40 9.40 18.80N

87339 B 04 N 6.25 6.25 12.50N

87340 B 04 N 6.75 6.75 13.50N

87341 B 04 N 5.40 5.40 10.80N

87350 B 04 N 7.52 7.52 15.05N

87380 B 04 N 10.70 10.70 21.40N

87385 B 04 N 7.85 7.85 15.70N

87390 B 04 N 11.50 11.50 23.00N

87391 B 04 N 11.50 11.50 23.00N

87400 B 04 N 3.10 3.10 6.20N

87420 B 04 N 7.85 7.85 15.70N

87425 B 04 N 7.85 7.85 15.70N

87427 B 04 N 6.25 6.25 12.50N

87430 B 04 N 7.85 7.85 15.70N

Wednesday, June 18, 2008 Page 352 of 455

Page 360: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87449 A 04 N 7.84 7.84 15.68N

87450 A 04 NY

87451 B 04 N 5.00 5.00 10.00N

87470 B 04 N 13.10 13.10 26.20N

87471 B 04 N 22.90 22.90 45.80N

87472 B 04 N 27.95 27.95 55.91N

87475 B 04 N 13.10 13.10 26.20N

87476 B 04 N 22.90 22.90 45.80N

87477 B 04 N 27.95 27.95 55.91N

87480 B 04 N 13.10 13.10 26.20N

87481 B 04 N 22.90 22.90 45.80N

87482 B 04 N 27.25 27.25 54.50N

87485 B 04 N 13.10 13.10 26.20N

87486 B 04 N 22.90 22.90 45.80N

87487 B 04 N 27.95 27.95 55.91N

87490 B 04 N 13.10 13.10 26.20N

87491 B 04 N 22.90 22.90 45.80N

87492 B 04 N 22.81 22.81 45.63N

87495 B 04 N 13.10 13.10 26.20N

87496 B 04 N 22.90 22.90 45.80N

87497 B 04 N 22.81 22.81 45.63N

Wednesday, June 18, 2008 Page 353 of 455

Page 361: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87498 B 04 N 22.91 22.91 45.83N

87500 04 1/1/2008 N 29.42N

87510 B 04 N 13.10 13.10 26.20N

87511 B 04 N 22.90 22.90 45.80N

87512 B 04 NY

87515 B 04 N 13.10 13.10 26.20N

87516 B 04 N 22.90 22.90 45.80N

87517 B 04 N 27.95 27.95 55.90N

87520 B 04 N 13.10 13.10 26.20N

87521 B 04 N 22.90 22.90 45.80N

87522 B 04 N 27.95 27.95 55.90N

87525 B 04 N 13.10 13.10 26.20N

87526 B 04 N 22.90 22.90 45.80N

87527 B 04 NY

87528 B 04 N 13.10 13.10 26.20N

87529 B 04 N 22.90 22.90 45.80N

87530 B 04 NY

87531 B 04 N 13.10 13.10 26.20N

87532 B 04 N 22.90 22.90 45.80N

87533 B 04 NY

87534 B 04 N 13.10 13.10 26.20N

Wednesday, June 18, 2008 Page 354 of 455

Page 362: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87535 B 04 N 22.90 22.90 45.80N

87536 B 04 N 43.45 43.45 86.90N

87537 B 04 N 13.10 13.10 26.20N

87538 B 04 N 22.90 22.90 45.80N

87539 B 04 NY

87540 B 04 N 13.10 13.10 26.20N

87541 B 04 N 22.90 22.90 45.80N

87542 B 04 NY

87550 B 04 N 13.10 13.10 26.20N

87551 B 04 N 22.90 22.90 45.80N

87552 B 04 NY

87555 B 04 N 13.10 13.10 26.20N

87556 B 04 N 22.90 22.90 45.80N

87557 B 04 NY

87560 B 04 N 13.10 13.10 26.20N

87561 B 04 N 22.90 22.90 45.80N

87562 B 04 NY

87580 B 04 N 13.10 13.10 26.20N

87581 B 04 N 22.90 22.90 45.80N

87582 B 04 NY

87590 B 04 N 13.10 13.10 26.20N

Wednesday, June 18, 2008 Page 355 of 455

Page 363: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87591 B 04 N 22.90 22.90 45.80N

87592 B 04 NY

87620 B 04 N 13.10 13.10 26.20N

87621 B 04 N 22.90 22.90 45.80N

87622 B 04 NY

87640 B 04 N 22.91 22.91 45.83N

87641 B 04 N 22.91 22.91 45.83N

87650 B 04 N 13.10 13.10 26.20N

87651 B 04 N 22.90 22.90 45.80N

87652 04 NY

87653 B 04 N 22.91 22.92 45.83N

87660 B 04 N 8.40 8.40 16.81N

87797 A 04 N 13.10 13.10 26.20N

87798 A 04 N 22.91 22.91 45.83N

87799 A 04 N 25.94 25.94 51.89N

87800 B 04 N 10.47 10.47 20.95N

87801 B 04 N 18.30 18.30 36.60N

87802 B 04 N 7.82 7.82 15.65N

87803 B 04 N 7.82 7.82 15.65N

87804 B 04 N 7.82 7.82 15.65N

87807 04 N 10.06N

Wednesday, June 18, 2008 Page 356 of 455

Page 364: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

87808 04 N 7.82 7.82 15.65N

87809 04 1/1/2008 N 10.06N

87810 B 04 N 7.85 7.85 15.70N

87850 B 04 N 7.85 7.85 15.70N

87880 04 N 4.20N

87880 H 04 N 7.85 7.85 15.70N

87899 A 04 NY

87900 04 N 162.20N

87901 04 N 168.05N

87902 B 04 N 84.02 84.02 168.05N

87903 04 N 682.72N

87904 04 N 32.44 9 291.96N

87999 A 04 NY

88104 B 04 N 5.90 5.90 11.80N

88106 B 04 N 5.90 5.90 11.80N

88107 B 04 N 5.90 5.90 11.80N

88108 B 04 N 4.45 4.45 8.90N

88112 C 04 N 29.33 23.68 63.61N

88125 B 04 N 1.67 1.67 3.35N

88130 B 04 N 7.00 7.00 14.00N

88140 B 04 N 4.77 4.77 9.55N

Wednesday, June 18, 2008 Page 357 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

88141 04 N 3.50N

88142 04 N 3.35N

88143 04 N 3.50N

88147 04 N 3.50N

88148 04 N 3.50N

88150 04 N 1 3.50N

88152 04 N 3.50N

88153 04 N 3.50N

88154 04 N 3.50N

88155 04 N 1 4.10N

88160 B 04 N 5.90 5.90 11.80N

88161 B 04 N 5.62 5.62 11.25N

88162 B 04 N 11.80 11.80 23.60N

88164 04 N 3.50N

88165 04 N 3.50N

88166 04 N 3.50N

88167 04 N 3.50N

88172 04 N 16.85N

88173 B 04 N 14.00 14.00 28.00N

88174 B 04 N 7.46 7.46 14.93N

88175 B 04 N 9.20 9.20 18.41N

Wednesday, June 18, 2008 Page 358 of 455

Page 366: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

88182 B 04 N 15.25 15.25 30.50N

88184 04 N 2.10N

88185 04 N 1.05 24 25.20N

88187 04 N 40.11N

88188 04 N 50.00N

88189 04 N 65.85N

88199 A 04 NY

88230 B 04 N 45.40 45.40 90..80N

88233 B 04 N 58.77 58.77 117.55N

88235 B 04 N 66.80 66.80 133.60N

88237 B 04 N 53.47 53.47 106.95N

88239 B 04 N 66.80 66.80 133.60N

88240 A 09 NY

88241 A 09 NY

88245 B 04 N 43.82 43.82 87.65N

88248 B 04 N 44.12 44.12 88.25N

88249 B 04 N 43.77 43.77 87.55N

88261 B 04 N 58.90 58.90 117.80N

88262 B 04 N 81.37 81.37 162.75N

88263 B 04 N 94.37 94.37 188.75N

88264 B 04 N 81.37 81.37 162.75N

Wednesday, June 18, 2008 Page 359 of 455

Page 367: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

88267 B 04 N 44.30 44.30 88.60N

88269 B 04 N 38.17 38.17 76.35N

88271 B 04 N 9.45 9.45 18.90N

88272 B 04 N 16.52 16.52 33.05N

88273 B 04 N 20.95 20.95 41.90N

88274 B 04 N 22.70 22.70 45.40N

88275 B 04 N 26.20 26.20 52.40N

88280 B 04 N 16.35 16.35 32.70N

88283 B 04 N 12.27 12.27 24.55N

88285 B 04 N 12.40 12.40 24.80N

88289 B 04 N 8.55 8.55 17.10N

88291 B 04 N 2.62 2.62 5.25N

88299 A 04 NY

88300 A 04 N 6.52 6.52 13.05N

88302 A 04 N 10.47 10.47 20.95N

88304 A 04 N 18.67 18.67 37.35N

88305 A 04 N 20.55 20.55 41.10N

88307 A 04 N 21.80 21.80 43.60N

88309 A 04 N 23.70 23.70 47.40N

88311 B 04 N 5.75 5.75 11.50N

88312 A 04 N 5.90 5.90 11.80N

Wednesday, June 18, 2008 Page 360 of 455

Page 368: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

88313 A 04 N 3.35 3.35 6.70N

88314 B 04 N 3.10 3.10 6.20N

88318 B 04 N 20.90 20.90 41.80N

88319 B 04 N 11.20 11.20 22.40N

88321 04 N 6.20N

88323 04 N 17.90N

88325 04 N 19.90N

88329 04 N 48.55N

88331 04 N 48.55N

88332 04 N 19.90N

88333 04 N 50.86N

88334 04 N 26.40N

88342 A 04 N 6.72 6.72 13.45N

88346 A 04 N 8.42 8.42 16.85N

88347 A 04 N 8.42 8.42 16.85N

88348 B 04 N 23.60 23.60 47.20N

88349 B 04 N 35.35 35.35 70.70N

88355 B 04 N 54.30 54.30 108.60N

88356 B 04 N 54.30 54.30 108.60N

88358 B 04 N 54.30 54.30 108.60N

88360 A 04 N 30.91 30.91 61.83N

Wednesday, June 18, 2008 Page 361 of 455

Page 369: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

88361 C 04 N 24.79 35.80 72.70N

88362 A 04 NY

88365 04 N 40.81N

88367 A 04 N 57.57 57.57 115.15N

88368 04 N 105.20N

88371 B 04 N 14.22 14.22 28.45N

88372 B 04 N 14.85 14.85 29.70N

88380 B 04 NY

88381 C 04 1/1/2008 N 31.82 83.72 115.54N

88384 04 NY

88385 04 N 46.41N

88386 04 N 58.39N

88399 A 04 NY

88400 A 04 N 1.30 1.30 2.60N

89049 B 04 N 18.52 18.52 37.05N

89050 B 04 N 1.75 1.75 3.50N

89051 B 04 N 3.10 3.10 6.20N

89055 A 04 N 1.49 1.49 2.98N

89060 B 04 N 4.67 4.67 9.35N

89100 B 04 N 3.10 3.10 6.20N

89105 B 04 N 29.75 29.75 59.50N

Wednesday, June 18, 2008 Page 362 of 455

Page 370: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

89125 B 04 N 1.67 1.67 3.35N

89130 A 04 I 14.60 14.60 29.20N

89132 A 04 NY

89135 B 04 N 14.60 14.60 29.20N

89136 B 04 NY

89140 B 04 N 23.60 23.60 47.20N

89141 A 04 N 14.00 14.00 28.00N

89160 B 04 N 0.67 0.67 1.35N

89190 B 04 N 1.67 1.67 3.35N

89225 B 04 N 1.40 1.40 2.80N

89235 B 04 N 2.30 2.30 4.61N

89240 A 04 NY

89250 09 NY

89310 B 04 N 3.35 3.35 6.70N

89321 09 NY

89322 04 1/1/2008 N 11.36N

90375 04 Y NY

90376 04 Y NY

90378 04 Y NY

90379 04 Y NY

90384 04 Y N 107.70N

Wednesday, June 18, 2008 Page 363 of 455

Page 371: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

90385 04 Y N 37.70N

90386 04 Y NY

90393 04 Y NY

90399 04 Y NY

90471 09 NY

90472 09 NY

90473 09 NY

90474 09 NY

90476 F 04 NY

90477 F 04 NY

90581 F 04 NY

90585 F 04 NY

90586 F 04 NY

90632 G 04 N 6.40 56.15N

90633 E 04 N 6.40N

90634 E 04 N 28.05N

90636 G 04 N 6.40 111.18N

90645 E 04 N 6.40N

90646 E 04 N 6.40N

90647 E 04 N 6.40N

90648 E 04 N 6.40N

Wednesday, June 18, 2008 Page 364 of 455

Page 372: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

90649 M 04 N 6.40 149.33Y

90650 04 1/1/2008 NY

90655 E 04 N 6.40N

90656 G 04 N 6.40N

90657 E 04 N 6.40N

90658 G 04 N 6.40 5.65N

90660 G 04 N 6.40 22.37N

90665 09 Y NY

90669 E 04 N 6.40N

90675 F 04 NY

90676 F 04 NY

90680 E 04 N 6.40N

90681 04 1/1/2008 Y

90690 09 NY

90691 09 NY

90692 09 NY

90693 09 Y

90696 04 1/1/2008 NY

90700 E 04 N 6.40N

90701 E 04 N 6.40N

90702 E 04 N 2.70N

Wednesday, June 18, 2008 Page 365 of 455

Page 373: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

90703 F 04 N 1.85N

90704 F 04 NY

90705 F 04 NY

90706 F 04 NY

90707 G 04 N 6.40 39.70N

90708 F 04 NY

90710 E 04 N 6.40N

90712 F 04 N 14.00N

90713 E 04 N 6.40N

90714 G 04 N 6.40 18.92N

90715 G 04 N 6.40 38.28N

90716 G 04 N 6.40 46.60N

90717 09 NY

90718 G 04 N 6.40 2.70N

90719 F 04 N 3.40N

90721 F 04 N 35.25N

90723 E 04 N 6.40N

90725 09 NY

90727 09 NY

90732 G 04 N 6.40 1 14.60N

90733 F 04 N 85.00N

Wednesday, June 18, 2008 Page 366 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

90734 E 04 N 6.40N

90735 F 04 N 243.80N

90736 F 04 N 190.02N

90740 G 04 NY

90743 G 04 NY

90744 E 04 N 6.40N

90746 G 04 N 6.40 74.38N

90747 G 04 NY

90748 E 04 N 6.40N

90749 04 NY

90760 04 N 19.11YN

90761 04 I 19.11 8 152.90YN

90765 04 I 19.11YN

90766 04 I 19.11 8 152.90YN

90767 04 I 19.11YN

90768 04 I 19.11YN

90769 04 1/1/2008 I 84.51YN

90770 04 1/1/2008 I 9.15YN

90771 04 1/1/2008 I 36.95YN

90772 04 I 9.81N

90773 04 I 10.26YN

Wednesday, June 18, 2008 Page 367 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

90774 04 I 29.55YN

90775 04 I 13.99 2 27.98YN

90776 04 1/1/2008 NYY

90779 04 IYY

90801 02 N 67.50N

90802 02 N 27.55N

90804 02 N 27.55N

90805 02 N 30.90N

90806 02 N 47.50N

90807 02 N 47.50N

90808 02 N 64.80N

90809 02 N 67.50N

90810 02 N 31.70N

90811 02 N 34.85N

90812 02 N 47.50N

90813 02 N 47.50N

90814 02 N 63.45N

90815 02 N 66.30N

90816 02 N 31.65N

90817 02 N 31.65N

90818 02 N 47.50N

Wednesday, June 18, 2008 Page 368 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

90819 02 N 47.50N

90821 02 N 65.90N

90822 02 N 68.30N

90823 02 N 33.30N

90824 02 N 35.95N

90826 02 N 47.50N

90827 02 N 48.65N

90828 02 N 65.05N

90829 02 N 66.90N

90845 D 04 NN

90846 09 NY

90847 02 N 61.20N

90849 02 N 61.20N

90853 02 N 33.70N

90857 09 NY

90862 04 N 22.45N

90865 02 N 63.40N

90870 04 I 44.40YN

90875 02 N 28.70N

90876 02 N 47.50N

90880 09 NY

Wednesday, June 18, 2008 Page 369 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

90885 09 NY

90887 09 NY

90889 09 NY

90899 02 NY

90901 09 IY

90911 09 IY

90918 04 I 252.35N

90919 04 I 213.65N

90920 04 I 213.65N

90921 04 I 213.65N

90922 04 I 8.30N

90923 04 I 7.10N

90924 04 I 7.10N

90925 04 I 7.10N

90935 04 I 35.75YN

90937 04 I 61.70YN

90940 04 IYY

90945 04 I 36.50YN

90947 04 N 60.90YN

90989 09 IY

90993 09 IY

Wednesday, June 18, 2008 Page 370 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

90997 04 NYY

90999 04 IYY

91000 04 I 20.80YN

91010 04 I 52.70YN

91011 04 I 60.60YN

91012 04 I 74.90YN

91020 04 I 74.90YN

91022 C 04 N 42.72 75.37 1 118.09N

91030 04 I 74.90YN

91034 C 04 I 31.17 99.11 1 130.28YN

91035 04 I 255.62YN

91037 04 I 84.00YN

91038 C 04 I 32.73 40.00 72.73YN

91040 04 I 248.27YN

91052 04 I 25.65YN

91055 04 I 27.85YN

91065 04 I 29.65YN

91100 04 I 99.10YN

91105 04 I 40.85YN

91110 C 04 I 140.95 563.92 704.90YN

91111 C 04 N 28.37 343.76 372.13YN

Wednesday, June 18, 2008 Page 371 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

91120 04 I 245.00YN

91122 04 I 57.20YN

91123 04 I 194.20N

91132 04 IYY

91133 04 IYY

91299 04 IY

92002 04 N 27.55N

92004 04 N 46.45N

92012 04 N 23.30N

92014 04 N 44.45N

92015 04 I 18.45N

92018 04 I 152.60YN

92019 04 I 152.60YN

92020 04 I 19.50N

92025 C 04 I 9.04 6.29 15.33N

92060 04 I 24.90N

92065 04 I 22.15N

92070 09 NY

92081 04 I 20.45N

92082 04 I 30.50N

92083 04 I 37.40N

Wednesday, June 18, 2008 Page 372 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

92100 04 I 23.80N

92120 04 I 22.30N

92130 04 I 24.55N

92135 L 04 I 26.35 26.35 52.70N

92136 04 I 50.05N

92140 04 I 22.15N

92225 04 I 30.50N

92226 04 I 30.50N

92230 B 04 I 22.20 22.20 44.40N

92235 B 04 I 26.35 26.35 52.70N

92240 B 04 I 28.25 28.25 56.50N

92250 B 04 I 22.20 22.20 44.40N

92260 B 04 I 26.35 26.35 52.70N

92265 04 I 74.90YN

92270 04 I 52.70N

92275 B 04 I 26.35 26.35 52.70N

92283 04 I 22.15N

92284 B 04 I 7.60 7.60 15.20N

92285 04 I 30.50N

92286 04 I 52.70N

92287 04 I 69.30N

Wednesday, June 18, 2008 Page 373 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

92310 04 NY

92311 09 NY

92312 09 NY

92313 09 NY

92314 09 NY

92315 09 NY

92316 09 NY

92317 09 NY

92325 09 NY

92326 09 NY

92340 04 N 30.09N

92341 09 NY

92342 09 NY

92352 09 NY

92353 09 NY

92354 09 NY

92355 09 NY

92358 09 NY

92370 04 N 4.76N

92371 09 NY

92499 04 IY

Wednesday, June 18, 2008 Page 374 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

92502 04 I 52.70YN

92504 04 I 37.40N

92506 04 I 37.40N

92507 04 I 19.85N

92508 09 IY

92511 04 I 112.40YN

92512 04 I 20.05N

92516 04 I 15.90YN

92520 04 I 30.50YN

92526 04 IY

92531 04 I 30.50N

92532 04 I 30.50N

92533 04 I 22.15N

92534 04 I 22.15N

92541 04 I 22.15N

92542 04 I 22.15N

92543 04 I 22.15N

92544 04 I 22.15N

92545 04 I 22.15N

92546 04 I 22.15N

92547 04 I 22.15N

Wednesday, June 18, 2008 Page 375 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

92548 04 I 39.35N

92551 04 N 15.20 1 15.20N

92552 04 I 15.20N

92553 04 I 15.20N

92555 04 I 15.20N

92556 04 I 15.20N

92557 04 I 37.40N

92559 09 NY

92560 04 I 15.20N

92561 04 I 26.35N

92562 04 N 7.60N

92563 04 N 15.20N

92564 04 N 15.20N

92565 04 N 15.20N

92567 04 N 15.20N

92568 04 N 13.70N

92569 04 N 14.68N

92571 04 N 15.20N

92572 04 N 15.20N

92575 04 N 15.20N

92576 04 N 15.20N

Wednesday, June 18, 2008 Page 376 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

92577 04 N 12.20N

92579 04 N 22.15N

92582 04 N 22.15N

92583 04 N 15.15YN

92584 04 I 74.90YN

92585 04 I 53.75YN

92586 04 I 47.80YN

92587 04 I 52.70YN

92588 04 I 61.00YN

92590 04 I 37.40N

92591 04 I 37.40N

92592 04 I 15.20N

92593 04 I 15.20N

92594 04 I 15.20N

92595 04 I 15.20N

92596 04 I 15.20N

92597 04 I 43.18N

92601 04 I 55.01N

92602 04 I 38.72N

92603 04 I 37.18N

92604 04 I 25.49N

Wednesday, June 18, 2008 Page 377 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

92605 04 I 24.90N

92606 04 I 24.90YN

92607 04 I 45.85N

92608 04 N 9.25N

92609 04 I 24.90N

92610 04 I 18.00N

92611 04 I 19.55YN

92612 04 I 30.25YN

92613 04 I 30.25YN

92614 04 I 30.25YN

92615 04 I 30.25N

92616 04 I 44.00YN

92617 04 I 44.00N

92620 04 I 24.46YN

92621 04 I 6.63N

92625 04 I 24.06YN

92626 09 NY

92627 09 NY

92630 09 NY

92633 09 NY

92640 04 N 26.67N

Wednesday, June 18, 2008 Page 378 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

92700 04 IYY

92950 04 I 112.50N

92953 04 IYY

92960 04 I 112.40YN

92961 04 I 112.40YN

92970 04 IYY

92971 04 IYY

92973 04 I 156.50YN

92974 04 I 183.90YN

92975 04 MYY

92977 04 MYY

92978 04 I 120.70YN

92979 04 I 74.20YN

92980 04 M 910.70YN

92981 04 MYY

92982 04 M 718.70YN

92984 04 MYY

92986 04 M 682.80YN

92987 04 M 682.80YN

92990 04 M 682.80YN

92992 04 M 898.75YN

Wednesday, June 18, 2008 Page 379 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

92993 04 M 958.60YN

92995 04 M 898.75YN

92996 04 MYY

92997 04 M 718.70YN

92998 04 MYY

93000 A 04 I 11.08 11.07 22.15N

93005 04 I 11.05N

93010 04 I 11.05 5 55.25N

93012 04 I 39.50N

93014 04 I 13.90N

93015 04 I 67.90YN

93016 04 I 21.60N

93017 04 I 27.90YN

93018 04 I 22.15N

93024 04 I 59.60N

93025 04 I 168.20YN

93040 A 04 I 3.80 3.80 7.60N

93041 04 I 3.80N

93042 04 I 4.20N

93224 04 I 180.30YN

93225 04 I 135.90YN

Wednesday, June 18, 2008 Page 380 of 455

Page 388: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

93226 04 I 44.40YN

93227 04 I 44.40N

93230 04 I 158.70YN

93231 04 I 135.90YN

93232 04 I 44.40YN

93233 04 I 44.40N

93235 04 I 180.30YN

93236 04 I 44.40YN

93237 04 I 44.40YN

93268 04 I 73.70N

93270 04 I 21.60YN

93271 04 I 39.50YN

93272 04 I 21.60N

93278 04 I 27.00N

93303 B 04 I 49.05 49.05 98.10YN

93304 B 04 I 26.50 26.50 53.00YN

93307 B 04 I 45.50 45.50 91.00YN

93308 B 04 I 26.35 26.35 52.70YN

93312 B 04 I 81.85 81.85 163.70YN

93313 B 04 I 55.50 55.50 111.00YN

93314 B 04 I 47.15 47.15 94.30N

Wednesday, June 18, 2008 Page 381 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

93315 B 04 I 81.85 81.85 163.70YN

93316 B 04 I 55.50 55.50 111.00YN

93317 B 04 I 53.13 53.12 106.25N

93318 B 04 I 81.85 81.85 163.70YN

93320 B 04 I 19.90 19.90 39.80YN

93321 B 04 I 12.95 12.95 25.90YN

93325 B 04 I 25.17 25.17 50.35YN

93350 B 04 I 81.85 81.85 163.70YN

93501 04 I 371.00YN

93503 04 I 149.80YN

93505 04 I 154.80YN

93508 04 I 318.80YN

93510 04 I 727.50YN

93511 04 I 723.20YN

93514 04 I 783.70YN

93524 04 I 963.70YN

93526 04 I 969.95YN

93527 04 I 991.50YN

93528 04 I 1008.05YN

93529 04 I 899.70YN

93530 04 I 399.90YN

Wednesday, June 18, 2008 Page 382 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

93531 04 I 1021.95YN

93532 04 I 1050.75YN

93533 04 I 940.30YN

93539 04 I 74.90YN

93540 04 I 74.90YN

93541 04 I 74.90YN

93542 04 I 74.90YN

93543 04 I 74.90YN

93544 04 I 74.90YN

93545 04 I 299.70YN

93555 04 I 121.00N

93556 04 I 181.35N

93561 04 I 109.20YN

93562 04 I 149.80YN

93571 B 04 I 57.82 57.82 115.65YN

93572 B 04 I 52.75 52.75 105.50YN

93580 04 MYY

93581 04 MYY

93600 04 I 224.70YN

93602 04 I 224.70YN

93603 04 I 224.70YN

Wednesday, June 18, 2008 Page 383 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

93609 04 I 282.40YN

93610 04 I 224.70YN

93612 04 I 224.70YN

93613 04 I 252.15YN

93615 04 I 224.70YN

93616 04 I 374.60YN

93618 04 I 374.60YN

93619 04 I 343.70YN

93620 04 I 489.60YN

93621 04 I 374.60YN

93622 04 I 374.60YN

93623 04 I 374.60YN

93624 04 I 224.70YN

93631 04 I 310.95YN

93640 04 I 222.35YN

93641 04 I 293.55YN

93642 04 I 262.25YN

93650 04 M 550.90YN

93651 04 M 550.90YN

93652 04 M 550.90YN

93660 04 I 69.30YN

Wednesday, June 18, 2008 Page 384 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

93662 04 I 205.00YN

93668 04 N 28.35N

93701 04 I 30.10YN

93720 04 I 74.90YN

93721 04 I 44.40YN

93722 04 I 22.15N

93724 04 I 224.70N

93727 04 I 31.35N

93731 04 I 31.35N

93732 04 I 31.35N

93733 04 I 22.15N

93734 04 I 31.35N

93735 04 I 31.35N

93736 04 I 22.15N

93740 04 I 7.60N

93741 04 I 29.75N

93742 04 I 36.90N

93743 04 I 33.85N

93744 04 I 42.00N

93745 04 I 36.90YN

93760 04 I 37.40YN

Wednesday, June 18, 2008 Page 385 of 455

Page 393: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

93762 04 I 37.40YN

93770 04 I 16.65N

93784 04 I 180.30YN

93786 04 I 134.60YN

93788 04 I 44.40N

93790 04 I 44.40N

93797 04 N 21.10N

93798 04 I 43.35N

93799 04 IYY

93875 A 04 I 25.03 25.02 50.05YN

93880 A 04 I 39.40 39.40 78.80YN

93882 A 04 I 26.20 26.20 52.40YN

93886 A 04 I 47.15 47.15 94.30YN

93888 A 04 I 31.53 31.52 63.05YN

93890 A 04 I 84.30 84.30 168.60YN

93892 A 04 I 70.87 70.86 141.73YN

93893 A 04 I 69.56 69.56 139.12YN

93922 A 04 I 25.03 25.02 50.05YN

93923 A 04 I 25.47 25.47 50.95YN

93924 A 04 I 28.00 28.00 56.00YN

93925 A 04 I 39.40 39.40 78.80YN

Wednesday, June 18, 2008 Page 386 of 455

Page 394: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

93926 A 04 I 26.35 26.35 52.70YN

93930 A 04 I 40.07 40.08 80.15YN

93931 A 04 I 26.60 26.60 53.20YN

93965 A 04 I 25.03 25.02 50.05YN

93970 B 04 I 17.38 70.17 87.55YN

93971 A 04 I 10.77 47.48 58.25YN

93975 A 04 I 59.60 59.60 119.20YN

93976 A 04 I 39.85 39.85 79.70YN

93978 A 04 I 41.15 41.15 82.30YN

93979 A 04 I 27.40 27.40 54.80YN

93980 A 04 I 45.83 45.82 91.65YN

93981 A 04 I 33.65 33.65 67.30YN

93982 04 1/1/2008 N 22.25N

93990 A 04 I 40.93 40.92 81.85YN

94002 04 I 46.34N

94003 04 I 33.61N

94004 04 I 24.47N

94010 C 04 I 7.65 29.75 37.40N

94014 04 I 52.90N

94015 04 I 29.90N

94016 04 I 23.00N

Wednesday, June 18, 2008 Page 387 of 455

Page 395: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

94060 C 04 I 12.50 40.20 52.70N

94070 C 04 I 15.25 37.45 52.70N

94150 C 04 I 1.60 6.00 7.60N

94200 C 04 I 1.55 15.10 16.65N

94240 C 04 I 4.50 26.00 30.50N

94250 C 04 I 3.20 4.40 7.60N

94260 C 04 I 4.45 10.75 15.20N

94350 C 04 I 1.60 51.10 52.70YN

94360 C 04 I 1.60 21.20 22.80YN

94370 C 04 I 4.45 10.75 15.20N

94375 C 04 I 7.70 36.70 44.40N

94400 C 04 I 4.45 17.70 22.15N

94450 C 04 I 4.45 17.70 22.15N

94452 A 04 I 14.29 14.28 28.57YN

94453 A 04 I 20.21 20.21 40.42YN

94610 04 N 35.06N

94620 C 04 I 12.30 29.80 42.10YN

94621 04 I 59.00YN

94640 04 N 14.50N

94642 04 N 22.05N

94644 04 N 17.87N

Wednesday, June 18, 2008 Page 388 of 455

Page 396: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

94645 04 N 6.92YN

94660 09 IY

94662 04 IYY

94664 04 N 15.20N

94667 04 N 15.20N

94668 04 N 8.20N

94680 C 04 I 7.65 29.75 37.40YN

94681 C 04 I 7.70 36.70 44.40YN

94690 C 04 I 4.50 26.00 30.50YN

94720 C 04 I 9.40 28.00 37.40YN

94725 C 04 I 3.40 34.00 37.40YN

94750 C 04 I 4.45 17.70 22.15YN

94760 C 04 I 1.50 2.90 4.40N

94761 C 04 I 4.45 10.75 15.20N

94762 C 04 I 7.55 14.60 22.15N

94770 C 04 I 1.60 13.60 15.20YN

94772 04 IYY

94774 04 I 52.90N

94777 04 N 23.00N

94799 04 IY

95004 04 N 1.70 65 110.50N

Wednesday, June 18, 2008 Page 389 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

95010 04 N 6.60 65 429.00N

95012 04 I 9.31N

95015 04 N 6.95 80 556.00N

95024 04 N 2.50 40 100.00N

95027 04 N 4.10 40 164.00N

95028 04 N 3.85 40 154.00N

95044 04 N 3.40 65 221.00N

95052 04 N 4.10 200 820.00N

95056 04 N 2.90 1 2.90N

95060 04 N 7.20N

95065 04 N 7.20N

95070 04 N 105.40YN

95071 04 N 59.04YN

95075 04 N 38.84N

95115 04 I 6.50N

95117 04 I 8.30N

95120 04 I 6.50N

95125 04 I 8.30N

95130 04 I 4.20N

95131 04 I 8.60N

95132 04 I 12.75N

Wednesday, June 18, 2008 Page 390 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

95133 04 I 17.00N

95134 04 I 21.30N

95144 04 I 14.30N

95145 04 I 21.60N

95146 04 I 32.40N

95147 04 I 37.80N

95148 04 I 43.25N

95149 04 I 48.60N

95165 04 I 36.00N

95170 04 I 12.30N

95180 04 N 47.50YN

95199 04 IY

95250 04 NY

95251 04 N 15.40N

95805 A 04 I 76.05 76.05 152.10YN

95806 A 04 I 55.27 55.28 110.55YN

95807 A 04 I 77.35 77.35 154.70YN

95808 A 04 I 96.65 96.65 193.30YN

95810 A 04 I 130.80 130.80 261.60YN

95811 A 04 I 136.15 136.15 272.30YN

95812 A 04 I 29.40 29.40 58.80YN

Wednesday, June 18, 2008 Page 391 of 455

Page 399: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

95813 A 04 I 40.90 40.90 81.80YN

95816 A 04 I 28.55 28.55 57.10YN

95819 A 04 I 26.35 26.35 52.70YN

95822 A 04 I 27.65 27.65 55.30YN

95824 A 04 I 26.35 26.35 52.70N

95827 A 04 I 33.40 33.40 66.80YN

95829 04 I 163.50N

95830 04 I 79.10N

95831 04 I 25.60YN

95832 04 I 22.15YN

95833 04 I 52.70YN

95834 04 I 52.70YN

95851 04 I 30.50YN

95852 04 I 30.50YN

95857 04 I 25.60YN

95860 04 I 37.40YN

95861 04 I 56.80YN

95863 04 I 65.70YN

95864 04 I 85.30YN

95865 C 04 I 50.72 13.65 64.37YN

95866 C 04 I 39.54 4.56 44.10YN

Wednesday, June 18, 2008 Page 392 of 455

Page 400: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

95867 04 I 30.70YN

95868 04 I 46.30YN

95869 04 I 52.70YN

95870 04 I 52.70YN

95872 04 I 56.80YN

95873 C 04 I 11.58 4.30 15.88YN

95874 C 04 N 11.76 4.30 16.06YN

95875 04 I 36.60YN

95900 04 IYY

95903 04 IYY

95904 04 IYY

95920 04 MY

95921 04 I 44.50YN

95922 04 I 44.50YN

95923 04 I 44.80YN

95925 04 I 74.90YN

95926 04 I 74.90YN

95927 04 I 74.90YN

95928 04 I 97.05YN

95929 04 I 100.85YN

95930 04 I 52.70YN

Wednesday, June 18, 2008 Page 393 of 455

Page 401: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

95933 04 I 30.50YN

95934 04 I 37.40YN

95936 04 I 37.40YN

95937 04 I 37.40YN

95950 C 04 I 61.31 118.99 180.30YN

95951 C 04 I 71.18 284.72 355.90YN

95953 C 04 I 77.53 102.77 180.30YN

95954 C 04 I 119.09 106.61 1 224.70YN

95955 04 I 62.05YN

95956 C 04 I 100.41 294.32 394.73YN

95957 C 04 I 65.03 37.30 102.33YN

95958 04 I 142.05YN

95961 04 I 180.30YN

95962 04 IYY

95965 A 04 I 138.25 138.25 276.50YN

95966 A 04 I 93.83 93.82 187.65YN

95967 A 04 I 82.35 82.35 164.70N

95970 04 I 41.90N

95971 04 I 41.90N

95972 04 I 41.90N

95973 04 I 41.90N

Wednesday, June 18, 2008 Page 394 of 455

Page 402: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

95974 04 I 68.50YN

95975 04 I 41.90YN

95978 04 I 110.51N

95979 04 I 53.28N

95980 04 1/1/2008 I 22.92N

95981 04 1/1/2008 I 8.89 6.41N

95982 04 1/1/2008 I 18.00 5.81N

95990 04 I 29.41N

95991 04 I 29.41N

95999 04 IYY

96000 04 I 82.00YN

96001 04 N 97.80YN

96002 04 I 19.20YN

96003 04 I 17.90YN

96004 04 I 67.50N

96020 04 I 85.31N

96105 04 I 52.70N

96110 04 N 16.07 2 32.15N

96111 04 N 16.07 2 32.15N

96116 09 IYY

96118 09 IY

Wednesday, June 18, 2008 Page 395 of 455

Page 403: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

96119 09 NY

96120 09 NY

96125 09 1/1/2008 N 46.07 7.81N

96150 04 NY

96151 04 NY

96152 04 NY

96153 04 NY

96154 04 NY

96155 04 NY

96401 04 I 22.15N

96402 04 I 18.39N

96405 04 IY

96406 04 IY

96409 04 I 62.22N

96411 04 I 36.36N

96413 04 I 25.40N

96415 04 I 19.11 8 152.90N

96416 04 I 22.15N

96417 04 I 25.40N

96420 04 I 37.40N

96422 04 I 37.40N

Wednesday, June 18, 2008 Page 396 of 455

Page 404: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

96423 04 I 14.17 8 113.40N

96425 04 I 33.80N

96440 04 I 102.00N

96445 04 I 101.30N

96450 04 I 83.20N

96521 04 I 32.90N

96522 04 I 34.70N

96523 09 NY

96542 04 IY

96549 04 IY

96567 04 IYY

96570 04 IYY

96571 04 IYY

96900 04 I 6.60N

96902 04 N 10.50N

96910 04 I 9.55N

96912 04 I 10.95N

96913 04 I 30.05N

96920 04 IY

96921 04 IY

96922 04 IY

Wednesday, June 18, 2008 Page 397 of 455

Page 405: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

96999 04 IYY

97001 09 IYY

97002 09 IYY

97003 09 IY

97004 09 IY

97005 04 NYY

97006 04 NYY

97010 04 I 4.40YN

97012 04 I 7.70YN

97014 04 I 6.50YN

97016 04 I 7.00YN

97018 04 I 5.95YN

97022 04 I 6.50YN

97024 04 I 4.50YN

97026 04 I 4.40YN

97028 04 I 4.70YN

97032 04 I 7.40YN

97033 04 I 7.70YN

97034 04 I 6.40YN

97035 04 I 5.50YN

97036 04 I 8.95YN

Wednesday, June 18, 2008 Page 398 of 455

Page 406: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

97039 04 IYY

97110 04 N 10.40YN

97112 04 I 10.90YN

97113 04 N 11.50YN

97116 04 I 9.75YN

97124 04 I 8.90N

97139 04 IY

97140 04 I 11.80N

97150 04 I 8.40N

97530 04 I 22.15YN

97532 09 IY

97533 04 I 18.75YN

97535 04 I 11.20YN

97537 04 I 11.00YN

97542 04 I 7.55YN

97545 04 I 27.00YN

97546 09 IY

97597 04 I 27.78YN

97598 04 I 35.97YN

97602 04 I 28.35YN

97605 04 IYY

Wednesday, June 18, 2008 Page 399 of 455

Page 407: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

97606 04 IYY

97750 04 I 22.15YN

97760 09 NYY

97761 09 NYY

97762 09 NYY

97799 04 IYY

97802 09 NY

97803 09 NY

97804 09 NY

98925 04 I 12.55N

98926 04 I 17.60N

98927 04 I 22.05N

98928 04 I 25.50N

98929 04 I 28.60N

98940 09 NY

98941 02 NY

98942 09 NY

98943 09 NY

99000 09 NY

99001 09 NY

99002 09 NY

Wednesday, June 18, 2008 Page 400 of 455

Page 408: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

99056 04 N 14.35N

99058 04 N 14.35N

99070 04 NY

99071 09 NY

99075 09 NY

99078 09 NY

99082 04 NY

99090 09 NY

99091 09 NY

99100 09 NY

99116 09 NY

99135 09 NY

99140 09 NY

99143 04 I 76.70N

99144 04 I 76.70N

99145 04 I 38.35 2 76.70N

99148 04 I 38.35N

99149 04 I 38.35N

99150 04 I 19.17 2 38.35N

99170 04 I 58.90N

99172 04 IY

Wednesday, June 18, 2008 Page 401 of 455

Page 409: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

99173 04 N 7.45 1 7.45N

99175 09 NY

99183 04 I 60.50YN

99185 04 IY

99186 04 IY

99190 04 IY

99191 04 IY

99192 04 IY

99195 04 I 33.25N

99199 04 IY

99201 04 N 27.95 1 27.95N

99202 04 N 32.00 1 32.00N

99203 04 N 41.60 1 41.60N

99204 04 N 66.40 1 66.40N

99205 04 N 70.85 1 70.85N

99211 04 N 12.30 1 12.30N

99212 04 N 24.25 1 24.25N

99213 04 N 28.35 1 28.35N

99214 04 N 42.50 1 42.50N

99215 04 N 48.00 1 48.00N

99217 09 NY

Wednesday, June 18, 2008 Page 402 of 455

Page 410: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

99218 04 N 69.55N

99219 04 N 69.55N

99220 04 N 69.55N

99221 04 N 33.90N

99222 04 N 51.40N

99223 04 N 69.00N

99231 04 N 16.40N

99232 04 N 24.90N

99233 04 N 35.05N

99234 04 N 69.55N

99235 04 N 76.65N

99236 04 N 94.20N

99238 04 N 29.65N

99239 04 N 39.05N

99241 04 N 32.15N

99242 04 N 40.20N

99243 04 N 51.30N

99244 04 N 71.40N

99245 04 N 92.80N

99251 04 N 32.15N

99252 04 N 33.95N

Wednesday, June 18, 2008 Page 403 of 455

Page 411: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

99253 04 N 46.45N

99254 04 N 66.40N

99255 04 N 87.10N

99281 04 N 14.35N

99282 04 N 24.20N

99283 04 N 32.20N

99284 04 N 44.00N

99285 04 N 69.25N

99288 09 NY

99289 04 IY

99290 04 IY

99291 04 N 84.90N

99292 04 N 42.35N

99293 04 N 497.21N

99294 04 N 245.39N

99295 04 N 416.90N

99296 04 N 206.90N

99298 04 N 86.56N

99299 04 N 81.22N

99300 04 N 75.88N

99304 04 N 27.55N

Wednesday, June 18, 2008 Page 404 of 455

Page 412: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

99305 04 N 36.10N

99306 04 N 47.70N

99307 04 N 14.80N

99308 04 N 18.91N

99309 04 N 23.40N

99310 04 N 32.05N

99315 04 N 26.55N

99316 04 N 34.00N

99318 04 N 23.10N

99324 04 N 18.60N

99325 04 N 26.70N

99326 04 N 34.85N

99327 04 N 42.95N

99328 04 N 51.05N

99334 04 N 16.00N

99335 04 N 21.00N

99336 04 N 26.05N

99337 04 N 31.05N

99341 04 N 27.95N

99342 04 N 37.40N

99343 04 N 54.90N

Wednesday, June 18, 2008 Page 405 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

99344 04 N 70.55N

99345 04 N 85.55N

99347 04 N 24.25N

99348 04 N 31.30N

99349 04 N 47.50N

99350 04 N 68.85N

99354 04 IY

99355 04 IY

99356 04 IY

99357 04 IY

99358 09 IY

99359 09 IY

99360 09 IY

99374 09 NY

99377 09 NY

99379 09 NY

99380 09 NY

99381 04 N 32.15 1 32.15N

99382 04 N 32.15 1 32.15N

99383 04 N 32.15 1 32.15N

99384 04 N 32.15 1 32.15N

Wednesday, June 18, 2008 Page 406 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

99385 04 N 32.15 1 32.15N

99386 09 NY

99387 09 NY

99391 04 N 32.15 1 32.15N

99392 04 N 32.15 1 32.15N

99393 04 N 32.15 1 32.15N

99394 04 N 32.15 1 32.15N

99395 04 N 32.15 1 32.15N

99396 09 NY

99397 09 NY

99420 04 N 15.45 1 15.45N

99431 04 N 38.75N

99432 09 NY

99433 04 9/1/2007 N 16.40N

99435 04 N 42.55N

99436 04 N 83.70N

99440 04 N 94.50N

99450 09 NY

99455 09 NY

99456 09 NY

99477 04 1/1/2008 N 189.20N

Wednesday, June 18, 2008 Page 407 of 455

Page 415: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

99499 04 NY

99500 04 NY

99501 04 NY

99502 04 NY

99503 04 NY

99504 04 NY

99505 04 NY

99506 04 NY

99507 04 NY

99509 04 NY

99510 04 N 24.25N

99511 04 NY

99512 04 NY

99600 04 NY

99999 04 NY

A4206 04 N 0.13 5 0.65N

A4207 04 N 0.05 5 0.25N

A4208 04 N 0.27 5 1.35N

A4209 04 N 0.26 5 1.30N

A4212 04 N 2.53 1 2.53N

A4213 04 N 0.32 5 1.60N

Wednesday, June 18, 2008 Page 408 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

A4215 04 N 0.05 5 0.25N

A4261 04 N 61.17N

A4267 04 N 0.45 30 13.62N

A4268 04 N 1.12 30 33.82N

A4269 04 Y NY

A9502 09 NY

A9503 09 NY

A9507 09 NY

A9526 09 NY

A9527 04 1/1/2007 NY

A9528 09 NY

A9529 09 NY

A9530 09 NY

A9531 09 NY

A9532 09 NY

A9543 04 Y NY

A9545 04 Y NY

A9563 04 NY

A9564 04 NY

A9605 09 NY

D1203 04 N 26.00N

Wednesday, June 18, 2008 Page 409 of 455

Page 417: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

E0720 09 Y

G0008 04 N 3.70N

G0009 04 N 3.70N

G0010 04 N 3.70N

G0101 04 I 32.86N

G0102 04 I 28.35N

G0103 B 04 N 8.80 8.80 17.60N

G0104 04 IYY

G0105 04 I 214.00YN

G0108 09 NY

G0109 09 NY

G0111 09 NY

G0117 04 IY

G0118 04 IY

G0121 04 IYY

G0123 04 N 3.50N

G0124 04 N 11.45N

G0125 04 N 920.70YN

G0127 04 N 14.35N

G0128 09 NY

G0130 B 04 N 48.52 48.52 97.05N

Wednesday, June 18, 2008 Page 410 of 455

Page 418: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G0141 04 N 11.45N

G0143 04 N 3.45N

G0144 04 N 3.45N

G0145 04 N 3.45N

G0147 04 N 3.45N

G0148 04 N 3.45N

G0159 04 M 449.50N

G0166 04 I 66.70N

G0168 04 I 22.55N

G0169 04 IY

G0170 04 MY

G0173 04 MY

G0175 09 NY

G0179 09 NY

G0180 09 NY

G0181 09 NY

G0182 09 NY

G0186 04 IY

G0202 B 04 N 35.95 35.95 71.90N

G0204 B 04 N 35.95 35.95 71.90N

G0206 B 04 N 19.60 19.60 39.20N

Wednesday, June 18, 2008 Page 411 of 455

Page 419: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G0219 B 04 N 35.25 35.25 70.50N

G0237 04 IY

G0238 04 IY

G0239 04 IY

G0245 09 NY

G0246 09 NY

G0247 09 NY

G0248 09 NY

G0249 09 NY

G0250 09 NY

G0251 04 NY

G0252 04 N 35.25 35.25 70.50YN

G0255 04 IY

G0256 04 I 256.30N

G0257 04 I 35.75N

G0259 04 I 172.50N

G0260 04 I 31.80N

G0261 04 I 256.30N

G0265 09 NY

G0266 09 NY

G0268 04 I 21.40N

Wednesday, June 18, 2008 Page 412 of 455

Page 420: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G0269 04 IY

G0270 09 NY

G0271 09 NY

G0275 04 I 78.45N

G0278 04 I 78.45N

G0281 04 IY

G0282 04 IY

G0283 04 IY

G0288 B 04 IY

G0289 04 MY

G0290 04 MYY

G0291 04 N MYY

G0293 09 MY

G0294 09 IY

G0295 09 IY

G0297 04 M 256.00YN

G0300 04 M 470.00YN

G0306 A 04 N 2.69 2.69 5.39N

G0307 A 04 N 3.21 3.21 6.42N

G0328 A 04 N 6.66 6.66 13.33N

G0329 04 I 9.05N

Wednesday, June 18, 2008 Page 413 of 455

Page 421: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G0339 B 04 NYY

G0340 B 04 NYY

G0365 A 04 I 25.03 25.02 50.05YN

G0377 04 1/1/2007 N 9.81N

G0380 04 1/1/2007 N 14.35N

G0381 04 1/1/2007 N 24.20N

G0382 04 1/1/2007 N 32.20N

G0383 04 1/1/2007 N 44.00N

G0384 04 1/1/2007 N 69.25N

G0392 04 1/1/2007 M 479.00YN

G0393 04 1/1/2007 M 479.00YN

G0394 04 1/1/2007 N 2.72N

G3001 04 Y NY

G9001 09 NY

G9002 09 NY

G9003 09 NY

G9004 09 NY

G9005 09 NY

G9006 09 NY

G9007 09 NY

G9008 04 NY

Wednesday, June 18, 2008 Page 414 of 455

Page 422: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G9009 09 NY

G9010 09 NY

G9011 09 NY

G9012 09 NY

G9016 09 NY

G9021 09 NY

G9022 09 NY

G9023 09 NY

G9024 09 NY

G9025 09 NY

G9026 09 NY

G9027 09 NY

G9028 09 NY

G9029 09 NY

G9030 09 NY

G9031 09 NY

G9032 09 NY

G9033 09 Y NY

G9034 09 NY

G9050 09 NY

G9051 09 NY

Wednesday, June 18, 2008 Page 415 of 455

Page 423: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G9052 09 NY

G9053 09 NY

G9054 09 NY

G9055 09 NY

G9056 09 NY

G9057 09 NY

G9058 09 NY

G9059 09 NY

G9060 09 NY

G9061 09 NY

G9062 09 NY

G9063 09 NY

G9064 09 NY

G9065 09 NY

G9066 09 NY

G9067 09 NY

G9068 09 NY

G9069 09 NY

G9070 09 NY

G9071 09 NY

G9072 09 NY

Wednesday, June 18, 2008 Page 416 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G9073 09 NY

G9074 09 NY

G9075 09 NY

G9077 09 NY

G9078 09 NY

G9079 09 NY

G9080 09 NY

G9083 09 NY

G9084 09 NY

G9085 09 NY

G9086 09 NY

G9087 09 NY

G9088 09 NY

G9089 09 NY

G9090 09 NY

G9091 09 NY

G9092 09 NY

G9093 09 NY

G9094 09 NY

G9095 09 NY

G9096 09 NY

Wednesday, June 18, 2008 Page 417 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G9097 09 NY

G9098 09 NY

G9099 09 NY

G9100 09 NY

G9101 09 NY

G9102 09 NY

G9103 09 NY

G9104 09 NY

G9105 09 NY

G9106 09 NY

G9107 09 NY

G9108 09 NY

G9109 09 NY

G9110 09 NY

G9111 09 NY

G9112 09 NY

G9113 09 NY

G9114 09 NY

G9115 09 NY

G9116 09 NY

G9117 09 NY

Wednesday, June 18, 2008 Page 418 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

G9123 09 NY

G9124 09 NY

G9125 09 NY

G9126 09 NY

G9128 09 NY

G9129 09 NY

G9130 09 NY

H0033 04 N 118.10 1 118.10N

H1000 04 N 14.60N

J0120 04 Y N 5.49 1 5.49N

J0128 04 Y N 80.66 10 806.60N

J0129 04 1/1/2007 Y NY

J0132 04 Y N 0.32 2 0.64N

J0133 04 Y N 0.14 10 1.40N

J0135 04 Y N 862.86 8 6902.88N

J0150 04 Y 39.55 5 197.75N

J0152 04 Y N 87.14 3 261.42N

J0170 04 Y N 0.14 24 3.36N

J0180 04 Y N 149.52 14 2093.28N

J0190 04 Y NY

J0200 04 Y NY

Wednesday, June 18, 2008 Page 419 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J0205 04 Y N 44.74 8 357.92N

J0207 04 Y N 540.07 2 1080.14N

J0210 04 N 0.83 16 13.28N

J0215 K 04 Y NY

J0220 04 1/1/2008 YY

J0256 04 Y N 2.94 600 1764.00N

J0278 04 Y N 1.37 3 4.11N

J0280 04 N 0.67 6 4.02N

J0282 04 Y N 0.77 5 3.85N

J0285 04 Y N 17.36 6 104.16N

J0287 04 Y N 23.92 50 1196.00N

J0288 04 Y N 15.94 40 637.60N

J0289 04 Y N 39.12 50 1956.00N

J0290 04 Y N 3.39 4 13.56N

J0295 04 Y N 9.39 8 75.12N

J0300 04 NY

J0348 04 1/1/2007 Y NY

J0350 04 Y NY

J0360 04 Y N 15.92 12 191.04N

J0364 04 1/1/2007 Y NY

J0365 04 Y N 2.82 1 2.82N

Wednesday, June 18, 2008 Page 420 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J0370 04 Y N 1.85N

J0380 04 N 13.31 10 133.10N

J0390 04 Y N 3.50N

J0395 04 Y N 191.39 1 191.39N

J0400 04 1/1/2008 Y 2.61 120 313.20N

J0456 04 Y N 30.58 1 30.58N

J0460 04 N 0.61 10 6.10N

J0470 04 N 28.55 5 142.75N

J0475 04 Y N 257.19 12 3086.28N

J0476 04 Y N 83.73 1 83.73N

J0480 04 Y N 1,765.65 1 1765.65N

J0500 04 N 17.81 4 71.24N

J0515 04 Y N 4.10 8 32.80N

J0520 04 Y N 5.42 2 10.84N

J0530 04 Y N 4.05 4 16.20N

J0540 04 Y N 8.10 2 16.20N

J0550 04 Y N 16.20 1 16.20N

J0560 04 Y N 16.36 4 65.44N

J0570 04 Y N 33.25 2 66.50N

J0580 04 Y N 53.78 1 53.78N

J0583 04 Y N 1.81 10 18.10N

Wednesday, June 18, 2008 Page 421 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J0585 K 04 Y NY

J0587 09 N NY

J0592 04 Y N 1.24 6 7.44N

J0594 04 1/1/2007 Y NY

J0595 04 Y N 3.17 2 6.34N

J0600 04 Y N 48.14 2 96.28N

J0610 04 N 0.55 10 5.50N

J0620 04 Y N 12.49 6 74.94N

J0630 04 Y N 45.30 2 90.60N

J0636 04 Y N 1.11 40 44.40N

J0637 04 Y N 41.05 14 574.70N

J0640 04 Y N 3.73 30 111.90N

J0690 04 Y N 1.83 4 7.32N

J0692 04 Y N 9.49 8 75.92N

J0694 04 Y N 9.54 12 114.48N

J0695 04 YY

J0696 04 Y N 16.42 16 262.72N

J0697 04 Y N 5.43 4 21.72N

J0698 04 Y N 8.49 10 84.90N

J0702 04 Y N 3.02 4 12.08N

J0704 04 Y N 4.03 3 12.09N

Wednesday, June 18, 2008 Page 422 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J0706 04 Y N 4.05 4 16.20N

J0710 04 Y N 1.63 2 3.26N

J0713 04 Y N 7.08 12 84.96N

J0715 04 Y N 5.90 12 70.80N

J0720 04 Y N 6.71 7 46.97N

J0725 04 Y NY

J0735 04 Y N 74.44 2 148.88N

J0740 04 Y N 885.21 2 1770.42N

J0743 04 Y N 18.88 6 113.28N

J0744 04 Y N 15.55 5 77.75N

J0745 04 Y N 0.55 12 6.60N

J0760 04 Y N 7.72 2 15.44N

J0770 04 Y N 29.73 4 118.92N

J0780 04 Y N 7.90 10 79.00N

J0785 04 NY

J0795 04 Y N 5.15 10 51.50N

J0800 04 N 129.26 2 258.52N

J0835 04 Y N 88.55 1 88.55N

J0878 04 Y N 0.35 500 175.00N

J0881 04 Y N 5.54 500 2770.00N

J0882 04 Y N 5.54 500 2770.00N

Wednesday, June 18, 2008 Page 423 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J0885 04 Y N 15.16 80 1212.80N

J0886 04 Y N 15.16 80 1212.80N

J0894 04 1/1/2007 Y NY

J0895 04 Y N 15.36 6 92.16N

J0900 04 NY

J0945 04 Y N 0.77 10 7.70N

J0950 04 Y N 8.10N

J0970 04 Y N 34.14 1 34.14N

J1000 04 Y N 6.35 1 6.35N

J1015 04 Y N 18.63N

J1020 04 Y N 2.20 8 17.60N

J1030 04 Y N 4.93 4 19.72N

J1040 04 Y N 9.87 4 39.48N

J1051 04 Y N 20.56 9 185.04N

J1055 04 Y N 61.69 1 61.69N

J1056 04 Y N 26.90 1 26.90N

J1060 04 Y NY

J1070 04 Y N 6.18 3 18.54N

J1080 04 Y N 11.80 2 23.60N

J1094 04 Y N 0.86 32 27.52N

J1100 04 Y N 0.10 40 4.00N

Wednesday, June 18, 2008 Page 424 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J1110 04 N 50.87 3 152.61N

J1120 04 N 22.42 2 44.84N

J1160 04 Y N 2.53 3 7.59N

J1162 04 Y N 755.86 80 60648.80N

J1165 04 Y N 0.40 20 8.00N

J1170 04 Y N 1.78 2 3.56N

J1180 04 NY

J1190 04 Y N 255.72 4 1022.88N

J1200 04 Y N 0.79 2 1.58N

J1205 04 Y N 10.99 1 10.99N

J1212 04 N 50.97 1 50.97N

J1230 04 N 3.62 6 21.72N

J1240 04 N 0.27 8 2.16N

J1245 04 Y N 5.09 6 30.54N

J1250 04 Y N 3.99 1 3.99N

J1260 04 Y N 4.85 20 97.00N

J1265 04 Y N 0.06 7 0.42N

J1270 04 Y N 6.00 4 24.00N

J1300 04 1/1/2008 Y 207.34 90 18660.60N

J1320 04 N 2.62 15 39.30N

J1324 04 1/1/2007 Y NY

Wednesday, June 18, 2008 Page 425 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J1325 04 Y N 22.18 3 66.54N

J1327 04 Y N 24.32 5 121.60N

J1330 04 NY

J1335 04 Y N 23.76 2 47.52N

J1364 04 Y NY

J1380 04 Y N 0.55 4 2.20N

J1390 04 Y N 1.12 2 2.24N

J1405 04 Y N 10.00N

J1410 04 Y N 68.03 4 272.12N

J1430 04 Y N 41.74 1 41.74N

J1435 04 Y N 0.19 5 0.95N

J1436 04 Y NY

J1438 04 Y N 186.86 4 747.44N

J1440 04 Y N 197.17 2 394.34N

J1441 04 Y N 363.48 1 363.48N

J1450 04 Y N 103.11 2 206.22N

J1451 04 Y N 13.79 1 13.79N

J1452 04 Y NY

J1455 04 Y N 88.16 2 176.32N

J1457 04 Y NY

J1458 04 1/1/2007 Y NY

Wednesday, June 18, 2008 Page 426 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J1460 04 Y N 14.21 156 2216.76N

J1470 04 Y NY

J1480 04 Y NY

J1490 04 Y NY

J1500 04 Y NY

J1510 04 Y NY

J1520 04 Y NY

J1530 04 Y NY

J1540 04 Y NY

J1550 04 Y NY

J1560 04 Y NY

J1561 04 1/1/2008 Y NY

J1562 04 1/1/2007 Y NY

J1565 04 Y N 19.00 4 76.00N

J1566 04 Y NY

J1567 04 Y NY

J1568 04 1/1/2008 Y NY

J1569 04 1/1/2008 Y NY

J1571 04 1/1/2008 Y NY

J1572 04 1/1/2008 Y NY

J1573 04 1/1/2008 Y NY

Wednesday, June 18, 2008 Page 427 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J1580 04 Y N 0.70 5 3.50N

J1590 04 Y NY

J1595 04 Y NY

J1600 04 N 10.80 1 10.80N

J1626 04 Y N 19.45 20 389.00N

J1630 04 N 2.37 40 94.80N

J1631 04 Y N 23.86 6 143.16N

J1640 04 Y N 7.65 1 7.65N

J1642 04 Y N 0.03 5 0.15N

J1644 04 Y N 1.18 10 11.80N

J1645 04 Y NY

J1650 04 Y N 7.40 84 621.60N

J1652 04 Y N 43.36 20 867.20N

J1655 04 Y N 4.51 20 90.20N

J1670 04 N 107.66 1 107.66N

J1675 04 Y NY

J1700 04 Y NY

J1710 04 Y N 5.83 5 29.15N

J1720 04 Y N 2.26 10 22.60N

J1730 04 NY

J1740 04 1/1/2007 Y N 167.69 3 503.07N

Wednesday, June 18, 2008 Page 428 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J1742 04 Y N 302.88 1 302.88N

J1743 04 1/1/2008 Y NY

J1745 04 Y N 68.94 100 6894.00N

J1751 04 Y N 16.00 40 640.00N

J1752 04 Y N 16.00 2 32.00N

J1756 04 Y N 0.67 100 67.00N

J1785 04 Y N 4.61 400 1844.00N

J1790 04 Y N 4.23 1 4.23N

J1800 04 Y N 8.22 3 24.66N

J1810 04 Y NY

J1815 04 Y N 0.23 20 4.60N

J1817 04 Y N 2.17 2 4.34N

J1825 04 Y NY

J1835 04 Y N 44.31 8 354.48N

J1840 04 N 2.93 3 8.79N

J1850 04 N 0.43 14 6.02N

J1885 04 Y N 1.05 8 8.40N

J1931 04 Y NY

J1940 04 Y N 0.45 10 4.50N

J1945 04 Y N 179.93 1 179.93N

J1950 04 Y N 591.46 2 1182.92N

Wednesday, June 18, 2008 Page 429 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J1955 04 Y NY

J1956 04 Y N 22.65 2 45.30N

J1960 04 Y N 3.94 2 7.88N

J1980 04 N 10.99 8 87.92N

J1990 04 Y N 26.22 3 78.66N

J2001 04 Y N 0.06 20 1.20N

J2010 04 Y N 3.52 4 14.08N

J2020 04 Y N 42.60 6 255.60N

J2060 04 Y N 1.18 4 4.72N

J2150 04 Y N 1.01 8 8.08N

J2175 04 Y N 0.87 6 5.22N

J2180 04 Y NY

J2185 04 Y N 6.15 10 61.50N

J2210 04 NY

J2248 04 1/1/2007 Y N 2.32 150 348.00N

J2250 04 Y N 0.62 10 6.20N

J2260 04 Y N 35.45 1 35.45N

J2270 04 Y N 0.78 10 7.80N

J2271 04 Y N 1.81 3 5.43N

J2275 04 Y N 2.49 10 24.90N

J2278 04 Y N 7.58 50 379.00N

Wednesday, June 18, 2008 Page 430 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J2280 04 Y NY

J2300 04 Y N 0.66 16 10.56N

J2310 04 N NY

J2315 04 1/1/2007 Y NY

J2320 04 N 4.02 4 16.08N

J2321 04 N 8.04 2 16.08N

J2322 04 N 16.94 1 16.94N

J2323 04 1/1/2008 Y NY

J2325 04 Y N 31.68 5 158.40N

J2353 04 Y NY

J2354 04 Y NY

J2355 04 Y N 305.04 1 305.04N

J2357 04 Y NY

J2360 04 N 20.43 1 20.43N

J2370 04 N 2.65 1 2.65N

J2400 04 Y NY

J2405 04 Y N 6.38 40 255.20N

J2410 04 Y N 3.23 10 32.30N

J2425 04 Y NY

J2430 04 Y N 237.76 3 713.28N

J2440 04 N 2.96 3 8.88N

Wednesday, June 18, 2008 Page 431 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J2460 04 Y N 0.71 10 7.10N

J2469 04 Y N 35.64 10 356.40N

J2501 04 Y N 5.82 20 116.40N

J2503 04 Y NY

J2504 04 Y N 195.38 1 195.38N

J2505 04 Y N 3243.53 1 3243.53N

J2510 04 Y N 10.86 1 10.86N

J2513 04 N 76.09 1 76.09N

J2515 04 N 5.24 4 20.96N

J2540 04 Y N 2.92 1 2.92N

J2543 04 Y N 12.38 12 148.56N

J2545 04 Y N 40.10 1 40.10N

J2550 04 Y N 0.48 1 0.48N

J2560 04 N 1.85 5 9.25N

J2590 04 NY

J2597 04 Y N 3.61 4 14.44N

J2650 04 NY

J2670 04 NY

J2675 04 Y N 3.28 3 9.84N

J2680 04 Y N 21.30 4 85.20N

J2690 04 Y N 2.96 1 2.96N

Wednesday, June 18, 2008 Page 432 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J2700 04 Y N 1.26 20 25.20N

J2710 04 Y N 1.56 8 12.48N

J2720 04 Y N 0.79 5 3.95N

J2724 04 1/1/2008 Y NY

J2730 04 Y N 108.03 3 324.09N

J2760 04 NY

J2765 04 Y N 0.40 14 5.60N

J2770 04 N N 110.30 4 441.20N

J2778 04 1/1/2008 Y NY

J2780 04 Y N 1.50 2 3.00N

J2783 04 Y N 133.87 3 401.61N

J2788 04 Y N 33.03 6 198.18N

J2790 04 Y N 99.92 1 99.92N

J2791 04 1/1/2008 Y NY

J2792 04 Y N 23.58 340 8017.20N

J2794 04 Y NY

J2795 04 N N 0.36 2 0.72N

J2800 04 N 15.49 3 46.47N

J2810 04 Y NY

J2820 04 Y NY

J2910 04 Y N 16.70 1 16.70N

Wednesday, June 18, 2008 Page 433 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J2916 04 Y N 8.56 10 85.60N

J2920 04 Y N 1.73 3 5.19N

J2930 04 Y N 2.88 4 11.52N

J2940 04 Y N 52.69 2 105.38N

J2941 04 Y N 35.68 20 713.60N

J2993 04 N N 1,503.32 2 3006.64N

J2994 04 Y NY

J2995 04 Y NY

J2996 04 Y N 280.60N

J2997 04 Y N 40.41 4 161.64N

J3000 04 Y N 9.06 2 18.12N

J3010 04 Y N 0.29 20 5.80N

J3030 04 Y N 65.71 1 65.71N

J3070 04 N 2.49 12 29.88N

J3100 04 Y N 2,908.32 1 2908.32N

J3105 04 Y N 19.09 3 57.27N

J3110 04 Y NY

J3120 04 N 8.46 4 33.84N

J3130 04 N 16.93 2 33.86N

J3140 04 Y N 0.41 4 1.64N

J3150 04 N 0.83 4 3.32N

Wednesday, June 18, 2008 Page 434 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J3230 04 Y N 12.86 8 102.88N

J3240 04 Y N 822.41 1 822.41N

J3243 04 1/1/2007 NY

J3246 04 Y N 105.80 1 105.80N

J3250 04 Y N 5.46 4 21.84N

J3260 04 Y N 7.73 5 38.65N

J3265 04 Y N 2.03 10 20.30N

J3280 04 Y NY

J3285 04 Y N 64.79 2 129.58N

J3301 04 N N 1.78 8 14.24N

J3302 04 Y N 0.54 32 17.28N

J3305 04 Y N 175.99 5 879.95N

J3310 04 Y N 1.75N

J3315 04 Y N 604.34 3 1813.02N

J3320 04 Y N 35.36 1 35.36N

J3350 04 NY

J3360 04 Y N 0.14 6 0.84N

J3364 04 Y N 56.42 2 112.84N

J3365 04 Y N 538.08 2 1076.16N

J3370 04 Y N 3.34 4 13.36N

J3396 04 Y N 11.20 150 1680.00N

Wednesday, June 18, 2008 Page 435 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J3400 04 Y N 3.80N

J3410 04 Y N 0.27 4 1.08N

J3411 04 Y N 0.84 2 1.68N

J3415 04 Y N 0.61 5 3.05N

J3420 04 Y N 0.18 1 0.18N

J3430 04 Y N 0.19 25 4.87N

J3465 04 Y N 5.72 60 343.20N

J3470 04 N 24.92 1 24.92N

J3471 04 Y N 0.13 999 129.87N

J3472 04 Y N 0.13 1,000 130.00N

J3473 04 1/1/2007 Y NY

J3475 04 Y N 0.07 20 1.40N

J3480 04 Y N 0.13 20 2.60N

J3485 04 Y N 1.21 50 60.50N

J3486 04 Y N 23.84 4 95.36N

J3487 04 Y N 237.65 4 950.60N

J3488 04 1/1/2008 Y NY

J3490 04 Y NY

J3520 04 Y N 1.40 20 28.00N

J3530 04 NY

J3590 04 Y NY

Wednesday, June 18, 2008 Page 436 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J7030 04 Y N 1.30 2 2.60N

J7040 04 Y N 1.17 2 2.34N

J7042 04 Y N 1.52 2 3.04N

J7050 04 Y N 3.64 2 7.28N

J7060 04 Y N 4.24 2 8.48N

J7070 04 Y N 1.43 2 2.86N

J7100 04 NY

J7110 04 NY

J7120 04 Y N 1.61 2 3.22N

J7130 04 NY

J7187 04 1/1/2007 Y NY

J7189 04 Y N 1.15 1,000 1150.00N

J7190 04 Y N 0.75 1250 937.50N

J7191 04 Y N 2.18 550 1199.00N

J7192 04 Y N 0.67 2000 1340.00N

J7193 04 Y N 0.91 812 738.92N

J7194 04 Y N 0.47 1000 470.00N

J7195 04 Y N 1.03 1000 1030.00N

J7198 04 Y N 1.15 615 707.25N

J7199 04 Y NY

J7300 04 Y N 423.10N

Wednesday, June 18, 2008 Page 437 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J7302 04 Y N 470.39 1 470.39N

J7303 04 Y N 43.80 3 131.40N

J7304 04 Y N 15.67 9 141.03N

J7306 04 Y NY

J7307 04 1/1/2008 Y N 651.69 1 651.69N

J7308 04 Y N 105.91 1 105.91N

J7310 04 Y N 4,984.32 1 4984.32N

J7311 04 1/1/2007 Y NY

J7318 04 N 4.92 25 123.00N

J7319 ^ 04 Y NY

J7321 04 1/1/2008 Y NY

J7322 04 1/1/2008 Y NY

J7323 04 1/1/2008 Y NY

J7324 04 1/1/2008 Y NY

J7330 04 NY

J7340 04 MY

J7341 04 NY

J7342 04 Y NY

J7343 04 NY

J7344 04 NY

J7346 04 1/1/2007 Y NY

Wednesday, June 18, 2008 Page 438 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J7347 04 1/1/2008 NY

J7348 04 1/1/2008 NY

J7349 04 1/1/2008 NY

J7500 09 N NY

J7501 04 N N 72.21 5 361.05N

J7502 04 Y N 6.70 15 100.50N

J7504 04 Y N 359.26 12 4311.12N

J7505 04 Y N 980.75 1 980.75N

J7506 04 Y N 0.02 20 0.40N

J7507 04 Y N 4.12 20 82.40N

J7509 04 Y N 0.31 12 3.72N

J7510 04 Y N 0.11 40 4.40N

J7511 04 N N 429.89 1 429.89N

J7513 04 Y N 512.28 4 2049.12N

J7515 04 Y N 1.67 20 33.40N

J7516 04 Y N 24.77 3 74.31N

J7517 04 Y N 3.21 8 25.68N

J7518 04 Y NY

J7520 04 Y N 8.31 6 49.86N

J7525 04 Y N 164.48 1 164.48N

J7599 04 Y NY

Wednesday, June 18, 2008 Page 439 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J7602 04 1/1/2008 Y NY

J7603 04 1/1/2008 Y NY

J7604 04 1/1/2008 Y N 5.53 1 5.53N

J7605 04 1/1/2008 Y N 5.73 1 5.73N

J7607 04 1/1/2007 Y NY

J7608 04 Y N 3.28 4 13.12N

J7609 04 1/1/2007 Y NY

J7610 04 1/1/2007 Y NY

J7611 04 4/1/2008 Y 0.03 5 0.15N

J7612 04 4/1/2008 Y 1.15 5 5.75N

J7613 04 4/1/2008 Y 0.06 5 0.15N

J7614 04 4/1/2008 Y 2.11 5 10.55N

J7615 04 1/1/2007 Y NY

J7620 04 Y NY

J7625 04 Y N 1.10N

J7626 04 Y N 4.91 4 19.64N

J7627 04 Y N 0.09 4 0.36N

J7628 04 Y NY

J7629 04 Y NY

J7630 04 Y N 1.10N

J7631 04 Y N 0.33 2 0.66N

Wednesday, June 18, 2008 Page 440 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J7632 04 1/1/2008 Y N 0.33 2 0.66N

J7633 04 Y N 5.16 2 10.32N

J7634 04 1/1/2007 Y NY

J7635 04 Y N 0.40 2 0.80N

J7636 04 Y NY

J7637 04 Y N 11.21 1 11.21N

J7638 04 Y NY

J7639 04 Y N 22.56 2 45.12N

J7640 04 Y N 1.85 5 9.25N

J7642 04 Y NY

J7644 04 Y N 0.40 5 2.00N

J7645 04 1/1/2007 Y NY

J7647 04 1/1/2007 Y NY

J7648 04 Y NY

J7649 04 Y NY

J7650 04 1/1/2007 Y NY

J7657 04 1/1/2007 Y NY

J7658 04 Y NY

J7659 04 Y NY

J7660 04 1/1/2007 Y NY

J7665 04 Y N 2.15N

Wednesday, June 18, 2008 Page 441 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J7667 04 1/1/2007 Y NY

J7668 04 Y NY

J7669 04 Y N 0.54 1 0.54N

J7670 04 1/1/2007 Y NY

J7674 04 Y N 0.47 2 0.94N

J7676 04 1/1/2008 Y NY

J7680 04 Y NY

J7681 04 Y NY

J7682 04 Y N 63.79 1 63.79N

J7683 04 Y NY

J7684 04 Y NY

J7685 04 1/1/2007 Y NY

J7699 04 Y NY

J7799 04 Y NY

J8499 04 Y NY

J8501 04 Y NY

J8510 04 Y NY

J8520 04 Y N 3.91 100 391.00N

J8521 04 Y N 13.07 200 2614.00N

J8530 04 Y N 1.91 60 114.60N

J8560 04 Y N 63.56 4 254.24N

Wednesday, June 18, 2008 Page 442 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J8565 04 Y N 70.68 1 70.68N

J8600 04 Y N 5.39 3 16.17N

J8610 04 Y N 0.36 12 4.32N

J8700 04 Y N 8.84 50 442.00N

J8999 04 Y NY

J9000 04 Y N 11.67 20 233.40N

J9001 04 Y N 459.35 10 4593.50N

J9010 04 N N 637.29 3 1911.87N

J9015 04 Y N 891.57 1 891.57N

J9017 04 Y N 39.87 15 598.05N

J9020 04 Y N 65.70 2 131.40N

J9025 04 Y N 4.93 185 912.05N

J9027 04 Y NY

J9031 04 Y N 190.89 1 190.89N

J9035 04 Y N 68.53 100 6853.00N

J9040 04 Y N 248.46 3 745.38N

J9041 04 Y N 36.12 35 1264.20N

J9045 04 Y N 28.98 20 579.60N

J9050 04 Y N 169.76 8 1358.08N

J9055 04 Y N 59.81 100 5981.00N

J9060 04 Y N 40.78 30 1223.40N

Wednesday, June 18, 2008 Page 443 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J9062 04 Y N 203.90 4 815.60N

J9065 04 Y N 47.78 10 477.80N

J9070 04 Y N 2.87 20 57.40N

J9080 04 Y N 5.74 10 57.46N

J9090 04 Y N 13.49 4 53.96N

J9091 04 Y N 28.78 2 57.56N

J9092 04 Y N 44.59 1 44.59N

J9093 04 Y N 2.87 20 57.40N

J9094 04 Y N 9.99 4 39.96N

J9095 04 Y N 13.49 4 53.96N

J9096 04 Y N 28.78 2 57.56N

J9097 04 Y N 44.59 2 89.18N

J9098 04 Y N 454.56 5 2272.80N

J9100 04 Y N 3.18 60 190.80N

J9110 04 Y N 9.01 4 36.04N

J9120 04 Y N 14.54 3 43.62N

J9130 04 Y N 11.76 10 117.60N

J9140 04 Y N 19.65 5 98.25N

J9150 04 Y N 32.68 6 196.08N

J9151 04 Y N 67.74 8 541.92N

J9160 04 Y N 1,694.66 6 10167.96N

Wednesday, June 18, 2008 Page 444 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J9165 04 Y NY

J9170 04 Y N 386.82 13 5028.66N

J9175 04 Y NY

J9178 04 Y N 29.87 100 2987.00N

J9181 04 Y N 13.38 45 602.10N

J9182 04 Y N 133.93 3 401.79N

J9185 04 Y N 292.33 1 292.33N

J9190 04 Y N 3.18 12 38.16N

J9200 04 Y N 127.44 1 127.44N

J9201 04 Y N 142.20 10 1422.00N

J9202 04 Y N 468.51 3 1405.53N

J9206 04 Y N 152.95 44 6729.80N

J9208 04 N N 134.50 5 672.50N

J9209 04 N N 35.75 25 893.75N

J9211 04 Y N 417.26 10 4172.60N

J9212 04 Y N 14.16 90 1274.40N

J9213 04 Y N 42.02 1 42.02N

J9214 04 Y N 14.16 90 1274.40N

J9215 04 Y N 8.23 20 164.60N

J9216 04 Y N 379.81 2 759.62N

J9217 04 Y N 736.43 6 4418.58N

Wednesday, June 18, 2008 Page 445 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J9218 04 Y N 154.69 12 1856.28N

J9219 04 Y N 5,666.17 1 5666.17N

J9225 04 Y N 5,500.00 1 5,500.00N

J9226 04 1/1/2008 Y N 15,400.00 1 15,400.00N

J9230 04 Y N 12.59 3 37.77N

J9245 04 Y NY

J9250 04 Y N 0.21 20 4.20N

J9260 04 Y N 2.24 600 1344.00N

J9261 04 1/1/2007 Y NY

J9263 04 Y N 10.30 400 4120.00N

J9264 04 Y N 9.91 450 4459.50N

J9265 04 Y N 146.69 15 2200.35N

J9266 04 Y N 1,894.04 5 9470.20N

J9268 04 Y N 2,354.63 1 2354.63N

J9270 04 Y N 98.41 1 98.41N

J9280 04 Y N 92.36 8 738.88N

J9290 04 Y N 369.46 2 738.92N

J9291 04 Y N 895.77 1 895.77N

J9293 04 Y N 411.65 5 2058.25N

J9300 04 Y N 2,751.34 3 8254.02N

J9303 04 1/1/2008 Y NY

Wednesday, June 18, 2008 Page 446 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

J9305 04 Y N 49.80 100 4980.00N

J9310 04 Y N 546.80 10 5468.00N

J9320 04 Y N 185.66 1 185.66N

J9340 04 Y N 104.60 3 313.80N

J9350 04 Y N 972.24 3 2916.72N

J9355 04 Y N 66.34 50 3317.00N

J9357 04 Y N 552.65 1 552.65N

J9360 04 Y N 1.01 20 20.20N

J9370 04 Y N 15.97 4 63.88N

J9375 04 Y N 31.94 1 31.94N

J9380 04 Y N 79.86 1 79.86N

J9390 04 Y N 119.14 8 953.12N

J9395 04 Y N 196.11 10 1961.10N

J9600 04 Y N 3,005.31 2 6010.62N

J9999 04 NY

M0064 02 N 10.00N

M0075 04 NY

M0076 04 NY

P3000 04 N 3.55N

P3001 04 N 11.45N

P7001 A 04 N 6.40 6.40 12.80N

Wednesday, June 18, 2008 Page 447 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

P9041 09 NY

P9043 09 NY

P9045 09 NY

P9046 09 NY

P9047 09 NY

P9048 09 NY

P9050 04 NY

P9604 04 N 2.90N

P9612 09 NY

P9615 09 NY

Q0044 02 N 7.60N

Q0081 04 IY

Q0083 04 I 19.00N

Q0084 04 I 19.00N

Q0085 04 I 19.00N

Q0111 B 04 N 2.40 2.40 4.80N

Q0112 B 04 N 2.40 2.40 4.80N

Q0113 B 04 N 2.40 2.40 4.80N

Q0114 B 04 N 2.40 2.40 4.80N

Q0163 04 Y N 0.09 2 0.18N

Q0164 04 Y N 0.44 10 4.40N

Wednesday, June 18, 2008 Page 448 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

Q0165 04 Y N 0.64 5 3.20N

Q0166 04 Y N 46.88 2 93.76N

Q0168 04 Y N 10.47 2 20.94N

Q0169 04 Y N 0.28 4 1.12N

Q0170 04 Y N 0.57 2 1.14N

Q0171 04 Y N 0.27 5 1.35N

Q0172 04 Y N 0.41 16 6.56N

Q0173 04 Y N 0.28 4 1.12N

Q0174 04 Y N 0.60 6 3.60N

Q0175 04 Y N 0.79 6 4.74N

Q0176 04 Y N 0.96 3 2.88N

Q0177 04 Y N 0.09 16 1.44N

Q0178 04 Y N 0.11 8 0.88N

Q0179 04 Y N 28.80 4 115.20N

Q0180 04 Y N 75.99 1 75.99N

Q0181 04 Y NY

Q0515 04 Y NY

Q2004 04 Y NY

Q2009 04 Y N 7.30 40 292.00N

Q2017 04 Y N 320.97 6 1925.82N

Q3014 09 NY

Wednesday, June 18, 2008 Page 449 of 455

Page 457: Physician Fee Schedule Key COLUMN HEADING … Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION ... applies to the code. A Professional and Technical components are each reimbursed

Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

Q3025 04 Y NY

Q3026 04 Y N 55.40N

Q3031 04 NY

Q4001 09 NY

Q4002 09 NY

Q4003 09 NY

Q4004 09 NY

Q4005 09 NY

Q4011 09 NY

Q4013 09 NY

Q4014 09 NY

Q4015 09 NY

Q4016 09 NY

Q4018 09 NY

Q4019 09 NY

Q4020 09 NY

Q4024 09 NY

Q4025 09 NY

Q4026 09 NY

Q4027 09 NY

Q4028 09 NY

Wednesday, June 18, 2008 Page 450 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

Q4029 09 NY

Q4031 09 NY

Q4033 09 NY

Q4035 09 NY

Q4036 09 NY

Q4037 09 NY

Q4041 09 NY

Q4044 09 NY

Q4045 09 NY

Q4046 09 NY

Q4047 09 NY

Q4048 09 NY

Q4049 09 NY

Q4050 09 NY

Q4051 09 NY

Q4080 04 Y NY

Q4081 04 1/1/2007 Y N 1.56 800 1248.00N

Q4083 04 1/1/2007 Y N 145.54 2 291.08N

Q4084 04 1/1/2007 Y N 244.63 2 489.26N

Q4085 04 1/1/2007 Y N 123.87 2 247.74N

Q4086 04 1/1/2007 N 260.53 2 521.06N

Wednesday, June 18, 2008 Page 451 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

Q4087 04 7/1/2007 Y

Q4088 04 7/1/2007 Y

Q4089 04 7/1/2007 Y

Q4090 04 7/1/2007 Y

Q4091 04 Y

Q4092 04 Y

Q4096 04 4/1/2008 Y

Q4097 04 4/1/2008 Y

Q4098 04 4/1/2008 Y

Q4099 04 4/1/2008 Y

R0070 04 N 4.10N

R0075 04 N 4.10N

R0076 09 NY

S0017 04 Y N 1.01 6 6.06N

S0021 04 Y NY

S0023 04 Y N 1.04 4 4.16N

S0028 04 Y N 1.24 2 2.48N

S0030 04 Y N 27.61 3 82.83N

S0032 04 Y N 6.58 3 19.74N

S0034 04 Y N 27.50 2 55.00N

S0039 04 Y N 5.86 12 70.32N

Wednesday, June 18, 2008 Page 452 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

S0040 04 Y N 15.64 10 156.40N

S0073 04 Y N 14.90 16 238.40N

S0074 04 Y N 7.28 12 87.36N

S0077 04 Y N 2.74 6 16.44N

S0078 04 Y N 109.50 2 219.00N

S0080 04 Y N 40.10 1 40.10N

S0081 04 Y N 2.16 12 25.92N

S0088 04 Y N 25.42 6 152.52N

S0092 04 Y N 97.36 1 97.36N

S0093 04 Y N 9.05 1 9.05N

S0142 04 Y NY

S0145 04 Y NY

S0146 04 Y NY

S0155 04 Y NY

S0162 04 N 341.92N

S0166 04 Y N 6.07 4 24.28N

S0190 04 Y N 306.10N

S0191 04 Y N 2.40N

S0195 04 N 72.27N

S0630 04 I 24.35N

S1015 04 NY

Wednesday, June 18, 2008 Page 453 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

S1016 04 NY

S2066 04 1/1/2008 MY

S2067 04 1/1/2008 MY

S2068 04 MY

S2070 04 I 198.98YN

S2075 04 MYY

S2076 04 MYY

S2077 04 MYY

S2079 04 MYY

S2080 04 M 388.70N

S2083 04 N 10.00N

S2135 04 I 90.50YN

S2225 04 I 43.80 17.00YN

S2325 04 MY

S3626 04 NY

S3628 04 4/1/2008

S4981 04 IY

S4989 04 NY

S4990 09 NY

S4993 04 Y N 1.35 91 122.85N

S9123 09 NY

Wednesday, June 18, 2008 Page 454 of 455

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Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP

S9124 09 NY

S9125 09 NY

S9127 09 NY

S9460 09 NY

S9474 09 NY

S9480 04 NN

T1015 D 04 N 0.0000 1Y

T1029 04 N 41.30N

Wednesday, June 18, 2008 Page 455 of 455


Physician Fee Schedule Key Revised 09-29-08 COLUMN HEADING ... · Fee Schedule Key - 1 Physician Fee Schedule Key Revised 09-29-08 COLUMN HEADING COLUMN DESCRIPTION HCPCS CPT–4

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Building 026 Heavy Fabrication - Stanford University · Building 499 499-A 499-B 26-A Column 12 Column 10 Column 9 Column 8 Column 7 Column 6 Column 5 Column 4 Column 2 Column 3 Column

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actweb.acttax.com 1… · Web viewCHANGES TO YEARLY SUMMARY PAGE 1) CHANGE SALES AMOUNT COLUMN HEADING TO "INVENTORY SALES*" AND FOR THIS COLUMN, ONLY SHOW THE INVENTORY SALES CATEGORY

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MOAC Excel 2013 exam 77 420 · You can use the Format Painter to copy the width of one column to other columns. To do so, select the heading of the first column, click the Format

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Blackbit Pim Import¼cher/Ultima... · JSON JMESPath / JSON Pointer Excel Column name or column heading Pimcore objects Data query selector 2. Map data from intermediate table to

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Mapping Vocabulary Rogich Earth Science. Instructions Make a 3 column chart Write the word in the slide heading in your first column Write the sentence.

Mapping Vocabulary Rogich Earth Science. Instructions Make a 3 column chart Write the word in the slide heading in your first column Write the sentence.

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Heading 1 Heading Connex 1 150 & 200 - Boral

PowerSchool ESL...Row 10 – Click on Fields and choose and other ESL field that you would like listed. Click in the Column Title field and type the name of the column heading. l.

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COMPARISON OF CALCULATED OSCILLATOR STRENGTHS … · Comparison of calculated oscillator strengths ... Under the column heading marked “gf-values” we give two entries for each

COMPARISON OF CALCULATED OSCILLATOR STRENGTHS … · Comparison of calculated oscillator strengths ... Under the column heading marked “gf-values” we give two entries for each

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ktdrr.orgktdrr.org/training/webcasts/webcast10-13/13/docs/webin…  · Web view-pmr.org/article/S0003-9993 ... The first contains as column heading the word ‘CRITERION: ... KT

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