1H99RPPS5 NHIC, CORP. REVISED FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 1 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- A9527 C 0.00 0.00 0.00 G0260 S 414.52 0.00 0.00 C1716 C 0.00 0.00 0.00 G0339 A 3,280.36 0.00 0.00 C1717 C 0.00 0.00 0.00 G0340 A 2,396.29 0.00 0.00 C1719 C 0.00 0.00 0.00 G0364 S 7.33 0.00 0.00 C1821 C 0.00 0.00 0.00 G0392 S 1,892.97 0.00 0.00 C2616 C 0.00 0.00 0.00 G0393 S 1,892.97 0.00 0.00 C2634 C 0.00 0.00 0.00 L8690 C 0.00 0.00 0.00 C2635 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00 C2636 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00 C2638 C 0.00 0.00 0.00 0016T S 219.75 0.00 0.00 C2639 C 0.00 0.00 0.00 0017T S 219.75 0.00 0.00 C2640 C 0.00 0.00 0.00 0027T S 959.80 0.00 0.00 C2641 C 0.00 0.00 0.00 0046T S 856.03 0.00 0.00 C2642 C 0.00 0.00 0.00 0047T S 856.03 0.00 0.00 C2643 C 0.00 0.00 0.00 0062T S 1,552.02 0.00 0.00 C2698 C 0.00 0.00 0.00 0063T S 1,552.02 0.00 0.00 C2699 C 0.00 0.00 0.00 0067T TC A 160.08 0.00 0.00 C8900 A 331.52 0.00 0.00 0071T A 3,280.36 0.00 0.00 C8901 A 286.76 0.00 0.00 0072T A 3,280.36 0.00 0.00 C8902 A 438.46 0.00 0.00 0073T A 290.20 0.00 0.00 C8903 A 331.52 0.00 0.00 0084T S 106.75 0.00 0.00 C8904 A 286.76 0.00 0.00 0088T S 868.19 0.00 0.00 C8905 A 438.46 0.00 0.00 0099T S 859.81 0.00 0.00 C8906 A 331.52 0.00 0.00 0100T S 1,978.31 0.00 0.00 C8907 A 286.76 0.00 0.00 0101T S 1,552.02 0.00 0.00 C8908 A 438.46 0.00 0.00 0102T S 1,552.02 0.00 0.00 C8909 A 331.52 0.00 0.00 0123T S 1,232.24 0.00 0.00 C8910 A 286.76 0.00 0.00 0124T S 272.06 0.00 0.00 C8911 A 438.46 0.00 0.00 0137T S 586.66 0.00 0.00 C8912 A 331.52 0.00 0.00 0144T TC A 84.22 0.00 0.00 C8913 A 286.76 0.00 0.00 0145T TC A 249.93 0.00 0.00 C8914 A 438.46 0.00 0.00 0146T TC A 249.93 0.00 0.00 C8918 A 331.52 0.00 0.00 0147T TC A 249.93 0.00 0.00 C8919 A 286.76 0.00 0.00 0148T TC A 249.93 0.00 0.00 C8920 A 438.46 0.00 0.00 0149T TC A 249.93 0.00 0.00 C9716 S 1,603.62 0.00 0.00 0150T TC A 249.93 0.00 0.00 C9724 S 1,346.42 0.00 0.00 0151T TC A 84.22 0.00 0.00 C9725 S 459.12 0.00 0.00 0170T S 1,603.62 0.00 0.00 C9726 S 542.60 0.00 0.00 0176T S 1,817.55 0.00 0.00 C9727 S 709.55 0.00 0.00 0177T S 1,817.55 0.00 0.00 C9728 S 162.00 0.00 0.00 0182T A 1,460.83 0.00 0.00 G0104 S 117.39 0.00 0.00 0186T S 969.54 0.00 0.00 G0105 S 533.93 0.00 0.00 10021 S 59.00 0.00 0.00 G0121 S 533.93 0.00 0.00 10022 S 230.06 0.00 0.00 G0127 S 15.66 0.00 0.00 10040 S 42.16 0.00 0.00 G0130 TC A 31.80 0.00 0.00 10060 S 66.52 0.00 0.00 G0173 A 3,280.36 0.00 0.00 10061 S 74.78 0.00 0.00 G0186 S 219.75 0.00 0.00 10080 S 74.78 0.00 0.00 G0247 S 29.35 0.00 0.00 10081 S 184.89 0.00 0.00 G0251 A 882.14 0.00 0.00 10120 S 74.78 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 2 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 10121 S 643.59 0.00 0.00 11446 S 710.18 0.00 0.00 10140 S 98.81 0.00 0.00 11450 S 710.18 0.00 0.00 10160 S 74.78 0.00 0.00 11451 S 710.18 0.00 0.00 10180 S 673.09 0.00 0.00 11462 S 710.18 0.00 0.00 11000 S 31.80 0.00 0.00 11463 S 710.18 0.00 0.00 11001 S 11.25 0.00 0.00 11470 S 710.18 0.00 0.00 11010 S 299.47 0.00 0.00 11471 S 710.18 0.00 0.00 11011 S 299.47 0.00 0.00 11600 S 131.57 0.00 0.00 11012 S 299.47 0.00 0.00 11601 S 150.17 0.00 0.00 11040 S 29.35 0.00 0.00 11602 S 163.37 0.00 0.00 11041 S 33.75 0.00 0.00 11603 S 174.13 0.00 0.00 11042 S 193.73 0.00 0.00 11604 S 518.53 0.00 0.00 11043 S 193.73 0.00 0.00 11606 S 643.59 0.00 0.00 11044 S 499.00 0.00 0.00 11620 S 133.05 0.00 0.00 11055 S 33.26 0.00 0.00 11621 S 151.63 0.00 0.00 11056 S 37.18 0.00 0.00 11622 S 167.77 0.00 0.00 11057 S 42.06 0.00 0.00 11623 S 182.44 0.00 0.00 11100 S 42.16 0.00 0.00 11624 S 643.59 0.00 0.00 11101 S 18.10 0.00 0.00 11626 S 710.18 0.00 0.00 11200 S 42.16 0.00 0.00 11640 S 139.89 0.00 0.00 11201 S 7.82 0.00 0.00 11641 S 162.88 0.00 0.00 11300 S 42.16 0.00 0.00 11642 S 181.95 0.00 0.00 11301 S 42.16 0.00 0.00 11643 S 197.61 0.00 0.00 11302 S 42.16 0.00 0.00 11644 S 643.59 0.00 0.00 11303 S 77.59 0.00 0.00 11646 S 710.18 0.00 0.00 11305 S 42.16 0.00 0.00 11719 S 15.17 0.00 0.00 11306 S 42.16 0.00 0.00 11720 S 19.56 0.00 0.00 11307 S 42.16 0.00 0.00 11721 S 23.96 0.00 0.00 11308 S 42.16 0.00 0.00 11730 S 42.16 0.00 0.00 11310 S 42.16 0.00 0.00 11732 S 23.96 0.00 0.00 11311 S 42.16 0.00 0.00 11740 S 15.76 0.00 0.00 11312 S 42.16 0.00 0.00 11750 S 125.21 0.00 0.00 11313 S 42.16 0.00 0.00 11752 S 172.67 0.00 0.00 11400 S 94.89 0.00 0.00 11755 S 88.05 0.00 0.00 11401 S 103.69 0.00 0.00 11760 S 111.92 0.00 0.00 11402 S 112.99 0.00 0.00 11762 S 160.93 0.00 0.00 11403 S 121.31 0.00 0.00 11765 S 77.59 0.00 0.00 11404 S 534.75 0.00 0.00 11770 S 771.82 0.00 0.00 11406 S 643.59 0.00 0.00 11771 S 771.82 0.00 0.00 11420 S 88.05 0.00 0.00 11772 S 771.82 0.00 0.00 11421 S 104.68 0.00 0.00 11900 S 38.16 0.00 0.00 11422 S 114.94 0.00 0.00 11901 S 40.60 0.00 0.00 11423 S 128.64 0.00 0.00 11920 S 111.92 0.00 0.00 11424 S 643.59 0.00 0.00 11921 S 111.92 0.00 0.00 11426 S 710.18 0.00 0.00 11922 S 50.38 0.00 0.00 11440 S 102.71 0.00 0.00 11950 S 49.41 0.00 0.00 11441 S 115.44 0.00 0.00 11951 S 58.69 0.00 0.00 11442 S 126.69 0.00 0.00 11952 S 68.01 0.00 0.00 11443 S 141.85 0.00 0.00 11954 S 68.01 0.00 0.00 11444 S 436.18 0.00 0.00 11960 S 698.18 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 3 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 11970 S 1,062.60 0.00 0.00 13150 S 371.55 0.00 0.00 11971 S 601.34 0.00 0.00 13151 S 371.55 0.00 0.00 11976 S 84.13 0.00 0.00 13152 S 371.55 0.00 0.00 11980 S 33.54 0.00 0.00 13153 S 115.87 0.00 0.00 11981 S 33.54 0.00 0.00 13160 S 698.18 0.00 0.00 11982 S 33.54 0.00 0.00 14000 S 629.58 0.00 0.00 11983 S 33.54 0.00 0.00 14001 S 691.22 0.00 0.00 12001 S 68.01 0.00 0.00 14020 S 691.22 0.00 0.00 12002 S 68.01 0.00 0.00 14021 S 691.22 0.00 0.00 12004 S 68.01 0.00 0.00 14040 S 629.58 0.00 0.00 12005 S 104.88 0.00 0.00 14041 S 691.22 0.00 0.00 12006 S 104.88 0.00 0.00 14060 S 691.22 0.00 0.00 12007 S 104.88 0.00 0.00 14061 S 691.22 0.00 0.00 12011 S 68.01 0.00 0.00 14300 S 875.41 0.00 0.00 12013 S 68.01 0.00 0.00 14350 S 759.83 0.00 0.00 12014 S 68.01 0.00 0.00 15002 S 371.55 0.00 0.00 12015 S 68.01 0.00 0.00 15003 S 371.55 0.00 0.00 12016 S 104.88 0.00 0.00 15004 S 371.55 0.00 0.00 12017 S 104.88 0.00 0.00 15005 S 371.55 0.00 0.00 12018 S 104.88 0.00 0.00 15040 S 115.87 0.00 0.00 12020 S 148.05 0.00 0.00 15050 S 371.55 0.00 0.00 12021 S 148.05 0.00 0.00 15100 S 698.18 0.00 0.00 12031 S 111.92 0.00 0.00 15101 S 759.83 0.00 0.00 12032 S 111.92 0.00 0.00 15110 S 489.75 0.00 0.00 12034 S 115.87 0.00 0.00 15111 S 380.91 0.00 0.00 12035 S 115.87 0.00 0.00 15115 S 489.75 0.00 0.00 12036 S 115.87 0.00 0.00 15116 S 380.91 0.00 0.00 12037 S 339.36 0.00 0.00 15120 S 698.18 0.00 0.00 12041 S 111.92 0.00 0.00 15121 S 759.83 0.00 0.00 12042 S 111.92 0.00 0.00 15130 S 629.58 0.00 0.00 12044 S 115.87 0.00 0.00 15131 S 520.74 0.00 0.00 12045 S 115.87 0.00 0.00 15135 S 629.58 0.00 0.00 12046 S 115.87 0.00 0.00 15136 S 520.74 0.00 0.00 12047 S 339.36 0.00 0.00 15150 S 489.75 0.00 0.00 12051 S 111.92 0.00 0.00 15151 S 380.91 0.00 0.00 12052 S 111.92 0.00 0.00 15152 S 380.91 0.00 0.00 12053 S 111.92 0.00 0.00 15155 S 489.75 0.00 0.00 12054 S 115.87 0.00 0.00 15156 S 380.91 0.00 0.00 12055 S 115.87 0.00 0.00 15157 S 380.91 0.00 0.00 12056 S 115.87 0.00 0.00 15200 S 691.22 0.00 0.00 12057 S 339.36 0.00 0.00 15201 S 511.38 0.00 0.00 13100 S 371.55 0.00 0.00 15220 S 629.58 0.00 0.00 13101 S 371.55 0.00 0.00 15221 S 371.55 0.00 0.00 13102 S 148.05 0.00 0.00 15240 S 691.22 0.00 0.00 13120 S 115.87 0.00 0.00 15241 S 371.55 0.00 0.00 13121 S 148.05 0.00 0.00 15260 S 629.58 0.00 0.00 13122 S 115.87 0.00 0.00 15261 S 511.38 0.00 0.00 13131 S 148.05 0.00 0.00 15300 S 371.55 0.00 0.00 13132 S 148.05 0.00 0.00 15301 S 371.55 0.00 0.00 13133 S 148.05 0.00 0.00 15320 S 371.55 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 4 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 15321 S 371.55 0.00 0.00 15822 S 759.83 0.00 0.00 15330 S 371.55 0.00 0.00 15823 S 959.21 0.00 0.00 15331 S 371.55 0.00 0.00 15824 S 759.83 0.00 0.00 15335 S 371.55 0.00 0.00 15825 S 759.83 0.00 0.00 15336 S 371.55 0.00 0.00 15826 S 759.83 0.00 0.00 15340 S 111.92 0.00 0.00 15828 S 759.83 0.00 0.00 15341 S 111.92 0.00 0.00 15829 S 959.21 0.00 0.00 15360 S 111.92 0.00 0.00 15830 S 771.82 0.00 0.00 15361 S 111.92 0.00 0.00 15832 S 771.82 0.00 0.00 15365 S 111.92 0.00 0.00 15833 S 771.82 0.00 0.00 15366 S 111.92 0.00 0.00 15834 S 771.82 0.00 0.00 15400 S 371.55 0.00 0.00 15835 S 591.98 0.00 0.00 15401 S 371.55 0.00 0.00 15836 S 705.23 0.00 0.00 15420 S 371.55 0.00 0.00 15837 S 856.03 0.00 0.00 15421 S 371.55 0.00 0.00 15838 S 856.03 0.00 0.00 15430 S 371.55 0.00 0.00 15839 S 705.23 0.00 0.00 15431 S 371.55 0.00 0.00 15840 S 875.41 0.00 0.00 15570 S 759.83 0.00 0.00 15841 S 875.41 0.00 0.00 15572 S 759.83 0.00 0.00 15842 S 1,074.39 0.00 0.00 15574 S 759.83 0.00 0.00 15845 S 875.41 0.00 0.00 15576 S 759.83 0.00 0.00 15847 S 771.82 0.00 0.00 15600 S 759.83 0.00 0.00 15850 S 141.45 0.00 0.00 15610 S 759.83 0.00 0.00 15851 S 73.86 0.00 0.00 15620 S 875.41 0.00 0.00 15852 S 33.54 0.00 0.00 15630 S 759.83 0.00 0.00 15860 S 33.54 0.00 0.00 15650 S 959.21 0.00 0.00 15876 S 759.83 0.00 0.00 15731 S 759.83 0.00 0.00 15877 S 759.83 0.00 0.00 15732 S 759.83 0.00 0.00 15878 S 759.83 0.00 0.00 15734 S 759.83 0.00 0.00 15879 S 759.83 0.00 0.00 15736 S 759.83 0.00 0.00 15920 S 299.47 0.00 0.00 15738 S 759.83 0.00 0.00 15922 S 875.41 0.00 0.00 15740 S 629.58 0.00 0.00 15931 S 771.82 0.00 0.00 15750 S 698.18 0.00 0.00 15933 S 771.82 0.00 0.00 15760 S 698.18 0.00 0.00 15934 S 759.83 0.00 0.00 15770 S 759.83 0.00 0.00 15935 S 875.41 0.00 0.00 15775 S 328.38 0.00 0.00 15936 S 806.80 0.00 0.00 15776 S 328.38 0.00 0.00 15937 S 875.41 0.00 0.00 15780 S 556.63 0.00 0.00 15940 S 771.82 0.00 0.00 15781 S 228.84 0.00 0.00 15941 S 771.82 0.00 0.00 15782 S 228.84 0.00 0.00 15944 S 759.83 0.00 0.00 15783 S 141.45 0.00 0.00 15945 S 875.41 0.00 0.00 15786 S 42.16 0.00 0.00 15946 S 875.41 0.00 0.00 15787 S 42.16 0.00 0.00 15950 S 771.82 0.00 0.00 15788 S 42.16 0.00 0.00 15951 S 887.40 0.00 0.00 15789 S 77.59 0.00 0.00 15952 S 691.22 0.00 0.00 15792 S 77.59 0.00 0.00 15953 S 806.80 0.00 0.00 15793 S 42.16 0.00 0.00 15956 S 691.22 0.00 0.00 15819 S 111.92 0.00 0.00 15958 S 806.80 0.00 0.00 15820 S 759.83 0.00 0.00 16000 S 38.64 0.00 0.00 15821 S 759.83 0.00 0.00 16020 S 58.69 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 5 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 16025 S 100.00 0.00 0.00 19126 S 765.61 0.00 0.00 16030 S 131.52 0.00 0.00 19296 S 2,041.75 0.00 0.00 16035 S 141.45 0.00 0.00 19297 S 2,041.75 0.00 0.00 17000 S 42.16 0.00 0.00 19298 S 2,041.75 0.00 0.00 17003 S 5.38 0.00 0.00 19300 S 881.19 0.00 0.00 17004 S 115.93 0.00 0.00 19301 S 765.61 0.00 0.00 17106 S 141.45 0.00 0.00 19302 S 1,487.66 0.00 0.00 17107 S 141.45 0.00 0.00 19303 S 1,028.35 0.00 0.00 17108 S 141.45 0.00 0.00 19304 S 1,028.35 0.00 0.00 17110 S 42.16 0.00 0.00 19316 S 1,028.35 0.00 0.00 17111 S 77.59 0.00 0.00 19318 S 1,136.10 0.00 0.00 17250 S 62.12 0.00 0.00 19324 S 1,136.10 0.00 0.00 17260 S 65.55 0.00 0.00 19325 S 2,041.75 0.00 0.00 17261 S 77.59 0.00 0.00 19328 S 742.28 0.00 0.00 17262 S 77.59 0.00 0.00 19330 S 742.28 0.00 0.00 17263 S 77.59 0.00 0.00 19340 S 958.87 0.00 0.00 17264 S 77.59 0.00 0.00 19342 S 1,243.27 0.00 0.00 17266 S 141.45 0.00 0.00 19350 S 881.19 0.00 0.00 17270 S 77.59 0.00 0.00 19355 S 1,028.35 0.00 0.00 17271 S 77.59 0.00 0.00 19357 S 1,442.65 0.00 0.00 17272 S 77.59 0.00 0.00 19366 S 1,112.15 0.00 0.00 17273 S 132.56 0.00 0.00 19370 S 1,028.35 0.00 0.00 17274 S 141.45 0.00 0.00 19371 S 1,028.35 0.00 0.00 17276 S 141.45 0.00 0.00 19380 S 1,219.90 0.00 0.00 17280 S 77.59 0.00 0.00 19396 S 1,686.18 0.00 0.00 17281 S 113.48 0.00 0.00 20000 S 74.78 0.00 0.00 17282 S 129.62 0.00 0.00 20005 S 712.30 0.00 0.00 17283 S 141.45 0.00 0.00 20103 S 512.24 0.00 0.00 17284 S 141.45 0.00 0.00 20150 S 2,285.48 0.00 0.00 17286 S 141.45 0.00 0.00 20200 S 643.59 0.00 0.00 17311 S 193.11 0.00 0.00 20205 S 705.23 0.00 0.00 17312 S 193.11 0.00 0.00 20206 S 325.74 0.00 0.00 17313 S 193.11 0.00 0.00 20220 S 357.70 0.00 0.00 17314 S 193.11 0.00 0.00 20225 S 518.53 0.00 0.00 17315 S 55.76 0.00 0.00 20240 S 710.18 0.00 0.00 17340 S 17.61 0.00 0.00 20245 S 771.82 0.00 0.00 17360 S 42.16 0.00 0.00 20250 S 773.94 0.00 0.00 17380 S 42.16 0.00 0.00 20251 S 773.94 0.00 0.00 19000 S 95.38 0.00 0.00 20500 S 88.05 0.00 0.00 19001 S 12.23 0.00 0.00 20520 S 135.00 0.00 0.00 19020 S 673.09 0.00 0.00 20525 S 771.82 0.00 0.00 19100 S 288.69 0.00 0.00 20526 S 43.54 0.00 0.00 19101 S 703.96 0.00 0.00 20550 S 32.77 0.00 0.00 19102 S 325.74 0.00 0.00 20551 S 32.29 0.00 0.00 19103 S 561.67 0.00 0.00 20552 S 31.80 0.00 0.00 19105 S 1,686.18 0.00 0.00 20553 S 35.70 0.00 0.00 19110 S 703.96 0.00 0.00 20555 S 1,552.02 0.00 0.00 19112 S 765.61 0.00 0.00 20600 S 32.29 0.00 0.00 19120 S 765.61 0.00 0.00 20605 S 36.69 0.00 0.00 19125 S 765.61 0.00 0.00 20610 S 49.41 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 6 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 20612 S 34.24 0.00 0.00 21083 S 824.68 0.00 0.00 20615 S 152.12 0.00 0.00 21084 S 961.15 0.00 0.00 20650 S 773.94 0.00 0.00 21085 S 372.23 0.00 0.00 20662 S 1,130.85 0.00 0.00 21086 S 897.07 0.00 0.00 20663 S 1,130.85 0.00 0.00 21087 S 888.75 0.00 0.00 20665 S 33.54 0.00 0.00 21088 S 2,120.26 0.00 0.00 20670 S 534.75 0.00 0.00 21100 S 959.64 0.00 0.00 20680 S 771.82 0.00 0.00 21110 S 395.97 0.00 0.00 20690 S 817.59 0.00 0.00 21120 S 1,277.07 0.00 0.00 20692 S 879.24 0.00 0.00 21121 S 1,277.07 0.00 0.00 20693 S 773.94 0.00 0.00 21122 S 1,277.07 0.00 0.00 20694 S 603.46 0.00 0.00 21123 S 1,277.07 0.00 0.00 20822 S 1,398.91 0.00 0.00 21125 S 1,277.07 0.00 0.00 20900 S 879.24 0.00 0.00 21127 S 1,819.77 0.00 0.00 20902 S 994.82 0.00 0.00 21137 S 1,274.81 0.00 0.00 20910 S 759.83 0.00 0.00 21138 S 2,120.26 0.00 0.00 20912 S 759.83 0.00 0.00 21139 S 2,120.26 0.00 0.00 20920 S 806.80 0.00 0.00 21150 S 2,120.26 0.00 0.00 20922 S 691.22 0.00 0.00 21181 S 1,277.07 0.00 0.00 20924 S 994.82 0.00 0.00 21198 S 2,120.26 0.00 0.00 20926 S 666.98 0.00 0.00 21199 S 2,120.26 0.00 0.00 20950 S 74.78 0.00 0.00 21206 S 1,220.67 0.00 0.00 20972 S 2,353.73 0.00 0.00 21208 S 1,488.43 0.00 0.00 20973 S 2,353.73 0.00 0.00 21209 S 1,220.67 0.00 0.00 20979 S 33.54 0.00 0.00 21210 S 1,488.43 0.00 0.00 20982 S 2,285.48 0.00 0.00 21215 S 1,488.43 0.00 0.00 21010 S 748.28 0.00 0.00 21230 S 1,488.43 0.00 0.00 21015 S 708.28 0.00 0.00 21235 S 1,277.07 0.00 0.00 21025 S 959.64 0.00 0.00 21240 S 1,136.87 0.00 0.00 21026 S 959.64 0.00 0.00 21242 S 1,220.67 0.00 0.00 21029 S 959.64 0.00 0.00 21243 S 1,220.67 0.00 0.00 21030 S 330.66 0.00 0.00 21244 S 1,488.43 0.00 0.00 21031 S 270.98 0.00 0.00 21245 S 1,488.43 0.00 0.00 21032 S 278.81 0.00 0.00 21246 S 1,488.43 0.00 0.00 21034 S 1,021.29 0.00 0.00 21248 S 1,488.43 0.00 0.00 21040 S 748.28 0.00 0.00 21249 S 1,488.43 0.00 0.00 21044 S 959.64 0.00 0.00 21260 S 2,120.26 0.00 0.00 21046 S 959.64 0.00 0.00 21267 S 1,488.43 0.00 0.00 21047 S 959.64 0.00 0.00 21270 S 1,220.67 0.00 0.00 21048 S 2,120.26 0.00 0.00 21275 S 1,488.43 0.00 0.00 21050 S 1,021.29 0.00 0.00 21280 S 1,220.67 0.00 0.00 21060 S 959.64 0.00 0.00 21282 S 907.66 0.00 0.00 21070 S 1,021.29 0.00 0.00 21295 S 419.73 0.00 0.00 21073 S 269.02 0.00 0.00 21296 S 639.44 0.00 0.00 21076 S 498.43 0.00 0.00 21310 S 178.41 0.00 0.00 21077 S 1,217.46 0.00 0.00 21315 S 178.41 0.00 0.00 21079 S 867.72 0.00 0.00 21320 S 646.63 0.00 0.00 21080 S 994.41 0.00 0.00 21325 S 925.51 0.00 0.00 21081 S 913.20 0.00 0.00 21330 S 1,009.30 0.00 0.00 21082 S 837.88 0.00 0.00 21335 S 1,277.07 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 7 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 21336 S 954.53 0.00 0.00 22103 S 2,486.85 0.00 0.00 21337 S 646.63 0.00 0.00 22305 S 123.31 0.00 0.00 21338 S 925.51 0.00 0.00 22310 S 123.31 0.00 0.00 21339 S 1,009.30 0.00 0.00 22315 S 123.31 0.00 0.00 21340 S 1,136.87 0.00 0.00 22505 S 625.85 0.00 0.00 21345 S 1,277.07 0.00 0.00 22520 S 1,677.72 0.00 0.00 21355 S 1,021.29 0.00 0.00 22521 S 1,677.72 0.00 0.00 21356 S 809.93 0.00 0.00 22522 S 1,677.72 0.00 0.00 21360 S 1,274.81 0.00 0.00 22523 S 4,222.94 0.00 0.00 21390 S 2,120.26 0.00 0.00 22524 S 4,222.94 0.00 0.00 21400 S 528.57 0.00 0.00 22525 S 4,222.94 0.00 0.00 21401 S 708.28 0.00 0.00 22526 S 1,552.02 0.00 0.00 21406 S 2,120.26 0.00 0.00 22527 S 1,552.02 0.00 0.00 21407 S 2,120.26 0.00 0.00 22900 S 887.40 0.00 0.00 21421 S 925.51 0.00 0.00 23000 S 643.59 0.00 0.00 21440 S 420.17 0.00 0.00 23020 S 1,000.96 0.00 0.00 21445 S 925.51 0.00 0.00 23030 S 564.25 0.00 0.00 21450 S 178.41 0.00 0.00 23031 S 734.73 0.00 0.00 21451 S 546.06 0.00 0.00 23035 S 773.94 0.00 0.00 21452 S 646.63 0.00 0.00 23040 S 879.24 0.00 0.00 21453 S 1,021.29 0.00 0.00 23044 S 994.82 0.00 0.00 21454 S 1,009.30 0.00 0.00 23065 S 133.05 0.00 0.00 21461 S 1,136.87 0.00 0.00 23066 S 710.18 0.00 0.00 21462 S 1,220.67 0.00 0.00 23075 S 643.59 0.00 0.00 21465 S 1,136.87 0.00 0.00 23076 S 710.18 0.00 0.00 21480 S 178.41 0.00 0.00 23077 S 771.82 0.00 0.00 21485 S 646.63 0.00 0.00 23100 S 712.30 0.00 0.00 21490 S 1,021.29 0.00 0.00 23101 S 1,346.38 0.00 0.00 21495 S 868.19 0.00 0.00 23105 S 994.82 0.00 0.00 21497 S 646.63 0.00 0.00 23106 S 994.82 0.00 0.00 21501 S 673.09 0.00 0.00 23107 S 994.82 0.00 0.00 21502 S 712.30 0.00 0.00 23120 S 1,078.62 0.00 0.00 21550 S 461.78 0.00 0.00 23125 S 1,078.62 0.00 0.00 21555 S 710.18 0.00 0.00 23130 S 1,261.98 0.00 0.00 21556 S 710.18 0.00 0.00 23140 S 889.52 0.00 0.00 21557 S 1,122.40 0.00 0.00 23145 S 1,078.62 0.00 0.00 21600 S 817.59 0.00 0.00 23146 S 1,078.62 0.00 0.00 21610 S 817.59 0.00 0.00 23150 S 994.82 0.00 0.00 21685 S 395.97 0.00 0.00 23155 S 1,078.62 0.00 0.00 21700 S 712.30 0.00 0.00 23156 S 1,078.62 0.00 0.00 21720 S 773.94 0.00 0.00 23170 S 817.59 0.00 0.00 21725 S 103.90 0.00 0.00 23172 S 817.59 0.00 0.00 21800 S 123.31 0.00 0.00 23174 S 817.59 0.00 0.00 21805 S 777.31 0.00 0.00 23180 S 994.82 0.00 0.00 21820 S 123.31 0.00 0.00 23182 S 994.82 0.00 0.00 21920 S 188.81 0.00 0.00 23184 S 994.82 0.00 0.00 21925 S 710.18 0.00 0.00 23190 S 994.82 0.00 0.00 21930 S 710.18 0.00 0.00 23195 S 1,078.62 0.00 0.00 21935 S 771.82 0.00 0.00 23330 S 436.18 0.00 0.00 22102 S 2,486.85 0.00 0.00 23331 S 601.34 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 8 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 23395 S 1,261.98 0.00 0.00 23800 S 1,662.54 0.00 0.00 23397 S 2,014.10 0.00 0.00 23802 S 1,529.75 0.00 0.00 23400 S 1,346.38 0.00 0.00 23921 S 511.38 0.00 0.00 23405 S 817.59 0.00 0.00 23930 S 564.25 0.00 0.00 23406 S 817.59 0.00 0.00 23931 S 673.09 0.00 0.00 23410 S 1,261.98 0.00 0.00 23935 S 712.30 0.00 0.00 23412 S 1,529.75 0.00 0.00 24000 S 994.82 0.00 0.00 23415 S 1,261.98 0.00 0.00 24006 S 994.82 0.00 0.00 23420 S 1,529.75 0.00 0.00 24065 S 180.00 0.00 0.00 23430 S 1,178.18 0.00 0.00 24066 S 643.59 0.00 0.00 23440 S 1,178.18 0.00 0.00 24075 S 643.59 0.00 0.00 23450 S 1,746.34 0.00 0.00 24076 S 710.18 0.00 0.00 23455 S 2,014.10 0.00 0.00 24077 S 771.82 0.00 0.00 23460 S 1,746.34 0.00 0.00 24100 S 603.46 0.00 0.00 23462 S 1,529.75 0.00 0.00 24101 S 994.82 0.00 0.00 23465 S 1,746.34 0.00 0.00 24102 S 994.82 0.00 0.00 23466 S 1,529.75 0.00 0.00 24105 S 773.94 0.00 0.00 23480 S 1,178.18 0.00 0.00 24110 S 712.30 0.00 0.00 23485 S 2,014.10 0.00 0.00 24115 S 879.24 0.00 0.00 23490 S 1,062.60 0.00 0.00 24116 S 879.24 0.00 0.00 23491 S 1,546.96 0.00 0.00 24120 S 773.94 0.00 0.00 23500 S 123.31 0.00 0.00 24125 S 879.24 0.00 0.00 23505 S 123.31 0.00 0.00 24126 S 879.24 0.00 0.00 23515 S 1,278.45 0.00 0.00 24130 S 879.24 0.00 0.00 23520 S 123.31 0.00 0.00 24134 S 817.59 0.00 0.00 23525 S 123.31 0.00 0.00 24136 S 817.59 0.00 0.00 23530 S 1,037.66 0.00 0.00 24138 S 817.59 0.00 0.00 23532 S 954.53 0.00 0.00 24140 S 879.24 0.00 0.00 23540 S 123.31 0.00 0.00 24145 S 879.24 0.00 0.00 23545 S 123.31 0.00 0.00 24147 S 817.59 0.00 0.00 23550 S 1,037.66 0.00 0.00 24149 S 1,552.02 0.00 0.00 23552 S 1,153.24 0.00 0.00 24152 S 2,285.48 0.00 0.00 23570 S 123.31 0.00 0.00 24153 S 4,222.94 0.00 0.00 23575 S 123.31 0.00 0.00 24155 S 1,062.60 0.00 0.00 23585 S 1,278.45 0.00 0.00 24160 S 817.59 0.00 0.00 23600 S 94.02 0.00 0.00 24164 S 879.24 0.00 0.00 23605 S 123.31 0.00 0.00 24200 S 150.66 0.00 0.00 23615 S 1,394.03 0.00 0.00 24201 S 643.59 0.00 0.00 23616 S 1,394.03 0.00 0.00 24300 S 785.09 0.00 0.00 23620 S 94.02 0.00 0.00 24301 S 994.82 0.00 0.00 23625 S 123.31 0.00 0.00 24305 S 994.82 0.00 0.00 23630 S 1,477.83 0.00 0.00 24310 S 773.94 0.00 0.00 23650 S 123.31 0.00 0.00 24320 S 1,062.60 0.00 0.00 23655 S 517.01 0.00 0.00 24330 S 1,546.96 0.00 0.00 23660 S 1,037.66 0.00 0.00 24331 S 1,062.60 0.00 0.00 23665 S 123.31 0.00 0.00 24332 S 1,130.85 0.00 0.00 23670 S 1,278.45 0.00 0.00 24340 S 1,062.60 0.00 0.00 23675 S 123.31 0.00 0.00 24341 S 1,062.60 0.00 0.00 23680 S 1,037.66 0.00 0.00 24342 S 1,062.60 0.00 0.00 23700 S 517.01 0.00 0.00 24343 S 1,552.02 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 9 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 24344 S 4,222.94 0.00 0.00 24675 S 123.31 0.00 0.00 24345 S 817.59 0.00 0.00 24685 S 1,037.66 0.00 0.00 24346 S 2,285.48 0.00 0.00 24800 S 1,178.18 0.00 0.00 24357 S 1,552.02 0.00 0.00 24802 S 1,261.98 0.00 0.00 24358 S 1,552.02 0.00 0.00 24925 S 773.94 0.00 0.00 24359 S 1,552.02 0.00 0.00 25000 S 773.94 0.00 0.00 24360 S 1,167.86 0.00 0.00 25001 S 1,130.85 0.00 0.00 24361 S 2,315.00 0.00 0.00 25020 S 773.94 0.00 0.00 24362 S 1,367.02 0.00 0.00 25023 S 879.24 0.00 0.00 24363 S 2,582.77 0.00 0.00 25024 S 879.24 0.00 0.00 24365 S 1,167.86 0.00 0.00 25025 S 879.24 0.00 0.00 24366 S 2,315.00 0.00 0.00 25028 S 603.46 0.00 0.00 24400 S 994.82 0.00 0.00 25031 S 712.30 0.00 0.00 24410 S 994.82 0.00 0.00 25035 S 712.30 0.00 0.00 24420 S 1,062.60 0.00 0.00 25040 S 1,078.62 0.00 0.00 24430 S 1,546.96 0.00 0.00 25065 S 184.89 0.00 0.00 24435 S 1,662.54 0.00 0.00 25066 S 710.18 0.00 0.00 24470 S 1,062.60 0.00 0.00 25075 S 643.59 0.00 0.00 24495 S 817.59 0.00 0.00 25076 S 771.82 0.00 0.00 24498 S 1,546.96 0.00 0.00 25077 S 771.82 0.00 0.00 24500 S 123.31 0.00 0.00 25085 S 773.94 0.00 0.00 24505 S 123.31 0.00 0.00 25100 S 712.30 0.00 0.00 24515 S 1,394.03 0.00 0.00 25101 S 879.24 0.00 0.00 24516 S 1,394.03 0.00 0.00 25105 S 994.82 0.00 0.00 24530 S 123.31 0.00 0.00 25107 S 879.24 0.00 0.00 24535 S 123.31 0.00 0.00 25109 S 1,130.85 0.00 0.00 24538 S 777.31 0.00 0.00 25110 S 773.94 0.00 0.00 24545 S 1,394.03 0.00 0.00 25111 S 710.06 0.00 0.00 24546 S 1,477.83 0.00 0.00 25112 S 825.64 0.00 0.00 24560 S 123.31 0.00 0.00 25115 S 889.52 0.00 0.00 24565 S 123.31 0.00 0.00 25116 S 889.52 0.00 0.00 24566 S 777.31 0.00 0.00 25118 S 817.59 0.00 0.00 24575 S 1,278.45 0.00 0.00 25119 S 879.24 0.00 0.00 24576 S 123.31 0.00 0.00 25120 S 879.24 0.00 0.00 24577 S 123.31 0.00 0.00 25125 S 879.24 0.00 0.00 24579 S 1,278.45 0.00 0.00 25126 S 879.24 0.00 0.00 24582 S 777.31 0.00 0.00 25130 S 879.24 0.00 0.00 24586 S 1,394.03 0.00 0.00 25135 S 879.24 0.00 0.00 24587 S 1,477.83 0.00 0.00 25136 S 879.24 0.00 0.00 24600 S 123.31 0.00 0.00 25145 S 817.59 0.00 0.00 24605 S 625.85 0.00 0.00 25150 S 817.59 0.00 0.00 24615 S 1,278.45 0.00 0.00 25151 S 817.59 0.00 0.00 24620 S 123.31 0.00 0.00 25210 S 840.95 0.00 0.00 24635 S 1,278.45 0.00 0.00 25215 S 956.54 0.00 0.00 24640 S 82.67 0.00 0.00 25230 S 994.82 0.00 0.00 24650 S 94.02 0.00 0.00 25240 S 994.82 0.00 0.00 24655 S 123.31 0.00 0.00 25248 S 712.30 0.00 0.00 24665 S 1,153.24 0.00 0.00 25250 S 708.75 0.00 0.00 24666 S 1,394.03 0.00 0.00 25251 S 708.75 0.00 0.00 24670 S 123.31 0.00 0.00 25259 S 94.02 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 10 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 25260 S 994.82 0.00 0.00 25490 S 1,062.60 0.00 0.00 25263 S 817.59 0.00 0.00 25491 S 1,062.60 0.00 0.00 25265 S 879.24 0.00 0.00 25492 S 1,062.60 0.00 0.00 25270 S 994.82 0.00 0.00 25500 S 94.02 0.00 0.00 25272 S 879.24 0.00 0.00 25505 S 123.31 0.00 0.00 25274 S 994.82 0.00 0.00 25515 S 1,037.66 0.00 0.00 25275 S 994.82 0.00 0.00 25520 S 123.31 0.00 0.00 25280 S 994.82 0.00 0.00 25525 S 1,153.24 0.00 0.00 25290 S 879.24 0.00 0.00 25526 S 1,237.04 0.00 0.00 25295 S 773.94 0.00 0.00 25530 S 94.02 0.00 0.00 25300 S 879.24 0.00 0.00 25535 S 123.31 0.00 0.00 25301 S 879.24 0.00 0.00 25545 S 1,037.66 0.00 0.00 25310 S 1,062.60 0.00 0.00 25560 S 94.02 0.00 0.00 25312 S 1,178.18 0.00 0.00 25565 S 123.31 0.00 0.00 25315 S 1,062.60 0.00 0.00 25574 S 1,278.45 0.00 0.00 25316 S 1,546.96 0.00 0.00 25575 S 1,278.45 0.00 0.00 25320 S 1,062.60 0.00 0.00 25600 S 94.02 0.00 0.00 25332 S 1,167.86 0.00 0.00 25605 S 123.31 0.00 0.00 25335 S 1,062.60 0.00 0.00 25606 S 838.95 0.00 0.00 25337 S 1,261.98 0.00 0.00 25607 S 1,477.83 0.00 0.00 25350 S 1,546.96 0.00 0.00 25608 S 1,477.83 0.00 0.00 25355 S 1,062.60 0.00 0.00 25609 S 1,477.83 0.00 0.00 25360 S 879.24 0.00 0.00 25622 S 94.02 0.00 0.00 25365 S 879.24 0.00 0.00 25624 S 123.31 0.00 0.00 25370 S 1,062.60 0.00 0.00 25628 S 1,037.66 0.00 0.00 25375 S 1,178.18 0.00 0.00 25630 S 94.02 0.00 0.00 25390 S 879.24 0.00 0.00 25635 S 123.31 0.00 0.00 25391 S 1,178.18 0.00 0.00 25645 S 1,037.66 0.00 0.00 25392 S 879.24 0.00 0.00 25650 S 94.02 0.00 0.00 25393 S 1,178.18 0.00 0.00 25651 S 1,390.87 0.00 0.00 25394 S 875.36 0.00 0.00 25652 S 2,185.74 0.00 0.00 25400 S 1,546.96 0.00 0.00 25660 S 123.31 0.00 0.00 25405 S 1,662.54 0.00 0.00 25670 S 838.95 0.00 0.00 25415 S 1,546.96 0.00 0.00 25671 S 668.46 0.00 0.00 25420 S 1,662.54 0.00 0.00 25675 S 123.31 0.00 0.00 25425 S 1,062.60 0.00 0.00 25676 S 777.31 0.00 0.00 25426 S 1,178.18 0.00 0.00 25680 S 123.31 0.00 0.00 25430 S 1,398.91 0.00 0.00 25685 S 838.95 0.00 0.00 25431 S 1,398.91 0.00 0.00 25690 S 123.31 0.00 0.00 25440 S 1,662.54 0.00 0.00 25695 S 777.31 0.00 0.00 25441 S 2,315.00 0.00 0.00 25800 S 1,662.54 0.00 0.00 25442 S 2,315.00 0.00 0.00 25805 S 1,261.98 0.00 0.00 25443 S 1,367.02 0.00 0.00 25810 S 1,746.34 0.00 0.00 25444 S 1,367.02 0.00 0.00 25820 S 825.64 0.00 0.00 25445 S 1,367.02 0.00 0.00 25825 S 1,746.34 0.00 0.00 25446 S 2,582.77 0.00 0.00 25830 S 1,746.34 0.00 0.00 25447 S 1,167.86 0.00 0.00 25907 S 773.94 0.00 0.00 25449 S 1,167.86 0.00 0.00 25922 S 773.94 0.00 0.00 25450 S 1,062.60 0.00 0.00 25929 S 691.22 0.00 0.00 25455 S 1,062.60 0.00 0.00 25931 S 1,130.85 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 11 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 26010 S 74.78 0.00 0.00 26370 S 956.54 0.00 0.00 26011 S 474.39 0.00 0.00 26372 S 956.54 0.00 0.00 26020 S 648.42 0.00 0.00 26373 S 840.95 0.00 0.00 26025 S 539.58 0.00 0.00 26390 S 956.54 0.00 0.00 26030 S 648.42 0.00 0.00 26392 S 840.95 0.00 0.00 26034 S 648.42 0.00 0.00 26410 S 710.06 0.00 0.00 26035 S 875.36 0.00 0.00 26412 S 840.95 0.00 0.00 26040 S 956.54 0.00 0.00 26415 S 956.54 0.00 0.00 26045 S 840.95 0.00 0.00 26416 S 840.95 0.00 0.00 26055 S 648.42 0.00 0.00 26418 S 825.64 0.00 0.00 26060 S 648.42 0.00 0.00 26420 S 956.54 0.00 0.00 26070 S 648.42 0.00 0.00 26426 S 840.95 0.00 0.00 26075 S 825.64 0.00 0.00 26428 S 840.95 0.00 0.00 26080 S 825.64 0.00 0.00 26432 S 710.06 0.00 0.00 26100 S 648.42 0.00 0.00 26433 S 710.06 0.00 0.00 26105 S 539.58 0.00 0.00 26434 S 840.95 0.00 0.00 26110 S 539.58 0.00 0.00 26437 S 710.06 0.00 0.00 26115 S 710.18 0.00 0.00 26440 S 710.06 0.00 0.00 26116 S 710.18 0.00 0.00 26442 S 840.95 0.00 0.00 26117 S 771.82 0.00 0.00 26445 S 710.06 0.00 0.00 26121 S 956.54 0.00 0.00 26449 S 840.95 0.00 0.00 26123 S 956.54 0.00 0.00 26450 S 710.06 0.00 0.00 26125 S 825.64 0.00 0.00 26455 S 710.06 0.00 0.00 26130 S 710.06 0.00 0.00 26460 S 710.06 0.00 0.00 26135 S 956.54 0.00 0.00 26471 S 648.42 0.00 0.00 26140 S 648.42 0.00 0.00 26474 S 648.42 0.00 0.00 26145 S 710.06 0.00 0.00 26476 S 539.58 0.00 0.00 26160 S 710.06 0.00 0.00 26477 S 539.58 0.00 0.00 26170 S 710.06 0.00 0.00 26478 S 539.58 0.00 0.00 26180 S 710.06 0.00 0.00 26479 S 539.58 0.00 0.00 26185 S 825.64 0.00 0.00 26480 S 840.95 0.00 0.00 26200 S 648.42 0.00 0.00 26483 S 840.95 0.00 0.00 26205 S 840.95 0.00 0.00 26485 S 779.31 0.00 0.00 26210 S 648.42 0.00 0.00 26489 S 840.95 0.00 0.00 26215 S 710.06 0.00 0.00 26490 S 840.95 0.00 0.00 26230 S 1,175.24 0.00 0.00 26492 S 840.95 0.00 0.00 26235 S 710.06 0.00 0.00 26494 S 840.95 0.00 0.00 26236 S 710.06 0.00 0.00 26496 S 840.95 0.00 0.00 26250 S 710.06 0.00 0.00 26497 S 840.95 0.00 0.00 26255 S 840.95 0.00 0.00 26498 S 956.54 0.00 0.00 26260 S 710.06 0.00 0.00 26499 S 840.95 0.00 0.00 26261 S 710.06 0.00 0.00 26500 S 825.64 0.00 0.00 26262 S 648.42 0.00 0.00 26502 S 956.54 0.00 0.00 26320 S 643.59 0.00 0.00 26508 S 710.06 0.00 0.00 26340 S 94.02 0.00 0.00 26510 S 840.95 0.00 0.00 26350 S 670.47 0.00 0.00 26516 S 670.47 0.00 0.00 26352 S 956.54 0.00 0.00 26517 S 840.95 0.00 0.00 26356 S 956.54 0.00 0.00 26518 S 840.95 0.00 0.00 26357 S 956.54 0.00 0.00 26520 S 710.06 0.00 0.00 26358 S 956.54 0.00 0.00 26525 S 710.06 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 12 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 26530 S 968.48 0.00 0.00 26755 S 94.02 0.00 0.00 26531 S 1,634.79 0.00 0.00 26756 S 777.31 0.00 0.00 26535 S 1,167.86 0.00 0.00 26765 S 954.53 0.00 0.00 26536 S 1,367.02 0.00 0.00 26770 S 94.02 0.00 0.00 26540 S 825.64 0.00 0.00 26775 S 240.17 0.00 0.00 26541 S 1,308.10 0.00 0.00 26776 S 777.31 0.00 0.00 26542 S 825.64 0.00 0.00 26785 S 777.31 0.00 0.00 26545 S 956.54 0.00 0.00 26820 S 1,040.33 0.00 0.00 26546 S 956.54 0.00 0.00 26841 S 956.54 0.00 0.00 26548 S 956.54 0.00 0.00 26842 S 956.54 0.00 0.00 26550 S 779.31 0.00 0.00 26843 S 840.95 0.00 0.00 26555 S 840.95 0.00 0.00 26844 S 840.95 0.00 0.00 26560 S 648.42 0.00 0.00 26850 S 956.54 0.00 0.00 26561 S 840.95 0.00 0.00 26852 S 956.54 0.00 0.00 26562 S 956.54 0.00 0.00 26860 S 840.95 0.00 0.00 26565 S 1,040.33 0.00 0.00 26861 S 779.31 0.00 0.00 26567 S 1,040.33 0.00 0.00 26862 S 956.54 0.00 0.00 26568 S 840.95 0.00 0.00 26863 S 840.95 0.00 0.00 26580 S 909.44 0.00 0.00 26910 S 840.95 0.00 0.00 26587 S 909.44 0.00 0.00 26951 S 648.42 0.00 0.00 26590 S 909.44 0.00 0.00 26952 S 825.64 0.00 0.00 26591 S 840.95 0.00 0.00 26990 S 603.46 0.00 0.00 26593 S 710.06 0.00 0.00 26991 S 603.46 0.00 0.00 26596 S 648.42 0.00 0.00 27000 S 712.30 0.00 0.00 26600 S 94.02 0.00 0.00 27001 S 879.24 0.00 0.00 26605 S 123.31 0.00 0.00 27003 S 879.24 0.00 0.00 26607 S 123.31 0.00 0.00 27033 S 1,062.60 0.00 0.00 26608 S 954.53 0.00 0.00 27035 S 1,178.18 0.00 0.00 26615 S 1,153.24 0.00 0.00 27040 S 436.18 0.00 0.00 26641 S 94.02 0.00 0.00 27041 S 518.53 0.00 0.00 26645 S 123.31 0.00 0.00 27047 S 710.18 0.00 0.00 26650 S 777.31 0.00 0.00 27048 S 771.82 0.00 0.00 26665 S 1,153.24 0.00 0.00 27049 S 771.82 0.00 0.00 26670 S 94.02 0.00 0.00 27050 S 773.94 0.00 0.00 26675 S 123.31 0.00 0.00 27052 S 773.94 0.00 0.00 26676 S 777.31 0.00 0.00 27060 S 973.32 0.00 0.00 26685 S 838.95 0.00 0.00 27062 S 973.32 0.00 0.00 26686 S 1,278.45 0.00 0.00 27065 S 973.32 0.00 0.00 26700 S 94.02 0.00 0.00 27066 S 1,078.62 0.00 0.00 26705 S 123.31 0.00 0.00 27067 S 1,078.62 0.00 0.00 26706 S 123.31 0.00 0.00 27080 S 817.59 0.00 0.00 26715 S 954.53 0.00 0.00 27086 S 436.18 0.00 0.00 26720 S 94.02 0.00 0.00 27087 S 773.94 0.00 0.00 26725 S 94.02 0.00 0.00 27097 S 879.24 0.00 0.00 26727 S 1,306.10 0.00 0.00 27098 S 879.24 0.00 0.00 26735 S 954.53 0.00 0.00 27100 S 1,178.18 0.00 0.00 26740 S 94.02 0.00 0.00 27105 S 1,178.18 0.00 0.00 26742 S 123.31 0.00 0.00 27110 S 1,178.18 0.00 0.00 26746 S 1,038.33 0.00 0.00 27111 S 1,178.18 0.00 0.00 26750 S 94.02 0.00 0.00 27193 S 123.31 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 13 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 27194 S 625.85 0.00 0.00 27393 S 817.59 0.00 0.00 27200 S 94.02 0.00 0.00 27394 S 879.24 0.00 0.00 27202 S 976.02 0.00 0.00 27395 S 1,062.60 0.00 0.00 27220 S 94.02 0.00 0.00 27396 S 879.24 0.00 0.00 27230 S 123.31 0.00 0.00 27397 S 1,062.60 0.00 0.00 27238 S 123.31 0.00 0.00 27400 S 1,062.60 0.00 0.00 27246 S 123.31 0.00 0.00 27403 S 994.82 0.00 0.00 27250 S 123.31 0.00 0.00 27405 S 1,178.18 0.00 0.00 27252 S 625.85 0.00 0.00 27407 S 1,662.54 0.00 0.00 27256 S 94.02 0.00 0.00 27409 S 1,178.18 0.00 0.00 27257 S 687.50 0.00 0.00 27416 S 2,285.48 0.00 0.00 27265 S 123.31 0.00 0.00 27418 S 1,062.60 0.00 0.00 27266 S 625.85 0.00 0.00 27420 S 1,062.60 0.00 0.00 27267 S 94.02 0.00 0.00 27422 S 1,529.75 0.00 0.00 27275 S 625.85 0.00 0.00 27424 S 1,062.60 0.00 0.00 27301 S 734.73 0.00 0.00 27425 S 1,346.38 0.00 0.00 27305 S 712.30 0.00 0.00 27427 S 1,062.60 0.00 0.00 27306 S 773.94 0.00 0.00 27428 S 1,662.54 0.00 0.00 27307 S 773.94 0.00 0.00 27429 S 1,662.54 0.00 0.00 27310 S 994.82 0.00 0.00 27430 S 1,178.18 0.00 0.00 27323 S 436.18 0.00 0.00 27435 S 1,178.18 0.00 0.00 27324 S 601.34 0.00 0.00 27437 S 1,084.06 0.00 0.00 27325 S 669.53 0.00 0.00 27438 S 1,367.02 0.00 0.00 27326 S 669.53 0.00 0.00 27440 S 1,908.99 0.00 0.00 27327 S 710.18 0.00 0.00 27441 S 1,167.86 0.00 0.00 27328 S 771.82 0.00 0.00 27442 S 1,167.86 0.00 0.00 27329 S 887.40 0.00 0.00 27443 S 1,167.86 0.00 0.00 27330 S 994.82 0.00 0.00 27446 S 14,604.07 0.00 0.00 27331 S 994.82 0.00 0.00 27496 S 973.32 0.00 0.00 27332 S 994.82 0.00 0.00 27497 S 773.94 0.00 0.00 27333 S 994.82 0.00 0.00 27498 S 773.94 0.00 0.00 27334 S 994.82 0.00 0.00 27499 S 773.94 0.00 0.00 27335 S 994.82 0.00 0.00 27500 S 123.31 0.00 0.00 27340 S 773.94 0.00 0.00 27501 S 123.31 0.00 0.00 27345 S 889.52 0.00 0.00 27502 S 123.31 0.00 0.00 27347 S 889.52 0.00 0.00 27503 S 123.31 0.00 0.00 27350 S 994.82 0.00 0.00 27508 S 123.31 0.00 0.00 27355 S 879.24 0.00 0.00 27509 S 838.95 0.00 0.00 27356 S 994.82 0.00 0.00 27510 S 123.31 0.00 0.00 27357 S 1,078.62 0.00 0.00 27516 S 123.31 0.00 0.00 27358 S 1,078.62 0.00 0.00 27517 S 123.31 0.00 0.00 27360 S 1,078.62 0.00 0.00 27520 S 123.31 0.00 0.00 27372 S 1,238.97 0.00 0.00 27530 S 123.31 0.00 0.00 27380 S 603.46 0.00 0.00 27532 S 123.31 0.00 0.00 27381 S 773.94 0.00 0.00 27538 S 123.31 0.00 0.00 27385 S 773.94 0.00 0.00 27550 S 123.31 0.00 0.00 27386 S 773.94 0.00 0.00 27552 S 517.01 0.00 0.00 27390 S 603.46 0.00 0.00 27560 S 123.31 0.00 0.00 27391 S 712.30 0.00 0.00 27562 S 517.01 0.00 0.00 27392 S 773.94 0.00 0.00 27566 S 976.02 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 14 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 27570 S 517.01 0.00 0.00 27705 S 1,000.96 0.00 0.00 27594 S 773.94 0.00 0.00 27707 S 712.30 0.00 0.00 27600 S 773.94 0.00 0.00 27709 S 817.59 0.00 0.00 27601 S 773.94 0.00 0.00 27726 S 1,390.87 0.00 0.00 27602 S 773.94 0.00 0.00 27730 S 817.59 0.00 0.00 27603 S 673.09 0.00 0.00 27732 S 817.59 0.00 0.00 27604 S 712.30 0.00 0.00 27734 S 817.59 0.00 0.00 27605 S 597.60 0.00 0.00 27740 S 817.59 0.00 0.00 27606 S 603.46 0.00 0.00 27742 S 1,000.96 0.00 0.00 27607 S 712.30 0.00 0.00 27745 S 1,546.96 0.00 0.00 27610 S 817.59 0.00 0.00 27750 S 123.31 0.00 0.00 27612 S 879.24 0.00 0.00 27752 S 123.31 0.00 0.00 27613 S 174.62 0.00 0.00 27756 S 838.95 0.00 0.00 27614 S 710.18 0.00 0.00 27758 S 1,153.24 0.00 0.00 27615 S 879.24 0.00 0.00 27759 S 1,394.03 0.00 0.00 27618 S 643.59 0.00 0.00 27760 S 123.31 0.00 0.00 27619 S 771.82 0.00 0.00 27762 S 123.31 0.00 0.00 27620 S 994.82 0.00 0.00 27766 S 1,037.66 0.00 0.00 27625 S 994.82 0.00 0.00 27767 S 94.02 0.00 0.00 27626 S 994.82 0.00 0.00 27768 S 94.02 0.00 0.00 27630 S 773.94 0.00 0.00 27769 S 2,185.74 0.00 0.00 27635 S 879.24 0.00 0.00 27780 S 123.31 0.00 0.00 27637 S 879.24 0.00 0.00 27781 S 123.31 0.00 0.00 27638 S 879.24 0.00 0.00 27784 S 1,037.66 0.00 0.00 27640 S 1,000.96 0.00 0.00 27786 S 123.31 0.00 0.00 27641 S 817.59 0.00 0.00 27788 S 123.31 0.00 0.00 27647 S 1,062.60 0.00 0.00 27792 S 1,037.66 0.00 0.00 27650 S 1,062.60 0.00 0.00 27808 S 123.31 0.00 0.00 27652 S 1,546.96 0.00 0.00 27810 S 123.31 0.00 0.00 27654 S 1,062.60 0.00 0.00 27814 S 1,037.66 0.00 0.00 27656 S 712.30 0.00 0.00 27816 S 123.31 0.00 0.00 27658 S 603.46 0.00 0.00 27818 S 123.31 0.00 0.00 27659 S 712.30 0.00 0.00 27822 S 1,037.66 0.00 0.00 27664 S 712.30 0.00 0.00 27823 S 1,278.45 0.00 0.00 27665 S 817.59 0.00 0.00 27824 S 123.31 0.00 0.00 27675 S 712.30 0.00 0.00 27825 S 123.31 0.00 0.00 27676 S 879.24 0.00 0.00 27826 S 1,037.66 0.00 0.00 27680 S 879.24 0.00 0.00 27827 S 1,278.45 0.00 0.00 27681 S 817.59 0.00 0.00 27828 S 1,394.03 0.00 0.00 27685 S 879.24 0.00 0.00 27829 S 976.02 0.00 0.00 27686 S 879.24 0.00 0.00 27830 S 123.31 0.00 0.00 27687 S 879.24 0.00 0.00 27831 S 123.31 0.00 0.00 27690 S 1,178.18 0.00 0.00 27832 S 976.02 0.00 0.00 27691 S 1,178.18 0.00 0.00 27840 S 123.31 0.00 0.00 27692 S 1,062.60 0.00 0.00 27842 S 517.01 0.00 0.00 27695 S 817.59 0.00 0.00 27846 S 1,037.66 0.00 0.00 27696 S 817.59 0.00 0.00 27848 S 1,037.66 0.00 0.00 27698 S 817.59 0.00 0.00 27860 S 517.01 0.00 0.00 27700 S 1,167.86 0.00 0.00 27870 S 1,662.54 0.00 0.00 27704 S 712.30 0.00 0.00 27871 S 1,662.54 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 15 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 27884 S 773.94 0.00 0.00 28126 S 768.08 0.00 0.00 27889 S 879.24 0.00 0.00 28130 S 768.08 0.00 0.00 27892 S 773.94 0.00 0.00 28140 S 768.08 0.00 0.00 27893 S 773.94 0.00 0.00 28150 S 768.08 0.00 0.00 27894 S 773.94 0.00 0.00 28153 S 768.08 0.00 0.00 28001 S 170.70 0.00 0.00 28160 S 768.08 0.00 0.00 28002 S 773.94 0.00 0.00 28171 S 768.08 0.00 0.00 28003 S 773.94 0.00 0.00 28173 S 768.08 0.00 0.00 28005 S 768.08 0.00 0.00 28175 S 768.08 0.00 0.00 28008 S 768.08 0.00 0.00 28190 S 180.98 0.00 0.00 28010 S 128.16 0.00 0.00 28192 S 643.59 0.00 0.00 28011 S 768.08 0.00 0.00 28193 S 518.53 0.00 0.00 28020 S 706.44 0.00 0.00 28200 S 768.08 0.00 0.00 28022 S 706.44 0.00 0.00 28202 S 768.08 0.00 0.00 28024 S 706.44 0.00 0.00 28208 S 768.08 0.00 0.00 28035 S 846.76 0.00 0.00 28210 S 1,079.66 0.00 0.00 28043 S 710.18 0.00 0.00 28220 S 270.98 0.00 0.00 28045 S 768.08 0.00 0.00 28222 S 597.60 0.00 0.00 28046 S 768.08 0.00 0.00 28225 S 597.60 0.00 0.00 28050 S 706.44 0.00 0.00 28226 S 597.60 0.00 0.00 28052 S 706.44 0.00 0.00 28230 S 267.56 0.00 0.00 28054 S 706.44 0.00 0.00 28232 S 255.82 0.00 0.00 28055 S 846.76 0.00 0.00 28234 S 706.44 0.00 0.00 28060 S 706.44 0.00 0.00 28238 S 1,079.66 0.00 0.00 28062 S 768.08 0.00 0.00 28240 S 706.44 0.00 0.00 28070 S 768.08 0.00 0.00 28250 S 768.08 0.00 0.00 28072 S 768.08 0.00 0.00 28260 S 768.08 0.00 0.00 28080 S 768.08 0.00 0.00 28261 S 768.08 0.00 0.00 28086 S 706.44 0.00 0.00 28262 S 883.67 0.00 0.00 28088 S 706.44 0.00 0.00 28264 S 909.17 0.00 0.00 28090 S 768.08 0.00 0.00 28270 S 768.08 0.00 0.00 28092 S 768.08 0.00 0.00 28272 S 245.06 0.00 0.00 28100 S 706.44 0.00 0.00 28280 S 706.44 0.00 0.00 28102 S 1,079.66 0.00 0.00 28285 S 768.08 0.00 0.00 28103 S 1,079.66 0.00 0.00 28286 S 883.67 0.00 0.00 28104 S 706.44 0.00 0.00 28288 S 768.08 0.00 0.00 28106 S 1,079.66 0.00 0.00 28289 S 768.08 0.00 0.00 28107 S 1,079.66 0.00 0.00 28290 S 820.60 0.00 0.00 28108 S 706.44 0.00 0.00 28292 S 820.60 0.00 0.00 28110 S 768.08 0.00 0.00 28293 S 882.24 0.00 0.00 28111 S 768.08 0.00 0.00 28294 S 882.24 0.00 0.00 28112 S 768.08 0.00 0.00 28296 S 882.24 0.00 0.00 28113 S 768.08 0.00 0.00 28297 S 882.24 0.00 0.00 28114 S 768.08 0.00 0.00 28298 S 882.24 0.00 0.00 28116 S 768.08 0.00 0.00 28299 S 1,081.62 0.00 0.00 28118 S 883.67 0.00 0.00 28300 S 1,018.01 0.00 0.00 28119 S 883.67 0.00 0.00 28302 S 706.44 0.00 0.00 28120 S 1,235.23 0.00 0.00 28304 S 1,018.01 0.00 0.00 28122 S 768.08 0.00 0.00 28305 S 1,079.66 0.00 0.00 28124 S 287.61 0.00 0.00 28306 S 883.67 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 16 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT ----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- --------- 28307 S 883.67 0.00 0.00 28606 S 777.31 0.00 0.00 28308 S 706.44 0.00 0.00 28615 S 1,037.66 0.00 0.00 28309 S 1,195.24 0.00 0.00 28630 S 83.64 0.00 0.00 28310 S 768.08 0.00 0.00 28635 S 517.01 0.00 0.00 28312 S 768.08 0.00 0.00 28636 S 838.95 0.00 0.00 28313 S 706.44 0.00 0.00 28645 S 838.95 0.00 0.00 28315 S 883.67 0.00 0.00 28660 S 62.61 0.00 0.00 28320 S 1,195.24 0.00 0.00 28665 S 517.01 0.00 0.00 28322 S 1,195.24 0.00 0.00 28666 S 838.95 0.00 0.00 28340 S 883.67 0.00 0.00 28675 S 838.95 0.00 0.00 28341 S 883.67 0.00 0.00 28705 S 1,195.24 0.00 0.00 28344 S 883.67 0.00 0.00 28715 S 1,662.54 0.00 0.00 28345 S 883.67 0.00 0.00 28725 S 1,195.24 0.00 0.00 28400 S 123.31 0.00 0.00 28730 S 1,195.24 0.00 0.00 28405 S 123.31 0.00 0.00 28735 S 1,195.24 0.00 0.00 28406 S 777.31 0.00 0.00 28737 S 1,279.04 0.00 0.00 28415 S 1,278.45 0.00 0.00 28740 S 1,195.24 0.00 0.00 28420 S 1,153.24 0.00 0.00 28750 S 1,195.24 0.00 0.00 28430 S 94.02 0.00 0.00 28755 S 883.67 0.00 0.00 28435 S 123.31 0.00 0.00 28760 S 1,195.24 0.00 0.00 28436 S 777.31 0.00 0.00 28810 S 706.44 0.00 0.00 28445 S 1,037.66 0.00 0.00 28820 S 706.44 0.00 0.00 28446 S 2,353.73 0.00 0.00 28825 S 706.44 0.00 0.00 28450 S 94.02 0.00 0.00 28890 S 251.42 0.00 0.00 28455 S 94.02 0.00 0.00 29000 S 58.13 0.00 0.00 28456 S 777.31 0.00 0.00 29010 S 121.81 0.00 0.00 28465 S 1,037.66 0.00 0.00 29015 S 121.81 0.00 0.00 28470 S 94.02 0.00 0.00 29020 S 58.13 0.00 0.00 28475 S 94.02 0.00 0.00 29025 S 58.13 0.00 0.00 28476 S 777.31 0.00 0.00 29035 S 121.81 0.00 0.00 28485 S 1,153.24 0.00 0.00 29040 S 58.13 0.00 0.00 28490 S 94.02 0.00 0.00 29044 S 121.81 0.00 0.00 28495 S 94.02 0.00 0.00 29046 S 121.81 0.00 0.00 28496 S 777.31 0.00 0.00 29049 S 58.13 0.00 0.00 28505 S 838.95 0.00 0.00 29055 S 121.81 0.00 0.00 28510 S 78.75 0.00 0.00 29058 S 58.13 0.00 0.00 28515 S 94.02 0.00 0.00 29065 S 63.58 0.00 0.00 28525 S 838.95 0.00 0.00 29075 S 61.14 0.00 0.00 28530 S 74.83 0.00 0.00 29085 S 58.13 0.00 0.00 28531 S 838.95 0.00 0.00 29086 S 49.89 0.00 0.00 28540 S 94.02 0.00 0.00 29105 S 56.74 0.00 0.00 28545 S 668.46 0.00 0.00 29125 S 48.43 0.00 0.00 28546 S 777.31 0.00 0.00 29126 S 54.30 0.00 0.00 28555 S 976.02 0.00 0.00 29130 S 22.01 0.00 0.00 28570 S 94.02 0.00 0.00 29131 S 32.29 0.00 0.00 28575 S 123.31 0.00 0.00 29200 S 32.29 0.00 0.00 28576 S 838.95 0.00 0.00 29220 S 33.75 0.00 0.00 28585 S 838.95 0.00 0.00 29240 S 37.18 0.00 0.00 28600 S 94.02 0.00 0.00 29260 S 34.73 0.00 0.00 28605 S 123.31 0.00 0.00 29280 S 35.70 0.00 0.00 0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1H99RPPS5 NHIC, CORP. FEB. 04, 2008 ASC FEE SCHEDULE DISCLOSURE PAGE 17 CBSA: 36084 EFFECTIVE DATE: 01/01/2008 0 PROC FC MOD FB MOD PROC FC MOD FB MOD