1HNPRDS08 MAINE - MEDICARE CARRIER 31142 PAGE 1 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 32.59 30.96 35.60 G0270 22.60 21.47 24.69 G0102 18.11 17.20 19.78 # G0270 22.26 21.15 24.32 # G0102 7.96 7.56 8.69 G0271 12.99 12.34 14.19 G0104 115.34 109.57 126.01 # G0271 12.65 12.02 13.82 # G0104 53.04 50.39 57.95 G0275 12.65 12.02 13.82 G0105 342.46 325.34 374.14 G0278 12.65 12.02 13.82 # G0105 186.03 176.73 203.24 G0281 10.37 9.85 11.33 G0105 53 115.34 109.57 126.01 G0283 10.37 9.85 11.33 # G0105 53 53.04 50.39 57.95 G0288 201.23 191.17 219.85 G0106 163.72 155.53 178.86 G0289 78.40 74.48 85.65 G0106 TC 118.56 112.63 129.52 G0308 675.31 641.54 737.77 G0106 26 45.16 42.90 49.34 G0309 554.01 526.31 605.26 G0108 24.25 23.04 26.50 G0310 434.41 412.69 474.59 G0109 13.76 13.07 15.03 G0311 473.47 449.80 517.27 G0117 40.50 38.48 44.25 G0312 390.18 370.67 426.27 G0118 26.92 25.57 29.41 G0313 306.84 291.50 335.23 C G0120 160.67 152.64 175.54 G0314 415.44 394.67 453.87 C G0120 TC 115.51 109.73 126.19 G0315 342.10 325.00 373.75 G0120 26 45.16 42.90 49.34 G0316 266.59 253.26 291.25 G0121 342.46 325.34 374.14 G0317 260.92 247.87 285.05 # G0121 186.03 176.73 203.24 G0318 214.11 203.40 233.91 G0121 53 115.34 109.57 126.01 G0319 167.68 159.30 183.20 # G0121 53 53.04 50.39 57.95 G0320 529.29 502.83 578.25 G0124 23.32 22.15 25.47 G0321 377.99 359.09 412.95 G0127 16.76 15.92 18.31 G0322 327.54 311.16 357.83 # G0127 7.96 7.56 8.69 G0323 204.63 194.40 223.56 G0128 3.56 3.38 3.89 G0324 18.79 17.85 20.53 G0130 32.89 31.25 35.94 G0325 11.22 10.66 12.26 G0130 TC 23.07 21.92 25.21 G0326 13.08 12.43 14.29 G0130 26 9.82 9.33 10.73 G0327 7.15 6.79 7.81 G0141 23.32 22.15 25.47 G0329 7.20 6.84 7.87 G0166 139.29 132.33 152.18 G0332 66.70 63.37 72.88 G0168 75.46 71.69 82.44 G0339 3,915.07 3,719.32 4,277.22 # G0168 22.98 21.83 25.10 G0340 2,658.17 2,525.26 2,904.05 G0179 41.05 39.00 44.85 G0341 328.41 311.99 358.79 G0180 53.92 51.22 58.90 G0342 606.33 576.01 662.41 G0181 97.98 93.08 107.04 G0343 1,002.98 952.83 1,095.75 G0182 101.37 96.30 110.75 G0344 84.99 80.74 92.85 G0202 120.21 114.20 131.33 # G0344 62.30 59.19 68.07 G0202 TC 88.17 83.76 96.32 G0364 11.26 10.70 12.31 G0202 26 32.04 30.44 35.01 # G0364 8.21 7.80 8.97 G0204 136.29 129.48 148.90 C G0365 143.88 136.69 157.19 G0204 TC 96.29 91.48 105.20 C G0365 TC 132.36 125.74 144.60 G0204 26 40.00 38.00 43.70 G0365 26 11.51 10.93 12.57 G0206 108.82 103.38 118.89 G0366 20.57 19.54 22.47 G0206 TC 76.78 72.94 83.88 G0367 12.61 11.98 13.78 G0206 26 32.04 30.44 35.01 G0368 7.96 7.56 8.69 G0237 11.94 11.34 13.04 G0372 13.37 12.70 14.61 G0238 12.61 11.98 13.78 # G0372 7.62 7.24 8.33 G0239 11.26 10.70 12.31 G0389 103.36 98.19 112.92 G0245 57.60 54.72 62.93 G0389 TC 76.53 72.70 83.61 # G0245 40.33 38.31 44.06 G0389 26 26.83 25.49 29.31 G0246 34.28 32.57 37.46 G0392 2,105.77 2,000.48 2,300.55 # G0246 20.74 19.70 22.66 # G0392 448.69 426.26 490.20 G0247 37.50 35.63 40.97 G0393 1,596.35 1,516.53 1,744.01 # G0247 23.28 22.12 25.44 # G0393 287.01 272.66 313.56 G0248 169.85 161.36 185.56 G0396 28.36 26.94 30.98 G0249 124.81 118.57 136.36 # G0396 27.00 25.65 29.50 G0250 8.68 8.25 9.49 G0397 55.57 52.79 60.71 G0268 43.00 40.85 46.98 # G0397 53.88 51.19 58.87 # G0268 28.44 27.02 31.07 G9041 21.84 20.75 23.86 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 MAINE - MEDICARE CARRIER 31142 PAGE 2 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 9.06 8.61 9.90 10121 216.89 206.05 236.96 G9043 9.06 8.61 9.90 # 10121 156.28 148.47 170.74 G9044 8.04 7.64 8.79 10140 124.23 118.02 135.72 M0064 33.77 32.08 36.89 # 10140 99.51 94.53 108.71 # M0064 15.83 15.04 17.30 10160 101.97 96.87 111.40 P3001 23.32 22.15 25.47 # 10160 80.30 76.29 87.73 Q0035 18.88 17.94 20.63 10180 189.25 179.79 206.76 Q0035 TC 11.26 10.70 12.31 # 10180 147.61 140.23 161.26 Q0035 26 7.62 7.24 8.33 11000 43.68 41.50 47.73 Q0091 37.03 35.18 40.46 # 11000 28.11 26.70 30.71 # Q0091 17.06 16.21 18.64 11001 18.54 17.61 20.25 Q0092 13.76 13.07 15.03 # 11001 14.14 13.43 15.44 R0070 139.41 132.44 152.31 11004 496.65 471.82 542.59 R0075 139.41 132.44 152.31 11005 656.14 623.33 716.83 0067T 532.57 505.94 581.83 11006 615.71 584.92 672.66 C 0067T TC 165.27 157.01 180.56 11008 236.75 224.91 258.65 0067T 26 122.06 115.96 133.35 11010 386.17 366.86 421.89 0073T 530.97 504.42 580.08 # 11010 238.54 226.61 260.60 0075T 1,049.95 997.45 1,147.07 11011 438.74 416.80 479.32 0076T 346.48 329.16 378.53 # 11011 255.22 242.46 278.83 0078T 1,184.45 1,125.23 1,294.01 11012 612.63 582.00 669.30 0079T 1,088.32 1,033.90 1,188.99 # 11012 372.57 353.94 407.03 0080T 212.77 202.13 232.45 11040 38.35 36.43 41.89 0081T 212.77 202.13 232.45 # 11040 24.13 22.92 26.36 0145T 525.14 498.88 573.71 11041 45.67 43.39 49.90 C 0145T TC 258.19 245.28 282.07 # 11041 31.11 29.55 33.98 0145T 26 96.57 91.74 105.50 11042 61.93 58.83 67.65 0146T 525.14 498.88 573.71 # 11042 40.94 38.89 44.72 C 0146T TC 258.19 245.28 282.07 11043 225.35 214.08 246.19 0146T 26 96.57 91.74 105.50 # 11043 196.91 187.06 215.12 0147T 525.14 498.88 573.71 11044 304.46 289.24 332.63 C 0147T TC 258.19 245.28 282.07 # 11044 271.28 257.72 296.38 0147T 26 96.57 91.74 105.50 11055 38.56 36.63 42.12 0148T 525.14 498.88 573.71 # 11055 20.28 19.27 22.16 C 0148T TC 258.19 245.28 282.07 11056 47.79 45.40 52.21 0148T 26 96.57 91.74 105.50 # 11056 28.49 27.07 31.13 0149T 525.14 498.88 573.71 11057 57.91 55.01 63.26 C 0149T TC 258.19 245.28 282.07 # 11057 37.25 35.39 40.70 0149T 26 96.57 91.74 105.50 11100 80.50 76.48 87.95 0150T 525.14 498.88 573.71 # 11100 40.55 38.52 44.30 C 0150T TC 258.19 245.28 282.07 11101 26.66 25.33 29.13 0150T 26 96.57 91.74 105.50 # 11101 20.57 19.54 22.47 0151T 173.51 164.83 189.55 11200 65.77 62.48 71.85 C 0151T TC 87.08 82.73 95.14 # 11200 55.61 52.83 60.75 0151T 26 63.39 60.22 69.25 11201 15.75 14.96 17.20 10021 118.26 112.35 129.20 # 11201 14.39 13.67 15.72 # 10021 60.36 57.34 65.94 11300 54.68 51.95 59.74 10022 123.93 117.73 135.39 # 11300 24.89 23.65 27.20 # 10022 58.24 55.33 63.63 11301 73.77 70.08 80.59 10040 80.67 76.64 88.14 # 11301 42.28 40.17 46.20 # 10040 70.85 67.31 77.41 11302 87.91 83.51 96.04 10060 88.59 84.16 96.78 # 11302 52.02 49.42 56.83 # 10060 76.74 72.90 83.84 11303 104.29 99.08 113.94 10061 152.68 145.05 166.81 # 11303 61.29 58.23 66.96 # 10061 137.44 130.57 150.16 11305 56.46 53.64 61.69 10080 140.18 133.17 153.15 # 11305 32.09 30.49 35.06 # 10080 79.91 75.91 87.30 11306 77.29 73.43 84.44 10081 216.12 205.31 236.11 # 11306 48.17 45.76 52.62 # 10081 137.90 131.01 150.66 11307 90.03 85.53 98.36 10120 113.43 107.76 123.92 # 11307 55.83 53.04 61.00 # 10120 76.19 72.38 83.24 11308 103.49 98.32 113.07 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 MAINE - MEDICARE CARRIER 31142 PAGE 3 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 68.27 64.86 74.59 11602 189.91 180.41 207.47 11310 67.55 64.17 73.80 # 11602 126.59 120.26 138.30 # 11310 36.06 34.26 39.40 11603 216.87 206.03 236.93 11311 84.52 80.29 92.33 # 11603 150.51 142.98 164.43 # 11311 52.36 49.74 57.20 11604 239.69 227.71 261.87 11312 98.19 93.28 107.27 # 11604 165.20 156.94 180.48 # 11312 60.27 57.26 65.85 11606 336.32 319.50 367.43 11313 124.31 118.09 135.80 # 11606 245.58 233.30 268.30 # 11313 80.97 76.92 88.46 11620 147.33 139.96 160.95 11400 96.29 91.48 105.20 # 11620 91.46 86.89 99.92 # 11400 61.41 58.34 67.09 11621 175.69 166.91 191.95 11401 115.80 110.01 126.51 # 11621 117.79 111.90 128.69 # 11401 80.93 76.88 88.41 11622 198.33 188.41 216.67 11402 128.59 122.16 140.48 # 11622 135.36 128.59 147.88 # 11402 88.97 84.52 97.20 11623 233.00 221.35 254.55 11403 148.14 140.73 161.84 # 11623 166.64 158.31 182.06 # 11403 112.93 107.28 123.37 11624 263.82 250.63 288.22 11404 168.29 159.88 183.86 # 11624 190.68 181.15 208.32 # 11404 125.29 119.03 136.88 11626 325.20 308.94 355.28 11406 235.08 223.33 256.83 # 11626 242.58 230.45 265.02 # 11406 186.66 177.33 203.93 11640 153.64 145.96 167.85 11420 96.38 91.56 105.29 # 11640 97.43 92.56 106.44 # 11420 66.92 63.57 73.11 11641 187.37 178.00 204.70 11421 123.59 117.41 135.02 # 11641 127.78 121.39 139.60 # 11421 89.73 85.24 98.03 11642 216.07 205.27 236.06 11422 138.20 131.29 150.98 # 11642 150.38 142.86 164.29 # 11422 107.05 101.70 116.96 11643 255.44 242.67 279.07 11423 161.48 153.41 176.42 # 11643 187.72 178.33 205.08 # 11423 124.91 118.66 136.46 11644 317.07 301.22 346.40 11424 185.43 176.16 202.58 # 11644 235.13 223.37 256.88 # 11424 144.80 137.56 158.19 11646 418.70 397.77 457.44 11426 264.80 251.56 289.29 # 11646 333.04 316.39 363.85 # 11426 219.77 208.78 240.10 11719 16.63 15.80 18.17 11440 107.08 101.73 116.99 # 11719 8.17 7.76 8.92 # 11440 80.33 76.31 87.76 11720 25.06 23.81 27.38 11441 132.95 126.30 145.25 # 11720 14.90 14.16 16.28 # 11441 104.50 99.28 114.17 11721 36.36 34.54 39.72 11442 149.37 141.90 163.19 # 11721 25.53 24.25 27.89 # 11442 116.19 110.38 126.94 11730 79.87 75.88 87.26 11443 180.18 171.17 196.85 # 11730 52.11 49.50 56.93 # 11443 143.95 136.75 157.26 11732 37.12 35.26 40.55 11444 227.38 216.01 248.41 # 11732 26.63 25.30 29.10 # 11444 184.72 175.48 201.80 11740 36.10 34.30 39.45 11446 306.15 290.84 334.47 # 11740 26.62 25.29 29.08 # 11446 260.78 247.74 284.90 11750 171.72 163.13 187.60 11450 284.73 270.49 311.06 # 11750 146.66 139.33 160.23 # 11450 187.89 178.50 205.28 11752 243.51 231.33 266.03 11451 376.88 358.04 411.75 # 11752 221.50 210.43 241.99 # 11451 249.57 237.09 272.65 11755 107.72 102.33 117.68 11462 281.43 267.36 307.46 # 11755 72.51 68.88 79.21 # 11462 180.53 171.50 197.23 11760 160.08 152.08 174.89 11463 383.53 364.35 419.00 # 11760 112.68 107.05 123.11 # 11463 252.49 239.87 275.85 11762 216.55 205.72 236.58 11470 309.58 294.10 338.22 # 11762 173.21 164.55 189.23 # 11470 214.10 203.40 233.91 11765 101.20 96.14 110.56 11471 397.63 377.75 434.41 # 11765 55.49 52.72 60.63 # 11471 271.67 258.09 296.80 11770 212.87 202.23 232.56 11600 146.15 138.84 159.67 # 11770 146.50 139.18 160.06 # 11600 90.62 86.09 99.00 11771 424.34 403.12 463.59 11601 174.29 165.58 190.42 # 11771 334.95 318.20 365.93 # 11601 116.39 110.57 127.16 11772 524.62 498.39 573.15 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 MAINE - MEDICARE CARRIER 31142 PAGE 4 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 441.32 419.25 482.14 12031 180.98 171.93 197.72 11900 44.36 42.14 48.46 # 12031 122.75 116.61 134.10 # 11900 25.73 24.44 28.11 12032 240.19 228.18 262.41 11901 55.40 52.63 60.52 # 12032 155.88 148.09 170.30 # 11901 39.83 37.84 43.52 12034 236.01 224.21 257.84 11920 161.44 153.37 176.38 # 12034 162.20 154.09 177.20 # 11920 96.09 91.29 104.98 12035 301.45 286.38 329.34 11921 182.99 173.84 199.92 # 12035 195.81 186.02 213.92 # 11921 113.57 107.89 124.07 12036 333.59 316.91 364.45 11922 52.74 50.10 57.62 # 12036 228.96 217.51 250.14 # 11922 25.99 24.69 28.39 12037 375.46 356.69 410.19 11950 63.66 60.48 69.55 # 12037 265.75 252.46 290.33 # 11950 41.99 39.89 45.87 12041 192.71 183.07 210.53 11951 82.96 78.81 90.63 # 12041 133.12 126.46 145.43 # 11951 56.89 54.05 62.16 12042 227.54 216.16 248.58 11952 119.07 113.12 130.09 # 12042 156.77 148.93 171.27 # 11952 84.53 80.30 92.35 12044 257.55 244.67 281.37 11954 139.18 132.22 152.05 # 12044 171.55 162.97 187.42 # 11954 95.50 90.73 104.34 12045 305.35 290.08 333.59 11960 752.47 714.85 822.08 # 12045 204.45 194.23 223.36 11970 494.11 469.40 539.81 12046 360.17 342.16 393.48 11971 394.27 374.56 430.74 # 12046 239.63 227.65 261.80 # 11971 246.98 234.63 269.82 12047 385.86 366.57 421.56 11976 122.50 116.38 133.84 # 12047 265.66 252.38 290.24 # 11976 83.90 79.71 91.67 12051 212.60 201.97 232.27 11980 88.84 84.40 97.06 # 12051 144.88 137.64 158.29 # 11980 69.54 66.06 75.97 12052 234.48 222.76 256.17 11981 113.01 107.36 123.46 # 12052 165.41 157.14 180.71 # 11981 73.39 69.72 80.18 12053 256.66 243.83 280.40 11982 130.45 123.93 142.52 # 12053 172.35 163.73 188.29 # 11982 89.14 84.68 97.38 12054 275.29 261.53 300.76 11983 199.02 189.07 217.43 # 12054 185.22 175.96 202.35 # 11983 162.79 154.65 177.85 12055 336.25 319.44 367.36 12001 123.68 117.50 135.13 # 12055 229.93 218.43 251.19 # 12001 86.09 81.79 94.06 12056 414.00 393.30 452.30 12002 131.85 125.26 144.05 # 12056 283.98 269.78 310.25 # 12002 96.29 91.48 105.20 12057 447.56 425.18 488.96 12004 154.75 147.01 169.06 # 12057 325.33 309.06 355.42 # 12004 113.10 107.45 123.57 13100 254.59 241.86 278.14 12005 192.88 183.24 210.73 # 13100 191.95 182.35 209.70 # 12005 140.74 133.70 153.76 13101 316.76 300.92 346.06 12006 240.21 228.20 262.43 # 13101 233.13 221.47 254.69 # 12006 178.24 169.33 194.73 13102 86.94 82.59 94.98 12007 269.76 256.27 294.71 # 13102 62.90 59.76 68.72 # 12007 203.73 193.54 222.57 13120 264.37 251.15 288.82 12011 131.59 125.01 143.76 # 13120 200.03 190.03 218.53 # 12011 89.27 84.81 97.53 13121 347.27 329.91 379.40 12013 144.71 137.47 158.09 # 13121 260.59 247.56 284.69 # 12013 102.05 96.95 111.49 13122 100.32 95.30 109.60 12014 170.20 161.69 185.94 # 13122 71.87 68.28 78.52 # 12014 122.45 116.33 133.78 13131 291.92 277.32 318.92 12015 214.17 203.46 233.98 # 13131 227.25 215.89 248.27 # 12015 153.90 146.21 168.14 13132 457.91 435.01 500.26 12016 253.79 241.10 277.27 # 13132 378.68 359.75 413.71 # 12016 187.43 178.06 204.77 13133 137.26 130.40 149.96 12017 226.33 215.01 247.26 # 13133 111.19 105.63 121.47 12018 270.23 256.72 295.23 13150 297.72 282.83 325.25 12020 222.05 210.95 242.59 # 13150 227.97 216.57 249.06 # 12020 157.04 149.19 171.57 13151 330.98 314.43 361.59 12021 129.86 123.37 141.88 # 13151 263.94 250.74 288.35 # 12021 113.95 108.25 124.49 13152 450.93 428.38 492.64 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 MAINE - MEDICARE CARRIER 31142 PAGE 5 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 355.79 338.00 388.70 15151 109.89 104.40 120.06 13153 152.46 144.84 166.57 # 15151 98.72 93.78 107.85 # 13153 121.65 115.57 132.91 15152 135.25 128.49 147.76 13160 670.04 636.54 732.02 # 15152 123.40 117.23 134.81 14000 525.86 499.57 574.51 15155 621.46 590.39 678.95 # 14000 436.47 414.65 476.85 # 15155 584.21 555.00 638.25 14001 685.30 651.04 748.70 15156 145.53 138.25 158.99 # 14001 585.76 556.47 639.94 # 15156 136.73 129.89 149.37 14020 586.26 556.95 640.49 15157 161.66 153.58 176.62 # 14020 497.89 473.00 543.95 # 15157 149.13 141.67 162.92 14021 772.61 733.98 844.08 15170 345.14 327.88 377.06 # 14021 679.16 645.20 741.98 # 15170 296.38 281.56 323.79 14040 617.83 586.94 674.98 15171 77.51 73.63 84.67 # 14040 536.56 509.73 586.19 # 15171 74.12 70.41 80.97 14041 849.92 807.42 928.53 15175 453.16 430.50 495.08 # 14041 745.64 708.36 814.61 # 15175 406.44 386.12 444.04 14060 631.63 600.05 690.06 15176 124.66 118.43 136.19 # 14060 566.28 537.97 618.67 # 15176 118.57 112.64 129.54 14061 922.34 876.22 1,007.65 15200 648.80 616.36 708.81 # 14061 807.90 767.51 882.64 # 15200 534.35 507.63 583.77 14300 886.99 842.64 969.04 15201 125.76 119.47 137.39 # 14300 784.74 745.50 857.33 # 15201 66.50 63.18 72.66 14350 629.14 597.68 687.33 15220 617.30 586.44 674.41 15002 275.56 261.78 301.05 # 15220 510.98 485.43 558.24 # 15002 189.90 180.41 207.47 15221 116.53 110.70 127.31 15003 59.47 56.50 64.98 # 15221 61.34 58.27 67.01 # 15003 37.80 35.91 41.30 15240 736.57 699.74 804.70 15004 331.90 315.31 362.61 # 15240 645.48 613.21 705.19 # 15004 235.06 223.31 256.81 15241 151.66 144.08 165.69 15005 100.36 95.34 109.64 # 15241 96.47 91.65 105.40 # 15005 76.32 72.50 83.38 15260 790.12 750.61 863.20 15040 216.04 205.24 236.03 # 15260 700.06 665.06 764.82 # 15040 109.04 103.59 119.13 15261 175.27 166.51 191.49 15050 438.42 416.50 478.98 # 15261 122.45 116.33 133.78 # 15050 363.59 345.41 397.22 15300 278.60 264.67 304.37 15100 732.54 695.91 800.30 # 15300 240.34 228.32 262.57 # 15100 599.47 569.50 654.93 15301 52.07 49.47 56.89 15101 167.58 159.20 183.08 # 15301 48.68 46.25 53.19 # 15101 96.81 91.97 105.77 15320 317.38 301.51 346.74 15110 721.49 685.42 788.23 # 15320 275.05 261.30 300.50 # 15110 618.89 587.95 676.14 15321 78.10 74.20 85.33 15111 104.18 98.97 113.82 # 15321 73.36 69.69 80.14 # 15111 91.31 86.74 99.75 15330 257.19 244.33 280.98 15115 712.12 676.51 777.99 # 15330 217.91 207.01 238.06 # 15115 638.31 606.39 697.35 15331 52.41 49.79 57.26 15116 137.87 130.98 150.63 # 15331 49.36 46.89 53.92 # 15116 124.33 118.11 135.83 15335 277.64 263.76 303.32 15120 766.00 727.70 836.86 # 15335 238.02 226.12 260.04 # 15120 650.20 617.69 710.34 15336 76.28 72.47 83.34 15121 231.58 220.00 253.00 # 15336 70.52 66.99 77.04 # 15121 150.31 142.79 164.21 15340 264.80 251.56 289.29 15130 571.01 542.46 623.83 # 15340 226.20 214.89 247.12 # 15130 471.12 447.56 514.69 15341 39.03 37.08 42.64 15131 83.86 79.67 91.62 # 15341 23.79 22.60 25.99 # 15131 73.70 70.02 80.52 15360 298.70 283.77 326.34 15135 719.92 683.92 786.51 # 15360 252.99 240.34 276.39 # 15135 649.15 616.69 709.19 15361 59.73 56.74 65.25 15136 80.60 76.57 88.06 # 15361 54.65 51.92 59.71 # 15136 74.50 70.78 81.40 15365 299.38 284.41 327.07 15150 598.57 568.64 653.94 # 15365 257.74 244.85 281.58 # 15150 542.70 515.57 592.91 15366 75.39 71.62 82.36 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 MAINE - MEDICARE CARRIER 31142 PAGE 6 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 70.31 66.79 76.81 # 15786 114.62 108.89 125.22 15400 309.37 293.90 337.99 15787 44.40 42.18 48.51 # 15400 288.72 274.28 315.42 # 15787 15.96 15.16 17.43 15401 85.59 81.31 93.51 15788 346.34 329.02 378.37 # 15401 49.70 47.22 54.30 # 15788 194.31 184.59 212.28 15420 348.23 330.82 380.44 15789 465.39 442.12 508.44 # 15420 309.97 294.47 338.64 # 15789 348.92 331.47 381.19 15421 96.72 91.88 105.66 15792 337.45 320.58 368.67 # 15421 73.36 69.69 80.14 # 15792 218.27 207.36 238.46 15430 441.73 419.64 482.59 15793 375.80 357.01 410.56 # 15430 427.51 406.13 467.05 # 15793 289.12 274.66 315.86 15570 726.32 690.00 793.50 15819 605.66 575.38 661.69 # 15570 584.79 555.55 638.88 15820 438.83 416.89 479.42 15572 685.17 650.91 748.55 # 15820 394.81 375.07 431.33 # 15572 580.88 551.84 634.62 15821 468.41 444.99 511.74 15574 737.77 700.88 806.01 # 15821 418.98 398.03 457.73 # 15574 629.43 597.96 687.65 15822 346.31 328.99 378.34 15576 657.63 624.75 718.46 # 15822 304.33 289.11 332.48 # 15576 555.38 527.61 606.75 15823 540.96 513.91 591.00 15600 289.98 275.48 316.80 # 15823 495.25 470.49 541.06 # 15600 169.78 161.29 185.48 15830 961.50 913.43 1,050.44 15610 263.79 250.60 288.19 15832 740.94 703.89 809.47 # 15610 199.79 189.80 218.27 15833 690.10 655.60 753.94 15620 370.35 351.83 404.60 15834 704.16 668.95 769.29 # 15620 260.65 247.62 284.76 15835 723.58 687.40 790.51 15630 378.82 359.88 413.86 15836 608.32 577.90 664.59 # 15630 282.99 268.84 309.17 15837 631.16 599.60 689.54 15650 408.83 388.39 446.65 # 15837 562.09 533.99 614.09 # 15650 310.30 294.79 339.01 15838 478.15 454.24 522.38 15731 903.55 858.37 987.13 15839 687.03 652.68 750.58 # 15731 816.87 776.03 892.43 # 15839 589.85 560.36 644.41 15732 1,257.25 1,194.39 1,373.55 15840 843.16 801.00 921.15 # 15732 1,098.11 1,043.20 1,199.68 15841 1,398.89 1,328.95 1,528.29 15734 1,286.39 1,222.07 1,405.38 15842 2,211.12 2,100.56 2,415.64 # 15734 1,124.20 1,067.99 1,228.19 15845 787.29 747.93 860.12 15736 1,155.43 1,097.66 1,262.31 15851 81.35 77.28 88.87 # 15736 972.25 923.64 1,062.19 # 15851 39.36 37.39 43.00 15738 1,228.75 1,167.31 1,342.41 15852 40.68 38.65 44.45 # 15738 1,062.16 1,009.05 1,160.41 15860 95.29 90.53 104.11 15740 803.07 762.92 877.36 15920 480.10 456.10 524.52 # 15740 700.81 665.77 765.64 15922 616.79 585.95 673.84 15750 760.18 722.17 830.50 15931 551.22 523.66 602.21 15756 1,992.93 1,893.28 2,177.27 15933 677.83 643.94 740.53 15757 1,990.62 1,891.09 2,174.75 15934 758.85 720.91 829.05 15758 1,984.05 1,884.85 2,167.58 15935 897.31 852.44 980.31 15760 688.95 654.50 752.68 15936 739.64 702.66 808.06 # 15760 585.00 555.75 639.11 15937 864.72 821.48 944.70 15770 540.71 513.67 590.72 15940 569.63 541.15 622.32 15775 264.13 250.92 288.56 15941 748.56 711.13 817.80 # 15775 186.26 176.95 203.49 15944 729.81 693.32 797.32 15776 373.81 355.12 408.39 15945 806.98 766.63 881.62 # 15776 284.42 270.20 310.73 15946 1,341.06 1,274.01 1,465.11 15780 684.83 650.59 748.18 15950 470.75 447.21 514.29 # 15780 549.73 522.24 600.58 15951 671.77 638.18 733.91 15781 435.86 414.07 476.18 15952 698.82 663.88 763.46 # 15781 358.33 340.41 391.47 15953 779.17 740.21 851.24 15782 468.03 444.63 511.32 15956 947.64 900.26 1,035.30 # 15782 348.51 331.08 380.74 15958 966.61 918.28 1,056.02 15783 401.62 381.54 438.77 16000 58.16 55.25 63.54 # 15783 306.14 290.83 334.45 # 16000 39.87 37.88 43.56 15786 194.18 184.47 212.14 16020 68.99 65.54 75.37 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 MAINE - MEDICARE CARRIER 31142 PAGE 7 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 47.66 45.28 52.07 17311 575.69 546.91 628.95 16025 122.66 116.53 134.01 # 17311 316.33 300.51 345.59 # 16025 96.93 92.08 105.89 17312 346.89 329.55 378.98 16030 146.92 139.57 160.51 # 17312 168.45 160.03 184.03 # 16030 111.03 105.48 121.30 17313 525.83 499.54 574.47 16035 182.49 173.37 199.38 # 17313 284.08 269.88 310.36 16036 72.47 68.85 79.18 17314 320.69 304.66 350.36 17000 61.88 58.79 67.61 # 17314 155.79 148.00 170.20 # 17000 43.26 41.10 47.27 17315 68.56 65.13 74.90 17003 6.22 5.91 6.80 # 17315 44.52 42.29 48.63 # 17003 4.19 3.98 4.58 17340 38.77 36.83 42.35 17004 143.52 136.34 156.79 # 17340 39.11 37.15 42.72 # 17004 113.39 107.72 123.88 17360 105.51 100.23 115.26 17106 319.90 303.91 349.50 # 17360 81.47 77.40 89.01 # 17106 274.53 260.80 299.92 19000 95.91 91.11 104.78 17107 561.58 533.50 613.53 # 19000 39.70 37.72 43.38 # 17107 497.58 472.70 543.61 19001 23.41 22.24 25.58 17108 761.91 723.81 832.38 # 19001 19.68 18.70 21.51 # 17108 692.84 658.20 756.93 19020 354.28 336.57 387.06 17110 81.09 77.04 88.60 # 19020 231.71 220.12 253.14 # 17110 50.28 47.77 54.94 19030 147.12 139.76 160.72 17111 99.04 94.09 108.20 # 19030 70.94 67.39 77.50 # 17111 65.18 61.92 71.21 19100 116.49 110.67 127.27 17250 61.03 57.98 66.68 # 19100 58.59 55.66 64.01 # 17250 30.22 28.71 33.02 19101 266.03 252.73 290.64 17260 77.45 73.58 84.62 # 19101 178.33 169.41 194.82 # 17260 55.44 52.67 60.57 19102 193.60 183.92 211.51 17261 110.47 104.95 120.69 # 19102 92.69 88.06 101.27 # 17261 73.22 69.56 79.99 19103 495.84 471.05 541.71 17262 134.89 128.15 147.37 # 19103 171.13 162.57 186.96 # 17262 93.92 89.22 102.60 19105 1,704.96 1,619.71 1,862.67 17263 148.73 141.29 162.48 # 19105 164.02 155.82 179.19 # 17263 103.69 98.51 113.29 19110 358.77 340.83 391.95 17264 160.70 152.67 175.57 # 19110 258.89 245.95 282.84 # 17264 110.93 105.38 121.19 19112 343.36 326.19 375.12 17266 182.71 173.57 199.61 # 19112 233.66 221.98 255.28 # 17266 128.54 122.11 140.43 19120 374.14 355.43 408.74 17270 116.09 110.29 126.83 # 19120 319.97 303.97 349.57 # 17270 79.19 75.23 86.51 19125 412.96 392.31 451.16 17271 127.10 120.75 138.86 # 19125 355.40 337.63 388.27 # 17271 89.18 84.72 97.43 19126 135.80 129.01 148.36 17272 145.97 138.67 159.47 19260 996.43 946.61 1,088.60 # 17272 103.65 98.47 113.24 19271 1,361.29 1,293.23 1,487.21 17273 162.78 154.64 177.84 19272 1,504.11 1,428.90 1,643.24 # 17273 116.73 110.89 127.52 19290 141.32 134.25 154.39 17274 194.35 184.63 212.32 # 19290 58.70 55.77 64.14 # 17274 143.56 136.38 156.84 19291 61.41 58.34 67.09 17276 227.37 216.00 248.40 # 19291 28.91 27.46 31.58 # 17276 173.19 164.53 189.21 19295 84.52 80.29 92.33 17280 108.43 103.01 118.46 19296 3,710.15 3,524.64 4,053.34 # 17280 72.20 68.59 78.88 # 19296 175.58 166.80 191.82 17281 138.31 131.39 151.10 19297 79.41 75.44 86.76 # 17281 100.73 95.69 110.04 19298 1,297.12 1,232.26 1,417.10 17282 160.36 152.34 175.19 # 19298 286.76 272.42 313.28 # 17282 116.69 110.86 127.49 19300 446.43 424.11 487.73 17283 194.73 184.99 212.74 # 19300 312.01 296.41 340.87 # 17283 146.65 139.32 160.22 19301 488.45 464.03 533.63 17284 227.74 216.35 248.80 19302 714.96 679.21 781.09 # 17284 174.92 166.17 191.10 19303 754.17 716.46 823.93 17286 291.66 277.08 318.64 19304 448.36 425.94 489.83 # 17286 237.82 225.93 259.82 19305 891.03 846.48 973.45 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 MAINE - MEDICARE CARRIER 31142 PAGE 8 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 930.06 883.56 1,016.09 # 20526 49.95 47.45 54.57 19307 934.89 888.15 1,021.37 20550 49.74 47.25 54.34 19316 647.96 615.56 707.89 # 20550 35.85 34.06 39.17 19318 952.75 905.11 1,040.88 20551 49.18 46.72 53.73 19324 399.50 379.53 436.46 # 20551 37.33 35.46 40.78 19325 532.99 506.34 582.29 20552 45.16 42.90 49.34 19328 401.88 381.79 439.06 # 20552 30.60 29.07 33.43 19330 511.40 485.83 558.70 20553 50.70 48.17 55.40 19340 334.90 318.16 365.88 # 20553 34.11 32.40 37.26 19342 757.38 719.51 827.44 20555 284.05 269.85 310.33 19350 733.53 696.85 801.38 20600 46.14 43.83 50.40 # 19350 564.57 536.34 616.79 # 20600 34.96 33.21 38.19 19355 599.23 569.27 654.66 20605 49.95 47.45 54.57 # 19355 459.05 436.10 501.52 # 20605 36.06 34.26 39.40 19357 1,277.40 1,213.53 1,395.56 20610 63.20 60.04 69.05 19361 1,334.27 1,267.56 1,457.69 # 20610 42.88 40.74 46.85 19364 2,329.15 2,212.69 2,544.59 20612 49.44 46.97 54.02 19366 1,160.90 1,102.86 1,268.29 # 20612 37.25 35.39 40.70 19367 1,517.91 1,442.01 1,658.31 20615 186.87 177.53 204.16 19368 1,870.83 1,777.29 2,043.88 # 20615 136.76 129.92 149.41 19369 1,724.52 1,638.29 1,884.03 20650 163.60 155.42 178.73 19370 561.00 532.95 612.89 # 20650 132.79 126.15 145.07 19371 646.82 614.48 706.65 20660 223.80 212.61 244.50 19380 632.37 600.75 690.86 # 20660 199.09 189.14 217.51 19396 174.27 165.56 190.39 20661 382.31 363.19 417.67 # 19396 117.72 111.83 128.60 20662 396.81 376.97 433.52 20000 169.69 161.21 185.39 20663 372.39 353.77 406.84 # 20000 132.11 125.50 144.33 20664 619.36 588.39 676.65 20005 250.20 237.69 273.34 20665 108.19 102.78 118.20 # 20005 201.11 191.05 219.71 # 20665 87.88 83.49 96.01 20100 508.42 483.00 555.45 20670 372.43 353.81 406.88 20101 329.48 313.01 359.96 # 20670 128.98 122.53 140.91 # 20101 170.68 162.15 186.47 20680 496.74 471.90 542.69 20102 387.08 367.73 422.89 # 20680 341.67 324.59 373.28 # 20102 206.27 195.96 225.35 20690 428.38 406.96 468.00 20103 471.83 448.24 515.48 20692 788.87 749.43 861.84 # 20103 298.81 283.87 326.45 20693 389.45 369.98 425.48 20150 781.68 742.60 853.99 20694 366.95 348.60 400.89 20200 157.63 149.75 172.21 # 20694 284.00 269.80 310.27 # 20200 78.40 74.48 85.65 20802 2,078.92 1,974.97 2,271.22 20205 216.55 205.72 236.58 20805 2,703.89 2,568.70 2,954.01 # 20205 124.45 118.23 135.96 20808 3,480.42 3,306.40 3,802.36 20206 233.04 221.39 254.60 20816 2,078.06 1,974.16 2,270.28 # 20206 54.94 52.19 60.02 20822 1,816.40 1,725.58 1,984.42 20220 167.27 158.91 182.75 20824 2,056.27 1,953.46 2,246.48 # 20220 69.07 65.62 75.46 20827 1,859.18 1,766.22 2,031.15 20225 684.77 650.53 748.11 20838 2,066.19 1,962.88 2,257.31 # 20225 104.09 98.89 113.72 20900 512.44 486.82 559.84 20240 195.82 186.03 213.93 # 20900 392.58 372.95 428.89 20245 530.45 503.93 579.52 20902 513.10 487.45 560.57 20250 315.47 299.70 344.66 20910 361.62 343.54 395.07 20251 350.69 333.16 383.13 20912 411.68 391.10 449.77 20500 105.39 100.12 115.14 20920 340.62 323.59 372.13 # 20500 85.08 80.83 92.95 20922 499.80 474.81 546.03 20501 115.76 109.97 126.47 # 20922 411.09 390.54 449.12 # 20501 35.17 33.41 38.42 20924 426.86 405.52 466.35 20520 160.76 152.72 175.63 20926 366.12 347.81 399.98 # 20520 121.82 115.73 133.09 20931 96.78 91.94 105.73 20525 403.80 383.61 441.15 20937 147.83 140.44 161.51 # 20525 210.47 199.95 229.94 20938 160.62 152.59 175.48 20526 64.51 61.28 70.47 20950 234.11 222.40 255.76 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 MAINE - MEDICARE CARRIER 31142 PAGE 9 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 78.35 74.43 85.59 # 21084 1,252.01 1,189.41 1,367.82 20955 2,171.59 2,063.01 2,372.46 21085 586.31 556.99 640.54 20956 2,285.59 2,171.31 2,497.01 # 21085 503.02 477.87 549.55 20957 2,159.97 2,051.97 2,359.77 21086 1,534.53 1,457.80 1,676.47 20962 2,265.03 2,151.78 2,474.55 # 21086 1,385.88 1,316.59 1,514.08 20969 2,423.39 2,302.22 2,647.55 21087 1,523.03 1,446.88 1,663.91 20970 2,409.51 2,289.03 2,632.38 # 21087 1,377.78 1,308.89 1,505.22 20972 2,196.37 2,086.55 2,399.53 21100 607.28 576.92 663.46 20973 2,358.69 2,240.76 2,576.87 # 21100 334.37 317.65 365.30 20974 51.39 48.82 56.14 21110 592.88 563.24 647.73 # 20974 40.55 38.52 44.30 # 21110 516.35 490.53 564.11 20975 151.56 143.98 165.58 21116 144.12 136.91 157.45 20979 46.90 44.56 51.24 # 21116 37.80 35.91 41.30 # 20979 32.00 30.40 34.96 21120 522.61 496.48 570.95 20982 3,469.98 3,296.48 3,790.95 # 21120 419.34 398.37 458.13 # 20982 354.24 336.53 387.01 21121 622.38 591.26 679.95 20985 127.51 121.13 139.30 # 21121 538.41 511.49 588.21 21010 615.74 584.95 672.69 21122 599.84 569.85 655.33 21015 360.05 342.05 393.36 21123 708.08 672.68 773.58 21025 819.26 778.30 895.05 21125 2,393.84 2,274.15 2,615.27 # 21025 705.83 670.54 771.12 # 21125 624.69 593.46 682.48 21026 481.34 457.27 525.86 21127 2,607.51 2,477.13 2,848.70 # 21026 406.17 385.86 443.74 # 21127 730.01 693.51 797.54 21029 617.52 586.64 674.64 21137 624.40 593.18 682.16 # 21029 526.10 499.80 574.77 21138 757.37 719.50 827.43 21030 401.47 381.40 438.61 21139 830.53 789.00 907.35 # 21030 337.14 320.28 368.32 21141 1,128.54 1,072.11 1,232.93 21031 307.09 291.74 335.50 21142 1,108.77 1,053.33 1,211.33 # 21031 239.71 227.72 261.88 21143 1,173.33 1,114.66 1,281.86 21032 313.06 297.41 342.02 21145 1,308.61 1,243.18 1,429.66 # 21032 236.54 224.71 258.42 21146 1,304.06 1,238.86 1,424.69 21034 1,118.29 1,062.38 1,221.74 21147 1,413.14 1,342.48 1,543.85 # 21034 998.43 948.51 1,090.79 21150 1,489.51 1,415.03 1,627.28 21040 402.83 382.69 440.09 21151 1,601.93 1,521.83 1,750.10 # 21040 331.05 314.50 361.68 21154 1,789.01 1,699.56 1,954.49 21044 742.50 705.38 811.19 21155 2,027.02 1,925.67 2,214.52 21045 1,032.64 981.01 1,128.16 21159 2,362.17 2,244.06 2,580.67 21046 904.15 858.94 987.78 21160 2,521.51 2,395.43 2,754.74 21047 1,110.82 1,055.28 1,213.57 21172 1,482.74 1,408.60 1,619.89 21048 921.37 875.30 1,006.60 21175 1,754.72 1,666.98 1,917.03 21049 1,068.45 1,015.03 1,167.28 21179 1,244.70 1,182.47 1,359.84 21050 717.18 681.32 783.52 21180 1,408.55 1,338.12 1,538.84 21060 662.83 629.69 724.14 21181 611.41 580.84 667.97 21070 538.78 511.84 588.62 21182 1,730.63 1,644.10 1,890.72 21073 306.96 291.61 335.35 21183 1,966.30 1,867.99 2,148.19 # 21073 198.95 189.00 217.35 21184 2,048.55 1,946.12 2,238.04 21076 836.96 795.11 914.38 21188 1,391.38 1,321.81 1,520.08 # 21076 740.80 703.76 809.32 21193 1,053.57 1,000.89 1,151.02 21077 2,070.09 1,966.59 2,261.58 21194 1,204.13 1,143.92 1,315.51 # 21077 1,868.29 1,774.88 2,041.11 21195 1,140.58 1,083.55 1,246.08 21079 1,416.23 1,345.42 1,547.23 21196 1,235.71 1,173.92 1,350.01 # 21079 1,243.21 1,181.05 1,358.21 21198 966.20 917.89 1,055.57 21080 1,608.64 1,528.21 1,757.44 21199 869.86 826.37 950.33 # 21080 1,401.08 1,331.03 1,530.68 21206 942.11 895.00 1,029.25 21081 1,466.69 1,393.36 1,602.36 21208 1,337.11 1,270.25 1,460.79 # 21081 1,273.01 1,209.36 1,390.76 # 21208 695.14 660.38 759.44 21082 1,345.21 1,277.95 1,469.64 21209 662.55 629.42 723.83 # 21082 1,171.86 1,113.27 1,280.26 # 21209 534.90 508.16 584.38 21083 1,278.62 1,214.69 1,396.89 21210 1,567.67 1,489.29 1,712.68 # 21083 1,083.93 1,029.73 1,184.19 # 21210 697.83 662.94 762.38 21084 1,466.00 1,392.70 1,601.61 21215 2,600.49 2,470.47 2,841.04 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 MAINE - MEDICARE CARRIER 31142 PAGE 10 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 726.37 690.05 793.56 21387 636.48 604.66 695.36 21230 653.34 620.67 713.77 21390 641.37 609.30 700.70 21235 596.16 566.35 651.30 21395 815.02 774.27 890.41 # 21235 471.56 447.98 515.18 21400 141.62 134.54 154.72 21240 940.83 893.79 1,027.86 # 21400 116.57 110.74 127.35 21242 866.05 822.75 946.16 21401 382.29 363.18 417.66 21243 1,410.18 1,339.67 1,540.62 # 21401 238.39 226.47 260.44 21244 874.35 830.63 955.22 21406 453.45 430.78 495.40 21245 941.72 894.63 1,028.82 21407 535.32 508.55 584.83 # 21245 770.06 731.56 841.29 21408 732.29 695.68 800.03 21246 736.17 699.36 804.26 21421 579.21 550.25 632.79 21247 1,375.95 1,307.15 1,503.22 # 21421 506.75 481.41 553.62 21248 872.60 828.97 953.32 21422 566.10 537.80 618.47 # 21248 739.87 702.88 808.31 21423 669.55 636.07 731.48 21249 1,225.52 1,164.24 1,338.88 21431 619.66 588.68 676.98 # 21249 1,053.51 1,000.83 1,150.95 21432 562.78 534.64 614.84 21255 1,170.32 1,111.80 1,278.57 21433 1,419.19 1,348.23 1,550.46 21256 978.43 929.51 1,068.94 21435 1,116.69 1,060.86 1,219.99 21260 1,051.30 998.74 1,148.55 21436 1,603.78 1,523.59 1,752.13 21261 1,866.24 1,772.93 2,038.87 21440 409.00 388.55 446.83 21263 1,647.20 1,564.84 1,799.57 # 21440 348.73 331.29 380.98 21267 1,329.05 1,262.60 1,451.99 21445 592.33 562.71 647.12 21268 1,540.65 1,463.62 1,683.16 # 21445 504.30 479.09 550.95 21270 754.32 716.60 824.09 21450 429.27 407.81 468.98 # 21270 590.78 561.24 645.43 # 21450 373.40 354.73 407.94 21275 677.55 643.67 740.22 21451 574.80 546.06 627.97 21280 436.92 415.07 477.33 # 21451 502.68 477.55 549.18 21282 289.67 275.19 316.47 21452 507.27 481.91 554.20 21295 144.92 137.67 158.32 # 21452 263.48 250.31 287.86 21296 338.82 321.88 370.16 21453 663.26 630.10 724.62 21310 92.95 88.30 101.55 # 21453 609.76 579.27 666.16 # 21310 24.89 23.65 27.20 21454 460.91 437.86 503.54 21315 214.46 203.74 234.30 21461 1,445.89 1,373.60 1,579.64 # 21315 124.73 118.49 136.26 # 21461 756.51 718.68 826.48 21320 205.45 195.18 224.46 21462 1,583.97 1,504.77 1,730.49 # 21320 116.74 110.90 127.54 # 21462 830.60 789.07 907.43 21325 407.04 386.69 444.69 21465 767.50 729.13 838.50 21330 495.90 471.11 541.78 21470 995.87 946.08 1,087.99 21335 621.14 590.08 678.59 21480 77.71 73.82 84.89 21336 541.31 514.24 591.38 # 21480 27.94 26.54 30.52 21337 323.16 307.00 353.05 21485 508.34 482.92 555.36 # 21337 236.14 224.33 257.98 # 21485 448.41 425.99 489.89 21338 649.68 617.20 709.78 21490 769.75 731.26 840.95 21339 703.78 668.59 768.88 21495 549.51 522.03 600.33 21340 669.67 636.19 731.62 21497 510.03 484.53 557.21 21343 983.43 934.26 1,074.40 # 21497 447.73 425.34 489.14 21344 1,269.05 1,205.60 1,386.44 21501 358.76 340.82 391.94 21345 661.36 628.29 722.53 # 21501 263.28 250.12 287.64 # 21345 549.63 522.15 600.47 21502 442.39 420.27 483.31 21346 794.36 754.64 867.84 21510 397.81 377.92 434.61 21347 952.54 904.91 1,040.65 21550 207.52 197.14 226.71 21348 1,009.75 959.26 1,103.15 # 21550 132.35 125.73 144.59 21355 357.48 339.61 390.55 21555 350.60 333.07 383.03 # 21355 266.06 252.76 290.67 # 21555 271.37 257.80 296.47 21356 406.16 385.85 443.73 21556 342.23 325.12 373.89 # 21356 313.05 297.40 342.01 21557 489.20 464.74 534.45 21360 443.47 421.30 484.50 21600 458.68 435.75 501.11 21365 927.87 881.48 1,013.70 21610 895.11 850.35 977.90 21366 1,041.41 989.34 1,137.74 21615 577.43 548.56 630.84 21385 598.94 568.99 654.34 21616 706.38 671.06 771.72 21386 559.32 531.35 611.05 21620 442.98 420.83 483.95 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 MAINE - MEDICARE CARRIER 31142 PAGE 11 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 463.17 440.01 506.01 22522 215.61 204.83 235.55 21630 1,068.46 1,015.04 1,167.30 22523 524.56 498.33 573.08 21632 1,058.60 1,005.67 1,156.52 22524 502.58 477.45 549.07 21685 839.11 797.15 916.72 22525 234.53 222.80 256.22 21700 365.56 347.28 399.37 22526 1,810.67 1,720.14 1,978.16 21705 528.51 502.08 577.39 # 22526 297.83 282.94 325.38 21720 322.70 306.57 352.56 22527 1,481.94 1,407.84 1,619.02 21725 443.21 421.05 484.21 # 22527 137.72 130.83 150.45 21740 919.21 873.25 1,004.24 22532 1,442.69 1,370.56 1,576.14 21750 608.81 578.37 665.13 22533 1,352.65 1,285.02 1,477.77 21800 80.38 76.36 87.81 22534 317.35 301.48 346.70 # 21800 81.39 77.32 88.92 22548 1,540.74 1,463.70 1,683.26 21805 211.86 201.27 231.46 22554 1,072.61 1,018.98 1,171.83 21810 426.98 405.63 466.47 22556 1,382.94 1,313.79 1,510.86 21820 109.16 103.70 119.26 22558 1,268.31 1,204.89 1,385.62 21825 479.73 455.74 524.10 22585 293.95 279.25 321.14 21920 203.37 193.20 222.18 22590 1,272.35 1,208.73 1,390.04 # 21920 129.56 123.08 141.54 22595 1,211.00 1,150.45 1,323.02 21925 343.20 326.04 374.95 22600 1,035.51 983.73 1,131.29 # 21925 276.84 263.00 302.45 22610 1,024.37 973.15 1,119.12 21930 382.99 363.84 418.42 22612 1,331.57 1,264.99 1,454.74 # 21930 305.45 290.18 333.71 22614 343.09 325.94 374.83 21935 975.42 926.65 1,065.65 22630 1,277.72 1,213.83 1,395.90 22010 750.47 712.95 819.89 22632 278.75 264.81 304.53 22015 745.22 707.96 814.15 22800 1,132.68 1,076.05 1,237.46 22100 674.16 640.45 736.52 22802 1,804.07 1,713.87 1,970.95 22101 674.31 640.59 736.68 22804 2,091.33 1,986.76 2,284.77 22102 676.38 642.56 738.94 22808 1,535.09 1,458.34 1,677.09 22103 123.36 117.19 134.77 22810 1,722.55 1,636.42 1,881.88 22110 831.44 789.87 908.35 22812 1,887.15 1,792.79 2,061.71 22112 828.96 787.51 905.64 22818 1,884.93 1,790.68 2,059.28 22114 830.62 789.09 907.45 22819 2,136.25 2,029.44 2,333.86 22116 123.20 117.04 134.60 22830 676.42 642.60 738.99 22206 1,973.60 1,874.92 2,156.16 22840 670.36 636.84 732.37 22207 1,949.38 1,851.91 2,129.70 22842 670.99 637.44 733.06 22208 494.41 469.69 540.14 22843 710.83 675.29 776.58 22210 1,466.46 1,393.14 1,602.11 22844 875.19 831.43 956.14 22212 1,214.34 1,153.62 1,326.66 22845 639.85 607.86 699.04 22214 1,226.19 1,164.88 1,339.61 22846 665.04 631.79 726.56 22216 322.09 305.99 351.89 22847 732.63 696.00 800.40 22220 1,326.04 1,259.74 1,448.70 22848 318.61 302.68 348.08 22222 1,219.38 1,158.41 1,332.17 22849 1,093.51 1,038.83 1,194.65 22224 1,314.45 1,248.73 1,436.04 22850 597.21 567.35 652.45 22226 320.74 304.70 350.41 22851 356.26 338.45 389.22 22305 153.49 145.82 167.69 22852 571.68 543.10 624.57 # 22305 140.97 133.92 154.01 22855 923.13 876.97 1,008.52 22310 232.60 220.97 254.12 22857 1,480.50 1,406.48 1,617.45 # 22310 216.69 205.86 236.74 22862 1,746.48 1,659.16 1,908.03 22315 703.51 668.33 768.58 22865 1,701.09 1,616.04 1,858.45 # 22315 622.25 591.14 679.81 22900 336.65 319.82 367.79 22318 1,320.01 1,254.01 1,442.11 23000 439.83 417.84 480.52 22319 1,449.28 1,376.82 1,583.34 # 23000 299.99 284.99 327.74 22325 1,150.98 1,093.43 1,257.44 23020 580.45 551.43 634.14 22326 1,205.41 1,145.14 1,316.91 23030 359.12 341.16 392.33 22327 1,191.53 1,131.95 1,301.74 # 23030 217.24 206.38 237.34 22328 242.29 230.18 264.71 23031 345.78 328.49 377.76 22505 105.03 99.78 114.75 # 23031 185.96 176.66 203.16 22520 2,131.05 2,024.50 2,328.18 23035 583.62 554.44 637.61 # 22520 508.18 482.77 555.19 23040 604.49 574.27 660.41 22521 2,032.56 1,930.93 2,220.57 23044 479.83 455.84 524.22 # 22521 479.77 455.78 524.15 23065 172.90 164.26 188.90 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 MAINE - MEDICARE CARRIER 31142 PAGE 12 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 137.69 130.81 150.43 23490 696.70 661.87 761.15 23066 416.09 395.29 454.58 23491 864.55 821.32 944.52 # 23066 283.36 269.19 309.57 23500 171.43 162.86 187.29 23075 212.57 201.94 232.23 # 23500 166.69 158.36 182.11 # 23075 147.22 139.86 160.84 23505 280.82 266.78 306.80 23076 468.73 445.29 512.08 # 23505 264.57 251.34 289.04 23077 991.96 942.36 1,083.71 23515 576.32 547.50 629.63 23100 406.72 386.38 444.34 23520 176.64 167.81 192.98 23101 376.58 357.75 411.41 # 23520 175.96 167.16 192.23 23105 534.31 507.59 583.73 23525 280.09 266.09 306.00 23106 400.66 380.63 437.72 # 23525 261.12 248.06 285.27 23107 556.58 528.75 608.06 23530 462.98 439.83 505.80 23120 470.90 447.36 514.46 23532 520.59 494.56 568.74 23125 589.94 560.44 644.51 23540 176.51 167.68 192.83 23130 507.38 482.01 554.31 # 23540 169.06 160.61 184.70 23140 429.62 408.14 469.36 23545 253.07 240.42 276.48 23145 578.84 549.90 632.39 # 23545 230.73 219.19 252.07 23146 516.44 490.62 564.21 23550 479.36 455.39 523.70 23150 545.98 518.68 596.48 23552 552.68 525.05 603.81 23155 661.77 628.68 722.98 23570 182.40 173.28 199.27 23156 565.13 536.87 617.40 # 23570 182.74 173.60 199.64 23170 448.41 425.99 489.89 23575 311.29 295.73 340.09 23172 462.71 439.57 505.51 # 23575 293.00 278.35 320.10 23174 630.27 598.76 688.57 23585 778.21 739.30 850.20 23180 588.99 559.54 643.47 23600 256.68 243.85 280.43 23182 566.85 538.51 619.29 # 23600 232.64 221.01 254.16 23184 636.75 604.91 695.65 23605 378.90 359.96 413.95 23190 466.02 442.72 509.13 # 23605 347.75 330.36 379.91 23195 628.08 596.68 686.18 23615 726.93 690.58 794.17 23200 734.83 698.09 802.80 23616 1,105.26 1,050.00 1,207.50 23210 769.33 730.86 840.49 23620 210.00 199.50 229.43 23220 906.49 861.17 990.35 # 23620 195.10 185.35 213.15 23221 1,060.63 1,007.60 1,158.74 23625 306.72 291.38 335.09 23222 1,430.43 1,358.91 1,562.75 # 23625 286.75 272.41 313.27 23330 187.13 177.77 204.44 23630 612.50 581.88 669.16 # 23330 125.51 119.23 137.11 23650 241.30 229.24 263.63 23331 492.74 468.10 538.32 # 23650 216.25 205.44 236.26 23332 746.22 708.91 815.25 23655 311.29 295.73 340.09 23350 139.76 132.77 152.69 23660 485.20 460.94 530.08 # 23350 46.30 43.99 50.59 23665 339.78 322.79 371.21 23395 1,083.73 1,029.54 1,183.97 # 23665 319.47 303.50 349.03 23397 970.33 921.81 1,060.08 23670 685.17 650.91 748.55 23400 824.58 783.35 900.85 23675 446.54 424.21 487.84 23405 530.80 504.26 579.90 # 23675 413.02 392.37 451.23 23406 663.94 630.74 725.35 23680 749.75 712.26 819.10 23410 760.84 722.80 831.22 23700 163.74 155.55 178.88 23412 809.43 768.96 884.30 23800 865.98 822.68 946.08 23415 622.41 591.29 679.98 23802 1,029.28 977.82 1,124.49 23420 892.13 847.52 974.65 23900 1,132.37 1,075.75 1,237.11 23430 625.96 594.66 683.86 23920 914.65 868.92 999.26 23440 646.58 614.25 706.39 23921 373.01 354.36 407.51 23450 810.45 769.93 885.42 23930 299.85 284.86 327.59 23455 862.69 819.56 942.49 # 23930 181.34 172.27 198.11 23460 933.85 887.16 1,020.23 23931 240.55 228.52 262.80 23462 914.46 868.74 999.05 # 23931 132.87 126.23 145.16 23465 950.95 903.40 1,038.91 23935 419.12 398.16 457.88 23466 935.86 889.07 1,022.43 24000 393.34 373.67 429.72 23470 1,037.73 985.84 1,133.72 24006 597.59 567.71 652.87 23472 1,281.39 1,217.32 1,399.92 24065 198.68 188.75 217.06 23480 696.83 661.99 761.29 # 24065 136.04 129.24 148.63 23485 818.53 777.60 894.24 24066 484.87 460.63 529.72 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 MAINE - MEDICARE CARRIER 31142 PAGE 13 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 329.80 313.31 360.31 24410 887.58 843.20 969.68 24075 390.98 371.43 427.14 24420 824.53 783.30 900.80 # 24075 257.58 244.70 281.41 24430 873.92 830.22 954.75 24076 393.29 373.63 429.67 24435 893.27 848.61 975.90 24077 684.62 650.39 747.95 24470 553.53 525.85 604.73 24100 331.20 314.64 361.84 24495 560.15 532.14 611.96 24101 415.35 394.58 453.77 24498 738.69 701.76 807.02 24102 516.40 490.58 564.17 24500 278.52 264.59 304.28 24105 278.53 264.60 304.29 # 24500 248.05 235.65 271.00 24110 486.01 461.71 530.97 24505 405.48 385.21 442.99 24115 566.62 538.29 619.03 # 24505 368.91 350.46 403.03 24116 733.53 696.85 801.38 24515 739.83 702.84 808.27 24120 436.39 414.57 476.76 24516 731.75 695.16 799.43 24125 497.29 472.43 543.29 24530 299.99 284.99 327.74 24126 530.69 504.16 579.78 # 24530 267.82 254.43 292.59 24130 422.80 401.66 461.91 24535 506.74 481.40 553.61 24134 640.26 608.25 699.49 # 24535 469.83 446.34 513.29 24136 527.45 501.08 576.24 24538 627.01 595.66 685.01 24138 549.79 522.30 600.65 24545 758.01 720.11 828.13 24140 613.67 582.99 670.44 24546 898.26 853.35 981.35 24145 516.73 490.89 564.52 24560 251.31 238.74 274.55 24147 537.39 510.52 587.10 # 24560 217.79 206.90 237.94 24149 963.15 914.99 1,052.24 24565 421.69 400.61 460.70 24150 822.05 780.95 898.09 # 24565 388.17 368.76 424.07 24151 953.82 906.13 1,042.05 24566 577.97 549.07 631.43 24152 610.32 579.80 666.77 24575 619.67 588.69 676.99 24153 585.91 556.61 640.10 24576 263.84 250.65 288.25 24155 710.28 674.77 775.99 # 24576 234.04 222.34 255.69 24160 507.68 482.30 554.65 24577 436.85 415.01 477.26 24164 415.22 394.46 453.63 # 24577 402.31 382.19 439.52 24200 168.33 159.91 183.90 24579 701.66 666.58 766.57 # 24200 114.50 108.78 125.10 24582 656.07 623.27 716.76 24201 468.24 444.83 511.55 24586 928.85 882.41 1,014.77 # 24201 303.68 288.50 331.78 24587 922.96 876.81 1,008.33 24220 152.16 144.55 166.23 24600 301.84 286.75 329.76 # 24220 60.74 57.70 66.36 # 24600 269.00 255.55 293.88 24300 327.50 311.13 357.80 24605 377.29 358.43 412.19 24301 633.49 601.82 692.09 24615 603.48 573.31 659.31 24305 485.78 461.49 530.71 24620 458.78 435.84 501.22 24310 397.36 377.49 434.11 24635 687.60 653.22 751.20 24320 643.78 611.59 703.33 24640 100.53 95.50 109.83 24330 604.32 574.10 660.22 # 24640 70.73 67.19 77.27 24331 665.96 632.66 727.56 24650 203.60 193.42 222.43 24332 501.66 476.58 548.07 # 24650 178.88 169.94 195.43 24340 514.96 489.21 562.59 24655 353.92 336.22 386.65 24341 600.33 570.31 655.86 # 24655 321.07 305.02 350.77 24342 663.60 630.42 724.98 24665 543.07 515.92 593.31 24343 588.36 558.94 642.78 24666 615.50 584.73 672.44 24344 916.00 870.20 1,000.73 24670 228.66 217.23 249.81 24345 585.52 556.24 639.68 # 24670 201.24 191.18 219.86 24346 913.67 867.99 998.19 24675 370.60 352.07 404.88 24357 371.11 352.55 405.43 # 24675 339.45 322.48 370.85 24358 436.14 414.33 476.48 24685 545.37 518.10 595.82 24359 536.97 510.12 586.64 24800 677.24 643.38 739.89 24360 757.10 719.25 827.14 24802 838.13 796.22 915.65 24361 852.72 810.08 931.59 24900 597.42 567.55 652.68 24362 831.84 790.25 908.79 24920 589.89 560.40 644.46 24363 1,256.40 1,193.58 1,372.62 24925 452.22 429.61 494.05 24365 538.37 511.45 588.17 24930 622.78 591.64 680.39 24366 577.36 548.49 630.76 24931 669.98 636.48 731.95 24400 693.14 658.48 757.25 24935 905.23 859.97 988.97 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 MAINE - MEDICARE CARRIER 31142 PAGE 14 FSY08 LOCALITY FEE SCHEDULE FOR AREA 99 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 310.95 295.40 339.71 25310 623.93 592.73 681.64 25001 273.58 259.90 298.89 25312 705.00 669.75 770.21 25020 499.78 474.79 546.01 25315 752.11 714.50 821.68 25023 947.60 900.22 1,035.25 25316 872.62 828.99 953.34 25024 631.51 599.93 689.92 25320 809.29 768.83 884.15 25025 968.13 919.72 1,057.68 25332 712.39 676.77 778.29 25028 438.19 416.28 478.72 25335 822.39 781.27 898.46 25031 346.89 329.55 378.98 25337 751.61 714.03 821.13 25035 604.64 574.41 660.57 25350 676.27 642.46 738.83 25040 488.16 463.75 533.31 25355 747.86 710.47 817.04 25065 198.59 188.66 216.96 25360 659.67 626.69 720.69 # 25065 136.29 129.48 148.90 25365 877.99 834.09 959.20 25066 338.30 321.39 369.60 25370 940.93 893.88 1,027.96 25075 294.27 279.56 321.49 25375 917.91 872.01 1,002.81 25076 413.81 393.12 452.09 25390 756.73 718.89 826.72 25077 671.77 638.18 733.91 25391 948.67 901.24 1,036.43 25085 403.06 382.91 440.35 25392 950.52 902.99 1,038.44 25100 298.08 283.18 325.66 25393 1,069.42 1,015.95 1,168.34 25101 348.12 330.71 380.32 25394 647.24 614.88 707.11 25105 425.50 404.23 464.86 25400 793.53 753.85 866.93 25107 519.25 493.29 567.28 25405 991.97 942.37 1,083.73 25109 426.35 405.03 465.78 25415 933.18 886.52 1,019.50 25110 326.91 310.56 357.14 25420 1,099.79 1,044.80 1,201.52 25111 267.52 254.14 292.26 25425 1,005.80 955.51 1,098.84 25112 326.49 310.17 356.70 25426 1,037.23 985.37 1,133.18 25115 721.53 685.45 788.27 25430 591.51 561.93 646.22 25116 598.58 568.65 653.95 25431 664.70 631.47 726.19 25118 330.21 313.70 360.76 25440 664.80 631.56 726.29 25119 439.26 417.30 479.90 25441 792.02 752.42 865.28 25120 518.87 492.93 566.87 25442 678.46 644.54 741.22 25125 589.68 560.20 644.23 25443 652.68 620.05 713.06 25126 602.19 572.08 657.89 25444 693.76 659.07 757.93 25130 384.18 364.97 419.72 25445 608.97 578.52 665.30 25135 477.61 453.73 521.79 25446 999.30 949.34 1,091.74 25136 422.21 401.10 461.27 25447 681.39 647.32 744.42 25145 529.58 503.10 578.57 25449 875.95 832.15 956.97 25150 500.60 475.57 546.91 25450 532.82 506.18 582.11 25151 590.29 560.78 644.90 25455 641.47 609.40 700.81 25170 799.57 759.59 873.53 25490 696.62 661.79 761.06 25210 420.63 399.60 459.54 25491 730.24 693.73 797.79 25215 544.74 517.50 595.13 25492 866.01 822.71 946.12 25230 374.03 355.33 408.63 25500 208.09 197.69 227.34 25240 385.75 366.46 421.43 # 25500 186.08 176.78 203.30 25246 155.29 147.5