1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 1 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ G0101 34.70 32.97 37.92 G0270 22.76 21.62 24.86 G0102 18.88 17.94 20.63 # G0270 20.92 19.87 22.85 # G0102 8.53 8.10 9.32 G0271 12.89 12.25 14.09 G0104 125.88 119.59 137.53 G0275 14.00 13.30 15.30 # G0104 58.22 55.31 63.61 G0278 14.00 13.30 15.30 G0105 369.09 350.64 403.24 G0281 11.48 10.91 12.55 # G0105 204.21 194.00 223.10 G0283 11.48 10.91 12.55 G0105 53 125.88 119.59 137.53 G0288 128.89 122.45 140.82 # G0105 53 58.22 55.31 63.61 G0289 82.76 78.62 90.41 G0106 199.16 189.20 217.58 G0329 7.89 7.50 8.63 G0106 TC 149.07 141.62 162.86 G0339 3,958.14 3,760.23 4,324.26 G0106 26 50.09 47.59 54.73 G0340 2,687.41 2,553.04 2,936.00 G0108 23.47 22.30 25.65 G0341 401.85 381.76 439.02 G0109 13.12 12.46 14.33 G0342 650.27 617.76 710.42 G0117 44.13 41.92 48.21 G0343 1,080.56 1,026.53 1,180.51 G0118 29.97 28.47 32.74 G0364 12.40 11.78 13.55 G0120 199.16 189.20 217.58 # G0364 9.07 8.62 9.91 G0120 TC 149.07 141.62 162.86 C G0365 165.23 156.97 180.52 G0120 26 50.09 47.59 54.73 C G0365 TC 153.27 145.61 167.45 G0121 369.09 350.64 403.24 G0365 26 11.96 11.36 13.06 # G0121 204.21 194.00 223.10 G0372 11.11 10.55 12.13 G0121 53 125.88 119.59 137.53 # G0372 8.16 7.75 8.91 # G0121 53 58.22 55.31 63.61 G0389 111.22 105.66 121.51 G0124 26.96 25.61 29.45 G0389 TC 81.27 77.21 88.79 G0127 18.88 17.94 20.63 G0389 26 29.95 28.45 32.72 # G0127 8.16 7.75 8.91 G0392 2,190.61 2,081.08 2,393.24 G0128 8.24 7.83 9.00 # G0392 440.16 418.15 480.87 G0130 31.92 30.32 34.87 G0393 1,656.77 1,573.93 1,810.02 G0130 TC 21.59 20.51 23.59 # G0393 310.39 294.87 339.10 G0130 26 10.33 9.81 11.28 G0396 31.01 29.46 33.88 G0141 26.96 25.61 29.45 # G0396 29.54 28.06 32.27 G0166 153.53 145.85 167.73 G0397 60.36 57.34 65.94 G0168 76.65 72.82 83.74 # G0397 58.88 55.94 64.33 # G0168 24.53 23.30 26.80 G0398 289.45 274.98 316.23 G0179 39.14 37.18 42.76 G0398 TC 205.81 195.52 224.85 G0180 51.68 49.10 56.47 G0398 26 83.64 79.46 91.38 G0181 99.87 94.88 109.11 G0399 207.56 197.18 226.76 G0182 102.08 96.98 111.53 G0399 TC 129.59 123.11 141.58 G0202 130.53 124.00 142.60 G0399 26 77.97 74.07 85.18 G0202 TC 95.88 91.09 104.75 G0400 186.80 177.46 204.08 G0202 26 34.65 32.92 37.86 G0400 TC 116.63 110.80 127.42 G0204 153.48 145.81 167.68 G0400 26 70.17 66.66 76.66 G0204 TC 110.67 105.14 120.91 G0402 91.88 87.29 100.38 G0204 26 42.81 40.67 46.77 G0403 20.71 19.67 22.62 G0206 121.85 115.76 133.12 G0404 13.66 12.98 14.93 G0206 TC 87.20 82.84 95.27 G0405 8.16 7.75 8.91 G0206 26 34.65 32.92 37.86 G0406 36.82 34.98 40.23 G0237 10.34 9.82 11.29 G0407 66.37 63.05 72.51 G0238 11.08 10.53 12.11 G0408 95.01 90.26 103.80 G0239 11.45 10.88 12.51 G0409 8.68 8.25 9.49 G0245 63.13 59.97 68.97 G0412 660.09 627.09 721.15 # G0245 44.28 42.07 48.38 G0413 966.48 918.16 1,055.88 G0246 36.92 35.07 40.33 G0414 915.49 869.72 1,000.18 # G0246 22.50 21.38 24.59 G0415 1,248.59 1,186.16 1,364.08 G0247 41.31 39.24 45.13 G0416 637.10 605.25 696.04 # G0247 24.67 23.44 26.96 G0416 TC 454.12 431.41 496.12 G0248 152.12 144.51 166.19 G0416 26 182.99 173.84 199.92 G0249 129.20 122.74 141.15 G0417 1,237.91 1,176.01 1,352.41 G0250 9.63 9.15 10.52 G0417 TC 887.16 842.80 969.22 G0268 46.75 44.41 51.07 G0417 26 350.75 333.21 383.19 # G0268 30.49 28.97 33.32 G0418 2,124.67 2,018.44 2,321.21 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 2 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ G0418 TC 1,515.49 1,439.72 1,655.68 # 10040 78.93 74.98 86.23 G0418 26 609.18 578.72 665.53 10060 97.17 92.31 106.16 G0419 2,522.11 2,396.00 2,755.40 # 10060 83.50 79.33 91.23 G0419 TC 1,818.48 1,727.56 1,986.69 10061 165.46 157.19 180.77 G0419 26 703.63 668.45 768.72 # 10061 147.35 139.98 160.98 G9041 22.70 21.57 24.81 10080 146.16 138.85 159.68 G9042 7.48 7.11 8.18 # 10080 85.54 81.26 93.45 G9043 7.11 6.75 7.76 10081 227.91 216.51 248.99 G9044 6.74 6.40 7.36 # 10081 148.06 140.66 161.76 M0064 40.88 38.84 44.67 10120 119.69 113.71 130.77 # M0064 16.48 15.66 18.01 # 10120 81.61 77.53 89.16 P3001 26.96 25.61 29.45 10121 231.51 219.93 252.92 Q0035 18.86 17.92 20.61 # 10121 165.70 157.42 181.03 Q0035 TC 10.71 10.17 11.70 10140 136.91 130.06 149.57 Q0035 26 8.16 7.75 8.91 # 10140 106.59 101.26 116.45 Q0091 40.32 38.30 44.05 10160 111.55 105.97 121.87 # Q0091 17.77 16.88 19.41 # 10160 86.04 81.74 94.00 Q0092 16.44 15.62 17.96 10180 205.27 195.01 224.26 R0070 149.59 142.11 163.43 # 10180 156.84 149.00 171.35 R0075 149.59 142.11 163.43 11000 48.02 45.62 52.46 0067T 589.25 559.79 643.76 # 11000 29.54 28.06 32.27 C 0067T TC 190.99 181.44 208.66 11001 20.03 19.03 21.88 0067T 26 126.10 119.80 137.77 # 11001 14.86 14.12 16.24 0073T 527.26 500.90 576.04 11004 533.02 506.37 582.33 0075T 1,099.30 1,044.34 1,200.99 11005 694.39 659.67 758.62 0075T 26 914.45 868.73 999.04 11006 655.63 622.85 716.28 0076T 362.78 344.64 396.34 11008 248.83 236.39 271.85 0076T 26 91.44 86.87 99.90 11010 416.06 395.26 454.55 0078T 1,243.36 1,181.19 1,358.37 # 11010 254.88 242.14 278.46 0079T 1,142.94 1,085.79 1,248.66 11011 463.02 439.87 505.85 0080T 222.15 211.04 242.70 # 11011 273.00 259.35 298.25 0081T 222.15 211.04 242.70 11012 631.02 599.47 689.39 0145T 594.74 565.00 649.75 # 11012 395.53 375.75 432.11 C 0145T TC 277.72 263.83 303.40 11040 42.02 39.92 45.91 0145T 26 100.72 95.68 110.03 # 11040 25.38 24.11 27.73 0146T 594.74 565.00 649.75 11041 48.92 46.47 53.44 C 0146T TC 277.72 263.83 303.40 # 11041 31.55 29.97 34.47 0146T 26 100.72 95.68 110.03 11042 66.28 62.97 72.42 0147T 594.74 565.00 649.75 # 11042 42.25 40.14 46.16 C 0147T TC 277.72 263.83 303.40 11043 242.49 230.37 264.93 0147T 26 100.72 95.68 110.03 # 11043 211.07 200.52 230.60 0148T 594.74 565.00 649.75 11044 331.46 314.89 362.12 C 0148T TC 277.72 263.83 303.40 # 11044 290.80 276.26 317.70 0148T 26 100.72 95.68 110.03 11055 43.38 41.21 47.39 0149T 594.74 565.00 649.75 # 11055 21.20 20.14 23.16 C 0149T TC 277.72 263.83 303.40 11056 52.82 50.18 57.71 0149T 26 100.72 95.68 110.03 # 11056 29.90 28.41 32.67 0150T 594.74 565.00 649.75 11057 63.54 60.36 69.41 C 0150T TC 277.72 263.83 303.40 # 11057 38.77 36.83 42.35 0150T 26 100.72 95.68 110.03 11100 92.96 88.31 101.56 0151T 192.89 183.25 210.74 # 11100 44.53 42.30 48.65 C 0151T TC 103.16 98.00 112.70 11101 29.93 28.43 32.69 0151T 26 66.29 62.98 72.43 # 11101 22.91 21.76 25.02 0171T 706.18 670.87 771.50 11200 72.82 69.18 79.56 0172T 353.09 335.44 385.76 # 11200 61.36 58.29 67.03 0177T 1,221.08 1,160.03 1,334.03 11201 16.73 15.89 18.27 10021 127.06 120.71 138.82 # 11201 15.25 14.49 16.66 # 10021 63.48 60.31 69.36 11300 60.70 57.67 66.32 10022 130.77 124.23 142.86 # 11300 27.06 25.71 29.57 # 10022 63.12 59.96 68.95 11301 83.12 78.96 90.80 10040 90.39 85.87 98.75 # 11301 46.15 43.84 50.42 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 3 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 11302 99.39 94.42 108.58 # 11462 198.24 188.33 216.58 # 11302 57.24 54.38 62.54 11463 412.68 392.05 450.86 11303 116.57 110.74 127.35 # 11463 276.64 262.81 302.23 # 11303 67.04 63.69 73.24 11470 336.88 320.04 368.05 11305 62.01 58.91 67.75 # 11470 234.11 222.40 255.76 # 11305 33.91 32.21 37.04 11471 422.59 401.46 461.68 11306 85.75 81.46 93.68 # 11471 293.57 278.89 320.72 # 11306 51.74 49.15 56.52 11600 158.20 150.29 172.83 11307 101.51 96.43 110.89 # 11600 99.79 94.80 109.02 # 11307 61.21 58.15 66.87 11601 195.50 185.73 213.59 11308 113.42 107.75 123.91 # 11601 129.33 122.86 141.29 # 11308 73.12 69.46 79.88 11602 214.91 204.16 234.78 11310 75.47 71.70 82.46 # 11602 142.46 135.34 155.64 # 11310 39.24 37.28 42.87 11603 243.59 231.41 266.12 11311 95.69 90.91 104.55 # 11603 168.92 160.47 184.54 # 11311 57.61 54.73 62.94 11604 268.76 255.32 293.62 11312 110.52 104.99 120.74 # 11604 185.21 175.95 202.34 # 11312 66.16 62.85 72.28 11606 376.77 357.93 411.62 11313 137.84 130.95 150.59 # 11606 273.25 259.59 298.53 # 11313 88.30 83.89 96.47 11620 161.71 153.62 176.66 11400 103.05 97.90 112.59 # 11620 101.46 96.39 110.85 # 11400 66.82 63.48 73.00 11621 197.34 187.47 215.59 11401 126.34 120.02 138.02 # 11621 130.80 124.26 142.90 # 11401 88.63 84.20 96.83 11622 223.27 212.11 243.93 11402 140.77 133.73 153.79 # 11622 150.82 143.28 164.77 # 11402 97.88 92.99 106.94 11623 259.94 246.94 283.98 11403 161.46 153.39 176.40 # 11623 185.26 176.00 202.40 # 11403 124.49 118.27 136.01 11624 291.77 277.18 318.76 11404 183.73 174.54 200.72 # 11624 210.07 199.57 229.51 # 11404 138.26 131.35 151.05 11626 353.96 336.26 386.70 11406 258.00 245.10 281.87 # 11626 261.91 248.81 286.13 # 11406 205.88 195.59 224.93 11640 169.07 160.62 184.71 11420 103.84 98.65 113.45 # 11640 106.96 101.61 116.85 # 11420 72.04 68.44 78.71 11641 207.58 197.20 226.78 11421 134.46 127.74 146.90 # 11641 139.56 132.58 152.47 # 11421 97.13 92.27 106.11 11642 239.13 227.17 261.25 11422 149.96 142.46 163.83 # 11642 164.45 156.23 179.66 # 11422 117.43 111.56 128.29 11643 280.32 266.30 306.25 11423 174.36 165.64 190.49 # 11643 204.90 194.66 223.86 # 11423 136.65 129.82 149.29 11644 345.39 328.12 377.34 11424 200.75 190.71 219.32 # 11644 254.82 242.08 278.39 # 11424 157.12 149.26 171.65 11646 453.28 430.62 495.21 11426 286.23 271.92 312.71 # 11646 357.53 339.65 390.60 # 11426 238.91 226.96 261.00 11719 19.06 18.11 20.83 11440 113.99 108.29 124.53 # 11719 8.33 7.91 9.10 # 11440 87.01 82.66 95.06 11720 27.78 26.39 30.35 11441 144.02 136.82 157.34 # 11720 15.58 14.80 17.02 # 11441 113.71 108.02 124.22 11721 39.57 37.59 43.23 11442 162.08 153.98 177.08 # 11721 26.63 25.30 29.10 # 11442 126.59 120.26 138.30 11730 87.63 83.25 95.74 11443 194.06 184.36 212.01 # 11730 53.99 51.29 58.98 # 11443 155.98 148.18 170.41 11732 40.65 38.62 44.41 11444 244.25 232.04 266.85 # 11732 28.08 26.68 30.68 # 11444 199.52 189.54 217.97 11740 40.30 38.29 44.03 11446 331.63 315.05 362.31 # 11740 28.84 27.40 31.51 # 11446 281.72 267.63 307.77 11750 190.28 180.77 207.89 11450 307.45 292.08 335.89 # 11750 157.75 149.86 172.34 # 11450 205.79 195.50 224.83 11752 270.35 256.83 295.35 11451 401.04 380.99 438.14 # 11752 235.97 224.17 257.80 # 11451 270.91 257.36 295.96 11755 118.86 112.92 129.86 11462 303.97 288.77 332.09 # 11755 77.83 73.94 85.03 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 4 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 11760 178.99 170.04 195.55 # 12014 130.49 123.97 142.57 # 11760 117.62 111.74 128.50 12015 225.54 214.26 246.40 11762 238.51 226.58 260.57 # 12015 163.43 155.26 178.55 # 11762 179.73 170.74 196.35 12016 269.18 255.72 294.08 11765 115.01 109.26 125.65 # 12016 199.31 189.34 217.74 # 11765 61.04 57.99 66.69 12017 236.98 225.13 258.90 11770 228.25 216.84 249.37 12018 293.60 278.92 320.76 # 11770 157.27 149.41 171.82 12020 236.58 224.75 258.46 11771 466.89 443.55 510.08 # 12020 167.08 158.73 182.54 # 11771 364.85 346.61 398.60 12021 139.36 132.39 152.25 11772 566.76 538.42 619.18 # 12021 121.25 115.19 132.47 # 11772 478.03 454.13 522.25 12031 210.30 199.79 229.76 11900 50.53 48.00 55.20 # 12031 140.80 133.76 153.82 # 11900 28.35 26.93 30.97 12032 271.94 258.34 297.09 11901 63.77 60.58 69.67 # 12032 173.98 165.28 190.07 # 11901 44.17 41.96 48.25 12034 266.48 253.16 291.13 11920 161.77 153.68 176.73 # 12034 180.34 171.32 197.02 # 11920 103.73 98.54 113.32 12035 324.70 308.47 354.74 11921 184.18 174.97 201.22 # 12035 210.84 200.30 230.35 # 11921 122.07 115.97 133.37 12036 354.71 336.97 387.52 11922 54.40 51.68 59.43 # 12036 242.33 230.21 264.74 # 11922 27.42 26.05 29.96 12037 399.73 379.74 436.70 11950 67.59 64.21 73.84 # 12037 282.17 268.06 308.27 # 11950 46.15 43.84 50.42 12041 220.07 209.07 240.43 11951 89.97 85.47 98.29 # 12041 150.57 143.04 164.50 # 11951 64.09 60.89 70.02 12042 257.09 244.24 280.88 11952 126.64 120.31 138.36 # 12042 176.50 167.68 192.83 # 11952 92.63 88.00 101.20 12044 296.21 281.40 323.61 11954 144.36 137.14 157.71 # 12044 189.00 179.55 206.48 # 11954 103.69 98.51 113.29 12045 327.09 310.74 357.35 11960 814.42 773.70 889.76 # 12045 218.77 207.83 239.00 11970 532.06 505.46 581.28 12046 387.25 367.89 423.07 11971 405.74 385.45 443.27 # 12046 257.49 244.62 281.31 # 11971 266.37 253.05 291.01 12047 415.33 394.56 453.74 11976 134.10 127.40 146.51 # 12047 281.87 267.78 307.95 # 11976 88.26 83.85 96.43 12051 236.79 224.95 258.69 11980 94.87 90.13 103.65 # 12051 161.38 153.31 176.31 # 11980 74.54 70.81 81.43 12052 268.87 255.43 293.74 11981 123.90 117.71 135.37 # 12052 190.13 180.62 207.71 # 11981 78.80 74.86 86.09 12053 295.15 280.39 322.45 11982 142.26 135.15 155.42 # 12053 192.01 182.41 209.77 # 11982 96.05 91.25 104.94 12054 311.62 296.04 340.45 11983 219.59 208.61 239.90 # 12054 203.30 193.14 222.11 # 11983 176.34 167.52 192.65 12055 374.40 355.68 409.03 12001 130.13 123.62 142.16 # 12055 246.86 234.52 269.70 # 12001 92.05 87.45 100.57 12056 441.59 419.51 482.44 12002 138.47 131.55 151.28 # 12056 301.48 286.41 329.37 # 12002 102.24 97.13 111.70 12057 494.01 469.31 539.71 12004 163.24 155.08 178.34 # 12057 346.14 328.83 378.15 # 12004 119.99 113.99 131.09 13100 280.52 266.49 306.46 12005 203.30 193.14 222.11 # 13100 211.02 200.47 230.54 # 12005 149.33 141.86 163.14 13101 354.86 337.12 387.69 12006 252.06 239.46 275.38 # 13101 256.52 243.69 280.24 # 12006 188.47 179.05 205.91 13102 95.46 90.69 104.29 12007 285.22 270.96 311.60 # 13102 67.73 64.34 73.99 # 12007 215.35 204.58 235.27 13120 291.45 276.88 318.41 12011 138.39 131.47 151.19 # 13120 220.47 209.45 240.87 # 12011 95.13 90.37 103.93 13121 393.11 373.45 429.47 12013 152.58 144.95 166.69 # 13121 291.45 276.88 318.41 # 12013 108.59 103.16 118.63 13122 106.72 101.38 116.59 12014 179.66 170.68 196.28 # 13122 77.52 73.64 84.69 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 5 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 13131 321.70 305.62 351.46 # 15121 155.18 147.42 169.53 # 13131 248.87 236.43 271.89 15130 593.52 563.84 648.42 13132 515.17 489.41 562.82 # 15130 497.40 472.53 543.41 # 13132 420.16 399.15 459.02 15131 88.51 84.08 96.69 13133 150.94 143.39 164.90 # 15131 79.64 75.66 87.01 # 13133 121.00 114.95 132.19 15135 763.18 725.02 833.77 13150 319.78 303.79 349.36 # 15135 682.96 648.81 746.13 # 13150 246.95 234.60 269.79 15136 81.31 77.24 88.83 13151 364.88 346.64 398.64 # 15136 75.39 71.62 82.36 # 13151 287.98 273.58 314.62 15150 617.75 586.86 674.89 13152 502.67 477.54 549.17 # 15150 566.74 538.40 619.16 # 13152 386.96 367.61 422.75 15151 114.44 108.72 125.03 13153 165.51 157.23 180.81 # 15151 105.20 99.94 114.93 # 13153 130.76 124.22 142.85 15152 149.24 141.78 163.05 13160 720.16 684.15 786.77 # 15152 138.89 131.95 151.74 14000 545.36 518.09 595.80 15155 650.97 618.42 711.18 # 14000 445.92 423.62 487.16 # 15155 608.46 578.04 664.75 14001 707.73 672.34 773.19 15156 159.18 151.22 173.90 # 14001 590.91 561.36 645.56 # 15156 150.67 143.14 164.61 14020 614.26 583.55 671.08 15157 175.75 166.96 192.00 # 14020 510.75 485.21 557.99 # 15157 163.55 155.37 178.68 14021 777.32 738.45 849.22 15170 377.74 358.85 412.68 # 14021 659.39 626.42 720.38 # 15170 325.98 309.68 356.13 14040 682.13 648.02 745.22 15171 84.04 79.84 91.82 # 14040 580.84 551.80 634.57 # 15171 79.98 75.98 87.38 14041 848.83 806.39 927.35 15175 479.06 455.11 523.38 # 14041 717.23 681.37 783.58 # 15175 430.26 408.75 470.06 14060 692.61 657.98 756.68 15176 134.54 127.81 146.98 # 14060 612.76 582.12 669.44 # 15176 126.78 120.44 138.51 14061 909.80 864.31 993.96 15200 709.85 674.36 775.51 # 14061 765.26 727.00 836.05 # 15200 583.05 553.90 636.99 14300 980.15 931.14 1,070.81 15201 131.57 124.99 143.74 # 14300 852.98 810.33 931.88 # 15201 72.05 68.45 78.72 14350 670.21 636.70 732.21 15220 677.23 643.37 739.88 15002 294.87 280.13 322.15 # 15220 553.02 525.37 604.18 # 15002 204.29 194.08 223.19 15221 122.65 116.52 134.00 15003 64.08 60.88 70.01 # 15221 66.09 62.79 72.21 # 15003 41.16 39.10 44.97 15240 812.71 772.07 887.88 15004 357.33 339.46 390.38 # 15240 707.72 672.33 773.18 # 15004 255.30 242.54 278.92 15241 163.59 155.41 178.72 15005 107.08 101.73 116.99 # 15241 103.33 98.16 112.88 # 15005 81.57 77.49 89.11 15260 882.93 838.78 964.60 15040 226.11 214.80 247.02 # 15260 768.70 730.27 839.81 # 15040 115.21 109.45 125.87 15261 190.99 181.44 208.66 15050 477.36 453.49 521.51 # 15261 130.73 124.19 142.82 # 15050 390.48 370.96 426.60 15300 303.21 288.05 331.26 15100 762.54 724.41 833.07 # 15300 259.21 246.25 283.19 # 15100 635.37 603.60 694.14 15301 56.67 53.84 61.92 15101 168.70 160.27 184.31 # 15301 52.23 49.62 57.06 # 15101 101.41 96.34 110.79 15320 341.50 324.43 373.09 15110 750.58 713.05 820.01 # 15320 293.07 278.42 320.18 # 15110 652.62 619.99 712.99 15321 84.44 80.22 92.25 15111 108.67 103.24 118.73 # 15321 78.53 74.60 85.79 # 15111 97.21 92.35 106.20 15330 280.51 266.48 306.45 15115 760.77 722.73 831.14 # 15330 235.41 223.64 257.19 # 15115 677.59 643.71 740.27 15331 56.67 53.84 61.92 15116 147.78 140.39 161.45 # 15331 52.60 49.97 57.47 # 15116 134.47 127.75 146.91 15335 294.79 280.05 322.06 15120 829.55 788.07 906.28 # 15335 250.80 238.26 274.00 # 15120 697.94 663.04 762.50 15336 78.78 74.84 86.07 15121 237.62 225.74 259.60 # 15336 72.13 68.52 78.80 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 6 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 15340 281.52 267.44 307.56 15776 398.54 378.61 435.40 # 15340 241.59 229.51 263.94 # 15776 300.95 285.90 328.79 15341 42.02 39.92 45.91 15780 739.15 702.19 807.52 # 15341 25.01 23.76 27.32 # 15780 579.08 550.13 632.65 15360 319.80 303.81 349.38 15781 475.54 451.76 519.52 # 15360 272.85 259.21 298.09 # 15781 383.12 363.96 418.55 15361 63.55 60.37 69.43 15782 504.50 479.28 551.17 # 15361 57.64 54.76 62.97 # 15782 368.46 350.04 402.55 15365 313.79 298.10 342.82 15783 433.22 411.56 473.29 # 15365 271.65 258.07 296.78 # 15783 331.93 315.33 362.63 15366 78.23 74.32 85.47 15786 212.67 202.04 232.35 # 15366 71.95 68.35 78.60 # 15786 123.95 117.75 135.41 15400 349.67 332.19 382.02 15787 43.67 41.49 47.71 # 15400 314.92 299.17 344.05 # 15787 17.05 16.20 18.63 15401 83.65 79.47 91.39 15788 381.21 362.15 416.47 # 15401 51.86 49.27 56.66 # 15788 212.63 202.00 232.30 15420 394.46 374.74 430.95 15789 506.33 481.01 553.16 # 15420 349.36 331.89 381.67 # 15789 382.85 363.71 418.27 15421 102.19 97.08 111.64 15792 375.12 356.36 409.81 # 15421 77.42 73.55 84.58 # 15792 234.27 222.56 255.94 15430 464.03 440.83 506.95 15793 421.37 400.30 460.35 # 15430 447.03 424.68 488.38 # 15793 317.85 301.96 347.25 15570 778.16 739.25 850.14 15819 656.95 624.10 717.72 # 15570 634.35 602.63 693.02 15820 473.32 449.65 517.10 15572 755.39 717.62 825.26 # 15820 427.48 406.11 467.03 # 15572 643.75 611.56 703.29 15821 502.90 477.76 549.42 15574 797.38 757.51 871.14 # 15821 452.62 429.99 494.49 # 15574 680.56 646.53 743.51 15822 370.70 352.17 405.00 15576 710.24 674.73 775.94 # 15822 327.08 310.73 357.34 # 15576 598.97 569.02 654.37 15823 584.91 555.66 639.01 15600 290.65 276.12 317.54 # 15823 537.22 510.36 586.91 # 15600 179.37 170.40 195.96 15830 1,036.01 984.21 1,131.84 15610 290.87 276.33 317.78 15832 791.43 751.86 864.64 # 15610 211.75 201.16 231.33 15833 747.49 710.12 816.64 15620 386.31 366.99 422.04 15834 742.72 705.58 811.42 # 15620 280.95 266.90 306.94 15835 785.80 746.51 858.49 15630 408.38 387.96 446.15 15836 655.42 622.65 716.05 # 15630 307.46 292.09 335.90 15837 681.99 647.89 745.07 15650 455.02 432.27 497.11 # 15837 593.63 563.95 648.54 # 15650 345.96 328.66 377.96 15838 514.66 488.93 562.27 15731 1,004.80 954.56 1,097.74 15839 755.04 717.29 824.88 # 15731 907.94 862.54 991.92 # 15839 643.02 610.87 702.50 15732 1,326.40 1,260.08 1,449.09 15840 904.38 859.16 988.03 # 15732 1,177.05 1,118.20 1,285.93 15841 1,508.95 1,433.50 1,648.53 15734 1,360.03 1,292.03 1,485.83 15842 2,376.65 2,257.82 2,596.49 # 15734 1,204.02 1,143.82 1,315.39 15845 850.87 808.33 929.58 15736 1,204.73 1,144.49 1,316.16 15851 83.47 79.30 91.20 # 15736 1,038.37 986.45 1,134.42 # 15851 41.69 39.61 45.55 15738 1,284.11 1,219.90 1,402.89 15852 43.34 41.17 47.35 # 15738 1,130.69 1,074.16 1,235.28 15860 101.74 96.65 111.15 15740 903.88 858.69 987.49 15920 519.79 493.80 567.87 # 15740 774.49 735.77 846.14 15922 659.96 626.96 721.00 15750 814.45 773.73 889.79 15931 590.27 560.76 644.87 15756 2,134.23 2,027.52 2,331.65 15933 728.15 691.74 795.50 15757 2,116.83 2,010.99 2,312.64 15934 809.94 769.44 884.86 15758 2,116.44 2,010.62 2,312.21 15935 965.17 916.91 1,054.45 15760 747.94 710.54 817.12 15936 785.26 746.00 857.90 # 15760 631.86 600.27 690.31 15937 918.58 872.65 1,003.55 15770 583.77 554.58 637.77 15940 607.10 576.75 663.26 15775 287.73 273.34 314.34 15941 790.69 751.16 863.83 # 15775 210.47 199.95 229.94 15944 778.28 739.37 850.28 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 7 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 15945 864.58 821.35 944.55 # 17280 80.41 76.39 87.85 15946 1,443.28 1,371.12 1,576.79 17281 157.53 149.65 172.10 15950 504.11 478.90 550.74 # 17281 112.06 106.46 122.43 15951 718.55 682.62 785.01 17282 182.56 173.43 199.44 15952 754.96 717.21 824.79 # 17282 130.06 123.56 142.09 15953 840.93 798.88 918.71 17283 220.25 209.24 240.63 15956 1,011.12 960.56 1,104.64 # 17283 162.58 154.45 177.62 15958 1,032.57 980.94 1,128.08 17284 255.95 243.15 279.62 16000 61.25 58.19 66.92 # 17284 193.85 184.16 211.78 # 16000 42.39 40.27 46.31 17286 322.80 306.66 352.66 16020 72.42 68.80 79.12 # 17286 259.96 246.96 284.00 # 16020 50.98 48.43 55.69 17311 621.58 590.50 679.08 16025 130.35 123.83 142.40 # 17311 348.39 330.97 380.62 # 16025 103.74 98.55 113.33 17312 373.08 354.43 407.59 16030 156.17 148.36 170.61 # 17312 185.28 176.02 202.42 # 16030 117.72 111.83 128.60 17313 567.46 539.09 619.95 16035 193.33 183.66 211.21 # 17313 312.75 297.11 341.68 16036 76.87 73.03 83.98 17314 345.76 328.47 377.74 17000 70.58 67.05 77.11 # 17314 172.01 163.41 187.92 # 17000 48.77 46.33 53.28 17315 74.05 70.35 80.90 17003 6.77 6.43 7.39 # 17315 48.92 46.47 53.44 # 17003 4.18 3.97 4.57 17340 43.45 41.28 47.47 17004 157.06 149.21 171.59 # 17340 41.98 39.88 45.86 # 17004 121.94 115.84 133.22 17360 118.06 112.16 128.98 17106 307.57 292.19 336.02 # 17360 90.34 85.82 98.69 # 17106 251.38 238.81 274.63 19000 103.06 97.91 112.60 17107 406.59 386.26 444.20 # 19000 42.81 40.67 46.77 # 17107 331.54 314.96 362.20 19001 25.47 24.20 27.83 17108 520.65 494.62 568.81 # 19001 21.40 20.33 23.38 # 17108 433.78 412.09 473.90 19020 383.54 364.36 419.01 17110 98.25 93.34 107.34 # 19020 252.30 239.69 275.64 # 17110 60.91 57.86 66.54 19030 158.07 150.17 172.70 17111 116.49 110.67 127.27 # 19030 77.85 73.96 85.05 # 17111 75.82 72.03 82.83 19100 125.17 118.91 136.75 17250 66.42 63.10 72.57 # 19100 62.32 59.20 68.08 # 17250 32.78 31.14 35.81 19101 284.62 270.39 310.95 17260 84.90 80.66 92.76 # 19101 190.36 180.84 207.97 # 17260 60.50 57.48 66.10 19102 206.96 196.61 226.10 17261 126.99 120.64 138.74 # 19102 101.60 96.52 111.00 # 17261 81.88 77.79 89.46 19103 523.62 497.44 572.06 17262 154.52 146.79 168.81 # 19103 186.10 176.80 203.32 # 17262 104.61 99.38 114.29 19105 2,031.92 1,930.32 2,219.87 17263 170.40 161.88 186.16 # 19105 186.47 177.15 203.72 # 17263 115.69 109.91 126.40 19110 396.21 376.40 432.86 17264 182.28 173.17 199.15 # 19110 284.19 269.98 310.48 # 17264 123.50 117.33 134.93 19112 371.52 352.94 405.88 17266 206.86 196.52 226.00 # 19112 255.81 243.02 279.47 # 17266 143.65 136.47 156.94 19120 407.31 386.94 444.98 17270 131.66 125.08 143.84 # 19120 347.43 330.06 379.57 # 17270 88.40 83.98 96.58 19125 450.76 428.22 492.45 17271 145.36 138.09 158.80 # 19125 385.33 366.06 420.97 # 17271 99.52 94.54 108.72 19126 143.84 136.65 157.15 17272 166.36 158.04 181.75 19260 1,063.87 1,010.68 1,162.28 # 17272 115.34 109.57 126.01 19271 1,450.24 1,377.73 1,584.39 17273 185.50 176.23 202.66 19272 1,605.33 1,525.06 1,753.82 # 17273 130.05 123.55 142.08 19290 153.89 146.20 168.13 17274 219.38 208.41 239.67 # 19290 64.42 61.20 70.38 # 17274 159.49 151.52 174.25 19291 66.31 62.99 72.44 17276 253.54 240.86 276.99 # 19291 31.93 30.33 34.88 # 17276 191.43 181.86 209.14 19295 87.05 82.70 95.11 17280 123.66 117.48 135.10 19296 3,630.44 3,448.92 3,966.26 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 8 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 19296 186.11 176.80 203.32 20250 336.55 319.72 367.68 19297 83.90 79.71 91.67 20251 373.13 354.47 407.64 19298 1,225.87 1,164.58 1,339.27 20500 105.62 100.34 115.39 # 19298 307.95 292.55 336.43 # 20500 86.40 82.08 94.39 19300 436.76 414.92 477.16 20501 120.91 114.86 132.09 # 19300 338.42 321.50 369.73 # 20501 38.84 36.90 42.44 19301 538.45 511.53 588.26 20520 169.51 161.03 185.18 19302 767.29 728.93 838.27 # 20520 127.73 121.34 139.54 19303 832.68 791.05 909.71 20525 415.49 394.72 453.93 19304 482.39 458.27 527.01 # 20525 222.52 211.39 243.10 19305 959.18 911.22 1,047.90 20526 68.00 64.60 74.29 19306 1,005.28 955.02 1,098.27 # 20526 52.85 50.21 57.74 19307 1,010.88 960.34 1,104.39 20550 52.68 50.05 57.56 19316 688.70 654.27 752.41 # 20550 38.63 36.70 42.21 19318 1,011.02 960.47 1,104.54 20551 52.13 49.52 56.95 19324 421.48 400.41 460.47 # 20551 39.56 37.58 43.22 19325 571.92 543.32 624.82 20552 47.61 45.23 52.01 19328 432.23 410.62 472.21 # 20552 33.56 31.88 36.66 19330 554.90 527.16 606.23 20553 53.27 50.61 58.20 19340 357.29 339.43 390.34 # 20553 37.37 35.50 40.83 19342 815.92 775.12 891.39 20555 310.17 294.66 338.86 19350 750.73 713.19 820.17 20600 49.62 47.14 54.21 # 19350 601.01 570.96 656.60 # 20600 37.05 35.20 40.48 19355 623.56 592.38 681.24 20605 53.30 50.64 58.24 # 19355 497.13 472.27 543.11 # 20605 38.51 36.58 42.07 19357 1,372.24 1,303.63 1,499.17 20610 68.89 65.45 75.27 19361 1,473.97 1,400.27 1,610.31 # 20610 45.97 43.67 50.22 19364 2,503.53 2,378.35 2,735.10 20612 52.90 50.26 57.80 19366 1,232.92 1,171.27 1,346.96 # 20612 39.59 37.61 43.25 19367 1,620.71 1,539.67 1,770.62 20615 194.82 185.08 212.84 19368 2,004.03 1,903.83 2,189.40 # 20615 144.17 136.96 157.50 19369 1,829.86 1,738.37 1,999.13 20650 176.11 167.30 192.40 19370 602.21 572.10 657.92 # 20650 141.36 134.29 154.43 19371 693.65 658.97 757.82 20660 227.19 215.83 248.20 19380 679.56 645.58 742.42 # 20660 213.89 203.20 233.68 19396 195.23 185.47 213.29 20661 414.48 393.76 452.82 # 19396 119.82 113.83 130.90 20662 432.02 410.42 471.98 20000 182.54 173.41 199.42 20663 397.19 377.33 433.93 # 20000 140.03 133.03 152.98 20664 677.61 643.73 740.29 20005 270.02 256.52 295.00 20665 109.38 103.91 119.50 # 20005 213.83 203.14 233.61 # 20665 91.27 86.71 99.72 20100 530.08 503.58 579.12 20670 354.58 336.85 387.38 20101 351.30 333.74 383.80 # 20670 134.25 127.54 146.67 # 20101 181.61 172.53 198.41 20680 528.46 502.04 577.35 20102 411.04 390.49 449.06 # 20680 372.08 353.48 406.50 # 20102 221.77 210.68 242.28 20690 488.80 464.36 534.01 20103 499.09 474.14 545.26 20692 915.10 869.35 999.75 # 20103 316.10 300.30 345.35 20693 411.26 390.70 449.31 20150 862.95 819.80 942.77 20694 377.76 358.87 412.70 20200 170.60 162.07 186.38 # 20694 300.86 285.82 328.69 # 20200 83.73 79.54 91.47 20696 969.69 921.21 1,059.39 20205 232.20 220.59 253.68 20697 1,223.09 1,161.94 1,336.23 # 20205 133.50 126.83 145.85 # 20697 0.18 0.17 0.20 20206 241.01 228.96 263.30 20802 2,228.89 2,117.45 2,435.07 # 20206 59.50 56.53 65.01 20805 2,731.24 2,594.68 2,983.88 20220 164.78 156.54 180.02 20808 3,710.19 3,524.68 4,053.38 # 20220 74.21 70.50 81.08 20816 2,052.86 1,950.22 2,242.75 20225 628.83 597.39 687.00 20822 1,739.61 1,652.63 1,900.52 # 20225 112.01 106.41 122.37 20824 2,043.73 1,941.54 2,232.77 20240 205.98 195.68 225.03 20827 1,813.56 1,722.88 1,981.31 20245 561.73 533.64 613.69 20838 2,271.31 2,157.74 2,481.40 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 9 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 20900 376.63 357.80 411.47 # 21076 752.42 714.80 822.02 # 20900 237.26 225.40 259.21 21077 2,133.69 2,027.01 2,331.06 20902 326.88 310.54 357.12 # 21077 1,905.60 1,810.32 2,081.87 20910 388.49 369.07 424.43 21079 1,460.34 1,387.32 1,595.42 20912 436.03 414.23 476.36 # 21079 1,260.72 1,197.68 1,377.33 20920 366.90 348.56 400.84 21080 1,657.98 1,575.08 1,811.34 20922 546.73 519.39 597.30 # 21080 1,416.95 1,346.10 1,548.02 # 20922 449.87 427.38 491.49 21081 1,514.72 1,438.98 1,654.83 20924 452.80 430.16 494.68 # 21081 1,291.43 1,226.86 1,410.89 20926 391.07 371.52 427.25 21082 1,409.94 1,339.44 1,540.36 20931 101.75 96.66 111.16 # 21082 1,196.27 1,136.46 1,306.93 20937 155.68 147.90 170.09 21083 1,340.37 1,273.35 1,464.35 20938 168.71 160.27 184.31 # 21083 1,107.47 1,052.10 1,209.92 20950 222.00 210.90 242.54 21084 1,533.18 1,456.52 1,675.00 # 20950 82.26 78.15 89.87 # 21084 1,275.88 1,212.09 1,393.90 20955 2,315.91 2,200.11 2,530.13 21085 618.12 587.21 675.29 20956 2,405.38 2,285.11 2,627.88 # 21085 512.39 486.77 559.79 20957 2,286.90 2,172.56 2,498.44 21086 1,554.10 1,476.40 1,697.86 20962 2,360.69 2,242.66 2,579.06 # 21086 1,393.66 1,323.98 1,522.58 20969 2,567.95 2,439.55 2,805.48 21087 1,550.05 1,472.55 1,693.43 20970 2,570.33 2,441.81 2,808.08 # 21087 1,390.35 1,320.83 1,518.95 20972 2,343.63 2,226.45 2,560.42 21100 638.88 606.94 697.98 20973 2,458.53 2,335.60 2,685.94 # 21100 358.67 340.74 391.85 20974 58.69 55.76 64.12 21110 668.17 634.76 729.97 # 20974 43.17 41.01 47.16 # 21110 567.25 538.89 619.72 20975 160.86 152.82 175.74 21116 136.01 129.21 148.59 20979 47.99 45.59 52.43 # 21116 39.89 37.90 43.59 # 20979 32.83 31.19 35.87 21120 554.76 527.02 606.07 20982 3,473.68 3,300.00 3,795.00 # 21120 444.22 422.01 485.31 # 20982 382.03 362.93 417.37 21121 688.50 654.08 752.19 20985 137.87 130.98 150.63 # 21121 586.10 556.80 640.32 21010 654.23 621.52 714.75 21122 645.25 612.99 704.94 21015 382.61 363.48 418.00 21123 769.62 731.14 840.81 21025 790.12 750.61 863.20 21125 2,751.87 2,614.28 3,006.42 # 21025 670.71 637.17 732.75 # 21125 673.88 640.19 736.22 21026 526.16 499.85 574.83 21127 3,272.47 3,108.85 3,575.18 # 21026 434.11 412.40 474.26 # 21127 783.77 744.58 856.27 21029 667.27 633.91 729.00 21137 645.72 613.43 705.44 # 21029 563.02 534.87 615.10 21138 805.52 765.24 880.03 21030 439.63 417.65 480.30 21139 908.05 862.65 992.05 # 21030 360.15 342.14 393.46 21141 1,214.14 1,153.43 1,326.44 21031 338.66 321.73 369.99 21142 1,197.03 1,137.18 1,307.76 # 21031 257.70 244.82 281.54 21143 1,248.07 1,185.67 1,363.52 21032 343.27 326.11 375.03 21145 1,390.43 1,320.91 1,519.05 # 21032 253.81 241.12 277.29 21146 1,486.10 1,411.80 1,623.57 21034 1,189.89 1,130.40 1,299.96 21147 1,537.16 1,460.30 1,679.35 # 21034 1,056.44 1,003.62 1,154.16 21150 1,521.24 1,445.18 1,661.96 21040 443.33 421.16 484.33 21151 1,851.57 1,758.99 2,022.84 # 21040 357.93 340.03 391.03 21154 1,863.86 1,770.67 2,036.27 21044 791.86 752.27 865.11 21155 2,086.99 1,982.64 2,280.04 21045 1,103.41 1,048.24 1,205.48 21159 2,521.59 2,395.51 2,754.84 21046 976.04 927.24 1,066.33 21160 2,618.54 2,487.61 2,860.75 21047 1,175.17 1,116.41 1,283.87 21172 1,604.95 1,524.70 1,753.41 21048 989.15 939.69 1,080.64 21175 1,935.58 1,838.80 2,114.62 21049 1,140.02 1,083.02 1,245.47 21179 1,330.83 1,264.29 1,453.93 21050 776.49 737.67 848.32 21180 1,515.86 1,440.07 1,656.08 21060 708.18 672.77 773.69 21181 635.68 603.90 694.49 21070 575.31 546.54 628.52 21182 1,850.16 1,757.65 2,021.30 21073 327.36 310.99 357.64 21183 2,061.83 1,958.74 2,252.55 # 21073 213.87 203.18 233.66 21184 2,196.54 2,086.71 2,399.72 21076 865.17 821.91 945.20 21188 1,477.46 1,403.59 1,614.13 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 10 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 21193 1,118.67 1,062.74 1,222.15 21345 715.90 680.11 782.13 21194 1,280.54 1,216.51 1,398.99 # 21345 587.99 558.59 642.38 21195 1,208.74 1,148.30 1,320.55 21346 856.02 813.22 935.20 21196 1,315.23 1,249.47 1,436.89 21347 991.47 941.90 1,083.19 21198 1,037.46 985.59 1,133.43 21348 1,039.24 987.28 1,135.37 21199 932.04 885.44 1,018.26 21355 389.94 370.44 426.01 21206 1,022.31 971.19 1,116.87 # 21355 290.86 276.32 317.77 21208 1,550.13 1,472.62 1,693.51 21356 436.45 414.63 476.82 # 21208 743.11 705.95 811.84 # 21356 334.05 317.35 364.95 21209 728.54 692.11 795.93 21360 474.07 450.37 517.93 # 21209 572.90 544.26 625.90 21365 989.38 939.91 1,080.90 21210 1,858.61 1,765.68 2,030.53 21366 1,095.01 1,040.26 1,196.30 # 21210 740.32 703.30 808.80 21385 640.10 608.10 699.32 21215 3,181.61 3,022.53 3,475.91 21386 595.74 565.95 650.84 # 21215 770.54 732.01 841.81 21387 667.07 633.72 728.78 21230 689.07 654.62 752.81 21390 690.64 656.11 754.53 21235 647.11 614.75 706.96 21395 867.82 824.43 948.09 # 21235 508.85 483.41 555.92 21400 157.37 149.50 171.93 21240 994.28 944.57 1,086.26 # 21400 128.90 122.46 140.83 21242 913.11 867.45 997.57 21401 420.16 399.15 459.02 21243 1,495.69 1,420.91 1,634.05 # 21401 263.04 249.89 287.37 21244 940.63 893.60 1,027.64 21406 483.62 459.44 528.36 21245 1,018.37 967.45 1,112.57 21407 571.67 543.09 624.55 # 21245 825.39 784.12 901.74 21408 784.55 745.32 857.12 21246 767.69 729.31 838.71 21421 647.64 615.26 707.55 21247 1,455.69 1,382.91 1,590.35 # 21421 551.90 524.31 602.96 21248 954.45 906.73 1,042.74 21422 599.81 569.82 655.29 # 21248 788.46 749.04 861.40 21423 711.21 675.65 777.00 21249 1,319.48 1,253.51 1,441.54 21431 660.89 627.85 722.03 # 21249 1,115.42 1,059.65 1,218.60 21432 599.08 569.13 654.50 21255 1,296.65 1,231.82 1,416.59 21433 1,527.60 1,451.22 1,668.90 21256 1,055.26 1,002.50 1,152.88 21435 1,207.27 1,146.91 1,318.95 21260 1,199.36 1,139.39 1,310.30 21436 1,774.33 1,685.61 1,938.45 21261 2,030.39 1,928.87 2,218.20 21440 473.28 449.62 517.06 21263 1,829.68 1,738.20 1,998.93 # 21440 392.32 372.70 428.61 21267 1,396.37 1,326.55 1,525.53 21445 668.28 634.87 730.10 21268 1,720.27 1,634.26 1,879.40 # 21445 550.35 522.83 601.25 21270 814.74 774.00 890.10 21450 493.22 468.56 538.84 # 21270 630.64 599.11 688.98 # 21450 411.52 390.94 449.58 21275 724.76 688.52 791.80 21451 648.76 616.32 708.77 21280 471.82 448.23 515.46 # 21451 551.17 523.61 602.15 21282 312.92 297.27 341.86 21452 538.40 511.48 588.20 21295 156.83 148.99 171.34 # 21452 297.36 282.49 324.86 21296 381.12 362.06 416.37 21453 750.79 713.25 820.24 21310 95.74 90.95 104.59 # 21453 665.40 632.13 726.95 # 21310 26.24 24.93 28.67 21454 493.85 469.16 539.53 21315 233.41 221.74 255.00 21461 1,713.82 1,628.13 1,872.35 # 21315 132.86 126.22 145.15 # 21461 819.93 778.93 895.77 21320 224.07 212.87 244.80 21462 1,849.41 1,756.94 2,020.48 # 21320 123.51 117.33 134.93 # 21462 905.98 860.68 989.78 21325 421.79 400.70 460.81 21465 816.11 775.30 891.60 21330 514.98 489.23 562.61 21470 1,064.14 1,010.93 1,162.57 21335 662.39 629.27 723.66 21480 81.11 77.05 88.61 21336 575.00 546.25 628.19 # 21480 29.72 28.23 32.46 21337 348.05 330.65 380.25 21485 580.89 551.85 634.63 # 21337 254.89 242.15 278.47 # 21485 495.12 470.36 540.91 21338 658.73 625.79 719.66 21490 824.60 783.37 900.88 21339 732.20 695.59 799.93 21495 611.49 580.92 668.06 21340 723.68 687.50 790.63 21497 587.11 557.75 641.41 21343 1,032.58 980.95 1,128.09 # 21497 500.97 475.92 547.31 21344 1,347.87 1,280.48 1,472.55 21501 387.50 368.13 423.35 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 11 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 21501 281.03 266.98 307.03 22310 252.49 239.87 275.85 21502 466.33 443.01 509.46 # 22310 235.12 223.36 256.86 21510 413.53 392.85 451.78 22315 752.34 714.72 821.93 21550 228.69 217.26 249.85 # 22315 666.58 633.25 728.24 # 21550 143.29 136.13 156.55 22318 1,404.95 1,334.70 1,534.91 21555 380.46 361.44 415.66 22319 1,541.60 1,464.52 1,684.20 # 21555 295.06 280.31 322.36 22325 1,236.36 1,174.54 1,350.72 21556 369.12 350.66 403.26 22326 1,285.50 1,221.23 1,404.41 21557 519.81 493.82 567.89 22327 1,278.54 1,214.61 1,396.80 21600 493.93 469.23 539.61 22328 255.41 242.64 279.04 21610 949.49 902.02 1,037.32 22505 109.32 103.85 119.43 21615 602.75 572.61 658.50 22520 2,102.83 1,997.69 2,297.34 21616 770.48 731.96 841.75 # 22520 526.87 500.53 575.61 21620 468.60 445.17 511.95 22521 2,049.09 1,946.64 2,238.64 21627 492.95 468.30 538.55 # 22521 496.79 471.95 542.74 21630 1,142.30 1,085.19 1,247.97 22522 231.37 219.80 252.77 21632 1,127.94 1,071.54 1,232.27 22523 552.71 525.07 603.83 21685 898.17 853.26 981.25 22524 529.87 503.38 578.89 21700 382.68 363.55 418.08 22525 246.75 234.41 269.57 21705 581.02 551.97 634.77 22526 1,776.28 1,687.47 1,940.59 21720 365.52 347.24 399.33 # 22526 310.12 294.61 338.80 21725 474.95 451.20 518.88 22527 1,383.15 1,313.99 1,511.09 21740 980.82 931.78 1,071.55 # 22527 140.65 133.62 153.66 21750 650.48 617.96 710.65 22532 1,540.78 1,463.74 1,683.30 21800 86.48 82.16 94.48 22533 1,458.27 1,385.36 1,593.16 # 21800 87.96 83.56 96.09 22534 334.34 317.62 365.26 21805 230.46 218.94 251.78 22548 1,634.28 1,552.57 1,785.46 21810 447.41 425.04 488.80 22554 1,128.01 1,071.61 1,232.35 21820 115.15 109.39 125.80 22556 1,468.40 1,394.98 1,604.23 # 21820 116.63 110.80 127.42 22558 1,354.43 1,286.71 1,479.72 21825 508.17 482.76 555.17 22585 308.14 292.73 336.64 21920 228.33 216.91 249.45 22590 1,357.97 1,290.07 1,483.58 # 21920 143.31 136.14 156.56 22595 1,290.50 1,225.98 1,409.88 21925 371.43 352.86 405.79 22600 1,107.23 1,051.87 1,209.65 # 21925 299.34 284.37 327.03 22610 1,093.81 1,039.12 1,194.99 21930 414.54 393.81 452.88 22612 1,414.97 1,344.22 1,545.85 # 21930 331.73 315.14 362.41 22614 360.28 342.27 393.61 21935 1,040.36 988.34 1,136.59 22630 1,358.45 1,290.53 1,484.11 22010 805.49 765.22 880.00 22632 292.40 277.78 319.45 22015 801.17 761.11 875.28 22800 1,203.47 1,143.30 1,314.80 22100 724.35 688.13 791.35 22802 1,910.27 1,814.76 2,086.97 22101 723.89 687.70 790.86 22804 2,207.01 2,096.66 2,411.16 22102 721.14 685.08 787.84 22808 1,627.35 1,545.98 1,777.88 22103 130.28 123.77 142.34 22810 1,816.20 1,725.39 1,984.20 22110 898.44 853.52 981.55 22812 1,990.55 1,891.02 2,174.67 22112 870.09 826.59 950.58 22818 1,998.21 1,898.30 2,183.05 22114 893.11 848.45 975.72 22819 2,300.76 2,185.72 2,513.58 22116 129.15 122.69 141.09 22830 717.65 681.77 784.04 22206 2,134.10 2,027.40 2,331.51 22840 702.54 667.41 767.52 22207 2,106.95 2,001.60 2,301.84 22842 704.38 669.16 769.53 22208 532.64 506.01 581.91 22843 750.27 712.76 819.67 22210 1,565.16 1,486.90 1,709.94 22844 921.65 875.57 1,006.91 22212 1,299.10 1,234.15 1,419.27 22845 670.66 637.13 732.70 22214 1,307.38 1,242.01 1,428.31 22846 696.42 661.60 760.84 22216 338.71 321.77 370.04 22847 770.19 731.68 841.43 22220 1,407.94 1,337.54 1,538.17 22848 335.89 319.10 366.97 22222 1,284.10 1,219.90 1,402.89 22849 1,161.05 1,103.00 1,268.45 22224 1,399.03 1,329.08 1,528.44 22850 634.98 603.23 693.71 22226 337.23 320.37 368.43 22851 374.55 355.82 409.19 22305 163.27 155.11 178.38 22852 607.59 577.21 663.79 # 22305 150.33 142.81 164.23 22855 982.06 932.96 1,072.90 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 12 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 22856 1,465.59 1,392.31 1,601.16 23405 563.41 535.24 615.53 22857 1,543.13 1,465.97 1,685.87 23406 703.38 668.21 768.44 22861 1,795.74 1,705.95 1,961.84 23410 745.56 708.28 814.52 22862 1,771.96 1,683.36 1,935.86 23412 778.79 739.85 850.83 22864 1,631.62 1,550.04 1,782.55 23415 621.58 590.50 679.08 22865 1,903.38 1,808.21 2,079.44 23420 874.59 830.86 955.49 22900 365.06 346.81 398.83 23430 662.10 629.00 723.35 23000 469.83 446.34 513.29 23440 682.49 648.37 745.63 # 23000 318.26 302.35 347.70 23450 855.71 812.92 934.86 23020 615.66 584.88 672.61 23455 912.57 866.94 996.98 23030 374.85 356.11 409.53 23460 988.13 938.72 1,079.53 # 23030 228.82 217.38 249.99 23462 969.22 920.76 1,058.87 23031 343.19 326.03 374.93 23465 1,010.91 960.36 1,104.41 # 23031 189.78 180.29 207.33 23466 998.75 948.81 1,091.13 23035 611.27 580.71 667.82 23470 1,099.89 1,044.90 1,201.64 23040 641.15 609.09 700.45 23472 1,361.67 1,293.59 1,487.63 23044 508.79 483.35 555.85 23480 735.94 699.14 804.01 23065 190.03 180.53 207.61 23485 869.01 825.56 949.39 # 23065 149.37 141.90 163.19 23490 754.22 716.51 823.99 23066 446.94 424.59 488.28 23491 915.13 869.37 999.78 # 23066 300.91 285.86 328.74 23500 181.59 172.51 198.39 23075 228.63 217.20 249.78 # 23500 180.48 171.46 197.18 # 23075 158.02 150.12 172.64 23505 298.39 283.47 325.99 23076 501.03 475.98 547.38 # 23505 282.50 268.38 308.64 23077 1,062.18 1,009.07 1,160.43 23515 627.42 596.05 685.46 23100 433.29 411.63 473.37 23520 188.14 178.73 205.54 23101 398.28 378.37 435.13 # 23520 189.25 179.79 206.76 23105 567.01 538.66 619.46 23525 292.84 278.20 319.93 23106 422.86 401.72 461.98 # 23525 273.61 259.93 298.92 23107 588.97 559.52 643.45 23530 478.97 455.02 523.27 23120 510.31 484.79 557.51 23532 551.76 524.17 602.80 23125 626.07 594.77 683.99 23540 186.08 176.78 203.30 23130 536.70 509.87 586.35 # 23540 183.50 174.33 200.48 23140 456.46 433.64 498.69 23545 269.39 255.92 294.31 23145 615.48 584.71 672.42 # 23545 247.95 235.55 270.88 23146 534.33 507.61 583.75 23550 508.96 483.51 556.04 23150 582.96 553.81 636.88 23552 585.90 556.61 640.10 23155 704.89 669.65 770.10 23570 193.98 184.28 211.92 23156 599.28 569.32 654.72 # 23570 196.57 186.74 214.75 23170 471.14 447.58 514.72 23575 331.34 314.77 361.99 23172 484.25 460.04 529.05 # 23575 312.11 296.50 340.98 23174 670.62 637.09 732.65 23585 851.23 808.67 929.97 23180 610.71 580.17 667.20 23600 271.61 258.03 296.73 23182 589.68 560.20 644.23 # 23600 250.91 238.36 274.11 23184 664.85 631.61 726.35 23605 400.10 380.10 437.12 23190 495.08 470.33 540.88 # 23605 369.04 350.59 403.18 23195 670.64 637.11 732.68 23615 778.99 740.04 851.05 23200 791.18 751.62 864.36 23616 1,154.98 1,097.23 1,261.81 23210 827.85 786.46 904.43 23620 223.73 212.54 244.42 23220 957.87 909.98 1,046.48 # 23620 210.79 200.25 230.29 23221 1,116.43 1,060.61 1,219.70 23625 324.37 308.15 354.37 23222 1,521.08 1,445.03 1,661.78 # 23625 304.41 289.19 332.57 23330 198.13 188.22 216.45 23630 669.72 636.23 731.66 # 23330 132.33 125.71 144.57 23650 253.24 240.58 276.67 23331 522.60 496.47 570.94 # 23650 231.42 219.85 252.83 23332 792.09 752.49 865.36 23655 334.86 318.12 365.84 23350 144.71 137.47 158.09 23660 515.89 490.10 563.62 # 23350 50.81 48.27 55.51 23665 361.18 343.12 394.59 23395 1,153.60 1,095.92 1,260.31 # 23665 339.74 322.75 371.16 23397 1,032.15 980.54 1,127.62 23670 752.20 714.59 821.78 23400 875.38 831.61 956.35 23675 471.17 447.61 514.75 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 13 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 23675 435.68 413.90 475.99 24332 536.44 509.62 586.06 23680 812.86 772.22 888.05 24340 544.86 517.62 595.26 23700 173.35 164.68 189.38 24341 643.15 610.99 702.64 23800 921.51 875.43 1,006.74 24342 701.69 666.61 766.60 23802 1,119.68 1,063.70 1,223.26 24343 624.29 593.08 682.04 23900 1,191.84 1,132.25 1,302.09 24344 972.36 923.74 1,062.30 23920 966.89 918.55 1,056.33 24345 620.03 589.03 677.38 23921 351.11 333.55 383.58 24346 974.78 926.04 1,064.95 23930 311.43 295.86 340.24 24357 391.41 371.84 427.62 # 23930 192.39 182.77 210.19 24358 461.52 438.44 504.21 23931 244.00 231.80 266.57 24359 580.06 551.06 633.72 # 23931 139.38 132.41 152.27 24360 807.14 766.78 881.80 23935 440.33 418.31 481.06 24361 905.84 860.55 989.63 24000 418.83 397.89 457.57 24362 956.09 908.29 1,044.53 24006 633.46 601.79 692.06 24363 1,344.22 1,277.01 1,468.56 24065 223.30 212.14 243.96 24365 570.02 541.52 622.75 # 24065 149.00 141.55 162.78 24366 610.49 579.97 666.97 24066 515.18 489.42 562.83 24400 736.54 699.71 804.67 # 24066 352.52 334.89 385.12 24410 939.86 892.87 1,026.80 24075 418.56 397.63 457.27 24420 884.84 840.60 966.69 # 24075 276.23 262.42 301.78 24430 939.66 892.68 1,026.58 24076 420.73 399.69 459.64 24435 953.96 906.26 1,042.20 24077 726.76 690.42 793.98 24470 560.64 532.61 612.50 24100 357.36 339.49 390.41 24495 587.20 557.84 641.52 24101 440.42 418.40 481.16 24498 782.14 743.03 854.48 24102 546.01 518.71 596.52 24500 295.74 280.95 323.09 24105 296.61 281.78 324.05 # 24500 267.64 254.26 292.40 24110 516.54 490.71 564.32 24505 428.43 407.01 468.06 24115 651.47 618.90 711.74 # 24505 391.46 371.89 427.67 24116 773.13 734.47 844.64 24515 784.56 745.33 857.13 24120 462.63 439.50 505.43 24516 775.59 736.81 847.33 24125 535.79 509.00 585.35 24530 318.17 302.26 347.60 24126 568.55 540.12 621.14 # 24530 287.85 273.46 314.48 24130 447.14 424.78 488.50 24535 535.55 508.77 585.09 24134 671.38 637.81 733.48 # 24535 498.21 473.30 544.30 24136 529.76 503.27 578.76 24538 662.56 629.43 723.84 24138 587.80 558.41 642.17 24545 817.43 776.56 893.04 24140 640.10 608.10 699.32 24546 946.61 899.28 1,034.17 24145 536.86 510.02 586.52 24560 265.85 252.56 290.44 24147 558.09 530.19 609.72 # 24560 235.53 223.75 257.31 24149 1,031.77 980.18 1,127.21 24565 440.62 418.59 481.38 24150 871.87 828.28 952.52 # 24565 407.35 386.98 445.03 24151 1,002.42 952.30 1,095.15 24566 622.10 591.00 679.65 24152 657.32 624.45 718.12 24575 656.01 623.21 716.69 24153 708.65 673.22 774.20 24576 279.82 265.83 305.70 24155 759.49 721.52 829.75 # 24576 250.98 238.43 274.19 24160 537.58 510.70 587.31 24577 458.51 435.58 500.92 24164 439.54 417.56 480.19 # 24577 422.65 401.52 461.75 24200 173.48 164.81 189.53 24579 745.64 708.36 814.61 # 24200 120.24 114.23 131.36 24582 693.86 659.17 758.05 24201 484.03 459.83 528.80 24586 985.22 935.96 1,076.35 # 24201 321.74 305.65 351.50 24587 981.61 932.53 1,072.41 24220 158.46 150.54 173.12 24600 311.48 295.91 340.30 # 24220 67.15 63.79 73.36 # 24600 283.38 269.21 309.59 24300 345.94 328.64 377.94 24605 402.33 382.21 439.54 24301 672.33 638.71 734.52 24615 639.22 607.26 698.35 24305 514.19 488.48 561.75 24620 485.81 461.52 530.75 24310 420.84 399.80 459.77 24635 669.44 635.97 731.37 24320 692.17 657.56 756.19 24640 103.43 98.26 113.00 24330 638.89 606.95 697.99 # 24640 75.34 71.57 82.31 24331 706.47 671.15 771.82 24650 216.04 205.24 236.03 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 14 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 24650 194.97 185.22 213.00 25246 160.73 152.69 175.59 24655 372.15 353.54 406.57 # 25246 73.86 70.17 80.70 # 24655 340.73 323.69 372.24 25248 392.19 372.58 428.47 24665 575.83 547.04 629.10 25250 464.78 441.54 507.77 24666 653.60 620.92 714.06 25251 635.05 603.30 693.80 24670 242.64 230.51 265.09 25259 347.26 329.90 379.39 # 24670 217.50 206.63 237.62 25260 608.08 577.68 664.33 24675 392.68 373.05 429.01 25263 607.16 576.80 663.32 # 24675 361.25 343.19 394.67 25265 719.50 683.53 786.06 24685 577.79 548.90 631.24 25270 488.65 464.22 533.85 24800 709.70 674.22 775.35 25272 549.33 521.86 600.14 24802 897.46 852.59 980.48 25274 650.19 617.68 710.33 24900 641.01 608.96 700.30 25275 597.54 567.66 652.81 24920 636.17 604.36 695.01 25280 556.77 528.93 608.27 24925 495.07 470.32 540.87 25290 473.69 450.01 517.51 24930 674.85 641.11 737.28 25295 518.62 492.69 566.59 24931 752.57 714.94 822.18 25300 609.54 579.06 665.92 24935 914.21 868.50 998.78 25301 579.76 550.77 633.39 25000 309.06 293.61 337.65 25310 602.48 572.36 658.21 25001 291.84 277.25 318.84 25312 696.86 662.02 761.32 25020 511.67 486.09 559.00 25315 746.42 709.10 815.47 25023 980.59 931.56 1,071.29 25316 863.16 820.00 943.00 25024 684.79 650.55 748.13 25320 859.54 816.56 939.04 25025 1,056.37 1,003.55 1,154.08 25332 755.27 717.51 825.14 25028 455.80 433.01 497.96 25335 858.52 815.59 937.93 25031 334.58 317.85 365.53 25337 790.15 750.64 863.24 25035 577.49 548.62 630.91 25350 662.18 629.07 723.43 25040 509.47 484.00 556.60 25355 743.48 706.31 812.26 25065 221.92 210.82 242.44 25360 642.75 610.61 702.20 # 25065 147.24 139.88 160.86 25365 871.91 828.31 952.56 25066 335.13 318.37 366.13 25370 950.80 903.26 1,038.75 25075 293.23 278.57 320.36 25375 917.28 871.42 1,002.13 25076 396.45 376.63 433.12 25390 748.38 710.96 817.60 25077 669.13 635.67 731.02 25391 949.37 901.90 1,037.19 25085 411.55 390.97 449.62 25392 964.52 916.29 1,053.73 25100 305.99 290.69 334.29 25393 1,080.92 1,026.87 1,180.90 25101 360.23 342.22 393.55 25394 694.34 659.62 758.56 25105 437.61 415.73 478.09 25400 784.33 745.11 856.88 25107 545.00 517.75 595.41 25405 996.14 946.33 1,088.28 25109 464.13 440.92 507.06 25415 936.53 889.70 1,023.16 25110 320.92 304.87 350.60 25420 1,113.69 1,058.01 1,216.71 25111 278.39 264.47 304.14 25425 965.68 917.40 1,055.01 25112 339.53 322.55 370.93 25426 1,005.40 955.13 1,098.40 25115 718.57 682.64 785.04 25430 634.60 602.87 693.30 25116 581.61 552.53 635.41 25431 699.24 664.28 763.92 25118 340.80 323.76 372.32 25440 697.03 662.18 761.51 25119 450.72 428.18 492.41 25441 843.53 801.35 921.55 25120 496.11 471.30 542.00 25442 720.76 684.72 787.43 25125 577.62 548.74 631.05 25443 692.08 657.48 756.10 25126 582.02 552.92 635.86 25444 736.43 699.61 804.55 25130 399.78 379.79 436.76 25445 644.58 612.35 704.20 25135 498.70 473.77 544.84 25446 1,060.69 1,007.66 1,158.81 25136 440.19 418.18 480.91 25447 728.49 692.07 795.88 25145 509.35 483.88 556.46 25449 929.18 882.72 1,015.13 25150 516.44 490.62 564.21 25450 540.07 513.07 590.03 25151 572.70 544.07 625.68 25455 618.75 587.81 675.98 25170 795.11 755.35 868.65 25490 681.40 647.33 744.43 25210 437.92 416.02 478.42 25491 718.79 682.85 785.28 25215 563.60 535.42 615.73 25492 864.19 820.98 944.13 25230 387.81 368.42 423.68 25500 221.32 210.25 241.79 25240 393.40 373.73 429.79 # 25500 201.36 191.29 219.98 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 15 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 25505 430.41 408.89 470.22 25920 611.10 580.55 667.63 # 25505 397.14 377.28 433.87 25922 516.58 490.75 564.36 25515 593.80 564.11 648.73 25924 596.72 566.88 651.91 25520 473.69 450.01 517.51 25927 697.24 662.38 761.74 # 25520 451.14 428.58 492.87 25929 498.67 473.74 544.80 25525 716.43 680.61 782.70 25931 635.80 604.01 694.61 25526 882.06 837.96 963.65 26010 222.12 211.01 242.66 25530 214.81 204.07 234.68 # 26010 116.76 110.92 127.56 # 25530 192.63 183.00 210.45 26011 338.80 321.86 370.14 25535 417.00 396.15 455.57 # 26011 162.46 154.34 177.49 # 25535 390.38 370.86 426.49 26020 375.20 356.44 409.91 25545 555.80 528.01 607.21 26025 366.10 347.80 399.97 25560 224.29 213.08 245.04 26030 432.21 410.60 472.19 # 25560 200.26 190.25 218.79 26034 468.63 445.20 511.98 25565 450.54 428.01 492.21 26035 729.53 693.05 797.01 # 25565 412.09 391.49 450.21 26037 503.88 478.69 550.49 25574 586.32 557.00 640.55 26040 269.20 255.74 294.10 25575 796.24 756.43 869.89 26045 409.21 388.75 447.06 25600 244.21 232.00 266.80 26055 495.86 471.07 541.73 # 25600 220.18 209.17 240.55 # 26055 258.90 245.96 282.85 25605 529.71 503.22 578.70 26060 230.55 219.02 251.87 # 25605 500.87 475.83 547.20 26070 262.08 248.98 286.33 25606 587.32 557.95 641.64 26075 277.67 263.79 303.36 25607 633.81 602.12 692.44 26080 335.32 318.55 366.33 25608 720.82 684.78 787.50 26100 281.65 267.57 307.71 25609 919.70 873.72 1,004.78 26105 288.05 273.65 314.70 25622 250.70 238.17 273.90 26110 276.79 262.95 302.39 # 25622 225.19 213.93 246.02 26115 542.61 515.48 592.80 25624 395.64 375.86 432.24 # 26115 314.14 298.43 343.19 # 25624 360.89 342.85 394.28 26116 422.04 400.94 461.08 25628 636.43 604.61 695.30 26117 574.29 545.58 627.42 25630 256.35 243.53 280.06 26121 528.13 501.72 576.98 # 25630 231.21 219.65 252.60 26123 723.73 687.54 790.67 25635 373.98 355.28 408.57 26125 256.70 243.87 280.45 # 25635 333.31 316.64 364.14 26130 399.91 379.91 436.90 25645 501.57 476.49 547.96 26135 486.96 462.61 532.00 25650 267.28 253.92 292.01 26140 443.24 421.08 484.24 # 25650 245.84 233.55 268.58 26145 450.27 427.76 491.92 25651 416.42 395.60 454.94 26160 495.40 470.63 541.22 25652 547.41 520.04 598.05 # 26160 281.73 267.64 307.79 25660 348.62 331.19 380.87 26170 354.66 336.93 387.47 25670 541.21 514.15 591.27 26180 387.67 368.29 423.53 25671 457.88 434.99 500.24 26185 464.12 440.91 507.05 25675 368.64 350.21 402.74 26200 397.29 377.43 434.04 # 25675 339.43 322.46 370.83 26205 533.28 506.62 582.61 25676 560.58 532.55 612.43 26210 385.66 366.38 421.34 25680 401.33 381.26 438.45 26215 489.67 465.19 534.97 25685 651.19 618.63 711.42 26230 444.33 422.11 485.43 25690 405.77 385.48 443.30 26235 436.74 414.90 477.14 25695 562.24 534.13 614.25 26236 387.35 367.98 423.18 25800 665.09 631.84 726.62 26250 516.00 490.20 563.73 25805 766.58 728.25 837.49 26255 783.32 744.15 855.77 25810 774.85 736.11 846.53 26260 483.24 459.08 527.94 25820 544.99 517.74 595.40 26261 598.92 568.97 654.32 25825 671.87 638.28 734.02 26262 403.43 383.26 440.75 25830 843.00 800.85 920.98 26320 301.85 286.76 329.77 25900 670.36 636.84 732.37 26340 273.32 259.65 298.60 25905 661.76 628.67 722.97 26350 633.21 601.55 691.78 25907 579.05 550.10 632.62 26352 718.42 682.50 784.88 25909 650.52 617.99 710.69 26356 940.53 893.50 1,027.53 25915 1,133.72 1,077.03 1,238.58 26357 770.32 731.80 841.57 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 16 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 26358 814.69 773.96 890.05 26550 1,327.36 1,260.99 1,450.14 26370 684.01 649.81 747.28 26551 2,871.84 2,728.25 3,137.49 26372 791.68 752.10 864.92 26553 2,536.50 2,409.68 2,771.13 26373 753.35 715.68 823.03 26554 3,281.95 3,117.85 3,585.53 26390 736.59 699.76 804.72 26555 1,221.51 1,160.43 1,334.49 26392 862.49 819.37 942.28 26556 2,620.04 2,489.04 2,862.40 26410 503.74 478.55 550.33 26560 504.45 479.23 551.11 26412 610.35 579.83 666.80 26561 805.84 765.55 880.38 26415 640.12 608.11 699.33 26562 1,171.72 1,113.13 1,280.10 26416 686.83 652.49 750.36 26565 599.78 569.79 655.26 26418 506.69 481.36 553.56 26567 605.59 575.31 661.61 26420 633.53 601.85 692.13 26568 796.37 756.55 870.03 26426 508.48 483.06 555.52 26580 1,243.01 1,180.86 1,357.99 26428 666.01 632.71 727.62 26587 850.05 807.55 928.68 26432 440.59 418.56 481.34 26590 1,125.79 1,069.50 1,229.93 26433 472.20 448.59 515.88 26591 388.16 368.75 424.06 26434 565.48 537.21 617.79 26593 528.02 501.62 576.86 26437 551.34 523.77 602.34 26596 649.03 616.58 709.07 26440 555.87 528.08 607.29 26600 234.14 222.43 255.79 26442 839.34 797.37 916.98 # 26600 216.02 205.22 236.00 26445 516.66 490.83 564.45 26605 269.28 255.82 294.19 26449 672.28 638.67 734.47 # 26605 245.25 232.99 267.94 26450 355.73 337.94 388.63 26607 383.95 364.75 419.46 26455 353.37 335.70 386.06 26608 416.63 395.80 455.17 26460 343.75 326.56 375.54 26615 483.70 459.52 528.45 26471 543.11 515.95 593.34 26641 309.77 294.28 338.42 26474 521.75 495.66 570.01 # 26641 282.78 268.64 308.94 26476 507.63 482.25 554.59 26645 352.40 334.78 385.00 26477 512.07 486.47 559.44 # 26645 324.68 308.45 354.72 26478 555.60 527.82 606.99 26650 416.80 395.96 455.35 26479 549.35 521.88 600.16 26665 537.23 510.37 586.93 26480 669.30 635.84 731.22 26670 279.33 265.36 305.16 26483 754.19 716.48 823.95 # 26670 251.61 239.03 274.88 26485 723.19 687.03 790.08 26675 375.77 356.98 410.53 26489 780.30 741.29 852.48 # 26675 346.94 329.59 379.03 26490 697.00 662.15 761.47 26676 436.97 415.12 477.39 26492 776.16 737.35 847.95 26685 495.18 470.42 540.98 26494 705.21 669.95 770.44 26686 548.19 520.78 598.90 26496 764.15 725.94 834.83 26700 266.42 253.10 291.07 26497 764.94 726.69 835.69 # 26700 247.94 235.54 270.87 26498 1,019.20 968.24 1,113.48 26705 345.02 327.77 376.94 26499 731.13 694.57 798.76 # 26705 316.56 300.73 345.84 26500 554.35 526.63 605.62 26706 378.27 359.36 413.26 26502 624.65 593.42 682.43 26715 484.26 460.05 529.06 26508 556.83 528.99 608.34 26720 162.06 153.96 177.05 26510 529.21 502.75 578.16 # 26720 148.01 140.61 161.70 26516 622.99 591.84 680.62 26725 288.79 274.35 315.50 26517 732.28 695.67 800.02 # 26725 258.84 245.90 282.79 26518 739.54 702.56 807.94 26727 409.75 389.26 447.65 26520 580.89 551.85 634.63 26735 504.21 479.00 550.85 26525 583.26 554.10 637.22 26740 188.55 179.12 205.99 26530 472.24 448.63 515.92 # 26740 176.72 167.88 193.06 26531 549.97 522.47 600.84 26742 316.20 300.39 345.45 26535 354.21 336.50 386.98 # 26742 286.99 272.64 313.54 26536 594.96 565.21 649.99 26746 618.22 587.31 675.41 26540 585.46 556.19 639.62 26750 151.32 143.75 165.31 26541 714.32 678.60 780.39 # 26750 147.25 139.89 160.87 26542 605.27 575.01 661.26 26755 265.61 252.33 290.18 26545 616.02 585.22 673.00 # 26755 230.86 219.32 252.22 26546 864.48 821.26 944.45 26756 361.62 343.54 395.07 26548 677.57 643.69 740.24 26765 411.00 390.45 449.02 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 17 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 26770 226.42 215.10 247.37 27087 564.33 536.11 616.53 # 26770 206.83 196.49 225.96 27090 746.16 708.85 815.18 26775 322.62 306.49 352.46 27091 1,443.57 1,371.39 1,577.10 # 26775 289.35 274.88 316.11 27093 177.47 168.60 193.89 26776 384.50 365.28 420.07 # 27093 67.68 64.30 73.95 26785 448.40 425.98 489.88 27095 214.44 203.72 234.28 26820 697.99 663.09 762.55 # 27095 77.29 73.43 84.44 26841 646.96 614.61 706.80 27096 162.82 154.68 177.88 26842 702.01 666.91 766.95 # 27096 64.85 61.61 70.85 26843 650.45 617.93 710.62 27097 594.83 565.09 649.85 26844 725.03 688.78 792.10 27098 557.91 530.01 609.51 26850 616.90 586.06 673.97 27100 734.17 697.46 802.08 26852 706.69 671.36 772.06 27105 770.05 731.55 841.28 26860 496.64 471.81 542.58 27110 857.99 815.09 937.35 26861 96.75 91.91 105.70 27111 764.95 726.70 835.71 26862 643.12 610.96 702.60 27120 1,162.18 1,104.07 1,269.68 26863 216.04 205.24 236.03 27122 995.87 946.08 1,087.99 26910 632.15 600.54 690.62 27125 1,014.50 963.78 1,108.35 26951 549.28 521.82 600.09 27130 1,306.74 1,241.40 1,427.61 26952 574.14 545.43 627.24 27132 1,527.24 1,450.88 1,668.51 26990 547.66 520.28 598.32 27134 1,769.71 1,681.22 1,933.40 26991 615.99 585.19 672.97 27137 1,349.58 1,282.10 1,474.42 # 26991 461.47 438.40 504.16 27138 1,404.56 1,334.33 1,534.48 26992 860.45 817.43 940.04 27140 808.45 768.03 883.23 27000 397.13 377.27 433.86 27146 1,139.70 1,082.72 1,245.13 27001 481.08 457.03 525.58 27147 1,327.35 1,260.98 1,450.13 27003 517.92 492.02 565.82 27151 1,380.33 1,311.31 1,508.01 27005 651.66 619.08 711.94 27156 1,547.89 1,470.50 1,691.08 27006 658.86 625.92 719.81 27158 1,245.54 1,183.26 1,360.75 27025 798.86 758.92 872.76 27161 1,102.15 1,047.04 1,204.10 27027 778.65 739.72 850.68 27165 1,232.28 1,170.67 1,346.27 27030 850.25 807.74 928.90 27170 1,066.45 1,013.13 1,165.10 27033 880.48 836.46 961.93 27175 593.87 564.18 648.81 27035 986.56 937.23 1,077.81 27176 819.54 778.56 895.34 27036 901.06 856.01 984.41 27177 1,000.32 950.30 1,092.85 27040 303.11 287.95 331.14 27178 811.51 770.93 886.57 # 27040 182.22 173.11 199.08 27179 874.21 830.50 955.08 27041 616.72 585.88 673.76 27181 979.43 930.46 1,070.03 27047 549.76 522.27 600.61 27185 612.42 581.80 669.07 # 27047 459.93 436.93 502.47 27187 896.06 851.26 978.95 27048 423.45 402.28 462.62 27193 411.27 390.71 449.32 27049 895.48 850.71 978.32 # 27193 414.97 394.22 453.35 27050 310.33 294.81 339.03 27194 639.41 607.44 698.56 27052 494.68 469.95 540.44 27200 150.05 142.55 163.93 27054 606.42 576.10 662.52 # 27200 153.37 145.70 167.56 27057 867.25 823.89 947.47 27202 573.45 544.78 626.50 27060 382.36 363.24 417.73 27220 463.57 440.39 506.45 27062 399.20 379.24 436.13 # 27220 460.24 437.23 502.81 27065 445.38 423.11 486.58 27222 878.93 834.98 960.23 27066 722.52 686.39 789.35 27226 933.76 887.07 1,020.13 27067 919.13 873.17 1,004.15 27227 1,512.52 1,436.89 1,652.42 27070 757.89 720.00 828.00 27228 1,732.00 1,645.40 1,892.21 27071 813.21 772.55 888.43 27230 412.83 392.19 451.02 27075 2,085.01 1,980.76 2,277.87 # 27230 407.29 386.93 444.97 27076 1,441.00 1,368.95 1,574.29 27232 696.79 661.95 761.24 27077 2,412.54 2,291.91 2,635.70 27235 819.71 778.72 895.53 27078 912.22 866.61 996.60 27236 1,072.47 1,018.85 1,171.68 27079 873.28 829.62 954.06 27238 399.24 379.28 436.17 27080 439.20 417.24 479.83 27240 857.61 814.73 936.94 27086 217.15 206.29 237.23 27244 1,103.33 1,048.16 1,205.38 # 27086 132.12 125.51 144.34 27245 1,139.93 1,082.93 1,245.37 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 18 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 27246 337.63 320.75 368.86 27381 715.87 680.08 782.09 # 27246 338.37 321.45 369.67 27385 562.57 534.44 614.61 27248 676.67 642.84 739.27 27386 742.50 705.38 811.19 27250 212.36 201.74 232.00 27390 389.61 370.13 425.65 27252 677.65 643.77 740.34 27391 507.59 482.21 554.54 27253 851.44 808.87 930.20 27392 625.19 593.93 683.02 27254 1,149.63 1,092.15 1,255.97 27393 449.88 427.39 491.50 27256 261.26 248.20 285.43 27394 581.29 552.23 635.06 # 27256 219.86 208.87 240.20 27395 787.01 747.66 859.81 27257 302.06 286.96 330.00 27396 546.65 519.32 597.22 27258 998.17 948.26 1,090.50 27397 806.07 765.77 880.64 27259 1,399.56 1,329.58 1,529.02 27400 610.13 579.62 666.56 27265 346.67 329.34 378.74 27403 572.03 543.43 624.94 27266 515.42 489.65 563.10 27405 602.81 572.67 658.57 27267 368.06 349.66 402.11 27407 687.90 653.51 751.54 27268 455.30 432.54 497.42 27409 865.39 822.12 945.44 27269 1,093.86 1,039.17 1,195.05 27412 1,495.53 1,420.75 1,633.86 27275 160.12 152.11 174.93 27415 1,247.68 1,185.30 1,363.10 27280 923.31 877.14 1,008.71 27416 866.62 823.29 946.78 27282 723.91 687.71 790.87 27418 747.04 709.69 816.14 27284 1,401.79 1,331.70 1,531.46 27420 668.69 635.26 730.55 27286 1,489.58 1,415.10 1,627.37 27422 665.97 632.67 727.57 27290 1,418.72 1,347.78 1,549.95 27424 667.79 634.40 729.56 27295 1,144.69 1,087.46 1,250.58 27425 390.13 370.62 426.21 27301 581.38 552.31 635.16 27427 641.27 609.21 700.59 # 27301 439.42 417.45 480.07 27428 988.25 938.84 1,079.67 27303 568.89 540.45 621.52 27429 1,106.84 1,051.50 1,209.23 27305 415.02 394.27 453.41 27430 661.77 628.68 722.98 27306 335.83 319.04 366.90 27435 710.73 675.19 776.47 27307 413.44 392.77 451.69 27437 588.54 559.11 642.98 27310 648.86 616.42 708.88 27438 753.92 716.22 823.65 27323 235.45 223.68 257.23 27440 688.20 653.79 751.86 # 27323 159.30 151.34 174.04 27441 710.48 674.96 776.20 27324 338.60 321.67 369.92 27442 780.37 741.35 852.55 27325 468.77 445.33 512.13 27443 731.29 694.73 798.94 27326 432.29 410.68 472.28 27445 1,138.68 1,081.75 1,244.01 27327 396.93 377.08 433.64 27446 1,009.32 958.85 1,102.68 # 27327 309.68 294.20 338.33 27447 1,398.95 1,329.00 1,528.35 27328 373.24 354.58 407.77 27448 736.26 699.45 804.37 27329 930.48 883.96 1,016.55 27450 917.68 871.80 1,002.57 27330 354.54 336.81 387.33 27454 1,157.10 1,099.25 1,264.14 27331 419.03 398.08 457.79 27455 847.94 805.54 926.37 27332 568.31 539.89 620.87 27457 873.13 829.47 953.89 27333 515.10 489.35 562.75 27465 1,102.42 1,047.30 1,204.40 27334 604.93 574.68 660.88 27466 1,067.52 1,014.14 1,166.26 27335 684.12 649.91 747.40 27468 1,207.95 1,147.55 1,319.68 27340 321.34 305.27 351.06 27470 1,064.32 1,011.10 1,162.77 27345 424.55 403.32 463.82 27472 1,150.29 1,092.78 1,256.70 27347 455.82 433.03 497.98 27475 586.23 556.92 640.46 27350 578.50 549.58 632.02 27477 655.84 623.05 716.51 27355 536.08 509.28 585.67 27479 841.07 799.02 918.87 27356 657.25 624.39 718.05 27485 599.05 569.10 654.47 27357 727.98 691.58 795.32 27486 1,276.79 1,212.95 1,394.89 27358 264.26 251.05 288.71 27487 1,609.81 1,529.32 1,758.72 27360 759.20 721.24 829.43 27488 1,080.79 1,026.75 1,180.76 27365 1,104.86 1,049.62 1,207.06 27495 1,023.12 971.96 1,117.75 27370 152.12 144.51 166.19 27496 447.42 425.05 488.81 # 27370 49.35 46.88 53.91 27497 485.18 460.92 530.06 27372 523.78 497.59 572.23 27498 528.90 502.46 577.83 # 27372 357.79 339.90 390.89 27499 586.26 556.95 640.49 27380 525.55 499.27 574.16 27500 450.94 428.39 492.65 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 19 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 27500 419.15 398.19 457.92 27613 221.17 210.11 241.63 27501 442.87 420.73 483.84 # 27613 149.82 142.33 163.68 # 27501 436.59 414.76 476.97 27614 495.56 470.78 541.40 27502 705.54 670.26 770.80 # 27614 369.13 350.67 403.27 27503 718.17 682.26 784.60 27615 792.15 752.54 865.42 27506 1,201.30 1,141.24 1,312.43 27618 432.17 410.56 472.14 27507 888.92 844.47 971.14 # 27618 342.33 325.21 373.99 27508 455.35 432.58 497.47 27619 688.48 654.06 752.17 # 27508 429.47 408.00 469.20 # 27619 529.51 503.03 578.48 27509 572.55 543.92 625.51 27620 414.35 393.63 452.67 27510 623.96 592.76 681.67 27625 535.68 508.90 585.24 27511 921.52 875.44 1,006.76 27626 577.86 548.97 631.32 27513 1,158.08 1,100.18 1,265.21 27630 474.19 450.48 518.05 27514 927.98 881.58 1,013.82 # 27630 333.71 317.02 364.57 27516 426.83 405.49 466.31 27635 532.56 505.93 581.82 # 27516 402.43 382.31 439.66 27637 675.36 641.59 737.83 27517 600.61 570.58 656.17 27638 702.87 667.73 767.89 27519 840.25 798.24 917.98 27640 779.74 740.75 851.86 27520 269.65 256.17 294.60 27641 625.26 594.00 683.10 # 27520 243.77 231.58 266.32 27645 944.95 897.70 1,032.36 27524 675.41 641.64 737.89 27646 836.10 794.30 913.45 27530 338.08 321.18 369.36 27647 739.05 702.10 807.42 # 27530 314.42 298.70 343.51 27648 146.58 139.25 160.14 27532 539.13 512.17 589.00 # 27648 48.98 46.53 53.51 # 27532 509.92 484.42 557.08 27650 607.89 577.50 664.13 27535 823.33 782.16 899.48 27652 668.98 635.53 730.86 27536 1,070.45 1,016.93 1,169.47 27654 653.85 621.16 714.33 27538 404.15 383.94 441.53 27656 477.58 453.70 521.76 # 27538 378.65 359.72 413.68 # 27656 315.28 299.52 344.45 27540 744.62 707.39 813.50 27658 345.52 328.24 377.48 27550 427.81 406.42 467.38 27659 453.33 430.66 495.26 # 27550 398.24 378.33 435.08 27664 329.45 312.98 359.93 27552 551.44 523.87 602.45 27665 377.23 358.37 412.13 27556 826.28 784.97 902.72 27675 461.96 438.86 504.69 27557 988.75 939.31 1,080.21 27676 560.72 532.68 612.58 27558 1,110.83 1,055.29 1,213.58 27680 391.32 371.75 427.51 27560 314.50 298.78 343.60 27681 465.90 442.61 509.00 # 27560 284.93 270.68 311.28 27685 561.38 533.31 613.31 27562 407.33 386.96 445.00 # 27685 431.99 410.39 471.95 27566 803.89 763.70 878.26 27686 508.64 483.21 555.69 27570 130.91 124.36 143.01 27687 418.72 397.78 457.45 27580 1,303.60 1,238.42 1,424.18 27690 576.70 547.87 630.05 27590 746.18 708.87 815.20 27691 676.39 642.57 738.96 27591 826.88 785.54 903.37 27692 102.33 97.21 111.79 27592 633.68 602.00 692.30 27695 445.97 423.67 487.22 27594 458.95 436.00 501.40 27696 531.90 505.31 581.11 27596 663.64 630.46 725.03 27698 597.19 567.33 652.43 27598 674.37 640.65 736.75 27700 564.92 536.67 617.17 27600 381.07 362.02 416.32 27702 901.44 856.37 984.83 27601 395.90 376.11 432.53 27703 1,042.88 990.74 1,139.35 27602 466.54 443.21 509.69 27704 511.35 485.78 558.65 27603 461.38 438.31 504.06 27705 691.93 657.33 755.93 # 27603 345.67 328.39 377.65 27707 353.08 335.43 385.74 27604 404.48 384.26 441.90 27709 1,014.88 964.14 1,108.76 # 27604 304.29 289.08 332.44 27712 986.99 937.64 1,078.29 27605 324.08 307.88 354.06 27715 963.22 915.06 1,052.32 # 27605 182.12 173.01 198.96 27720 792.08 752.48 865.35 27606 267.28 253.92 292.01 27722 789.96 750.46 863.03 27607 551.24 523.68 602.23 27724 1,161.68 1,103.60 1,269.14 27610 588.62 559.19 643.07 27725 1,082.70 1,028.57 1,182.86 27612 514.12 488.41 561.67 27726 828.46 787.04 905.10 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 20 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 27727 876.63 832.80 957.72 27870 948.85 901.41 1,036.62 27730 525.14 498.88 573.71 27871 623.41 592.24 681.08 27732 359.28 341.32 392.52 27880 838.92 796.97 916.52 27734 536.98 510.13 586.65 27881 808.51 768.08 883.29 27740 595.42 565.65 650.50 27882 570.17 541.66 622.91 27742 625.80 594.51 683.69 27884 530.30 503.79 579.36 27745 679.55 645.57 742.41 27886 604.84 574.60 660.79 27750 291.11 276.55 318.03 27888 639.75 607.76 698.92 # 27750 266.71 253.37 291.38 27889 624.00 592.80 681.72 27752 467.83 444.44 511.11 27892 491.21 466.65 536.65 # 27752 436.03 414.23 476.36 27893 497.53 472.65 543.55 27756 506.57 481.24 553.43 27894 763.73 725.54 834.37 27758 798.39 758.47 872.24 28001 240.34 228.32 262.57 27759 904.18 858.97 987.82 # 28001 167.15 158.79 182.61 27760 280.78 266.74 306.75 28002 447.38 425.01 488.76 # 27760 254.53 241.80 278.07 # 28002 353.11 335.45 385.77 27762 419.15 398.19 457.92 28003 613.65 582.97 670.42 # 27762 386.98 367.63 422.77 # 28003 518.27 492.36 566.21 27766 544.27 517.06 594.62 28005 565.61 537.33 617.93 27767 223.40 212.23 244.06 28008 379.07 360.12 414.14 # 27767 224.51 213.28 245.27 # 28008 282.95 268.80 309.12 27768 357.38 339.51 390.44 28010 210.07 199.57 229.51 27769 620.77 589.73 678.19 # 28010 196.39 186.57 214.56 27780 251.40 238.83 274.65 28011 296.89 282.05 324.36 # 27780 227.37 216.00 248.40 # 28011 276.19 262.38 301.74 27781 363.08 344.93 396.67 28020 449.98 427.48 491.60 # 27781 338.31 321.39 369.60 # 28020 332.06 315.46 362.78 27784 619.53 588.55 676.83 28022 415.61 394.83 454.05 27786 266.17 252.86 290.79 # 28022 307.67 292.29 336.13 # 27786 239.18 227.22 261.30 28024 395.20 375.44 431.76 27788 366.17 347.86 400.04 # 28024 291.69 277.11 318.68 # 27788 337.33 320.46 368.53 28035 452.88 430.24 494.78 27792 625.90 594.61 683.80 # 28035 335.33 318.56 366.34 27808 278.73 264.79 304.51 28043 301.79 286.70 329.71 # 27808 249.90 237.41 273.02 # 28043 241.16 229.10 263.47 27810 410.23 389.72 448.18 28045 423.51 402.33 462.68 # 27810 377.33 358.46 412.23 # 28045 305.95 290.65 334.25 27814 696.40 661.58 760.82 28046 767.66 729.28 838.67 27816 263.74 250.55 288.13 # 28046 624.23 593.02 681.97 # 27816 237.12 225.26 259.05 28050 398.26 378.35 435.10 27818 422.83 401.69 461.94 # 28050 289.21 274.75 315.96 # 27818 385.50 366.23 421.16 28052 367.37 349.00 401.35 27822 763.86 725.67 834.52 # 28052 263.12 249.96 287.45 27823 869.43 825.96 949.85 28054 345.49 328.22 377.45 27824 264.62 251.39 289.10 # 28054 240.13 228.12 262.34 # 27824 254.64 241.91 278.20 28055 367.24 348.88 401.21 27825 480.91 456.86 525.39 28060 446.10 423.80 487.37 # 27825 441.72 419.63 482.57 # 28060 336.67 319.84 367.82 27826 734.90 698.16 802.88 28062 524.50 498.28 573.02 27827 976.93 928.08 1,067.29 # 28062 394.37 374.65 430.85 27828 1,168.19 1,109.78 1,276.25 28070 442.32 420.20 483.23 27829 588.73 559.29 643.18 # 28070 329.19 312.73 359.64 27830 307.40 292.03 335.83 28072 436.72 414.88 477.11 # 27830 287.81 273.42 314.43 # 28072 319.16 303.20 348.68 27831 334.48 317.76 365.42 28080 429.65 408.17 469.40 27832 632.91 601.26 691.45 # 28080 323.92 307.72 353.88 27840 309.33 293.86 337.94 28086 468.65 445.22 512.00 27842 430.88 409.34 470.74 # 28086 332.97 316.32 363.77 27846 664.80 631.56 726.29 28088 398.06 378.16 434.88 27848 752.45 714.83 822.05 # 28088 277.55 263.67 303.22 27860 160.80 152.76 175.67 28090 401.64 381.56 438.79 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 21 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 28090 290.36 275.84 317.22 # 28202 417.63 396.75 456.26 28092 363.22 345.06 396.82 28208 395.95 376.15 432.57 # 28092 255.27 242.51 278.89 # 28208 288.00 273.60 314.64 28100 517.71 491.82 565.59 28210 508.40 482.98 555.43 # 28100 376.86 358.02 411.72 # 28210 390.48 370.96 426.60 28102 514.12 488.41 561.67 28220 390.82 371.28 426.97 28103 415.04 394.29 453.43 # 28220 290.64 276.11 317.53 28104 443.99 421.79 485.06 28222 451.12 428.56 492.84 # 28104 329.75 313.26 360.25 # 28222 345.76 328.47 377.74 28106 438.05 416.15 478.57 28225 340.13 323.12 371.59 28107 493.09 468.44 538.71 # 28225 241.05 229.00 263.35 # 28107 360.00 342.00 393.30 28226 408.38 387.96 446.15 28108 374.18 355.47 408.79 # 28226 300.80 285.76 328.62 # 28108 272.52 258.89 297.72 28230 375.58 356.80 410.32 28110 393.29 373.63 429.67 # 28230 276.51 262.68 302.08 # 28110 272.03 258.43 297.19 28232 333.73 317.04 364.60 28111 446.88 424.54 488.22 # 28232 235.40 223.63 257.17 # 28111 317.49 301.62 346.86 28234 346.30 328.99 378.34 28112 423.36 402.19 462.52 # 28234 246.86 234.52 269.70 # 28112 297.30 282.44 324.81 28238 597.31 567.44 652.56 28113 506.43 481.11 553.28 # 28238 468.66 445.23 512.01 # 28113 389.61 370.13 425.65 28240 386.36 367.04 422.10 28114 917.86 871.97 1,002.77 # 28240 283.59 269.41 309.82 # 28114 751.88 714.29 821.43 28250 490.49 465.97 535.87 28116 655.31 622.54 715.92 # 28250 375.89 357.10 410.67 # 28116 532.58 505.95 581.84 28260 597.78 567.89 653.07 28118 508.55 483.12 555.59 # 28260 484.29 460.08 529.09 # 28118 385.44 366.17 421.10 28261 866.12 822.81 946.23 28119 453.34 430.67 495.27 # 28261 737.84 700.95 806.09 # 28119 340.96 323.91 372.50 28262 1,209.35 1,148.88 1,321.21 28120 503.58 478.40 550.16 # 28262 1,032.64 981.01 1,128.16 # 28120 367.17 348.81 401.13 28264 774.94 736.19 846.62 28122 583.95 554.75 637.96 # 28264 649.99 617.49 710.11 # 28122 470.83 447.29 514.38 28270 417.74 396.85 456.38 28124 415.49 394.72 453.93 # 28270 314.23 298.52 343.30 # 28124 314.93 299.18 344.06 28272 341.85 324.76 373.47 28126 336.38 319.56 367.49 # 28272 244.99 232.74 267.65 # 28126 236.94 225.09 258.85 28280 458.13 435.22 500.50 28130 585.13 555.87 639.25 # 28280 341.31 324.24 372.88 28140 549.72 522.23 600.56 28285 404.79 384.55 442.23 # 28140 428.10 406.70 467.71 # 28285 301.65 286.57 329.56 28150 374.62 355.89 409.27 28286 395.60 375.82 432.19 # 28150 270.36 256.84 295.37 # 28286 289.50 275.03 316.28 28153 349.54 332.06 381.87 28288 507.59 482.21 554.54 # 28153 246.03 233.73 268.79 # 28288 394.09 374.39 430.55 28160 358.69 340.76 391.87 28289 639.62 607.64 698.79 # 28160 256.66 243.83 280.40 # 28289 510.60 485.07 557.83 28171 571.83 543.24 624.73 28290 499.22 474.26 545.40 28173 654.22 621.51 714.74 # 28290 373.16 354.50 407.68 # 28173 522.25 496.14 570.56 28292 680.74 646.70 743.71 28175 480.95 456.90 525.44 # 28292 550.98 523.43 601.94 # 28175 368.94 350.49 403.06 28293 909.48 864.01 993.61 28190 215.06 204.31 234.96 # 28293 665.86 632.57 727.46 # 28190 125.59 119.31 137.21 28294 656.29 623.48 717.00 28192 411.03 390.48 449.05 # 28294 506.20 480.89 553.02 # 28192 300.49 285.47 328.29 28296 643.33 611.16 702.83 28193 470.95 447.40 514.51 # 28296 503.22 478.06 549.77 # 28193 357.08 339.23 390.11 28297 726.67 690.34 793.89 28200 411.06 390.51 449.09 # 28297 565.12 536.86 617.39 # 28200 299.79 284.80 327.52 28298 628.04 596.64 686.14 28202 545.17 517.91 595.60 # 28298 481.65 457.57 526.21 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 22 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 28299 805.53 765.25 880.04 # 28490 103.51 98.33 113.08 # 28299 651.37 618.80 711.62 28495 149.22 141.76 163.02 28300 609.78 579.29 666.18 # 28495 132.22 125.61 144.45 28302 604.69 574.46 660.63 28496 364.67 346.44 398.41 28304 696.59 661.76 761.02 # 28496 202.38 192.26 221.10 # 28304 555.37 527.60 606.74 28505 578.60 549.67 632.12 28305 639.93 607.93 699.12 # 28505 442.56 420.43 483.49 28306 523.81 497.62 572.26 28510 102.40 97.28 111.87 # 28306 376.67 357.84 411.52 # 28510 100.55 95.52 109.85 28307 618.71 587.77 675.94 28515 134.93 128.18 147.41 # 28307 425.36 404.09 464.70 # 28515 124.21 118.00 135.70 28308 474.87 451.13 518.80 28525 487.69 463.31 532.81 # 28308 345.85 328.56 377.84 # 28525 352.01 334.41 384.57 28309 821.93 780.83 897.95 28530 98.74 93.80 107.87 28310 467.37 444.00 510.60 # 28530 91.34 86.77 99.79 # 28310 336.87 320.03 368.03 28531 321.70 305.62 351.46 28312 428.47 407.05 468.11 # 28531 174.19 165.48 190.30 # 28312 300.56 285.53 328.36 28540 174.99 166.24 191.18 28313 449.42 426.95 490.99 # 28540 163.53 155.35 178.65 # 28313 344.43 327.21 376.29 28545 215.02 204.27 234.91 28315 412.66 392.03 450.83 # 28545 198.02 188.12 216.34 # 28315 306.93 291.58 335.32 28546 408.11 387.70 445.86 28320 576.73 547.89 630.07 # 28546 267.27 253.91 292.00 28322 677.42 643.55 740.08 28555 754.81 717.07 824.63 # 28322 532.88 506.24 582.18 # 28555 593.26 563.60 648.14 28340 540.53 513.50 590.53 28570 151.16 143.60 165.14 # 28340 415.95 395.15 454.42 # 28570 136.00 129.20 148.58 28341 621.99 590.89 679.52 28575 288.59 274.16 315.28 # 28341 491.86 467.27 537.36 # 28575 269.73 256.24 294.68 28344 416.99 396.14 455.56 28576 315.78 299.99 344.99 # 28344 293.15 278.49 320.26 28585 803.46 763.29 877.78 28345 501.22 476.16 547.58 # 28585 666.30 632.99 727.94 # 28345 381.81 362.72 417.13 28600 182.71 173.57 199.61 28360 886.55 842.22 968.55 # 28600 164.22 156.01 179.41 28400 211.60 201.02 231.17 28605 235.64 223.86 257.44 # 28400 194.23 184.52 212.20 # 28605 220.12 209.11 240.48 28405 343.71 326.52 375.50 28606 349.07 331.62 381.36 # 28405 321.90 305.81 351.68 28615 701.25 666.19 766.12 28406 471.19 447.63 514.77 28630 129.91 123.41 141.92 28415 1,032.98 981.33 1,128.53 # 28630 99.96 94.96 109.20 28420 1,087.13 1,032.77 1,187.69 28635 155.18 147.42 169.53 28430 198.02 188.12 216.34 # 28635 125.24 118.98 136.83 # 28430 176.21 167.40 192.51 28636 256.15 243.34 279.84 28435 278.74 264.80 304.52 # 28636 185.54 176.26 202.70 # 28435 258.03 245.13 281.90 28645 546.98 519.63 597.57 28436 378.64 359.71 413.67 # 28645 431.64 410.06 471.57 28445 973.17 924.51 1,063.19 28660 94.71 89.97 103.47 28446 1,068.35 1,014.93 1,167.17 # 28660 76.59 72.76 83.67 28450 183.25 174.09 200.20 28665 137.80 130.91 150.55 # 28450 164.02 155.82 179.19 # 28665 124.49 118.27 136.01 28455 253.76 241.07 277.23 28666 177.50 168.63 193.92 # 28455 236.76 224.92 258.66 28675 499.55 474.57 545.76 28456 243.77 231.58 266.32 # 28675 361.28 343.22 394.70 28465 556.27 528.46 607.73 28705 1,199.71 1,139.72 1,310.68 28470 182.83 173.69 199.74 28715 889.47 845.00 971.75 # 28470 164.71 156.47 179.94 28725 731.44 694.87 799.10 28475 231.38 219.81 252.78 28730 767.20 728.84 838.17 # 28475 213.63 202.95 233.39 28735 733.00 696.35 800.80 28476 301.84 286.75 329.76 28737 649.96 617.46 710.08 28485 480.99 456.94 525.48 28740 746.53 709.20 815.58 28490 118.29 112.38 129.24 # 28740 575.74 546.95 628.99 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 23 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 28750 727.84 691.45 795.17 29240 52.55 49.92 57.41 # 28750 548.54 521.11 599.28 # 29240 40.72 38.68 44.48 28755 438.63 416.70 479.21 29260 45.49 43.22 49.70 # 28755 311.83 296.24 340.68 # 29260 33.66 31.98 36.78 28760 687.46 653.09 751.05 29280 44.06 41.86 48.14 # 28760 540.33 513.31 590.31 # 29280 31.87 30.28 34.82 28800 525.36 499.09 573.95 29305 203.27 193.11 222.08 28805 692.43 657.81 756.48 # 29305 141.16 134.10 154.22 28810 404.94 384.69 442.39 29325 226.08 214.78 247.00 28820 464.82 441.58 507.82 # 29325 159.53 151.55 174.28 # 28820 320.28 304.27 349.91 29345 117.23 111.37 128.08 28825 504.15 478.94 550.78 # 29345 91.35 86.78 99.80 # 28825 365.89 347.60 399.74 29355 121.16 115.10 132.37 28890 305.54 290.26 333.80 # 29355 97.13 92.27 106.11 # 28890 208.31 197.89 227.57 29358 132.17 125.56 144.39 29000 235.56 223.78 257.35 # 29358 92.98 88.33 101.58 # 29000 153.49 145.82 167.69 29365 105.26 100.00 115.00 29010 214.26 203.55 234.08 # 29365 79.38 75.41 86.72 # 29010 141.06 134.01 154.11 29405 77.49 73.62 84.66 29015 208.71 198.27 228.01 # 29405 58.27 55.36 63.66 # 29015 145.49 138.22 158.95 29425 83.82 79.63 91.57 29020 199.74 189.75 218.21 # 29425 64.23 61.02 70.17 # 29020 130.61 124.08 142.69 29435 102.67 97.54 112.17 29025 225.97 214.67 246.87 # 29435 77.53 73.65 84.70 # 29025 158.69 150.76 173.37 29440 46.01 43.71 50.27 29035 210.39 199.87 229.85 # 29440 31.59 30.01 34.51 # 29035 126.11 119.80 137.77 29445 128.51 122.08 140.39 29040 202.17 192.06 220.87 # 29445 102.63 97.50 112.13 # 29040 140.43 133.41 153.42 29450 135.63 128.85 148.18 29044 227.59 216.21 248.64 # 29450 114.19 108.48 124.75 # 29044 146.63 139.30 160.20 29505 66.23 62.92 72.36 29046 248.16 235.75 271.11 # 29505 42.94 40.79 46.91 # 29046 167.94 159.54 183.47 29515 61.94 58.84 67.67 29049 75.07 71.32 82.02 # 29515 44.93 42.68 49.08 # 29049 54.74 52.00 59.80 29520 44.41 42.19 48.52 29055 180.06 171.06 196.72 # 29520 33.69 32.01 36.81 # 29055 120.91 114.86 132.09 29530 46.21 43.90 50.49 29058 96.84 92.00 105.80 # 29530 34.38 32.66 37.56 # 29058 74.66 70.93 81.57 29540 37.94 36.04 41.45 29065 81.73 77.64 89.29 # 29540 30.55 29.02 33.37 # 29065 60.66 57.63 66.27 29550 36.87 35.03 40.28 29075 75.92 72.12 82.94 # 29550 28.74 27.30 31.40 # 29075 54.85 52.11 59.93 29580 46.59 44.26 50.90 29085 80.81 76.77 88.29 # 29580 33.65 31.97 36.77 # 29085 59.00 56.05 64.46 29590 49.71 47.22 54.30 29086 62.05 58.95 67.79 # 29590 38.99 37.04 42.60 # 29086 43.57 41.39 47.60 29700 56.36 53.54 61.57 29105 74.91 71.16 81.83 # 29700 31.96 30.36 34.91 # 29105 53.10 50.45 58.02 29705 58.92 55.97 64.37 29125 58.38 55.46 63.78 # 29705 43.77 41.58 47.82 # 29125 38.05 36.15 41.57 29710 103.26 98.10 112.82 29126 67.09 63.74 73.30 # 29710 75.17 71.41 82.12 # 29126 46.76 44.42 51.08 29715 79.12 75.16 86.43 29130 35.36 33.59 38.63 # 29715 51.77 49.18 56.56 # 29130 26.12 24.81 28.53 29720 69.54 66.06 75.97 29131 44.03 41.83 48.10 # 29720 40.33 38.31 44.06 # 29131 29.61 28.13 32.35 29730 57.28 54.42 62.58 29200 47.07 44.72 51.43 # 29730 42.12 40.01 46.01 # 29200 36.72 34.88 40.11 29740 82.04 77.94 89.63 29220 48.56 46.13 53.05 # 29740 61.33 58.26 67.00 # 29220 38.21 36.30 41.75 29750 89.47 85.00 97.75 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 24 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 29750 70.24 66.73 76.74 # 29893 393.49 373.82 429.89 29800 463.25 440.09 506.10 29894 467.09 443.74 510.30 29804 573.75 545.06 626.82 29895 451.79 429.20 493.58 29805 418.66 397.73 457.39 29897 473.39 449.72 517.18 29806 956.57 908.74 1,045.05 29898 529.02 502.57 577.96 29807 931.91 885.31 1,018.11 29899 950.67 903.14 1,038.61 29819 524.44 498.22 572.95 29900 407.43 387.06 445.12 29820 483.99 459.79 528.76 29901 446.26 423.95 487.54 29821 528.60 502.17 577.50 29902 477.13 453.27 521.26 29822 513.55 487.87 561.05 29904 553.51 525.83 604.70 29823 561.76 533.67 613.72 29905 596.08 566.28 651.22 29824 599.13 569.17 654.55 29906 627.95 596.55 686.03 29825 523.70 497.52 572.15 29907 767.81 729.42 838.83 29826 600.49 570.47 656.04 30000 203.78 193.59 222.63 29827 979.84 930.85 1,070.48 # 30000 105.44 100.17 115.20 29828 820.12 779.11 895.98 30020 197.12 187.26 215.35 29830 403.83 383.64 441.19 # 30020 106.18 100.87 116.00 29834 440.07 418.07 480.78 30100 123.87 117.68 135.33 29835 451.50 428.93 493.27 # 30100 63.98 60.78 69.90 29836 519.40 493.43 567.44 30110 199.15 189.19 217.57 29837 473.28 449.62 517.06 # 30110 117.45 111.58 128.32 29838 529.18 502.72 578.13 30115 384.47 365.25 420.04 29840 396.92 377.07 433.63 30117 735.92 699.12 803.99 29843 426.38 405.06 465.82 # 30117 298.58 283.65 326.20 29844 442.24 420.13 483.15 30118 692.24 657.63 756.27 29845 506.11 480.80 552.92 30120 462.11 439.00 504.85 29846 465.35 442.08 508.39 # 30120 402.96 382.81 440.23 29847 483.34 459.17 528.05 30124 243.01 230.86 265.49 29848 441.42 419.35 482.25 30125 552.55 524.92 603.66 29850 510.92 485.37 558.18 30130 336.25 319.44 367.36 29851 840.62 798.59 918.38 30140 384.59 365.36 420.16 29855 704.96 669.71 770.17 30150 708.54 673.11 774.08 29856 901.57 856.49 984.96 30160 712.06 676.46 777.93 29860 581.40 552.33 635.18 30200 99.07 94.12 108.24 29861 644.38 612.16 703.98 # 30200 54.70 51.97 59.77 29862 720.88 684.84 787.57 30210 129.99 123.49 142.01 29863 714.38 678.66 780.46 # 30210 88.96 84.51 97.19 29866 938.21 891.30 1,025.00 30220 256.91 244.06 280.67 29867 1,137.36 1,080.49 1,242.56 # 30220 112.74 107.10 123.17 29868 1,516.65 1,440.82 1,656.94 30300 199.72 189.73 218.19 29870 363.52 345.34 397.14 # 30300 108.78 103.34 118.84 29871 456.42 433.60 498.64 30310 183.31 174.14 200.26 29873 456.95 434.10 499.22 30320 403.91 383.71 441.27 29874 479.10 455.15 523.42 30400 929.42 882.95 1,015.39 29875 441.70 419.62 482.56 30410 1,099.32 1,044.35 1,201.00 29876 580.58 551.55 634.28 30420 1,235.31 1,173.54 1,349.57 29877 549.56 522.08 600.39 30430 814.98 774.23 890.36 29879 587.85 558.46 642.23 30435 1,072.52 1,018.89 1,171.72 29880 613.63 582.95 670.39 30450 1,419.32 1,348.35 1,550.60 29881 572.06 543.46 624.98 30460 685.56 651.28 748.97 29882 619.20 588.24 676.48 30462 1,376.27 1,307.46 1,503.58 29883 755.38 717.61 825.25 30465 880.63 836.60 962.09 29884 547.92 520.52 598.60 30520 540.61 513.58 590.62 29885 664.46 631.24 725.93 30540 602.25 572.14 657.96 29886 560.46 532.44 612.31 30545 865.81 822.52 945.90 29887 660.63 627.60 721.74 30560 236.48 224.66 258.36 29888 894.14 849.43 976.84 # 30560 123.72 117.53 135.16 29889 1,093.55 1,038.87 1,194.70 30580 560.52 532.49 612.36 29891 623.52 592.34 681.19 # 30580 448.14 425.73 489.59 29892 637.01 605.16 695.93 30600 516.74 490.90 564.54 29893 525.47 499.20 574.08 # 30600 398.07 378.17 434.90 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 25 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 30620 551.80 524.21 602.84 31290 1,066.19 1,012.88 1,164.81 30630 559.24 531.28 610.97 31291 1,122.24 1,066.13 1,226.05 30801 198.75 188.81 217.13 31292 922.94 876.79 1,008.31 # 30801 118.52 112.59 129.48 31293 1,005.57 955.29 1,098.58 30802 256.07 243.27 279.76 31294 1,153.84 1,096.15 1,260.57 # 30802 168.46 160.04 184.05 31300 1,137.83 1,080.94 1,243.08 30901 93.28 88.62 101.91 31320 582.76 553.62 636.66 # 30901 57.42 54.55 62.73 31360 1,815.56 1,724.78 1,983.50 30903 172.08 163.48 188.00 31365 2,269.19 2,155.73 2,479.09 # 30903 74.85 71.11 81.78 31367 1,961.98 1,863.88 2,143.46 30905 214.18 203.47 233.99 31368 2,190.56 2,081.03 2,393.18 # 30905 96.25 91.44 105.16 31370 1,846.41 1,754.09 2,017.20 30906 246.07 233.77 268.84 31375 1,746.56 1,659.23 1,908.11 # 30906 125.92 119.62 137.56 31380 1,720.70 1,634.67 1,879.87 30915 518.62 492.69 566.59 31382 1,885.30 1,791.04 2,059.70 30920 746.57 709.24 815.63 31390 2,528.88 2,402.44 2,762.81 30930 108.92 103.47 118.99 31395 2,683.72 2,549.53 2,931.96 31000 158.03 150.13 172.65 31400 906.40 861.08 990.24 # 31000 94.07 89.37 102.78 31420 757.56 719.68 827.63 31002 180.22 171.21 196.89 31500 104.06 98.86 113.69 31020 427.95 406.55 467.53 31502 33.20 31.54 36.27 # 31020 314.09 298.39 343.15 31505 75.38 71.61 82.35 31030 620.80 589.76 678.22 # 31505 45.07 42.82 49.24 # 31030 468.12 444.71 511.42 31510 191.86 182.27 209.61 31032 511.71 486.12 559.04 # 31510 112.75 107.11 123.18 31040 672.53 638.90 734.74 31511 191.81 182.22 209.55 31050 442.35 420.23 483.26 # 31511 120.83 114.79 132.01 31051 577.92 549.02 631.37 31512 189.50 180.03 207.03 31070 389.17 369.71 425.17 # 31512 121.47 115.40 132.71 31075 705.01 669.76 770.22 31513 123.86 117.67 135.32 31080 908.48 863.06 992.52 31515 189.77 180.28 207.32 31081 1,104.77 1,049.53 1,206.96 # 31515 102.89 97.75 112.41 31084 1,062.52 1,009.39 1,160.80 31520 143.94 136.74 157.25 31085 1,120.65 1,064.62 1,224.31 31525 227.60 216.22 248.65 31086 1,005.84 955.55 1,098.88 # 31525 149.60 142.12 163.44 31087 993.72 944.03 1,085.63 31526 148.54 141.11 162.28 31090 897.44 852.57 980.46 31527 181.33 172.26 198.10 31200 480.09 456.09 524.50 31528 135.43 128.66 147.96 31201 656.43 623.61 717.15 31529 152.69 145.06 166.82 31205 771.39 732.82 842.74 31530 186.57 177.24 203.83 31225 1,657.23 1,574.37 1,810.53 31531 201.18 191.12 219.79 31230 1,856.88 1,764.04 2,028.65 31535 178.84 169.90 195.39 31231 170.66 162.13 186.45 31536 199.73 189.74 218.20 # 31231 71.21 67.65 77.80 31540 229.50 218.03 250.73 31233 239.29 227.33 261.43 31541 250.92 238.37 274.13 # 31233 128.01 121.61 139.85 31545 340.25 323.24 371.73 31235 274.69 260.96 300.10 31546 516.71 490.87 564.50 # 31235 152.69 145.06 166.82 31560 296.98 282.13 324.45 31237 295.81 281.02 323.17 31561 325.29 309.03 355.38 # 31237 170.12 161.61 185.85 31570 316.62 300.79 345.91 31238 304.62 289.39 332.80 # 31570 214.96 204.21 234.84 # 31238 184.84 175.60 201.94 31571 236.75 224.91 258.65 31239 602.67 572.54 658.42 31575 105.60 100.32 115.37 31240 151.26 143.70 165.26 # 31575 71.21 67.65 77.80 31254 258.51 245.58 282.42 31576 205.51 195.23 224.51 31255 381.18 362.12 416.44 # 31576 115.68 109.90 126.39 31256 187.36 177.99 204.69 31577 221.09 210.04 241.55 31267 301.33 286.26 329.20 # 31577 140.13 133.12 153.09 31276 480.44 456.42 524.88 31578 256.97 244.12 280.74 31287 220.03 209.03 240.38 # 31578 159.38 151.41 174.12 31288 255.06 242.31 278.66 31579 199.31 189.34 217.74 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 26 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 31579 131.65 125.07 143.83 31750 1,215.65 1,154.87 1,328.10 31580 1,087.51 1,033.13 1,188.10 31755 1,543.42 1,466.25 1,686.19 31582 1,728.16 1,641.75 1,888.01 31760 1,292.64 1,228.01 1,412.21 31584 1,378.52 1,309.59 1,506.03 31766 1,681.47 1,597.40 1,837.01 31587 899.69 854.71 982.92 31770 1,249.18 1,186.72 1,364.73 31588 1,024.10 972.90 1,118.84 31775 1,290.63 1,226.10 1,410.02 31590 805.06 764.81 879.53 31780 1,098.75 1,043.81 1,200.38 31595 694.00 659.30 758.20 31781 1,329.23 1,262.77 1,452.19 31600 369.65 351.17 403.85 31785 1,005.06 954.81 1,098.03 31601 245.61 233.33 268.33 31786 1,390.97 1,321.42 1,519.63 31603 208.51 198.08 227.79 31800 634.81 603.07 693.53 31605 171.35 162.78 187.20 31805 767.20 728.84 838.17 31610 642.61 610.48 702.05 31820 387.08 367.73 422.89 31611 483.78 459.59 528.53 # 31820 297.99 283.09 325.55 31612 73.80 70.11 80.63 31825 541.00 513.95 591.04 # 31612 44.96 42.71 49.12 # 31825 439.34 417.37 479.98 31613 400.32 380.30 437.35 31830 389.66 370.18 425.71 31614 664.02 630.82 725.44 # 31830 308.70 293.27 337.26 31615 168.05 159.65 183.60 32035 655.51 622.73 716.14 # 31615 119.25 113.29 130.28 32036 710.48 674.96 776.20 31620 266.49 253.17 291.15 32095 582.63 553.50 636.53 # 31620 67.23 63.87 73.45 32100 897.33 852.46 980.33 31622 297.54 282.66 325.06 32110 1,352.01 1,284.41 1,477.07 # 31622 138.95 132.00 151.80 32120 807.18 766.82 881.84 31623 326.51 310.18 356.71 32124 856.85 814.01 936.11 # 31623 140.93 133.88 153.96 32140 916.89 871.05 1,001.71 31624 303.22 288.06 331.27 32141 1,388.67 1,319.24 1,517.13 # 31624 141.30 134.24 154.38 32150 923.74 877.55 1,009.18 31625 326.22 309.91 356.40 32151 945.24 897.98 1,032.68 # 31625 164.30 156.09 179.50 32160 710.58 675.05 776.31 31628 392.37 372.75 428.66 32200 1,037.94 986.04 1,133.95 # 31628 183.50 174.33 200.48 32201 889.01 844.56 971.24 31629 603.58 573.40 659.41 # 32201 203.62 193.44 222.46 # 31629 196.56 186.73 214.74 32215 744.02 706.82 812.84 31630 195.59 185.81 213.68 32220 1,485.00 1,410.75 1,622.36 31631 220.58 209.55 240.98 32225 924.50 878.28 1,010.02 31632 71.03 67.48 77.60 32310 852.50 809.88 931.36 # 31632 49.95 47.45 54.57 32320 1,487.61 1,413.23 1,625.21 31633 85.94 81.64 93.89 32400 145.47 138.20 158.93 # 31633 63.02 59.87 68.85 # 32400 87.43 83.06 95.52 31635 334.40 317.68 365.33 32402 525.20 498.94 573.78 # 31635 182.09 172.99 198.94 32405 98.92 93.97 108.07 31636 215.67 204.89 235.62 # 32405 98.55 93.62 107.66 31637 76.30 72.49 83.36 32420 108.85 103.41 118.92 31638 242.75 230.61 265.20 32421 151.97 144.37 166.03 31640 249.93 237.43 273.04 # 32421 75.45 71.68 82.43 31641 247.52 235.14 270.41 32422 191.28 181.72 208.98 31643 170.09 161.59 185.83 # 32422 121.41 115.34 132.64 31645 292.04 277.44 319.06 32440 1,486.07 1,411.77 1,623.54 # 31645 154.52 146.79 168.81 32442 2,773.84 2,635.15 3,030.42 31646 265.46 252.19 290.02 32445 3,157.25 2,999.39 3,449.30 # 31646 133.86 127.17 146.25 32480 1,402.31 1,332.19 1,532.02 31656 304.58 289.35 332.75 32482 1,496.34 1,421.52 1,634.75 # 31656 108.28 102.87 118.30 32484 1,354.23 1,286.52 1,479.50 31715 53.48 50.81 58.43 32486 2,166.18 2,057.87 2,366.55 31717 285.97 271.67 312.42 32488 2,193.85 2,084.16 2,396.78 # 31717 106.30 100.99 116.14 32491 1,396.41 1,326.59 1,525.58 31720 50.19 47.68 54.83 32500 1,357.02 1,289.17 1,482.55 31725 90.18 85.67 98.52 32501 235.78 223.99 257.59 31730 818.52 777.59 894.23 32503 1,710.57 1,625.04 1,868.80 # 31730 138.31 131.39 151.10 32504 1,964.31 1,866.09 2,146.00 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 27 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 32540 1,565.66 1,487.38 1,710.49 33206 456.61 433.78 498.85 32550 754.52 716.79 824.31 33207 488.28 463.87 533.45 # 32550 218.48 207.56 238.69 33208 526.65 500.32 575.37 32551 168.06 159.66 183.61 33210 180.62 171.59 197.33 32560 281.22 267.16 307.23 33211 181.07 172.02 197.82 # 32560 107.10 101.75 117.01 33212 340.92 323.87 372.45 32601 293.94 279.24 321.13 33213 389.31 369.84 425.32 32602 318.76 302.82 348.24 33214 482.76 458.62 527.41 32603 412.82 392.18 451.01 33215 308.62 293.19 337.17 32604 463.81 440.62 506.71 33216 381.18 362.12 416.44 32605 366.03 347.73 399.89 33217 377.68 358.80 412.62 32606 442.92 420.77 483.89 33218 394.16 374.45 430.62 32650 631.26 599.70 689.66 33220 397.78 377.89 434.57 32651 998.57 948.64 1,090.94 33222 346.74 329.40 378.81 32652 1,516.18 1,440.37 1,656.43 33223 419.51 398.53 458.31 32653 967.31 918.94 1,056.78 33224 510.48 484.96 557.70 32654 1,071.48 1,017.91 1,170.60 33225 460.36 437.34 502.94 32655 882.42 838.30 964.05 33226 492.84 468.20 538.43 32656 755.28 717.52 825.15 33233 243.41 231.24 265.93 32657 744.41 707.19 813.27 33234 490.47 465.95 535.84 32658 681.39 647.32 744.42 33235 634.31 602.59 692.98 32659 693.09 658.44 757.21 33236 741.32 704.25 809.89 32660 978.24 929.33 1,068.73 33237 821.35 780.28 897.32 32661 760.54 722.51 830.89 33238 883.24 839.08 964.94 32662 851.11 808.55 929.83 33240 469.54 446.06 512.97 32663 1,312.42 1,246.80 1,433.82 33241 230.20 218.69 251.49 32664 806.71 766.37 881.33 33243 1,304.12 1,238.91 1,424.75 32665 1,137.28 1,080.42 1,242.48 33244 861.64 818.56 941.34 32800 870.42 826.90 950.94 33249 913.24 867.58 997.72 32810 842.49 800.37 920.43 33250 1,388.99 1,319.54 1,517.47 32815 2,501.64 2,376.56 2,733.04 33251 1,538.46 1,461.54 1,680.77 32820 1,257.28 1,194.42 1,373.58 33254 1,293.63 1,228.95 1,413.29 32851 2,430.29 2,308.78 2,655.10 33255 1,583.58 1,504.40 1,730.06 32852 2,692.42 2,557.80 2,941.47 33256 1,886.41 1,792.09 2,060.90 32853 2,899.47 2,754.50 3,167.68 33257 549.80 522.31 600.66 32854 3,161.95 3,003.85 3,454.43 33258 620.14 589.13 677.50 32855 257.29 244.43 281.09 33259 807.00 766.65 881.65 32856 310.42 294.90 339.14 33261 1,531.53 1,454.95 1,673.19 32900 1,278.86 1,214.92 1,397.16 33265 1,290.67 1,226.14 1,410.06 32905 1,259.94 1,196.94 1,376.48 33266 1,768.98 1,680.53 1,932.61 32906 1,563.71 1,485.52 1,708.35 33282 327.01 310.66 357.26 32940 1,154.51 1,096.78 1,261.30 33284 236.34 224.52 258.20 32960 132.05 125.45 144.27 33300 2,205.60 2,095.32 2,409.62 # 32960 95.82 91.03 104.68 33305 3,686.77 3,502.43 4,027.79 32997 342.17 325.06 373.82 33310 1,107.94 1,052.54 1,210.42 32998 2,732.85 2,596.21 2,985.64 33315 1,408.46 1,338.04 1,538.75 # 32998 298.12 283.21 325.69 33320 1,006.21 955.90 1,099.29 33010 120.24 114.23 131.36 33321 1,130.92 1,074.37 1,235.53 33011 117.46 111.59 128.33 33322 1,316.44 1,250.62 1,438.21 33015 511.50 485.93 558.82 33330 1,328.26 1,261.85 1,451.13 33020 819.27 778.31 895.06 33332 1,326.34 1,260.02 1,449.02 33025 755.48 717.71 825.37 33335 1,788.90 1,699.46 1,954.38 33030 1,208.86 1,148.42 1,320.68 33400 2,161.67 2,053.59 2,361.63 33031 1,349.35 1,281.88 1,474.16 33401 1,427.28 1,355.92 1,559.31 33050 935.33 888.56 1,021.84 33403 1,433.43 1,361.76 1,566.02 33120 1,474.27 1,400.56 1,610.64 33404 1,695.96 1,611.16 1,852.83 33130 1,300.11 1,235.10 1,420.37 33405 2,199.38 2,089.41 2,402.82 33140 1,486.25 1,411.94 1,623.73 33406 2,719.54 2,583.56 2,971.09 33141 141.93 134.83 155.05 33410 2,400.81 2,280.77 2,622.89 33202 737.89 701.00 806.15 33411 3,137.48 2,980.61 3,427.70 33203 780.68 741.65 852.90 33412 2,370.39 2,251.87 2,589.65 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 28 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 33413 3,086.75 2,932.41 3,372.27 33615 1,920.55 1,824.52 2,098.20 33414 2,062.66 1,959.53 2,253.46 33617 2,051.98 1,949.38 2,241.79 33415 1,911.26 1,815.70 2,088.06 33619 2,515.89 2,390.10 2,748.62 33416 1,918.47 1,822.55 2,095.93 33641 1,533.48 1,456.81 1,675.33 33417 1,599.49 1,519.52 1,747.45 33645 1,508.19 1,432.78 1,647.70 33420 1,305.63 1,240.35 1,426.40 33647 1,610.24 1,529.73 1,759.19 33422 1,606.60 1,526.27 1,755.21 33660 1,677.65 1,593.77 1,832.84 33425 2,513.41 2,387.74 2,745.90 33665 1,820.76 1,729.72 1,989.18 33426 2,274.36 2,160.64 2,484.74 33670 1,889.07 1,794.62 2,063.81 33427 2,367.93 2,249.53 2,586.96 33675 1,884.31 1,790.09 2,058.60 33430 2,634.74 2,503.00 2,878.45 33676 1,960.13 1,862.12 2,141.44 33460 2,237.23 2,125.37 2,444.18 33677 2,036.97 1,935.12 2,225.39 33463 2,829.50 2,688.03 3,091.23 33681 1,745.70 1,658.42 1,907.18 33464 2,274.17 2,160.46 2,484.53 33684 1,787.08 1,697.73 1,952.39 33465 2,546.13 2,418.82 2,781.64 33688 1,784.64 1,695.41 1,949.72 33468 1,792.71 1,703.07 1,958.53 33690 1,105.83 1,050.54 1,208.12 33470 1,142.11 1,085.00 1,247.75 33692 1,681.80 1,597.71 1,837.37 33471 1,259.52 1,196.54 1,376.02 33694 1,893.10 1,798.45 2,068.22 33472 1,271.17 1,207.61 1,388.75 33697 2,052.06 1,949.46 2,241.88 33474 1,960.72 1,862.68 2,142.08 33702 1,461.18 1,388.12 1,596.34 33475 2,202.03 2,091.93 2,405.72 33710 1,774.40 1,685.68 1,938.53 33476 1,399.15 1,329.19 1,528.57 33720 1,480.63 1,406.60 1,617.59 33478 1,497.19 1,422.33 1,635.68 33722 1,487.44 1,413.07 1,625.03 33496 1,601.01 1,520.96 1,749.10 33724 1,501.95 1,426.85 1,640.88 33500 1,502.36 1,427.24 1,641.33 33726 1,961.20 1,863.14 2,142.61 33501 1,047.79 995.40 1,144.71 33730 1,865.64 1,772.36 2,038.21 33502 1,206.31 1,145.99 1,317.89 33732 1,563.90 1,485.71 1,708.57 33503 1,304.27 1,239.06 1,424.92 33735 1,197.18 1,137.32 1,307.92 33504 1,376.91 1,308.06 1,504.27 33736 1,329.15 1,262.69 1,452.09 33505 1,905.19 1,809.93 2,081.42 33737 1,237.52 1,175.64 1,351.99 33506 1,961.35 1,863.28 2,142.77 33750 1,262.42 1,199.30 1,379.20 33507 1,659.29 1,576.33 1,812.78 33755 1,229.47 1,168.00 1,343.20 33508 15.59 14.81 17.03 33762 1,228.08 1,166.68 1,341.68 33510 1,871.57 1,777.99 2,044.69 33764 1,209.88 1,149.39 1,321.80 33511 2,044.11 1,941.90 2,233.19 33766 1,332.52 1,265.89 1,455.77 33512 2,304.29 2,189.08 2,517.44 33767 1,343.81 1,276.62 1,468.11 33513 2,352.24 2,234.63 2,569.82 33768 408.72 388.28 446.52 33514 2,495.71 2,370.92 2,726.56 33770 2,041.89 1,939.80 2,230.77 33516 2,594.12 2,464.41 2,834.07 33771 2,093.02 1,988.37 2,286.63 33517 177.79 168.90 194.24 33774 1,724.92 1,638.67 1,884.47 33518 385.47 366.20 421.13 33775 1,794.60 1,704.87 1,960.60 33519 513.98 488.28 561.52 33776 1,889.49 1,795.02 2,064.27 33521 621.46 590.39 678.95 33777 1,846.83 1,754.49 2,017.66 33522 705.71 670.42 770.98 33778 2,270.83 2,157.29 2,480.88 33523 804.81 764.57 879.26 33779 2,195.14 2,085.38 2,398.19 33530 490.40 465.88 535.76 33780 2,279.72 2,165.73 2,490.59 33533 1,821.36 1,730.29 1,989.83 33781 2,224.12 2,112.91 2,429.85 33534 2,120.72 2,014.68 2,316.88 33786 2,189.73 2,080.24 2,392.28 33535 2,355.09 2,237.34 2,572.94 33788 1,479.08 1,405.13 1,615.90 33536 2,522.07 2,395.97 2,755.37 33800 927.92 881.52 1,013.75 33542 2,433.61 2,311.93 2,658.72 33802 1,001.28 951.22 1,093.90 33545 2,870.67 2,727.14 3,136.21 33803 1,083.31 1,029.14 1,183.51 33548 2,817.29 2,676.43 3,077.89 33813 1,236.02 1,174.22 1,350.35 33572 224.90 213.66 245.71 33814 1,452.26 1,379.65 1,586.60 33600 1,627.94 1,546.54 1,778.52 33820 931.34 884.77 1,017.49 33602 1,552.74 1,475.10 1,696.37 33822 987.66 938.28 1,079.02 33606 1,690.62 1,606.09 1,847.00 33824 1,117.44 1,061.57 1,220.81 33608 1,735.35 1,648.58 1,895.87 33840 1,133.06 1,076.41 1,237.87 33610 1,693.03 1,608.38 1,849.64 33845 1,306.10 1,240.80 1,426.92 33611 1,863.27 1,770.11 2,035.63 33851 1,197.16 1,137.30 1,307.90 33612 1,918.80 1,822.86 2,096.29 33852 1,308.48 1,243.06 1,429.52 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 29 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 33853 1,796.71 1,706.87 1,962.90 34803 1,256.60 1,193.77 1,372.84 33860 3,001.37 2,851.30 3,279.00 34804 1,225.71 1,164.42 1,339.08 33861 2,329.22 2,212.76 2,544.67 34805 1,151.70 1,094.12 1,258.24 33863 2,994.11 2,844.40 3,271.06 34806 103.28 98.12 112.84 33864 3,078.24 2,924.33 3,362.98 34808 203.06 192.91 221.85 33870 2,431.31 2,309.74 2,656.20 34812 334.64 317.91 365.60 33875 1,888.60 1,794.17 2,063.30 34813 233.45 221.78 255.05 33877 3,367.88 3,199.49 3,679.41 34820 481.79 457.70 526.36 33880 1,747.82 1,660.43 1,909.49 34825 687.76 653.37 751.38 33881 1,500.89 1,425.85 1,639.73 34826 202.61 192.48 221.35 33883 1,094.29 1,039.58 1,195.52 34830 1,785.49 1,696.22 1,950.65 33884 398.62 378.69 435.49 34831 1,890.34 1,795.82 2,065.19 33886 940.30 893.29 1,027.28 34832 1,918.46 1,822.54 2,095.92 33889 779.59 740.61 851.70 34833 600.87 570.83 656.45 33891 974.95 926.20 1,065.13 34834 272.62 258.99 297.84 33910 1,583.88 1,504.69 1,730.39 34900 890.23 845.72 972.58 33915 1,274.87 1,211.13 1,392.80 35001 1,108.45 1,053.03 1,210.98 33916 1,588.95 1,509.50 1,735.93 35002 1,169.69 1,111.21 1,277.89 33917 1,436.32 1,364.50 1,569.18 35005 1,023.72 972.53 1,118.41 33920 1,730.77 1,644.23 1,890.86 35011 971.63 923.05 1,061.51 33922 1,311.65 1,246.07 1,432.98 35013 1,205.70 1,145.42 1,317.23 33924 275.40 261.63 300.87 35021 1,184.79 1,125.55 1,294.38 33925 1,682.82 1,598.68 1,838.48 35022 1,338.87 1,271.93 1,462.72 33926 2,232.73 2,121.09 2,439.25 35045 945.22 897.96 1,032.65 33933 355.82 338.03 388.73 35081 1,694.66 1,609.93 1,851.42 33935 3,311.04 3,145.49 3,617.31 35082 2,125.62 2,019.34 2,322.24 33944 250.75 238.21 273.94 35091 1,786.49 1,697.17 1,951.75 33945 4,431.83 4,210.24 4,841.78 35092 2,538.34 2,411.42 2,773.13 33960 957.85 909.96 1,046.45 35102 1,837.45 1,745.58 2,007.42 33961 537.75 510.86 587.49 35103 2,195.33 2,085.56 2,398.39 33967 266.17 252.86 290.79 35111 1,354.05 1,286.35 1,479.30 33968 33.94 32.24 37.08 35112 1,659.77 1,576.78 1,813.30 33970 354.50 336.78 387.30 35121 1,605.82 1,525.53 1,754.36 33971 685.00 650.75 748.36 35122 1,924.90 1,828.66 2,102.96 33973 516.34 490.52 564.10 35131 1,369.41 1,300.94 1,496.08 33974 872.12 828.51 952.79 35132 1,655.91 1,573.11 1,809.08 33975 1,063.66 1,010.48 1,162.05 35141 1,087.01 1,032.66 1,187.56 33976 1,183.52 1,124.34 1,292.99 35142 1,301.00 1,235.95 1,421.34 33977 1,151.17 1,093.61 1,257.65 35151 1,225.84 1,164.55 1,339.23 33978 1,265.42 1,202.15 1,382.47 35152 1,424.44 1,353.22 1,556.20 33979 2,331.05 2,214.50 2,546.68 35180 824.17 782.96 900.40 33980 3,441.79 3,269.70 3,760.16 35182 1,675.13 1,591.37 1,830.08 34001 926.95 880.60 1,012.69 35184 986.97 937.62 1,078.26 34051 928.58 882.15 1,014.47 35188 828.45 787.03 905.08 34101 589.35 559.88 643.86 35189 1,544.41 1,467.19 1,687.27 34111 589.18 559.72 643.68 35190 723.80 687.61 790.75 34151 1,360.23 1,292.22 1,486.05 35201 907.29 861.93 991.22 34201 964.62 916.39 1,053.85 35206 741.66 704.58 810.27 34203 941.23 894.17 1,028.30 35207 674.88 641.14 737.31 34401 1,407.89 1,337.50 1,538.13 35211 1,318.60 1,252.67 1,440.57 34421 714.96 679.21 781.09 35216 1,844.07 1,751.87 2,014.65 34451 1,469.13 1,395.67 1,605.02 35221 1,355.27 1,287.51 1,480.64 34471 1,037.48 985.61 1,133.45 35226 819.16 778.20 894.93 34490 592.70 563.07 647.53 35231 1,138.00 1,081.10 1,243.27 34501 917.91 872.01 1,002.81 35236 948.19 900.78 1,035.90 34502 1,485.86 1,411.57 1,623.31 35241 1,376.05 1,307.25 1,503.34 34510 1,043.45 991.28 1,139.97 35246 1,495.23 1,420.47 1,633.54 34520 1,001.64 951.56 1,094.29 35251 1,610.19 1,529.68 1,759.13 34530 944.61 897.38 1,031.99 35256 996.28 946.47 1,088.44 34800 1,121.15 1,065.09 1,224.85 35261 1,007.84 957.45 1,101.07 34802 1,226.24 1,164.93 1,339.67 35266 835.63 793.85 912.93 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 30 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 35271 1,316.78 1,250.94 1,438.58 35511 1,159.96 1,101.96 1,267.25 35276 1,381.06 1,312.01 1,508.81 35512 1,206.92 1,146.57 1,318.56 35281 1,539.20 1,462.24 1,681.58 35515 1,298.71 1,233.77 1,418.84 35286 915.03 869.28 999.67 35516 1,190.20 1,130.69 1,300.29 35301 1,025.50 974.23 1,120.36 35518 1,180.17 1,121.16 1,289.33 35302 1,089.14 1,034.68 1,189.88 35521 1,241.65 1,179.57 1,356.51 35303 1,198.55 1,138.62 1,309.41 35522 1,179.12 1,120.16 1,288.18 35304 1,246.15 1,183.84 1,361.42 35523 1,249.96 1,187.46 1,365.58 35305 1,197.07 1,137.22 1,307.80 35525 1,105.76 1,050.47 1,208.04 35306 446.49 424.17 487.80 35526 1,629.00 1,547.55 1,779.68 35311 1,472.30 1,398.69 1,608.49 35531 1,980.23 1,881.22 2,163.40 35321 872.35 828.73 953.04 35533 1,534.97 1,458.22 1,676.95 35331 1,438.99 1,367.04 1,572.10 35535 1,965.36 1,867.09 2,147.15 35341 1,352.96 1,285.31 1,478.11 35536 1,706.38 1,621.06 1,864.22 35351 1,258.39 1,195.47 1,374.79 35537 2,116.33 2,010.51 2,312.09 35355 1,022.51 971.38 1,117.09 35538 2,375.77 2,256.98 2,595.53 35361 1,548.88 1,471.44 1,692.16 35539 2,201.35 2,091.28 2,404.97 35363 1,688.80 1,604.36 1,845.01 35540 2,465.96 2,342.66 2,694.06 35371 806.12 765.81 880.68 35548 1,177.81 1,118.92 1,286.76 35372 966.76 918.42 1,056.18 35549 1,279.85 1,215.86 1,398.24 35390 157.60 149.72 172.18 35551 1,458.54 1,385.61 1,593.45 35400 149.10 141.65 162.90 35556 1,356.32 1,288.50 1,481.78 35450 506.28 480.97 553.12 35558 1,200.32 1,140.30 1,311.35 35452 350.94 333.39 383.40 35560 1,742.80 1,655.66 1,904.01 35454 307.60 292.22 336.05 35563 1,336.61 1,269.78 1,460.25 35456 372.28 353.67 406.72 35565 1,295.89 1,231.10 1,415.77 35458 478.13 454.22 522.35 35566 1,626.33 1,545.01 1,776.76 35459 438.83 416.89 479.42 35570 1,520.12 1,444.11 1,660.73 35460 305.04 289.79 333.26 35571 1,314.12 1,248.41 1,435.67 35470 2,795.95 2,656.15 3,054.57 35572 341.92 324.82 373.54 # 35470 453.64 430.96 495.60 35583 1,400.65 1,330.62 1,530.21 35471 3,072.67 2,919.04 3,356.90 35585 1,638.20 1,556.29 1,789.73 # 35471 543.67 516.49 593.96 35587 1,355.39 1,287.62 1,480.76 35472 2,130.49 2,023.97 2,327.57 35600 251.75 239.16 275.03 # 35472 362.29 344.18 395.81 35601 1,411.72 1,341.13 1,542.30 35473 2,035.39 1,933.62 2,223.66 35606 1,150.85 1,093.31 1,257.31 # 35473 320.80 304.76 350.47 35612 902.23 857.12 985.69 35474 2,716.59 2,580.76 2,967.87 35616 1,103.72 1,048.53 1,205.81 # 35474 387.96 368.56 423.84 35621 1,085.04 1,030.79 1,185.41 35475 2,190.61 2,081.08 2,393.24 35623 1,332.40 1,265.78 1,455.65 # 35475 486.00 461.70 530.96 35626 1,530.10 1,453.60 1,671.64 35476 1,656.77 1,573.93 1,810.02 35631 1,820.51 1,729.48 1,988.90 # 35476 310.76 295.22 339.50 35632 1,866.07 1,772.77 2,038.69 35480 549.52 522.04 600.35 35633 2,014.64 1,913.91 2,201.00 35481 395.08 375.33 431.63 35634 1,826.39 1,735.07 1,995.33 35482 346.22 328.91 378.25 35636 1,618.72 1,537.78 1,768.45 35483 417.18 396.32 455.77 35637 1,672.75 1,589.11 1,827.48 35484 520.35 494.33 568.48 35638 1,709.53 1,624.05 1,867.66 35485 483.43 459.26 528.15 35642 1,017.54 966.66 1,111.66 35490 607.06 576.71 663.22 35645 961.27 913.21 1,050.19 35491 405.17 384.91 442.65 35646 1,688.72 1,604.28 1,844.92 35492 369.48 351.01 403.66 35647 1,529.11 1,452.65 1,670.55 35493 449.96 427.46 491.58 35650 1,046.05 993.75 1,142.81 35494 571.12 542.56 623.94 35651 1,355.60 1,287.82 1,480.99 35495 520.88 494.84 569.07 35654 1,349.57 1,282.09 1,474.40 35500 315.31 299.54 344.47 35656 1,063.82 1,010.63 1,162.22 35501 1,527.19 1,450.83 1,668.45 35661 1,065.88 1,012.59 1,164.48 35506 1,302.84 1,237.70 1,423.36 35663 1,235.56 1,173.78 1,349.85 35508 1,347.51 1,280.13 1,472.15 35665 1,156.84 1,099.00 1,263.85 35509 1,467.97 1,394.57 1,603.76 35666 1,248.90 1,186.46 1,364.43 35510 1,238.63 1,176.70 1,353.21 35671 1,100.58 1,045.55 1,202.38 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 31 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 35681 78.79 74.85 86.08 # 36215 242.72 230.58 265.17 35682 351.53 333.95 384.04 36216 1,231.42 1,169.85 1,345.33 35683 414.74 394.00 453.10 # 36216 273.57 259.89 298.87 35685 197.41 187.54 215.67 36217 2,009.14 1,908.68 2,194.98 35686 165.40 157.13 180.70 # 36217 327.09 310.74 357.35 35691 968.80 920.36 1,058.41 36218 188.50 179.08 205.94 35693 860.77 817.73 940.39 # 36218 52.09 49.49 56.91 35694 1,001.02 950.97 1,093.62 36245 1,243.42 1,181.25 1,358.44 35695 1,043.18 991.02 1,139.67 # 36245 250.09 237.59 273.23 35697 147.27 139.91 160.90 36246 1,220.47 1,159.45 1,333.37 35700 151.42 143.85 165.43 # 36246 272.23 258.62 297.41 35701 522.19 496.08 570.49 36247 1,919.10 1,823.15 2,096.62 35721 443.16 421.00 484.15 # 36247 323.92 307.72 353.88 35741 484.93 460.68 529.78 36248 161.88 153.79 176.86 35761 359.61 341.63 392.87 # 36248 52.09 49.49 56.91 35800 461.78 438.69 504.49 36260 553.77 526.08 604.99 35820 1,813.23 1,722.57 1,980.96 36261 338.65 321.72 369.98 35840 602.14 572.03 657.83 36262 258.05 245.15 281.92 35860 390.40 370.88 426.51 36400 24.59 23.36 26.86 35870 1,255.81 1,193.02 1,371.97 # 36400 17.20 16.34 18.79 35875 579.56 550.58 633.17 36405 22.43 21.31 24.51 35876 926.03 879.73 1,011.69 # 36405 15.04 14.29 16.43 35879 906.94 861.59 990.83 36406 16.28 15.47 17.79 35881 1,008.13 957.72 1,101.38 # 36406 8.89 8.45 9.72 35883 1,172.95 1,114.30 1,281.45 36410 18.13 17.22 19.80 35884 1,236.50 1,174.68 1,350.88 # 36410 8.52 8.09 9.30 35901 487.63 463.25 532.74 36420 46.91 44.56 51.24 35903 551.34 523.77 602.34 36425 36.98 35.13 40.40 35905 1,705.60 1,620.32 1,863.37 36430 35.81 34.02 39.12 35907 1,878.20 1,784.29 2,051.93 36440 49.27 46.81 53.83 36000 24.41 23.19 26.67 36450 113.73 108.04 124.25 # 36000 9.26 8.80 10.12 36455 124.68 118.45 136.22 36002 163.54 155.36 178.66 36460 322.32 306.20 352.13 # 36002 108.09 102.69 118.09 36470 131.27 124.71 143.42 36005 333.11 316.45 363.92 # 36470 66.21 62.90 72.34 # 36005 48.83 46.39 53.35 36471 161.26 153.20 176.18 36010 573.63 544.95 626.69 # 36471 92.87 88.23 101.46 # 36010 122.24 116.13 133.55 36475 1,728.03 1,641.63 1,887.87 36011 909.16 863.70 993.26 # 36475 330.26 313.75 360.81 # 36011 157.97 150.07 172.58 36476 367.98 349.58 402.02 36012 854.51 811.78 933.55 # 36476 161.33 153.26 176.25 # 36012 178.73 169.79 195.26 36478 1,422.31 1,351.19 1,553.87 36013 789.96 750.46 863.03 # 36478 333.59 316.91 364.45 # 36013 127.86 121.47 139.69 36479 387.20 367.84 423.02 36014 824.30 783.09 900.55 # 36479 162.44 154.32 177.47 # 36014 155.55 147.77 169.94 36481 403.09 382.94 440.38 36015 903.70 858.52 987.30 36500 178.94 169.99 195.49 # 36015 179.86 170.87 196.50 36510 105.04 99.79 114.76 36100 522.03 495.93 570.32 # 36510 55.14 52.38 60.24 # 36100 157.16 149.30 171.70 36511 87.10 82.75 95.16 36120 432.83 411.19 472.87 36512 88.57 84.14 96.76 # 36120 99.01 94.06 108.17 36513 90.91 86.36 99.31 36140 478.29 454.38 522.54 36514 504.47 479.25 551.14 # 36140 101.95 96.85 111.38 # 36514 86.36 82.04 94.35 36145 474.07 450.37 517.93 36515 1,888.56 1,794.13 2,063.25 # 36145 99.95 94.95 109.19 # 36515 84.51 80.28 92.32 36160 525.44 499.17 574.05 36516 2,138.93 2,031.98 2,336.78 # 36160 132.47 125.85 144.73 # 36516 60.58 57.55 66.18 36200 638.87 606.93 697.97 36522 1,332.40 1,265.78 1,455.65 # 36200 152.37 144.75 166.46 # 36522 98.40 93.48 107.50 36215 1,127.00 1,070.65 1,231.25 36555 264.60 251.37 289.08 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 32 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 36555 123.38 117.21 134.79 36625 101.42 96.35 110.80 36556 224.78 213.54 245.57 36640 114.96 109.21 125.59 # 36556 116.46 110.64 127.24 36660 64.44 61.22 70.40 36557 814.37 773.65 889.70 36680 57.06 54.21 62.34 # 36557 289.05 274.60 315.79 36800 151.97 144.37 166.03 36558 788.03 748.63 860.92 36810 201.46 191.39 220.10 # 36558 276.39 262.57 301.96 36815 142.48 135.36 155.66 36560 1,120.54 1,064.51 1,224.19 36818 645.98 613.68 705.73 # 36560 342.36 325.24 374.03 36819 761.91 723.81 832.38 36561 1,108.94 1,053.49 1,211.51 36820 764.69 726.46 835.43 # 36561 331.13 314.57 361.76 36821 637.99 606.09 697.00 36563 1,119.09 1,063.14 1,222.61 36822 360.25 342.24 393.58 # 36563 342.02 324.92 373.66 36823 1,218.50 1,157.58 1,331.22 36565 936.30 889.49 1,022.91 36825 553.20 525.54 604.37 # 36565 325.95 309.65 356.10 36830 630.83 599.29 689.18 36566 3,522.51 3,346.38 3,848.34 36831 436.52 414.69 476.89 # 36566 349.16 331.70 381.46 36832 556.56 528.73 608.04 36568 301.88 286.79 329.81 36833 628.48 597.06 686.62 # 36568 94.86 90.12 103.64 36834 591.37 561.80 646.07 36569 261.62 248.54 285.82 36835 438.78 416.84 479.37 # 36569 94.52 89.79 103.26 36838 1,122.10 1,066.00 1,225.90 36570 1,140.60 1,083.57 1,246.11 36860 184.24 175.03 201.28 # 36570 305.86 290.57 334.16 # 36860 99.58 94.60 108.79 36571 1,183.51 1,124.33 1,292.98 36861 144.85 137.61 158.25 # 36571 297.01 282.16 324.48 36870 1,804.17 1,713.96 1,971.05 36575 155.62 147.84 170.02 # 36870 300.30 285.29 328.08 # 36575 36.96 35.11 40.38 37140 1,292.30 1,227.69 1,411.84 36576 346.50 329.18 378.56 37145 1,388.80 1,319.36 1,517.26 # 36576 181.25 172.19 198.02 37160 1,206.99 1,146.64 1,318.64 36578 486.34 462.02 531.32 37180 1,350.48 1,282.96 1,475.40 # 36578 207.97 197.57 227.21 37181 1,461.26 1,388.20 1,596.43 36580 224.74 213.50 245.53 37182 881.55 837.47 963.09 # 36580 67.62 64.24 73.88 37183 419.25 398.29 458.03 36581 737.04 700.19 805.22 37184 2,369.77 2,251.28 2,588.97 # 36581 196.56 186.73 214.74 # 37184 450.75 428.21 492.44 36582 1,028.24 976.83 1,123.35 37185 782.65 743.52 855.05 # 36582 288.87 274.43 315.59 # 37185 165.65 157.37 180.98 36583 1,028.56 977.13 1,123.70 37186 1,599.01 1,519.06 1,746.92 # 36583 289.20 274.74 315.95 # 37186 254.84 242.10 278.42 36584 221.51 210.43 241.99 37187 2,271.29 2,157.73 2,481.39 # 36584 69.94 66.44 76.41 # 37187 418.81 397.87 457.55 36585 1,056.70 1,003.87 1,154.45 37188 1,932.27 1,835.66 2,111.01 # 36585 271.49 257.92 296.61 # 37188 303.45 288.28 331.52 36589 159.70 151.72 174.48 37195 322.37 306.25 352.19 # 36589 134.56 127.83 147.00 37200 233.96 222.26 255.60 36590 259.90 246.91 283.95 37201 277.51 263.63 303.17 # 36590 189.66 180.18 207.21 37202 334.12 317.41 365.02 36591 22.36 21.24 24.43 37203 1,313.73 1,248.04 1,435.25 36592 24.58 23.35 26.85 # 37203 266.42 253.10 291.07 36593 32.81 31.17 35.85 37204 926.38 880.06 1,012.07 36595 593.46 563.79 648.36 37205 3,264.90 3,101.66 3,566.91 # 36595 189.03 179.58 206.52 # 37205 436.83 414.99 477.24 36596 133.30 126.64 145.64 37206 1,952.23 1,854.62 2,132.81 # 36596 44.94 42.69 49.09 # 37206 212.51 201.88 232.16 36597 124.36 118.14 135.86 37207 418.85 397.91 457.60 # 36597 63.00 59.85 68.83 37208 202.32 192.20 221.03 36598 112.23 106.62 122.61 37209 114.48 108.76 125.07 # 36598 60.11 57.10 65.67 37210 3,462.43 3,289.31 3,782.71 36600 29.64 28.16 32.38 # 37210 554.50 526.78 605.80 # 36600 14.85 14.11 16.23 37215 1,090.40 1,035.88 1,191.26 36620 49.00 46.55 53.53 37250 108.30 102.89 118.32 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 33 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 37251 80.30 76.29 87.73 38550 424.10 402.90 463.34 37500 660.17 627.16 721.23 38555 881.28 837.22 962.80 37565 656.43 623.61 717.15 38562 633.99 602.29 692.63 37600 670.82 637.28 732.87 38564 627.29 595.93 685.32 37605 764.83 726.59 835.58 38570 511.13 485.57 558.41 37606 500.10 475.10 546.37 38571 808.25 767.84 883.02 37607 357.37 339.50 390.43 38572 881.90 837.81 963.48 37609 273.16 259.50 298.43 38700 715.20 679.44 781.36 # 37609 185.18 175.92 202.31 38720 1,186.54 1,127.21 1,296.29 37615 445.40 423.13 486.60 38724 1,286.71 1,222.37 1,405.73 37616 1,029.11 977.65 1,124.30 38740 593.92 564.22 648.85 37617 1,221.51 1,160.43 1,334.49 38745 754.92 717.17 824.75 37618 355.50 337.73 388.39 38746 246.82 234.48 269.65 37620 644.23 612.02 703.82 38747 240.60 228.57 262.86 37650 484.27 460.06 529.07 38760 744.78 707.54 813.67 37660 1,145.78 1,088.49 1,251.76 38765 1,157.82 1,099.93 1,264.92 37700 238.18 226.27 260.21 38770 779.70 740.72 851.83 37718 395.75 375.96 432.35 38780 981.10 932.05 1,071.86 37722 453.07 430.42 494.98 38790 76.93 73.08 84.04 37735 600.24 570.23 655.76 38792 37.56 35.68 41.03 37760 591.14 561.58 645.82 38794 294.03 279.33 321.23 37765 428.99 407.54 468.67 39000 454.14 431.43 496.14 37766 521.87 495.78 570.15 39010 749.53 712.05 818.86 37780 245.84 233.55 268.58 39200 829.11 787.65 905.80 37785 332.52 315.89 363.27 39220 1,068.60 1,015.17 1,167.45 # 37785 246.39 234.07 269.18 39400 467.96 444.56 511.24 37788 1,317.50 1,251.63 1,439.37 39501 760.28 722.27 830.61 37790 479.44 455.47 523.79 39502 911.07 865.52 995.35 38100 992.48 942.86 1,084.29 39503 5,305.31 5,040.04 5,796.05 38101 997.00 947.15 1,089.22 39520 910.51 864.98 994.73 38102 236.06 224.26 257.90 39530 871.24 827.68 951.83 38115 1,103.93 1,048.73 1,206.04 39531 909.62 864.14 993.76 38120 918.52 872.59 1,003.48 39540 776.34 737.52 848.15 38200 133.93 127.23 146.31 39541 837.49 795.62 914.96 38205 77.52 73.64 84.69 39545 827.26 785.90 903.79 38206 77.52 73.64 84.69 39560 713.74 678.05 779.76 38220 148.90 141.46 162.68 39561 1,111.06 1,055.51 1,213.84 # 38220 58.32 55.40 63.71 40490 117.72 111.83 128.60 38221 164.89 156.65 180.15 # 40490 67.81 64.42 74.08 # 38221 73.94 70.24 80.78 40500 443.85 421.66 484.91 38230 298.09 283.19 325.67 # 40500 324.81 308.57 354.86 38240 120.08 114.08 131.19 40510 428.45 407.03 468.08 38241 120.82 114.78 132.00 # 40510 320.13 304.12 349.74 38242 91.56 86.98 100.03 40520 440.47 418.45 481.22 38300 243.78 231.59 266.33 # 40520 323.65 307.47 353.59 # 38300 162.82 154.68 177.88 40525 502.12 477.01 548.56 38305 410.08 389.58 448.02 40527 593.02 563.37 647.88 38308 392.75 373.11 429.08 40530 485.80 461.51 530.74 38380 509.12 483.66 556.21 # 40530 367.13 348.77 401.09 38381 752.05 714.45 821.62 40650 366.44 348.12 400.34 38382 608.91 578.46 665.23 # 40650 258.13 245.22 282.00 38500 282.57 268.44 308.71 40652 430.84 409.30 470.70 # 38500 221.20 210.14 241.66 # 40652 314.76 299.02 343.87 38505 120.35 114.33 131.48 40654 507.83 482.44 554.81 # 38505 71.18 67.62 77.76 # 40654 382.14 363.03 417.48 38510 456.65 433.82 498.89 40700 841.96 799.86 919.84 # 38510 375.32 356.55 410.03 40701 1,042.38 990.26 1,138.80 38520 410.85 390.31 448.86 40702 807.64 767.26 882.35 38525 371.87 353.28 406.27 40720 889.43 844.96 971.70 38530 477.49 453.62 521.66 40761 963.34 915.17 1,052.45 38542 459.76 436.77 502.29 40800 178.31 169.39 194.80 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 34 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 40800 113.99 108.29 124.53 41019 459.80 436.81 502.33 40801 271.94 258.34 297.09 41100 149.28 141.82 163.09 # 40801 196.90 187.06 215.12 # 41100 99.00 94.05 108.16 40804 181.96 172.86 198.79 41105 149.62 142.14 163.46 # 40804 115.42 109.65 126.10 # 41105 100.45 95.43 109.74 40805 284.91 270.66 311.26 41108 128.72 122.28 140.62 # 40805 203.95 193.75 222.81 # 41108 81.03 76.98 88.53 40806 95.07 90.32 103.87 41110 185.40 176.13 202.55 # 40806 30.74 29.20 33.58 # 41110 118.49 112.57 129.46 40808 160.59 152.56 175.44 41112 291.56 276.98 318.53 # 40808 95.90 91.11 104.78 # 41112 225.02 213.77 245.84 40810 178.19 169.28 194.67 41113 319.20 303.24 348.73 # 40810 113.49 107.82 123.99 # 41113 249.70 237.22 272.80 40812 249.45 236.98 272.53 41114 575.82 547.03 629.08 # 40812 175.51 166.73 191.74 41115 215.65 204.87 235.60 40814 335.03 318.28 366.02 # 41115 133.58 126.90 145.94 # 40814 271.45 257.88 296.56 41116 286.14 271.83 312.60 40816 353.11 335.45 385.77 # 41116 197.05 187.20 215.28 # 40816 283.98 269.78 310.25 41120 949.46 901.99 1,037.29 40818 312.18 296.57 341.06 41130 1,169.61 1,111.13 1,277.80 # 40818 244.53 232.30 267.15 41135 1,943.04 1,845.89 2,122.77 40819 267.26 253.90 291.99 41140 1,998.39 1,898.47 2,183.24 # 40819 208.85 198.41 228.17 41145 2,502.65 2,377.52 2,734.15 40820 233.31 221.64 254.89 41150 1,979.87 1,880.88 2,163.01 # 40820 154.20 146.49 168.46 41153 2,146.12 2,038.81 2,344.63 40830 213.59 202.91 233.35 41155 2,666.19 2,532.88 2,912.81 # 40830 142.25 135.14 155.41 41250 201.08 191.03 219.68 40831 282.92 268.77 309.09 # 41250 127.15 120.79 138.91 # 40831 199.74 189.75 218.21 41251 207.38 197.01 226.56 40840 719.33 683.36 785.86 # 41251 147.86 140.47 161.54 # 40840 571.46 542.89 624.32 41252 271.95 258.35 297.10 40842 707.87 672.48 773.35 # 41252 191.36 181.79 209.06 # 40842 558.89 530.95 610.59 41500 403.43 383.26 440.75 40843 922.71 876.57 1,008.06 41510 370.86 352.32 405.17 # 40843 724.93 688.68 791.98 41512 564.19 535.98 616.38 40844 1,223.13 1,161.97 1,336.27 41520 305.43 290.16 333.68 # 40844 1,015.00 964.25 1,108.89 # 41520 228.17 216.76 249.27 40845 1,330.42 1,263.90 1,453.49 41530 2,866.59 2,723.26 3,131.75 # 40845 1,137.82 1,080.93 1,243.07 # 41530 369.39 350.92 403.56 41000 141.42 134.35 154.50 41800 201.04 190.99 219.64 # 41000 100.01 95.01 109.26 # 41800 115.64 109.86 126.34 41005 199.49 189.52 217.95 41805 207.44 197.07 226.63 # 41005 114.47 108.75 125.06 # 41805 147.55 140.17 161.20 41006 317.85 301.96 347.25 41806 300.96 285.91 328.80 # 41006 232.83 221.19 254.37 # 41806 227.76 216.37 248.83 41007 319.12 303.16 348.63 41822 252.55 239.92 275.91 # 41007 226.33 215.01 247.26 # 41822 157.17 149.31 171.71 41008 327.49 311.12 357.79 41823 375.86 357.07 410.63 # 41008 240.98 228.93 263.27 # 41823 285.29 271.03 311.68 41009 347.76 330.37 379.93 41825 181.48 172.41 198.27 # 41009 261.63 248.55 285.83 # 41825 113.46 107.79 123.96 41010 179.56 170.58 196.17 41826 253.85 241.16 277.33 # 41010 98.60 93.67 107.72 # 41826 182.13 173.02 198.97 41015 374.24 355.53 408.86 41827 376.98 358.13 411.85 # 41015 301.04 285.99 328.89 # 41827 270.51 256.98 295.53 41016 383.88 364.69 419.39 41828 267.85 254.46 292.63 # 41016 312.17 296.56 341.04 # 41828 194.28 184.57 212.26 41017 386.84 367.50 422.63 41830 339.69 322.71 371.12 # 41017 313.64 297.96 342.65 # 41830 249.86 237.37 272.98 41018 442.18 420.07 483.08 41872 319.90 303.91 349.50 # 41018 366.02 347.72 399.88 # 41872 233.39 221.72 254.98 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 35 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 41874 323.46 307.29 353.38 42425 774.46 735.74 846.10 # 41874 227.71 216.32 248.77 42426 1,256.52 1,193.69 1,372.74 42000 139.63 132.65 152.55 42440 428.14 406.73 467.74 # 42000 92.68 88.05 101.26 42450 405.47 385.20 442.98 42100 132.34 125.72 144.58 # 42450 327.09 310.74 357.35 # 42100 98.33 93.41 107.42 42500 386.72 367.38 422.49 42104 184.70 175.47 201.79 # 42500 311.31 295.74 340.10 # 42104 123.71 117.52 135.15 42505 501.00 475.95 547.34 42106 233.95 222.25 255.59 # 42505 415.97 395.17 454.45 # 42106 161.86 153.77 176.84 42507 469.68 446.20 513.13 42107 405.24 384.98 442.73 42508 665.22 631.96 726.75 # 42107 311.34 295.77 340.14 42509 762.00 723.90 832.49 42120 882.22 838.11 963.83 42510 577.27 548.41 630.67 42140 221.52 210.44 242.01 42550 139.49 132.52 152.40 # 42140 139.82 132.83 152.75 # 42550 63.70 60.52 69.60 42145 637.97 606.07 696.98 42600 435.04 413.29 475.28 42160 213.57 202.89 233.32 # 42600 323.76 307.57 353.71 # 42160 138.16 131.25 150.94 42650 74.48 70.76 81.37 42180 215.87 205.08 235.84 # 42650 54.15 51.44 59.16 # 42180 167.07 158.72 182.53 42660 95.59 90.81 104.43 42182 294.21 279.50 321.43 # 42660 71.93 68.33 78.58 # 42182 242.82 230.68 265.28 42665 276.07 262.27 301.61 42200 805.42 765.15 879.92 # 42665 188.82 179.38 206.29 42205 856.46 813.64 935.69 42700 167.92 159.52 183.45 42210 964.43 916.21 1,053.64 # 42700 123.56 117.38 134.99 42215 634.83 603.09 693.55 42720 414.68 393.95 453.04 42220 494.93 470.18 540.71 # 42720 363.67 345.49 397.31 42225 857.19 814.33 936.48 42725 742.59 705.46 811.28 42226 849.35 806.88 927.91 42800 140.79 133.75 153.81 42227 825.91 784.61 902.30 # 42800 101.97 96.87 111.40 42235 675.13 641.37 737.58 42802 215.88 205.09 235.85 42260 747.81 710.42 816.98 # 42802 124.20 117.99 135.69 # 42260 619.16 588.20 676.43 42804 180.30 171.29 196.98 42280 139.49 132.52 152.40 # 42804 105.26 100.00 115.00 # 42280 94.02 89.32 102.72 42806 203.08 192.93 221.87 42281 180.92 171.87 197.65 # 42806 123.23 117.07 134.63 # 42281 138.04 131.14 150.81 42808 204.97 194.72 223.93 42300 185.18 175.92 202.31 # 42808 150.63 143.10 164.57 # 42300 138.23 131.32 151.02 42809 152.39 144.77 166.49 42305 393.08 373.43 429.44 # 42809 118.01 112.11 128.93 42310 143.95 136.75 157.26 42810 345.98 328.68 377.98 # 42310 112.90 107.26 123.35 # 42810 259.47 246.50 283.48 42320 222.66 211.53 243.26 42815 506.70 481.37 553.58 # 42320 161.66 153.58 176.62 42820 267.17 253.81 291.88 42330 207.27 196.91 226.45 42821 278.85 264.91 304.65 # 42330 149.97 142.47 163.84 42825 239.77 227.78 261.95 42335 330.77 314.23 361.36 42826 231.30 219.74 252.70 # 42335 235.40 223.63 257.17 42830 189.00 179.55 206.48 42340 414.73 393.99 453.09 42831 204.01 193.81 222.88 # 42340 309.00 293.55 337.58 42835 170.20 161.69 185.94 42400 98.70 93.77 107.84 42836 222.05 210.95 242.59 # 42400 53.97 51.27 58.96 42842 884.56 840.33 966.38 42405 272.22 258.61 297.40 42844 1,241.33 1,179.26 1,356.15 # 42405 208.64 198.21 227.94 42845 2,024.61 1,923.38 2,211.89 42408 405.70 385.42 443.23 42860 171.22 162.66 187.06 # 42408 299.23 284.27 326.91 42870 524.52 498.29 573.03 42409 294.64 279.91 321.90 42890 1,262.19 1,199.08 1,378.94 # 42409 203.70 193.52 222.55 42892 1,654.92 1,572.17 1,808.00 42410 568.06 539.66 620.61 42894 2,117.83 2,011.94 2,313.73 42415 1,025.41 974.14 1,120.26 42900 316.88 301.04 346.20 42420 1,174.96 1,116.21 1,283.64 42950 724.08 687.88 791.06 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 36 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 42953 891.85 847.26 974.35 43245 177.72 168.83 194.15 42955 680.62 646.59 743.58 43246 238.00 226.10 260.02 42960 155.04 147.29 169.38 43247 190.28 180.77 207.89 42961 385.11 365.85 420.73 43248 180.17 171.16 196.83 42962 476.52 452.69 520.59 43249 165.80 157.51 181.14 42970 356.25 338.44 389.21 43250 177.70 168.82 194.14 42971 419.79 398.80 458.62 43251 206.99 196.64 226.14 42972 471.12 447.56 514.69 43255 269.52 256.04 294.45 43020 482.03 457.93 526.62 43256 242.06 229.96 264.45 43030 478.85 454.91 523.15 43257 297.18 282.32 324.67 43045 1,207.16 1,146.80 1,318.82 43258 253.89 241.20 277.38 43100 571.66 543.08 624.54 43259 289.51 275.03 316.28 43101 940.81 893.77 1,027.84 43260 331.28 314.72 361.93 43107 2,327.25 2,210.89 2,542.52 43261 348.17 330.76 380.37 43108 3,939.05 3,742.10 4,303.42 43262 408.84 388.40 446.66 43112 2,485.59 2,361.31 2,715.51 43263 404.49 384.27 441.91 43113 3,937.82 3,740.93 4,302.07 43264 490.76 466.22 536.15 43116 4,490.01 4,265.51 4,905.34 43265 550.70 523.17 601.65 43117 2,273.91 2,160.21 2,484.24 43267 406.99 386.64 444.64 43118 3,239.24 3,077.28 3,538.87 43268 414.01 393.31 452.31 43121 2,571.79 2,443.20 2,809.68 43269 453.16 430.50 495.08 43122 2,298.29 2,183.38 2,510.89 43271 408.47 388.05 446.26 43123 3,959.84 3,761.85 4,326.13 43272 407.73 387.34 445.44 43124 3,386.53 3,217.20 3,699.78 43273 123.55 117.37 134.98 43130 723.62 687.44 790.56 43279 1,138.29 1,081.38 1,243.59 43135 1,347.38 1,280.01 1,472.01 43280 949.91 902.41 1,037.77 43200 199.02 189.07 217.43 43300 566.83 538.49 619.26 # 43200 97.36 92.49 106.36 43305 1,015.91 965.11 1,109.88 43201 273.97 260.27 299.31 43310 1,404.95 1,334.70 1,534.91 # 43201 122.40 116.28 133.72 43312 1,550.52 1,472.99 1,693.94 43202 261.95 248.85 286.18 43313 2,470.99 2,347.44 2,699.56 # 43202 107.80 102.41 117.77 43314 2,834.20 2,692.49 3,096.36 43204 212.28 201.67 231.92 43320 1,236.95 1,175.10 1,351.37 43205 213.02 202.37 232.73 43324 1,198.04 1,138.14 1,308.86 43215 145.37 138.10 158.82 43325 1,180.03 1,121.03 1,289.18 43216 183.64 174.46 200.63 43326 1,202.86 1,142.72 1,314.13 # 43216 135.58 128.80 148.12 43330 1,156.90 1,099.06 1,263.92 43217 349.87 332.38 382.24 43331 1,255.51 1,192.73 1,371.64 # 43217 159.48 151.51 174.24 43340 1,203.07 1,142.92 1,314.36 43219 161.81 153.72 176.78 43341 1,325.45 1,259.18 1,448.06 43220 119.79 113.80 130.87 43350 1,031.81 980.22 1,127.25 43226 133.61 126.93 145.97 43351 1,207.46 1,147.09 1,319.15 43227 198.77 188.83 217.15 43352 987.70 938.32 1,079.07 43228 211.88 201.29 231.48 43360 2,106.91 2,001.56 2,301.79 43231 180.87 171.83 197.60 43361 2,358.95 2,241.00 2,577.15 43232 248.95 236.50 271.98 43400 1,463.93 1,390.73 1,599.34 43234 259.61 246.63 283.62 43401 1,371.56 1,302.98 1,498.43 # 43234 112.48 106.86 122.89 43405 1,331.76 1,265.17 1,454.95 43235 280.33 266.31 306.26 43410 914.17 868.46 998.73 # 43235 137.63 130.75 150.36 43415 1,550.61 1,473.08 1,694.04 43236 349.33 331.86 381.64 43420 916.08 870.28 1,000.82 # 43236 167.45 159.08 182.94 43425 1,363.64 1,295.46 1,489.78 43237 226.96 215.61 247.95 43450 148.58 141.15 162.32 43238 281.84 267.75 307.91 # 43450 84.26 80.05 92.06 43239 324.42 308.20 354.43 43453 281.18 267.12 307.19 # 43239 162.87 154.73 177.94 # 43453 91.53 86.95 99.99 43240 378.25 359.34 413.24 43456 569.80 541.31 622.51 43241 147.79 140.40 161.46 # 43456 147.26 139.90 160.89 43242 403.93 383.73 441.29 43458 363.42 345.25 397.04 43243 254.61 241.88 278.16 # 43458 171.92 163.32 187.82 43244 282.24 268.13 308.35 43460 208.37 197.95 227.64 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 37 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 43496 1,968.04 1,869.64 2,150.09 44021 854.03 811.33 933.03 43500 680.81 646.77 743.79 44025 859.19 816.23 938.66 43501 1,168.71 1,110.27 1,276.81 44050 813.16 772.50 888.38 43502 1,322.52 1,256.39 1,444.85 44055 1,301.44 1,236.37 1,421.83 43510 845.25 802.99 923.44 44100 108.78 103.34 118.84 43520 616.24 585.43 673.24 44110 736.91 700.06 805.07 43600 100.95 95.90 110.29 44111 857.17 814.31 936.46 43605 722.20 686.09 789.00 44120 1,061.51 1,008.43 1,159.69 43610 852.29 809.68 931.13 44121 217.75 206.86 237.89 43611 1,060.95 1,007.90 1,159.09 44125 1,030.44 978.92 1,125.76 43620 1,726.56 1,640.23 1,886.26 44126 2,126.28 2,019.97 2,322.97 43621 1,967.39 1,869.02 2,149.37 44127 2,473.26 2,349.60 2,702.04 43622 1,995.21 1,895.45 2,179.77 44128 218.65 207.72 238.88 43631 1,266.55 1,203.22 1,383.70 44130 1,114.46 1,058.74 1,217.55 43632 1,729.42 1,642.95 1,889.39 44137 981.03 931.98 1,071.78 43633 1,644.85 1,562.61 1,797.00 44139 109.06 103.61 119.15 43634 1,816.91 1,726.06 1,984.97 44140 1,172.37 1,113.75 1,280.81 43635 100.90 95.86 110.24 44141 1,551.14 1,473.58 1,694.62 43640 1,019.62 968.64 1,113.94 44143 1,446.94 1,374.59 1,580.78 43641 1,028.46 977.04 1,123.60 44144 1,520.77 1,444.73 1,661.44 43644 1,509.55 1,434.07 1,649.18 44145 1,460.81 1,387.77 1,595.94 43645 1,613.82 1,533.13 1,763.10 44146 1,832.51 1,740.88 2,002.01 43651 567.14 538.78 619.60 44147 1,651.75 1,569.16 1,804.53 43652 663.51 630.33 724.88 44150 1,608.04 1,527.64 1,756.79 43653 485.41 461.14 530.31 44151 1,837.62 1,745.74 2,007.60 43752 39.92 37.92 43.61 44155 1,801.08 1,711.03 1,967.68 43760 317.60 301.72 346.98 44156 1,977.73 1,878.84 2,160.67 # 43760 47.74 45.35 52.15 44157 1,876.91 1,783.06 2,050.52 43761 116.57 110.74 127.35 44158 1,923.41 1,827.24 2,101.33 # 43761 102.53 97.40 112.01 44160 1,080.98 1,026.93 1,180.97 43770 968.04 919.64 1,057.59 44180 805.99 765.69 880.54 43771 1,103.15 1,047.99 1,205.19 44186 569.62 541.14 622.31 43772 834.20 792.49 911.36 44187 961.53 913.45 1,050.47 43773 1,104.07 1,048.87 1,206.20 44188 1,063.09 1,009.94 1,161.43 43774 835.71 793.92 913.01 44202 1,212.95 1,152.30 1,325.15 43800 809.21 768.75 884.06 44203 216.83 205.99 236.89 43810 876.94 833.09 958.05 44204 1,354.21 1,286.50 1,479.48 43820 1,137.99 1,081.09 1,243.25 44205 1,182.34 1,123.22 1,291.70 43825 1,127.96 1,071.56 1,232.29 44206 1,537.44 1,460.57 1,679.66 43830 602.50 572.38 658.24 44207 1,613.53 1,532.85 1,762.78 43831 504.99 479.74 551.70 44208 1,756.60 1,668.77 1,919.09 43832 925.66 879.38 1,011.29 44210 1,571.26 1,492.70 1,716.61 43840 1,154.34 1,096.62 1,261.11 44211 1,928.72 1,832.28 2,107.12 43843 1,099.68 1,044.70 1,201.41 44212 1,810.56 1,720.03 1,978.03 43845 1,699.84 1,614.85 1,857.08 44213 171.01 162.46 186.83 43846 1,417.99 1,347.09 1,549.15 44227 1,466.07 1,392.77 1,601.69 43847 1,548.03 1,470.63 1,691.22 44300 731.42 694.85 799.08 43848 1,680.13 1,596.12 1,835.54 44310 913.80 868.11 998.33 43850 1,406.45 1,336.13 1,536.55 44312 522.51 496.38 570.84 43855 1,469.82 1,396.33 1,605.78 44314 886.68 842.35 968.70 43860 1,428.52 1,357.09 1,560.65 44316 1,212.57 1,151.94 1,324.73 43865 1,485.36 1,411.09 1,622.75 44320 1,042.62 990.49 1,139.06 43870 614.14 583.43 670.94 44322 835.43 793.66 912.71 43880 1,395.55 1,325.77 1,524.64 44340 525.79 499.50 574.43 43886 293.87 279.18 321.06 44345 913.10 867.45 997.57 43887 273.99 260.29 299.33 44346 1,025.04 973.79 1,119.86 43888 386.37 367.05 422.11 44360 150.02 142.52 163.90 44005 954.29 906.58 1,042.57 44361 165.28 157.02 180.57 44010 751.24 713.68 820.73 44363 195.36 185.59 213.43 44015 129.54 123.06 141.52 44364 210.67 200.14 230.16 44020 843.95 801.75 922.01 44365 187.59 178.21 204.94 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 38 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 44366 248.29 235.88 271.26 45005 222.22 211.11 242.78 44369 253.54 240.86 276.99 # 45005 134.98 128.23 147.46 44370 273.22 259.56 298.49 45020 473.50 449.83 517.30 44372 241.06 229.01 263.36 45100 251.92 239.32 275.22 44373 195.36 185.59 213.43 45108 305.74 290.45 334.02 44376 288.48 274.06 315.17 45110 1,618.37 1,537.45 1,768.07 44377 306.37 291.05 334.71 45111 949.98 902.48 1,037.85 44378 392.82 373.18 429.16 45112 1,665.80 1,582.51 1,819.89 44379 416.10 395.30 454.60 45113 1,709.71 1,624.22 1,867.85 44380 65.54 62.26 71.60 45114 1,559.53 1,481.55 1,703.78 44382 78.62 74.69 85.89 45116 1,402.21 1,332.10 1,531.92 44383 168.54 160.11 184.13 45119 1,712.72 1,627.08 1,871.14 44385 230.96 219.41 252.32 45120 1,367.89 1,299.50 1,494.43 # 44385 100.10 95.10 109.37 45121 1,495.90 1,421.11 1,634.28 44386 321.78 305.69 351.54 45123 971.40 922.83 1,061.25 # 44386 117.35 111.48 128.20 45126 2,536.24 2,409.43 2,770.84 44388 319.26 303.30 348.80 45130 949.93 902.43 1,037.79 # 44388 155.86 148.07 170.28 45135 1,162.75 1,104.61 1,270.30 44389 371.28 352.72 405.63 45136 1,613.17 1,532.51 1,762.39 # 44389 174.24 165.53 190.36 45150 348.32 330.90 380.54 44390 428.48 407.06 468.12 45160 865.13 821.87 945.15 # 44390 208.89 198.45 228.22 45170 676.28 642.47 738.84 44391 480.15 456.14 524.56 45190 589.70 560.22 644.25 # 44391 238.37 226.45 260.42 45300 97.58 92.70 106.61 44392 401.49 381.42 438.63 # 45300 45.09 42.84 49.27 # 44392 205.18 194.92 224.16 45303 765.52 727.24 836.33 44393 465.94 442.64 509.04 # 45303 76.80 72.96 83.90 # 44393 261.51 248.43 285.69 45305 158.68 150.75 173.36 44394 470.04 446.54 513.52 # 45305 68.85 65.41 75.22 # 44394 242.31 230.19 264.72 45307 176.39 167.57 192.71 44397 261.83 248.74 286.05 # 45307 86.92 82.57 94.96 44500 24.86 23.62 27.16 45308 161.89 153.80 176.87 44602 1,205.78 1,145.49 1,317.31 # 45308 73.90 70.21 80.74 44603 1,382.54 1,313.41 1,510.42 45309 181.48 172.41 198.27 44604 925.21 878.95 1,010.79 # 45309 85.36 81.09 93.25 44605 1,142.06 1,084.96 1,247.70 45315 195.86 186.07 213.98 44615 940.94 893.89 1,027.97 # 45315 97.53 92.65 106.55 44620 752.48 714.86 822.09 45317 189.03 179.58 206.52 44625 890.32 845.80 972.67 # 45317 102.52 97.39 112.00 44626 1,412.60 1,341.97 1,543.27 45320 190.51 180.98 208.13 44640 1,233.12 1,171.46 1,347.18 # 45320 97.72 92.83 106.75 44650 1,282.27 1,218.16 1,400.88 45321 94.63 89.90 103.39 44660 1,249.38 1,186.91 1,364.95 45327 110.46 104.94 120.68 44661 1,396.43 1,326.61 1,525.60 45330 125.88 119.59 137.53 44680 929.53 883.05 1,015.51 # 45330 58.22 55.31 63.61 44700 900.50 855.48 983.80 45331 160.26 152.25 175.09 44701 150.90 143.36 164.86 # 45331 70.80 67.26 77.35 44715 355.62 337.84 388.52 45332 263.33 250.16 287.68 44720 249.37 236.90 272.44 # 45332 103.26 98.10 112.82 44721 346.57 329.24 378.63 45333 265.00 251.75 289.51 44800 663.00 629.85 724.33 # 45333 102.71 97.57 112.21 44820 731.63 695.05 799.31 45334 155.98 148.18 170.41 44850 645.61 613.33 705.33 45335 226.88 215.54 247.87 44900 661.92 628.82 723.14 # 45335 86.03 81.73 93.99 44901 933.20 886.54 1,019.52 45337 133.21 126.55 145.53 # 44901 171.29 162.73 187.14 45338 295.16 280.40 322.46 44950 559.41 531.44 611.16 # 45338 133.61 126.93 145.97 44955 75.74 71.95 82.74 45339 304.92 289.67 333.12 44960 753.84 716.15 823.57 # 45339 176.64 167.81 192.98 44970 515.31 489.54 562.97 45340 405.76 385.47 443.29 45000 362.60 344.47 396.14 # 45340 108.17 102.76 118.17 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 39 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 45341 148.90 141.46 162.68 46070 200.22 190.21 218.74 45342 227.55 216.17 248.60 46080 201.96 191.86 220.64 45345 165.22 156.96 180.50 # 46080 138.00 131.10 150.77 45355 189.17 179.71 206.67 46083 154.06 146.36 168.31 45378 369.09 350.64 403.24 # 46083 93.43 88.76 102.07 # 45378 204.21 194.00 223.10 46200 340.56 323.53 372.06 45378 53 125.88 119.59 137.53 # 46200 262.19 249.08 286.44 # 45378 53 58.22 55.31 63.61 46210 313.57 297.89 342.57 45379 468.50 445.08 511.84 # 46210 221.15 210.09 241.60 # 45379 255.56 242.78 279.20 46211 423.11 401.95 462.24 45380 443.25 421.09 484.25 # 46211 321.45 305.38 351.19 # 45380 246.21 233.90 268.99 46220 164.25 156.04 179.45 45381 431.86 410.27 471.81 # 46220 99.93 94.93 109.17 # 45381 233.34 221.67 254.92 46221 214.57 203.84 234.42 45382 584.77 555.53 638.86 # 46221 159.11 151.15 173.82 # 45382 314.91 299.16 344.03 46230 224.06 212.86 244.79 45383 526.33 500.01 575.01 # 46230 148.64 141.21 162.39 # 45383 315.99 300.19 345.22 46250 373.33 354.66 407.86 45384 434.67 412.94 474.88 # 46250 263.17 250.01 287.51 # 45384 255.38 242.61 279.00 46255 415.87 395.08 454.34 45385 499.16 474.20 545.33 # 46255 299.05 284.10 326.72 # 45385 292.14 277.53 319.16 46257 350.04 332.54 382.42 45386 619.43 588.46 676.73 46258 382.74 363.60 418.14 # 45386 250.86 238.32 274.07 46260 397.14 377.28 433.87 45387 327.41 311.04 357.70 46261 444.10 421.90 485.19 45391 282.71 268.57 308.86 46262 463.88 440.69 506.79 45392 358.30 340.39 391.45 46270 403.45 383.28 440.77 45395 1,749.81 1,662.32 1,911.67 # 46270 316.95 301.10 346.27 45397 1,895.97 1,801.17 2,071.35 46275 426.62 405.29 466.08 45400 1,009.73 959.24 1,103.13 # 46275 339.37 322.40 370.76 45402 1,348.98 1,281.53 1,473.76 46280 387.93 368.53 423.81 45500 446.71 424.37 488.03 46285 414.85 394.11 453.23 45505 489.93 465.43 535.24 # 46285 335.36 318.59 366.38 45520 113.88 108.19 124.42 46288 458.11 435.20 500.48 # 45520 34.77 33.03 37.98 46320 147.76 140.37 161.43 45540 931.54 884.96 1,017.70 # 46320 94.52 89.79 103.26 45541 802.03 761.93 876.22 46500 180.66 171.63 197.37 45550 1,280.80 1,216.76 1,399.27 # 46500 107.83 102.44 117.81 45560 636.00 604.20 694.83 46505 234.78 223.04 256.50 45562 973.69 925.01 1,063.76 # 46505 197.81 187.92 216.11 45563 1,406.39 1,336.07 1,536.48 46600 72.85 69.21 79.59 45800 1,094.65 1,039.92 1,195.91 # 46600 34.40 32.68 37.58 45805 1,236.54 1,174.71 1,350.92 46604 458.13 435.22 500.50 45820 1,088.52 1,034.09 1,189.20 # 46604 59.24 56.28 64.72 45825 1,307.86 1,242.47 1,428.84 46606 186.84 177.50 204.13 45900 172.71 164.07 188.68 # 46606 65.58 62.30 71.65 45905 146.88 139.54 160.47 46608 192.42 182.80 210.22 45910 173.94 165.24 190.03 # 46608 71.91 68.31 78.56 45915 274.56 260.83 299.95 46610 190.42 180.90 208.04 # 45915 195.08 185.33 213.13 # 46610 71.38 67.81 77.98 45990 96.40 91.58 105.32 46611 149.33 141.86 163.14 46020 220.96 209.91 241.40 # 46611 73.55 69.87 80.35 # 46020 192.87 183.23 210.71 46612 227.64 216.26 248.70 46030 111.53 105.95 121.84 # 46612 86.79 82.45 94.82 # 46030 76.41 72.59 83.48 46614 114.29 108.58 124.87 46040 431.76 410.17 471.70 # 46614 62.17 59.06 67.92 # 46040 345.26 328.00 377.20 46615 130.57 124.04 142.65 46045 355.56 337.78 388.45 # 46615 88.05 83.65 96.20 46050 156.29 148.48 170.75 46700 551.02 523.47 601.99 # 46050 80.88 76.84 88.37 46705 454.65 431.92 496.71 46060 391.10 371.55 427.28 46706 145.86 138.57 159.36 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 40 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 46710 938.90 891.96 1,025.75 47142 4,017.31 3,816.44 4,388.91 46712 1,907.41 1,812.04 2,083.85 47143 301.07 286.02 328.92 46715 448.71 426.27 490.21 47144 451.59 429.01 493.36 46716 1,104.62 1,049.39 1,206.80 47145 451.59 429.01 493.36 46730 1,665.04 1,581.79 1,819.06 47146 295.45 280.68 322.78 46735 1,941.61 1,844.53 2,121.21 47147 344.72 327.48 376.60 46740 1,786.55 1,697.22 1,951.80 47300 971.38 922.81 1,061.23 46742 2,108.99 2,003.54 2,304.07 47350 1,190.67 1,131.14 1,300.81 46744 2,992.81 2,843.17 3,269.65 47360 1,620.02 1,539.02 1,769.87 46746 3,459.95 3,286.95 3,779.99 47361 2,659.05 2,526.10 2,905.02 46748 3,640.56 3,458.53 3,977.31 47362 1,236.36 1,174.54 1,350.72 46750 665.98 632.68 727.58 47370 1,087.04 1,032.69 1,187.59 46751 554.42 526.70 605.71 47371 1,107.89 1,052.50 1,210.38 46753 502.63 477.50 549.13 47380 1,271.40 1,207.83 1,389.00 46754 243.66 231.48 266.20 47381 1,297.03 1,232.18 1,417.01 # 46754 186.36 177.04 203.60 47382 810.36 769.84 885.32 46760 941.71 894.62 1,028.81 47400 1,852.66 1,760.03 2,024.03 46761 813.55 772.87 888.80 47420 1,165.16 1,106.90 1,272.94 46762 803.60 763.42 877.93 47425 1,176.93 1,118.08 1,285.79 46900 197.60 187.72 215.88 47460 1,113.96 1,058.26 1,217.00 # 46900 121.07 115.02 132.27 47480 742.75 705.61 811.45 46910 206.11 195.80 225.17 47490 504.62 479.39 551.30 # 46910 115.54 109.76 126.22 47500 100.55 95.52 109.85 46916 204.69 194.46 223.63 47505 38.84 36.90 42.44 # 46916 128.17 121.76 140.02 47510 477.15 453.29 521.28 46917 396.48 376.66 433.16 47511 597.99 568.09 653.30 # 46917 116.26 110.45 127.02 47525 573.04 544.39 626.05 46922 214.78 204.04 234.65 # 47525 123.14 116.98 134.53 # 46922 115.33 109.56 125.99 47530 1,384.17 1,314.96 1,512.20 46924 448.31 425.89 489.77 # 47530 358.31 340.39 391.45 # 46924 161.07 153.02 175.97 47550 149.29 141.83 163.10 46930 189.97 180.47 207.54 47552 323.64 307.46 353.58 # 46930 136.37 129.55 148.98 47553 323.58 307.40 353.51 46937 220.75 209.71 241.17 47554 471.35 447.78 514.95 # 46937 154.58 146.85 168.88 47555 388.24 368.83 424.15 46938 383.13 363.97 418.57 47556 439.24 417.28 479.87 # 46938 314.74 299.00 343.85 47560 241.14 229.08 263.44 46940 184.97 175.72 202.08 47561 262.13 249.02 286.37 # 46940 128.04 121.64 139.89 47562 642.03 609.93 701.42 46942 171.58 163.00 187.45 47563 656.37 623.55 717.08 # 46942 113.91 108.21 124.44 47564 757.50 719.63 827.57 46945 240.64 228.61 262.90 47570 676.73 642.89 739.32 # 46945 184.44 175.22 201.50 47600 921.65 875.57 1,006.91 46946 259.75 246.76 283.77 47605 851.31 808.74 930.05 # 46946 193.94 184.24 211.88 47610 1,090.82 1,036.28 1,191.72 46947 324.44 308.22 354.45 47612 1,102.21 1,047.10 1,204.17 47000 310.21 294.70 338.91 47620 1,196.09 1,136.29 1,306.73 # 47000 97.64 92.76 106.67 47630 542.27 515.16 592.43 47001 93.30 88.64 101.94 47700 909.56 864.08 993.69 47010 1,042.83 990.69 1,139.29 47701 1,563.33 1,485.16 1,707.93 47011 189.11 179.65 206.60 47711 1,354.72 1,286.98 1,480.03 47015 988.35 938.93 1,079.77 47712 1,733.71 1,647.02 1,894.07 47100 723.94 687.74 790.90 47715 1,139.46 1,082.49 1,244.86 47120 2,030.67 1,929.14 2,218.51 47720 985.15 935.89 1,076.27 47122 3,017.47 2,866.60 3,296.59 47721 1,161.59 1,103.51 1,269.04 47125 2,702.94 2,567.79 2,952.96 47740 1,122.61 1,066.48 1,226.45 47130 2,906.04 2,760.74 3,174.85 47741 1,271.01 1,207.46 1,388.58 47135 4,280.16 4,066.15 4,676.07 47760 1,916.48 1,820.66 2,093.76 47136 3,651.89 3,469.30 3,989.70 47765 2,535.12 2,408.36 2,769.61 47140 3,060.12 2,907.11 3,343.18 47780 2,096.55 1,991.72 2,290.48 47141 3,647.03 3,464.68 3,984.38 47785 2,734.61 2,597.88 2,987.56 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 41 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 47800 1,367.95 1,299.55 1,494.48 49320 289.38 274.91 316.15 47801 975.99 927.19 1,066.27 49321 304.42 289.20 332.58 47802 1,314.14 1,248.43 1,435.69 49322 331.07 314.52 361.70 47900 1,184.01 1,124.81 1,293.53 49323 562.25 534.14 614.26 48000 1,641.18 1,559.12 1,792.99 49324 344.45 327.23 376.31 48001 2,013.90 1,913.21 2,200.19 49325 369.23 350.77 403.39 48020 1,013.30 962.64 1,107.04 49326 169.16 160.70 184.81 48100 769.19 730.73 840.34 49400 169.17 160.71 184.82 48102 516.83 490.99 564.64 # 49400 95.61 90.83 104.45 # 48102 249.91 237.41 273.02 49402 745.50 708.23 814.46 48105 2,483.25 2,359.09 2,712.95 49419 400.27 380.26 437.30 48120 959.73 911.74 1,048.50 49420 127.42 121.05 139.21 48140 1,358.05 1,290.15 1,483.67 49421 343.14 325.98 374.88 48145 1,410.03 1,339.53 1,540.46 49422 342.91 325.76 374.62 48146 1,611.00 1,530.45 1,760.02 49423 547.78 520.39 598.45 48148 1,069.86 1,016.37 1,168.83 # 49423 76.44 72.62 83.51 48150 2,714.95 2,579.20 2,966.08 49424 148.27 140.86 161.99 48152 2,510.95 2,385.40 2,743.21 # 49424 39.95 37.95 43.64 48153 2,711.09 2,575.54 2,961.87 49425 670.36 636.84 732.37 48154 2,517.00 2,391.15 2,749.82 49426 571.25 542.69 624.09 48155 1,563.97 1,485.77 1,708.64 49427 45.91 43.61 50.15 48400 99.24 94.28 108.42 49428 385.15 365.89 420.77 48500 980.57 931.54 1,071.27 49429 405.13 384.87 442.60 48510 932.06 885.46 1,018.28 49435 108.30 102.89 118.32 48511 903.43 858.26 987.00 49436 161.51 153.43 176.44 # 48511 204.73 194.49 223.66 49440 1,062.22 1,009.11 1,160.48 48520 948.90 901.46 1,036.68 # 49440 230.06 218.56 251.34 48540 1,132.69 1,076.06 1,237.47 49441 1,154.62 1,096.89 1,261.42 48545 1,148.73 1,091.29 1,254.98 # 49441 255.56 242.78 279.20 48547 1,547.26 1,469.90 1,690.39 49442 1,035.39 983.62 1,131.16 48548 1,449.25 1,376.79 1,583.31 # 49442 211.00 200.45 230.52 48551 204.63 194.40 223.56 49446 968.04 919.64 1,057.59 48552 208.28 197.87 227.55 # 49446 169.89 161.40 185.61 48554 2,163.68 2,055.50 2,363.83 49450 725.88 689.59 793.03 48556 1,077.22 1,023.36 1,176.86 # 49450 67.85 64.46 74.13 49000 675.64 641.86 738.14 49451 690.12 655.61 753.95 49002 888.70 844.27 970.91 # 49451 94.56 89.83 103.30 49010 839.00 797.05 916.61 49452 868.26 824.85 948.58 49020 1,385.67 1,316.39 1,513.85 # 49452 147.38 140.01 161.01 49021 864.09 820.89 944.02 49460 796.69 756.86 870.39 # 49021 172.78 164.14 188.76 # 49460 48.45 46.03 52.93 49040 869.34 825.87 949.75 49465 165.96 157.66 181.31 49041 881.25 837.19 962.77 # 49465 31.77 30.18 34.71 # 49041 204.36 194.14 223.26 49491 674.64 640.91 737.05 49060 974.14 925.43 1,064.24 49492 823.10 781.95 899.24 49061 866.37 823.05 946.51 49495 343.26 326.10 375.02 # 49061 189.11 179.65 206.60 49496 521.12 495.06 569.32 49062 661.42 628.35 722.60 49500 342.34 325.22 374.00 49080 162.86 154.72 177.93 49501 516.86 491.02 564.67 # 49080 68.96 65.51 75.34 49505 447.77 425.38 489.19 49081 152.03 144.43 166.09 49507 550.70 523.17 601.65 # 49081 64.79 61.55 70.78 49520 546.49 519.17 597.05 49180 162.87 154.73 177.94 49521 665.86 632.57 727.46 # 49180 88.57 84.14 96.76 49525 494.51 469.78 540.25 49203 1,058.47 1,005.55 1,156.38 49540 584.38 555.16 638.43 49204 1,350.71 1,283.17 1,475.65 49550 496.85 472.01 542.81 49205 1,546.02 1,468.72 1,689.03 49553 543.63 516.45 593.92 49215 1,937.65 1,840.77 2,116.89 49555 517.15 491.29 564.98 49220 844.14 801.93 922.22 49557 627.50 596.13 685.55 49250 505.38 480.11 552.13 49560 641.43 609.36 700.76 49255 685.90 651.61 749.35 49561 808.64 768.21 883.44 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 42 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 49565 665.42 632.15 726.97 50360 2,204.68 2,094.45 2,408.62 49566 817.00 776.15 892.57 50365 2,482.50 2,358.38 2,712.14 49568 239.86 227.87 262.05 50370 1,031.81 980.22 1,127.25 49570 353.21 335.55 385.88 50380 1,750.87 1,663.33 1,912.83 49572 437.42 415.55 477.88 50382 1,279.07 1,215.12 1,397.39 49580 275.86 262.07 301.38 # 50382 285.36 271.09 311.75 49582 408.15 387.74 445.90 50384 1,099.69 1,044.71 1,201.42 49585 379.47 360.50 414.58 # 50384 259.77 246.78 283.80 49587 449.20 426.74 490.75 50385 1,253.27 1,190.61 1,369.20 49590 492.69 468.06 538.27 # 50385 244.41 232.19 267.02 49600 636.74 604.90 695.64 50386 811.66 771.08 886.74 49605 4,383.29 4,164.13 4,788.75 # 50386 184.68 175.45 201.77 49606 991.46 941.89 1,083.17 50387 592.93 563.28 647.77 49610 592.95 563.30 647.80 # 50387 103.47 98.30 113.05 49611 536.36 509.54 585.97 50389 344.06 326.86 375.89 49650 368.31 349.89 402.37 # 50389 56.81 53.97 62.07 49651 476.34 452.52 520.40 50390 100.55 95.52 109.85 49652 691.49 656.92 755.46 50391 130.11 123.60 142.14 49653 864.04 820.84 943.97 # 50391 102.38 97.26 111.85 49654 794.22 754.51 867.69 50392 184.98 175.73 202.09 49655 955.87 908.08 1,044.29 50393 225.46 214.19 246.32 49656 796.92 757.07 870.63 50394 105.56 100.28 115.32 49657 1,149.48 1,092.01 1,255.81 # 50394 51.22 48.66 55.96 49900 707.89 672.50 773.38 50395 186.27 176.96 203.50 49904 1,322.93 1,256.78 1,445.30 50396 120.57 114.54 131.72 49905 320.90 304.86 350.59 50398 532.62 505.99 581.89 50010 697.61 662.73 762.14 # 50398 76.44 72.62 83.51 50020 993.97 944.27 1,085.91 50400 1,177.71 1,118.82 1,286.64 50021 909.56 864.08 993.69 50405 1,427.82 1,356.43 1,559.89 # 50021 172.41 163.79 188.36 50500 1,134.40 1,077.68 1,239.33 50040 939.08 892.13 1,025.95 50520 1,054.64 1,001.91 1,152.20 50045 946.71 899.37 1,034.28 50525 1,316.91 1,251.06 1,438.72 50060 1,166.55 1,108.22 1,274.45 50526 1,377.00 1,308.15 1,504.37 50065 1,224.48 1,163.26 1,337.75 50540 1,153.11 1,095.45 1,259.77 50070 1,218.92 1,157.97 1,331.67 50541 940.24 893.23 1,027.21 50075 1,497.68 1,422.80 1,636.22 50542 1,193.36 1,133.69 1,303.74 50080 891.62 847.04 974.10 50543 1,522.20 1,446.09 1,663.00 50081 1,308.69 1,243.26 1,429.75 50544 1,282.09 1,217.99 1,400.69 50100 946.08 898.78 1,033.60 50545 1,376.06 1,307.26 1,503.35 50120 965.42 917.15 1,054.72 50546 1,220.49 1,159.47 1,333.39 50125 996.86 947.02 1,089.07 50547 1,458.75 1,385.81 1,593.68 50130 1,057.30 1,004.44 1,155.11 50548 1,387.21 1,317.85 1,515.53 50135 1,144.53 1,087.30 1,250.40 50551 378.39 359.47 413.39 50200 144.64 137.41 158.02 # 50551 305.57 290.29 333.83 50205 667.52 634.14 729.26 50553 394.87 375.13 431.40 50220 1,039.40 987.43 1,135.54 # 50553 322.78 306.64 352.64 50225 1,204.06 1,143.86 1,315.44 50555 430.57 409.04 470.40 50230 1,305.96 1,240.66 1,426.76 # 50555 353.30 335.64 385.99 50234 1,326.06 1,259.76 1,448.72 50557 439.34 417.37 479.98 50236 1,501.55 1,426.47 1,640.44 # 50557 358.75 340.81 391.93 50240 1,348.91 1,281.46 1,473.68 50561 498.12 473.21 544.19 50250 1,252.45 1,189.83 1,368.30 # 50561 409.77 389.28 447.67 50280 961.47 913.40 1,050.41 50562 604.23 574.02 660.12 50290 884.15 839.94 965.93 50570 511.42 485.85 558.73 50320 1,305.70 1,240.42 1,426.48 50572 555.86 528.07 607.28 50323 183.98 174.78 201.00 50574 587.84 558.45 642.22 50325 183.98 174.78 201.00 50575 743.24 706.08 811.99 50327 194.88 185.14 212.91 50576 586.94 557.59 641.23 50328 171.14 162.58 186.97 50580 628.45 597.03 686.58 50329 169.26 160.80 184.92 50590 949.97 902.47 1,037.84 50340 803.47 763.30 877.80 # 50590 575.48 546.71 628.72 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 43 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 50592 3,646.23 3,463.92 3,983.51 50980 370.55 352.02 404.82 # 50592 371.58 353.00 405.95 51020 473.98 450.28 517.82 50593 4,705.58 4,470.30 5,140.85 51030 468.43 445.01 511.76 # 50593 470.49 446.97 514.02 51040 296.51 281.68 323.93 50600 954.40 906.68 1,042.68 51045 471.80 448.21 515.44 50605 916.43 870.61 1,001.20 51050 480.71 456.67 525.17 50610 972.59 923.96 1,062.55 51060 591.79 562.20 646.53 50620 924.43 878.21 1,009.94 51065 587.53 558.15 641.87 50630 900.58 855.55 983.88 51080 412.02 391.42 450.13 50650 1,053.78 1,001.09 1,151.25 51100 61.92 58.82 67.64 50660 1,164.63 1,106.40 1,272.36 # 51100 39.37 37.40 43.01 50684 183.19 174.03 200.13 51101 127.66 121.28 139.47 # 50684 50.85 48.31 55.56 # 51101 52.61 49.98 57.48 50686 92.64 88.01 101.21 51102 239.87 227.88 262.06 50688 81.14 77.08 88.64 # 51102 153.36 145.69 167.54 50690 101.49 96.42 110.88 51500 629.50 598.03 687.73 # 50690 71.54 67.96 78.15 51520 595.39 565.62 650.46 50700 942.92 895.77 1,030.14 51525 875.12 831.36 956.06 50715 1,107.47 1,052.10 1,209.92 51530 778.65 739.72 850.68 50722 963.12 914.96 1,052.20 51535 789.81 750.32 862.87 50725 1,107.22 1,051.86 1,209.64 51550 960.13 912.12 1,048.94 50727 510.66 485.13 557.90 51555 1,276.67 1,212.84 1,394.77 50728 700.82 665.78 765.65 51565 1,306.06 1,240.76 1,426.87 50740 1,085.75 1,031.46 1,186.18 51570 1,491.65 1,417.07 1,629.63 50750 1,185.52 1,126.24 1,295.18 51575 1,865.14 1,771.88 2,037.66 50760 1,103.43 1,048.26 1,205.50 51580 1,944.27 1,847.06 2,124.12 50770 1,145.72 1,088.43 1,251.69 51585 2,165.38 2,057.11 2,365.68 50780 1,107.27 1,051.91 1,209.70 51590 1,971.99 1,873.39 2,154.40 50782 1,086.01 1,031.71 1,186.47 51595 2,241.20 2,129.14 2,448.51 50783 1,123.64 1,067.46 1,227.58 51596 2,409.63 2,289.15 2,632.52 50785 1,230.21 1,168.70 1,344.01 51597 2,322.51 2,206.38 2,537.34 50800 934.76 888.02 1,021.22 51600 196.94 187.09 215.15 50810 1,222.09 1,160.99 1,335.14 # 51600 45.37 43.10 49.57 50815 1,246.24 1,183.93 1,361.52 51605 39.32 37.35 42.95 50820 1,324.55 1,258.32 1,447.07 51610 113.42 107.75 123.91 50825 1,682.98 1,598.83 1,838.65 # 51610 64.99 61.74 71.00 50830 1,825.26 1,734.00 1,994.10 51700 89.00 84.55 97.23 50840 1,254.86 1,192.12 1,370.94 # 51700 45.37 43.10 49.57 50845 1,272.89 1,209.25 1,390.64 51701 62.00 58.90 67.74 50860 963.26 915.10 1,052.37 # 51701 27.62 26.24 30.18 50900 847.46 805.09 925.85 51702 80.11 76.10 87.52 50920 897.69 852.81 980.73 # 51702 30.57 29.04 33.40 50930 1,084.12 1,029.91 1,184.40 51703 143.52 136.34 156.79 50940 901.28 856.22 984.65 # 51703 83.63 79.45 91.37 50945 999.88 949.89 1,092.37 51705 115.65 109.87 126.35 50947 1,415.38 1,344.61 1,546.30 # 51705 68.34 64.92 74.66 50948 1,316.18 1,250.37 1,437.93 51710 162.89 154.75 177.96 50951 395.36 375.59 431.93 # 51710 97.09 92.24 106.08 # 50951 318.84 302.90 348.34 51715 299.75 284.76 327.47 50953 417.17 396.31 455.76 # 51715 203.26 193.10 222.07 # 50953 351.36 333.79 383.86 51720 118.69 112.76 129.67 50955 461.59 438.51 504.29 # 51720 85.05 80.80 92.92 # 50955 379.52 360.54 414.62 51725 225.14 213.88 245.96 50957 448.61 426.18 490.11 51725 TC 147.47 140.10 161.12 # 50957 367.65 349.27 401.66 51725 26 77.66 73.78 84.85 50961 405.15 384.89 442.62 51726 328.45 312.03 358.83 # 50961 329.37 312.90 359.84 51726 TC 240.07 228.07 262.28 50970 385.79 366.50 421.48 51726 26 88.38 83.96 96.55 50972 371.43 352.86 405.79 51736 54.49 51.77 59.54 50974 491.82 467.23 537.31 51736 TC 22.73 21.59 24.83 50976 484.16 459.95 528.94 51736 26 31.76 30.17 34.70 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 44 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 51741 85.95 81.65 93.90 52270 422.30 401.19 461.37 51741 TC 26.60 25.27 29.06 # 52270 188.29 178.88 205.71 51741 26 59.35 56.38 64.84 52275 577.59 548.71 631.02 51772 252.00 239.40 275.31 # 52275 257.82 244.93 281.67 51772 TC 169.83 161.34 185.54 52276 275.28 261.52 300.75 51772 26 82.17 78.06 89.77 52277 336.08 319.28 367.17 51784 206.26 195.95 225.34 52281 317.10 301.25 346.44 51784 TC 127.88 121.49 139.71 # 52281 159.62 151.64 174.39 51784 26 78.38 74.46 85.63 52282 346.77 329.43 378.84 51785 224.20 212.99 244.94 52283 290.71 276.17 317.60 51785 TC 145.63 138.35 159.10 # 52283 207.16 196.80 226.32 51785 26 78.58 74.65 85.85 52285 293.05 278.40 320.16 51792 235.46 223.69 257.24 # 52285 200.63 190.60 219.19 51792 TC 179.02 170.07 195.58 52290 253.30 240.64 276.74 51792 26 56.44 53.62 61.66 52300 290.69 276.16 317.58 51795 309.36 293.89 337.97 52301 305.23 289.97 333.47 51795 TC 230.61 219.08 251.94 52305 288.84 274.40 315.56 51795 26 78.75 74.81 86.03 52310 260.53 247.50 284.63 51797 152.39 144.77 166.49 # 52310 156.65 148.82 171.14 51797 TC 107.73 102.34 117.69 52315 460.65 437.62 503.26 51797 26 44.66 42.43 48.79 # 52315 284.68 270.45 311.02 51798 20.64 19.61 22.55 52317 990.63 941.10 1,082.27 51800 1,062.34 1,009.22 1,160.60 # 52317 361.06 343.01 394.46 51820 1,078.98 1,025.03 1,178.78 52318 491.98 467.38 537.49 51840 644.86 612.62 704.51 52320 255.60 242.82 279.24 51841 765.00 726.75 835.76 52325 332.39 315.77 363.14 51845 589.41 559.94 643.93 52327 549.76 522.27 600.61 51860 718.74 682.80 785.22 # 52327 271.76 258.17 296.90 51865 891.59 847.01 974.06 52330 806.65 766.32 881.27 51880 467.10 443.75 510.31 # 52330 273.57 259.89 298.87 51900 826.52 785.19 902.97 52332 499.51 474.53 545.71 51920 763.87 725.68 834.53 # 52332 161.25 153.19 176.17 51925 992.08 942.48 1,083.85 52334 265.82 252.53 290.41 51940 1,631.73 1,550.14 1,782.66 52341 302.25 287.14 330.21 51960 1,412.47 1,341.85 1,543.13 52342 328.58 312.15 358.97 51980 724.19 687.98 791.18 52343 365.43 347.16 399.23 51990 739.87 702.88 808.31 52344 396.38 376.56 433.04 51992 807.26 766.90 881.94 52345 422.70 401.57 461.81 52000 215.63 204.85 235.58 52346 476.99 453.14 521.11 # 52000 128.38 121.96 140.25 52351 325.47 309.20 355.58 52001 394.25 374.54 430.72 52352 382.16 363.05 417.51 # 52001 297.02 282.17 324.50 52353 439.53 417.55 480.18 52005 298.47 283.55 326.08 52354 406.31 385.99 443.89 # 52005 136.92 130.07 149.58 52355 484.19 459.98 528.98 52007 560.88 532.84 612.77 52400 497.78 472.89 543.82 # 52007 171.23 162.67 187.07 52402 278.13 264.22 303.85 52010 416.53 395.70 455.06 52450 476.64 452.81 520.73 # 52010 165.88 157.59 181.23 52500 497.71 472.82 543.74 52204 459.46 436.49 501.96 52601 843.19 801.03 921.18 # 52204 145.23 137.97 158.67 52630 452.06 429.46 493.88 52214 603.12 572.96 658.90 52640 308.69 293.26 337.25 # 52214 225.31 214.04 246.15 52647 2,253.16 2,140.50 2,461.58 52224 864.65 821.42 944.63 # 52647 657.98 625.08 718.84 # 52224 175.19 166.43 191.39 52648 2,300.04 2,185.04 2,512.80 52234 255.29 242.53 278.91 # 52648 701.90 666.81 766.83 52235 299.24 284.28 326.92 52649 1,003.48 953.31 1,096.31 52240 522.89 496.75 571.26 52700 441.78 419.69 482.64 52250 250.80 238.26 274.00 53000 151.60 144.02 165.62 52260 216.23 205.42 236.23 53010 297.93 283.03 325.48 52265 438.59 416.66 479.16 53020 100.16 95.15 109.42 # 52265 162.80 154.66 177.86 53025 65.83 62.54 71.92 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 45 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 53040 399.54 379.56 436.49 53852 2,492.97 2,368.32 2,723.57 53060 175.59 166.81 191.83 # 53852 631.99 600.39 690.45 # 53060 154.89 147.15 169.22 54000 160.99 152.94 175.88 53080 443.37 421.20 484.38 # 54000 109.23 103.77 119.34 53085 624.47 593.25 682.24 54001 197.34 187.47 215.59 53200 158.33 150.41 172.97 # 54001 140.41 133.39 153.40 # 53200 143.91 136.71 157.22 54015 316.17 300.36 345.41 53210 784.31 745.09 856.85 54050 121.17 115.11 132.38 53215 952.31 904.69 1,040.39 # 54050 96.03 91.23 104.91 53220 458.83 435.89 501.27 54055 115.65 109.87 126.35 53230 610.68 580.15 667.17 # 54055 88.30 83.89 96.47 53235 650.30 617.79 710.46 54056 126.73 120.39 138.45 53240 436.94 415.09 477.35 # 54056 99.37 94.40 108.56 53250 405.49 385.22 443.00 54057 139.46 132.49 152.36 53260 202.10 192.00 220.80 # 54057 92.88 88.24 101.48 # 53260 178.07 169.17 194.55 54060 187.98 178.58 205.37 53265 225.09 213.84 245.92 # 54060 129.20 122.74 141.15 # 53265 187.38 178.01 204.71 54065 205.65 195.37 224.68 53270 205.48 195.21 224.49 # 54065 157.96 150.06 172.57 # 53270 182.92 173.77 199.84 54100 189.34 179.87 206.85 53275 270.71 257.17 295.75 # 54100 117.25 111.39 128.10 53400 815.50 774.73 890.94 54105 283.34 269.17 309.55 53405 897.95 853.05 981.01 # 54105 219.75 208.76 240.07 53410 1,002.18 952.07 1,094.88 54110 635.94 604.14 694.76 53415 1,155.12 1,097.36 1,261.96 54111 821.15 780.09 897.10 53420 820.10 779.10 895.97 54112 963.85 915.66 1,053.01 53425 965.21 916.95 1,054.49 54115 459.89 436.90 502.44 53430 961.92 913.82 1,050.89 # 54115 428.83 407.39 468.50 53431 1,180.54 1,121.51 1,289.74 54120 643.66 611.48 703.20 53440 895.25 850.49 978.06 54125 828.61 787.18 905.26 53442 788.88 749.44 861.86 54130 1,225.18 1,163.92 1,338.51 53444 813.61 772.93 888.87 54135 1,554.87 1,477.13 1,698.70 53445 899.22 854.26 982.40 54150 172.29 163.68 188.23 53446 657.67 624.79 718.51 # 54150 99.09 94.14 108.26 53447 831.08 789.53 907.96 54160 239.19 227.23 261.31 53448 1,312.10 1,246.50 1,433.48 # 54160 147.88 140.49 161.56 53449 625.21 593.95 683.04 54161 201.11 191.05 219.71 53450 416.40 395.58 454.92 54162 276.93 263.08 302.54 53460 467.41 444.04 510.65 # 54162 200.04 190.04 218.55 53500 750.02 712.52 819.40 54163 222.22 211.11 242.78 53502 493.47 468.80 539.12 54164 195.89 186.10 214.02 53505 496.49 471.67 542.42 54200 113.20 107.54 123.67 53510 645.50 613.23 705.21 # 54200 86.21 81.90 94.19 53515 812.58 771.95 887.74 54205 547.62 520.24 598.28 53520 566.90 538.56 619.34 54220 218.58 207.65 238.80 53600 88.49 84.07 96.68 # 54220 137.99 131.09 150.75 # 53600 66.31 62.99 72.44 54230 100.20 95.19 109.47 53601 86.49 82.17 94.50 # 54230 82.09 77.99 89.69 # 53601 55.44 52.67 60.57 54231 144.81 137.57 158.21 53605 66.62 63.29 72.78 # 54231 120.78 114.74 131.95 53620 126.92 120.57 138.66 54235 92.77 88.13 101.35 # 53620 90.32 85.80 98.67 # 54235 75.39 71.62 82.36 53621 120.33 114.31 131.46 54240 103.87 98.68 113.48 # 53621 74.86 71.12 81.79 54240 TC 35.45 33.68 38.73 53660 75.29 71.53 82.26 54240 26 68.42 65.00 74.75 # 53660 42.39 40.27 46.31 54250 128.73 122.29 140.63 53661 74.91 71.16 81.83 54250 TC 12.55 11.92 13.71 # 53661 41.64 39.56 45.49 54250 26 116.18 110.37 126.93 53665 38.83 36.89 42.42 54300 663.02 629.87 724.35 53850 2,592.52 2,462.89 2,832.32 54304 776.40 737.58 848.22 # 53850 579.96 550.96 633.60 54308 739.31 702.34 807.69 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 46 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 54312 852.67 810.04 931.55 55040 342.51 325.38 374.19 54316 1,032.68 981.05 1,128.21 55041 515.07 489.32 562.72 54318 741.87 704.78 810.50 55060 383.11 363.95 418.54 54322 808.27 767.86 883.04 55100 220.44 209.42 240.83 54324 1,004.16 953.95 1,097.04 # 55100 163.14 154.98 178.23 54326 942.37 895.25 1,029.54 55110 389.81 370.32 425.87 54328 957.56 909.68 1,046.13 55120 357.86 339.97 390.97 54332 1,046.07 993.77 1,142.84 55150 493.65 468.97 539.32 54336 1,179.58 1,120.60 1,288.69 55175 367.35 348.98 401.33 54340 575.92 547.12 629.19 55180 696.05 661.25 760.44 54344 988.78 939.34 1,080.24 55200 503.83 478.64 550.44 54348 1,052.01 999.41 1,149.32 # 55200 280.91 266.86 306.89 54352 1,478.99 1,405.04 1,615.80 55250 445.80 423.51 487.04 54360 745.08 707.83 814.00 # 55250 231.02 219.47 252.39 54380 825.66 784.38 902.04 55300 184.27 175.06 201.32 54385 1,000.85 950.81 1,093.43 55400 514.57 488.84 562.17 54390 1,206.95 1,146.60 1,318.59 55450 391.58 372.00 427.80 54400 545.85 518.56 596.34 # 55450 259.60 246.62 283.61 54401 669.50 636.03 731.43 55500 379.10 360.15 414.17 54405 829.01 787.56 905.69 55520 388.17 368.76 424.07 54406 747.56 710.18 816.71 55530 359.23 341.27 392.46 54408 805.06 764.81 879.53 55535 434.48 412.76 474.67 54410 882.88 838.74 964.55 55540 469.91 446.41 513.37 54411 1,045.09 992.84 1,141.77 55550 429.22 407.76 468.92 54415 538.07 511.17 587.85 55600 432.86 411.22 472.90 54416 720.88 684.84 787.57 55605 511.15 485.59 558.43 54417 916.86 871.02 1,001.67 55650 727.03 690.68 794.28 54420 724.94 688.69 791.99 55680 344.52 327.29 376.38 54430 657.26 624.40 718.06 55700 237.70 225.82 259.69 54435 426.35 405.03 465.78 # 55700 140.11 133.10 153.07 54450 75.09 71.34 82.04 55705 275.48 261.71 300.97 # 54450 60.30 57.29 65.88 55706 391.02 371.47 427.19 54500 77.49 73.62 84.66 55720 469.09 445.64 512.49 54505 217.93 207.03 238.08 55725 598.68 568.75 654.06 54512 546.26 518.95 596.79 55801 1,110.33 1,054.81 1,213.03 54520 330.94 314.39 361.55 55810 1,342.66 1,275.53 1,466.86 54522 591.48 561.91 646.20 55812 1,649.52 1,567.04 1,802.10 54530 516.93 491.08 564.74 55815 1,809.70 1,719.22 1,977.10 54535 748.88 711.44 818.16 55821 894.03 849.33 976.73 54550 498.35 473.43 544.44 55831 968.64 920.21 1,058.24 54560 677.63 643.75 740.31 55840 1,370.65 1,302.12 1,497.44 54600 461.40 438.33 504.08 55842 1,468.70 1,395.27 1,604.56 54620 309.49 294.02 338.12 55845 1,679.10 1,595.15 1,834.42 54640 473.67 449.99 517.49 55860 896.72 851.88 979.66 54650 722.67 686.54 789.52 55862 1,131.60 1,075.02 1,236.27 54660 362.05 343.95 395.54 55865 1,371.80 1,303.21 1,498.69 54670 412.39 391.77 450.54 55866 1,784.27 1,695.06 1,949.32 54680 798.05 758.15 871.87 55870 180.18 171.17 196.85 54690 643.12 610.96 702.60 # 55870 148.02 140.62 161.71 54692 787.47 748.10 860.32 55873 1,168.88 1,110.44 1,277.01 54700 214.80 204.06 234.67 55875 778.65 739.72 850.68 54800 135.07 128.32 147.57 55876 144.63 137.40 158.01 54830 375.70 356.92 410.46 # 55876 108.03 102.63 118.02 54840 329.77 313.28 360.27 55920 436.44 414.62 476.81 54860 425.83 404.54 465.22 56405 100.78 95.74 110.10 54861 575.19 546.43 628.39 # 56405 98.56 93.63 107.67 54865 362.80 344.66 396.36 56420 116.91 111.06 127.72 54900 768.71 730.27 839.81 # 56420 85.12 80.86 92.99 54901 1,093.41 1,038.74 1,194.55 56440 169.44 160.97 185.12 55000 124.51 118.28 136.02 56441 140.02 133.02 152.97 # 55000 86.06 81.76 94.02 # 56441 132.25 125.64 144.49 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 47 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 56442 45.54 43.26 49.75 57200 274.86 261.12 300.29 56501 121.20 115.14 132.41 57210 340.12 323.11 371.58 # 56501 104.94 99.69 114.64 57220 296.06 281.26 323.45 56515 206.08 195.78 225.15 57230 370.70 352.17 405.00 # 56515 181.68 172.60 198.49 57240 616.97 586.12 674.04 56605 77.84 73.95 85.04 57250 602.71 572.57 658.46 # 56605 56.40 53.58 61.62 57260 749.91 712.41 819.27 56606 35.87 34.08 39.19 57265 836.47 794.65 913.85 # 56606 27.73 26.34 30.29 57267 250.58 238.05 273.76 56620 456.29 433.48 498.50 57268 445.73 423.44 486.96 56625 548.49 521.07 599.23 57270 737.91 701.01 806.16 56630 801.01 760.96 875.10 57280 897.63 852.75 980.66 56631 1,018.55 967.62 1,112.76 57282 471.66 448.08 515.29 56632 1,178.92 1,119.97 1,287.97 57283 637.97 606.07 696.98 56633 1,044.19 991.98 1,140.78 57284 778.52 739.59 850.53 56634 1,102.84 1,047.70 1,204.86 57285 624.82 593.58 682.62 56637 1,302.52 1,237.39 1,423.00 57287 657.83 624.94 718.68 56640 1,296.70 1,231.87 1,416.65 57288 689.64 655.16 753.43 56700 172.12 163.51 188.04 57289 724.26 688.05 791.26 56740 273.97 260.27 299.31 57291 502.70 477.57 549.21 56800 225.73 214.44 246.61 57292 767.43 729.06 838.42 56805 1,060.63 1,007.60 1,158.74 57295 457.22 434.36 499.51 56810 242.19 230.08 264.59 57296 877.81 833.92 959.01 56820 103.13 97.97 112.67 57300 491.62 467.04 537.10 # 56820 78.74 74.80 86.02 57305 818.06 777.16 893.73 56821 137.89 131.00 150.65 57307 914.76 869.02 999.37 # 56821 106.84 101.50 116.73 57308 585.64 556.36 639.81 57000 176.93 168.08 193.29 57310 461.55 438.47 504.24 57010 397.65 377.77 434.44 57311 526.32 500.00 575.00 57020 87.61 83.23 95.71 57320 524.10 497.90 572.59 # 57020 75.78 71.99 82.79 57330 742.66 705.53 811.36 57022 154.12 146.41 168.37 57335 1,078.99 1,025.04 1,178.80 57023 288.10 273.70 314.76 57400 126.04 119.74 137.70 57061 105.77 100.48 115.55 57410 99.21 94.25 108.39 # 57061 89.87 85.38 98.19 57415 148.45 141.03 162.18 57065 178.36 169.44 194.86 57420 108.40 102.98 118.43 # 57065 158.03 150.13 172.65 # 57420 83.63 79.45 91.37 57100 82.36 78.24 89.98 57421 145.87 138.58 159.37 # 57100 60.92 57.87 66.55 # 57421 114.08 108.38 124.64 57105 126.22 119.91 137.90 57423 858.10 815.20 937.48 # 57105 115.87 110.08 126.59 57425 904.68 859.45 988.37 57106 438.86 416.92 479.46 57452 102.03 96.93 111.47 57107 1,291.66 1,227.08 1,411.14 # 57452 85.39 81.12 93.29 57109 1,475.28 1,401.52 1,611.75 57454 143.72 136.53 157.01 57110 832.16 790.55 909.13 # 57454 127.08 120.73 138.84 57111 1,491.94 1,417.34 1,629.94 57455 134.07 127.37 146.48 57112 1,585.48 1,506.21 1,732.14 # 57455 103.39 98.22 112.95 57120 473.48 449.81 517.28 57456 126.82 120.48 138.55 57130 168.19 159.78 183.75 # 57456 96.50 91.68 105.43 # 57130 149.34 141.87 163.15 57460 280.74 266.70 306.71 57135 180.16 171.15 196.82 # 57460 152.46 144.84 166.57 # 57135 160.94 152.89 175.82 57461 314.35 298.63 343.42 57150 47.70 45.32 52.12 # 57461 175.72 166.93 191.97 # 57150 27.73 26.34 30.29 57500 124.52 118.29 136.03 57155 394.48 374.76 430.97 # 57500 69.44 65.97 75.87 57160 72.32 68.70 79.01 57505 94.60 89.87 103.35 # 57160 44.59 42.36 48.71 # 57505 84.25 80.04 92.05 57170 64.72 61.48 70.70 57510 123.62 117.44 135.06 # 57170 45.12 42.86 49.29 # 57510 107.73 102.34 117.69 57180 132.80 126.16 145.08 57511 135.07 128.32 147.57 # 57180 99.16 94.20 108.33 # 57511 121.76 115.67 133.02 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 48 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 57513 133.22 126.56 145.54 58353 1,088.32 1,033.90 1,188.99 # 57513 122.50 116.38 133.84 # 58353 204.41 194.19 223.32 57520 285.99 271.69 312.44 58356 1,994.38 1,894.66 2,178.86 # 57520 252.72 240.08 276.09 # 58356 323.79 307.60 353.74 57522 244.67 232.44 267.31 58400 414.70 393.97 453.07 # 57522 224.34 213.12 245.09 58410 740.17 703.16 808.63 57530 317.99 302.09 347.40 58520 722.33 686.21 789.14 57531 1,567.52 1,489.14 1,712.51 58540 838.01 796.11 915.53 57540 718.79 682.85 785.28 58541 790.79 751.25 863.94 57545 758.52 720.59 828.68 58542 879.12 835.16 960.43 57550 375.95 357.15 410.72 58543 893.60 848.92 976.26 57555 553.53 525.85 604.73 58544 965.33 917.06 1,054.62 57556 529.60 503.12 578.59 58545 825.04 783.79 901.36 57558 116.26 110.45 127.02 58546 1,044.90 992.66 1,141.56 # 57558 104.80 99.56 114.49 58548 1,629.28 1,547.82 1,779.99 57700 284.06 269.86 310.34 58550 815.35 774.58 890.77 57720 283.35 269.18 309.56 58552 900.59 855.56 983.89 57800 56.36 53.54 61.57 58553 1,050.34 997.82 1,147.49 # 57800 45.26 43.00 49.45 58554 1,206.05 1,145.75 1,317.61 58100 102.74 97.60 112.24 58555 224.43 213.21 245.19 # 58100 81.67 77.59 89.23 # 58555 177.11 168.25 193.49 58110 45.63 43.35 49.85 58558 302.70 287.57 330.71 # 58110 38.61 36.68 42.18 # 58558 249.46 236.99 272.54 58120 231.82 220.23 253.26 58559 320.70 304.67 350.37 # 58120 199.29 189.33 217.73 58560 362.39 344.27 395.91 58140 841.80 799.71 919.67 58561 512.64 487.01 560.06 58145 500.58 475.55 546.88 58562 319.61 303.63 349.17 58146 1,071.89 1,018.30 1,171.05 # 58562 271.92 258.32 297.07 58150 912.68 867.05 997.11 58563 1,770.96 1,682.41 1,934.77 58152 1,151.21 1,093.65 1,257.70 # 58563 320.70 304.67 350.37 58180 877.43 833.56 958.59 58565 1,879.80 1,785.81 2,053.68 58200 1,205.65 1,145.37 1,317.18 # 58565 408.46 388.04 446.25 58210 1,605.98 1,525.68 1,754.53 58570 848.77 806.33 927.28 58240 2,531.02 2,404.47 2,765.14 58571 933.47 886.80 1,019.82 58260 762.72 724.58 833.27 58572 1,054.41 1,001.69 1,151.94 58262 851.69 809.11 930.48 58573 1,195.33 1,135.56 1,305.89 58263 917.51 871.63 1,002.37 58600 335.45 318.68 366.48 58267 974.81 926.07 1,064.98 58605 305.18 289.92 333.41 58270 816.42 775.60 891.94 58611 72.50 68.88 79.21 58275 908.66 863.23 992.71 58615 230.69 219.16 252.03 58280 971.88 923.29 1,061.78 58660 619.98 588.98 677.33 58285 1,217.83 1,156.94 1,330.48 58661 595.47 565.70 650.56 58290 1,066.98 1,013.63 1,165.67 58662 652.19 619.58 712.52 58291 1,159.28 1,101.32 1,266.52 58670 337.84 320.95 369.09 58292 1,221.41 1,160.34 1,334.39 58671 337.65 320.77 368.89 58293 1,267.95 1,204.55 1,385.23 58672 685.53 651.25 748.94 58294 1,127.12 1,070.76 1,231.37 58673 745.83 708.54 814.82 58301 89.87 85.38 98.19 58700 702.83 667.69 767.84 # 58301 63.25 60.09 69.10 58720 660.72 627.68 721.83 58321 73.77 70.08 80.59 58740 805.35 765.08 879.84 # 58321 46.42 44.10 50.72 58750 837.64 795.76 915.12 58322 81.91 77.81 89.48 58752 844.33 802.11 922.43 # 58322 54.92 52.17 60.00 58760 757.71 719.82 827.79 58323 18.07 17.17 19.75 58770 776.96 738.11 848.83 # 58323 11.79 11.20 12.88 58800 297.06 282.21 324.54 58340 121.69 115.61 132.95 # 58800 275.99 262.19 301.52 # 58340 55.52 52.74 60.65 58805 373.99 355.29 408.58 58345 258.52 245.59 282.43 58820 289.35 274.88 316.11 58346 423.15 401.99 462.29 58822 651.42 618.85 711.68 58350 90.29 85.78 98.65 58823 874.04 830.34 954.89 # 58350 72.55 68.92 79.26 # 58823 172.01 163.41 187.92 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 49 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 58825 642.44 610.32 701.87 59412 94.65 89.92 103.41 58900 381.60 362.52 416.90 59414 83.66 79.48 91.40 58920 646.09 613.79 705.86 59425 403.16 383.00 440.45 58925 674.16 640.45 736.52 # 59425 311.85 296.26 340.70 58940 462.43 439.31 505.21 59426 722.03 685.93 788.82 58943 1,029.08 977.63 1,124.27 # 59426 551.98 524.38 603.04 58950 982.21 933.10 1,073.07 59430 127.84 121.45 139.67 58951 1,266.10 1,202.80 1,383.22 # 59430 114.90 109.16 125.53 58952 1,427.80 1,356.41 1,559.87 59510 1,820.69 1,729.66 1,989.11 58953 1,770.21 1,681.70 1,933.96 59514 831.23 789.67 908.12 58954 1,921.41 1,825.34 2,099.14 59515 984.72 935.48 1,075.80 58956 1,233.35 1,171.68 1,347.43 59525 442.80 420.66 483.76 58957 1,362.66 1,294.53 1,488.71 59610 1,692.76 1,608.12 1,849.34 58958 1,514.24 1,438.53 1,654.31 59612 786.55 747.22 859.30 58960 848.85 806.41 927.37 59614 882.53 838.40 964.16 58970 208.52 198.09 227.80 59618 1,904.15 1,808.94 2,080.28 # 58970 185.23 175.97 202.37 59620 912.55 866.92 996.96 58976 238.90 226.96 261.00 59622 1,067.63 1,014.25 1,166.39 # 58976 208.22 197.81 227.48 59812 286.09 271.79 312.56 59000 120.04 114.04 131.15 # 59812 265.76 252.47 290.34 # 59000 74.20 70.49 81.06 59820 340.55 323.52 372.05 59001 169.60 161.12 185.29 # 59820 315.78 299.99 344.99 59012 186.31 176.99 203.54 59821 345.56 328.28 377.52 59015 143.29 136.13 156.55 # 59821 319.32 303.35 348.85 # 59015 121.48 115.41 132.72 59830 395.28 375.52 431.85 59020 65.02 61.77 71.04 59840 198.05 188.15 216.37 59020 TC 30.61 29.08 33.44 # 59840 191.40 181.83 209.10 59020 26 34.41 32.69 37.59 59841 343.78 326.59 375.58 59025 43.22 41.06 47.22 # 59841 323.45 307.28 353.37 59025 TC 15.51 14.73 16.94 59850 353.80 336.11 386.53 59025 26 27.71 26.32 30.27 59851 363.77 345.58 397.42 59030 103.40 98.23 112.96 59852 510.83 485.29 558.08 59050 46.18 43.87 50.45 59855 376.72 357.88 411.56 59051 38.21 36.30 41.75 59856 444.00 421.80 485.07 59070 371.41 352.84 405.77 59857 532.08 505.48 581.30 # 59070 271.96 258.36 297.11 59866 219.23 208.27 239.51 59072 449.44 426.97 491.02 59870 427.19 405.83 466.70 59074 351.44 333.87 383.95 59871 122.66 116.53 134.01 # 59074 269.37 255.90 294.29 60000 145.60 138.32 159.07 59076 439.09 417.14 479.71 # 60000 132.66 126.03 144.93 59100 747.96 710.56 817.14 60100 108.68 103.25 118.74 59120 715.49 679.72 781.68 # 60100 78.74 74.80 86.02 59121 718.33 682.41 784.77 60200 587.91 558.51 642.29 59130 837.03 795.18 914.46 60210 626.92 595.57 684.91 59135 849.06 806.61 927.60 60212 898.62 853.69 981.74 59136 792.31 752.69 865.59 60220 687.38 653.01 750.96 59140 356.98 339.13 390.00 60225 825.85 784.56 902.24 59150 694.70 659.97 758.97 60240 872.75 829.11 953.48 59151 678.45 644.53 741.21 60252 1,180.04 1,121.04 1,289.20 59160 196.32 186.50 214.48 60254 1,523.20 1,447.04 1,664.10 # 59160 163.79 155.60 178.94 60260 985.49 936.22 1,076.65 59200 68.83 65.39 75.20 60270 1,242.35 1,180.23 1,357.26 # 59200 41.11 39.05 44.91 60271 953.12 905.46 1,041.28 59300 176.89 168.05 193.26 60280 397.47 377.60 434.24 # 59300 133.63 126.95 145.99 60281 529.68 503.20 578.68 59320 140.21 133.20 153.18 60300 102.77 97.63 112.27 59325 221.20 210.14 241.66 # 60300 48.43 46.01 52.91 59350 252.90 240.26 276.30 60500 904.53 859.30 988.20 59400 1,607.98 1,527.58 1,756.72 60502 1,135.18 1,078.42 1,240.18 59409 701.91 666.81 766.83 60505 1,248.17 1,185.76 1,363.62 59410 816.88 776.04 892.45 60512 220.56 209.53 240.96 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 50 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 60520 931.22 884.66 1,017.36 61519 2,556.24 2,428.43 2,792.69 60521 1,067.92 1,014.52 1,166.70 61520 3,282.53 3,118.40 3,586.16 60522 1,288.33 1,223.91 1,407.50 61521 2,746.55 2,609.22 3,000.60 60540 986.43 937.11 1,077.68 61522 1,886.55 1,792.22 2,061.05 60545 1,120.90 1,064.86 1,224.59 61524 1,781.17 1,692.11 1,945.93 60600 1,302.63 1,237.50 1,423.13 61526 2,999.57 2,849.59 3,277.03 60605 1,639.65 1,557.67 1,791.32 61530 2,547.26 2,419.90 2,782.89 60650 1,095.22 1,040.46 1,196.53 61531 1,036.30 984.49 1,132.16 61000 101.07 96.02 110.42 61533 1,304.85 1,239.61 1,425.55 61001 98.72 93.78 107.85 61534 1,406.39 1,336.07 1,536.48 61020 117.06 111.21 127.89 61535 844.40 802.18 922.51 61026 116.72 110.88 127.51 61536 2,236.73 2,124.89 2,443.62 61050 100.77 95.73 110.09 61537 2,068.55 1,965.12 2,259.89 61055 129.40 122.93 141.37 61538 2,220.74 2,109.70 2,426.16 61070 75.04 71.29 81.98 61539 2,024.78 1,923.54 2,212.07 61105 382.69 363.56 418.09 61540 1,896.85 1,802.01 2,072.31 61107 280.13 266.12 306.04 61541 1,829.80 1,738.31 1,999.06 61108 758.83 720.89 829.02 61542 1,979.61 1,880.63 2,162.72 61120 622.39 591.27 679.96 61543 1,848.35 1,755.93 2,019.32 61140 1,075.43 1,021.66 1,174.91 61544 1,524.97 1,448.72 1,666.03 61150 1,150.64 1,093.11 1,257.08 61545 2,726.22 2,589.91 2,978.40 61151 834.29 792.58 911.47 61546 1,976.29 1,877.48 2,159.10 61154 1,077.19 1,023.33 1,176.83 61548 1,352.63 1,285.00 1,477.75 61156 1,072.70 1,019.07 1,171.93 61550 895.51 850.73 978.34 61210 327.09 310.74 357.35 61552 1,177.97 1,119.07 1,286.93 61215 417.52 396.64 456.14 61556 1,415.02 1,344.27 1,545.91 61250 725.74 689.45 792.87 61557 1,450.97 1,378.42 1,585.18 61253 801.12 761.06 875.22 61558 1,523.84 1,447.65 1,664.80 61304 1,414.92 1,344.17 1,545.80 61559 2,073.55 1,969.87 2,265.35 61305 1,710.44 1,624.92 1,868.66 61563 1,677.26 1,593.40 1,832.41 61312 1,773.34 1,684.67 1,937.37 61564 2,085.04 1,980.79 2,277.91 61313 1,693.68 1,609.00 1,850.35 61566 1,932.07 1,835.47 2,110.79 61314 1,565.45 1,487.18 1,710.26 61567 2,181.89 2,072.80 2,383.72 61315 1,781.75 1,692.66 1,946.56 61570 1,579.25 1,500.29 1,725.33 61316 77.05 73.20 84.18 61571 1,713.08 1,627.43 1,871.54 61320 1,647.72 1,565.33 1,800.13 61575 2,057.09 1,954.24 2,247.38 61321 1,806.11 1,715.80 1,973.17 61576 3,314.36 3,148.64 3,620.94 61322 2,006.68 1,906.35 2,192.30 61580 2,182.98 2,073.83 2,384.90 61323 2,039.26 1,937.30 2,227.90 61581 2,449.27 2,326.81 2,675.83 61330 1,419.20 1,348.24 1,550.48 61582 2,495.69 2,370.91 2,726.55 61332 1,630.05 1,548.55 1,780.83 61583 2,506.60 2,381.27 2,738.46 61333 1,653.23 1,570.57 1,806.16 61584 2,446.53 2,324.20 2,672.83 61334 1,077.79 1,023.90 1,177.49 61585 2,601.41 2,471.34 2,842.04 61340 1,228.28 1,166.87 1,341.90 61586 1,883.25 1,789.09 2,057.45 61343 1,895.48 1,800.71 2,070.82 61590 2,767.65 2,629.27 3,023.66 61345 1,754.86 1,667.12 1,917.19 61591 2,785.32 2,646.05 3,042.96 61440 1,717.77 1,631.88 1,876.66 61592 2,746.94 2,609.59 3,001.03 61450 1,631.64 1,550.06 1,782.57 61595 2,096.53 1,991.70 2,290.46 61458 1,734.70 1,647.97 1,895.17 61596 2,308.79 2,193.35 2,522.35 61460 1,764.67 1,676.44 1,927.91 61597 2,490.54 2,366.01 2,720.91 61470 1,636.24 1,554.43 1,787.59 61598 2,224.30 2,113.09 2,430.05 61480 1,581.08 1,502.03 1,727.33 61600 1,886.91 1,792.56 2,061.44 61490 1,639.92 1,557.92 1,791.61 61601 2,044.91 1,942.66 2,234.06 61500 1,165.17 1,106.91 1,272.95 61605 1,982.33 1,883.21 2,165.69 61501 1,001.10 951.05 1,093.71 61606 2,617.08 2,486.23 2,859.16 61510 1,873.22 1,779.56 2,046.49 61607 2,434.97 2,313.22 2,660.20 61512 2,207.23 2,096.87 2,411.40 61608 2,814.82 2,674.08 3,075.19 61514 1,640.22 1,558.21 1,791.94 61609 538.55 511.62 588.36 61516 1,600.46 1,520.44 1,748.51 61610 1,652.62 1,569.99 1,805.49 61517 77.05 73.20 84.18 61611 417.61 396.73 456.24 61518 2,376.10 2,257.30 2,595.90 61612 1,485.01 1,410.76 1,622.37 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 51 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 61613 2,749.70 2,612.22 3,004.05 62141 990.21 940.70 1,081.81 61615 2,188.94 2,079.49 2,391.41 62142 756.16 718.35 826.10 61616 2,859.06 2,716.11 3,123.53 62143 884.09 839.89 965.87 61618 1,126.14 1,069.83 1,230.30 62145 1,211.54 1,150.96 1,323.60 61619 1,300.14 1,235.13 1,420.40 62146 1,041.34 989.27 1,137.66 61623 525.37 499.10 573.97 62147 1,236.29 1,174.48 1,350.65 61624 1,046.20 993.89 1,142.97 62148 110.23 104.72 120.43 61626 854.72 811.98 933.78 62160 168.81 160.37 184.43 61630 1,194.49 1,134.77 1,304.99 62161 1,301.16 1,236.10 1,421.52 61635 1,307.89 1,242.50 1,428.88 62162 1,621.29 1,540.23 1,771.26 61680 1,953.99 1,856.29 2,134.73 62163 1,049.71 997.22 1,146.80 61682 3,662.00 3,478.90 4,000.74 62164 1,734.13 1,647.42 1,894.53 61684 2,440.53 2,318.50 2,666.28 62165 1,353.46 1,285.79 1,478.66 61686 3,923.40 3,727.23 4,286.31 62180 1,366.08 1,297.78 1,492.45 61690 1,863.23 1,770.07 2,035.58 62190 778.54 739.61 850.55 61692 3,169.25 3,010.79 3,462.41 62192 829.07 787.62 905.76 61697 3,598.71 3,418.77 3,931.59 62194 340.22 323.21 371.69 61698 3,880.38 3,686.36 4,239.31 62200 1,179.43 1,120.46 1,288.53 61700 2,994.78 2,845.04 3,271.80 62201 1,015.48 964.71 1,109.42 61702 3,378.50 3,209.58 3,691.02 62220 869.74 826.25 950.19 61703 1,157.21 1,099.35 1,264.25 62223 895.67 850.89 978.52 61705 2,209.28 2,098.82 2,413.64 62225 428.76 407.32 468.42 61708 1,943.82 1,846.63 2,123.62 62230 719.55 683.57 786.11 61710 1,754.47 1,666.75 1,916.76 62252 91.41 86.84 99.87 61711 2,249.24 2,136.78 2,457.30 62252 TC 49.89 47.40 54.51 61720 1,013.74 963.05 1,107.51 62252 26 41.52 39.44 45.36 61735 1,249.10 1,186.65 1,364.65 62256 501.57 476.49 547.96 61750 1,206.44 1,146.12 1,318.04 62258 966.58 918.25 1,055.99 61751 1,176.85 1,118.01 1,285.71 62263 598.53 568.60 653.89 61760 1,325.28 1,259.02 1,447.87 # 62263 347.89 330.50 380.08 61770 1,319.80 1,253.81 1,441.88 62264 365.68 347.40 399.51 61790 731.35 694.78 799.00 # 62264 211.89 201.30 231.50 61791 948.18 900.77 1,035.89 62267 237.23 225.37 259.18 61795 220.36 209.34 240.74 # 62267 154.79 147.05 169.11 61796 689.24 654.78 753.00 62268 433.31 411.64 473.39 61797 187.83 178.44 205.21 # 62268 249.94 237.44 273.06 61798 689.24 654.78 753.00 62269 470.81 447.27 514.36 61799 259.62 246.64 283.64 # 62269 254.54 241.81 278.08 61800 132.30 125.69 144.54 62270 144.36 137.14 157.71 61850 840.74 798.70 918.51 # 62270 72.64 69.01 79.36 61860 1,339.56 1,272.58 1,463.47 62272 169.81 161.32 185.52 61863 1,296.66 1,231.83 1,416.60 # 62272 76.28 72.47 83.34 61864 328.53 312.10 358.92 62273 152.31 144.69 166.39 61867 1,926.58 1,830.25 2,104.79 # 62273 103.14 97.98 112.68 61868 505.11 479.85 551.83 62280 282.80 268.66 308.96 61870 1,018.53 967.60 1,112.74 # 62280 140.84 133.80 153.87 61875 997.29 947.43 1,089.54 62281 262.34 249.22 286.60 61880 470.95 447.40 514.51 # 62281 136.28 129.47 148.89 61885 548.00 520.60 598.69 62282 272.63 259.00 297.85 61886 690.87 656.33 754.78 # 62282 125.87 119.58 137.52 61888 343.12 325.96 374.85 62284 208.31 197.89 227.57 62000 767.52 729.14 838.51 # 62284 85.21 80.95 93.09 62005 1,067.28 1,013.92 1,166.01 62287 504.31 479.09 550.95 62010 1,300.83 1,235.79 1,421.16 62290 302.67 287.54 330.67 62100 1,388.62 1,319.19 1,517.07 # 62290 158.49 150.57 173.16 62115 1,223.68 1,162.50 1,336.88 62291 282.95 268.80 309.12 62116 1,525.14 1,448.88 1,666.21 # 62291 152.82 145.18 166.96 62117 1,659.33 1,576.36 1,812.81 62292 450.30 427.79 491.96 62120 1,591.30 1,511.74 1,738.50 62294 726.19 689.88 793.36 62121 1,441.48 1,369.41 1,574.82 62310 200.04 190.04 218.55 62140 901.40 856.33 984.78 # 62310 93.57 88.89 102.22 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 52 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 62311 176.92 168.07 193.28 63180 1,208.24 1,147.83 1,320.00 # 62311 77.84 73.95 85.04 63182 1,285.02 1,220.77 1,403.89 62318 213.97 203.27 233.76 63185 986.87 937.53 1,078.16 # 62318 93.82 89.13 102.50 63190 1,134.28 1,077.57 1,239.21 62319 193.61 183.93 211.52 63191 1,056.72 1,003.88 1,154.46 # 62319 87.88 83.49 96.01 63194 1,291.44 1,226.87 1,410.90 62350 348.73 331.29 380.98 63195 1,296.74 1,231.90 1,416.69 62351 735.61 698.83 803.65 63196 1,525.73 1,449.44 1,666.86 62355 262.32 249.20 286.58 63197 1,455.38 1,382.61 1,590.00 62360 254.67 241.94 278.23 63198 1,605.55 1,525.27 1,754.06 62361 349.25 331.79 381.56 63199 1,741.87 1,654.78 1,903.00 62362 365.94 347.64 399.79 63200 1,300.76 1,235.72 1,421.08 62365 289.85 275.36 316.66 63250 2,523.92 2,397.72 2,757.38 62367 35.59 33.81 38.88 63251 2,613.14 2,482.48 2,854.85 # 62367 22.28 21.17 24.35 63252 2,613.54 2,482.86 2,855.29 62368 50.67 48.14 55.36 63265 1,440.59 1,368.56 1,573.84 # 62368 34.77 33.03 37.98 63266 1,480.95 1,406.90 1,617.94 63001 1,065.15 1,011.89 1,163.67 63267 1,194.49 1,134.77 1,304.99 63003 1,072.09 1,018.49 1,171.26 63268 1,203.35 1,143.18 1,314.66 63005 1,019.99 968.99 1,114.34 63270 1,771.13 1,682.57 1,934.96 63011 961.82 913.73 1,050.79 63271 1,781.69 1,692.61 1,946.50 63012 1,036.86 985.02 1,132.77 63272 1,642.81 1,560.67 1,794.77 63015 1,278.36 1,214.44 1,396.61 63273 1,551.28 1,473.72 1,694.78 63016 1,316.04 1,250.24 1,437.78 63275 1,546.98 1,469.63 1,690.07 63017 1,074.97 1,021.22 1,174.40 63276 1,541.01 1,463.96 1,683.55 63020 1,015.30 964.54 1,109.22 63277 1,353.83 1,286.14 1,479.06 63030 844.61 802.38 922.74 63278 1,327.62 1,261.24 1,450.43 63035 177.90 169.01 194.36 63280 1,826.75 1,735.41 1,995.72 63040 1,231.20 1,169.64 1,345.09 63281 1,806.03 1,715.73 1,973.09 63042 1,154.18 1,096.47 1,260.94 63282 1,704.66 1,619.43 1,862.34 63043 389.76 370.27 425.81 63283 1,616.08 1,535.28 1,765.57 63044 354.43 336.71 387.22 63285 2,238.67 2,126.74 2,445.75 63045 1,102.78 1,047.64 1,204.79 63286 2,231.08 2,119.53 2,437.46 63046 1,055.86 1,003.07 1,153.53 63287 2,355.53 2,237.75 2,573.41 63047 964.28 916.07 1,053.48 63290 2,386.38 2,267.06 2,607.12 63048 192.27 182.66 210.06 63295 283.78 269.59 310.03 63050 1,325.61 1,259.33 1,448.23 63300 1,594.99 1,515.24 1,742.53 63051 1,500.64 1,425.61 1,639.45 63301 1,795.57 1,705.79 1,961.66 63055 1,417.29 1,346.43 1,548.39 63302 1,783.64 1,694.46 1,948.63 63056 1,309.59 1,244.11 1,430.73 63303 1,870.82 1,777.28 2,043.87 63057 293.81 279.12 320.99 63304 1,978.71 1,879.77 2,161.74 63064 1,549.87 1,472.38 1,693.24 63305 2,022.54 1,921.41 2,209.62 63066 181.58 172.50 198.38 63306 2,110.69 2,005.16 2,305.93 63075 1,209.88 1,149.39 1,321.80 63307 1,976.20 1,877.39 2,159.00 63076 226.70 215.37 247.68 63308 293.95 279.25 321.14 63077 1,332.72 1,266.08 1,455.99 63600 745.03 707.78 813.95 63078 181.03 171.98 197.78 63610 1,242.14 1,180.03 1,357.03 63081 1,555.45 1,477.68 1,699.33 # 63610 397.41 377.54 434.17 63082 244.85 232.61 267.50 63615 1,001.03 950.98 1,093.63 63085 1,671.32 1,587.75 1,825.91 63620 689.24 654.78 753.00 63086 174.69 165.96 190.85 63621 215.93 205.13 235.90 63087 2,130.63 2,024.10 2,327.72 63650 371.90 353.31 406.31 63088 239.12 227.16 261.23 63655 735.76 698.97 803.82 63090 1,749.89 1,662.40 1,911.76 63660 391.75 372.16 427.98 63091 164.75 156.51 179.99 63685 354.07 336.37 386.83 63101 1,999.37 1,899.40 2,184.31 63688 317.90 302.01 347.31 63102 1,990.50 1,890.98 2,174.63 63700 1,067.72 1,014.33 1,166.48 63103 263.72 250.53 288.11 63702 1,200.09 1,140.09 1,311.10 63170 1,332.67 1,266.04 1,455.95 63704 1,335.89 1,269.10 1,459.47 63172 1,199.46 1,139.49 1,310.41 63706 1,551.06 1,473.51 1,694.54 63173 1,477.48 1,403.61 1,614.15 63707 789.80 750.31 862.86 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 53 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 63709 958.94 910.99 1,047.64 64484 125.54 119.26 137.15 63710 956.16 908.35 1,044.60 # 64484 62.70 59.57 68.51 63740 811.69 771.11 886.78 64505 92.97 88.32 101.57 63741 527.79 501.40 576.61 # 64505 77.44 73.57 84.61 63744 554.00 526.30 605.25 64508 131.10 124.55 143.23 63746 485.30 461.04 530.20 # 64508 64.19 60.98 70.13 64400 98.21 93.30 107.30 64510 130.27 123.76 142.32 # 64400 57.91 55.01 63.26 # 64510 62.25 59.14 68.01 64402 100.28 95.27 109.56 64517 155.60 147.82 169.99 # 64402 65.90 62.61 72.00 # 64517 109.39 103.92 119.51 64405 94.50 89.78 103.25 64520 171.00 162.45 186.82 # 64405 67.51 64.13 73.75 # 64520 70.44 66.92 76.96 64408 109.19 103.73 119.29 64530 176.32 167.50 192.63 # 64408 81.83 77.74 89.40 # 64530 83.16 79.00 90.85 64410 127.48 121.11 139.28 64550 14.43 13.71 15.77 # 64410 72.40 68.78 79.10 # 64550 8.52 8.09 9.30 64412 127.16 120.80 138.92 64553 185.56 176.28 202.72 # 64412 64.68 61.45 70.67 # 64553 144.90 137.66 158.31 64413 105.15 99.89 114.87 64555 197.24 187.38 215.49 # 64413 70.40 66.88 76.91 # 64555 142.53 135.40 155.71 64415 119.67 113.69 130.74 64560 195.10 185.35 213.15 # 64415 67.91 64.51 74.19 # 64560 146.67 139.34 160.24 64416 84.09 79.89 91.87 64561 1,078.82 1,024.88 1,178.61 64417 120.80 114.76 131.97 # 64561 398.61 378.68 435.48 # 64417 67.20 63.84 73.42 64565 155.97 148.17 170.40 64418 123.53 117.35 134.95 # 64565 109.02 103.57 119.11 # 64418 67.33 63.96 73.55 64573 518.64 492.71 566.62 64420 147.49 140.12 161.14 64575 256.42 243.60 280.14 # 64420 60.61 57.58 66.22 64577 316.67 300.84 345.97 64421 217.81 206.92 237.96 64580 267.72 254.33 292.48 # 64421 82.88 78.74 90.55 64581 772.60 733.97 844.07 64425 117.18 111.32 128.02 64585 311.47 295.90 340.29 # 64425 85.76 81.47 93.69 # 64585 148.07 140.67 161.77 64430 144.26 137.05 157.61 64590 291.76 277.17 318.75 # 64430 81.79 77.70 89.36 # 64590 165.70 157.42 181.03 64435 133.14 126.48 145.45 64595 302.35 287.23 330.31 # 64435 77.69 73.81 84.88 # 64595 130.81 124.27 142.91 64445 124.28 118.07 135.78 64600 368.90 350.46 403.03 # 64445 74.01 70.31 80.86 # 64600 194.04 184.34 211.99 64446 84.73 80.49 92.56 64605 516.16 490.35 563.90 64447 64.57 61.34 70.54 # 64605 306.92 291.57 335.31 64448 74.92 71.17 81.85 64610 623.05 591.90 680.69 64449 84.21 80.00 92.00 # 64610 428.96 407.51 468.64 64450 94.32 89.60 103.04 64612 141.02 133.97 154.07 # 64450 66.23 62.92 72.36 # 64612 123.64 117.46 135.08 64455 47.87 45.48 52.30 64613 138.80 131.86 151.64 # 64455 37.52 35.64 40.99 # 64613 116.62 110.79 127.41 64470 241.69 229.61 264.05 64614 155.80 148.01 170.21 # 64470 95.66 90.88 104.51 # 64614 129.92 123.42 141.93 64472 103.77 98.58 113.37 64620 247.92 235.52 270.85 # 64472 60.88 57.84 66.52 # 64620 151.80 144.21 165.84 64475 216.77 205.93 236.82 64622 297.70 282.82 325.24 # 64475 75.18 71.42 82.13 # 64622 161.28 153.22 176.20 64476 87.23 82.87 95.30 64623 110.71 105.17 120.95 # 64476 45.46 43.19 49.67 # 64623 45.27 43.01 49.46 64479 255.60 242.82 279.24 64626 346.13 328.82 378.14 # 64479 113.27 107.61 123.75 # 64626 213.41 202.74 233.15 64480 127.56 121.18 139.36 64627 151.40 143.83 165.40 # 64480 73.58 69.90 80.39 # 64627 53.06 50.41 57.97 64483 249.04 236.59 272.08 64630 213.75 203.06 233.52 # 64483 99.68 94.70 108.91 # 64630 177.15 168.29 193.53 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 54 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 64632 79.29 75.33 86.63 64823 682.07 647.97 745.17 # 64632 67.46 64.09 73.70 64831 603.22 573.06 659.02 64640 210.03 199.53 229.46 64832 313.87 298.18 342.91 # 64640 161.60 153.52 176.55 64834 666.09 632.79 727.71 64650 61.43 58.36 67.11 64835 721.70 685.62 788.46 # 64650 36.29 34.48 39.65 64836 721.75 685.66 788.51 64653 71.24 67.68 77.83 64837 348.36 330.94 380.58 # 64653 45.36 43.09 49.55 64840 824.00 782.80 900.22 64680 281.77 267.68 307.83 64856 907.50 862.13 991.45 # 64680 147.58 140.20 161.23 64857 948.71 901.27 1,036.46 64681 363.11 344.95 396.69 64858 1,089.15 1,034.69 1,189.89 # 64681 197.86 187.97 216.17 64859 236.15 224.34 257.99 64702 412.34 391.72 450.48 64861 1,225.03 1,163.78 1,338.35 64704 302.04 286.94 329.98 64862 1,196.77 1,136.93 1,307.47 64708 426.21 404.90 465.64 64864 790.02 750.52 863.10 64712 489.88 465.39 535.20 64865 1,048.82 996.38 1,145.84 64713 681.44 647.37 744.48 64866 1,086.74 1,032.40 1,187.26 64714 583.60 554.42 637.58 64868 952.87 905.23 1,041.01 64716 468.95 445.50 512.33 64870 927.19 880.83 1,012.95 64718 503.57 478.39 550.15 64872 110.93 105.38 121.19 64719 348.99 331.54 381.27 64874 162.99 154.84 178.07 64721 369.40 350.93 403.57 64876 177.57 168.69 193.99 # 64721 367.92 349.52 401.95 64885 1,028.66 977.23 1,123.81 64722 299.25 284.29 326.93 64886 1,219.50 1,158.53 1,332.31 64726 262.72 249.58 287.02 64890 977.48 928.61 1,067.90 64727 169.86 161.37 185.58 64891 1,013.02 962.37 1,106.73 64732 339.85 322.86 371.29 64892 949.33 901.86 1,037.14 64734 367.99 349.59 402.03 64893 998.86 948.92 1,091.26 64736 349.89 332.40 382.26 64895 1,173.90 1,115.21 1,282.49 64738 409.82 389.33 447.73 64896 1,293.88 1,229.19 1,413.57 64740 411.90 391.31 450.01 64897 1,136.57 1,079.74 1,241.70 64742 420.54 399.51 459.44 64898 1,239.79 1,177.80 1,354.47 64744 365.96 347.66 399.81 64901 554.85 527.11 606.18 64746 397.26 377.40 434.01 64902 637.55 605.67 696.52 64752 449.21 426.75 490.76 64905 910.14 864.63 994.32 64755 795.49 755.72 869.08 64907 1,192.09 1,132.49 1,302.36 64760 424.25 403.04 463.50 64910 732.41 695.79 800.16 64761 403.51 383.33 440.83 64911 883.92 839.72 965.68 64763 487.95 463.55 533.08 65091 531.22 504.66 580.36 64766 561.22 533.16 613.13 65093 530.28 503.77 579.34 64771 526.24 499.93 574.92 65101 612.58 581.95 669.24 64772 504.37 479.15 551.02 65103 639.44 607.47 698.59 64774 365.84 347.55 399.68 65105 705.17 669.91 770.40 64776 351.20 333.64 383.69 65110 1,024.86 973.62 1,119.66 64778 168.76 160.32 184.37 65112 1,204.45 1,144.23 1,315.86 64782 413.60 392.92 451.86 65114 1,253.90 1,191.21 1,369.89 64783 202.01 191.91 220.70 65125 384.23 365.02 419.77 64784 643.49 611.32 703.02 # 65125 240.80 228.76 263.07 64786 961.53 913.45 1,050.47 65130 605.82 575.53 661.86 64787 231.93 220.33 253.38 65135 616.92 586.07 673.98 64788 343.62 326.44 375.41 65140 671.97 638.37 734.13 64790 732.37 695.75 800.11 65150 487.41 463.04 532.50 64792 951.27 903.71 1,039.27 65155 708.28 672.87 773.80 64795 173.24 164.58 189.27 65175 546.12 518.81 596.63 64802 538.61 511.68 588.43 65205 47.95 45.55 52.38 64804 819.11 778.15 894.87 # 65205 37.97 36.07 41.48 64809 773.14 734.48 844.65 65210 58.73 55.79 64.16 64818 599.04 569.09 654.45 # 65210 45.79 43.50 50.03 64820 674.14 640.43 736.49 65220 49.05 46.60 53.59 64821 609.65 579.17 666.05 # 65220 37.22 35.36 40.66 64822 601.47 571.40 657.11 65222 64.57 61.34 70.54 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 55 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 65222 50.15 47.64 54.79 65875 519.33 493.36 567.36 65235 580.53 551.50 634.23 65880 547.09 519.74 597.70 65260 795.33 755.56 868.89 65900 802.22 762.11 876.43 65265 895.17 850.41 977.97 65920 649.50 617.03 709.58 65270 225.37 214.10 246.22 65930 534.07 507.37 583.48 # 65270 118.16 112.25 129.09 66020 156.34 148.52 170.80 65272 414.48 393.76 452.82 # 66020 109.39 103.92 119.51 # 65272 287.68 273.30 314.30 66030 138.55 131.62 151.36 65273 315.82 300.03 345.03 # 66030 91.60 87.02 100.07 65275 463.03 439.88 505.86 66130 589.41 559.94 643.93 # 65275 375.41 356.64 410.14 # 66130 479.98 455.98 524.38 65280 554.01 526.31 605.26 66150 715.06 679.31 781.21 65285 863.03 819.88 942.86 66155 713.07 677.42 779.03 65286 586.40 557.08 640.64 66160 810.58 770.05 885.56 # 65286 407.47 387.10 445.17 66165 698.73 663.79 763.36 65290 406.80 386.46 444.43 66170 981.60 932.52 1,072.40 65400 556.25 528.44 607.71 66172 1,233.62 1,171.94 1,347.73 # 65400 492.29 467.68 537.83 66180 973.38 924.71 1,063.42 65410 121.17 115.11 132.38 66185 616.04 585.24 673.03 # 65410 88.27 83.86 96.44 66220 601.95 571.85 657.63 65420 430.95 409.40 470.81 66225 773.08 734.43 844.59 # 65420 310.81 295.27 339.56 66250 623.85 592.66 681.56 65426 542.89 515.75 593.11 # 66250 457.12 434.26 499.40 # 65426 395.39 375.62 431.96 66500 293.34 278.67 320.47 65430 97.51 92.63 106.52 66505 321.08 305.03 350.78 # 65430 88.27 83.86 96.44 66600 678.19 644.28 740.92 65435 67.53 64.15 73.77 66605 878.31 834.39 959.55 # 65435 59.03 56.08 64.49 66625 356.31 338.49 389.26 65436 319.99 303.99 349.59 66630 468.60 445.17 511.95 # 65436 307.05 291.70 335.46 66635 473.32 449.65 517.10 65450 265.62 252.34 290.19 66680 423.93 402.73 463.14 # 65450 262.29 249.18 286.56 66682 516.24 490.43 563.99 65600 322.08 305.98 351.88 66700 372.34 353.72 406.78 # 65600 278.46 264.54 304.22 # 66700 327.24 310.88 357.51 65710 916.04 870.24 1,000.78 66710 365.87 347.58 399.72 65730 1,018.33 967.41 1,112.52 # 66710 326.32 310.00 356.50 65750 1,031.80 980.21 1,127.24 66711 524.07 497.87 572.55 65755 1,025.80 974.51 1,120.69 66720 384.33 365.11 419.88 65756 986.69 937.36 1,077.96 # 66720 345.88 328.59 377.88 65770 1,178.70 1,119.77 1,287.74 66740 363.29 345.13 396.90 65772 371.89 353.30 406.30 # 66740 327.80 311.41 358.12 # 65772 333.45 316.78 364.30 66761 373.65 354.97 408.22 65775 455.83 433.04 498.00 # 66761 339.27 322.31 370.66 65780 734.81 698.07 802.78 66762 391.21 371.65 427.40 65781 1,114.82 1,059.08 1,217.94 # 66762 350.18 332.67 382.57 65782 961.60 913.52 1,050.55 66770 434.34 412.62 474.51 65800 127.42 121.05 139.21 # 66770 397.00 377.15 433.72 # 65800 111.52 105.94 121.83 66820 329.95 313.45 360.47 65805 139.25 132.29 152.13 66821 268.09 254.69 292.89 # 65805 111.52 105.94 121.83 # 66821 252.56 239.93 275.92 65810 386.57 367.24 422.33 66825 631.67 600.09 690.10 65815 531.13 504.57 580.26 66830 589.89 560.40 644.46 # 65815 391.76 372.17 428.00 66840 574.79 546.05 627.96 65820 622.89 591.75 680.51 66850 655.98 623.18 716.66 65850 705.93 670.63 771.22 66852 701.75 666.66 766.66 65855 283.77 269.58 310.02 66920 626.21 594.90 684.14 # 65855 249.02 236.57 272.06 66930 711.55 675.97 777.37 65860 262.09 248.99 286.34 66940 646.54 614.21 706.34 # 65860 215.51 204.73 235.44 66982 888.37 843.95 970.54 65865 395.80 376.01 432.41 66983 614.72 583.98 671.58 65870 488.83 464.39 534.05 66984 637.87 605.98 696.88 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 56 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 66985 631.99 600.39 690.45 67320 275.56 261.78 301.05 66986 771.86 733.27 843.26 67331 260.84 247.80 284.97 66990 78.62 74.69 85.89 67332 283.72 269.53 309.96 67005 389.78 370.29 425.83 67334 257.40 244.53 281.21 67010 450.79 428.25 492.49 67335 129.45 122.98 141.43 67015 481.79 457.70 526.36 67340 306.60 291.27 334.96 67025 600.74 570.70 656.31 67343 539.94 512.94 589.88 # 67025 519.41 493.44 567.46 67345 196.63 186.80 214.82 67027 710.18 674.67 775.87 # 67345 178.52 169.59 195.03 67028 179.89 170.90 196.54 67346 171.24 162.68 187.08 # 67028 143.29 136.13 156.55 67400 779.34 740.37 851.43 67030 431.46 409.89 471.37 67405 664.01 630.81 725.43 67031 319.06 303.11 348.58 67412 721.71 685.62 788.46 # 67031 292.07 277.47 319.09 67413 722.13 686.02 788.92 67036 802.18 762.07 876.38 67414 1,103.44 1,048.27 1,205.51 67039 1,028.13 976.72 1,123.23 67415 90.58 86.05 98.96 67040 1,185.53 1,126.25 1,295.19 67420 1,373.91 1,305.21 1,500.99 67041 1,106.81 1,051.47 1,209.19 67430 1,046.47 994.15 1,143.27 67042 1,267.28 1,203.92 1,384.51 67440 1,009.64 959.16 1,103.03 67043 1,330.11 1,263.60 1,453.14 67445 1,182.97 1,123.82 1,292.39 67101 643.17 611.01 702.66 67450 1,047.97 995.57 1,144.91 # 67101 555.55 527.77 606.94 67500 76.11 72.30 83.15 67105 594.60 564.87 649.60 # 67500 68.72 65.28 75.07 # 67105 532.49 505.87 581.75 67505 74.42 70.70 81.31 67107 1,008.92 958.47 1,102.24 # 67505 66.65 63.32 72.82 67108 1,341.99 1,274.89 1,466.12 67515 79.12 75.16 86.43 67110 719.65 683.67 786.22 # 67515 72.84 69.20 79.58 # 67110 639.43 607.46 698.58 67550 811.25 770.69 886.29 67112 1,107.51 1,052.13 1,209.95 67560 826.50 785.18 902.96 67113 1,456.65 1,383.82 1,591.39 67570 971.15 922.59 1,060.98 67115 407.22 386.86 444.89 67700 225.88 214.59 246.78 67120 543.08 515.93 593.32 # 67700 95.75 90.96 104.60 # 67120 458.42 435.50 500.83 67710 190.71 181.17 208.35 67121 752.37 714.75 821.96 # 67710 80.17 76.16 87.58 67141 429.88 408.39 469.65 67715 200.68 190.65 219.25 # 67141 399.94 379.94 436.93 # 67715 90.52 85.99 98.89 67145 433.24 411.58 473.32 67800 106.09 100.79 115.91 # 67145 408.84 388.40 446.66 # 67800 87.23 82.87 95.30 67208 495.95 471.15 541.82 67801 135.94 129.14 148.51 # 67208 478.20 454.29 522.43 # 67801 113.02 107.37 123.48 67210 578.30 549.39 631.80 67805 168.51 160.08 184.09 # 67210 558.71 530.77 610.39 # 67805 138.93 131.98 151.78 67218 1,171.47 1,112.90 1,279.84 67808 302.48 287.36 330.46 67220 888.20 843.79 970.36 67810 193.81 184.12 211.74 # 67220 846.05 803.75 924.31 # 67810 81.06 77.01 88.56 67221 251.82 239.23 275.11 67820 44.43 42.21 48.54 # 67221 186.39 177.07 203.63 # 67820 45.91 43.61 50.15 67225 25.81 24.52 28.20 67825 107.56 102.18 117.51 # 67225 24.33 23.11 26.58 # 67825 100.90 95.86 110.24 67227 505.30 480.04 552.05 67830 225.74 214.45 246.62 # 67227 472.40 448.78 516.10 # 67830 115.21 109.45 125.87 67228 997.74 947.85 1,090.03 67835 367.37 349.00 401.35 # 67228 877.59 833.71 958.77 67840 235.77 223.98 257.58 67229 959.35 911.38 1,048.09 # 67840 133.37 126.70 145.71 67250 654.89 622.15 715.47 67850 189.72 180.23 207.26 67255 700.85 665.81 765.68 # 67850 119.85 113.86 130.94 67311 495.47 470.70 541.31 67875 147.16 139.80 160.77 67312 592.05 562.45 646.82 # 67875 82.83 78.69 90.49 67314 555.55 527.77 606.94 67880 379.37 360.40 414.46 67316 664.45 631.23 725.91 # 67880 302.48 287.36 330.46 67318 581.48 552.41 635.27 67882 467.53 444.15 510.77 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 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 57 FSY09 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 67882 389.53 370.05 425.56 # 68130 342.82 325.68 374.53 67900 540.08 513.08 590.04 68135 130.79 124.25 142.89 # 67900 429.54 408.06 469.27 # 68135 126.35 120.03 138.03 67901 582.14 553.03 635.98 68200 35.77 33.98 39.08 # 67901 481.22 457.16 525.73 # 68200 29.49 28.02 32.22 67902 595.63 565.85 650.73 68320 599.72 569.73 655.19 67903 515.67 489.89 563.37 # 68320 440.76 418.72 481.53 # 67903 415.86 395.07 454.33 68325 546.97 519.62 597.56 67904 610.56 580.03 667.03 68326 532.99 506.34 582.29 # 67904 493.74 469.05 539.41 68328 594.21 564.50 649.18 67906 430.83 409.29 470.68 68330 503.43 478.26 550.00 67908 411.38 390.81 449.43 # 68330 378.85 359.91 413.90 # 67908 360.36 342.34 393.69 68335 534.61 507.88 584.06 67909 451.96 429.36 493.76 68340 453.70 431.02 495.67 # 67909 368.41 349.99 402.49 # 68340 327.27 310.91 357.55 67911 462.06 438.96 504.80 68360 441.87 419.78 482.75 67912 769.40 730.93 840.57 # 68360 338.36 321.44 369.66 # 67912 416.35 395.53 454.86 68362 541.87 514.78 592.00 67914 329.42 312.95 359.89 68371 347.50 330.13 379.65 # 67914 242.55 230.42 264.98 68400 238.32 226.40 260.36 67915 295.32 280.55 322.63 # 68400 114.48 108.76 125.07 # 67915 214.36 203.64 234.19 68420 271.21 257.65 296.30 67916 452.99 430.34 494.89 # 68420 146.62 139.29 160.18 # 67916 362.05 343.95 395.54 68440 89.85 85.36 98.16 67917 494.43 469.71 540.17 # 68440 80.61 76.58 88.07 # 67917 399.79 379.80 436.77 68500 807.36 766.99 882.04 67921 313.79 298.10 342.82 68505 812.61 771.98 887.78 # 67921 226.92 215.57 247.91 68510 385.14 365.88 420.76 67922 286.01 271.71 312.47 # 68510 249.84 237.35 272.95 # 67922 206.53 196.20 225.63 68520 572.21 543.60 625.14 67923 477.23 453.37 521.38 68525 229.49 218.02 250.72 # 67923 390.35 370.83 426.45 68530 368.46 350.04 402.55 67924 494.32 469.60 540.04 # 68530 220.96 209.91 241.40 # 67924 377.13 358.27 412.01 68540 772.22 733.61 843.65 67930 310.64 295.11 339.38 68550 947.92 900.52 1,035.60 # 67930 207.13 196.77 226.29 68700 498.57 473.64 544.69 67935 503.30 478.14 549.86 68705 200.64 190.61 219.20 # 67935 378.71 359.77 413.74 # 68705 138.90 131.96 151.75 67938 206.13 195.82 225.19 68720 632.63 601.00 691.15 # 67938 96.33 91.51 105.24 68745 634.86 603.12 693.59 67950 486.48 462.16 531.48 68750 653.44 620.77 713.89 # 67950 392.58 372.95 428.89 68760 170.07 161.57 185.81 67961 486.06 461.76 531.02 # 68760 121.64 115.56 132.89 # 67961 383.66 364.48 419.15 68761 123.66 117.48 135.10 67966 639.26 607.30 698.40 # 68761 98.90 93.96 108.05 # 67966 543.15 515.99 593.39 68770 492.07 467.47 537.59 67971 612.70 582.07 669.38 68801 102.79 97.65 112.30 67973 793.11 753.45 866.47 # 68801 88.75 84.31 96.96 67974 789.81 750.32 862.87 68810 198.78 188.84 217.17 67975 578.75 549.81 632.28 # 68810 158.48 150.56 173.14 68020 99.63 94.65 108.85 68811 171.68 163.10 187.57 # 68020 92.60 87.97 101.17 68815 375.32 356.55 410.03 68040 55.40 52.63 60.52 # 68815 215.99 205.19 235.97 # 68040 45.78 43.49 50.01 68816 579.06 550.11 632.63 68100 146.05