1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 1 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 EFFECTIVE JANUARY 1, 2008-DECEMBER 31, 2008 DATE 07/17/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ G0101 34.20 32.49 37.36 G0270 23.54 22.36 25.71 G0102 19.28 18.32 21.07 # G0270 23.17 22.01 25.31 # G0102 8.13 7.72 8.88 G0271 13.40 12.73 14.64 G0104 123.10 116.95 134.49 # G0271 13.03 12.38 14.24 # G0104 54.71 51.97 59.77 G0275 13.03 12.38 14.24 G0105 362.54 344.41 396.07 G0278 13.03 12.38 14.24 # G0105 190.80 181.26 208.45 G0281 10.74 10.20 11.73 G0105 53 123.10 116.95 134.49 G0283 10.74 10.20 11.73 # G0105 53 54.71 51.97 59.77 G0288 220.13 209.12 240.49 G0106 175.75 166.96 192.00 G0289 80.08 76.08 87.49 G0106 TC 129.59 123.11 141.58 G0308 697.73 662.84 762.27 G0106 26 46.16 43.85 50.43 G0309 571.83 543.24 624.73 G0108 26.58 25.25 29.04 G0310 447.80 425.41 489.22 G0109 15.06 14.31 16.46 G0311 486.37 462.05 531.36 G0117 42.93 40.78 46.90 G0312 400.47 380.45 437.52 G0118 28.95 27.50 31.63 G0313 314.58 298.85 343.68 C G0120 172.41 163.79 188.36 G0314 427.74 406.35 467.30 C G0120 TC 126.25 119.94 137.93 G0315 351.90 334.31 384.46 G0120 26 46.16 43.85 50.43 G0316 273.82 260.13 299.15 G0121 362.54 344.41 396.07 G0317 269.01 255.56 293.89 # G0121 190.80 181.26 208.45 G0318 220.55 209.52 240.95 G0121 53 123.10 116.95 134.49 G0319 172.47 163.85 188.43 # G0121 53 54.71 51.97 59.77 G0320 544.69 517.46 595.08 G0124 24.14 22.93 26.37 G0321 387.09 367.74 422.90 G0127 17.80 16.91 19.45 G0322 335.92 319.12 366.99 # G0127 8.13 7.72 8.88 G0323 210.14 199.63 229.57 G0128 3.60 3.42 3.93 G0324 19.43 18.46 21.23 G0130 35.14 33.38 38.39 G0325 11.52 10.94 12.58 G0130 TC 25.11 23.85 27.43 G0326 13.42 12.75 14.66 G0130 26 10.03 9.53 10.96 G0327 7.36 6.99 8.04 G0141 24.14 22.93 26.37 G0329 7.67 7.29 8.38 G0166 152.65 145.02 166.77 G0332 73.23 69.57 80.01 G0168 81.23 77.17 88.75 G0339 3,915.07 3,719.32 4,277.22 # G0168 23.61 22.43 25.79 G0340 2,658.17 2,525.26 2,904.05 G0179 43.49 41.32 47.52 G0341 335.51 318.73 366.54 G0180 56.87 54.03 62.13 G0342 620.11 589.10 677.47 G0181 101.59 96.51 110.99 G0343 1,026.86 975.52 1,121.85 G0182 105.31 100.04 115.05 G0344 88.47 84.05 96.66 G0202 129.22 122.76 141.17 # G0344 63.56 60.38 69.44 G0202 TC 96.49 91.67 105.42 G0364 11.67 11.09 12.75 G0202 26 32.73 31.09 35.75 # G0364 8.32 7.90 9.09 G0204 146.27 138.96 159.80 C G0365 156.21 148.40 170.66 G0204 TC 105.41 100.14 115.16 C G0365 TC 144.48 137.26 157.85 G0204 26 40.86 38.82 44.64 G0365 26 11.73 11.14 12.81 G0206 116.76 110.92 127.56 G0366 21.89 20.80 23.92 G0206 TC 84.03 79.83 91.80 G0367 13.76 13.07 15.03 G0206 26 32.73 31.09 35.75 G0368 8.13 7.72 8.88 G0237 13.02 12.37 14.23 G0372 14.08 13.38 15.39 G0238 13.76 13.07 15.03 # G0372 7.76 7.37 8.48 G0239 12.27 11.66 13.41 G0389 111.09 105.54 121.37 G0245 60.19 57.18 65.76 G0389 TC 83.67 79.49 91.41 # G0245 41.24 39.18 45.06 G0389 26 27.43 26.06 29.97 G0246 36.06 34.26 39.40 G0392 2,277.99 2,164.09 2,488.70 # G0246 21.19 20.13 23.15 # G0392 458.75 435.81 501.18 G0247 39.44 37.47 43.09 G0393 1,731.28 1,644.72 1,891.43 # G0247 23.83 22.64 26.04 # G0393 293.80 279.11 320.98 G0248 186.43 177.11 203.68 G0396 28.96 27.51 31.64 G0249 136.99 130.14 149.66 # G0396 27.47 26.10 30.02 G0250 8.89 8.45 9.72 G0397 56.63 53.80 61.87 G0268 45.11 42.85 49.28 # G0397 54.77 52.03 59.83 # G0268 29.12 27.66 31.81 G9041 22.48 21.36 24.56 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 2 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ G9042 9.56 9.08 10.44 10121 227.75 216.36 248.81 G9043 9.56 9.08 10.44 # 10121 161.21 153.15 176.12 G9044 8.45 8.03 9.23 10140 130.48 123.96 142.55 M0064 35.81 34.02 39.12 # 10140 103.35 98.18 112.91 # M0064 16.10 15.30 17.60 10160 107.34 101.97 117.27 P3001 24.14 22.93 26.37 # 10160 83.55 79.37 91.28 Q0035 20.03 19.03 21.88 10180 198.78 188.84 217.17 Q0035 TC 12.27 11.66 13.41 # 10180 153.06 145.41 167.22 Q0035 26 7.76 7.37 8.48 11000 45.67 43.39 49.90 Q0091 39.34 37.37 42.98 # 11000 28.57 27.14 31.21 # Q0091 17.41 16.54 19.02 11001 19.21 18.25 20.99 Q0092 15.06 14.31 16.46 # 11001 14.38 13.66 15.71 R0070 109.13 103.67 119.22 11004 506.85 481.51 553.74 R0075 109.13 103.67 119.22 11005 669.38 635.91 731.30 0067T 566.20 537.89 618.57 11006 627.31 595.94 685.33 C 0067T TC 179.68 170.70 196.31 11008 240.84 228.80 263.12 0067T 26 123.73 117.54 135.17 11010 407.30 386.94 444.98 0073T 582.36 553.24 636.23 # 11010 245.22 232.96 267.90 0075T 1,072.19 1,018.58 1,171.37 11011 462.20 439.09 504.95 0076T 353.82 336.13 386.55 # 11011 260.72 247.68 284.83 0078T 1,203.37 1,143.20 1,314.68 11012 644.93 612.68 704.58 0079T 1,104.55 1,049.32 1,206.72 # 11012 381.37 362.30 416.65 0080T 215.34 204.57 235.26 11040 40.20 38.19 43.92 0081T 215.34 204.57 235.26 # 11040 24.59 23.36 26.86 0145T 563.65 535.47 615.79 11041 47.73 45.34 52.14 C 0145T TC 280.69 266.66 306.66 # 11041 31.74 30.15 34.67 0145T 26 98.12 93.21 107.19 11042 64.81 61.57 70.81 0146T 563.65 535.47 615.79 # 11042 41.76 39.67 45.62 C 0146T TC 280.69 266.66 306.66 11043 236.01 224.21 257.84 0146T 26 98.12 93.21 107.19 # 11043 204.78 194.54 223.72 0147T 563.65 535.47 615.79 11044 318.87 302.93 348.37 C 0147T TC 280.69 266.66 306.66 # 11044 282.44 268.32 308.57 0147T 26 98.12 93.21 107.19 11055 40.70 38.67 44.47 0148T 563.65 535.47 615.79 # 11055 20.62 19.59 22.53 C 0148T TC 280.69 266.66 306.66 11056 50.14 47.63 54.77 0148T 26 98.12 93.21 107.19 # 11056 28.95 27.50 31.63 0149T 563.65 535.47 615.79 11057 60.52 57.49 66.11 C 0149T TC 280.69 266.66 306.66 # 11057 37.85 35.96 41.35 0149T 26 98.12 93.21 107.19 11100 85.60 81.32 93.52 0150T 563.65 535.47 615.79 # 11100 41.74 39.65 45.60 C 0150T TC 280.69 266.66 306.66 11101 27.84 26.45 30.42 0150T 26 98.12 93.21 107.19 # 11101 21.15 20.09 23.10 0151T 183.55 174.37 200.53 11200 69.42 65.95 75.84 C 0151T TC 94.68 89.95 103.44 # 11200 58.27 55.36 63.66 0151T 26 64.60 61.37 70.58 11201 16.23 15.42 17.73 10021 125.22 118.96 136.80 # 11201 14.74 14.00 16.10 # 10021 61.65 58.57 67.36 11300 58.23 55.32 63.62 10022 131.53 124.95 143.69 # 11300 25.51 24.23 27.86 # 10022 59.41 56.44 64.91 11301 78.02 74.12 85.24 10040 84.43 80.21 92.24 # 11301 43.45 41.28 47.47 # 10040 73.65 69.97 80.47 11302 92.86 88.22 101.45 10060 92.82 88.18 101.41 # 11302 53.46 50.79 58.41 # 10060 79.81 75.82 87.19 11303 110.12 104.61 120.30 10061 158.53 150.60 173.19 # 11303 62.91 59.76 68.72 # 10061 141.81 134.72 154.93 11305 59.48 56.51 64.99 10080 149.50 142.03 163.33 # 11305 32.72 31.08 35.74 # 10080 83.34 79.17 91.05 11306 81.30 77.24 88.83 10081 228.09 216.69 249.19 # 11306 49.33 46.86 53.89 # 10081 142.22 135.11 155.38 11307 94.80 90.06 103.57 10120 119.98 113.98 131.08 # 11307 57.26 54.40 62.56 # 10120 79.09 75.14 86.41 11308 108.42 103.00 118.45 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 3 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 11308 69.76 66.27 76.21 11602 200.70 190.67 219.27 11310 71.60 68.02 78.22 # 11602 131.19 124.63 143.32 # 11310 37.03 35.18 40.46 11603 228.30 216.89 249.42 11311 89.14 84.68 97.38 # 11603 155.44 147.67 169.82 # 11311 53.83 51.14 58.81 11604 252.01 239.41 275.32 11312 103.59 98.41 113.17 # 11604 170.23 161.72 185.98 # 11312 61.95 58.85 67.68 11606 351.32 333.75 383.81 11313 130.70 124.17 142.80 # 11606 251.70 239.12 274.99 # 11313 83.12 78.96 90.80 11620 156.14 148.33 170.58 11400 102.58 97.45 112.07 # 11620 94.80 90.06 103.57 # 11400 64.29 61.08 70.24 11621 185.68 176.40 202.86 11401 122.60 116.47 133.94 # 11621 122.12 116.01 133.41 # 11401 84.31 80.09 92.10 11622 209.37 198.90 228.74 11402 135.94 129.14 148.51 # 11622 140.23 133.22 153.20 # 11402 92.45 87.83 101.00 11623 244.89 232.65 267.55 11403 155.97 148.17 170.40 # 11623 172.04 163.44 187.96 # 11403 117.31 111.44 128.16 11624 276.74 262.90 302.34 11404 177.02 168.17 193.40 # 11624 196.45 186.63 214.62 # 11404 129.81 123.32 141.82 11626 340.06 323.06 371.52 11406 245.27 233.01 267.96 # 11626 249.36 236.89 272.42 # 11406 192.12 182.51 209.89 11640 162.86 154.72 177.93 11420 102.13 97.02 111.57 # 11640 101.15 96.09 110.50 # 11420 69.79 66.30 76.25 11641 198.04 188.14 216.36 11421 130.38 123.86 142.44 # 11641 132.61 125.98 144.88 # 11421 93.21 88.55 101.83 11642 227.96 216.56 249.04 11422 145.61 138.33 159.08 # 11642 155.84 148.05 170.26 # 11422 111.41 105.84 121.72 11643 268.22 254.81 293.03 11423 169.73 161.24 185.43 # 11643 193.87 184.18 211.81 # 11423 129.58 123.10 141.57 11644 332.38 315.76 363.12 11424 194.43 184.71 212.42 # 11644 242.42 230.30 264.85 # 11424 149.82 142.33 163.68 11646 436.60 414.77 476.99 11426 275.51 261.73 300.99 # 11646 342.55 325.42 374.23 # 11426 226.07 214.77 246.99 11719 17.62 16.74 19.25 11440 113.86 108.17 124.40 # 11719 8.32 7.90 9.09 # 11440 84.49 80.27 92.31 11720 26.29 24.98 28.73 11441 140.46 133.44 153.46 # 11720 15.14 14.38 16.54 # 11441 109.24 103.78 119.35 11721 37.82 35.93 41.32 11442 157.58 149.70 172.16 # 11721 25.93 24.63 28.32 # 11442 121.15 115.09 132.35 11730 83.46 79.29 91.18 11443 189.28 179.82 206.79 # 11730 52.98 50.33 57.88 # 11443 149.51 142.03 163.33 11732 38.58 36.65 42.15 11444 237.95 226.05 259.96 # 11732 27.06 25.71 29.57 # 11444 191.11 181.55 208.78 11740 38.23 36.32 41.77 11446 318.64 302.71 348.12 # 11740 27.82 26.43 30.39 # 11446 268.83 255.39 293.70 11750 179.69 170.71 196.32 11450 300.78 285.74 328.60 # 11750 152.18 144.57 166.26 # 11450 194.46 184.74 212.45 11752 254.39 241.67 277.92 11451 397.16 377.30 433.90 # 11752 230.23 218.72 251.53 # 11451 257.39 244.52 281.20 11755 113.36 107.69 123.84 11462 297.98 283.08 325.54 # 11755 74.70 70.97 81.62 # 11462 187.21 177.85 204.53 11760 169.57 161.09 185.25 11463 404.41 384.19 441.82 # 11760 117.53 111.65 128.40 # 11463 260.55 247.52 284.65 11762 226.62 215.29 247.58 11470 326.11 309.80 356.27 # 11762 179.03 170.08 195.59 # 11470 221.29 210.23 241.76 11765 108.40 102.98 118.43 11471 418.18 397.27 456.86 # 11765 58.22 55.31 63.61 # 11471 279.90 265.91 305.80 11770 223.60 212.42 244.28 11600 154.83 147.09 169.15 # 11770 150.74 143.20 164.68 # 11600 93.87 89.18 102.56 11771 442.97 420.82 483.94 11601 184.19 174.98 201.23 # 11771 344.83 327.59 376.73 # 11601 120.62 114.59 131.78 11772 548.29 520.88 599.01 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 4 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 11772 456.85 434.01 499.11 12031 190.83 181.29 208.48 11900 46.89 44.55 51.23 # 12031 126.89 120.55 138.63 # 11900 26.45 25.13 28.90 12032 254.83 242.09 278.40 11901 58.08 55.18 63.46 # 12032 162.27 154.16 177.28 # 11901 40.98 38.93 44.77 12034 248.35 235.93 271.32 11920 170.89 162.35 186.70 # 12034 167.32 158.95 182.79 # 11920 99.15 94.19 108.32 12035 317.94 302.04 347.35 11921 193.28 183.62 211.16 # 12035 201.96 191.86 220.64 # 11921 117.08 111.23 127.91 12036 350.47 332.95 382.89 11922 55.99 53.19 61.17 # 12036 235.61 223.83 257.40 # 11922 26.62 25.29 29.08 12037 393.94 374.24 430.38 11950 66.86 63.52 73.05 # 12037 273.50 259.83 298.80 # 11950 43.07 40.92 47.06 12041 202.90 192.76 221.67 11951 86.68 82.35 94.70 # 12041 137.48 130.61 150.20 # 11951 58.06 55.16 63.43 12042 240.00 228.00 262.20 11952 124.46 118.24 135.98 # 12042 162.31 154.19 177.32 # 11952 86.54 82.21 94.54 12044 271.21 257.65 296.30 11954 145.62 138.34 159.09 # 12044 176.79 167.95 193.14 # 11954 97.67 92.79 106.71 12045 321.46 305.39 351.20 11960 784.19 744.98 856.73 # 12045 210.69 200.16 230.18 11970 512.05 486.45 559.42 12046 379.06 360.11 414.13 11971 420.89 399.85 459.83 # 12046 246.72 234.38 269.54 # 11971 259.19 246.23 283.16 12047 405.79 385.50 443.33 11976 127.71 121.32 139.52 # 12047 273.82 260.13 299.15 # 11976 85.33 81.06 93.22 12051 224.36 213.14 245.11 11980 92.12 87.51 100.64 # 12051 150.02 142.52 163.90 # 11980 70.93 67.38 77.49 12052 247.47 235.10 270.37 11981 118.70 112.77 129.69 # 12052 171.64 163.06 187.52 # 11981 75.20 71.44 82.16 12053 270.44 256.92 295.46 11982 136.62 129.79 149.26 # 12053 177.88 168.99 194.34 # 11982 91.27 86.71 99.72 12054 289.50 275.03 316.28 11983 206.63 196.30 225.75 # 12054 190.62 181.09 208.25 # 11983 166.86 158.52 182.30 12055 352.60 334.97 385.22 12001 129.49 123.02 141.47 # 12055 235.87 224.08 257.69 # 12001 88.23 83.82 96.39 12056 434.70 412.97 474.92 12002 137.81 130.92 150.56 # 12056 291.96 277.36 318.96 # 12002 98.78 93.84 107.92 12057 469.29 445.83 512.70 12004 161.55 153.47 176.49 # 12057 335.10 318.35 366.10 # 12004 115.83 110.04 126.55 13100 268.04 254.64 292.84 12005 201.10 191.05 219.71 # 13100 199.27 189.31 217.71 # 12005 143.86 136.67 157.17 13101 333.72 317.03 364.58 12006 250.10 237.60 273.24 # 13101 241.90 229.81 264.28 # 12006 182.07 172.97 198.92 13102 90.81 86.27 99.21 12007 280.61 266.58 306.57 # 13102 64.42 61.20 70.38 # 12007 208.12 197.71 227.37 13120 278.21 264.30 303.95 12011 137.91 131.01 150.66 # 13120 207.58 197.20 226.78 # 12011 91.45 86.88 99.91 13121 365.85 347.56 399.69 12013 151.49 143.92 165.51 # 13121 270.68 257.15 295.72 # 12013 104.65 99.42 114.33 13122 104.74 99.50 114.43 12014 177.71 168.82 194.14 # 13122 73.51 69.83 80.30 # 12014 125.30 119.04 136.90 13131 306.85 291.51 335.24 12015 223.31 212.14 243.96 # 13131 235.85 224.06 257.67 # 12015 157.14 149.28 171.67 13132 480.03 456.03 524.43 12016 264.07 250.87 288.50 # 13132 393.04 373.39 429.40 # 12016 191.21 181.65 208.90 13133 142.71 135.57 155.91 12017 230.90 219.36 252.26 # 13133 114.09 108.39 124.65 12018 275.67 261.89 301.17 13150 312.84 297.20 341.78 12020 233.81 222.12 255.44 # 13150 236.26 224.45 258.12 # 12020 162.44 154.32 177.47 13151 347.36 329.99 379.49 12021 135.40 128.63 147.92 # 13151 273.76 260.07 299.08 # 12021 117.93 112.03 128.83 13152 472.50 448.88 516.21 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 5 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 13152 368.05 349.65 402.10 15151 112.85 107.21 123.29 13153 158.50 150.58 173.17 # 15151 100.58 95.55 109.88 # 13153 124.67 118.44 136.21 15152 138.74 131.80 151.57 13160 689.95 655.45 753.77 # 15152 125.73 119.44 137.36 14000 552.32 524.70 603.41 15155 644.66 612.43 704.29 # 14000 454.19 431.48 496.20 # 15155 603.77 573.58 659.62 14001 717.26 681.40 783.61 15156 149.17 141.71 162.97 # 14001 607.98 577.58 664.22 # 15156 139.50 132.53 152.41 14020 615.65 584.87 672.60 15157 165.92 157.62 181.26 # 14020 518.63 492.70 566.61 # 15157 152.17 144.56 166.24 14021 807.94 767.54 882.67 15170 356.85 339.01 389.86 # 14021 705.34 670.07 770.58 # 15170 303.32 288.15 331.37 14040 647.87 615.48 707.80 15171 79.19 75.23 86.51 # 14040 558.65 530.72 610.33 # 15171 75.47 71.70 82.46 14041 888.29 843.88 970.46 15175 467.66 444.28 510.92 # 14041 773.80 735.11 845.38 # 15175 416.36 395.54 454.87 14060 660.66 627.63 721.77 15176 127.53 121.15 139.32 # 14060 588.92 559.47 643.39 # 15176 120.84 114.80 132.02 14061 964.38 916.16 1,053.58 15200 678.53 644.60 741.29 # 14061 838.74 796.80 916.32 # 15200 552.88 525.24 604.03 14300 925.16 878.90 1,010.74 15201 132.90 126.26 145.20 # 14300 812.89 772.25 888.09 # 15201 67.85 64.46 74.13 14350 649.29 616.83 709.35 15220 647.92 615.52 707.85 15002 288.40 273.98 315.08 # 15220 531.20 504.64 580.34 # 15002 194.36 184.64 212.34 15221 123.31 117.14 134.71 15003 62.20 59.09 67.95 # 15221 62.72 59.58 68.52 # 15003 38.41 36.49 41.96 15240 771.28 732.72 842.63 15004 346.63 329.30 378.70 # 15240 671.28 637.72 733.38 # 15004 240.32 228.30 262.55 15241 159.38 151.41 174.12 15005 103.96 98.76 113.57 # 15241 98.79 93.85 107.93 # 15005 77.57 73.69 84.74 15260 827.02 785.67 903.52 15040 229.56 218.08 250.79 # 15260 728.14 691.73 795.49 # 15040 112.09 106.49 122.46 15261 184.20 174.99 201.24 15050 461.19 438.13 503.85 # 15261 126.21 119.90 137.89 # 15050 379.04 360.09 414.10 15300 288.47 274.05 315.16 15100 766.61 728.28 837.52 # 15300 246.46 234.14 269.26 # 15100 620.52 589.49 677.91 15301 53.27 50.61 58.20 15101 177.29 168.43 193.69 # 15301 49.55 47.07 54.13 # 15101 99.60 94.62 108.81 15320 328.29 311.88 358.66 15110 750.62 713.09 820.05 # 15320 281.82 267.73 307.89 # 15110 637.99 606.09 697.00 15321 79.90 75.91 87.30 15111 107.15 101.79 117.06 # 15321 74.70 70.97 81.62 # 15111 93.02 88.37 101.63 15330 267.12 253.76 291.82 15115 740.03 703.03 808.48 # 15330 224.00 212.80 244.72 # 15115 658.99 626.04 719.95 15331 53.64 50.96 58.60 15116 141.71 134.62 154.81 # 15331 50.29 47.78 54.95 # 15116 126.84 120.50 138.58 15335 287.62 273.24 314.23 15120 799.89 759.90 873.89 # 15335 244.13 231.92 266.71 # 15120 672.76 639.12 734.99 15336 78.17 74.26 85.40 15121 243.90 231.71 266.47 # 15336 71.85 68.26 78.50 # 15121 154.68 146.95 168.99 15340 276.57 262.74 302.15 15130 598.28 568.37 653.63 # 15340 234.20 222.49 255.86 # 15130 488.62 464.19 533.82 15341 40.94 38.89 44.72 15131 86.22 81.91 94.20 # 15341 24.21 23.00 26.45 # 15131 75.07 71.32 82.02 15360 313.15 297.49 342.11 15135 749.13 711.67 818.42 # 15360 262.96 249.81 287.28 # 15135 671.44 637.87 733.55 15361 61.19 58.13 66.85 15136 82.68 78.55 90.33 # 15361 55.62 52.84 60.77 # 15136 75.99 72.19 83.02 15365 312.83 297.19 341.77 15150 621.60 590.52 679.10 # 15365 267.10 253.75 291.81 # 15150 560.27 532.26 612.10 15366 77.25 73.39 84.40 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 6 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 15366 71.67 68.09 78.30 # 15786 118.60 112.67 129.57 15400 323.19 307.03 353.08 15787 47.49 45.12 51.89 # 15400 300.52 285.49 328.31 # 15787 16.26 15.45 17.77 15401 90.07 85.57 98.41 15788 372.89 354.25 407.39 # 15401 50.66 48.13 55.35 # 15788 205.98 195.68 225.03 15420 363.95 345.75 397.61 15789 493.96 469.26 539.65 # 15420 321.95 305.85 351.73 # 15789 366.08 347.78 399.95 15421 100.34 95.32 109.62 15792 363.79 345.60 397.44 # 15421 74.70 70.97 81.62 # 15792 232.95 221.30 254.50 15430 462.60 439.47 505.39 15793 399.21 379.25 436.14 # 15430 446.98 424.63 488.32 # 15793 304.05 288.85 332.18 15570 758.66 720.73 828.84 15819 626.37 595.05 684.31 # 15570 603.28 573.12 659.09 15820 460.03 437.03 502.58 15572 714.32 678.60 780.39 # 15820 411.71 391.12 449.79 # 15572 599.83 569.84 655.32 15821 490.43 465.91 535.80 15574 770.18 731.67 841.42 # 15821 436.16 414.35 476.50 # 15574 651.22 618.66 711.46 15822 363.78 345.59 397.43 15576 687.82 653.43 751.44 # 15822 317.68 301.80 347.07 # 15576 575.56 546.78 628.80 15823 565.04 536.79 617.31 15600 310.76 295.22 339.50 # 15823 514.86 489.12 562.49 # 15600 178.79 169.85 195.33 15830 987.24 937.88 1,078.56 15610 279.97 265.97 305.87 15832 764.62 726.39 835.35 # 15610 209.71 199.22 229.10 15833 712.68 677.05 778.61 15620 393.17 373.51 429.54 15834 726.69 690.36 793.91 # 15620 272.73 259.09 297.95 15835 745.38 708.11 814.33 15630 401.42 381.35 438.55 15836 627.77 596.38 685.84 # 15630 296.22 281.41 323.62 15837 656.98 624.13 717.75 15650 431.74 410.15 471.67 # 15837 581.15 552.09 634.90 # 15650 323.57 307.39 353.50 15838 495.89 471.10 541.77 15731 940.01 893.01 1,026.96 15839 715.01 679.26 781.15 # 15731 844.85 802.61 923.00 # 15839 608.33 577.91 664.60 15732 1,306.82 1,241.48 1,427.70 15840 871.40 827.83 952.00 # 15732 1,132.10 1,075.50 1,236.83 15841 1,440.25 1,368.24 1,573.48 15734 1,336.33 1,269.51 1,459.94 15842 2,272.25 2,158.64 2,482.44 # 15734 1,158.27 1,100.36 1,265.41 15845 814.70 773.97 890.07 15736 1,202.14 1,142.03 1,313.33 15851 86.21 81.90 94.19 # 15736 1,001.03 950.98 1,093.63 # 15851 40.12 38.11 43.83 15738 1,275.19 1,211.43 1,393.14 15852 41.43 39.36 45.26 # 15738 1,092.30 1,037.69 1,193.34 15860 97.01 92.16 105.98 15740 840.90 798.86 918.69 15920 495.74 470.95 541.59 # 15740 728.64 692.21 796.04 15922 637.32 605.45 696.27 15750 786.53 747.20 859.28 15931 566.97 538.62 619.41 15756 2,047.04 1,944.69 2,236.39 15933 699.41 664.44 764.11 15757 2,046.97 1,944.62 2,236.31 15934 780.80 741.76 853.02 15758 2,039.08 1,937.13 2,227.70 15935 924.74 878.50 1,010.28 15760 720.87 684.83 787.55 15936 761.44 723.37 831.88 # 15760 606.75 576.41 662.87 15937 890.99 846.44 973.41 15770 560.34 532.32 612.17 15940 586.44 557.12 640.69 15775 274.72 260.98 300.13 15941 774.33 735.61 845.95 # 15775 189.22 179.76 206.72 15944 753.71 716.02 823.42 15776 389.07 369.62 425.06 15945 833.26 791.60 910.34 # 15776 290.93 276.38 317.84 15946 1,380.22 1,311.21 1,507.89 15780 720.98 684.93 787.67 15950 486.26 461.95 531.24 # 15780 572.66 544.03 625.63 15951 693.49 658.82 757.64 15781 460.92 437.87 503.55 15952 720.32 684.30 786.95 # 15781 375.79 357.00 410.55 15953 803.55 763.37 877.88 15782 498.03 473.13 544.10 15956 976.15 927.34 1,066.44 # 15782 366.81 348.47 400.74 15958 996.94 947.09 1,089.15 15783 425.49 404.22 464.85 16000 60.59 57.56 66.19 # 15783 320.66 304.63 350.32 # 16000 40.52 38.49 44.26 15786 205.96 195.66 225.01 16020 72.78 69.14 79.51 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 7 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 16020 49.36 46.89 53.92 17311 610.62 580.09 667.10 16025 127.76 121.37 139.58 # 17311 325.88 309.59 356.03 # 16025 99.51 94.53 108.71 17312 369.42 350.95 403.59 16030 153.42 145.75 167.61 # 17312 173.51 164.83 189.55 # 16030 114.02 108.32 124.57 17313 558.06 530.16 609.68 16035 186.06 176.76 203.27 # 17313 292.64 278.01 319.71 16036 73.76 70.07 80.58 17314 341.52 324.44 373.11 17000 65.75 62.46 71.83 # 17314 160.48 152.46 175.33 # 17000 45.31 43.04 49.50 17315 72.27 68.66 78.96 17003 6.56 6.23 7.16 # 17315 45.88 43.59 50.13 # 17003 4.33 4.11 4.73 17340 39.85 37.86 43.54 17004 151.12 143.56 165.09 # 17340 40.22 38.21 43.94 # 17004 118.04 112.14 128.96 17360 110.84 105.30 121.10 17106 334.49 317.77 365.44 # 17360 84.45 80.23 92.26 # 17106 284.68 270.45 311.02 19000 102.19 97.08 111.64 17107 583.61 554.43 637.59 # 19000 40.48 38.46 44.23 # 17107 513.35 487.68 560.83 19001 24.14 22.93 26.37 17108 790.71 751.17 863.85 # 19001 20.05 19.05 21.91 # 17108 714.88 679.14 781.01 19020 374.70 355.97 409.37 17110 86.61 82.28 94.62 # 19020 240.14 228.13 262.35 # 17110 52.78 50.14 57.66 19030 156.09 148.29 170.53 17111 105.42 100.15 115.17 # 19030 72.45 68.83 79.15 # 17111 68.24 64.83 74.55 19100 123.01 116.86 134.39 17250 65.10 61.85 71.13 # 19100 59.44 56.47 64.94 # 17250 31.28 29.72 34.18 19101 279.84 265.85 305.73 17260 81.80 77.71 89.37 # 19101 183.56 174.38 200.54 # 17260 57.64 54.76 62.97 19102 205.36 195.09 224.35 17261 117.14 111.28 127.97 # 19102 94.59 89.86 103.34 # 17261 76.25 72.44 83.31 19103 530.93 504.38 580.04 17262 142.57 135.44 155.76 # 19103 174.44 165.72 190.58 # 17262 97.59 92.71 106.62 19105 1,858.37 1,765.45 2,030.27 17263 157.05 149.20 171.58 # 19105 166.63 158.30 182.05 # 17263 107.61 102.23 117.56 19110 377.10 358.25 411.99 17264 169.63 161.15 185.32 # 19110 267.44 254.07 292.18 # 17264 114.99 109.24 125.63 19112 362.62 344.49 396.16 17266 192.44 182.82 210.24 # 19112 242.18 230.07 264.58 # 17266 132.97 126.32 145.27 19120 388.39 368.97 424.32 17270 122.84 116.70 134.21 # 19120 328.91 312.46 359.33 # 17270 82.32 78.20 89.93 19125 428.23 406.82 467.84 17271 134.32 127.60 146.74 # 19125 365.04 346.79 398.81 # 17271 92.68 88.05 101.26 19126 137.80 130.91 150.55 17272 154.06 146.36 168.31 19260 1,026.75 975.41 1,121.72 # 17272 107.60 102.22 117.55 19271 1,411.18 1,340.62 1,541.71 17273 171.57 162.99 187.44 19272 1,556.62 1,478.79 1,700.61 # 17273 121.02 114.97 132.22 19290 150.67 143.14 164.61 17274 204.36 194.14 223.26 # 19290 59.97 56.97 65.52 # 17274 148.60 141.17 162.35 19291 65.20 61.94 71.23 17276 238.33 226.41 260.37 # 19291 29.51 28.03 32.23 # 17276 178.85 169.91 195.40 19295 92.75 88.11 101.33 17280 114.91 109.16 125.53 19296 4,059.73 3,856.74 4,435.25 # 17280 75.14 71.38 82.09 # 19296 179.25 170.29 195.83 17281 145.84 138.55 159.33 19297 80.80 76.76 88.27 # 17281 104.58 99.35 114.25 19298 1,402.49 1,332.37 1,532.23 17282 168.96 160.51 184.59 # 19298 293.25 278.59 320.38 # 17282 121.01 114.96 132.20 19300 470.01 446.51 513.49 17283 204.58 194.35 223.50 # 19300 322.44 306.32 352.27 # 17283 151.80 144.21 165.84 19301 499.94 474.94 546.18 17284 238.87 226.93 260.97 19302 731.45 694.88 799.11 # 17284 180.88 171.84 197.62 19303 771.35 732.78 842.70 17286 304.58 289.35 332.75 19304 462.01 438.91 504.75 # 17286 245.47 233.20 268.18 19305 913.18 867.52 997.65 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 8 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 19306 953.33 905.66 1,041.51 # 20526 51.17 48.61 55.90 19307 958.07 910.17 1,046.70 20550 51.75 49.16 56.53 19316 668.11 634.70 729.91 # 20550 36.51 34.68 39.88 19318 980.86 931.82 1,071.59 20551 51.19 48.63 55.92 19324 413.06 392.41 451.27 # 20551 38.18 36.27 41.71 19325 551.34 523.77 602.34 20552 47.20 44.84 51.57 19328 416.37 395.55 454.88 # 20552 31.21 29.65 34.10 19330 528.35 501.93 577.22 20553 53.03 50.38 57.94 19340 342.24 325.13 373.90 # 20553 34.82 33.08 38.04 19342 782.69 743.56 855.09 20555 290.28 275.77 317.14 19350 769.58 731.10 840.77 20600 48.14 45.73 52.59 # 19350 584.09 554.89 638.12 # 20600 35.87 34.08 39.19 19355 626.35 595.03 684.28 20605 52.25 49.64 57.09 # 19355 472.46 448.84 516.17 # 20605 37.01 35.16 40.43 19357 1,321.96 1,255.86 1,444.24 20610 66.29 62.98 72.43 19361 1,375.91 1,307.11 1,503.18 # 20610 43.98 41.78 48.05 19364 2,390.43 2,270.91 2,611.55 20612 51.53 48.95 56.29 19366 1,188.97 1,129.52 1,298.95 # 20612 38.15 36.24 41.68 19367 1,561.38 1,483.31 1,705.81 20615 196.71 186.87 214.90 19368 1,919.20 1,823.24 2,096.73 # 20615 141.69 134.61 154.80 19369 1,771.60 1,683.02 1,935.47 20650 170.87 162.33 186.68 19370 580.70 551.67 634.42 # 20650 137.04 130.19 149.72 19371 668.77 635.33 730.63 20660 229.99 218.49 251.26 19380 654.40 621.68 714.93 # 20660 202.85 192.71 221.62 19396 182.88 173.74 199.80 20661 397.82 377.93 434.62 # 19396 120.80 114.76 131.97 20662 412.64 392.01 450.81 20000 178.19 169.28 194.67 20663 386.24 366.93 421.97 # 20000 136.93 130.08 149.59 20664 639.92 607.92 699.11 20005 261.00 247.95 285.14 20665 113.58 107.90 124.09 # 20005 207.10 196.75 226.26 # 20665 91.28 86.72 99.73 20100 518.93 492.98 566.93 20670 401.87 381.78 439.05 20101 349.20 331.74 381.50 # 20670 134.59 127.86 147.04 # 20101 174.86 166.12 191.04 20680 523.51 497.33 571.93 20102 409.83 389.34 447.74 # 20680 353.26 335.60 385.94 # 20102 211.33 200.76 230.87 20690 439.30 417.34 479.94 20103 497.26 472.40 543.26 20692 808.93 768.48 883.75 # 20103 307.31 291.94 335.73 20693 403.64 383.46 440.98 20150 801.26 761.20 875.38 20694 385.95 366.65 421.65 20200 167.24 158.88 182.71 # 20694 294.88 280.14 322.16 # 20200 80.25 76.24 87.68 20802 2,126.71 2,020.37 2,323.43 20205 228.57 217.14 249.71 20805 2,779.31 2,640.34 3,036.39 # 20205 127.46 121.09 139.25 20808 3,584.69 3,405.46 3,916.28 20206 252.29 239.68 275.63 20816 2,157.30 2,049.44 2,356.86 # 20206 56.76 53.92 62.01 20822 1,888.97 1,794.52 2,063.70 20220 179.11 170.15 195.67 20824 2,132.98 2,026.33 2,330.28 # 20220 71.31 67.74 77.90 20827 1,935.55 1,838.77 2,114.59 20225 744.67 707.44 813.56 20838 2,123.76 2,017.57 2,320.21 # 20225 107.15 101.79 117.06 20900 539.51 512.53 589.41 20240 202.38 192.26 221.10 # 20900 407.92 387.52 445.65 20245 547.81 520.42 598.48 20902 531.38 504.81 580.53 20250 324.93 308.68 354.98 20910 376.14 357.33 410.93 20251 361.28 343.22 394.70 20912 427.87 406.48 467.45 20500 111.08 105.53 121.36 20920 353.27 335.61 385.95 # 20500 88.77 84.33 96.98 20922 523.19 497.03 571.58 20501 124.41 118.19 135.92 # 20922 425.80 404.51 465.19 # 20501 35.94 34.14 39.26 20924 442.44 420.32 483.37 20520 169.42 160.95 185.09 20926 379.40 360.43 414.49 # 20520 126.67 120.34 138.39 20931 98.44 93.52 107.55 20525 429.56 408.08 469.29 20937 150.75 143.21 164.69 # 20525 217.30 206.44 237.41 20938 163.61 155.43 178.74 20526 67.16 63.80 73.37 20950 252.00 239.40 275.31 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 9 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 20950 81.00 76.95 88.49 # 21084 1,291.09 1,226.54 1,410.52 20955 2,231.18 2,119.62 2,437.56 21085 608.58 578.15 664.87 20956 2,343.98 2,226.78 2,560.80 # 21085 517.13 491.27 564.96 20957 2,201.27 2,091.21 2,404.89 21086 1,586.65 1,507.32 1,733.42 20962 2,329.06 2,212.61 2,544.50 # 21086 1,423.47 1,352.30 1,555.15 20969 2,491.37 2,366.80 2,721.82 21087 1,575.22 1,496.46 1,720.93 20970 2,470.87 2,347.33 2,699.43 # 21087 1,415.75 1,344.96 1,546.70 20972 2,242.86 2,130.72 2,450.33 21100 650.23 617.72 710.38 20973 2,410.95 2,290.40 2,633.96 # 21100 350.61 333.08 383.04 20974 53.88 51.19 58.87 21110 628.68 597.25 686.84 # 20974 41.99 39.89 45.87 # 21110 544.67 517.44 595.06 20975 155.61 147.83 170.00 21116 155.31 147.54 169.67 20979 49.04 46.59 53.58 # 21116 38.59 36.66 42.16 # 20979 32.69 31.06 35.72 21120 554.75 527.01 606.06 20982 3,782.67 3,593.54 4,132.57 # 21120 441.37 419.30 482.20 # 20982 362.02 343.92 395.51 21121 654.06 621.36 714.56 20985 129.68 123.20 141.68 # 21121 561.87 533.78 613.85 21010 635.33 603.56 694.09 21122 625.65 594.37 683.53 21015 373.86 355.17 408.45 21123 734.38 697.66 802.31 21025 857.28 814.42 936.58 21125 2,589.59 2,460.11 2,829.13 # 21025 732.75 696.11 800.53 # 21125 647.31 614.94 707.18 21026 507.62 482.24 554.58 21127 2,815.81 2,675.02 3,076.27 # 21026 425.09 403.84 464.42 # 21127 754.58 716.85 824.38 21029 646.71 614.37 706.53 21137 646.48 614.16 706.28 # 21029 546.35 519.03 596.88 21138 782.00 742.90 854.34 21030 422.62 401.49 461.71 21139 857.71 814.82 937.04 # 21030 351.99 334.39 384.55 21141 1,165.34 1,107.07 1,273.13 21031 324.33 308.11 354.33 21142 1,141.19 1,084.13 1,246.75 # 21031 250.36 237.84 273.52 21143 1,212.75 1,152.11 1,324.93 21032 330.85 314.31 361.46 21145 1,346.52 1,279.19 1,471.07 # 21032 246.84 234.50 269.68 21146 1,337.48 1,270.61 1,461.20 21034 1,163.80 1,105.61 1,271.45 21147 1,457.48 1,384.61 1,592.30 # 21034 1,032.20 980.59 1,127.68 21150 1,539.40 1,462.43 1,681.79 21040 424.11 402.90 463.34 21151 1,653.86 1,571.17 1,806.85 # 21040 345.30 328.04 377.25 21154 1,851.22 1,758.66 2,022.46 21044 768.86 730.42 839.98 21155 2,081.27 1,977.21 2,273.79 21045 1,067.48 1,014.11 1,166.23 21159 2,416.41 2,295.59 2,639.93 21046 938.60 891.67 1,025.42 21160 2,595.96 2,466.16 2,836.08 21047 1,145.07 1,087.82 1,250.99 21172 1,520.03 1,444.03 1,660.63 21048 956.26 908.45 1,044.72 21175 1,795.40 1,705.63 1,961.47 21049 1,103.40 1,048.23 1,205.46 21179 1,280.19 1,216.18 1,398.61 21050 743.03 705.88 811.76 21180 1,447.46 1,375.09 1,581.35 21060 685.80 651.51 749.24 21181 632.03 600.43 690.49 21070 558.00 530.10 609.62 21182 1,781.09 1,692.04 1,945.85 21073 324.19 307.98 354.18 21183 2,022.26 1,921.15 2,209.32 # 21073 205.60 195.32 224.62 21184 2,097.52 1,992.64 2,291.54 21076 866.08 822.78 946.20 21188 1,444.66 1,372.43 1,578.29 # 21076 760.51 722.48 830.85 21193 1,085.61 1,031.33 1,186.03 21077 2,141.97 2,034.87 2,340.10 21194 1,242.33 1,180.21 1,357.24 # 21077 1,920.42 1,824.40 2,098.06 21195 1,182.99 1,123.84 1,292.42 21079 1,467.67 1,394.29 1,603.43 21196 1,280.02 1,216.02 1,398.42 # 21079 1,277.72 1,213.83 1,395.90 21198 1,003.61 953.43 1,096.44 21080 1,667.29 1,583.93 1,821.52 21199 894.30 849.59 977.03 # 21080 1,439.42 1,367.45 1,572.57 21206 978.02 929.12 1,068.49 21081 1,521.09 1,445.04 1,661.80 21208 1,426.57 1,355.24 1,558.53 # 21081 1,308.46 1,243.04 1,429.50 # 21208 721.77 685.68 788.53 21082 1,394.73 1,324.99 1,523.74 21209 698.57 663.64 763.19 # 21082 1,204.40 1,144.18 1,315.81 # 21209 558.42 530.50 610.08 21083 1,327.78 1,261.39 1,450.60 21210 1,677.94 1,594.04 1,833.15 # 21083 1,114.03 1,058.33 1,217.08 # 21210 722.97 686.82 789.84 21084 1,526.03 1,449.73 1,667.19 21215 2,809.07 2,668.62 3,068.91 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 10 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 21215 751.55 713.97 821.07 21387 661.18 628.12 722.34 21230 675.30 641.54 737.77 21390 663.84 630.65 725.25 21235 627.81 596.42 685.88 21395 840.47 798.45 918.22 # 21235 491.02 466.47 536.44 21400 150.09 142.59 163.98 21240 971.23 922.67 1,061.07 # 21400 122.58 116.45 133.92 21242 895.93 851.13 978.80 21401 406.33 386.01 443.91 21243 1,454.96 1,382.21 1,589.54 # 21401 248.34 235.92 271.31 21244 910.58 865.05 994.81 21406 470.61 447.08 514.14 21245 986.38 937.06 1,077.62 21407 554.31 526.59 605.58 # 21245 797.91 758.01 871.71 21408 756.01 718.21 825.94 21246 760.34 722.32 830.67 21421 613.63 582.95 670.39 21247 1,419.15 1,348.19 1,550.42 # 21421 534.08 507.38 583.49 21248 910.02 864.52 994.20 21422 588.85 559.41 643.32 # 21248 764.30 726.09 835.00 21423 694.34 659.62 758.56 21249 1,273.54 1,209.86 1,391.34 21431 651.80 619.21 712.09 # 21249 1,084.71 1,030.47 1,185.04 21432 585.55 556.27 639.71 21255 1,214.80 1,154.06 1,327.17 21433 1,460.02 1,387.02 1,595.07 21256 1,010.40 959.88 1,103.86 21435 1,151.50 1,093.93 1,258.02 21260 1,091.70 1,037.12 1,192.69 21436 1,648.56 1,566.13 1,801.05 21261 1,922.89 1,826.75 2,100.76 21440 436.58 414.75 476.96 21263 1,695.99 1,611.19 1,852.87 # 21440 370.41 351.89 404.67 21267 1,384.45 1,315.23 1,512.51 21445 627.03 595.68 685.03 21268 1,587.42 1,508.05 1,734.26 # 21445 530.38 503.86 579.44 21270 790.46 750.94 863.58 21450 458.16 435.25 500.54 # 21270 610.91 580.36 667.41 # 21450 396.82 376.98 433.53 21275 699.94 664.94 764.68 21451 610.35 579.83 666.80 21280 455.13 432.37 497.23 # 21451 531.17 504.61 580.30 21282 303.38 288.21 331.44 21452 548.19 520.78 598.90 21295 152.44 144.82 166.54 # 21452 280.55 266.52 306.50 21296 355.16 337.40 388.01 21453 703.89 668.70 769.01 21310 99.92 94.92 109.16 # 21453 645.15 612.89 704.82 # 21310 25.20 23.94 27.53 21454 478.89 454.95 523.19 21315 228.98 217.53 250.16 21461 1,553.29 1,475.63 1,696.97 # 21315 130.47 123.95 142.54 # 21461 796.45 756.63 870.12 21320 218.65 207.72 238.88 21462 1,698.05 1,613.15 1,855.12 # 21320 121.26 115.20 132.48 # 21462 870.95 827.40 951.51 21325 432.17 410.56 472.14 21465 793.74 754.05 867.16 21330 523.32 497.15 571.72 21470 1,028.07 976.67 1,123.17 21335 649.41 616.94 709.48 21480 83.04 78.89 90.72 21336 570.31 541.79 623.06 # 21480 28.39 26.97 31.02 21337 342.85 325.71 374.57 21485 540.82 513.78 590.85 # 21337 247.32 234.95 270.19 # 21485 475.03 451.28 518.97 21338 687.47 653.10 751.07 21490 794.69 754.96 868.20 21339 740.88 703.84 809.42 21495 579.75 550.76 633.37 21340 692.94 658.29 757.03 21497 543.13 515.97 593.37 21343 1,026.87 975.53 1,121.86 # 21497 474.74 451.00 518.65 21344 1,312.39 1,246.77 1,433.79 21501 379.27 360.31 414.36 21345 692.92 658.27 757.01 # 21501 274.44 260.72 299.83 # 21345 570.25 541.74 623.00 21502 457.03 434.18 499.31 21346 829.72 788.23 906.46 21510 413.31 392.64 451.54 21347 995.42 945.65 1,087.50 21550 220.30 209.29 240.68 21348 1,040.62 988.59 1,136.88 # 21550 137.78 130.89 150.52 21355 376.81 357.97 411.67 21555 368.02 349.62 402.06 # 21355 276.44 262.62 302.01 # 21555 281.04 266.99 307.04 21356 428.46 407.04 468.10 21556 354.37 336.65 387.15 # 21356 326.23 309.92 356.41 21557 503.06 477.91 549.60 21360 460.54 437.51 503.14 21600 475.77 451.98 519.78 21365 956.96 909.11 1,045.48 21610 917.42 871.55 1,002.28 21366 1,071.78 1,018.19 1,170.92 21615 593.71 564.02 648.62 21385 622.23 591.12 679.79 21616 726.13 689.82 793.29 21386 578.74 549.80 632.27 21620 458.50 435.58 500.92 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 11 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 21627 480.45 456.43 524.89 22522 218.98 208.03 239.23 21630 1,099.22 1,044.26 1,200.90 22523 538.09 511.19 587.87 21632 1,086.45 1,032.13 1,186.95 22524 515.80 490.01 563.51 21685 867.70 824.32 947.97 22525 239.19 227.23 261.31 21700 379.46 360.49 414.56 22526 1,962.81 1,864.67 2,144.37 21705 541.65 514.57 591.76 # 22526 301.93 286.83 329.85 21720 331.48 314.91 362.15 22527 1,614.46 1,533.74 1,763.80 21725 457.96 435.06 500.32 # 22527 138.69 131.76 151.52 21740 941.41 894.34 1,028.49 22532 1,480.00 1,406.00 1,616.90 21750 623.97 592.77 681.69 22533 1,390.34 1,320.82 1,518.94 21800 84.64 80.41 92.47 22534 323.26 307.10 353.17 # 21800 85.76 81.47 93.69 22548 1,578.67 1,499.74 1,724.70 21805 221.71 210.62 242.21 22554 1,100.36 1,045.34 1,202.14 21810 441.93 419.83 482.80 22556 1,418.72 1,347.78 1,549.95 21820 114.86 109.12 125.49 22558 1,301.95 1,236.85 1,422.38 21825 496.67 471.84 542.62 22585 299.09 284.14 326.76 21920 215.84 205.05 235.81 22590 1,305.00 1,239.75 1,425.71 # 21920 134.80 128.06 147.27 22595 1,243.00 1,180.85 1,357.98 21925 359.24 341.28 392.47 22600 1,063.96 1,010.76 1,162.37 # 21925 286.38 272.06 312.87 22610 1,053.01 1,000.36 1,150.41 21930 400.94 380.89 438.02 22612 1,365.46 1,297.19 1,491.77 # 21930 315.81 300.02 345.02 22614 349.50 332.03 381.83 21935 999.62 949.64 1,092.09 22630 1,310.07 1,244.57 1,431.26 22010 774.99 736.24 846.68 22632 283.77 269.58 310.02 22015 769.69 731.21 840.89 22800 1,163.61 1,105.43 1,271.24 22100 695.27 660.51 759.59 22802 1,848.72 1,756.28 2,019.72 22101 696.18 661.37 760.58 22804 2,142.73 2,035.59 2,340.93 22102 698.59 663.66 763.21 22808 1,573.97 1,495.27 1,719.56 22103 125.82 119.53 137.46 22810 1,765.72 1,677.43 1,929.04 22110 855.32 812.55 934.43 22812 1,936.90 1,840.06 2,116.07 22112 853.44 810.77 932.39 22818 1,928.71 1,832.27 2,107.11 22114 854.78 812.04 933.85 22819 2,182.95 2,073.80 2,384.87 22116 125.45 119.18 137.06 22830 695.96 661.16 760.33 22206 2,017.88 1,916.99 2,204.54 22840 682.57 648.44 745.71 22207 1,993.63 1,893.95 2,178.04 22842 683.32 649.15 746.52 22208 501.96 476.86 548.39 22843 723.66 687.48 790.60 22210 1,503.44 1,428.27 1,642.51 22844 892.89 848.25 975.49 22212 1,247.90 1,185.51 1,363.34 22845 650.70 618.17 710.90 22214 1,260.75 1,197.71 1,377.37 22846 676.39 642.57 738.96 22216 328.14 311.73 358.49 22847 745.91 708.61 814.90 22220 1,358.97 1,291.02 1,484.67 22848 325.08 308.83 355.15 22222 1,245.57 1,183.29 1,360.78 22849 1,120.73 1,064.69 1,224.39 22224 1,349.68 1,282.20 1,474.53 22850 614.65 583.92 671.51 22226 326.66 310.33 356.88 22851 362.58 344.45 396.12 22305 159.98 151.98 174.78 22852 588.77 559.33 643.23 # 22305 146.22 138.91 159.75 22855 946.20 898.89 1,033.72 22310 241.05 229.00 263.35 22857 1,521.33 1,445.26 1,662.05 # 22310 223.58 212.40 244.26 22862 1,787.34 1,697.97 1,952.67 22315 731.63 695.05 799.31 22865 1,741.21 1,654.15 1,902.27 # 22315 642.42 610.30 701.85 22900 346.08 328.78 378.10 22318 1,351.87 1,284.28 1,476.92 23000 465.46 442.19 508.52 22319 1,481.92 1,407.82 1,618.99 # 23000 311.93 296.33 340.78 22325 1,182.12 1,123.01 1,291.46 23020 600.13 570.12 655.64 22326 1,236.11 1,174.30 1,350.45 23030 380.46 361.44 415.66 22327 1,223.22 1,162.06 1,336.37 # 23030 224.70 213.47 245.49 22328 246.76 234.42 269.58 23031 368.53 350.10 402.62 22505 107.57 102.19 117.52 # 23031 193.08 183.43 210.94 22520 2,301.92 2,186.82 2,514.84 23035 604.59 574.36 660.51 # 22520 520.22 494.21 568.34 23040 625.00 593.75 682.81 22521 2,196.21 2,086.40 2,399.36 23044 496.76 471.92 542.71 # 22521 491.46 466.89 536.92 23065 181.45 172.38 198.24 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 12 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 23065 142.79 135.65 156.00 23490 718.89 682.95 785.39 23066 440.20 418.19 480.92 23491 891.02 846.47 973.44 # 23066 294.49 279.77 321.74 23500 179.88 170.89 196.52 23075 223.98 212.78 244.70 # 23500 174.68 165.95 190.84 # 23075 152.23 144.62 166.31 23505 293.35 278.68 320.48 23076 484.13 459.92 528.91 # 23505 275.51 261.73 300.99 23077 1,019.39 968.42 1,113.68 23515 595.81 566.02 650.92 23100 421.96 400.86 460.99 23520 185.16 175.90 202.29 23101 390.72 371.18 426.86 # 23520 184.42 175.20 201.48 23105 552.91 525.26 604.05 23525 293.43 278.76 320.57 23106 415.76 394.97 454.22 # 23525 272.61 258.98 297.83 23107 575.75 546.96 629.00 23530 478.81 454.87 523.10 23120 487.82 463.43 532.94 23532 538.93 511.98 588.78 23125 609.30 578.84 665.67 23540 185.01 175.76 202.12 23130 526.27 499.96 574.95 # 23540 176.84 168.00 193.20 23140 443.91 421.71 484.97 23545 265.42 252.15 289.97 23145 598.47 568.55 653.83 # 23545 240.88 228.84 263.17 23146 534.91 508.16 584.38 23550 496.21 471.40 542.11 23150 564.75 536.51 616.99 23552 571.79 543.20 624.68 23155 683.38 649.21 746.59 23570 191.17 181.61 208.85 23156 584.31 555.09 638.35 # 23570 191.54 181.96 209.25 23170 464.07 440.87 507.00 23575 325.62 309.34 355.74 23172 479.91 455.91 524.30 # 23575 305.55 290.27 333.81 23174 652.19 619.58 712.52 23585 801.41 761.34 875.54 23180 611.13 580.57 667.66 23600 269.85 256.36 294.81 23182 588.49 559.07 642.93 # 23600 243.46 231.29 265.98 23184 659.87 626.88 720.91 23605 396.07 376.27 432.71 23190 482.32 458.20 526.93 # 23605 361.87 343.78 395.35 23195 648.39 615.97 708.37 23615 751.16 713.60 820.64 23200 756.56 718.73 826.54 23616 1,137.42 1,080.55 1,242.63 23210 792.48 752.86 865.79 23620 220.70 209.67 241.12 23220 933.81 887.12 1,020.19 # 23620 204.34 194.12 223.24 23221 1,090.54 1,036.01 1,191.41 23625 320.71 304.67 350.37 23222 1,469.53 1,396.05 1,605.46 # 23625 298.78 283.84 326.42 23330 198.24 188.33 216.58 23630 632.75 601.11 691.28 # 23330 130.58 124.05 142.66 23650 252.30 239.69 275.64 23331 510.73 485.19 557.97 # 23650 224.79 213.55 245.58 23332 770.17 731.66 841.41 23655 323.48 307.31 353.41 23350 149.89 142.40 163.76 23660 502.22 477.11 548.68 # 23350 47.29 44.93 51.67 23665 355.00 337.25 387.84 23395 1,116.80 1,060.96 1,220.10 # 23665 332.69 316.06 363.47 23397 998.66 948.73 1,091.04 23670 706.47 671.15 771.82 23400 850.09 807.59 928.73 23675 465.67 442.39 508.75 23405 548.70 521.27 599.46 # 23675 428.87 407.43 468.54 23406 684.85 650.61 748.20 23680 772.73 734.09 844.20 23410 784.29 745.08 856.84 23700 169.48 161.01 185.16 23412 833.97 792.27 911.11 23800 892.44 847.82 974.99 23415 642.52 610.39 701.95 23802 1,058.44 1,005.52 1,156.35 23420 920.80 874.76 1,005.97 23900 1,161.64 1,103.56 1,269.09 23430 646.57 614.24 706.38 23920 940.66 893.63 1,027.67 23440 667.25 633.89 728.97 23921 387.66 368.28 423.52 23450 834.93 793.18 912.16 23930 317.57 301.69 346.94 23455 888.36 843.94 970.53 # 23930 187.47 178.10 204.82 23460 962.01 913.91 1,051.00 23931 256.93 244.08 280.69 23462 941.29 894.23 1,028.36 # 23931 138.72 131.78 151.55 23465 978.78 929.84 1,069.32 23935 434.94 413.19 475.17 23466 965.54 917.26 1,054.85 24000 407.92 387.52 445.65 23470 1,067.86 1,014.47 1,166.64 24006 617.89 587.00 675.05 23472 1,316.87 1,251.03 1,438.68 24065 210.48 199.96 229.95 23480 718.94 682.99 785.44 # 24065 141.71 134.62 154.81 23485 843.09 800.94 921.08 24066 511.54 485.96 558.85 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 13 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 24066 341.29 324.23 372.86 24410 913.99 868.29 998.53 24075 413.77 393.08 452.04 24420 851.04 808.49 929.76 # 24075 267.31 253.94 292.03 24430 900.21 855.20 983.48 24076 406.73 386.39 444.35 24435 922.27 876.16 1,007.58 24077 704.79 669.55 769.98 24470 572.26 543.65 625.20 24100 343.51 326.33 375.28 24495 582.52 553.39 636.40 24101 431.15 409.59 471.03 24498 761.95 723.85 832.43 24102 534.32 507.60 583.74 24500 292.77 278.13 319.85 24105 291.07 276.52 318.00 # 24500 259.32 246.35 283.30 24110 503.45 478.28 550.02 24505 424.02 402.82 463.24 24115 581.84 552.75 635.66 # 24505 383.88 364.69 419.39 24116 756.51 718.68 826.48 24515 764.01 725.81 834.68 24120 452.23 429.62 494.06 24516 754.80 717.06 824.62 24125 514.97 489.22 562.60 24530 315.13 299.37 344.28 24126 549.60 522.12 600.44 # 24530 279.82 265.83 305.70 24130 438.87 416.93 479.47 24535 528.29 501.88 577.16 24134 662.56 629.43 723.84 # 24535 487.77 463.38 532.89 24136 545.78 518.49 596.26 24538 649.55 617.07 709.63 24138 570.34 541.82 623.09 24545 781.49 742.42 853.78 24140 636.14 604.33 694.98 24546 925.76 879.47 1,011.39 24145 536.53 509.70 586.16 24560 264.53 251.30 289.00 24147 559.02 531.07 610.73 # 24560 227.73 216.34 248.79 24149 994.80 945.06 1,086.82 24565 440.34 418.32 481.07 24150 847.28 804.92 925.66 # 24565 403.54 383.36 440.86 24151 982.93 933.78 1,073.85 24566 599.74 569.75 655.21 24152 629.91 598.41 688.17 24575 640.81 608.77 700.09 24153 601.49 571.42 657.13 24576 277.98 264.08 303.69 24155 732.01 695.41 799.72 # 24576 245.26 233.00 267.95 24160 525.73 499.44 574.36 24577 456.14 433.33 498.33 24164 430.53 409.00 470.35 # 24577 418.23 397.32 456.92 24200 178.08 169.18 194.56 24579 724.41 688.19 791.42 # 24200 118.97 113.02 129.97 24582 681.30 647.24 744.33 24201 495.76 470.97 541.62 24586 956.76 908.92 1,045.26 # 24201 315.10 299.35 344.25 24587 950.78 903.24 1,038.73 24220 162.41 154.29 177.43 24600 315.13 299.37 344.28 # 24220 62.04 58.94 67.78 # 24600 279.07 265.12 304.89 24300 344.02 326.82 375.84 24605 392.26 372.65 428.55 24301 654.52 621.79 715.06 24615 623.58 592.40 681.26 24305 503.62 478.44 550.21 24620 475.74 451.95 519.74 24310 412.23 391.62 450.36 24635 716.44 680.62 782.71 24320 663.86 630.67 725.27 24640 105.85 100.56 115.64 24330 624.66 593.43 682.44 # 24640 73.13 69.47 79.89 24331 687.74 653.35 751.35 24650 214.72 203.98 234.58 24332 519.85 493.86 567.94 # 24650 187.58 178.20 204.93 24340 533.24 506.58 582.57 24655 370.75 352.21 405.04 24341 622.75 591.61 680.35 # 24655 334.69 317.96 365.65 24342 685.09 650.84 748.47 24665 563.02 534.87 615.10 24343 610.12 579.61 666.55 24666 636.62 604.79 695.51 24344 946.09 898.79 1,033.61 24670 240.70 228.67 262.97 24345 606.96 576.61 663.10 # 24670 210.59 200.06 230.07 24346 943.66 896.48 1,030.95 24675 387.57 368.19 423.42 24357 386.16 366.85 421.88 # 24675 353.37 335.70 386.06 24358 452.64 430.01 494.51 24685 565.10 536.85 617.38 24359 554.24 526.53 605.51 24800 699.37 664.40 764.06 24360 781.01 741.96 853.25 24802 863.12 819.96 942.95 24361 879.67 835.69 961.04 24900 616.20 585.39 673.20 24362 851.92 809.32 930.72 24920 607.66 577.28 663.87 24363 1,292.30 1,227.69 1,411.84 24925 467.86 444.47 511.14 24365 556.93 529.08 608.44 24930 641.14 609.08 700.44 24366 596.79 566.95 651.99 24931 683.46 649.29 746.68 24400 715.76 679.97 781.97 24935 930.91 884.36 1,017.01 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2007 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS08 VERMONT - MEDICARE CARRIER 31145 PAGE 14 FSY08 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 12/27/07 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 25000 327.66 311.28 357.97 25310 652.57 619.94 712.93 25001 285.85 271.56 312.29 25312 735.95 699.15 804.02 25020 524.99 498.74 573.55 25315 784.10 744.90 856.64 25023 986.40 937.08 1,077.64 25316 908.41 862.99 992.44 25024 652.48 619.86 712.84 25320 840.77 798.73 918.54 25025 996.48 946.66 1,088.66 25332 735.95 699.15 804.02 25028 460.10 437.10 502.67 25335 850.88 808.34 929.59 25031 364.34 346.12 398.04 25337 780.54 741.51 852.74 25035 633.60 601.92 692.21 25350 706.57 671.24 771.93 25040 506.52 481.19 553.37 25355 779.20 740.24 851.28 25065 210.77 200.23 230.26 25360 689.73 655.24 753.53 # 25065 142.37 135.25 155.54 25365 912.47 866.85 996.88 25066 354.87 337.13 387.70 25370 977.20 928.34 1,067.59 25075 308.24 292.83 336.75 25375 953.72 906.03 1,041.93 25076 434.72 412.98 474.93 25390 788.79 749.35 861.75 25077 698.76 663.82 763.39 25391 985.33 936.06 1,076.47 25085 420.54 399.51 459.44 25392 986.84 937.50 1,078.13 25100 311.72 296.13 340.55 25393 1,107.98 1,052.58 1,210.47 25101 363.35 345.18 396.96 25394 668.43 635.01 730.26 25105 443.71 421.52 484.75 25400 826.49 785.17 902.95 25107 541.10 514.05 591.16 25405 1,030.00 978.50 1,125.28 25109 441.48 419.41 482.32 25415 970.06 921.56 1,059.79 25110 343.16 326.00 374.90 25420 1,140.46 1,083.44 1,245.96 25111 280.08 266.08 305.99 25425 1,050.45 997.93 1,147.62 25112 340.34 323.32 371.82 25426 1,073.99 1,020.29 1,173.33 25115 753.91 716.21 823.64 25430 612.39 581.77 669.04 25116 628.04 596.64 686.14 25431 686.04 651.74 749.50 25118 345.04 327.79 376.96 25440 688.02 653.62 751.66 25119 458.00 435.10 500.37 25441 817.21 776.35 892.80 25120 545.05 517.80 595.47 25442 702.08 666.98 767.03 25125 617.94 587.04 675.10 25443 676.00 642.20 738.53 25126 630.52 598.99 688.84 25444 717.07 681.22 783.40 25130 400.82 380.78 437.90 25445 629.73 598.24 687.98 25135 497.01 472.16 542.98 25446 1,029.85 978.36 1,125.11 25136 439.20 417.24 479.83 25447 705.05 669.80 770.27 25145 555.86 528.07 607.28 25449 903.33 858.16 986.88 25150 520.71 494.67 568.87 25450 552.93 525.28 604.07 25151 618.00 587.10 675.17 25455 668.60 635.17 730.45 25170 832.75 791.11 909.78 25490 726.96 690.61 794.20 25210 438.20 416.29 478.73 25491 761.74 723.65 832.20 25215 566.50 538.18 618.91 25492 900.18 855.17 983.45 25230 389.82 370.33 425.88 25500 218.67 207.74 238.90 25240 402.79 382.65 440.05 # 25500 194.51 184.78 212.50 25246 165.32 157.05