1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 1 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 32.37 30.75 35.36 G0270 21.57 20.49 23.56 G0102 17.26 16.40 18.86 # G0270 19.96 18.96 21.80 # G0102 8.24 7.83 9.00 G0271 12.41 11.79 13.56 G0104 114.31 108.59 124.88 G0275 13.38 12.71 14.62 # G0104 55.37 52.60 60.49 G0278 13.38 12.71 14.62 G0105 339.38 322.41 370.77 G0281 10.86 10.32 11.87 # G0105 195.74 185.95 213.84 G0283 10.86 10.32 11.87 G0105 53 114.31 108.59 124.88 G0288 112.70 107.07 123.13 # G0105 53 55.37 52.60 60.49 G0289 79.57 75.59 86.93 G0106 178.50 169.58 195.02 G0329 7.17 6.81 7.83 G0106 TC 130.17 123.66 142.21 G0339 3,958.14 3,760.23 4,324.26 G0106 26 48.33 45.91 52.80 G0340 2,687.41 2,553.04 2,936.00 G0108 20.47 19.45 22.37 G0341 383.62 364.44 419.11 G0109 11.45 10.88 12.51 G0342 625.23 593.97 683.07 G0117 40.56 38.53 44.31 G0343 1,038.33 986.41 1,134.37 G0118 26.92 25.57 29.41 G0364 11.63 11.05 12.71 G0120 178.50 169.58 195.02 # G0364 8.73 8.29 9.53 G0120 TC 130.17 123.66 142.21 C G0365 145.62 138.34 159.09 G0120 26 48.33 45.91 52.80 C G0365 TC 133.99 127.29 146.38 G0121 339.38 322.41 370.77 G0365 26 11.63 11.05 12.71 # G0121 195.74 185.95 213.84 G0372 10.50 9.98 11.48 G0121 53 114.31 108.59 124.88 # G0372 7.92 7.52 8.65 # G0121 53 55.37 52.60 60.49 G0389 99.85 94.86 109.09 G0124 25.49 24.22 27.85 G0389 TC 70.99 67.44 77.56 G0127 17.26 16.40 18.86 G0389 26 28.86 27.42 31.53 # G0127 7.92 7.52 8.65 G0392 1,953.95 1,856.25 2,134.69 G0128 7.57 7.19 8.27 # G0392 428.92 407.47 468.59 G0130 28.97 27.52 31.65 G0393 1,472.20 1,398.59 1,608.38 G0130 TC 18.92 17.97 20.67 # G0393 299.20 284.24 326.88 G0130 26 10.04 9.54 10.97 G0396 30.06 28.56 32.84 G0141 25.49 24.22 27.85 # G0396 28.77 27.33 31.43 G0166 134.11 127.40 146.51 G0397 58.69 55.76 64.12 G0168 68.94 65.49 75.31 # G0397 57.40 54.53 62.71 # G0168 23.53 22.35 25.70 G0398 260.34 247.32 284.42 G0179 36.23 34.42 39.58 G0398 TC 179.69 170.71 196.32 G0180 48.21 45.80 52.67 G0398 26 80.66 76.63 88.12 G0181 95.20 90.44 104.01 G0399 189.20 179.74 206.70 G0182 97.13 92.27 106.11 G0399 TC 113.81 108.12 124.34 G0202 117.20 111.34 128.04 G0399 26 75.40 71.63 82.37 G0202 TC 83.69 79.51 91.44 G0400 170.28 161.77 186.04 G0202 26 33.51 31.83 36.60 G0400 TC 102.42 97.30 111.90 G0204 138.00 131.10 150.77 G0400 26 67.86 64.47 74.14 G0204 TC 96.58 91.75 105.51 G0402 86.50 82.18 94.51 G0204 26 41.43 39.36 45.26 G0403 18.90 17.96 20.65 G0206 109.62 104.14 119.76 G0404 11.95 11.35 13.05 G0206 TC 76.11 72.30 83.15 G0405 7.92 7.52 8.65 G0206 26 33.51 31.83 36.60 G0406 35.67 33.89 38.97 G0237 9.05 8.60 9.89 G0407 64.37 61.15 70.32 G0238 9.70 9.22 10.60 G0408 92.20 87.59 100.73 G0239 10.02 9.52 10.95 G0409 7.59 7.21 8.29 G0245 59.18 56.22 64.65 G0412 628.14 596.73 686.24 # G0245 42.75 40.61 46.70 G0413 921.11 875.05 1,006.31 G0246 34.30 32.59 37.48 G0414 871.17 827.61 951.75 # G0246 21.74 20.65 23.75 G0415 1,192.99 1,133.34 1,303.34 G0247 38.36 36.44 41.91 G0416 570.64 542.11 623.43 # G0247 23.86 22.67 26.07 G0416 TC 396.32 376.50 432.98 G0248 132.55 125.92 144.81 G0416 26 174.32 165.60 190.44 G0249 112.58 106.95 122.99 G0417 1,108.14 1,052.73 1,210.64 G0250 9.25 8.79 10.11 G0417 TC 774.29 735.58 845.92 G0268 43.61 41.43 47.64 G0417 26 333.85 317.16 364.73 # G0268 29.44 27.97 32.17 G0418 1,903.01 1,807.86 2,079.04 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 99 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 1,322.68 1,256.55 1,445.03 # 10040 74.40 70.68 81.28 G0418 26 580.33 551.31 634.01 10060 90.46 85.94 98.83 G0419 2,256.17 2,143.36 2,464.86 # 10060 78.54 74.61 85.80 G0419 TC 1,587.11 1,507.75 1,733.91 10061 155.99 148.19 170.42 G0419 26 669.06 635.61 730.95 # 10061 140.21 133.20 153.18 G9041 21.84 20.75 23.86 10080 133.12 126.46 145.43 G9042 7.00 6.65 7.65 # 10080 80.30 76.29 87.73 G9043 6.68 6.35 7.30 10081 210.58 200.05 230.06 G9044 6.36 6.04 6.95 # 10081 141.01 133.96 154.05 M0064 37.36 35.49 40.81 10120 110.26 104.75 120.46 # M0064 16.10 15.30 17.60 # 10120 77.09 73.24 84.23 P3001 25.49 24.22 27.85 10121 215.03 204.28 234.92 Q0035 17.29 16.43 18.89 # 10121 157.70 149.82 172.29 Q0035 TC 9.37 8.90 10.24 10140 126.91 120.56 138.64 Q0035 26 7.92 7.52 8.65 # 10140 100.50 95.48 109.80 Q0091 36.89 35.05 40.31 10160 103.17 98.01 112.71 # Q0091 17.24 16.38 18.84 # 10160 80.95 76.90 88.44 Q0092 14.35 13.63 15.67 10180 190.18 180.67 207.77 R0070 149.59 142.11 163.43 # 10180 147.99 140.59 161.68 R0075 149.59 142.11 163.43 11000 44.78 42.54 48.92 0067T 538.43 511.51 588.24 # 11000 28.68 27.25 31.34 C 0067T TC 167.38 159.01 182.86 11001 18.94 17.99 20.69 0067T 26 123.40 117.23 134.81 # 11001 14.43 13.71 15.77 0073T 459.65 436.67 502.17 11004 516.07 490.27 563.81 0075T 1,061.50 1,008.43 1,159.69 11005 673.30 639.64 735.59 0075T 26 914.45 868.73 999.04 11006 634.97 603.22 693.70 0076T 350.29 332.78 382.70 11008 241.40 229.33 263.73 0076T 26 91.44 86.87 99.90 11010 383.45 364.28 418.92 0078T 1,197.48 1,137.61 1,308.25 # 11010 243.03 230.88 265.51 0079T 1,100.29 1,045.28 1,202.07 11011 428.03 406.63 467.62 0080T 215.11 204.35 235.00 # 11011 262.48 249.36 286.76 0081T 215.11 204.35 235.00 11012 584.32 555.10 638.37 0145T 530.92 504.37 580.03 # 11012 379.16 360.20 414.23 C 0145T TC 243.40 231.23 265.91 11040 39.07 37.12 42.69 0145T 26 97.63 92.75 106.66 # 11040 24.57 23.34 26.84 0146T 530.92 504.37 580.03 11041 45.64 43.36 49.86 C 0146T TC 243.40 231.23 265.91 # 11041 30.50 28.98 33.33 0146T 26 97.63 92.75 106.66 11042 61.76 58.67 67.47 0147T 530.92 504.37 580.03 # 11042 40.82 38.78 44.60 C 0147T TC 243.40 231.23 265.91 11043 226.11 214.80 247.02 0147T 26 97.63 92.75 106.66 # 11043 198.74 188.80 217.12 0148T 530.92 504.37 580.03 11044 308.85 293.41 337.42 C 0148T TC 243.40 231.23 265.91 # 11044 273.42 259.75 298.71 0148T 26 97.63 92.75 106.66 11055 39.91 37.91 43.60 0149T 530.92 504.37 580.03 # 11055 20.58 19.55 22.48 C 0149T TC 243.40 231.23 265.91 11056 49.01 46.56 53.54 0149T 26 97.63 92.75 106.66 # 11056 29.04 27.59 31.73 0150T 530.92 504.37 580.03 11057 59.25 56.29 64.73 C 0150T TC 243.40 231.23 265.91 # 11057 37.67 35.79 41.16 0150T 26 97.63 92.75 106.66 11100 84.82 80.58 92.67 0151T 175.42 166.65 191.65 # 11100 42.63 40.50 46.58 C 0151T TC 90.40 85.88 98.76 11101 28.03 26.63 30.62 0151T 26 64.09 60.89 70.02 # 11101 21.91 20.81 23.93 0171T 677.73 643.84 740.42 11200 67.21 63.85 73.43 0172T 338.87 321.93 370.22 # 11200 57.22 54.36 62.51 0177T 1,145.82 1,088.53 1,251.81 11201 15.97 15.17 17.45 10021 116.83 110.99 127.64 # 11201 14.68 13.95 16.04 # 10021 61.43 58.36 67.11 11300 55.32 52.55 60.43 10022 120.01 114.01 131.11 # 11300 26.01 24.71 28.42 # 10022 61.07 58.02 66.72 11301 76.46 72.64 83.54 10040 84.39 80.17 92.20 # 11301 44.25 42.04 48.35 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 99 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 91.58 87.00 100.05 # 11462 187.00 177.65 204.30 # 11302 54.86 52.12 59.94 11463 380.97 361.92 416.21 11303 107.48 102.11 117.43 # 11463 262.45 249.33 286.73 # 11303 64.32 61.10 70.27 11470 311.41 295.84 340.22 11305 57.29 54.43 62.59 # 11470 221.87 210.78 242.40 # 11305 32.81 31.17 35.85 11471 391.83 372.24 428.08 11306 79.46 75.49 86.81 # 11471 279.43 265.46 305.28 # 11306 49.83 47.34 54.44 11600 145.40 138.13 158.85 11307 93.89 89.20 102.58 # 11600 94.51 89.78 103.25 # 11307 58.78 55.84 64.22 11601 179.98 170.98 196.63 11308 105.66 100.38 115.44 # 11601 122.33 116.21 133.64 # 11308 70.55 67.02 77.07 11602 197.82 187.93 216.12 11310 69.23 65.77 75.64 # 11602 134.70 127.97 147.17 # 11310 37.67 35.79 41.16 11603 225.45 214.18 246.31 11311 88.36 83.94 96.53 # 11603 160.40 152.38 175.24 # 11311 55.18 52.42 60.28 11604 249.09 236.64 272.14 11312 102.00 96.90 111.44 # 11604 176.30 167.49 192.61 # 11312 63.35 60.18 69.21 11606 352.15 334.54 384.72 11313 127.84 121.45 139.67 # 11606 261.97 248.87 286.20 # 11313 84.68 80.45 92.52 11620 148.48 141.06 162.22 11400 93.96 89.26 102.65 # 11620 95.98 91.18 104.86 # 11400 62.40 59.28 68.17 11621 181.63 172.55 198.43 11401 116.10 110.30 126.85 # 11621 123.66 117.48 135.10 # 11401 83.25 79.09 90.95 11622 205.80 195.51 224.84 11402 129.53 123.05 141.51 # 11622 142.68 135.55 155.88 # 11402 92.17 87.56 100.69 11623 241.13 229.07 263.43 11403 149.46 141.99 163.29 # 11623 176.07 167.27 192.36 # 11403 117.25 111.39 128.10 11624 271.40 257.83 296.50 11404 170.21 161.70 185.96 # 11624 200.22 190.21 218.74 # 11404 130.60 124.07 142.68 11626 330.59 314.06 361.17 11406 241.62 229.54 263.97 # 11626 250.39 237.87 273.55 # 11406 196.21 186.40 214.36 11640 155.07 147.32 169.42 11420 95.32 90.55 104.13 # 11640 100.96 95.91 110.30 # 11420 67.62 64.24 73.88 11641 191.06 181.51 208.74 11421 124.13 117.92 135.61 # 11641 131.80 125.21 143.99 # 11421 91.60 87.02 100.07 11642 220.71 209.67 241.12 11422 138.68 131.75 151.51 # 11642 155.65 147.87 170.05 # 11422 110.34 104.82 120.54 11643 260.46 247.44 284.56 11423 161.79 153.70 176.76 # 11643 194.76 185.02 212.77 # 11423 128.94 122.49 140.86 11644 321.68 305.60 351.44 11424 186.85 177.51 204.14 # 11644 242.78 230.64 265.24 # 11424 148.84 141.40 162.61 11646 425.14 403.88 464.46 11426 269.14 255.68 294.03 # 11646 341.73 324.64 373.34 # 11426 227.92 216.52 249.00 11719 17.44 16.57 19.06 11440 104.23 99.02 113.87 # 11719 8.10 7.70 8.86 # 11440 80.72 76.68 88.18 11720 25.78 24.49 28.16 11441 132.74 126.10 145.02 # 11720 15.15 14.39 16.55 # 11441 106.33 101.01 116.16 11721 37.14 35.28 40.57 11442 149.66 142.18 163.51 # 11721 25.87 24.58 28.27 # 11442 118.74 112.80 129.72 11730 81.77 77.68 89.33 11443 180.30 171.29 196.98 # 11730 52.46 49.84 57.32 # 11443 147.12 139.76 160.72 11732 38.23 36.32 41.77 11444 228.16 216.75 249.26 # 11732 27.28 25.92 29.81 # 11444 189.18 179.72 206.68 11740 36.92 35.07 40.33 11446 311.96 296.36 340.81 # 11740 26.94 25.59 29.43 # 11446 268.48 255.06 293.32 11750 177.42 168.55 193.83 11450 283.22 269.06 309.42 # 11750 149.08 141.63 162.87 # 11450 194.65 184.92 212.66 11752 252.50 239.88 275.86 11451 370.81 352.27 405.11 # 11752 222.55 211.42 243.13 # 11451 257.44 244.57 281.26 11755 109.96 104.46 120.13 11462 279.12 265.16 304.93 # 11755 74.21 70.50 81.08 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 4 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 163.85 155.66 179.01 # 12014 125.73 119.44 137.36 # 11760 110.39 104.87 120.60 12015 212.07 201.47 231.69 11762 222.14 211.03 242.68 # 12015 157.96 150.06 172.57 # 11762 170.93 162.38 186.74 12016 253.66 240.98 277.13 11765 103.68 98.50 113.28 # 12016 192.79 183.15 210.62 # 11765 56.66 53.83 61.90 12017 229.46 217.99 250.69 11770 211.83 201.24 231.43 12018 282.99 268.84 309.17 # 11770 149.99 142.49 163.86 12020 219.06 208.11 239.33 11771 436.23 414.42 476.58 # 12020 158.51 150.58 173.17 # 11771 347.33 329.96 379.45 12021 130.60 124.07 142.68 11772 529.38 502.91 578.35 # 12021 114.82 109.08 125.44 # 11772 452.09 429.49 493.91 12031 193.69 184.01 211.61 11900 46.49 44.17 50.80 # 12031 133.14 126.48 145.45 # 11900 27.16 25.80 29.67 12032 248.85 236.41 271.87 11901 59.34 56.37 64.83 # 12032 163.50 155.33 178.63 # 11901 42.27 40.16 46.18 12034 246.39 234.07 269.18 11920 148.96 141.51 162.74 # 12034 171.34 162.77 187.19 # 11920 98.40 93.48 107.50 12035 299.76 284.77 327.49 11921 170.09 161.59 185.83 # 12035 200.56 190.53 219.11 # 11921 115.98 110.18 126.71 12036 329.14 312.68 359.58 11922 49.83 47.34 54.44 # 12036 231.23 219.67 252.62 # 11922 26.32 25.00 28.75 12037 371.49 352.92 405.86 11950 62.92 59.77 68.74 # 12037 269.07 255.62 293.96 # 11950 44.24 42.03 48.33 12041 203.26 193.10 222.07 11951 84.16 79.95 91.94 # 12041 142.71 135.57 155.91 # 11951 61.62 58.54 67.32 12042 237.19 225.33 259.13 11952 118.54 112.61 129.50 # 12042 166.98 158.63 182.42 # 11952 88.91 84.46 97.13 12044 273.36 259.69 298.64 11954 134.93 128.18 147.41 # 12044 179.96 170.96 196.60 # 11954 99.50 94.53 108.71 12045 302.85 287.71 330.87 11960 763.67 725.49 834.31 # 12045 208.49 198.07 227.78 11970 502.45 477.33 548.93 12046 358.40 340.48 391.55 11971 369.13 350.67 403.27 # 12046 245.35 233.08 268.04 # 11971 247.71 235.32 270.62 12047 384.81 365.57 420.41 11976 125.58 119.30 137.20 # 12047 268.54 255.11 293.38 # 11976 85.64 81.36 93.56 12051 218.32 207.40 238.51 11980 89.83 85.34 98.14 # 12051 152.62 144.99 166.74 # 11980 72.11 68.50 78.78 12052 247.69 235.31 270.61 11981 115.09 109.34 125.74 # 12052 179.09 170.14 195.66 # 11981 75.80 72.01 82.81 12053 272.25 258.64 297.44 11982 132.60 125.97 144.87 # 12053 182.39 173.27 199.26 # 11982 92.34 87.72 100.88 12054 288.29 273.88 314.96 11983 207.16 196.80 226.32 # 12054 193.92 184.22 211.85 # 11983 169.48 161.01 185.16 12055 347.84 330.45 380.02 12001 121.70 115.62 132.96 # 12055 236.72 224.88 258.61 # 12001 88.53 84.10 96.72 12056 410.46 389.94 448.43 12002 129.76 123.27 141.76 # 12056 288.39 273.97 315.07 # 12002 98.20 93.29 107.28 12057 459.40 436.43 501.89 12004 153.19 145.53 167.36 # 12057 330.57 314.04 361.15 # 12004 115.51 109.73 126.19 13100 259.58 246.60 283.59 12005 191.11 181.55 208.78 # 13100 199.03 189.08 217.44 # 12005 144.09 136.89 157.42 13101 328.01 311.61 358.35 12006 237.49 225.62 259.46 # 13101 242.33 230.21 264.74 # 12006 182.09 172.99 198.94 13102 89.22 84.76 97.47 12007 268.70 255.27 293.56 # 13102 65.07 61.82 71.09 # 12007 207.83 197.44 227.06 13120 269.93 256.43 294.89 12011 129.20 122.74 141.15 # 13120 208.09 197.69 227.34 # 12011 91.52 86.94 99.98 13121 363.31 345.14 396.91 12013 142.68 135.55 155.88 # 13121 274.73 260.99 300.14 # 12013 104.35 99.13 114.00 13122 100.01 95.01 109.26 12014 168.57 160.14 184.16 # 13122 74.57 70.84 81.47 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 99 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 298.52 283.59 326.13 # 15121 148.42 141.00 162.15 # 13131 235.07 223.32 256.82 15130 553.72 526.03 604.93 13132 479.66 455.68 524.03 # 15130 469.98 446.48 513.45 # 13132 396.88 377.04 433.60 15131 84.56 80.33 92.38 13133 142.09 134.99 155.24 # 15131 76.83 72.99 83.94 # 13133 116.00 110.20 126.73 15135 718.38 682.46 784.83 13150 297.12 282.26 324.60 # 15135 648.49 616.07 708.48 # 13150 233.67 221.99 255.29 15136 78.26 74.35 85.50 13151 339.31 322.34 370.69 # 15136 73.11 69.45 79.87 # 13151 272.32 258.70 297.51 15150 584.00 554.80 638.02 13152 468.30 444.89 511.62 # 15150 539.55 512.57 589.46 # 13152 367.49 349.12 401.49 15151 109.63 104.15 119.77 13153 155.80 148.01 170.21 # 15151 101.58 96.50 110.98 # 13153 125.53 119.25 137.14 15152 142.43 135.31 155.61 13160 685.93 651.63 749.37 # 15152 133.42 126.75 145.76 14000 505.23 479.97 551.97 15155 616.22 585.41 673.22 # 14000 418.59 397.66 457.31 # 15155 579.18 550.22 632.75 14001 658.32 625.40 719.21 15156 152.27 144.66 166.36 # 14001 556.54 528.71 608.02 # 15156 144.86 137.62 158.26 14020 569.23 540.77 621.89 15157 167.94 159.54 183.47 # 14020 479.05 455.10 523.37 # 15157 157.31 149.44 171.86 14021 723.28 687.12 790.19 15170 358.17 340.26 391.30 # 14021 620.54 589.51 677.94 # 15170 313.08 297.43 342.04 14040 634.90 603.16 693.63 15171 80.85 76.81 88.33 # 14040 546.65 519.32 597.22 # 15171 77.31 73.44 84.46 14041 790.56 751.03 863.68 15175 456.35 433.53 498.56 # 14041 675.90 642.11 738.43 # 15175 413.84 393.15 452.12 14060 647.09 614.74 706.95 15176 129.26 122.80 141.22 # 14060 577.53 548.65 630.95 # 15176 122.50 116.38 133.84 14061 846.63 804.30 924.95 15200 662.34 629.22 723.60 # 14061 720.70 684.67 787.37 # 15200 551.87 524.28 602.92 14300 918.17 872.26 1,003.10 15201 121.19 115.13 132.40 # 14300 807.37 767.00 882.05 # 15201 69.34 65.87 75.75 14350 637.22 605.36 696.16 15220 628.86 597.42 687.03 15002 274.97 261.22 300.40 # 15220 520.65 494.62 568.81 # 15002 196.06 186.26 214.20 15221 112.75 107.11 123.18 15003 59.79 56.80 65.32 # 15221 63.47 60.30 69.35 # 15003 39.82 37.83 43.50 15240 757.30 719.44 827.36 15004 334.00 317.30 364.90 # 15240 665.83 632.54 727.42 # 15004 245.11 232.85 267.78 15241 151.68 144.10 165.72 15005 101.23 96.17 110.60 # 15241 99.19 94.23 108.36 # 15005 79.00 75.05 86.31 15260 823.70 782.52 899.90 15040 206.83 196.49 225.96 # 15260 724.18 687.97 791.17 # 15040 110.21 104.70 120.41 15261 177.23 168.37 193.63 15050 442.13 420.02 483.02 # 15261 124.74 118.50 136.28 # 15050 366.44 348.12 400.34 15300 286.88 272.54 313.42 15100 712.50 676.88 778.41 # 15300 248.55 236.12 271.54 # 15100 601.71 571.62 657.36 15301 54.33 51.61 59.35 15101 155.51 147.73 169.89 # 15301 50.47 47.95 55.14 # 15101 96.89 92.05 105.86 15320 323.74 307.55 353.68 15110 707.45 672.08 772.89 # 15320 281.55 267.47 307.59 # 15110 622.10 591.00 679.65 15321 81.02 76.97 88.52 15111 103.87 98.68 113.48 # 15321 75.86 72.07 82.88 # 15111 93.88 89.19 102.57 15330 264.04 250.84 288.47 15115 717.40 681.53 783.76 # 15330 224.75 213.51 245.54 # 15115 644.94 612.69 704.59 15331 54.33 51.61 59.35 15116 141.11 134.05 154.16 # 15331 50.79 48.25 55.49 # 15116 129.52 123.04 141.50 15335 278.99 265.04 304.80 15120 776.28 737.47 848.09 # 15335 240.66 228.63 262.92 # 15120 661.62 628.54 722.82 15336 75.74 71.95 82.74 15121 220.24 209.23 240.61 # 15336 69.94 66.44 76.41 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 99 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 263.66 250.48 288.05 15776 374.55 355.82 409.19 # 15340 228.88 217.44 250.06 # 15776 289.52 275.04 316.30 15341 39.07 37.12 42.69 15780 684.98 650.73 748.34 # 15341 24.25 23.04 26.50 # 15780 545.52 518.24 595.98 15360 297.85 282.96 325.40 15781 437.88 415.99 478.39 # 15360 256.94 244.09 280.70 # 15781 357.36 339.49 390.41 15361 61.03 57.98 66.68 15782 460.56 437.53 503.16 # 15361 55.88 53.09 61.05 # 15782 342.04 324.94 373.68 15365 293.99 279.29 321.18 15783 398.18 378.27 435.01 # 15365 257.27 244.41 281.07 # 15783 309.94 294.44 338.61 15366 75.28 71.52 82.25 15786 195.06 185.31 213.11 # 15366 69.81 66.32 76.27 # 15786 117.76 111.87 128.65 15400 326.06 309.76 356.22 15787 39.67 37.69 43.34 # 15400 295.79 281.00 323.15 # 15787 16.48 15.66 18.01 15401 77.84 73.95 85.04 15788 342.08 324.98 373.73 # 15401 50.15 47.64 54.79 # 15788 195.21 185.45 213.27 15420 367.57 349.19 401.57 15789 464.38 441.16 507.33 # 15420 328.27 311.86 358.64 # 15789 356.81 338.97 389.82 15421 96.48 91.66 105.41 15792 335.75 318.96 366.80 # 15421 74.90 71.16 81.83 # 15792 213.04 202.39 232.75 15430 433.32 411.65 473.40 15793 385.28 366.02 420.92 # 15430 418.51 397.58 457.22 # 15793 295.10 280.35 322.40 15570 727.45 691.08 794.74 15819 623.10 591.95 680.74 # 15570 602.17 572.06 657.87 15820 441.57 419.49 482.41 15572 707.02 671.67 772.42 # 15820 401.63 381.55 438.78 # 15572 609.76 579.27 666.16 15821 470.10 446.60 513.59 15574 746.30 708.99 815.34 # 15821 426.30 404.99 465.74 # 15574 644.52 612.29 704.13 15822 344.76 327.52 376.65 15576 663.68 630.50 725.08 # 15822 306.75 291.41 335.12 # 15576 566.74 538.40 619.16 15823 548.44 521.02 599.17 15600 262.89 249.75 287.21 # 15823 506.89 481.55 553.78 # 15600 165.95 157.65 181.30 15830 987.78 938.39 1,079.15 15610 265.63 252.35 290.20 15832 752.05 714.45 821.62 # 15610 196.71 186.87 214.90 15833 708.98 673.53 774.56 15620 354.17 336.46 386.93 15834 706.35 671.03 771.68 # 15620 262.38 249.26 286.65 15835 747.67 710.29 816.83 15630 374.91 356.16 409.58 15836 622.43 591.31 680.01 # 15630 286.99 272.64 313.54 15837 640.38 608.36 699.61 15650 418.93 397.98 457.68 # 15837 563.40 535.23 615.51 # 15650 323.92 307.72 353.88 15838 487.19 462.83 532.25 15731 943.91 896.71 1,031.22 15839 708.52 673.09 774.05 # 15731 859.52 816.54 939.02 # 15839 610.93 580.38 667.44 15732 1,251.66 1,189.08 1,367.44 15840 859.48 816.51 938.99 # 15732 1,121.54 1,065.46 1,225.28 15841 1,439.77 1,367.78 1,572.95 15734 1,282.00 1,217.90 1,400.59 15842 2,270.82 2,157.28 2,480.87 # 15734 1,146.08 1,088.78 1,252.10 15845 808.36 767.94 883.13 15736 1,133.79 1,077.10 1,238.67 15851 76.85 73.01 83.96 # 15736 988.86 939.42 1,080.33 # 15851 40.46 38.44 44.21 15738 1,212.69 1,152.06 1,324.87 15852 41.95 39.85 45.83 # 15738 1,079.03 1,025.08 1,178.84 15860 98.31 93.39 107.40 15740 842.66 800.53 920.61 15920 493.08 468.43 538.69 # 15740 729.93 693.43 797.44 15922 625.73 594.44 683.61 15750 771.94 733.34 843.34 15931 563.38 535.21 615.49 15756 2,040.59 1,938.56 2,229.34 15933 691.73 657.14 755.71 15757 2,024.76 1,923.52 2,212.05 15934 772.61 733.98 844.08 15758 2,024.03 1,922.83 2,211.25 15935 918.04 872.14 1,002.96 15760 698.52 663.59 763.13 15936 748.75 711.31 818.01 # 15760 597.39 567.52 652.65 15937 874.68 830.95 955.59 15770 551.54 523.96 602.55 15940 578.87 549.93 632.42 15775 270.21 256.70 295.21 15941 749.51 712.03 818.83 # 15775 202.90 192.76 221.67 15944 738.82 701.88 807.16 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 99 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 820.49 779.47 896.39 # 17280 75.69 71.91 82.70 15946 1,375.20 1,306.44 1,502.41 17281 145.48 138.21 158.94 15950 478.31 454.39 522.55 # 17281 105.87 100.58 115.67 15951 682.41 648.29 745.53 17282 168.80 160.36 184.41 15952 717.78 681.89 784.17 # 17282 123.06 116.91 134.45 15953 798.94 758.99 872.84 17283 204.50 194.28 223.42 15956 963.03 914.88 1,052.11 # 17283 154.25 146.54 168.52 15958 981.63 932.55 1,072.43 17284 238.29 226.38 260.34 16000 57.67 54.79 63.01 # 17284 184.18 174.97 201.22 # 16000 41.25 39.19 45.07 17286 302.43 287.31 330.41 16020 66.99 63.64 73.19 # 17286 247.67 235.29 270.58 # 16020 48.31 45.89 52.77 17311 570.88 542.34 623.69 16025 122.59 116.46 133.93 # 17311 332.87 316.23 363.66 # 16025 99.40 94.43 108.59 17312 340.66 323.63 372.17 16030 146.27 138.96 159.80 # 17312 177.05 168.20 193.43 # 16030 112.77 107.13 123.20 17313 520.71 494.67 568.87 16035 186.85 177.51 204.14 # 17313 298.80 283.86 326.44 16036 74.40 70.68 81.28 17314 315.72 299.93 344.92 17000 64.44 61.22 70.40 # 17314 164.35 156.13 179.55 # 17000 45.44 43.17 49.65 17315 68.63 65.20 74.98 17003 6.24 5.93 6.82 # 17315 46.73 44.39 51.05 # 17003 3.99 3.79 4.36 17340 41.50 39.43 45.34 17004 145.54 138.26 159.00 # 17340 40.21 38.20 43.93 # 17004 114.94 109.19 125.57 17360 109.69 104.21 119.84 17106 285.53 271.25 311.94 # 17360 85.53 81.25 93.44 # 17106 236.58 224.75 258.46 19000 93.88 89.19 102.57 17107 377.40 358.53 412.31 # 19000 41.38 39.31 45.21 # 17107 312.02 296.42 340.88 19001 24.23 23.02 26.47 17108 484.43 460.21 529.24 # 19001 20.69 19.66 22.61 # 17108 408.74 388.30 446.55 19020 352.54 334.91 385.15 17110 88.82 84.38 97.04 # 19020 238.21 226.30 260.25 # 17110 56.29 53.48 61.50 19030 145.03 137.78 158.45 17111 105.97 100.67 115.77 # 19030 75.14 71.38 82.09 # 17111 70.54 67.01 77.06 19100 115.31 109.54 125.97 17250 60.32 57.30 65.90 # 19100 60.56 57.53 66.16 # 17250 31.01 29.46 33.88 19101 263.72 250.53 288.11 17260 78.38 74.46 85.63 # 19101 181.60 172.52 198.40 # 17260 57.12 54.26 62.40 19102 189.92 180.42 207.48 17261 116.27 110.46 127.03 # 19102 98.13 93.22 107.20 # 17261 76.98 73.13 84.10 19103 474.01 450.31 517.86 17262 142.19 135.08 155.34 # 19103 179.96 170.96 196.60 # 17262 98.71 93.77 107.84 19105 1,788.08 1,698.68 1,953.48 17263 157.03 149.18 171.56 # 19105 180.28 171.27 196.96 # 17263 109.36 103.89 119.47 19110 366.69 348.36 400.61 17264 168.09 159.69 183.64 # 19110 269.10 255.65 294.00 # 17264 116.88 111.04 127.70 19112 342.05 324.95 373.69 17266 191.39 181.82 209.09 # 19112 241.24 229.18 263.56 # 17266 136.31 129.49 148.91 19120 383.65 364.47 419.14 17270 121.04 114.99 132.24 # 19120 331.48 314.91 362.15 # 17270 83.36 79.19 91.07 19125 425.15 403.89 464.47 17271 133.79 127.10 146.17 # 19125 368.14 349.73 402.19 # 17271 93.85 89.16 102.53 19126 139.79 132.80 152.72 17272 153.41 145.74 167.60 19260 1,013.50 962.83 1,107.25 # 17272 108.96 103.51 119.04 19271 1,371.02 1,302.47 1,497.84 17273 171.41 162.84 187.27 19272 1,520.73 1,444.69 1,661.39 # 17273 123.10 116.95 134.49 19290 140.13 133.12 153.09 17274 203.48 193.31 222.31 # 19290 62.18 59.07 67.93 # 17274 151.31 143.74 165.30 19291 60.79 57.75 66.41 17276 236.21 224.40 258.06 # 19291 30.84 29.30 33.70 # 17276 182.10 173.00 198.95 19295 75.87 72.08 82.89 17280 113.37 107.70 123.86 19296 3,180.59 3,021.56 3,474.79 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 8 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 179.82 170.83 196.45 20250 319.51 303.53 349.06 19297 81.48 77.41 89.02 20251 354.13 336.42 386.88 19298 1,096.85 1,042.01 1,198.31 20500 98.10 93.20 107.18 # 19298 297.14 282.28 324.62 # 20500 81.35 77.28 88.87 19300 406.24 385.93 443.82 20501 108.96 103.51 119.04 # 19300 320.57 304.54 350.22 # 20501 37.46 35.59 40.93 19301 517.36 491.49 565.21 20520 156.84 149.00 171.35 19302 737.06 700.21 805.24 # 20520 120.45 114.43 131.59 19303 800.93 760.88 875.01 20525 379.45 360.48 414.55 19304 458.92 435.97 501.37 # 20525 211.33 200.76 230.87 19305 920.10 874.10 1,005.22 20526 63.91 60.71 69.82 19306 963.48 915.31 1,052.61 # 20526 50.70 48.17 55.40 19307 968.94 920.49 1,058.56 20550 49.58 47.10 54.17 19316 654.75 622.01 715.31 # 20550 37.34 35.47 40.79 19318 961.41 913.34 1,050.34 20551 49.08 46.63 53.62 19324 400.00 380.00 437.00 # 20551 38.13 36.22 41.65 19325 540.88 513.84 590.92 20552 44.66 42.43 48.79 19328 408.14 387.73 445.89 # 20552 32.42 30.80 35.42 19330 525.29 499.03 573.88 20553 49.98 47.48 54.60 19340 343.05 325.90 374.79 # 20553 36.13 34.32 39.47 19342 772.64 734.01 844.11 20555 299.07 284.12 326.74 19350 699.03 664.08 763.69 20600 46.48 44.16 50.78 # 19350 568.59 540.16 621.18 # 20600 35.53 33.75 38.81 19355 584.24 555.03 638.28 20605 49.78 47.29 54.38 # 19355 474.09 450.39 517.95 # 20605 36.90 35.06 40.32 19357 1,297.78 1,232.89 1,417.82 20610 63.94 60.74 69.85 19361 1,398.47 1,328.55 1,527.83 # 20610 43.97 41.77 48.04 19364 2,392.32 2,272.70 2,613.61 20612 49.57 47.09 54.15 19366 1,182.36 1,123.24 1,291.73 # 20612 37.97 36.07 41.48 19367 1,544.73 1,467.49 1,687.61 20615 180.87 171.83 197.60 19368 1,914.72 1,818.98 2,091.83 # 20615 136.75 129.91 149.40 19369 1,748.60 1,661.17 1,910.35 20650 164.59 156.36 179.81 19370 569.36 540.89 622.02 # 20650 134.32 127.60 146.74 19371 656.42 623.60 717.14 20660 217.86 206.97 238.02 19380 642.76 610.62 702.21 # 20660 206.27 195.96 225.35 19396 180.85 171.81 197.58 20661 387.58 368.20 423.43 # 19396 115.15 109.39 125.80 20662 406.74 386.40 444.36 20000 169.55 161.07 185.23 20663 374.29 355.58 408.92 # 20000 132.51 125.88 144.76 20664 640.14 608.13 699.35 20005 252.79 240.15 276.17 20665 101.91 96.81 111.33 # 20005 203.83 193.64 222.69 # 20665 86.12 81.81 94.08 20100 512.56 486.93 559.97 20670 317.73 301.84 347.12 20101 322.02 305.92 351.81 # 20670 125.78 119.49 137.41 # 20101 174.19 165.48 190.30 20680 489.09 464.64 534.34 20102 377.58 358.70 412.51 # 20680 352.85 335.21 385.49 # 20102 212.67 202.04 232.35 20690 467.38 444.01 510.61 20103 461.19 438.13 503.85 20692 873.97 830.27 954.81 # 20103 301.77 286.68 329.68 20693 388.27 368.86 424.19 20150 824.30 783.09 900.55 20694 350.24 332.73 382.64 20200 155.94 148.14 170.36 # 20694 283.25 269.09 309.45 # 20200 80.25 76.24 87.68 20696 931.80 885.21 1,017.99 20205 213.97 203.27 233.76 20697 1,065.60 1,012.32 1,164.17 # 20205 127.97 121.57 139.81 # 20697 0.18 0.17 0.20 20206 214.73 203.99 234.59 20802 2,147.05 2,039.70 2,345.66 # 20206 56.59 53.76 61.82 20805 2,628.12 2,496.71 2,871.22 20220 149.64 142.16 163.48 20808 3,539.66 3,362.68 3,867.08 # 20220 70.74 67.20 77.28 20816 1,946.26 1,848.95 2,126.29 20225 557.04 529.19 608.57 20822 1,647.87 1,565.48 1,800.30 # 20225 106.78 101.44 116.66 20824 1,938.52 1,841.59 2,117.83 20240 195.56 185.78 213.65 20827 1,714.92 1,629.17 1,873.55 20245 533.12 506.46 582.43 20838 2,179.05 2,070.10 2,380.62 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 99 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 344.21 327.00 376.05 # 21076 722.33 686.21 789.14 # 20900 222.79 211.65 243.40 21077 2,025.86 1,924.57 2,213.26 20902 309.03 293.58 337.62 # 21077 1,827.14 1,735.78 1,996.15 20910 365.21 346.95 398.99 21079 1,383.12 1,313.96 1,511.05 20912 411.27 390.71 449.32 # 21079 1,209.20 1,148.74 1,321.05 20920 346.33 329.01 378.36 21080 1,569.43 1,490.96 1,714.60 20922 509.69 484.21 556.84 # 21080 1,359.44 1,291.47 1,485.19 # 20922 425.31 404.04 464.65 21081 1,433.12 1,361.46 1,565.68 20924 427.48 406.11 467.03 # 21081 1,238.59 1,176.66 1,353.16 20926 369.17 350.71 403.32 21082 1,332.30 1,265.69 1,455.54 20931 98.03 93.13 107.10 # 21082 1,146.14 1,088.83 1,252.15 20937 149.82 142.33 163.68 21083 1,263.86 1,200.67 1,380.77 20938 162.47 154.35 177.50 # 21083 1,060.95 1,007.90 1,159.09 20950 199.72 189.73 218.19 21084 1,445.15 1,372.89 1,578.82 # 20950 77.98 74.08 85.19 # 21084 1,220.99 1,159.94 1,333.93 20955 2,214.74 2,104.00 2,419.60 21085 583.18 554.02 637.12 20956 2,301.79 2,186.70 2,514.71 # 21085 491.06 466.51 536.49 20957 2,205.16 2,094.90 2,409.14 21086 1,478.02 1,404.12 1,614.74 20962 2,253.81 2,141.12 2,462.29 # 21086 1,338.24 1,271.33 1,462.03 20969 2,457.74 2,334.85 2,685.08 21087 1,473.88 1,400.19 1,610.22 20970 2,460.03 2,337.03 2,687.58 # 21087 1,334.74 1,268.00 1,458.20 20972 2,259.22 2,146.26 2,468.20 21100 578.57 549.64 632.09 20973 2,372.69 2,254.06 2,592.17 # 21100 334.43 317.71 365.37 20974 54.27 51.56 59.29 21110 610.71 580.17 667.20 # 20974 40.74 38.70 44.51 # 21110 522.78 496.64 571.14 20975 153.39 145.72 167.58 21116 122.39 116.27 133.71 20979 44.89 42.65 49.05 # 21116 38.65 36.72 42.23 # 20979 31.69 30.11 34.63 21120 507.86 482.47 554.84 20982 3,061.68 2,908.60 3,344.89 # 21120 411.56 390.98 449.63 # 20982 368.17 349.76 402.22 21121 637.66 605.78 696.65 20985 132.82 126.18 145.11 # 21121 548.44 521.02 599.17 21010 623.14 591.98 680.78 21122 604.49 574.27 660.41 21015 360.90 342.86 394.29 21123 725.82 689.53 792.96 21025 737.23 700.37 805.43 21125 2,448.89 2,326.45 2,675.42 # 21025 633.20 601.54 691.77 # 21125 638.51 606.58 697.57 21026 485.51 461.23 530.41 21127 2,911.36 2,765.79 3,180.66 # 21026 405.31 385.04 442.80 # 21127 743.16 706.00 811.90 21029 621.85 590.76 679.37 21137 612.58 581.95 669.24 # 21029 531.02 504.47 580.14 21138 764.91 726.66 835.66 21030 406.54 386.21 444.14 21139 863.01 819.86 942.84 # 21030 337.30 320.44 368.51 21141 1,152.68 1,095.05 1,259.31 21031 311.29 295.73 340.09 21142 1,141.14 1,084.08 1,246.69 # 21031 240.75 228.71 263.02 21143 1,187.52 1,128.14 1,297.36 21032 315.37 299.60 344.54 21145 1,327.68 1,261.30 1,450.50 # 21032 237.43 225.56 259.39 21146 1,415.79 1,345.00 1,546.75 21034 1,120.34 1,064.32 1,223.97 21147 1,464.84 1,391.60 1,600.34 # 21034 1,004.07 953.87 1,096.95 21150 1,450.93 1,378.38 1,585.14 21040 409.76 389.27 447.66 21151 1,752.35 1,664.73 1,914.44 # 21040 335.37 318.60 366.39 21154 1,773.74 1,685.05 1,937.81 21044 751.01 713.46 820.48 21155 1,995.92 1,896.12 2,180.54 21045 1,048.99 996.54 1,146.02 21159 2,414.86 2,294.12 2,638.24 21046 919.48 873.51 1,004.54 21160 2,508.85 2,383.41 2,740.92 21047 1,120.81 1,064.77 1,224.49 21172 1,536.77 1,459.93 1,678.92 21048 933.02 886.37 1,019.33 21175 1,852.65 1,760.02 2,024.02 21049 1,085.46 1,031.19 1,185.87 21179 1,270.51 1,206.98 1,388.03 21050 733.45 696.78 801.30 21180 1,446.87 1,374.53 1,580.71 21060 670.80 637.26 732.85 21181 604.12 573.91 660.00 21070 543.60 516.42 593.88 21182 1,769.04 1,680.59 1,932.68 21073 301.65 286.57 329.56 21183 1,971.75 1,873.16 2,154.13 # 21073 202.78 192.64 221.54 21184 2,105.51 2,000.23 2,300.26 21076 820.57 779.54 896.47 21188 1,397.77 1,327.88 1,527.06 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 10 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,066.35 1,013.03 1,164.98 21345 667.01 633.66 728.71 21194 1,220.32 1,159.30 1,333.20 # 21345 555.57 527.79 606.96 21195 1,144.52 1,087.29 1,250.38 21346 800.98 760.93 875.07 21196 1,246.05 1,183.75 1,361.31 21347 929.25 882.79 1,015.21 21198 979.05 930.10 1,069.62 21348 991.73 942.14 1,083.46 21199 892.38 847.76 974.92 21355 360.56 342.53 393.91 21206 965.04 916.79 1,054.31 # 21355 274.25 260.54 299.62 21208 1,404.78 1,334.54 1,534.72 21356 403.13 382.97 440.42 # 21208 701.69 666.61 766.60 # 21356 313.91 298.21 342.94 21209 671.98 638.38 734.14 21360 447.36 424.99 488.74 # 21209 536.39 509.57 586.01 21365 942.59 895.46 1,029.78 21210 1,675.18 1,591.42 1,830.13 21366 1,045.35 993.08 1,142.04 # 21210 700.91 665.86 765.74 21385 603.82 573.63 659.67 21215 2,830.83 2,689.29 3,092.68 21386 565.17 536.91 617.45 # 21215 730.26 693.75 797.81 21387 630.08 598.58 688.37 21230 654.65 621.92 715.21 21390 655.17 622.41 715.77 21235 599.12 569.16 654.53 21395 827.25 785.89 903.77 # 21235 478.67 454.74 522.95 21400 144.13 136.92 157.46 21240 944.62 897.39 1,032.00 # 21400 119.33 113.36 130.36 21242 866.12 822.81 946.23 21401 383.50 364.33 418.98 21243 1,422.13 1,351.02 1,553.67 # 21401 246.62 234.29 269.43 21244 884.36 840.14 966.16 21406 456.96 434.11 499.23 21245 949.76 902.27 1,037.61 21407 541.58 514.50 591.68 # 21245 781.64 742.56 853.94 21408 745.65 708.37 814.63 21246 731.27 694.71 798.92 21421 592.85 563.21 647.69 21247 1,386.42 1,317.10 1,514.67 # 21421 509.43 483.96 556.55 21248 893.32 848.65 975.95 21422 564.86 536.62 617.11 # 21248 748.71 711.27 817.96 21423 672.27 638.66 734.46 21249 1,241.50 1,179.43 1,356.34 21431 613.33 582.66 670.06 # 21249 1,063.71 1,010.52 1,162.10 21432 564.47 536.25 616.69 21255 1,219.39 1,158.42 1,332.18 21433 1,458.61 1,385.68 1,593.53 21256 1,003.70 953.52 1,096.55 21435 1,149.33 1,091.86 1,255.64 21260 1,129.52 1,073.04 1,234.00 21436 1,692.30 1,607.69 1,848.84 21261 1,933.65 1,836.97 2,112.52 21440 428.44 407.02 468.07 21263 1,742.74 1,655.60 1,903.94 # 21440 357.90 340.01 391.01 21267 1,315.43 1,249.66 1,437.11 21445 612.05 581.45 668.67 21268 1,631.48 1,549.91 1,782.40 # 21445 509.31 483.84 556.42 21270 760.33 722.31 830.66 21450 446.95 424.60 488.29 # 21270 599.94 569.94 655.43 # 21450 375.77 356.98 410.53 21275 688.49 654.07 752.18 21451 592.02 562.42 646.78 21280 444.16 421.95 485.24 # 21451 506.99 481.64 553.89 21282 292.31 277.69 319.34 21452 480.31 456.29 524.73 21295 145.46 138.19 158.92 # 21452 270.32 256.80 295.32 21296 354.50 336.78 387.30 21453 685.52 651.24 748.93 21310 86.22 81.91 94.20 # 21453 611.12 580.56 667.64 # 21310 25.67 24.39 28.05 21454 465.43 442.16 508.48 21315 211.94 201.34 231.54 21461 1,537.48 1,460.61 1,679.70 # 21315 124.33 118.11 135.83 # 21461 758.70 720.77 828.89 21320 204.26 194.05 223.16 21462 1,664.17 1,580.96 1,818.10 # 21320 116.66 110.83 127.45 # 21462 842.23 800.12 920.14 21325 387.08 367.73 422.89 21465 774.26 735.55 845.88 21330 476.32 452.50 520.38 21470 1,011.67 961.09 1,105.25 21335 620.16 589.15 677.52 21480 73.63 69.95 80.44 21336 532.68 506.05 581.96 # 21480 28.86 27.42 31.53 21337 319.01 303.06 348.52 21485 528.52 502.09 577.40 # 21337 237.85 225.96 259.85 # 21485 453.80 431.11 495.78 21338 607.17 576.81 663.33 21490 781.94 742.84 854.27 21339 679.07 645.12 741.89 21495 564.22 536.01 616.41 21340 685.73 651.44 749.16 21497 533.31 506.64 582.64 21343 968.50 920.08 1,058.09 # 21497 458.27 435.36 500.66 21344 1,279.08 1,215.13 1,397.40 21501 356.56 338.73 389.54 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 11 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 263.80 250.61 288.20 22310 238.26 226.35 260.30 21502 443.00 420.85 483.98 # 22310 223.12 211.96 243.75 21510 390.25 370.74 426.35 22315 705.74 670.45 771.02 21550 209.26 198.80 228.62 # 22315 631.02 599.47 689.39 # 21550 134.86 128.12 147.34 22318 1,340.82 1,273.78 1,464.85 21555 353.18 335.52 385.85 22319 1,473.71 1,400.02 1,610.02 # 21555 278.78 264.84 304.57 22325 1,177.14 1,118.28 1,286.02 21556 349.22 331.76 381.52 22326 1,225.94 1,164.64 1,339.34 21557 496.72 471.88 542.66 22327 1,218.31 1,157.39 1,331.00 21600 465.75 442.46 508.83 22328 246.04 233.74 268.80 21610 907.46 862.09 991.40 22505 104.75 99.51 114.44 21615 576.33 547.51 629.64 22520 1,878.55 1,784.62 2,052.31 21616 733.78 697.09 801.65 # 22520 505.54 480.26 552.30 21620 443.75 421.56 484.79 22521 1,828.80 1,737.36 1,997.96 21627 465.15 441.89 508.17 # 22521 476.41 452.59 520.48 21630 1,089.41 1,034.94 1,190.18 22522 223.42 212.25 244.09 21632 1,079.38 1,025.41 1,179.22 22523 528.24 501.83 577.10 21685 854.08 811.38 933.09 22524 506.21 480.90 553.04 21700 363.07 344.92 396.66 22525 237.61 225.73 259.59 21705 555.12 527.36 606.46 22526 1,578.37 1,499.45 1,724.37 21720 347.09 329.74 379.20 # 22526 301.02 285.97 328.87 21725 449.53 427.05 491.11 22527 1,220.43 1,159.41 1,333.32 21740 941.07 894.02 1,028.12 # 22527 137.93 131.03 150.68 21750 623.15 591.99 680.79 22532 1,472.18 1,398.57 1,608.36 21800 80.10 76.10 87.52 22533 1,392.00 1,322.40 1,520.76 # 21800 81.39 77.32 88.92 22534 321.96 305.86 351.74 21805 214.66 203.93 234.52 22548 1,561.39 1,483.32 1,705.82 21810 424.08 402.88 463.31 22554 1,074.41 1,020.69 1,173.79 21820 106.77 101.43 116.64 22556 1,403.03 1,332.88 1,532.81 # 21820 108.06 102.66 118.06 22558 1,295.59 1,230.81 1,415.43 21825 480.80 456.76 525.27 22585 296.96 282.11 324.43 21920 208.91 198.46 228.23 22590 1,294.17 1,229.46 1,413.88 # 21920 134.83 128.09 147.30 22595 1,229.32 1,167.85 1,343.03 21925 346.06 328.76 378.07 22600 1,053.05 1,000.40 1,150.46 # 21925 283.25 269.09 309.45 22610 1,040.35 988.33 1,136.58 21930 386.17 366.86 421.89 22612 1,351.56 1,283.98 1,476.58 # 21930 314.02 298.32 343.07 22614 346.90 329.56 378.99 21935 997.42 947.55 1,089.68 22630 1,295.99 1,231.19 1,415.87 22010 764.12 725.91 834.80 22632 281.64 267.56 307.69 22015 759.79 721.80 830.07 22800 1,146.72 1,089.38 1,252.79 22100 686.12 651.81 749.58 22802 1,826.58 1,735.25 1,995.54 22101 685.57 651.29 748.98 22804 2,112.04 2,006.44 2,307.41 22102 683.10 648.95 746.29 22808 1,555.89 1,478.10 1,699.82 22103 125.38 119.11 136.98 22810 1,739.45 1,652.48 1,900.35 22110 853.17 810.51 932.09 22812 1,904.23 1,809.02 2,080.37 22112 828.24 786.83 904.85 22818 1,914.42 1,818.70 2,091.51 22114 848.55 806.12 927.04 22819 2,203.97 2,093.77 2,407.84 22116 124.43 118.21 135.94 22830 682.18 648.07 745.28 22206 2,045.36 1,943.09 2,234.55 22840 676.59 642.76 739.17 22207 2,019.01 1,918.06 2,205.77 22842 678.29 644.38 741.04 22208 513.64 487.96 561.15 22843 722.61 686.48 789.45 22210 1,492.79 1,418.15 1,630.87 22844 886.51 842.18 968.51 22212 1,237.07 1,175.22 1,351.50 22845 646.29 613.98 706.08 22214 1,244.45 1,182.23 1,359.56 22846 671.09 637.54 733.17 22216 326.04 309.74 356.20 22847 741.87 704.78 810.50 22220 1,343.62 1,276.44 1,467.91 22848 323.08 306.93 352.97 22222 1,234.26 1,172.55 1,348.43 22849 1,109.06 1,053.61 1,211.65 22224 1,334.52 1,267.79 1,457.96 22850 603.13 572.97 658.92 22226 324.76 308.52 354.80 22851 360.84 342.80 394.22 22305 152.80 145.16 166.93 22852 576.83 547.99 630.19 # 22305 141.52 134.44 154.61 22855 936.88 890.04 1,023.55 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 99 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 1,400.71 1,330.67 1,530.27 23405 533.32 506.65 582.65 22857 1,477.62 1,403.74 1,614.30 23406 667.72 634.33 729.48 22861 1,731.28 1,644.72 1,891.43 23410 706.67 671.34 772.04 22862 1,706.64 1,621.31 1,864.51 23412 738.47 701.55 806.78 22864 1,573.45 1,494.78 1,719.00 23415 587.64 558.26 642.00 22865 1,816.64 1,725.81 1,984.68 23420 829.27 787.81 905.98 22900 348.31 330.89 380.52 23430 627.49 596.12 685.54 23000 431.32 409.75 471.21 23440 647.69 615.31 707.61 # 23000 299.27 284.31 326.96 23450 813.91 773.21 889.19 23020 582.81 553.67 636.72 23455 868.34 824.92 948.66 23030 343.85 326.66 375.66 23460 939.81 892.82 1,026.74 # 23030 216.63 205.80 236.67 23462 922.80 876.66 1,008.16 23031 312.87 297.23 341.81 23465 962.12 914.01 1,051.11 # 23031 179.21 170.25 195.79 23466 948.00 900.60 1,035.69 23035 577.90 549.01 631.36 23470 1,047.52 995.14 1,144.41 23040 606.96 576.61 663.10 23472 1,299.07 1,234.12 1,419.24 23044 480.84 456.80 525.32 23480 698.67 663.74 763.30 23065 176.61 167.78 192.95 23485 826.49 785.17 902.95 # 23065 141.18 134.12 154.24 23490 716.38 680.56 782.64 23066 410.37 389.85 448.33 23491 869.80 826.31 950.26 # 23066 283.15 268.99 309.34 23500 168.78 160.34 184.39 23075 211.16 200.60 230.69 # 23500 167.82 159.43 183.34 # 23075 149.64 142.16 163.48 23505 278.73 264.79 304.51 23076 475.18 451.42 519.13 # 23505 264.88 251.64 289.39 23077 1,014.72 963.98 1,108.58 23515 593.81 564.12 648.74 23100 408.16 387.75 445.91 23520 174.96 166.21 191.14 23101 375.33 356.56 410.04 # 23520 175.92 167.12 192.19 23105 536.06 509.26 585.65 23525 273.22 259.56 298.49 23106 398.62 378.69 435.49 # 23525 256.47 243.65 280.20 23107 557.17 529.31 608.71 23530 454.26 431.55 496.28 23120 480.99 456.94 525.48 23532 521.39 495.32 569.62 23125 593.37 563.70 648.26 23540 173.37 164.70 189.41 23130 505.99 480.69 552.79 # 23540 171.12 162.56 186.94 23140 432.71 411.07 472.73 23545 250.92 238.37 274.13 23145 582.73 553.59 636.63 # 23545 232.24 220.63 253.72 23146 505.58 480.30 552.35 23550 481.02 456.97 525.52 23150 551.73 524.14 602.76 23552 554.19 526.48 605.45 23155 668.04 634.64 729.84 23570 180.41 171.39 197.10 23156 567.29 538.93 619.77 # 23570 182.67 173.54 199.57 23170 446.00 423.70 487.26 23575 309.15 293.69 337.74 23172 457.64 434.76 499.97 # 23575 292.40 277.78 319.45 23174 634.01 602.31 692.66 23585 810.48 769.96 885.45 23180 576.52 547.69 629.84 23600 251.67 239.09 274.95 23182 556.21 528.40 607.66 # 23600 233.63 221.95 255.24 23184 628.29 596.88 686.41 23605 373.44 354.77 407.99 23190 468.18 444.77 511.49 # 23605 346.38 329.06 378.42 23195 635.75 603.96 694.55 23615 738.67 701.74 807.00 23200 752.67 715.04 822.30 23616 1,099.18 1,044.22 1,200.85 23210 787.00 747.65 859.80 23620 207.26 196.90 226.44 23220 911.55 865.97 995.87 # 23620 195.99 186.19 214.12 23221 1,065.16 1,011.90 1,163.69 23625 302.66 287.53 330.66 23222 1,452.38 1,379.76 1,586.72 # 23625 285.27 271.01 311.66 23330 181.85 172.76 198.67 23630 634.64 602.91 693.35 # 23330 124.52 118.29 136.03 23650 237.29 225.43 259.24 23331 493.08 468.43 538.69 # 23650 218.29 207.38 238.49 23332 751.52 713.94 821.03 23655 314.86 299.12 343.99 23350 130.86 124.32 142.97 23660 487.47 463.10 532.57 # 23350 49.05 46.60 53.59 23665 337.38 320.51 368.59 23395 1,096.71 1,041.87 1,198.15 # 23665 318.70 302.77 348.19 23397 982.68 933.55 1,073.58 23670 714.73 678.99 780.84 23400 831.67 790.09 908.60 23675 441.27 419.21 482.09 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 99 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 410.35 389.83 448.30 24332 506.26 480.95 553.09 23680 772.53 733.90 843.99 24340 514.77 489.03 562.38 23700 163.83 155.64 178.99 24341 606.35 576.03 662.43 23800 875.99 832.19 957.02 24342 665.46 632.19 727.02 23802 1,066.07 1,012.77 1,164.69 24343 588.92 559.47 643.39 23900 1,141.18 1,084.12 1,246.74 24344 922.08 875.98 1,007.38 23920 922.47 876.35 1,007.80 24345 585.23 555.97 639.37 23921 333.73 317.04 364.60 24346 924.13 877.92 1,009.61 23930 286.05 271.75 312.51 24357 367.71 349.32 401.72 # 23930 182.35 173.23 199.21 24358 434.90 413.16 475.13 23931 221.62 210.54 242.12 24359 549.73 522.24 600.58 # 23931 130.48 123.96 142.55 24360 766.10 727.80 836.97 23935 415.15 394.39 453.55 24361 860.47 817.45 940.07 24000 394.93 375.18 431.46 24362 909.44 863.97 993.57 24006 600.00 570.00 655.50 24363 1,282.38 1,218.26 1,401.00 24065 204.69 194.46 223.63 24365 539.36 512.39 589.25 # 24065 139.95 132.95 152.89 24366 578.31 549.39 631.80 24066 475.09 451.34 519.04 24400 698.07 663.17 762.65 # 24066 333.38 316.71 364.22 24410 894.21 849.50 976.93 24075 384.33 365.11 419.88 24420 838.95 797.00 916.55 # 24075 260.33 247.31 284.41 24430 893.72 849.03 976.38 24076 398.26 378.35 435.10 24435 904.78 859.54 988.47 24077 692.62 657.99 756.69 24470 532.74 506.10 582.02 24100 336.41 319.59 367.53 24495 552.83 525.19 603.97 24101 414.81 394.07 453.18 24498 742.62 705.49 811.31 24102 516.59 490.76 564.37 24500 274.08 260.38 299.44 24105 276.85 263.01 302.46 # 24500 249.60 237.12 272.69 24110 487.59 463.21 532.69 24505 399.68 379.70 436.66 24115 617.86 586.97 675.02 # 24505 367.47 349.10 401.47 24116 734.52 697.79 802.46 24515 743.76 706.57 812.56 24120 436.73 414.89 477.12 24516 736.41 699.59 804.53 24125 506.46 481.14 553.31 24530 295.08 280.33 322.38 24126 537.46 510.59 587.18 # 24530 268.67 255.24 293.53 24130 421.24 400.18 460.21 24535 501.60 476.52 548.00 24134 635.57 603.79 694.36 # 24535 469.07 445.62 512.46 24136 503.20 478.04 549.75 24538 625.71 594.42 683.58 24138 553.85 526.16 605.08 24545 776.67 737.84 848.52 24140 604.92 574.67 660.87 24546 899.38 854.41 982.57 24145 506.34 481.02 553.17 24560 245.95 233.65 268.70 24147 524.91 498.66 573.46 # 24560 219.54 208.56 239.84 24149 978.21 929.30 1,068.70 24565 412.20 391.59 450.33 24150 828.55 787.12 905.19 # 24565 383.21 364.05 418.66 24151 953.96 906.26 1,042.20 24566 586.11 556.80 640.32 24152 623.61 592.43 681.29 24575 620.06 589.06 677.42 24153 673.56 639.88 735.86 24576 258.49 245.57 282.41 24155 721.69 685.61 788.45 # 24576 233.37 221.70 254.96 24160 507.96 482.56 554.94 24577 428.90 407.46 468.58 24164 414.74 394.00 453.10 # 24577 397.66 377.78 434.45 24200 159.86 151.87 174.65 24579 706.56 671.23 771.91 # 24200 113.48 107.81 123.98 24582 653.83 621.14 714.31 24201 444.75 422.51 485.89 24586 937.04 890.19 1,023.72 # 24201 303.36 288.19 331.42 24587 933.67 886.99 1,020.04 24220 144.32 137.10 157.67 24600 292.39 277.77 319.44 # 24220 64.77 61.53 70.76 # 24600 267.91 254.51 292.69 24300 320.81 304.77 350.49 24605 378.10 359.20 413.08 24301 637.19 605.33 696.13 24615 605.70 575.42 661.73 24305 485.48 461.21 530.39 24620 458.53 435.60 500.94 24310 396.84 377.00 433.55 24635 628.59 597.16 686.73 24320 656.89 624.05 717.66 24640 96.05 91.25 104.94 24330 605.18 574.92 661.16 # 24640 71.57 67.99 78.19 24331 669.86 636.37 731.83 24650 199.33 189.36 217.76 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 14 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 180.97 171.92 197.71 25246 146.97 139.62 160.56 24655 346.63 329.30 378.70 # 25246 71.29 67.73 77.89 # 24655 319.26 303.30 348.80 25248 367.48 349.11 401.48 24665 543.07 515.92 593.31 25250 438.17 416.26 478.70 24666 618.37 587.45 675.57 25251 601.20 571.14 656.81 24670 224.40 213.18 245.16 25259 321.88 305.79 351.66 # 24670 202.50 192.38 221.24 25260 569.14 540.68 621.78 24675 366.21 347.90 400.09 25263 568.36 539.94 620.93 # 24675 338.83 321.89 370.17 25265 676.46 642.64 739.04 24685 544.99 517.74 595.40 25270 456.04 433.24 498.23 24800 674.37 640.65 736.75 25272 514.10 488.40 561.66 24802 853.19 810.53 932.11 25274 610.53 580.00 667.00 24900 608.59 578.16 664.88 25275 564.55 536.32 616.77 24920 604.46 574.24 660.38 25280 521.35 495.28 569.57 24925 467.32 443.95 510.54 25290 439.36 417.39 480.00 24930 641.58 609.50 700.93 25295 484.82 460.58 529.67 24931 721.86 685.77 788.64 25300 575.17 546.41 628.37 24935 877.08 833.23 958.21 25301 547.39 520.02 598.02 25000 286.49 272.17 313.00 25310 564.53 536.30 616.75 25001 272.60 258.97 297.82 25312 655.39 622.62 716.01 25020 475.63 451.85 519.63 25315 702.95 667.80 767.97 25023 922.56 876.43 1,007.89 25316 815.27 774.51 890.69 25024 649.04 616.59 709.08 25320 810.03 769.53 884.96 25025 1,007.05 956.70 1,100.21 25332 716.09 680.29 782.33 25028 423.57 402.39 462.75 25335 813.91 773.21 889.19 25031 312.35 296.73 341.24 25337 745.21 707.95 814.14 25035 540.98 513.93 591.02 25350 621.90 590.81 679.43 25040 480.90 456.86 525.39 25355 700.06 665.06 764.82 25065 203.02 192.87 221.80 25360 603.24 573.08 659.04 # 25065 137.96 131.06 150.72 25365 823.87 782.68 900.08 25066 312.85 297.21 341.79 25370 898.29 853.38 981.39 25075 274.28 260.57 299.66 25375 866.62 823.29 946.78 25076 370.17 351.66 404.41 25390 704.92 669.67 770.12 25077 632.19 600.58 690.67 25391 897.86 852.97 980.92 25085 386.27 366.96 422.00 25392 912.20 866.59 996.58 25100 286.23 271.92 312.71 25393 1,024.31 973.09 1,119.05 25101 337.57 320.69 368.79 25394 658.30 625.39 719.20 25105 410.81 390.27 448.81 25400 739.34 702.37 807.73 25107 511.91 486.31 559.26 25405 942.24 895.13 1,029.40 25109 438.18 416.27 478.71 25415 884.35 840.13 966.15 25110 299.40 284.43 327.09 25420 1,054.71 1,001.97 1,152.27 25111 259.73 246.74 283.75 25425 909.17 863.71 993.27 25112 318.68 302.75 348.16 25426 957.50 909.63 1,046.07 25115 674.96 641.21 737.39 25430 600.23 570.22 655.75 25116 543.53 516.35 593.80 25431 663.49 630.32 724.87 25118 318.99 303.04 348.50 25440 660.04 627.04 721.10 25119 423.20 402.04 462.35 25441 800.73 760.69 874.79 25120 463.11 439.95 505.94 25442 682.43 648.31 745.56 25125 540.72 513.68 590.73 25443 654.95 622.20 715.53 25126 545.36 518.09 595.80 25444 697.91 663.01 762.46 25130 374.84 356.10 409.52 25445 610.44 579.92 666.91 25135 469.13 445.67 512.52 25446 1,009.46 958.99 1,102.84 25136 413.87 393.18 452.16 25447 689.21 654.75 752.96 25145 475.93 452.13 519.95 25449 883.34 839.17 965.05 25150 486.31 461.99 531.29 25450 510.51 484.98 557.73 25151 536.81 509.97 586.47 25455 585.71 556.42 639.88 25170 749.45 711.98 818.78 25490 641.55 609.47 700.89 25210 411.45 390.88 449.51 25491 676.46 642.64 739.04 25215 530.99 504.44 580.11 25492 815.97 775.17 891.45 25230 364.20 345.99 397.89 25500 205.28 195.02 224.27 25240 368.83 350.39 402.95 # 25500 187.88 178.49 205.26 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 15 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 401.66 381.58 438.82 25920 576.92 548.07 630.28 # 25505 372.67 354.04 407.15 25922 487.64 463.26 532.75 25515 561.09 533.04 613.00 25924 563.30 535.14 615.41 25520 444.65 422.42 485.78 25927 652.06 619.46 712.38 # 25520 425.01 403.76 464.32 25929 472.87 449.23 516.61 25525 677.20 643.34 739.84 25931 593.38 563.71 648.27 25526 833.69 792.01 910.81 26010 201.17 191.11 219.78 25530 197.91 188.01 216.21 # 26010 109.38 103.91 119.50 # 25530 178.59 169.66 195.11 26011 306.18 290.87 334.50 25535 389.58 370.10 425.62 # 26011 152.55 144.92 166.66 # 25535 366.39 348.07 400.28 26020 351.63 334.05 384.16 25545 523.86 497.67 572.32 26025 343.87 326.68 375.68 25560 207.82 197.43 227.04 26030 407.26 386.90 444.94 # 25560 186.88 177.54 204.17 26034 440.73 418.69 481.49 25565 421.16 400.10 460.12 26035 690.68 656.15 754.57 # 25565 387.67 368.29 423.53 26037 476.31 452.49 520.36 25574 553.71 526.02 604.92 26040 251.44 238.87 274.70 25575 754.06 716.36 823.81 26045 384.74 365.50 420.33 25600 226.22 214.91 247.15 26055 446.92 424.57 488.26 # 25600 205.28 195.02 224.27 # 26055 240.47 228.45 262.72 25605 496.38 471.56 542.29 26060 215.13 204.37 235.03 # 25605 471.26 447.70 514.86 26070 246.75 234.41 269.57 25606 552.19 524.58 603.27 26075 260.91 247.86 285.04 25607 598.72 568.78 654.10 26080 313.90 298.21 342.94 25608 682.64 648.51 745.79 26100 263.85 250.66 288.26 25609 872.28 828.67 952.97 26105 269.72 256.23 294.66 25622 231.80 220.21 253.24 26110 258.94 245.99 282.89 # 25622 209.57 199.09 228.95 26115 492.28 467.67 537.82 25624 367.88 349.49 401.91 # 26115 293.24 278.58 320.37 # 25624 337.61 320.73 368.84 26116 395.67 375.89 432.27 25628 601.77 571.68 657.43 26117 543.25 516.09 593.50 25630 238.02 226.12 260.04 26121 498.14 473.23 544.21 # 25630 216.12 205.31 236.11 26123 683.17 649.01 746.36 25635 348.27 330.86 380.49 26125 246.61 234.28 269.42 # 25635 312.84 297.20 341.78 26130 376.01 357.21 410.79 25645 473.68 450.00 517.50 26135 459.30 436.34 501.79 25650 248.38 235.96 271.35 26140 417.19 396.33 455.78 # 25650 229.70 218.22 250.95 26145 424.14 402.93 463.37 25651 391.14 371.58 427.32 26160 448.80 426.36 490.31 25652 516.47 490.65 564.25 # 26160 262.64 249.51 286.94 25660 327.53 311.15 357.82 26170 332.95 316.30 363.75 25670 511.50 485.93 558.82 26180 363.87 345.68 397.53 25671 430.56 409.03 470.38 26185 435.56 413.78 475.85 25675 344.64 327.41 376.52 26200 373.96 355.26 408.55 # 25675 319.20 303.24 348.73 26205 503.67 478.49 550.26 25676 529.40 502.93 578.37 26210 362.00 343.90 395.49 25680 379.67 360.69 414.79 26215 462.11 439.00 504.85 25685 617.29 586.43 674.39 26230 419.05 398.10 457.82 25690 381.45 362.38 416.74 26235 411.65 391.07 449.73 25695 531.87 505.28 581.07 26236 364.26 346.05 397.96 25800 629.24 597.78 687.45 26250 487.34 462.97 532.42 25805 725.83 689.54 792.97 26255 745.76 708.47 814.74 25810 733.48 696.81 801.33 26260 456.25 433.44 498.46 25820 512.52 486.89 559.92 26261 567.50 539.13 620.00 25825 632.87 601.23 691.41 26262 380.06 361.06 415.22 25830 787.63 748.25 860.49 26320 283.00 268.85 309.18 25900 630.94 599.39 689.30 26340 251.18 238.62 274.41 25905 623.77 592.58 681.47 26350 581.98 552.88 635.81 25907 544.06 516.86 594.39 26352 664.48 631.26 725.95 25909 612.77 582.13 669.45 26356 869.64 826.16 950.08 25915 1,075.16 1,021.40 1,174.61 26357 714.34 678.62 780.41 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 99 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 755.75 717.96 825.65 26550 1,262.09 1,198.99 1,378.84 26370 631.79 600.20 690.23 26551 2,744.26 2,607.05 2,998.11 26372 734.22 697.51 802.14 26553 2,437.95 2,316.05 2,663.46 26373 697.65 662.77 762.19 26554 3,144.36 2,987.14 3,435.21 26390 688.17 653.76 751.82 26555 1,148.57 1,091.14 1,254.81 26392 803.21 763.05 877.51 26556 2,518.12 2,392.21 2,751.04 26410 462.27 439.16 505.03 26560 466.65 443.32 509.82 26412 563.56 535.38 615.69 26561 756.38 718.56 826.34 26415 598.94 568.99 654.34 26562 1,102.11 1,047.00 1,204.05 26416 644.03 611.83 703.60 26565 556.41 528.59 607.88 26418 463.08 439.93 505.92 26567 561.94 533.84 613.92 26420 586.11 556.80 640.32 26568 739.72 702.73 808.14 26426 474.01 450.31 517.86 26580 1,178.74 1,119.80 1,287.77 26428 616.54 585.71 673.57 26587 810.78 770.24 885.78 26432 404.21 384.00 441.60 26590 1,073.14 1,019.48 1,172.40 26433 434.45 412.73 474.64 26591 354.60 336.87 387.40 26434 523.35 497.18 571.76 26593 486.80 462.46 531.83 26437 509.68 484.20 556.83 26596 610.61 580.08 667.09 26440 509.54 484.06 556.67 26600 216.19 205.38 236.19 26442 778.11 739.20 850.08 # 26600 200.41 190.39 218.95 26445 471.86 448.27 515.51 26605 249.28 236.82 272.34 26449 626.86 595.52 684.85 # 26605 228.35 216.93 249.47 26450 328.50 312.08 358.89 26607 361.57 343.49 395.01 26455 326.28 309.97 356.47 26608 390.21 370.70 426.31 26460 317.00 301.15 346.32 26615 455.47 432.70 497.61 26471 502.07 476.97 548.52 26641 289.40 274.93 316.17 26474 481.29 457.23 525.81 # 26641 265.88 252.59 290.48 26476 468.40 444.98 511.73 26645 329.31 312.84 359.77 26477 472.18 448.57 515.86 # 26645 305.16 289.90 333.39 26478 513.32 487.65 560.80 26650 389.38 369.91 425.40 26479 507.65 482.27 554.61 26665 506.24 480.93 553.07 26480 616.84 586.00 673.90 26670 261.62 248.54 285.82 26483 698.77 663.83 763.40 # 26670 237.47 225.60 259.44 26485 668.78 635.34 730.64 26675 351.02 333.47 383.49 26489 727.93 691.53 795.26 # 26675 325.89 309.60 356.04 26490 649.39 616.92 709.46 26676 408.79 388.35 446.60 26492 724.46 688.24 791.48 26685 465.99 442.69 509.09 26494 656.98 624.13 717.75 26686 517.86 491.97 565.77 26496 713.92 678.22 779.95 26700 250.28 237.77 273.44 26497 714.42 678.70 780.51 # 26700 234.18 222.47 255.84 26498 958.12 910.21 1,046.74 26705 321.88 305.79 351.66 26499 682.10 648.00 745.20 # 26705 297.08 282.23 324.56 26500 512.97 487.32 560.42 26706 355.51 337.73 388.39 26502 580.23 551.22 633.90 26715 455.88 433.09 498.05 26508 515.55 489.77 563.24 26720 149.63 142.15 163.47 26510 488.36 463.94 533.53 # 26720 137.39 130.52 150.10 26516 578.77 549.83 632.30 26725 268.55 255.12 293.39 26517 682.81 648.67 745.97 # 26725 242.46 230.34 264.89 26518 689.89 655.40 753.71 26727 383.52 364.34 418.99 26520 532.81 506.17 582.10 26735 475.17 451.41 519.12 26525 535.03 508.28 584.52 26740 174.22 165.51 190.34 26530 445.20 422.94 486.38 # 26740 163.91 155.71 179.07 26531 518.93 492.98 566.93 26742 294.92 280.17 322.20 26535 334.84 318.10 365.82 # 26742 269.48 256.01 294.41 26536 550.44 522.92 601.36 26746 585.22 555.96 639.35 26540 542.47 515.35 592.65 26750 140.41 133.39 153.40 26541 665.61 632.33 727.18 # 26750 136.87 130.03 149.53 26542 561.43 533.36 613.36 26755 246.99 234.64 269.84 26545 571.56 542.98 624.43 # 26755 216.72 205.88 236.76 26546 805.35 765.08 879.84 26756 337.39 320.52 368.60 26548 630.68 599.15 689.02 26765 386.06 366.76 421.77 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 17 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 212.14 201.53 231.76 27087 535.24 508.48 584.75 # 26770 195.07 185.32 213.12 27090 708.26 672.85 773.78 26775 299.87 284.88 327.61 27091 1,378.64 1,309.71 1,506.17 # 26775 270.88 257.34 295.94 27093 160.95 152.90 175.84 26776 359.36 341.39 392.60 # 27093 65.30 62.04 71.35 26785 422.12 401.01 461.16 27095 194.11 184.40 212.06 26820 649.76 617.27 709.86 # 27095 74.62 70.89 81.52 26841 599.83 569.84 655.32 27096 148.54 141.11 162.28 26842 653.49 620.82 713.94 # 27096 63.19 60.03 69.03 26843 604.94 574.69 660.89 27097 564.36 536.14 616.56 26844 675.85 642.06 738.37 27098 530.96 504.41 580.07 26850 572.53 543.90 625.49 27100 695.94 661.14 760.31 26852 658.37 625.45 719.27 27105 730.11 693.60 797.64 26860 456.46 433.64 498.69 27110 815.81 775.02 891.27 26861 92.99 88.34 101.59 27111 728.77 692.33 796.18 26862 597.37 567.50 652.63 27120 1,108.29 1,052.88 1,210.81 26863 207.57 197.19 226.77 27122 947.69 900.31 1,035.36 26910 589.01 559.56 643.49 27125 966.13 917.82 1,055.49 26951 507.34 481.97 554.27 27130 1,246.85 1,184.51 1,362.19 26952 531.96 505.36 581.16 27132 1,458.21 1,385.30 1,593.10 26990 516.34 490.52 564.10 27134 1,693.06 1,608.41 1,849.67 26991 571.58 543.00 624.45 27137 1,288.93 1,224.48 1,408.15 # 26991 436.95 415.10 477.37 27138 1,341.86 1,274.77 1,465.99 26992 816.70 775.87 892.25 27140 767.99 729.59 839.03 27000 374.51 355.78 409.15 27146 1,086.66 1,032.33 1,187.18 27001 454.70 431.97 496.77 27147 1,266.17 1,202.86 1,383.29 27003 489.54 465.06 534.82 27151 1,322.63 1,256.50 1,444.98 27005 617.95 587.05 675.11 27156 1,479.09 1,405.14 1,615.91 27006 624.30 593.09 682.05 27158 1,189.41 1,129.94 1,299.43 27025 759.01 721.06 829.22 27161 1,049.35 996.88 1,146.41 27027 742.61 705.48 811.30 27165 1,173.87 1,115.18 1,282.46 27030 808.83 768.39 883.65 27170 1,016.65 965.82 1,110.69 27033 837.39 795.52 914.85 27175 563.87 535.68 616.03 27035 944.47 897.25 1,031.84 27176 778.45 739.53 850.46 27036 856.07 813.27 935.26 27177 951.52 903.94 1,039.53 27040 278.11 264.20 303.83 27178 771.14 732.58 842.47 # 27040 172.79 164.15 188.77 27179 831.03 789.48 907.90 27041 587.15 557.79 641.46 27181 931.11 884.55 1,017.23 27047 516.20 490.39 563.95 27185 583.95 554.75 637.96 # 27047 437.94 416.04 478.45 27187 851.55 808.97 930.32 27048 400.94 380.89 438.02 27193 388.28 368.87 424.20 27049 855.49 812.72 934.63 # 27193 391.50 371.93 427.72 27050 293.34 278.67 320.47 27194 607.65 577.27 663.86 27052 467.21 443.85 510.43 27200 140.05 133.05 153.01 27054 573.91 545.21 626.99 # 27200 142.95 135.80 156.17 27057 827.64 786.26 904.20 27202 535.70 508.92 585.26 27060 361.80 343.71 395.27 27220 437.53 415.65 478.00 27062 376.20 357.39 411.00 # 27220 434.63 412.90 474.84 27065 420.25 399.24 459.13 27222 835.65 793.87 912.95 27066 684.95 650.70 748.31 27226 890.96 846.41 973.37 27067 872.66 829.03 953.38 27227 1,444.10 1,371.90 1,577.69 27070 717.42 681.55 783.78 27228 1,654.93 1,572.18 1,808.01 27071 769.80 731.31 841.01 27230 388.27 368.86 424.19 27075 2,000.22 1,900.21 2,185.24 # 27230 383.44 364.27 418.91 27076 1,376.54 1,307.71 1,503.87 27232 665.47 632.20 727.03 27077 2,313.46 2,197.79 2,527.46 27235 778.82 739.88 850.86 27078 867.37 824.00 947.60 27236 1,021.53 970.45 1,116.02 27079 834.52 792.79 911.71 27238 376.06 357.26 410.85 27080 416.35 395.53 454.86 27240 815.57 774.79 891.01 27086 198.53 188.60 216.89 27244 1,051.20 998.64 1,148.44 # 27086 124.46 118.24 135.98 27245 1,084.80 1,030.56 1,185.14 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 99 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 318.06 302.16 347.48 27381 677.21 643.35 739.85 # 27246 318.71 302.77 348.19 27385 530.39 503.87 579.45 27248 643.11 610.95 702.59 27386 702.17 667.06 767.12 27250 204.17 193.96 223.05 27390 366.80 348.46 400.73 27252 644.89 612.65 704.55 27391 479.31 455.34 523.64 27253 809.45 768.98 884.33 27392 592.44 562.82 647.24 27254 1,096.17 1,041.36 1,197.56 27393 424.65 403.42 463.93 27256 248.41 235.99 271.39 27394 550.10 522.60 600.99 # 27256 212.33 201.71 231.97 27395 746.55 709.22 815.60 27257 289.58 275.10 316.37 27396 516.66 490.83 564.45 27258 950.18 902.67 1,038.07 27397 764.32 726.10 835.02 27259 1,334.86 1,268.12 1,458.34 27400 577.33 548.46 630.73 27265 327.25 310.89 357.52 27403 541.18 514.12 591.24 27266 487.61 463.23 532.71 27405 570.25 541.74 623.00 27267 347.68 330.30 379.85 27407 653.15 620.49 713.56 27268 431.83 410.24 471.78 27409 822.12 781.01 898.16 27269 1,046.77 994.43 1,143.59 27412 1,426.83 1,355.49 1,558.81 27275 151.03 143.48 165.00 27415 1,188.89 1,129.45 1,298.87 27280 877.51 833.63 958.67 27416 825.34 784.07 901.68 27282 689.35 654.88 753.11 27418 708.39 672.97 773.92 27284 1,345.95 1,278.65 1,470.45 27420 633.61 601.93 692.22 27286 1,420.88 1,349.84 1,552.32 27422 630.98 599.43 689.34 27290 1,357.11 1,289.25 1,482.64 27424 632.71 601.07 691.23 27295 1,094.80 1,040.06 1,196.07 27425 366.47 348.15 400.37 27301 539.87 512.88 589.81 27427 607.33 576.96 663.50 # 27301 416.19 395.38 454.69 27428 937.74 890.85 1,024.48 27303 538.47 511.55 588.28 27429 1,050.57 998.04 1,147.75 27305 392.16 372.55 428.43 27430 627.07 595.72 685.08 27306 316.17 300.36 345.41 27435 672.70 639.07 734.93 27307 390.30 370.79 426.41 27437 557.12 529.26 608.65 27310 614.87 584.13 671.75 27438 715.98 680.18 782.21 27323 216.36 205.54 236.37 27440 654.69 621.96 715.25 # 27323 150.02 142.52 163.90 27441 676.35 642.53 738.91 27324 319.70 303.72 349.28 27442 741.57 704.49 810.16 27325 443.82 421.63 484.87 27443 693.91 659.21 758.09 27326 408.59 388.16 446.38 27445 1,085.12 1,030.86 1,185.49 27327 368.27 349.86 402.34 27446 961.28 913.22 1,050.20 # 27327 292.26 277.65 319.30 27447 1,334.49 1,267.77 1,457.94 27328 353.19 335.53 385.86 27448 699.22 664.26 763.90 27329 888.39 843.97 970.57 27450 872.26 828.65 952.95 27330 334.16 317.45 365.07 27454 1,103.35 1,048.18 1,205.41 27331 394.94 375.19 431.47 27455 805.38 765.11 879.88 27332 537.13 510.27 586.81 27457 830.72 789.18 907.56 27333 486.15 461.84 531.12 27465 1,051.76 999.17 1,149.05 27334 572.61 543.98 625.58 27466 1,015.96 965.16 1,109.93 27335 648.46 616.04 708.45 27468 1,152.01 1,094.41 1,258.57 27340 301.25 286.19 329.12 27470 1,012.47 961.85 1,106.13 27345 399.94 379.94 436.93 27472 1,095.44 1,040.67 1,196.77 27347 429.92 408.42 469.68 27475 554.81 527.07 606.13 27350 546.89 519.55 597.48 27477 621.94 590.84 679.47 27355 506.71 481.37 553.58 27479 799.70 759.72 873.68 27356 622.69 591.56 680.29 27485 567.29 538.93 619.77 27357 689.89 655.40 753.71 27486 1,217.23 1,156.37 1,329.83 27358 254.07 241.37 277.58 27487 1,537.54 1,460.66 1,679.76 27360 718.31 682.39 784.75 27488 1,028.71 977.27 1,123.86 27365 1,052.25 999.64 1,149.59 27495 973.75 925.06 1,063.82 27370 137.17 130.31 149.86 27496 423.00 401.85 462.13 # 27370 47.64 45.26 52.05 27497 461.09 438.04 503.75 27372 482.03 457.93 526.62 27498 503.29 478.13 549.85 # 27372 337.41 320.54 368.62 27499 557.36 529.49 608.91 27380 494.79 470.05 540.56 27500 424.05 402.85 463.28 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 19 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 396.35 376.53 433.01 27613 203.31 193.14 222.11 27501 417.64 396.76 456.27 # 27613 141.15 134.09 154.20 # 27501 412.16 391.55 450.28 27614 460.05 437.05 502.61 27502 670.98 637.43 733.04 # 27614 349.90 332.41 382.27 27503 681.60 647.52 744.65 27615 754.40 716.68 824.18 27506 1,143.75 1,086.56 1,249.54 27618 402.03 381.93 439.22 27507 846.83 804.49 925.16 # 27618 323.77 307.58 353.72 27508 427.17 405.81 466.68 27619 642.01 609.91 701.40 # 27508 404.62 384.39 442.05 # 27619 503.52 478.34 550.09 27509 539.13 512.17 589.00 27620 391.26 371.70 427.46 27510 592.06 562.46 646.83 27625 508.50 483.08 555.54 27511 877.81 833.92 959.01 27626 548.54 521.11 599.28 27513 1,104.85 1,049.61 1,207.05 27630 437.34 415.47 477.79 27514 882.52 838.39 964.15 # 27630 314.95 299.20 344.08 27516 399.03 379.08 435.94 27635 503.71 478.52 550.30 # 27516 377.77 358.88 412.71 27637 639.42 607.45 698.57 27517 567.76 539.37 620.28 27638 667.07 633.72 728.78 27519 798.79 758.85 872.68 27640 739.84 702.85 808.28 27520 249.61 237.13 272.70 27641 593.27 563.61 648.15 # 27520 227.06 215.71 248.07 27645 897.44 852.57 980.46 27524 640.04 608.04 699.25 27646 794.49 754.77 867.99 27530 314.47 298.75 343.56 27647 707.58 672.20 773.03 # 27530 293.85 279.16 321.03 27648 132.34 125.72 144.58 27532 507.09 481.74 554.00 # 27648 47.32 44.95 51.69 # 27532 481.65 457.57 526.21 27650 575.05 546.30 628.25 27535 783.53 744.35 856.00 27652 636.18 604.37 695.03 27536 1,018.70 967.77 1,112.94 27654 621.19 590.13 678.65 27538 377.02 358.17 411.90 27656 439.11 417.15 479.72 # 27538 354.79 337.05 387.61 # 27656 297.72 282.83 325.25 27540 705.77 670.48 771.05 27658 326.20 309.89 356.37 27550 401.58 381.50 438.73 27659 429.91 408.41 469.67 # 27550 375.81 357.02 410.57 27664 310.31 294.79 339.01 27552 520.88 494.84 569.07 27665 356.04 338.24 388.98 27556 785.34 746.07 857.98 27675 438.64 416.71 479.22 27557 941.43 894.36 1,028.51 27676 531.63 505.05 580.81 27558 1,059.60 1,006.62 1,157.61 27680 369.94 351.44 404.16 27560 292.94 278.29 320.03 27681 440.76 418.72 481.53 # 27560 267.17 253.81 291.88 27685 521.81 495.72 570.08 27562 384.24 365.03 419.78 # 27685 409.09 388.64 446.94 27566 763.71 725.52 834.35 27686 481.46 457.39 526.00 27570 122.91 116.76 134.27 27687 396.34 376.52 433.00 27580 1,240.52 1,178.49 1,355.26 27690 547.09 519.74 597.70 27590 716.09 680.29 782.33 27691 640.78 608.74 700.05 27591 789.22 749.76 862.22 27692 98.57 93.64 107.69 27592 605.83 575.54 661.87 27695 421.50 400.43 460.49 27594 435.48 413.71 475.77 27696 505.62 480.34 552.39 27596 633.55 601.87 692.15 27698 567.72 539.33 620.23 27598 642.75 610.61 702.20 27700 539.45 512.48 589.35 27600 361.55 343.47 394.99 27702 857.12 814.26 936.40 27601 374.33 355.61 408.95 27703 992.89 943.25 1,084.74 27602 444.78 422.54 485.92 27704 484.11 459.90 528.89 27603 427.43 406.06 466.97 27705 656.84 624.00 717.60 # 27603 326.62 310.29 356.83 27707 331.04 314.49 361.66 27604 374.91 356.16 409.58 27709 968.61 920.18 1,058.21 # 27604 287.63 273.25 314.24 27712 938.33 891.41 1,025.12 27605 296.70 281.87 324.15 27715 916.23 870.42 1,000.98 # 27605 173.02 164.37 189.03 27720 751.52 713.94 821.03 27606 253.71 241.02 277.17 27722 750.11 712.60 819.49 27607 522.77 496.63 571.12 27724 1,108.41 1,052.99 1,210.94 27610 557.86 529.97 609.47 27725 1,029.14 977.68 1,124.33 27612 487.70 463.32 532.82 27726 790.99 751.44 864.16 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 99 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 837.54 795.66 915.01 27870 902.72 857.58 986.22 27730 496.72 471.88 542.66 27871 590.52 560.99 645.14 27732 339.71 322.72 371.13 27880 805.69 765.41 880.22 27734 511.41 485.84 558.72 27881 770.80 732.26 842.10 27740 566.52 538.19 618.92 27882 544.61 517.38 594.99 27742 598.05 568.15 653.37 27884 504.93 479.68 551.63 27745 644.22 612.01 703.81 27886 576.04 547.24 629.33 27750 270.02 256.52 295.00 27888 608.33 577.91 664.60 # 27750 248.76 236.32 271.77 27889 596.77 566.93 651.97 27752 438.45 416.53 479.01 27892 466.78 443.44 509.96 # 27752 410.75 390.21 448.74 27893 472.11 448.50 515.78 27756 478.05 454.15 522.27 27894 726.83 690.49 794.06 27758 757.83 719.94 827.93 28001 222.92 211.77 243.54 27759 859.66 816.68 939.18 # 28001 159.15 151.19 173.87 27760 260.07 247.07 284.13 28002 418.01 397.11 456.68 # 27760 237.20 225.34 259.14 # 28002 335.88 319.09 366.95 27762 391.87 372.28 428.12 28003 578.75 549.81 632.28 # 27762 363.85 345.66 397.51 # 28003 495.66 470.88 541.51 27766 513.37 487.70 560.86 28005 538.62 511.69 588.44 27767 206.93 196.58 226.07 28008 352.45 334.83 385.05 # 27767 207.89 197.50 227.13 # 28008 268.71 255.27 293.56 27768 336.39 319.57 367.51 28010 197.26 187.40 215.51 27769 590.59 561.06 645.22 # 28010 185.34 176.07 202.48 27780 232.60 220.97 254.12 28011 279.47 265.50 305.33 # 27780 211.66 201.08 231.24 # 28011 261.43 248.36 285.61 27781 338.75 321.81 370.08 28020 417.18 396.32 455.77 # 27781 317.17 301.31 346.51 # 28020 314.44 298.72 343.53 27784 586.73 557.39 641.00 28022 385.43 366.16 421.08 27786 246.46 234.14 269.26 # 28022 291.39 276.82 318.34 # 27786 222.94 211.79 243.56 28024 366.21 347.90 400.09 27788 341.70 324.62 373.31 # 28024 276.03 262.23 301.56 # 27788 316.58 300.75 345.86 28035 420.04 399.04 458.90 27792 592.67 563.04 647.50 # 28035 317.62 301.74 347.00 27808 257.41 244.54 281.22 28043 280.60 266.57 306.56 # 27808 232.28 220.67 253.77 # 28043 227.78 216.39 248.85 27810 383.43 364.26 418.90 28045 392.57 372.94 428.88 # 27810 354.76 337.02 387.57 # 28045 290.15 275.64 316.99 27814 659.55 626.57 720.56 28046 720.91 684.86 787.59 27816 244.51 232.28 267.12 # 28046 595.95 566.15 651.07 # 27816 221.32 210.25 241.79 28050 368.32 349.90 402.39 27818 396.13 376.32 432.77 # 28050 273.31 259.64 298.59 # 27818 363.60 345.42 397.23 28052 339.75 322.76 371.17 27822 721.11 685.05 787.81 # 28052 248.93 236.48 271.95 27823 822.91 781.76 899.02 28054 318.26 302.35 347.70 27824 246.43 234.11 269.23 # 28054 226.47 215.15 247.42 # 27824 237.73 225.84 259.72 28055 350.44 332.92 382.86 27825 451.96 429.36 493.76 28060 414.82 394.08 453.19 # 27825 417.82 396.93 456.47 # 28060 319.48 303.51 349.04 27826 694.34 659.62 758.56 28062 489.42 464.95 534.69 27827 924.32 878.10 1,009.82 # 28062 376.05 357.25 410.84 27828 1,108.72 1,053.28 1,211.27 28070 410.94 390.39 448.95 27829 555.21 527.45 606.57 # 28070 312.39 296.77 341.29 27830 286.93 272.58 313.47 28072 403.54 383.36 440.86 # 27830 269.86 256.37 294.83 # 28072 301.12 286.06 328.97 27831 314.53 298.80 343.62 28080 396.99 377.14 433.71 27832 600.25 570.24 655.78 # 28080 304.88 289.64 333.09 27840 292.14 277.53 319.16 28086 432.46 410.84 472.47 27842 407.12 386.76 444.77 # 28086 314.26 298.55 343.33 27846 630.28 598.77 688.59 28088 366.31 347.99 400.19 27848 713.70 678.02 779.72 # 28088 261.31 248.24 285.48 27860 151.94 144.34 165.99 28090 371.98 353.38 406.39 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 99 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 275.03 261.28 300.47 # 28202 398.26 378.35 435.10 28092 334.70 317.97 365.67 28208 366.82 348.48 400.75 # 28092 240.66 228.63 262.92 # 28208 272.77 259.13 298.00 28100 479.48 455.51 523.84 28210 474.56 450.83 518.45 # 28100 356.77 338.93 389.77 # 28210 371.81 353.22 406.20 28102 486.74 462.40 531.76 28220 363.07 344.92 396.66 28103 394.14 374.43 430.59 # 28220 275.79 262.00 301.30 28104 412.42 391.80 450.57 28222 420.94 399.89 459.87 # 28104 312.90 297.26 341.85 # 28222 329.15 312.69 359.59 28106 417.43 396.56 456.04 28225 314.56 298.83 343.65 28107 457.38 434.51 499.69 # 28225 228.25 216.84 249.37 # 28107 341.43 324.36 373.01 28226 378.38 359.46 413.38 28108 346.76 329.42 378.83 # 28226 284.66 270.43 310.99 # 28108 258.19 245.28 282.07 28230 348.35 330.93 380.57 28110 363.05 344.90 396.64 # 28230 262.04 248.94 286.28 # 28110 257.41 244.54 281.22 28232 307.69 292.31 336.16 28111 414.36 393.64 452.69 # 28232 222.02 210.92 242.56 # 28111 301.64 286.56 329.54 28234 318.64 302.71 348.12 28112 391.32 371.75 427.51 # 28234 232.00 220.40 253.46 # 28112 281.50 267.43 307.54 28238 559.27 531.31 611.01 28113 469.96 446.46 513.43 # 28238 447.19 424.83 488.55 # 28113 368.18 349.77 402.24 28240 358.36 340.44 391.51 28114 856.83 813.99 936.09 # 28240 268.83 255.39 293.70 # 28114 712.22 676.61 778.10 28250 456.93 434.08 499.19 28116 614.80 584.06 671.67 # 28250 357.09 339.24 390.13 # 28116 507.87 482.48 554.85 28260 560.93 532.88 612.81 28118 472.94 449.29 516.68 # 28260 462.06 438.96 504.80 # 28118 365.69 347.41 399.52 28261 818.13 777.22 893.80 28119 421.88 400.79 460.91 # 28261 706.37 671.05 771.71 # 28119 323.96 307.76 353.92 28262 1,138.55 1,081.62 1,243.86 28120 466.69 443.36 509.86 # 28262 984.60 935.37 1,075.68 # 28120 347.84 330.45 380.02 28264 727.57 691.19 794.87 28122 546.10 518.80 596.62 # 28264 618.71 587.77 675.94 # 28122 447.55 425.17 488.95 28270 387.75 368.36 423.61 28124 386.02 366.72 421.73 # 28270 297.57 282.69 325.09 # 28124 298.41 283.49 326.01 28272 316.71 300.87 346.00 28126 310.62 295.09 339.35 # 28272 232.33 220.71 253.82 # 28126 223.99 212.79 244.71 28280 425.14 403.88 464.46 28130 555.85 528.06 607.27 # 28280 323.36 307.19 353.27 28140 513.68 488.00 561.20 28285 375.61 356.83 410.35 # 28140 407.72 387.33 445.43 # 28285 285.75 271.46 312.18 28150 346.81 329.47 378.89 28286 367.37 349.00 401.35 # 28150 255.99 243.19 279.67 # 28286 274.94 261.19 300.37 28153 322.83 306.69 352.69 28288 470.69 447.16 514.23 # 28153 232.65 221.02 254.17 # 28288 371.81 353.22 406.20 28160 331.22 314.66 361.86 28289 597.25 567.39 652.50 # 28160 242.33 230.21 264.74 # 28289 484.84 460.60 529.69 28171 546.98 519.63 597.57 28290 463.37 440.20 506.23 28173 614.57 583.84 671.42 # 28290 353.55 335.87 386.25 # 28173 499.58 474.60 545.79 28292 635.65 603.87 694.45 28175 449.34 426.87 490.90 # 28292 522.61 496.48 570.95 # 28175 351.75 334.16 384.28 28293 846.50 804.18 924.81 28190 197.06 187.21 215.29 # 28293 634.25 602.54 692.92 # 28190 119.12 113.16 130.13 28294 614.34 583.62 671.16 28192 381.27 362.21 416.54 # 28294 483.58 459.40 528.31 # 28192 284.97 270.72 311.33 28296 601.10 571.05 656.71 28193 438.86 416.92 479.46 # 28296 479.03 455.08 523.34 # 28193 339.66 322.68 371.08 28297 679.35 645.38 742.19 28200 381.12 362.06 416.37 # 28297 538.60 511.67 588.42 # 28200 284.17 269.96 310.45 28298 586.76 557.42 641.03 28202 509.37 483.90 556.49 # 28298 459.22 436.26 501.70 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 22 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 757.83 719.94 827.93 # 28490 95.70 90.92 104.56 # 28299 623.52 592.34 681.19 28495 137.99 131.09 150.75 28300 579.41 550.44 633.01 # 28495 123.17 117.01 134.56 28302 574.74 546.00 627.90 28496 329.63 313.15 360.12 28304 652.94 620.29 713.33 # 28496 188.24 178.83 205.65 # 28304 529.90 503.41 578.92 28505 539.18 512.22 589.05 28305 609.80 579.31 666.21 # 28505 420.66 399.63 459.57 28306 485.72 461.43 530.64 28510 94.73 89.99 103.49 # 28306 357.53 339.65 390.60 # 28510 93.12 88.46 101.73 28307 570.77 542.23 623.56 28515 124.93 118.68 136.48 # 28307 402.32 382.20 439.53 # 28515 115.59 109.81 126.28 28308 440.21 418.20 480.93 28525 451.36 428.79 493.11 # 28308 327.80 311.41 358.12 # 28525 333.16 316.50 363.98 28309 785.61 746.33 858.28 28530 91.36 86.79 99.81 28310 434.23 412.52 474.40 # 28530 84.92 80.67 92.77 # 28310 320.54 304.51 350.19 28531 292.70 278.07 319.78 28312 396.10 376.30 432.75 # 28531 164.20 155.99 179.39 # 28312 284.66 270.43 310.99 28540 162.80 154.66 177.86 28313 416.72 395.88 455.26 # 28540 152.82 145.18 166.96 # 28313 325.25 308.99 355.34 28545 199.83 189.84 218.32 28315 383.77 364.58 419.27 # 28545 185.02 175.77 202.14 # 28315 291.65 277.07 318.63 28546 371.98 353.38 406.39 28320 548.69 521.26 599.45 # 28546 249.27 236.81 272.33 28322 632.15 600.54 690.62 28555 704.06 668.86 769.19 # 28322 506.22 480.91 553.05 # 28555 563.31 535.14 615.41 28340 505.54 480.26 552.30 28570 140.12 133.11 153.08 # 28340 397.00 377.15 433.72 # 28570 126.91 120.56 138.64 28341 584.14 554.93 638.17 28575 268.40 254.98 293.23 # 28341 470.77 447.23 514.31 # 28575 251.98 239.38 275.29 28344 384.47 365.25 420.04 28576 297.50 282.63 325.02 # 28344 276.58 262.75 302.16 28585 753.56 715.88 823.26 28345 466.28 442.97 509.42 # 28585 634.07 602.37 692.73 # 28345 362.25 344.14 395.76 28600 168.81 160.37 184.43 28360 845.75 803.46 923.98 # 28600 152.70 145.07 166.83 28400 195.46 185.69 213.54 28605 219.12 208.16 239.38 # 28400 180.32 171.30 197.00 # 28605 205.60 195.32 224.62 28405 322.62 306.49 352.46 28606 329.07 312.62 359.51 # 28405 303.62 288.44 331.71 28615 662.49 629.37 723.78 28406 442.96 420.81 483.93 28630 121.62 115.54 132.87 28415 980.18 931.17 1,070.85 # 28630 95.54 90.76 104.37 28420 1,033.86 982.17 1,129.50 28635 144.76 137.52 158.15 28430 183.17 174.01 200.11 # 28635 118.67 112.74 129.65 # 28430 164.17 155.96 179.35 28636 237.01 225.16 258.93 28435 260.12 247.11 284.18 # 28636 175.49 166.72 191.73 # 28435 242.08 229.98 264.48 28645 511.66 486.08 558.99 28436 353.93 336.23 386.66 # 28645 411.17 390.61 449.20 28445 925.89 879.60 1,011.54 28660 88.62 84.19 96.82 28446 1,017.65 966.77 1,111.79 # 28660 72.83 69.19 79.57 28450 169.34 160.87 185.00 28665 129.66 123.18 141.66 # 28450 152.60 144.97 166.72 # 28665 118.06 112.16 128.98 28455 236.72 224.88 258.61 28666 167.98 159.58 183.52 # 28455 221.90 210.81 242.43 28675 461.60 438.52 504.30 28456 226.16 214.85 247.08 # 28675 341.15 324.09 372.70 28465 527.28 500.92 576.06 28705 1,145.72 1,088.43 1,251.69 28470 169.21 160.75 184.86 28715 846.77 804.43 925.09 # 28470 153.43 145.76 167.62 28725 697.12 662.26 761.60 28475 216.38 205.56 236.39 28730 729.02 692.57 796.46 # 28475 200.92 190.87 219.50 28735 698.34 663.42 762.93 28476 280.27 266.26 306.20 28737 619.92 588.92 677.26 28485 454.76 432.02 496.82 28740 695.40 660.63 759.72 28490 108.58 103.15 118.62 # 28740 546.60 519.27 597.16 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 99 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 675.57 641.79 738.06 29240 49.22 46.76 53.77 # 28750 519.36 493.39 567.40 # 29240 38.91 36.96 42.50 28755 405.88 385.59 443.43 29260 42.30 40.19 46.22 # 28755 295.41 280.64 322.74 # 29260 32.00 30.40 34.96 28760 642.85 610.71 702.32 29280 40.83 38.79 44.61 # 28760 514.67 488.94 562.28 # 29280 30.20 28.69 32.99 28800 500.51 475.48 546.80 29305 187.32 177.95 204.64 28805 664.24 631.03 725.68 # 29305 133.21 126.55 145.53 28810 385.04 365.79 420.66 29325 208.65 198.22 227.95 28820 429.07 407.62 468.76 # 29325 150.68 143.15 164.62 # 28820 303.14 287.98 331.18 29345 109.18 103.72 119.28 28825 467.54 444.16 510.78 # 29345 86.64 82.31 94.66 # 28825 347.08 329.73 379.19 29355 113.26 107.60 123.74 28890 282.73 268.59 308.88 # 29355 92.33 87.71 100.87 # 28890 198.03 188.13 216.35 29358 122.36 116.24 133.68 29000 216.61 205.78 236.65 # 29358 88.22 83.81 96.38 # 29000 145.11 137.85 158.53 29365 97.64 92.76 106.67 29010 197.26 187.40 215.51 # 29365 75.09 71.34 82.04 # 29010 133.49 126.82 145.84 29405 71.83 68.24 78.48 29015 193.66 183.98 211.58 # 29405 55.08 52.33 60.18 # 29015 138.59 131.66 151.41 29425 78.06 74.16 85.28 29020 184.46 175.24 201.53 # 29425 60.99 57.94 66.63 # 29020 124.23 118.02 135.72 29435 95.38 90.61 104.20 29025 209.03 198.58 228.37 # 29435 73.48 69.81 80.28 # 29025 150.41 142.89 164.32 29440 42.91 40.76 46.87 29035 192.16 182.55 209.93 # 29440 30.35 28.83 33.15 # 29035 118.73 112.79 129.71 29445 120.84 114.80 132.02 29040 187.27 177.91 204.60 # 29445 98.30 93.39 107.40 # 29040 133.48 126.81 145.83 29450 128.44 122.02 140.32 29044 208.93 198.48 228.25 # 29450 109.76 104.27 119.91 # 29044 138.39 131.47 151.19 29505 61.09 58.04 66.75 29046 228.36 216.94 249.48 # 29505 40.80 38.76 44.57 # 29046 158.47 150.55 173.13 29515 57.56 54.68 62.88 29049 69.83 66.34 76.29 # 29515 42.74 40.60 46.69 # 29049 52.12 49.51 56.94 29520 41.27 39.21 45.09 29055 165.82 157.53 181.16 # 29520 31.93 30.33 34.88 # 29055 114.29 108.58 124.87 29530 43.02 40.87 47.00 29058 90.85 86.31 99.26 # 29530 32.72 31.08 35.74 # 29058 71.52 67.94 78.13 29540 35.56 33.78 38.85 29065 75.59 71.81 82.58 # 29540 29.12 27.66 31.81 # 29065 57.23 54.37 62.53 29550 34.44 32.72 37.63 29075 70.02 66.52 76.50 # 29550 27.36 25.99 29.89 # 29075 51.66 49.08 56.44 29580 43.30 41.14 47.31 29085 74.77 71.03 81.68 # 29580 32.03 30.43 34.99 # 29085 55.76 52.97 60.92 29590 47.04 44.69 51.39 29086 57.10 54.25 62.39 # 29590 37.70 35.82 41.19 # 29086 41.00 38.95 44.79 29700 51.93 49.33 56.73 29105 69.58 66.10 76.02 # 29700 30.67 29.14 33.51 # 29105 50.58 48.05 55.26 29705 55.16 52.40 60.26 29125 53.76 51.07 58.73 # 29705 41.96 39.86 45.84 # 29125 36.05 34.25 39.39 29710 96.65 91.82 105.59 29126 62.19 59.08 67.94 # 29710 72.17 68.56 78.84 # 29126 44.47 42.25 48.59 29715 73.50 69.83 80.30 29130 33.27 31.61 36.35 # 29715 49.67 47.19 54.27 # 29130 25.22 23.96 27.55 29720 64.02 60.82 69.94 29131 40.98 38.93 44.77 # 29720 38.57 36.64 42.14 # 29131 28.42 27.00 31.05 29730 53.66 50.98 58.63 29200 44.12 41.91 48.20 # 29730 40.45 38.43 44.19 # 29200 35.10 33.35 38.35 29740 77.08 73.23 84.21 29220 45.37 43.10 49.57 # 29740 59.05 56.10 64.52 # 29220 36.35 34.53 39.71 29750 84.28 80.07 92.08 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 24 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 67.53 64.15 73.77 # 29893 372.50 353.88 406.96 29800 437.11 415.25 477.54 29894 443.29 421.13 484.30 29804 543.47 516.30 593.75 29895 428.85 407.41 468.52 29805 394.66 374.93 431.17 29897 448.68 426.25 490.19 29806 908.53 863.10 992.57 29898 502.74 477.60 549.24 29807 884.68 840.45 966.52 29899 904.39 859.17 988.05 29819 495.59 470.81 541.43 29900 383.77 364.58 419.27 29820 457.52 434.64 499.84 29901 421.17 400.11 460.13 29821 499.70 474.72 545.93 29902 450.85 428.31 492.56 29822 485.13 460.87 530.00 29904 524.57 498.34 573.09 29823 530.91 504.36 580.01 29905 564.13 535.92 616.31 29824 566.18 537.87 618.55 29906 594.24 564.53 649.21 29825 494.95 470.20 540.73 29907 729.01 692.56 796.44 29826 568.73 540.29 621.33 30000 184.54 175.31 201.61 29827 931.47 884.90 1,017.64 # 30000 98.87 93.93 108.02 29828 779.85 740.86 851.99 30020 178.75 169.81 195.28 29830 381.03 361.98 416.28 # 30020 99.52 94.54 108.72 29834 415.27 394.51 453.69 30100 112.44 106.82 122.84 29835 426.27 404.96 465.70 # 30100 60.27 57.26 65.85 29836 490.65 466.12 536.04 30110 181.48 172.41 198.27 29837 447.19 424.83 488.55 # 30110 110.31 104.79 120.51 29838 500.09 475.09 546.35 30115 356.24 338.43 389.19 29840 373.69 355.01 408.26 30117 656.60 623.77 717.34 29843 401.72 381.63 438.87 # 30117 275.59 261.81 301.08 29844 417.48 396.61 456.10 30118 650.44 617.92 710.61 29845 478.40 454.48 522.65 30120 428.45 407.03 468.08 29846 439.45 417.48 480.10 # 30120 376.92 358.07 411.78 29847 456.68 433.85 498.93 30124 226.87 215.53 247.86 29848 415.52 394.74 453.95 30125 516.32 490.50 564.08 29850 485.97 461.67 530.92 30130 309.49 294.02 338.12 29851 798.49 758.57 872.36 30140 352.02 334.42 384.58 29855 667.64 634.26 729.40 30150 663.26 630.10 724.62 29856 856.53 813.70 935.76 30160 668.26 634.85 730.08 29860 550.74 523.20 601.68 30200 90.07 85.57 98.41 29861 611.24 580.68 667.78 # 30200 51.42 48.85 56.18 29862 682.70 648.57 745.86 30210 118.57 112.64 129.54 29863 676.58 642.75 739.16 # 30210 82.82 78.68 90.48 29866 890.13 845.62 972.46 30220 231.35 219.78 252.75 29867 1,081.70 1,027.62 1,181.76 # 30220 105.74 100.45 115.52 29868 1,446.90 1,374.56 1,580.74 30300 179.11 170.15 195.67 29870 342.38 325.26 374.05 # 30300 99.88 94.89 109.12 29871 430.90 409.36 470.76 30310 169.26 160.80 184.92 29873 428.77 407.33 468.43 30320 373.97 355.27 408.56 29874 452.91 430.26 494.80 30400 861.25 818.19 940.92 29875 416.85 396.01 455.41 30410 1,024.72 973.48 1,119.50 29876 549.45 521.98 600.28 30420 1,156.76 1,098.92 1,263.76 29877 519.56 493.58 567.62 30430 748.76 711.32 818.02 29879 556.39 528.57 607.86 30435 995.02 945.27 1,087.06 29880 581.16 552.10 634.92 30450 1,331.05 1,264.50 1,454.18 29881 541.21 514.15 591.27 30460 647.19 614.83 707.05 29882 586.78 557.44 641.06 30462 1,298.29 1,233.38 1,418.39 29883 716.44 680.62 782.71 30465 826.31 784.99 902.74 29884 518.02 492.12 565.94 30520 503.86 478.67 550.47 29885 629.09 597.64 687.29 30540 562.50 534.38 614.54 29886 529.99 503.49 579.01 30545 811.63 771.05 886.71 29887 625.50 594.23 683.36 30560 212.20 201.59 231.83 29888 850.20 807.69 928.84 # 30560 113.97 108.27 124.51 29889 1,038.76 986.82 1,134.84 30580 521.77 495.68 570.03 29891 590.38 560.86 644.99 # 30580 423.86 402.67 463.07 29892 604.97 574.72 660.93 30600 479.99 455.99 524.39 29893 487.48 463.11 532.58 # 30600 376.60 357.77 411.44 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 25 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 510.09 484.59 557.28 31290 1,018.01 967.11 1,112.18 30630 521.97 495.87 570.25 31291 1,071.92 1,018.32 1,171.07 30801 178.51 169.58 195.02 31292 880.19 836.18 961.61 # 30801 108.62 103.19 118.67 31293 959.63 911.65 1,048.40 30802 232.98 221.33 254.53 31294 1,102.57 1,047.44 1,204.56 # 30802 156.65 148.82 171.14 31300 1,066.94 1,013.59 1,165.63 30901 87.14 82.78 95.20 31320 534.86 508.12 584.34 # 30901 55.90 53.11 61.08 31360 1,722.24 1,636.13 1,881.55 30903 157.37 149.50 171.93 31365 2,160.17 2,052.16 2,359.98 # 30903 72.66 69.03 79.38 31367 1,853.81 1,761.12 2,025.29 30905 196.13 186.32 214.27 31368 2,070.73 1,967.19 2,262.27 # 30905 93.39 88.72 102.03 31370 1,739.10 1,652.15 1,899.97 30906 226.22 214.91 247.15 31375 1,644.87 1,562.63 1,797.02 # 30906 121.54 115.46 132.78 31380 1,620.20 1,539.19 1,770.07 30915 487.35 462.98 532.43 31382 1,777.47 1,688.60 1,941.89 30920 703.49 668.32 768.57 31390 2,404.19 2,283.98 2,626.58 30930 101.11 96.05 110.46 31395 2,545.66 2,418.38 2,781.14 31000 143.32 136.15 156.57 31400 844.89 802.65 923.05 # 31000 87.60 83.22 95.70 31420 714.48 678.76 780.57 31002 166.32 158.00 181.70 31500 101.87 96.78 111.30 31020 387.39 368.02 423.22 31502 32.06 30.46 35.03 # 31020 288.19 273.78 314.85 31505 68.62 65.19 74.97 31030 569.86 541.37 622.58 # 31505 42.21 40.10 46.12 # 31030 436.85 415.01 477.26 31510 176.44 167.62 192.76 31032 477.86 453.97 522.07 # 31510 107.52 102.14 117.46 31040 632.77 601.13 691.30 31511 177.58 168.70 194.01 31050 411.17 390.61 449.20 # 31511 115.74 109.95 126.44 31051 538.17 511.26 587.95 31512 175.12 166.36 191.31 31070 359.98 341.98 393.28 # 31512 115.86 110.07 126.58 31075 659.59 626.61 720.60 31513 118.05 112.15 128.97 31080 852.54 809.91 931.40 31515 174.01 165.31 190.11 31081 1,033.12 981.46 1,128.68 # 31515 98.32 93.40 107.41 31084 996.92 947.07 1,089.13 31520 137.75 130.86 150.49 31085 1,052.00 999.40 1,149.31 31525 210.99 200.44 230.51 31086 944.52 897.29 1,031.88 # 31525 143.03 135.88 156.26 31087 935.87 889.08 1,022.44 31526 141.83 134.74 154.95 31090 834.55 792.82 911.74 31527 173.76 165.07 189.83 31200 442.29 420.18 483.21 31528 129.43 122.96 141.40 31201 613.20 582.54 669.92 31529 145.97 138.67 159.47 31205 722.21 686.10 789.02 31530 178.91 169.96 195.45 31225 1,570.25 1,491.74 1,715.50 31531 192.56 182.93 210.37 31230 1,763.76 1,675.57 1,926.91 31535 171.08 162.53 186.91 31231 154.00 146.30 168.25 31536 191.16 181.60 208.84 # 31231 67.36 63.99 73.59 31540 219.83 208.84 240.17 31233 219.06 208.11 239.33 31541 240.44 228.42 262.68 # 31233 122.11 116.00 133.40 31545 326.54 310.21 356.74 31235 252.17 239.56 275.49 31546 497.14 472.28 543.12 # 31235 145.89 138.60 159.39 31560 285.03 270.78 311.40 31237 272.20 258.59 297.38 31561 312.34 296.72 341.23 # 31237 162.69 154.56 177.74 31570 294.48 279.76 321.72 31238 281.15 267.09 307.15 # 31570 205.91 195.61 224.95 # 31238 176.80 167.96 193.15 31571 226.85 215.51 247.84 31239 569.35 540.88 622.01 31575 97.31 92.44 106.31 31240 144.45 137.23 157.81 # 31575 67.36 63.99 73.59 31254 247.80 235.41 270.72 31576 188.52 179.09 205.95 31255 366.04 347.74 399.90 # 31576 110.25 104.74 120.45 31256 179.27 170.31 195.86 31577 204.57 194.34 223.49 31267 289.10 274.65 315.85 # 31577 134.04 127.34 146.44 31276 461.73 438.64 504.44 31578 237.59 225.71 259.57 31287 210.75 200.21 230.24 # 31578 152.57 144.94 166.68 31288 244.49 232.27 267.11 31579 184.55 175.32 201.62 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 99 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 125.61 119.33 137.23 31750 1,132.05 1,075.45 1,236.77 31580 1,016.90 966.06 1,110.97 31755 1,427.45 1,356.08 1,559.49 31582 1,615.85 1,535.06 1,765.32 31760 1,241.42 1,179.35 1,356.25 31584 1,299.44 1,234.47 1,419.64 31766 1,621.96 1,540.86 1,771.99 31587 856.27 813.46 935.48 31770 1,203.85 1,143.66 1,315.21 31588 962.55 914.42 1,051.58 31775 1,245.16 1,182.90 1,360.34 31590 738.74 701.80 807.07 31780 1,052.53 999.90 1,149.89 31595 646.83 614.49 706.66 31781 1,278.24 1,214.33 1,396.48 31600 357.18 339.32 390.22 31785 964.21 916.00 1,053.40 31601 235.51 223.73 257.29 31786 1,337.07 1,270.22 1,460.75 31603 201.89 191.80 220.57 31800 592.48 562.86 647.29 31605 166.77 158.43 182.19 31805 734.54 697.81 802.48 31610 604.80 574.56 660.74 31820 359.38 341.41 392.62 31611 450.03 427.53 491.66 # 31820 281.76 267.67 307.82 31612 68.70 65.27 75.06 31825 504.96 479.71 551.67 # 31612 43.58 41.40 47.61 # 31825 416.39 395.57 454.91 31613 371.23 352.67 405.57 31830 361.57 343.49 395.01 31614 619.17 588.21 676.44 # 31830 291.04 276.49 317.96 31615 156.48 148.66 170.96 32035 625.99 594.69 683.89 # 31615 113.97 108.27 124.51 32036 678.96 645.01 741.76 31620 238.93 226.98 261.03 32095 557.11 529.25 608.64 # 31620 65.33 62.06 71.37 32100 861.58 818.50 941.28 31622 272.55 258.92 297.76 32110 1,302.07 1,236.97 1,422.52 # 31622 134.38 127.66 146.81 32120 773.23 734.57 844.76 31623 298.14 283.23 325.71 32124 822.05 780.95 898.09 # 31623 136.45 129.63 149.07 32140 880.14 836.13 961.55 31624 277.84 263.95 303.54 32141 1,340.30 1,273.29 1,464.28 # 31624 136.78 129.94 149.43 32150 886.94 842.59 968.98 31625 300.23 285.22 328.00 32151 906.30 860.99 990.14 # 31625 159.16 151.20 173.88 32160 682.53 648.40 745.66 31628 359.90 341.91 393.20 32200 995.00 945.25 1,087.04 # 31628 177.93 169.03 194.38 32201 793.60 753.92 867.01 31629 545.22 517.96 595.65 # 32201 196.48 186.66 214.66 # 31629 190.61 181.08 208.24 32215 712.12 676.51 777.99 31630 188.83 179.39 206.30 32220 1,424.58 1,353.35 1,556.35 31631 213.21 202.55 232.93 32225 887.42 843.05 969.51 31632 67.07 63.72 73.28 32310 817.70 776.82 893.34 # 31632 48.72 46.28 53.22 32320 1,429.67 1,358.19 1,561.92 31633 81.37 77.30 88.90 32400 135.14 128.38 147.64 # 31633 61.40 58.33 67.08 # 32400 84.58 80.35 92.40 31635 308.93 293.48 337.50 32402 501.30 476.24 547.68 # 31635 176.24 167.43 192.54 32405 95.39 90.62 104.21 31636 208.58 198.15 227.87 # 32405 95.07 90.32 103.87 31637 74.11 70.40 80.96 32420 105.23 99.97 114.97 31638 234.66 222.93 256.37 32421 139.74 132.75 152.66 31640 241.69 229.61 264.05 # 32421 73.07 69.42 79.83 31641 239.76 227.77 261.94 32422 177.09 168.24 193.48 31643 164.85 156.61 180.10 # 32422 116.22 110.41 126.97 31645 269.47 256.00 294.40 32440 1,429.32 1,357.85 1,561.53 # 31645 149.66 142.18 163.51 32442 2,687.25 2,552.89 2,935.82 31646 244.23 232.02 266.82 32445 3,054.56 2,901.83 3,337.10 # 31646 129.57 123.09 141.55 32480 1,349.14 1,281.68 1,473.93 31656 275.78 261.99 301.29 32482 1,438.73 1,366.79 1,571.81 # 31656 104.76 99.52 114.45 32484 1,304.29 1,239.08 1,424.94 31715 51.90 49.31 56.71 32486 2,094.06 1,989.36 2,287.76 31717 259.31 246.34 283.29 32488 2,118.96 2,013.01 2,314.96 # 31717 102.78 97.64 112.29 32491 1,339.95 1,272.95 1,463.89 31720 48.81 46.37 53.33 32500 1,303.41 1,238.24 1,423.98 31725 87.99 83.59 96.13 32501 228.64 217.21 249.79 31730 726.83 690.49 794.06 32503 1,647.11 1,564.75 1,799.46 # 31730 134.21 127.50 146.63 32504 1,892.09 1,797.49 2,067.11 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 99 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 1,509.14 1,433.68 1,648.73 33206 432.95 411.30 473.00 32550 677.68 643.80 740.37 33207 463.90 440.71 506.82 # 32550 210.67 200.14 230.16 33208 500.61 475.58 546.92 32551 162.68 154.55 177.73 33210 173.10 164.45 189.12 32560 255.70 242.92 279.36 33211 173.98 165.28 190.07 # 32560 104.00 98.80 113.62 33212 323.59 307.41 353.52 32601 283.23 269.07 309.43 33213 369.74 351.25 403.94 32602 307.33 291.96 335.75 33214 458.05 435.15 500.42 32603 398.49 378.57 435.36 33215 292.44 277.82 319.49 32604 447.67 425.29 489.08 33216 359.90 341.91 393.20 32605 353.32 335.65 386.00 33217 356.78 338.94 389.78 32606 427.63 406.25 467.19 33218 371.97 353.37 406.38 32650 603.60 573.42 659.43 33220 375.50 356.73 410.24 32651 961.10 913.05 1,050.01 33222 326.32 310.00 356.50 32652 1,461.86 1,388.77 1,597.09 33223 396.65 376.82 433.34 32653 931.08 884.53 1,017.21 33224 487.97 463.57 533.11 32654 1,032.16 980.55 1,127.63 33225 440.79 418.75 481.56 32655 847.85 805.46 926.28 33226 471.04 447.49 514.61 32656 723.57 687.39 790.50 33233 228.04 216.64 249.14 32657 712.80 677.16 778.73 33234 465.05 441.80 508.07 32658 651.64 619.06 711.92 33235 600.41 570.39 655.95 32659 662.62 629.49 723.91 33236 708.42 673.00 773.95 32660 939.21 892.25 1,026.09 33237 783.08 743.93 855.52 32661 728.64 692.21 796.04 33238 845.10 802.85 923.28 32662 815.74 774.95 891.19 33240 445.36 423.09 486.55 32663 1,263.72 1,200.53 1,380.61 33241 216.11 205.30 236.10 32664 774.19 735.48 845.80 33243 1,249.75 1,187.26 1,365.35 32665 1,095.38 1,040.61 1,196.70 33244 817.22 776.36 892.81 32800 835.28 793.52 912.55 33249 867.15 823.79 947.36 32810 807.31 766.94 881.98 33250 1,337.14 1,270.28 1,460.82 32815 2,418.23 2,297.32 2,641.92 33251 1,482.33 1,408.21 1,619.44 32820 1,204.87 1,144.63 1,316.32 33254 1,244.21 1,182.00 1,359.30 32851 2,320.22 2,204.21 2,534.84 33255 1,522.92 1,446.77 1,663.79 32852 2,566.83 2,438.49 2,804.26 33256 1,816.29 1,725.48 1,984.30 32853 2,774.98 2,636.23 3,031.66 33257 525.76 499.47 574.39 32854 3,021.51 2,870.43 3,300.99 33258 593.86 564.17 648.80 32855 257.29 244.43 281.09 33259 772.82 734.18 844.31 32856 310.42 294.90 339.14 33261 1,475.98 1,402.18 1,612.51 32900 1,230.92 1,169.37 1,344.78 33265 1,241.63 1,179.55 1,356.48 32905 1,212.52 1,151.89 1,324.67 33266 1,705.00 1,619.75 1,862.71 32906 1,506.96 1,431.61 1,646.35 33282 307.26 291.90 335.69 32940 1,110.99 1,055.44 1,213.76 33284 220.34 209.32 240.72 32960 123.95 117.75 135.41 33300 2,136.14 2,029.33 2,333.73 # 32960 92.39 87.77 100.94 33305 3,576.08 3,397.28 3,906.87 32997 333.31 316.64 364.14 33310 1,065.09 1,011.84 1,163.62 32998 2,408.12 2,287.71 2,630.87 33315 1,355.56 1,287.78 1,480.95 # 32998 286.93 272.58 313.47 33320 967.12 918.76 1,056.57 33010 115.48 109.71 126.17 33321 1,088.12 1,033.71 1,188.77 33011 113.08 107.43 123.54 33322 1,266.31 1,202.99 1,383.44 33015 486.31 461.99 531.29 33330 1,280.56 1,216.53 1,399.01 33020 786.94 747.59 859.73 33332 1,276.07 1,212.27 1,394.11 33025 725.72 689.43 792.84 33335 1,725.25 1,638.99 1,884.84 33030 1,163.11 1,104.95 1,270.69 33400 2,084.83 1,980.59 2,277.68 33031 1,300.26 1,235.25 1,420.54 33401 1,365.01 1,296.76 1,491.27 33050 898.06 853.16 981.13 33403 1,374.88 1,306.14 1,502.06 33120 1,419.81 1,348.82 1,551.14 33404 1,632.60 1,550.97 1,783.62 33130 1,251.26 1,188.70 1,367.01 33405 2,119.64 2,013.66 2,315.71 33140 1,432.65 1,361.02 1,565.17 33406 2,625.85 2,494.56 2,868.74 33141 137.03 130.18 149.71 33410 2,317.30 2,201.44 2,531.66 33202 707.85 672.46 773.33 33411 3,033.65 2,881.97 3,314.27 33203 747.98 710.58 817.17 33412 2,283.03 2,168.88 2,494.21 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 28 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 2,981.63 2,832.55 3,257.43 33615 1,849.19 1,756.73 2,020.24 33414 1,989.96 1,890.46 2,174.03 33617 1,981.62 1,882.54 2,164.92 33415 1,847.33 1,754.96 2,018.20 33619 2,432.39 2,310.77 2,657.39 33416 1,851.06 1,758.51 2,022.29 33641 1,480.39 1,406.37 1,617.33 33417 1,538.36 1,461.44 1,680.66 33645 1,452.58 1,379.95 1,586.94 33420 1,260.88 1,197.84 1,377.52 33647 1,546.87 1,469.53 1,689.96 33422 1,546.24 1,468.93 1,689.27 33660 1,619.33 1,538.36 1,769.11 33425 2,430.47 2,308.95 2,655.29 33665 1,756.92 1,669.07 1,919.43 33426 2,193.38 2,083.71 2,396.27 33670 1,826.32 1,735.00 1,995.25 33427 2,284.52 2,170.29 2,495.83 33675 1,819.57 1,728.59 1,987.88 33430 2,542.80 2,415.66 2,778.01 33676 1,891.38 1,796.81 2,066.33 33460 2,164.25 2,056.04 2,364.45 33677 1,965.85 1,867.56 2,147.69 33463 2,738.47 2,601.55 2,991.78 33681 1,680.43 1,596.41 1,835.87 33464 2,197.43 2,087.56 2,400.69 33684 1,723.95 1,637.75 1,883.41 33465 2,463.24 2,340.08 2,691.09 33688 1,726.65 1,640.32 1,886.37 33468 1,723.58 1,637.40 1,883.01 33690 1,061.74 1,008.65 1,159.95 33470 1,096.41 1,041.59 1,197.83 33692 1,621.43 1,540.36 1,771.41 33471 1,211.11 1,150.55 1,323.13 33694 1,826.21 1,734.90 1,995.14 33472 1,221.94 1,160.84 1,334.97 33697 1,971.27 1,872.71 2,153.62 33474 1,897.97 1,803.07 2,073.53 33702 1,407.33 1,336.96 1,537.50 33475 2,126.05 2,019.75 2,322.71 33710 1,696.65 1,611.82 1,853.59 33476 1,347.17 1,279.81 1,471.78 33720 1,424.74 1,353.50 1,556.53 33478 1,440.44 1,368.42 1,573.68 33722 1,433.78 1,362.09 1,566.40 33496 1,542.26 1,465.15 1,684.92 33724 1,445.63 1,373.35 1,579.35 33500 1,446.94 1,374.59 1,580.78 33726 1,892.17 1,797.56 2,067.19 33501 1,007.46 957.09 1,100.65 33730 1,804.14 1,713.93 1,971.02 33502 1,158.56 1,100.63 1,265.72 33732 1,504.68 1,429.45 1,643.87 33503 1,243.90 1,181.71 1,358.97 33735 1,149.76 1,092.27 1,256.11 33504 1,324.78 1,258.54 1,447.32 33736 1,277.26 1,213.40 1,395.41 33505 1,842.97 1,750.82 2,013.44 33737 1,189.34 1,129.87 1,299.35 33506 1,894.98 1,800.23 2,070.26 33750 1,204.96 1,144.71 1,316.42 33507 1,600.49 1,520.47 1,748.54 33755 1,182.82 1,123.68 1,292.23 33508 15.11 14.35 16.50 33762 1,181.33 1,122.26 1,290.60 33510 1,802.58 1,712.45 1,969.32 33764 1,165.17 1,106.91 1,272.95 33511 1,969.37 1,870.90 2,151.54 33766 1,278.11 1,214.20 1,396.33 33512 2,221.98 2,110.88 2,427.51 33767 1,296.25 1,231.44 1,416.16 33513 2,270.68 2,157.15 2,480.72 33768 395.97 376.17 432.60 33514 2,408.02 2,287.62 2,630.76 33770 1,973.28 1,874.62 2,155.81 33516 2,502.38 2,377.26 2,733.85 33771 2,024.94 1,923.69 2,212.24 33517 172.55 163.92 188.51 33774 1,660.27 1,577.26 1,813.85 33518 374.33 355.61 408.95 33775 1,727.38 1,641.01 1,887.16 33519 498.89 473.95 545.04 33776 1,818.17 1,727.26 1,986.35 33521 603.03 572.88 658.81 33777 1,779.23 1,690.27 1,943.81 33522 684.57 650.34 747.89 33778 2,190.52 2,080.99 2,393.14 33523 780.72 741.68 852.93 33779 2,119.54 2,013.56 2,315.59 33530 476.30 452.49 520.36 33780 2,198.21 2,088.30 2,401.55 33533 1,753.48 1,665.81 1,915.68 33781 2,151.80 2,044.21 2,350.84 33534 2,043.07 1,940.92 2,232.06 33786 2,114.65 2,008.92 2,310.26 33535 2,270.63 2,157.10 2,480.67 33788 1,424.43 1,353.21 1,556.19 33536 2,434.14 2,312.43 2,659.29 33800 894.07 849.37 976.78 33542 2,353.53 2,235.85 2,571.23 33802 962.24 914.13 1,051.25 33545 2,777.31 2,638.44 3,034.21 33803 1,044.84 992.60 1,141.49 33548 2,717.74 2,581.85 2,969.13 33813 1,182.60 1,123.47 1,291.99 33572 218.05 207.15 238.22 33814 1,396.70 1,326.87 1,525.90 33600 1,568.43 1,490.01 1,713.51 33820 893.92 849.22 976.60 33602 1,497.04 1,422.19 1,635.52 33822 948.48 901.06 1,036.22 33606 1,628.68 1,547.25 1,779.34 33824 1,073.50 1,019.83 1,172.80 33608 1,670.03 1,586.53 1,824.51 33840 1,090.59 1,036.06 1,191.47 33610 1,630.52 1,548.99 1,781.34 33845 1,251.02 1,188.47 1,366.74 33611 1,798.15 1,708.24 1,964.48 33851 1,151.74 1,094.15 1,258.27 33612 1,853.29 1,760.63 2,024.72 33852 1,257.68 1,194.80 1,374.02 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 29 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,725.82 1,639.53 1,885.46 34803 1,214.28 1,153.57 1,326.61 33860 2,903.58 2,758.40 3,172.16 34804 1,183.24 1,124.08 1,292.69 33861 2,247.90 2,135.51 2,455.84 34805 1,112.90 1,057.26 1,215.85 33863 2,896.27 2,751.46 3,164.18 34806 100.23 95.22 109.50 33864 2,975.88 2,827.09 3,251.15 34808 197.39 187.52 215.65 33870 2,346.66 2,229.33 2,563.73 34812 325.54 309.26 355.65 33875 1,822.28 1,731.17 1,990.85 34813 227.16 215.80 248.17 33877 3,267.52 3,104.14 3,569.76 34820 468.41 444.99 511.74 33880 1,689.17 1,604.71 1,845.42 34825 661.20 628.14 722.36 33881 1,449.85 1,377.36 1,583.96 34826 196.66 186.83 214.85 33883 1,055.68 1,002.90 1,153.34 34830 1,728.98 1,642.53 1,888.91 33884 387.34 367.97 423.17 34831 1,833.87 1,742.18 2,003.51 33886 906.88 861.54 990.77 34832 1,858.29 1,765.38 2,030.19 33889 758.12 720.21 828.24 34833 583.02 553.87 636.95 33891 948.53 901.10 1,036.27 34834 264.06 250.86 288.49 33910 1,525.80 1,449.51 1,666.94 34900 858.05 815.15 937.42 33915 1,229.31 1,167.84 1,343.02 35001 1,068.27 1,014.86 1,167.09 33916 1,524.15 1,447.94 1,665.13 35002 1,128.66 1,072.23 1,233.06 33917 1,376.57 1,307.74 1,503.90 35005 985.01 935.76 1,076.12 33920 1,669.21 1,585.75 1,823.61 35011 938.26 891.35 1,025.05 33922 1,261.71 1,198.62 1,378.41 35013 1,164.81 1,106.57 1,272.56 33924 267.31 253.94 292.03 35021 1,141.37 1,084.30 1,246.95 33925 1,621.78 1,540.69 1,771.79 35022 1,292.69 1,228.06 1,412.27 33926 2,166.94 2,058.59 2,367.38 35045 912.42 866.80 996.82 33933 355.82 338.03 388.73 35081 1,640.58 1,558.55 1,792.33 33935 3,191.83 3,032.24 3,487.08 35082 2,059.06 1,956.11 2,249.53 33944 250.75 238.21 273.94 35091 1,732.36 1,645.74 1,892.60 33945 4,289.15 4,074.69 4,685.89 35092 2,462.07 2,338.97 2,689.82 33960 930.38 883.86 1,016.44 35102 1,779.98 1,690.98 1,944.63 33961 521.18 495.12 569.39 35103 2,127.77 2,021.38 2,324.59 33967 255.17 242.41 278.77 35111 1,309.15 1,243.69 1,430.24 33968 32.70 31.07 35.73 35112 1,606.02 1,525.72 1,754.58 33970 342.02 324.92 373.66 35121 1,554.74 1,477.00 1,698.55 33971 654.96 622.21 715.54 35122 1,863.25 1,770.09 2,035.60 33973 498.01 473.11 544.08 35131 1,323.85 1,257.66 1,446.31 33974 833.13 791.47 910.19 35132 1,603.16 1,523.00 1,751.45 33975 1,031.09 979.54 1,126.47 35141 1,050.40 997.88 1,147.56 33976 1,145.25 1,087.99 1,251.19 35142 1,257.39 1,194.52 1,373.70 33977 1,102.56 1,047.43 1,204.54 35151 1,185.04 1,125.79 1,294.66 33978 1,214.57 1,153.84 1,326.92 35152 1,377.11 1,308.25 1,504.49 33979 2,260.11 2,147.10 2,469.17 35180 790.03 750.53 863.11 33980 3,319.44 3,153.47 3,626.49 35182 1,616.05 1,535.25 1,765.54 34001 894.39 849.67 977.12 35184 952.60 904.97 1,040.72 34051 892.59 847.96 975.15 35188 796.60 756.77 870.29 34101 567.07 538.72 619.53 35189 1,493.33 1,418.66 1,631.46 34111 566.90 538.56 619.34 35190 696.61 661.78 761.05 34151 1,315.86 1,250.07 1,437.58 35201 874.01 830.31 954.86 34201 933.73 887.04 1,020.10 35206 714.33 678.61 780.40 34203 907.76 862.37 991.73 35207 641.75 609.66 701.11 34401 1,356.33 1,288.51 1,481.79 35211 1,269.90 1,206.41 1,387.37 34421 688.16 653.75 751.81 35216 1,782.04 1,692.94 1,946.88 34451 1,420.66 1,349.63 1,552.07 35221 1,311.71 1,246.12 1,433.04 34471 1,004.11 953.90 1,096.99 35226 788.97 749.52 861.95 34490 569.90 541.41 622.62 35231 1,095.96 1,041.16 1,197.33 34501 882.82 838.68 964.48 35236 914.96 869.21 999.59 34502 1,432.21 1,360.60 1,564.69 35241 1,325.35 1,259.08 1,447.94 34510 1,006.36 956.04 1,099.45 35246 1,442.24 1,370.13 1,575.65 34520 966.36 918.04 1,055.75 35251 1,560.11 1,482.10 1,704.42 34530 909.47 864.00 993.60 35256 962.14 914.03 1,051.13 34800 1,082.06 1,027.96 1,182.15 35261 971.71 923.12 1,061.59 34802 1,183.78 1,124.59 1,293.28 35266 805.97 765.67 880.52 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 30 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,268.22 1,204.81 1,385.53 35511 1,119.97 1,063.97 1,223.57 35276 1,330.64 1,264.11 1,453.73 35512 1,166.83 1,108.49 1,274.76 35281 1,489.06 1,414.61 1,626.80 35515 1,258.53 1,195.60 1,374.94 35286 881.80 837.71 963.37 35516 1,154.25 1,096.54 1,261.02 35301 990.27 940.76 1,081.87 35518 1,139.94 1,082.94 1,245.38 35302 1,054.49 1,001.77 1,152.04 35521 1,200.38 1,140.36 1,311.41 35303 1,160.90 1,102.86 1,268.29 35522 1,139.17 1,082.21 1,244.54 35304 1,207.35 1,146.98 1,319.03 35523 1,205.36 1,145.09 1,316.85 35305 1,159.61 1,101.63 1,266.87 35525 1,068.48 1,015.06 1,167.32 35306 435.01 413.26 475.25 35526 1,573.68 1,495.00 1,719.25 35311 1,422.98 1,351.83 1,554.60 35531 1,918.10 1,822.20 2,095.53 35321 841.84 799.75 919.71 35533 1,484.46 1,410.24 1,621.78 35331 1,390.67 1,321.14 1,519.31 35535 1,900.71 1,805.67 2,076.52 35341 1,308.59 1,243.16 1,429.63 35536 1,653.25 1,570.59 1,806.18 35351 1,217.92 1,157.02 1,330.57 35537 2,050.78 1,948.24 2,240.48 35355 988.80 939.36 1,080.26 35538 2,301.89 2,186.80 2,514.82 35361 1,498.75 1,423.81 1,637.38 35539 2,135.89 2,029.10 2,333.47 35363 1,630.87 1,549.33 1,781.73 35540 2,392.36 2,272.74 2,613.65 35371 777.94 739.04 849.90 35548 1,137.77 1,080.88 1,243.01 35372 934.20 887.49 1,020.61 35549 1,235.63 1,173.85 1,349.93 35390 153.17 145.51 167.34 35551 1,408.03 1,337.63 1,538.27 35400 144.82 137.58 158.22 35556 1,312.38 1,246.76 1,433.77 35450 490.61 466.08 535.99 35558 1,159.43 1,101.46 1,266.68 35452 339.94 322.94 371.38 35560 1,686.67 1,602.34 1,842.69 35454 297.98 283.08 325.54 35563 1,293.24 1,228.58 1,412.87 35456 360.80 342.76 394.17 35565 1,252.67 1,190.04 1,368.55 35458 463.47 440.30 506.35 35566 1,575.29 1,496.53 1,721.01 35459 425.12 403.86 464.44 35570 1,467.99 1,394.59 1,603.78 35460 295.66 280.88 323.01 35571 1,270.65 1,207.12 1,388.19 35470 2,477.50 2,353.63 2,706.67 35572 331.78 315.19 362.47 # 35470 436.83 414.99 477.24 35583 1,355.80 1,288.01 1,481.21 35471 2,725.18 2,588.92 2,977.26 35585 1,586.07 1,506.77 1,732.79 # 35471 521.87 495.78 570.15 35587 1,310.02 1,244.52 1,431.20 35472 1,889.49 1,795.02 2,064.27 35600 243.94 231.74 266.50 # 35472 349.01 331.56 381.29 35601 1,363.78 1,295.59 1,489.93 35473 1,802.44 1,712.32 1,969.17 35606 1,112.66 1,057.03 1,215.58 # 35473 308.66 293.23 337.21 35612 868.43 825.01 948.76 35474 2,402.19 2,282.08 2,624.39 35616 1,067.58 1,014.20 1,166.33 # 35474 373.44 354.77 407.99 35621 1,049.29 996.83 1,146.35 35475 1,953.95 1,856.25 2,134.69 35623 1,288.51 1,224.08 1,407.69 # 35475 468.86 445.42 512.23 35626 1,477.35 1,403.48 1,614.00 35476 1,472.20 1,398.59 1,608.38 35631 1,764.14 1,675.93 1,927.32 # 35476 299.52 284.54 327.22 35632 1,804.32 1,714.10 1,971.22 35480 533.05 506.40 582.36 35633 1,948.56 1,851.13 2,128.80 35481 382.08 362.98 417.43 35634 1,765.79 1,677.50 1,929.13 35482 334.51 317.78 365.45 35636 1,566.50 1,488.18 1,711.41 35483 403.65 383.47 440.99 35637 1,620.38 1,539.36 1,770.26 35484 504.63 479.40 551.31 35638 1,655.16 1,572.40 1,808.26 35485 468.29 444.88 511.61 35642 979.26 930.30 1,069.85 35490 581.87 552.78 635.70 35645 928.38 881.96 1,014.25 35491 389.98 370.48 426.05 35646 1,633.92 1,552.22 1,785.05 35492 353.72 336.03 386.43 35647 1,478.88 1,404.94 1,615.68 35493 430.87 409.33 470.73 35650 1,010.82 960.28 1,104.32 35494 547.32 519.95 597.94 35651 1,309.33 1,243.86 1,430.44 35495 499.41 474.44 545.61 35654 1,305.39 1,240.12 1,426.14 35500 306.74 291.40 335.11 35656 1,027.93 976.53 1,123.01 35501 1,474.54 1,400.81 1,610.93 35661 1,028.75 977.31 1,123.91 35506 1,258.81 1,195.87 1,375.25 35663 1,194.10 1,134.40 1,304.56 35508 1,301.05 1,236.00 1,421.40 35665 1,117.95 1,062.05 1,221.36 35509 1,417.89 1,347.00 1,549.05 35666 1,204.57 1,144.34 1,315.99 35510 1,196.78 1,136.94 1,307.48 35671 1,061.07 1,008.02 1,159.22 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 31 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 76.60 72.77 83.69 # 36215 233.77 222.08 255.39 35682 342.01 324.91 373.65 36216 1,098.03 1,043.13 1,199.60 35683 403.51 383.33 440.83 # 36216 263.53 250.35 287.90 35685 192.07 182.47 209.84 36217 1,780.63 1,691.60 1,945.34 35686 160.69 152.66 175.56 # 36217 315.19 299.43 344.34 35691 935.05 888.30 1,021.55 36218 169.08 160.63 184.72 35693 827.64 786.26 904.20 # 36218 50.23 47.72 54.88 35694 967.41 919.04 1,056.90 36245 1,105.69 1,050.41 1,207.97 35695 1,007.85 957.46 1,101.08 # 36245 240.28 228.27 262.51 35697 143.17 136.01 156.41 36246 1,088.64 1,034.21 1,189.34 35700 147.24 139.88 160.86 # 36246 262.52 249.39 286.80 35701 499.82 474.83 546.05 36247 1,702.25 1,617.14 1,859.71 35721 424.02 402.82 463.24 # 36247 312.50 296.88 341.41 35741 465.03 441.78 508.05 36248 145.89 138.60 159.39 35761 342.14 325.03 373.78 # 36248 50.23 47.72 54.88 35800 441.59 419.51 482.44 36260 531.02 504.47 580.14 35820 1,755.15 1,667.39 1,917.50 36261 322.42 306.30 352.25 35840 578.15 549.24 631.63 36262 244.87 232.63 267.52 35860 373.12 354.46 407.63 36400 23.26 22.10 25.42 35870 1,214.25 1,153.54 1,326.57 # 36400 16.81 15.97 18.37 35875 557.57 529.69 609.14 36405 21.05 20.00 23.00 35876 894.66 849.93 977.42 # 36405 14.61 13.88 15.96 35879 875.61 831.83 956.60 36406 15.04 14.29 16.43 35881 973.42 924.75 1,063.46 # 36406 8.60 8.17 9.40 35883 1,136.34 1,079.52 1,241.45 36410 16.65 15.82 18.19 35884 1,199.17 1,139.21 1,310.09 # 36410 8.28 7.87 9.05 35901 465.83 442.54 508.92 36420 45.72 43.43 49.94 35903 527.15 500.79 575.91 36425 35.88 34.09 39.20 35905 1,651.18 1,568.62 1,803.91 36430 31.34 29.77 34.24 35907 1,820.07 1,729.07 1,988.43 36440 47.94 45.54 52.37 36000 22.13 21.02 24.17 36450 109.92 104.42 120.08 # 36000 8.92 8.47 9.74 36455 120.26 114.25 131.39 36002 151.97 144.37 166.03 36460 313.17 297.51 342.14 # 36002 103.66 98.48 113.25 36470 119.71 113.72 130.78 36005 294.74 280.00 322.00 # 36470 63.02 59.87 68.85 # 36005 47.07 44.72 51.43 36471 148.36 140.94 162.08 36010 511.50 485.93 558.82 # 36471 88.78 84.34 96.99 # 36010 118.25 112.34 129.19 36475 1,537.55 1,460.67 1,679.77 36011 807.28 766.92 881.96 # 36475 319.79 303.80 349.37 # 36011 152.82 145.18 166.96 36476 336.70 319.87 367.85 36012 761.30 723.24 831.73 # 36476 156.66 148.83 171.15 # 36012 172.54 163.91 188.50 36478 1,271.20 1,207.64 1,388.79 36013 700.50 665.48 765.30 # 36478 322.69 306.56 352.54 # 36013 123.67 117.49 135.11 36479 353.45 335.78 386.15 36014 732.61 695.98 800.38 # 36479 157.63 149.75 172.21 # 36014 149.98 142.48 163.85 36481 384.86 365.62 420.46 36015 804.10 763.90 878.49 36500 172.66 164.03 188.63 # 36015 173.48 164.81 189.53 36510 96.81 91.97 105.77 36100 469.43 445.96 512.85 # 36510 53.33 50.66 58.26 # 36100 151.54 143.96 165.55 36511 84.14 79.93 91.92 36120 386.75 367.41 422.52 36512 85.43 81.16 93.33 # 36120 95.91 91.11 104.78 36513 87.67 83.29 95.78 36140 426.39 405.07 465.83 36514 447.77 425.38 489.19 # 36140 98.52 93.59 107.63 # 36514 83.50 79.33 91.23 36145 422.61 401.48 461.70 36515 1,653.61 1,570.93 1,806.57 # 36145 96.67 91.84 105.62 # 36515 81.89 77.80 89.47 36160 470.07 446.57 513.56 36516 1,869.33 1,775.86 2,042.24 # 36160 127.71 121.32 139.52 # 36516 58.63 55.70 64.06 36200 571.17 542.61 624.00 36522 1,168.86 1,110.42 1,276.98 # 36200 147.32 139.95 160.94 # 36522 93.78 89.09 102.45 36215 1,004.17 953.96 1,097.05 36555 243.22 231.06 265.72 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 32 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 120.19 114.18 131.31 36625 98.75 93.81 107.88 36556 207.87 197.48 227.10 36640 110.39 104.87 120.60 # 36556 113.51 107.83 124.00 36660 62.96 59.81 68.78 36557 734.53 697.80 802.47 36680 55.54 52.76 60.67 # 36557 276.87 263.03 302.48 36800 144.25 137.04 157.60 36558 710.19 674.68 775.88 36810 194.93 185.18 212.96 # 36558 264.44 251.22 288.90 36815 137.10 130.25 149.79 36560 1,006.62 956.29 1,099.73 36818 621.99 590.89 679.52 # 36560 328.65 312.22 359.05 36819 735.11 698.35 803.10 36561 995.35 945.58 1,087.42 36820 737.51 700.63 805.72 # 36561 317.70 301.82 347.09 36821 614.37 583.65 671.20 36563 1,005.74 955.45 1,098.77 36822 341.25 324.19 372.82 # 36563 328.74 312.30 359.15 36823 1,174.17 1,115.46 1,282.78 36565 844.94 802.69 923.09 36825 531.49 504.92 580.66 # 36565 313.19 297.53 342.16 36830 609.12 578.66 665.46 36566 3,100.42 2,945.40 3,387.21 36831 420.00 399.00 458.85 # 36566 335.73 318.94 366.78 36832 536.95 510.10 586.62 36568 272.17 258.56 297.34 36833 606.82 576.48 662.95 # 36568 91.81 87.22 100.30 36834 569.94 541.44 622.66 36569 236.81 224.97 258.72 36835 419.03 398.08 457.79 # 36569 91.24 86.68 99.68 36838 1,084.77 1,030.53 1,185.11 36570 1,019.78 968.79 1,114.11 36860 170.10 161.60 185.84 # 36570 292.53 277.90 319.59 # 36860 96.35 91.53 105.26 36571 1,057.06 1,004.21 1,154.84 36861 138.51 131.58 151.32 # 36571 284.72 270.48 311.05 36870 1,596.50 1,516.68 1,744.18 36575 139.15 132.19 152.02 # 36870 286.30 271.99 312.79 # 36575 35.77 33.98 39.08 37140 1,247.16 1,184.80 1,362.52 36576 317.22 301.36 346.56 37145 1,338.77 1,271.83 1,462.60 # 36576 173.25 164.59 189.28 37160 1,165.43 1,107.16 1,273.23 36578 440.45 418.43 481.19 37180 1,305.58 1,240.30 1,426.35 # 36578 197.92 188.02 216.22 37181 1,412.13 1,341.52 1,542.75 36580 202.32 192.20 221.03 37182 849.13 806.67 927.67 # 36580 65.43 62.16 71.48 37183 403.44 383.27 440.76 36581 658.58 625.65 719.50 37184 2,106.07 2,000.77 2,300.89 # 36581 187.71 178.32 205.07 # 37184 434.18 412.47 474.34 36582 920.46 874.44 1,005.61 37185 697.57 662.69 762.09 # 36582 276.31 262.49 301.86 # 37185 160.03 152.03 174.83 36583 920.97 874.92 1,006.16 37186 1,416.67 1,345.84 1,547.72 # 36583 276.82 262.98 302.43 # 37186 245.61 233.33 268.33 36584 198.99 189.04 217.40 37187 2,017.26 1,916.40 2,203.86 # 36584 66.94 63.59 73.13 # 37187 403.34 383.17 440.65 36585 943.39 896.22 1,030.65 37188 1,710.80 1,625.26 1,869.05 # 36585 259.30 246.34 283.29 # 37188 291.74 277.15 318.72 36589 150.22 142.71 164.12 37195 294.68 279.95 321.94 # 36589 128.32 121.90 140.19 37200 225.58 214.30 246.45 36590 242.85 230.71 265.32 37201 265.70 252.42 290.28 # 36590 181.66 172.58 198.47 37202 318.41 302.49 347.86 36591 19.50 18.53 21.31 37203 1,168.53 1,110.10 1,276.62 36592 21.43 20.36 23.41 # 37203 256.09 243.29 279.78 36593 29.43 27.96 32.15 37204 894.57 849.84 977.32 36595 534.19 507.48 583.60 37205 2,884.23 2,740.02 3,151.02 # 36595 181.84 172.75 198.66 # 37205 420.36 399.34 459.24 36596 119.73 113.74 130.80 37206 1,720.67 1,634.64 1,879.84 # 36596 42.75 40.61 46.70 # 37206 204.98 194.73 223.94 36597 114.13 108.42 124.68 37207 405.99 385.69 443.54 # 36597 60.66 57.63 66.27 37208 196.75 186.91 214.95 36598 101.33 96.26 110.70 37209 110.62 105.09 120.85 # 36598 55.92 53.12 61.09 37210 3,067.14 2,913.78 3,350.85 36600 27.36 25.99 29.89 # 37210 533.70 507.02 583.07 # 36600 14.47 13.75 15.81 37215 1,043.41 991.24 1,139.93 36620 48.19 45.78 52.65 37250 104.59 99.36 114.26 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 33 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 77.83 73.94 85.03 38550 403.96 383.76 441.32 37500 632.27 600.66 690.76 38555 843.43 801.26 921.45 37565 630.53 599.00 688.85 38562 605.81 575.52 661.85 37600 644.97 612.72 704.63 38564 601.96 571.86 657.64 37605 736.84 700.00 805.00 38570 490.99 466.44 536.41 37606 479.01 455.06 523.32 38571 775.07 736.32 846.77 37607 342.04 324.94 373.68 38572 851.00 808.45 929.72 37609 252.84 240.20 276.23 38700 683.64 649.46 746.88 # 37609 176.18 167.37 192.48 38720 1,137.36 1,080.49 1,242.56 37615 425.45 404.18 464.81 38724 1,234.11 1,172.40 1,348.26 37616 989.64 940.16 1,081.18 38740 569.55 541.07 622.23 37617 1,181.14 1,122.08 1,290.39 38745 725.36 689.09 792.45 37618 338.89 321.95 370.24 38746 239.35 227.38 261.49 37620 616.71 585.87 673.75 38747 233.74 222.05 255.36 37650 463.28 440.12 506.14 38760 715.46 679.69 781.64 37660 1,107.03 1,051.68 1,209.43 38765 1,115.54 1,059.76 1,218.72 37700 226.18 214.87 247.10 38770 747.42 710.05 816.56 37718 377.85 358.96 412.80 38780 940.63 893.60 1,027.64 37722 434.22 412.51 474.39 38790 73.31 69.64 80.09 37735 576.54 547.71 629.87 38792 35.28 33.52 38.55 37760 567.95 539.55 620.48 38794 277.84 263.95 303.54 37765 410.28 389.77 448.24 39000 432.48 410.86 472.49 37766 500.26 475.25 546.54 39010 717.92 682.02 784.32 37780 233.37 221.70 254.96 39200 796.83 756.99 870.54 37785 308.91 293.46 337.48 39220 1,027.04 975.69 1,122.04 # 37785 233.87 222.18 255.51 39400 446.73 424.39 488.05 37788 1,260.80 1,197.76 1,377.42 39501 730.95 694.40 798.56 37790 457.92 435.02 500.27 39502 878.08 834.18 959.31 38100 959.48 911.51 1,048.24 39503 5,151.92 4,894.32 5,628.47 38101 963.72 915.53 1,052.86 39520 875.62 831.84 956.62 38102 229.35 217.88 250.56 39530 839.20 797.24 916.83 38115 1,067.79 1,014.40 1,166.56 39531 877.58 833.70 958.76 38120 884.19 839.98 965.98 39540 747.87 710.48 817.05 38200 129.26 122.80 141.22 39541 806.83 766.49 881.46 38205 74.67 70.94 81.58 39545 792.65 753.02 865.97 38206 74.67 70.94 81.58 39560 685.70 651.42 749.13 38220 134.85 128.11 147.33 39561 1,065.30 1,012.04 1,163.85 # 38220 55.94 53.14 61.11 40490 108.34 102.92 118.36 38221 150.17 142.66 164.06 # 40490 64.86 61.62 70.86 # 38221 70.94 67.39 77.50 40500 407.77 387.38 445.49 38230 283.09 268.94 309.28 # 40500 304.06 288.86 332.19 38240 115.27 109.51 125.94 40510 396.41 376.59 433.08 38241 115.91 110.11 126.63 # 40510 302.04 286.94 329.98 38242 87.89 83.50 96.03 40520 406.81 386.47 444.44 38300 223.55 212.37 244.23 # 40520 305.03 289.78 333.25 # 38300 153.02 145.37 167.18 40525 474.74 451.00 518.65 38305 389.70 370.22 425.75 40527 561.59 533.51 613.54 38308 375.37 356.60 410.09 40530 449.81 427.32 491.42 38380 483.98 459.78 528.75 # 40530 346.43 329.11 378.48 38381 721.30 685.24 788.03 40650 337.26 320.40 368.46 38382 582.44 553.32 636.32 # 40650 242.89 230.75 265.36 38500 264.76 251.52 289.25 40652 396.61 376.78 433.30 # 38500 211.30 200.74 230.85 # 40652 295.48 280.71 322.82 38505 110.35 104.83 120.55 40654 468.75 445.31 512.11 # 38505 67.51 64.13 73.75 # 40654 359.24 341.28 392.47 38510 430.56 409.03 470.38 40700 800.59 760.56 874.64 # 38510 359.70 341.72 392.98 40701 991.01 941.46 1,082.68 38520 392.14 372.53 428.41 40702 771.88 733.29 843.28 38525 355.30 337.54 388.17 40720 846.54 804.21 924.84 38530 456.92 434.07 499.18 40761 916.59 870.76 1,001.37 38542 438.38 416.46 478.93 40800 161.17 153.11 176.08 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 34 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 105.13 99.87 114.85 41019 442.99 420.84 483.97 40801 249.57 237.09 272.65 41100 136.86 130.02 149.52 # 40801 184.19 174.98 201.23 # 41100 93.05 88.40 101.66 40804 164.63 156.40 179.86 41105 137.34 130.47 150.04 # 40804 106.66 101.33 116.53 # 41105 94.50 89.78 103.25 40805 261.63 248.55 285.83 41108 117.34 111.47 128.19 # 40805 191.10 181.55 208.78 # 41108 75.79 72.00 82.80 40806 84.36 80.14 92.16 41110 168.93 160.48 184.55 # 40806 28.32 26.90 30.94 # 41110 110.63 105.10 120.87 40808 144.69 137.46 158.08 41112 267.52 254.14 292.26 # 40808 88.33 83.91 96.50 # 41112 209.55 199.07 228.93 40810 161.71 153.62 176.66 41113 293.87 279.18 321.06 # 40810 105.35 100.08 115.09 # 41113 233.32 221.65 254.90 40812 228.78 217.34 249.94 41114 544.01 516.81 594.33 # 40812 164.37 156.15 179.57 41115 196.47 186.65 214.65 40814 308.85 293.41 337.42 # 41115 124.97 118.72 136.53 # 40814 253.45 240.78 276.90 41116 261.29 248.23 285.46 40816 325.74 309.45 355.87 # 41116 183.67 174.49 200.66 # 40816 265.51 252.23 290.06 41120 879.67 835.69 961.04 40818 285.09 270.84 311.47 41130 1,093.15 1,038.49 1,194.26 # 40818 226.15 214.84 247.07 41135 1,835.68 1,743.90 2,005.49 40819 244.88 232.64 267.54 41140 1,880.04 1,786.04 2,053.95 # 40819 194.00 184.30 211.95 41145 2,360.78 2,242.74 2,579.15 40820 209.55 199.07 228.93 41150 1,866.47 1,773.15 2,039.12 # 40820 140.63 133.60 153.64 41153 2,028.91 1,927.46 2,216.58 40830 194.79 185.05 212.81 41155 2,532.36 2,405.74 2,766.60 # 40830 132.63 126.00 144.90 41250 184.56 175.33 201.63 40831 258.78 245.84 282.72 # 41250 120.15 114.14 131.26 # 40831 186.32 177.00 203.55 41251 191.81 182.22 209.55 40840 671.11 637.55 733.18 # 41251 139.96 132.96 152.90 # 40840 542.28 515.17 592.45 41252 251.48 238.91 274.75 40842 661.12 628.06 722.27 # 41252 181.26 172.20 198.03 # 40842 531.33 504.76 580.47 41500 369.53 351.05 403.71 40843 865.67 822.39 945.75 41510 339.58 322.60 370.99 # 40843 693.36 658.69 757.49 41512 523.91 497.71 572.37 40844 1,147.14 1,089.78 1,253.25 41520 279.58 265.60 305.44 # 40844 965.82 917.53 1,055.16 # 41520 212.27 201.66 231.91 40845 1,252.54 1,189.91 1,368.40 41530 2,518.48 2,392.56 2,751.44 # 40845 1,084.73 1,030.49 1,185.06 # 41530 342.87 325.73 374.59 41000 129.61 123.13 141.60 41800 181.04 171.99 197.79 # 41000 93.54 88.86 102.19 # 41800 106.64 101.31 116.51 41005 180.02 171.02 196.67 41805 186.96 177.61 204.25 # 41005 105.95 100.65 115.75 # 41805 134.79 128.05 147.26 41006 292.95 278.30 320.05 41806 275.73 261.94 301.23 # 41006 218.88 207.94 239.13 # 41806 211.96 201.36 231.56 41007 293.31 278.64 320.44 41822 231.65 220.07 253.08 # 41007 212.47 201.85 232.13 # 41822 148.55 141.12 162.29 41008 302.07 286.97 330.02 41823 345.39 328.12 377.34 # 41008 226.70 215.37 247.68 # 41823 266.48 253.16 291.13 41009 320.91 304.86 350.59 41825 164.72 156.48 179.95 # 41009 245.87 233.58 268.62 # 41825 105.46 100.19 115.22 41010 161.62 153.54 176.57 41826 232.76 221.12 254.29 # 41010 91.08 86.53 99.51 # 41826 170.28 161.77 186.04 41015 345.67 328.39 377.65 41827 346.51 329.18 378.56 # 41015 281.90 267.81 307.98 # 41827 253.75 241.06 277.22 41016 354.75 337.01 387.56 41828 248.80 236.36 271.81 # 41016 292.27 277.66 319.31 # 41828 184.71 175.47 201.79 41017 357.32 339.45 390.37 41830 312.65 297.02 341.57 # 41017 293.55 278.87 320.70 # 41830 234.39 222.67 256.07 41018 410.66 390.13 448.65 41872 292.86 278.22 319.95 # 41018 344.31 327.09 376.15 # 41872 217.49 206.62 237.61 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 99 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 297.37 282.50 324.88 42425 738.95 702.00 807.30 # 41874 213.95 203.25 233.74 42426 1,203.53 1,143.35 1,314.85 42000 127.73 121.34 139.54 42440 407.10 386.75 444.76 # 42000 86.83 82.49 94.86 42450 375.85 357.06 410.62 42100 121.78 115.69 133.04 # 42450 307.57 292.19 336.02 # 42100 92.15 87.54 100.67 42500 358.02 340.12 391.14 42104 168.99 160.54 184.62 # 42500 292.31 277.69 319.34 # 42104 115.85 110.06 126.57 42505 466.67 443.34 509.84 42106 214.24 203.53 234.06 # 42505 392.59 372.96 428.90 # 42106 151.43 143.86 165.44 42507 438.93 416.98 479.53 42107 374.87 356.13 409.55 42508 624.75 593.51 682.54 # 42107 293.06 278.41 320.17 42509 720.10 684.10 786.72 42120 824.14 782.93 900.37 42510 542.80 515.66 593.01 42140 200.95 190.90 219.54 42550 127.49 121.12 139.29 # 42140 129.77 123.28 141.77 # 42550 61.46 58.39 67.15 42145 602.02 571.92 657.71 42600 402.57 382.44 439.81 42160 194.91 185.16 212.93 # 42600 305.62 290.34 333.89 # 42160 129.21 122.75 141.16 42650 68.63 65.20 74.98 42180 200.25 190.24 218.78 # 42650 50.91 48.36 55.61 # 42180 157.74 149.85 172.33 42660 88.73 84.29 96.93 42182 275.07 261.32 300.52 # 42660 68.12 64.71 74.42 # 42182 230.30 218.79 251.61 42665 252.98 240.33 276.38 42200 762.24 724.13 832.75 # 42665 176.97 168.12 193.34 42205 812.80 772.16 887.98 42700 154.21 146.50 168.48 42210 914.44 868.72 999.03 # 42700 115.56 109.78 126.25 42215 597.31 567.44 652.56 42720 391.59 372.01 427.81 42220 465.70 442.42 508.78 # 42720 347.15 329.79 379.26 42225 793.63 753.95 867.04 42725 706.08 670.78 771.40 42226 789.84 750.35 862.90 42800 129.46 122.99 141.44 42227 767.36 728.99 838.34 # 42800 95.64 90.86 104.49 42235 626.62 595.29 684.58 42802 195.60 185.82 213.69 42260 701.30 666.24 766.18 # 42802 115.72 109.93 126.42 # 42260 589.22 559.76 643.72 42804 163.17 155.01 178.26 42280 129.20 122.74 141.15 # 42804 97.78 92.89 106.82 # 42280 89.59 85.11 97.88 42806 184.66 175.43 201.74 42281 167.07 158.72 182.53 # 42806 115.09 109.34 125.74 # 42281 129.71 123.22 141.70 42808 189.79 180.30 207.35 42300 170.76 162.22 186.55 # 42808 142.44 135.32 155.62 # 42300 129.85 123.36 141.86 42809 141.63 134.55 154.73 42305 372.56 353.93 407.02 # 42809 111.68 106.10 122.02 42310 133.05 126.40 145.36 42810 317.41 301.54 346.77 # 42310 105.99 100.69 115.79 # 42810 242.05 229.95 264.44 42320 205.47 195.20 224.48 42815 476.43 452.61 520.50 # 42320 152.33 144.71 166.42 42820 252.84 240.20 276.23 42330 191.37 181.80 209.07 42821 263.76 250.57 288.16 # 42330 141.45 134.38 154.54 42825 225.49 214.22 246.35 42335 304.40 289.18 332.56 42826 217.92 207.02 238.07 # 42335 221.30 210.24 241.78 42830 177.20 168.34 193.59 42340 383.83 364.64 419.34 42831 191.01 181.46 208.68 # 42340 291.71 277.12 318.69 42835 159.58 151.60 174.34 42400 89.75 85.26 98.05 42836 208.96 198.51 228.29 # 42400 50.78 48.24 55.48 42842 828.10 786.70 904.71 42405 253.18 240.52 276.60 42844 1,165.73 1,107.44 1,273.56 # 42405 197.78 187.89 216.07 42845 1,918.68 1,822.75 2,096.16 42408 375.76 356.97 410.52 42860 160.03 152.03 174.83 # 42408 283.00 268.85 309.18 42870 483.25 459.09 527.95 42409 270.55 257.02 295.57 42890 1,189.92 1,130.42 1,299.98 # 42409 191.32 181.75 209.01 42892 1,564.41 1,486.19 1,709.12 42410 540.92 513.87 590.95 42894 2,005.48 1,905.21 2,190.99 42415 980.18 931.17 1,070.85 42900 301.65 286.57 329.56 42420 1,124.35 1,068.13 1,228.35 42950 670.38 636.86 732.39 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 99 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 822.35 781.23 898.41 43245 170.19 161.68 185.93 42955 631.58 600.00 690.00 43246 228.19 216.78 249.30 42960 146.42 139.10 159.97 43247 182.09 172.99 198.94 42961 362.97 344.82 396.54 43248 172.12 163.51 188.04 42962 450.44 427.92 492.11 43249 158.42 150.50 173.08 42970 338.02 321.12 369.29 43250 170.27 161.76 186.02 42971 397.27 377.41 434.02 43251 198.14 188.23 216.46 42972 446.84 424.50 488.18 43255 257.96 245.06 281.82 43020 459.75 436.76 502.27 43256 231.78 220.19 253.22 43030 455.52 432.74 497.65 43257 285.27 271.01 311.66 43045 1,158.41 1,100.49 1,265.56 43258 243.03 230.88 265.51 43100 544.52 517.29 594.88 43259 277.14 263.28 302.77 43101 903.87 858.68 987.48 43260 317.24 301.38 346.59 43107 2,243.75 2,131.56 2,451.29 43261 333.46 316.79 364.31 43108 3,825.03 3,633.78 4,178.85 43262 391.70 372.12 427.94 43112 2,398.33 2,278.41 2,620.17 43263 387.45 368.08 423.29 43113 3,811.70 3,621.12 4,164.29 43264 470.34 446.82 513.84 43116 4,349.71 4,132.22 4,752.05 43265 527.89 501.50 576.73 43117 2,195.07 2,085.32 2,398.12 43267 390.09 370.59 426.18 43118 3,142.02 2,984.92 3,432.66 43268 396.21 376.40 432.86 43121 2,487.43 2,363.06 2,717.52 43269 434.26 412.55 474.43 43122 2,218.92 2,107.97 2,424.17 43271 391.38 371.81 427.58 43123 3,844.49 3,652.27 4,200.11 43272 390.73 371.19 426.87 43124 3,278.65 3,114.72 3,581.93 43273 118.41 112.49 129.36 43130 690.72 656.18 754.61 43279 1,099.87 1,044.88 1,201.61 43135 1,300.39 1,235.37 1,420.68 43280 916.40 870.58 1,001.17 43200 181.07 172.02 197.82 43300 539.17 512.21 589.04 # 43200 92.50 87.88 101.06 43305 972.11 923.50 1,062.03 43201 248.74 236.30 271.75 43310 1,353.87 1,286.18 1,479.11 # 43201 116.69 110.86 127.49 43312 1,495.77 1,420.98 1,634.13 43202 237.34 225.47 259.29 43313 2,389.00 2,269.55 2,609.98 # 43202 103.04 97.89 112.57 43314 2,731.27 2,594.71 2,983.92 43204 203.09 192.94 221.88 43320 1,191.58 1,132.00 1,301.80 43205 203.78 193.59 222.63 43324 1,156.24 1,098.43 1,263.19 43215 139.22 132.26 152.10 43325 1,138.37 1,081.45 1,243.67 43216 171.59 163.01 187.46 43326 1,157.35 1,099.48 1,264.40 # 43216 129.72 123.23 141.71 43330 1,116.38 1,060.56 1,219.64 43217 318.88 302.94 348.38 43331 1,207.05 1,146.70 1,318.71 # 43217 153.01 145.36 167.16 43340 1,159.93 1,101.93 1,267.22 43219 154.52 146.79 168.81 43341 1,273.37 1,209.70 1,391.16 43220 114.51 108.78 125.10 43350 991.86 942.27 1,083.61 43226 127.70 121.32 139.52 43351 1,159.19 1,101.23 1,266.41 43227 190.49 180.97 208.12 43352 947.33 899.96 1,034.95 43228 202.84 192.70 221.61 43360 2,032.26 1,930.65 2,220.25 43231 172.92 164.27 188.91 43361 2,276.78 2,162.94 2,487.38 43232 238.43 226.51 260.49 43400 1,398.18 1,328.27 1,527.51 43234 235.90 224.11 257.73 43401 1,324.34 1,258.12 1,446.84 # 43234 107.72 102.33 117.68 43405 1,280.77 1,216.73 1,399.24 43235 255.76 242.97 279.42 43410 875.99 832.19 957.02 # 43235 131.44 124.87 143.60 43415 1,492.29 1,417.68 1,630.33 43236 318.39 302.47 347.84 43420 878.71 834.77 959.99 # 43236 159.93 151.93 174.72 43425 1,310.65 1,245.12 1,431.89 43237 217.20 206.34 237.29 43450 136.11 129.30 148.70 43238 269.85 256.36 294.81 # 43450 80.07 76.07 87.48 43239 296.47 281.65 323.90 43453 252.23 239.62 275.56 # 43239 155.73 147.94 170.13 # 43453 87.01 82.66 95.06 43240 362.63 344.50 396.18 43456 508.82 483.38 555.89 43241 141.26 134.20 154.33 # 43456 140.69 133.66 153.71 43242 387.03 367.68 422.83 43458 331.38 314.81 362.03 43243 243.75 231.56 266.29 # 43458 164.54 156.31 179.76 43244 270.15 256.64 295.14 43460 199.84 189.85 218.33 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 99 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 1,881.92 1,787.82 2,055.99 44021 823.71 782.52 899.90 43500 655.48 622.71 716.12 44025 829.20 787.74 905.90 43501 1,128.63 1,072.20 1,233.03 44050 784.41 745.19 856.97 43502 1,278.01 1,214.11 1,396.23 44055 1,259.06 1,196.11 1,375.53 43510 809.50 769.03 884.38 44100 104.50 99.28 114.17 43520 592.05 562.45 646.82 44110 710.39 674.87 776.10 43600 97.14 92.28 106.12 44111 827.41 786.04 903.95 43605 696.16 661.35 760.55 44120 1,026.28 974.97 1,121.22 43610 822.49 781.37 898.58 44121 211.65 201.07 231.23 43611 1,023.77 972.58 1,118.47 44125 995.49 945.72 1,087.58 43620 1,670.76 1,587.22 1,825.30 44126 2,058.34 1,955.42 2,248.73 43621 1,906.26 1,810.95 2,082.59 44127 2,395.95 2,276.15 2,617.57 43622 1,933.41 1,836.74 2,112.25 44128 212.51 201.88 232.16 43631 1,223.52 1,162.34 1,336.69 44130 1,077.32 1,023.45 1,176.97 43632 1,676.15 1,592.34 1,831.19 44137 951.62 904.04 1,039.65 43633 1,593.34 1,513.67 1,740.72 44139 106.01 100.71 115.82 43634 1,760.12 1,672.11 1,922.93 44140 1,131.91 1,075.31 1,236.61 43635 98.09 93.19 107.17 44141 1,495.35 1,420.58 1,633.67 43640 983.72 934.53 1,074.71 44143 1,395.91 1,326.11 1,525.03 43641 992.56 942.93 1,084.37 44144 1,469.64 1,396.16 1,605.58 43644 1,458.18 1,385.27 1,593.06 44145 1,412.35 1,341.73 1,542.99 43645 1,559.78 1,481.79 1,704.06 44146 1,767.52 1,679.14 1,931.01 43651 544.20 516.99 594.54 44147 1,600.76 1,520.72 1,748.83 43652 637.95 606.05 696.96 44150 1,547.19 1,469.83 1,690.30 43653 464.13 440.92 507.06 44151 1,770.26 1,681.75 1,934.01 43752 38.59 36.66 42.16 44155 1,735.62 1,648.84 1,896.17 43760 281.09 267.04 307.10 44156 1,904.98 1,809.73 2,081.19 # 43760 45.97 43.67 50.22 44157 1,809.02 1,718.57 1,976.36 43761 111.20 105.64 121.49 44158 1,854.48 1,761.76 2,026.02 # 43761 98.96 94.01 108.11 44160 1,043.70 991.52 1,140.25 43770 931.29 884.73 1,017.44 44180 777.00 738.15 848.87 43771 1,062.78 1,009.64 1,161.09 44186 547.01 519.66 597.61 43772 803.74 763.55 878.08 44187 922.40 876.28 1,007.72 43773 1,063.60 1,010.42 1,161.98 44188 1,020.48 969.46 1,114.88 43774 805.05 764.80 879.52 44202 1,171.30 1,112.74 1,279.65 43800 780.45 741.43 852.64 44203 210.83 200.29 230.33 43810 846.47 804.15 924.77 44204 1,309.03 1,243.58 1,430.12 43820 1,100.14 1,045.13 1,201.90 44205 1,142.54 1,085.41 1,248.22 43825 1,088.97 1,034.52 1,189.70 44206 1,484.98 1,410.73 1,622.34 43830 577.70 548.82 631.14 44207 1,561.78 1,483.69 1,706.24 43831 481.23 457.17 525.75 44208 1,696.52 1,611.69 1,853.44 43832 891.15 846.59 973.58 44210 1,515.51 1,439.73 1,655.69 43840 1,115.82 1,060.03 1,219.03 44211 1,861.12 1,768.06 2,033.27 43843 1,061.60 1,008.52 1,159.80 44212 1,745.67 1,658.39 1,907.15 43845 1,644.04 1,561.84 1,796.12 44213 166.25 157.94 181.63 43846 1,369.15 1,300.69 1,495.79 44227 1,417.32 1,346.45 1,548.42 43847 1,496.62 1,421.79 1,635.06 44300 704.28 669.07 769.43 43848 1,623.91 1,542.71 1,774.12 44310 881.91 837.81 963.48 43850 1,360.32 1,292.30 1,486.15 44312 500.66 475.63 546.97 43855 1,421.12 1,350.06 1,552.57 44314 853.64 810.96 932.60 43860 1,381.05 1,312.00 1,508.80 44316 1,170.81 1,112.27 1,279.11 43865 1,436.42 1,364.60 1,569.29 44320 1,005.25 954.99 1,098.24 43870 590.71 561.17 645.35 44322 792.44 752.82 865.74 43880 1,348.94 1,281.49 1,473.71 44340 502.70 477.57 549.21 43886 277.68 263.80 303.37 44345 879.25 835.29 960.58 43887 259.56 246.58 283.57 44346 988.33 938.91 1,079.75 43888 367.66 349.28 401.67 44360 143.16 136.00 156.40 44005 921.68 875.60 1,006.94 44361 157.80 149.91 172.40 44010 724.11 687.90 791.09 44363 187.03 177.68 204.33 44015 125.83 119.54 137.47 44364 201.48 191.41 220.12 44020 814.48 773.76 889.82 44365 179.36 170.39 195.95 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 38 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 237.48 225.61 259.45 45005 203.47 193.30 222.30 44369 242.59 230.46 265.03 # 45005 127.46 121.09 139.25 44370 261.13 248.07 285.28 45020 452.94 430.29 494.83 44372 231.25 219.69 252.64 45100 238.88 226.94 260.98 44373 187.03 177.68 204.33 45108 291.12 276.56 318.04 44376 276.68 262.85 302.28 45110 1,559.62 1,481.64 1,703.89 44377 293.47 278.80 320.62 45111 915.47 869.70 1,000.16 44378 376.49 357.67 411.32 45112 1,612.62 1,531.99 1,761.79 44379 398.58 378.65 435.45 45113 1,651.20 1,568.64 1,803.94 44380 62.16 59.05 67.91 45114 1,508.64 1,433.21 1,648.19 44382 74.67 70.94 81.58 45116 1,356.22 1,288.41 1,481.67 44383 160.97 152.92 175.86 45119 1,654.73 1,571.99 1,807.79 44385 210.02 199.52 229.45 45120 1,320.28 1,254.27 1,442.41 # 44385 96.00 91.20 104.88 45121 1,445.05 1,372.80 1,578.72 44386 290.65 276.12 317.54 45123 937.41 890.54 1,024.12 # 44386 112.54 106.91 122.95 45126 2,446.60 2,324.27 2,672.91 44388 291.84 277.25 318.84 45130 917.04 871.19 1,001.87 # 44388 149.48 142.01 163.31 45135 1,121.28 1,065.22 1,225.00 44389 338.62 321.69 369.94 45136 1,554.13 1,476.42 1,697.88 # 44389 166.96 158.61 182.40 45150 331.65 315.07 362.33 44390 391.77 372.18 428.01 45160 832.66 791.03 909.68 # 44390 200.46 190.44 219.01 45170 650.24 617.73 710.39 44391 439.11 417.15 479.72 45190 564.13 535.92 616.31 # 44391 228.47 217.05 249.61 45300 88.82 84.38 97.04 44392 368.26 349.85 402.33 # 45300 43.09 40.94 47.08 # 44392 197.23 187.37 215.48 45303 674.01 640.31 736.36 44393 429.33 407.86 469.04 # 45303 73.99 70.29 80.83 # 44393 251.22 238.66 274.46 45305 144.30 137.09 157.65 44394 430.90 409.36 470.76 # 45305 66.04 62.74 72.15 # 44394 232.50 220.88 254.01 45307 161.82 153.73 176.79 44397 250.83 238.29 274.03 # 45307 83.88 79.69 91.64 44500 24.00 22.80 26.22 45308 147.75 140.36 161.41 44602 1,169.79 1,111.30 1,278.00 # 45308 71.09 67.54 77.67 44603 1,340.21 1,273.20 1,464.18 45309 165.58 157.30 180.90 44604 894.79 850.05 977.56 # 45309 81.84 77.75 89.41 44605 1,102.93 1,047.78 1,204.95 45315 179.34 170.37 195.93 44615 908.47 863.05 992.51 # 45315 93.67 88.99 102.34 44620 725.68 689.40 792.81 45317 174.32 165.60 190.44 44625 859.80 816.81 939.33 # 45317 98.95 94.00 108.10 44626 1,367.37 1,299.00 1,493.85 45320 174.61 165.88 190.76 44640 1,192.70 1,133.07 1,303.03 # 45320 93.77 89.08 102.44 44650 1,240.14 1,178.13 1,354.85 45321 90.87 86.33 99.28 44660 1,204.06 1,143.86 1,315.44 45327 105.89 100.60 115.69 44661 1,349.68 1,282.20 1,474.53 45330 114.31 108.59 124.88 44680 897.44 852.57 980.46 # 45330 55.37 52.60 60.49 44700 869.56 826.08 949.99 45331 145.17 137.91 158.60 44701 146.71 139.37 160.28 # 45331 67.23 63.87 73.45 44715 355.62 337.84 388.52 45332 238.10 226.20 260.13 44720 241.33 229.26 263.65 # 45332 98.64 93.71 107.77 44721 336.67 319.84 367.82 45333 239.53 227.55 261.68 44800 636.44 604.62 695.31 # 45333 98.14 93.23 107.21 44820 704.35 669.13 769.50 45334 149.03 141.58 162.82 44850 621.52 590.44 679.01 45335 204.70 194.47 223.64 44900 637.49 605.62 696.46 # 45335 81.99 77.89 89.57 44901 829.18 787.72 905.88 45337 127.49 121.12 139.29 # 44901 165.39 157.12 180.69 45338 268.45 255.03 293.28 44950 539.23 512.27 589.11 # 45338 127.70 121.32 139.52 44955 73.55 69.87 80.35 45339 280.83 266.79 306.81 44960 727.32 690.95 794.59 # 45339 169.07 160.62 184.71 44970 494.98 470.23 540.76 45340 362.63 344.50 396.18 45000 345.89 328.60 377.89 # 45340 103.36 98.19 112.92 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 39 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 142.24 135.13 155.40 46070 187.98 178.58 205.37 45342 217.74 206.85 237.88 46080 188.25 178.84 205.67 45345 158.03 150.13 172.65 # 46080 132.53 125.90 144.79 45355 181.94 172.84 198.77 46083 141.16 134.10 154.22 45378 339.38 322.41 370.77 # 46083 88.34 83.92 96.51 # 45378 195.74 185.95 213.84 46200 313.76 298.07 342.78 45378 53 114.31 108.59 124.88 # 46200 245.48 233.21 268.19 # 45378 53 55.37 52.60 60.49 46210 286.58 272.25 313.09 45379 430.80 409.26 470.65 # 46210 206.06 195.76 225.12 # 45379 245.28 233.02 267.97 46211 389.74 370.25 425.79 45380 407.54 387.16 445.23 # 46211 301.17 286.11 329.03 # 45380 235.88 224.09 257.70 46220 150.83 143.29 164.78 45381 396.39 376.57 433.06 # 46220 94.79 90.05 103.56 # 45381 223.43 212.26 244.10 46221 198.19 188.28 216.52 45382 536.78 509.94 586.43 # 46221 149.88 142.39 163.75 # 45382 301.67 286.59 329.58 46230 207.92 197.52 227.15 45383 486.87 462.53 531.91 # 46230 142.22 135.11 155.38 # 45383 303.61 288.43 331.69 46250 345.72 328.43 377.69 45384 401.35 381.28 438.47 # 46250 249.74 237.25 272.84 # 45384 245.14 232.88 267.81 46255 386.31 366.99 422.04 45385 460.45 437.43 503.04 # 46255 284.53 270.30 310.85 # 45385 280.09 266.09 306.00 46257 332.81 316.17 363.60 45386 561.78 533.69 613.74 46258 364.17 345.96 397.85 # 45386 240.67 228.64 262.94 46260 378.62 359.69 413.64 45387 313.75 298.06 342.77 46261 424.16 402.95 463.39 45391 270.91 257.36 295.96 46262 442.27 420.16 483.18 45392 343.49 326.32 375.27 46270 374.89 356.15 409.57 45395 1,685.06 1,600.81 1,840.93 # 46270 299.52 284.54 327.22 45397 1,828.75 1,737.31 1,997.91 46275 397.53 377.65 434.30 45400 974.02 925.32 1,064.12 # 46275 321.52 305.44 351.26 45402 1,304.23 1,239.02 1,424.87 46280 368.65 350.22 402.75 45500 426.38 405.06 465.82 46285 387.09 367.74 422.90 45505 466.89 443.55 510.08 # 46285 317.84 301.95 347.24 45520 101.89 96.80 111.32 46288 436.59 414.76 476.97 # 45520 32.96 31.31 36.01 46320 136.67 129.84 149.32 45540 899.50 854.53 982.71 # 46320 90.29 85.78 98.65 45541 770.65 732.12 841.94 46500 165.37 157.10 180.67 45550 1,236.43 1,174.61 1,350.80 # 46500 101.93 96.83 111.35 45560 609.72 579.23 666.11 46505 219.40 208.43 239.69 45562 935.27 888.51 1,021.79 # 46505 187.20 177.84 204.52 45563 1,354.17 1,286.46 1,479.43 46600 66.14 62.83 72.25 45800 1,051.66 999.08 1,148.94 # 46600 32.64 31.01 35.66 45805 1,189.65 1,130.17 1,299.70 46604 404.19 383.98 441.58 45820 1,045.96 993.66 1,142.71 # 46604 56.67 53.84 61.92 45825 1,256.26 1,193.45 1,372.47 46606 168.55 160.12 184.14 45900 164.90 156.66 180.16 # 46606 62.91 59.76 68.72 45905 139.35 132.38 152.24 46608 174.05 165.35 190.15 45910 165.33 157.06 180.62 # 46608 69.05 65.60 75.44 45915 254.57 241.84 278.12 46610 172.18 163.57 188.11 # 45915 185.32 176.05 202.46 # 46610 68.47 65.05 74.81 45990 92.74 88.10 101.32 46611 136.57 129.74 149.20 46020 206.87 196.53 226.01 # 46611 70.55 67.02 77.07 # 46020 182.39 173.27 199.26 46612 205.93 195.63 224.97 46030 103.25 98.09 112.80 # 46612 83.22 79.06 90.92 # 46030 72.65 69.02 79.37 46614 104.67 99.44 114.36 46040 402.01 381.91 439.20 # 46614 59.26 56.30 64.75 # 46040 326.64 310.31 356.86 46615 121.47 115.40 132.71 46045 337.90 321.01 369.16 # 46615 84.43 80.21 92.24 46050 142.10 135.00 155.25 46700 527.16 500.80 575.92 # 46050 76.40 72.58 83.47 46705 432.17 410.56 472.14 46060 371.25 352.69 405.59 46706 138.91 131.96 151.75 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 40 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 900.15 855.14 983.41 47142 3,879.73 3,685.74 4,238.60 46712 1,838.85 1,746.91 2,008.95 47143 301.07 286.02 328.92 46715 428.05 406.65 467.65 47144 451.59 429.01 493.36 46716 1,045.59 993.31 1,142.31 47145 451.59 429.01 493.36 46730 1,596.39 1,516.57 1,744.06 47146 287.17 272.81 313.73 46735 1,864.53 1,771.30 2,037.00 47147 335.06 318.31 366.06 46740 1,717.23 1,631.37 1,876.08 47300 934.48 887.76 1,020.92 46742 2,028.91 1,927.46 2,216.58 47350 1,147.11 1,089.75 1,253.21 46744 2,893.55 2,748.87 3,161.20 47360 1,563.94 1,485.74 1,708.60 46746 3,333.55 3,166.87 3,641.90 47361 2,573.73 2,445.04 2,811.80 46748 3,508.79 3,333.35 3,833.35 47362 1,191.61 1,132.03 1,301.83 46750 638.55 606.62 697.61 47370 1,048.91 996.46 1,145.93 46751 527.85 501.46 576.68 47371 1,067.18 1,013.82 1,165.89 46753 480.97 456.92 525.46 47380 1,227.70 1,166.32 1,341.27 46754 226.09 214.79 247.01 47381 1,251.33 1,188.76 1,367.07 # 46754 176.17 167.36 192.46 47382 778.74 739.80 850.77 46760 904.00 858.80 987.62 47400 1,789.38 1,699.91 1,954.90 46761 782.46 743.34 854.84 47420 1,122.93 1,066.78 1,226.80 46762 771.04 732.49 842.36 47425 1,134.46 1,077.74 1,239.40 46900 181.41 172.34 198.19 47460 1,070.36 1,016.84 1,169.37 # 46900 114.74 109.00 125.35 47480 711.28 675.72 777.08 46910 188.73 179.29 206.18 47490 478.01 454.11 522.23 # 46910 109.83 104.34 119.99 47500 96.98 92.13 105.95 46916 187.31 177.94 204.63 47505 37.46 35.59 40.93 # 46916 120.64 114.61 131.80 47510 453.64 430.96 495.60 46917 354.64 336.91 387.45 47511 572.28 543.67 625.22 # 46917 110.50 104.98 120.73 47525 507.15 481.79 554.06 46922 196.35 186.53 214.51 # 47525 115.18 109.42 125.83 # 46922 109.71 104.22 119.85 47530 1,234.45 1,172.73 1,348.64 46924 404.09 383.89 441.47 # 47530 340.69 323.66 372.21 # 46924 153.83 146.14 168.06 47550 145.01 137.76 158.42 46930 173.12 164.46 189.13 47552 310.93 295.38 339.69 # 46930 126.42 120.10 138.12 47553 312.20 296.59 341.08 46937 205.18 194.92 224.16 47554 454.88 432.14 496.96 # 46937 147.53 140.15 161.17 47555 374.33 355.61 408.95 46938 356.95 339.10 389.97 47556 423.53 402.35 462.70 # 46938 297.36 282.49 324.86 47560 234.24 222.53 255.91 46940 172.50 163.88 188.46 47561 253.89 241.20 277.38 # 46940 122.90 116.76 134.27 47562 616.71 585.87 673.75 46942 159.44 151.47 174.19 47563 631.33 599.76 689.72 # 46942 109.19 103.73 119.29 47564 730.27 693.76 797.82 46945 219.97 208.97 240.32 47570 651.69 619.11 711.98 # 46945 171.02 162.47 186.84 47600 887.66 843.28 969.77 46946 238.99 227.04 261.10 47605 819.99 778.99 895.84 # 46946 181.66 172.58 198.47 47610 1,052.83 1,000.19 1,150.22 46947 309.87 294.38 338.54 47612 1,064.08 1,010.88 1,162.51 47000 279.36 265.39 305.20 47620 1,155.10 1,097.35 1,261.95 # 47000 94.17 89.46 102.88 47630 518.37 492.45 566.32 47001 90.68 86.15 99.07 47700 873.28 829.62 954.06 47010 1,002.17 952.06 1,094.87 47701 1,503.34 1,428.17 1,642.40 47011 182.40 173.28 199.27 47711 1,306.92 1,241.57 1,427.81 47015 950.60 903.07 1,038.53 47712 1,675.43 1,591.66 1,830.41 47100 693.56 658.88 757.71 47715 1,097.90 1,043.01 1,199.46 47120 1,960.11 1,862.10 2,141.42 47720 947.69 900.31 1,035.36 47122 2,921.02 2,774.97 3,191.22 47721 1,119.31 1,063.34 1,222.84 47125 2,615.39 2,484.62 2,857.31 47740 1,081.58 1,027.50 1,181.63 47130 2,812.73 2,672.09 3,072.90 47741 1,225.64 1,164.36 1,339.01 47135 4,138.58 3,931.65 4,521.40 47760 1,854.64 1,761.91 2,026.20 47136 3,527.82 3,351.43 3,854.14 47765 2,457.75 2,334.86 2,685.09 47140 2,952.95 2,805.30 3,226.10 47780 2,030.28 1,928.77 2,218.09 47141 3,520.25 3,344.24 3,845.88 47785 2,651.97 2,519.37 2,897.28 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 41 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,319.77 1,253.78 1,441.85 49320 277.24 263.38 302.89 47801 934.09 887.39 1,020.50 49321 291.85 277.26 318.85 47802 1,266.63 1,203.30 1,383.80 49322 317.74 301.85 347.13 47900 1,141.21 1,084.15 1,246.77 49323 539.63 512.65 589.55 48000 1,585.57 1,506.29 1,732.23 49324 330.88 314.34 361.49 48001 1,949.01 1,851.56 2,129.29 49325 355.09 337.34 387.94 48020 975.74 926.95 1,065.99 49326 164.64 156.41 179.87 48100 740.63 703.60 809.14 49400 156.46 148.64 170.94 48102 472.65 449.02 516.37 # 49400 92.37 87.75 100.91 # 48102 240.11 228.10 262.32 49402 718.27 682.36 784.71 48105 2,403.98 2,283.78 2,626.35 49419 383.22 364.06 418.67 48120 926.07 879.77 1,011.74 49420 121.80 115.71 133.07 48140 1,311.73 1,246.14 1,433.06 49421 327.91 311.51 358.24 48145 1,362.32 1,294.20 1,488.33 49422 329.72 313.23 360.21 48146 1,552.83 1,475.19 1,696.47 49423 484.22 460.01 529.01 48148 1,031.44 979.87 1,126.85 # 49423 73.58 69.90 80.39 48150 2,624.21 2,493.00 2,866.95 49424 132.79 126.15 145.07 48152 2,425.97 2,304.67 2,650.37 # 49424 38.43 36.51 41.99 48153 2,620.73 2,489.69 2,863.14 49425 643.89 611.70 703.46 48154 2,432.40 2,310.78 2,657.40 49426 548.59 521.16 599.33 48155 1,505.98 1,430.68 1,645.28 49427 44.29 42.08 48.39 48400 95.86 91.07 104.73 49428 368.92 350.47 403.04 48500 942.67 895.54 1,029.87 49429 389.71 370.22 425.75 48510 895.44 850.67 978.27 49435 105.44 100.17 115.20 48511 806.16 765.85 880.73 49436 153.84 146.15 168.07 # 48511 197.44 187.57 215.71 49440 945.96 898.66 1,033.46 48520 915.34 869.57 1,000.01 # 49440 220.97 209.92 241.41 48540 1,094.32 1,039.60 1,195.54 49441 1,028.75 977.31 1,123.91 48545 1,108.88 1,053.44 1,211.46 # 49441 245.46 233.19 268.17 48547 1,496.32 1,421.50 1,634.73 49442 921.18 875.12 1,006.39 48548 1,399.97 1,329.97 1,529.47 # 49442 202.96 192.81 221.73 48551 204.63 194.40 223.56 49446 859.16 816.20 938.63 48552 202.13 192.02 220.82 # 49446 163.80 155.61 178.95 48554 2,066.61 1,963.28 2,257.77 49450 638.90 606.96 698.00 48556 1,032.61 980.98 1,128.13 # 49450 65.61 62.33 71.68 49000 649.88 617.39 710.00 49451 610.04 579.54 666.47 49002 858.90 815.96 938.35 # 49451 91.18 86.62 99.61 49010 808.62 768.19 883.42 49452 770.14 731.63 841.37 49020 1,336.63 1,269.80 1,460.27 # 49452 142.09 134.99 155.24 49021 768.92 730.47 840.04 49460 698.66 663.73 763.29 # 49021 166.64 158.31 182.06 # 49460 46.78 44.44 51.11 49040 837.49 795.62 914.96 49465 147.54 140.16 161.18 49041 786.84 747.50 859.63 # 49465 30.62 29.09 33.45 # 49041 197.12 187.26 215.35 49491 648.64 616.21 708.64 49060 938.24 891.33 1,025.03 49492 792.40 752.78 865.70 49061 772.44 733.82 843.89 49495 329.31 312.84 359.77 # 49061 182.40 173.28 199.27 49496 499.74 474.75 545.96 49062 635.71 603.92 694.51 49500 326.63 310.30 356.85 49080 148.34 140.92 162.06 49501 495.96 471.16 541.83 # 49080 66.54 63.21 72.69 49505 429.06 407.61 468.75 49081 138.51 131.58 151.32 49507 528.99 502.54 577.92 # 49081 62.50 59.38 68.29 49520 525.07 498.82 573.64 49180 150.16 142.65 164.05 49521 641.15 609.09 700.45 # 49180 85.43 81.16 93.33 49525 474.51 450.78 518.40 49203 1,020.24 969.23 1,114.61 49540 561.77 533.68 613.73 49204 1,304.25 1,239.04 1,424.90 49550 476.85 453.01 520.96 49205 1,494.04 1,419.34 1,632.24 49553 522.15 496.04 570.45 49215 1,873.05 1,779.40 2,046.31 49555 496.53 471.70 542.46 49220 812.67 772.04 887.85 49557 603.65 573.47 659.49 49250 484.24 460.03 529.03 49560 617.29 586.43 674.39 49255 658.48 625.56 719.39 49561 779.89 740.90 852.04 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 42 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 640.29 608.28 699.52 50360 2,117.36 2,011.49 2,313.21 49566 787.91 748.51 860.79 50365 2,385.10 2,265.85 2,605.73 49568 233.10 221.45 254.67 50370 989.54 940.06 1,081.07 49570 337.17 320.31 368.36 50380 1,668.89 1,585.45 1,823.27 49572 419.28 398.32 458.07 50382 1,140.67 1,083.64 1,246.19 49580 261.96 248.86 286.19 # 50382 274.93 261.18 300.36 49582 390.34 370.82 426.44 50384 982.00 932.90 1,072.84 49585 362.71 344.57 396.26 # 50384 250.25 237.74 273.40 49587 430.59 409.06 470.42 50385 1,113.11 1,057.45 1,216.07 49590 472.79 449.15 516.52 # 50385 234.17 222.46 255.83 49600 611.03 580.48 667.55 50386 722.92 686.77 789.79 49605 4,243.65 4,031.47 4,636.19 # 50386 176.68 167.85 193.03 49606 957.28 909.42 1,045.83 50387 526.13 499.82 574.79 49610 569.34 540.87 622.00 # 50387 99.71 94.72 108.93 49611 512.08 486.48 559.45 50389 305.02 289.77 333.24 49650 352.26 334.65 384.85 # 50389 54.76 52.02 59.82 49651 456.10 433.30 498.30 50390 96.98 92.13 105.95 49652 665.64 632.36 727.21 50391 122.77 116.63 134.12 49653 832.10 790.50 909.08 # 50391 98.62 93.69 107.74 49654 765.56 727.28 836.37 50392 177.27 168.41 193.67 49655 921.45 875.38 1,006.69 50393 216.27 205.46 236.28 49656 768.22 729.81 839.28 50394 95.61 90.83 104.45 49657 1,109.87 1,054.38 1,212.54 # 50394 48.27 45.86 52.74 49900 677.37 643.50 740.03 50395 178.41 169.49 194.91 49904 1,261.66 1,198.58 1,378.37 50396 115.05 109.30 125.70 49905 311.67 296.09 340.50 50398 471.02 447.47 514.59 50010 666.24 632.93 727.87 # 50398 73.58 69.90 80.39 50020 952.07 904.47 1,040.14 50400 1,127.29 1,070.93 1,231.57 50021 808.54 768.11 883.33 50405 1,367.31 1,298.94 1,493.78 # 50021 166.32 158.00 181.70 50500 1,090.79 1,036.25 1,191.69 50040 897.05 852.20 980.03 50520 1,009.23 958.77 1,102.59 50045 905.05 859.80 988.77 50525 1,263.97 1,200.77 1,380.89 50060 1,116.04 1,060.24 1,219.28 50526 1,325.54 1,259.26 1,448.15 50065 1,173.40 1,114.73 1,281.94 50540 1,105.02 1,049.77 1,207.24 50070 1,166.02 1,107.72 1,273.88 50541 899.58 854.60 982.79 50075 1,433.93 1,362.23 1,566.56 50542 1,141.23 1,084.17 1,246.80 50080 851.67 809.09 930.45 50543 1,456.55 1,383.72 1,591.28 50081 1,251.99 1,189.39 1,367.80 50544 1,228.67 1,167.24 1,342.33 50100 909.33 863.86 993.44 50545 1,318.55 1,252.62 1,440.51 50120 923.09 876.94 1,008.48 50546 1,167.65 1,109.27 1,275.66 50125 953.83 906.14 1,042.06 50547 1,399.10 1,329.15 1,528.52 50130 1,010.65 960.12 1,104.14 50548 1,329.84 1,263.35 1,452.85 50135 1,095.12 1,040.36 1,196.41 50551 356.54 338.71 389.52 50200 138.60 131.67 151.42 # 50551 293.09 278.44 320.21 50205 641.15 609.09 700.45 50553 372.69 354.06 407.17 50220 994.70 944.97 1,086.72 # 50553 309.88 294.39 338.55 50225 1,153.35 1,095.68 1,260.03 50555 406.43 386.11 444.03 50230 1,251.30 1,188.74 1,367.05 # 50555 339.12 322.16 370.48 50234 1,269.93 1,206.43 1,387.39 50557 414.54 393.81 452.88 50236 1,436.43 1,364.61 1,569.30 # 50557 344.33 327.11 376.18 50240 1,290.26 1,225.75 1,409.61 50561 470.41 446.89 513.92 50250 1,196.80 1,136.96 1,307.50 # 50561 393.44 373.77 429.84 50280 919.05 873.10 1,004.07 50562 578.71 549.77 632.24 50290 847.83 805.44 926.26 50570 491.37 466.80 536.82 50320 1,246.42 1,184.10 1,361.72 50572 534.20 507.49 583.61 50323 183.98 174.78 201.00 50574 564.99 536.74 617.25 50325 183.98 174.78 201.00 50575 714.62 678.89 780.72 50327 189.03 179.58 206.52 50576 564.09 535.89 616.27 50328 165.95 157.65 181.30 50580 604.40 574.18 660.31 50329 163.55 155.37 178.68 50590 873.89 830.20 954.73 50340 768.14 729.73 839.19 # 50590 547.63 520.25 598.29 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 99 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 3,209.09 3,048.64 3,505.94 50980 355.70 337.92 388.61 # 50592 356.15 338.34 389.09 51020 449.13 426.67 490.67 50593 4,143.09 3,935.94 4,526.33 51030 445.10 422.85 486.28 # 50593 453.40 430.73 495.34 51040 279.61 265.63 305.47 50600 913.22 867.56 997.69 51045 447.90 425.51 489.34 50605 879.11 835.15 960.42 51050 456.48 433.66 498.71 50610 930.13 883.62 1,016.16 51060 562.61 534.48 614.65 50620 883.53 839.35 965.25 51065 558.92 530.97 610.62 50630 861.78 818.69 941.49 51080 390.64 371.11 426.78 50650 1,007.60 957.22 1,100.80 51100 57.68 54.80 63.02 50660 1,114.73 1,058.99 1,217.84 # 51100 38.04 36.14 41.56 50684 163.25 155.09 178.35 51101 116.18 110.37 126.93 # 50684 47.94 45.54 52.37 # 51101 50.80 48.26 55.50 50686 87.98 83.58 96.12 51102 222.16 211.05 242.71 50688 76.33 72.51 83.39 # 51102 146.79 139.45 160.37 50690 93.97 89.27 102.66 51500 601.50 571.43 657.14 # 50690 67.88 64.49 74.16 51520 567.11 538.75 619.56 50700 901.21 856.15 984.57 51525 835.70 793.92 913.01 50715 1,064.91 1,011.66 1,163.41 51530 743.85 706.66 812.66 50722 926.13 879.82 1,011.79 51535 754.87 717.13 824.70 50725 1,061.23 1,008.17 1,159.40 51550 918.90 872.96 1,003.90 50727 484.24 460.03 529.03 51555 1,223.11 1,161.95 1,336.24 50728 668.59 635.16 730.43 51565 1,250.74 1,188.20 1,366.43 50740 1,042.95 990.80 1,139.42 51570 1,430.33 1,358.81 1,562.63 50750 1,133.86 1,077.17 1,238.75 51575 1,787.82 1,698.43 1,953.19 50760 1,057.40 1,004.53 1,155.21 51580 1,862.24 1,769.13 2,034.50 50770 1,099.35 1,044.38 1,201.04 51585 2,075.26 1,971.50 2,267.23 50780 1,060.09 1,007.09 1,158.15 51590 1,891.15 1,796.59 2,066.08 50782 1,040.45 988.43 1,136.69 51595 2,149.51 2,042.03 2,348.33 50783 1,078.79 1,024.85 1,178.58 51596 2,310.08 2,194.58 2,523.77 50785 1,177.65 1,118.77 1,286.59 51597 2,227.77 2,116.38 2,433.84 50800 892.48 847.86 975.04 51600 175.80 167.01 192.06 50810 1,173.96 1,115.26 1,282.55 # 51600 43.75 41.56 47.79 50815 1,191.73 1,132.14 1,301.96 51605 37.32 35.45 40.77 50820 1,269.27 1,205.81 1,386.68 51610 103.85 98.66 113.46 50825 1,612.57 1,531.94 1,761.73 # 51610 61.66 58.58 67.37 50830 1,751.56 1,663.98 1,913.58 51700 81.76 77.67 89.32 50840 1,199.69 1,139.71 1,310.67 # 51700 43.75 41.56 47.79 50845 1,215.71 1,154.92 1,328.16 51701 56.43 53.61 61.65 50860 920.79 874.75 1,005.96 # 51701 26.47 25.15 28.92 50900 810.09 769.59 885.03 51702 72.21 68.60 78.89 50920 857.13 814.27 936.41 # 51702 29.05 27.60 31.74 50930 1,040.51 988.48 1,136.75 51703 132.09 125.49 144.31 50940 861.39 818.32 941.07 # 51703 79.91 75.91 87.30 50945 957.22 909.36 1,045.76 51705 105.70 100.42 115.48 50947 1,357.11 1,289.25 1,482.64 # 51705 64.48 61.26 70.45 50948 1,260.62 1,197.59 1,377.23 51710 149.13 141.67 162.92 50951 372.46 353.84 406.92 # 51710 91.80 87.21 100.29 # 50951 305.79 290.50 334.08 51715 279.13 265.17 304.95 50953 393.36 373.69 429.74 # 51715 195.07 185.32 213.12 # 50953 336.03 319.23 367.11 51720 110.69 105.16 120.93 50955 434.54 412.81 474.73 # 51720 81.38 77.31 88.91 # 50955 363.04 344.89 396.62 51725 203.52 193.34 222.34 50957 423.43 402.26 462.60 51725 TC 128.57 122.14 140.46 # 50957 352.89 335.25 385.54 51725 26 74.95 71.20 81.88 50961 381.97 362.87 417.30 51726 294.51 279.78 321.75 # 50961 315.94 300.14 345.16 51726 TC 209.27 198.81 228.63 50970 370.41 351.89 404.67 51726 26 85.24 80.98 93.13 50972 356.68 338.85 389.68 51736 50.44 47.92 55.11 50974 472.49 448.87 516.20 51736 TC 19.82 18.83 21.65 50976 465.26 442.00 508.30 51736 26 30.62 29.09 33.45 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 44 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 80.43 76.41 87.87 52270 384.07 364.87 419.60 51741 TC 23.22 22.06 25.37 # 52270 180.20 171.19 196.87 51741 26 57.21 54.35 62.50 52275 525.75 499.46 574.38 51772 227.48 216.11 248.53 # 52275 247.15 234.79 270.01 51772 TC 148.08 140.68 161.78 52276 263.80 250.61 288.20 51772 26 79.41 75.44 86.76 52277 322.41 306.29 352.23 51784 187.17 177.81 204.48 52281 289.73 275.24 316.53 51784 TC 111.50 105.93 121.82 # 52281 152.52 144.89 166.62 51784 26 75.67 71.89 82.67 52282 332.82 316.18 363.61 51785 202.78 192.64 221.54 52283 271.19 257.63 296.27 51785 TC 126.96 120.61 138.70 # 52283 198.40 188.48 216.75 51785 26 75.81 72.02 82.82 52285 272.62 258.99 297.84 51792 210.70 200.17 230.20 # 52285 192.10 182.50 209.88 51792 TC 156.26 148.45 170.72 52290 242.69 230.56 265.14 51792 26 54.44 51.72 59.48 52300 278.74 264.80 304.52 51795 277.13 263.27 302.76 52301 292.52 277.89 319.57 51795 TC 201.14 191.08 219.74 52305 277.13 263.27 302.76 51795 26 75.99 72.19 83.02 52310 240.49 228.47 262.74 51797 136.87 130.03 149.53 # 52310 149.99 142.49 163.86 51797 TC 93.97 89.27 102.66 52315 426.33 405.01 465.76 51797 26 42.90 40.76 46.87 # 52315 273.02 259.37 298.28 51798 18.17 17.26 19.85 52317 895.32 850.55 978.13 51800 1,015.59 964.81 1,109.53 # 52317 346.82 329.48 378.90 51820 1,034.18 982.47 1,129.84 52318 472.74 449.10 516.47 51840 616.63 585.80 673.67 52320 245.22 232.96 267.90 51841 732.49 695.87 800.25 52325 319.15 303.19 348.67 51845 562.08 533.98 614.08 52327 503.87 478.68 550.48 51860 686.85 652.51 750.39 # 52327 261.67 248.59 285.88 51865 852.46 809.84 931.32 52330 726.96 690.61 794.20 51880 444.87 422.63 486.02 # 52330 262.52 249.39 286.80 51900 790.10 750.60 863.19 52332 448.80 426.36 490.31 51920 729.79 693.30 797.30 # 52332 154.11 146.40 168.36 51925 949.57 902.09 1,037.40 52334 254.77 242.03 278.33 51940 1,568.08 1,489.68 1,713.13 52341 289.16 274.70 315.91 51960 1,351.35 1,283.78 1,476.35 52342 314.49 298.77 343.59 51980 690.67 656.14 754.56 52343 349.96 332.46 382.33 51990 709.36 673.89 774.97 52344 379.33 360.36 414.41 51992 775.12 736.36 846.81 52345 404.66 384.43 442.09 52000 198.54 188.61 216.90 52346 456.90 434.06 499.17 # 52000 122.53 116.40 133.86 52351 311.67 296.09 340.50 52001 369.64 351.16 403.83 52352 365.98 347.68 399.83 # 52001 284.93 270.68 311.28 52353 421.20 400.14 460.16 52005 271.43 257.86 296.54 52354 389.22 369.76 425.22 # 52005 130.69 124.16 142.78 52355 464.20 440.99 507.14 52007 503.18 478.02 549.72 52400 475.46 451.69 519.44 # 52007 163.71 155.52 178.85 52402 267.70 254.32 292.47 52010 377.39 358.52 412.30 52450 451.93 429.33 493.73 # 52010 159.03 151.08 173.74 52500 472.10 448.50 515.78 52204 412.71 392.07 450.88 52601 806.87 766.53 881.51 # 52204 138.94 131.99 151.79 52630 430.54 409.01 470.36 52214 543.23 516.07 593.48 52640 291.98 277.38 318.99 # 52214 214.07 203.37 233.88 52647 2,016.45 1,915.63 2,202.97 52224 768.39 729.97 839.47 # 52647 626.70 595.37 684.68 # 52224 167.72 159.33 183.23 52648 2,061.38 1,958.31 2,252.06 52234 244.63 232.40 267.26 # 52648 669.05 635.60 730.94 52235 286.86 272.52 313.40 52649 956.49 908.67 1,044.97 52240 502.23 477.12 548.69 52700 420.31 399.29 459.18 52250 240.08 228.08 262.29 53000 143.12 135.96 156.35 52260 207.18 196.82 226.34 53010 280.32 266.30 306.25 52265 396.26 376.45 432.92 53020 95.78 90.99 104.64 # 52265 156.00 148.20 170.43 53025 62.79 59.65 68.60 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 99 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 379.26 360.30 414.35 53852 2,223.13 2,111.97 2,428.77 53060 165.93 157.63 181.27 # 53852 601.81 571.72 657.48 # 53060 147.89 140.50 161.58 54000 147.75 140.36 161.41 53080 419.14 398.18 457.91 # 54000 102.66 97.53 112.16 53085 597.48 567.61 652.75 54001 182.53 173.40 199.41 53200 150.43 142.91 164.35 # 54001 132.93 126.28 145.22 # 53200 137.86 130.97 150.62 54015 301.08 286.03 328.93 53210 748.46 711.04 817.70 54050 111.60 106.02 121.92 53215 909.84 864.35 994.00 # 54050 89.70 85.22 98.00 53220 435.84 414.05 476.16 54055 106.65 101.32 116.52 53230 581.59 552.51 635.39 # 54055 82.82 78.68 90.48 53235 618.64 587.71 675.87 54056 116.40 110.58 127.17 53240 414.28 393.57 452.61 # 54056 92.57 87.94 101.13 53250 384.21 365.00 419.75 54057 127.56 121.18 139.36 53260 190.58 181.05 208.21 # 54057 86.98 82.63 95.02 # 53260 169.64 161.16 185.33 54060 173.12 164.46 189.13 53265 211.23 200.67 230.77 # 54060 121.91 115.81 133.18 # 53265 178.38 169.46 194.88 54065 190.80 181.26 208.45 53270 194.14 184.43 212.09 # 54065 149.25 141.79 163.06 # 53270 174.50 165.78 190.65 54100 174.01 165.31 190.11 53275 257.67 244.79 281.51 # 54100 111.20 105.64 121.49 53400 777.65 738.77 849.59 54105 263.72 250.53 288.11 53405 856.86 814.02 936.12 # 54105 208.33 197.91 227.60 53410 957.19 909.33 1,045.73 54110 605.81 575.52 661.85 53415 1,104.95 1,049.70 1,207.16 54111 783.97 744.77 856.49 53420 786.54 747.21 859.29 54112 920.43 874.41 1,005.57 53425 922.18 876.07 1,007.48 54115 433.32 411.65 473.40 53430 921.02 874.97 1,006.22 # 54115 406.27 385.96 443.85 53431 1,129.41 1,072.94 1,233.88 54120 612.85 582.21 669.54 53440 853.40 810.73 932.34 54125 791.09 751.54 864.27 53442 750.89 713.35 820.35 54130 1,171.47 1,112.90 1,279.84 53444 776.28 737.47 848.09 54135 1,488.94 1,414.49 1,626.66 53445 856.33 813.51 935.54 54150 159.29 151.33 174.03 53446 625.20 593.94 683.03 # 54150 95.52 90.74 104.35 53447 791.95 752.35 865.20 54160 220.44 209.42 240.83 53448 1,254.59 1,191.86 1,370.64 # 54160 140.88 133.84 153.92 53449 594.69 564.96 649.70 54161 191.02 181.47 208.69 53450 394.74 375.00 431.25 54162 256.94 244.09 280.70 53460 443.89 421.70 484.96 # 54162 189.94 180.44 207.51 53500 715.26 679.50 781.43 54163 209.27 198.81 228.63 53502 469.24 445.78 512.65 54164 183.94 174.74 200.95 53505 471.69 448.11 515.33 54200 103.82 98.63 113.42 53510 614.37 583.65 671.20 # 54200 80.31 76.29 87.73 53515 775.77 736.98 847.53 54205 519.43 493.46 567.48 53520 538.72 511.78 588.55 54220 202.06 191.96 220.75 53600 82.92 78.77 90.59 # 54220 131.85 125.26 144.05 # 53600 63.60 60.42 69.48 54230 93.73 89.04 102.40 53601 80.07 76.07 87.48 # 54230 77.95 74.05 85.16 # 53601 53.01 50.36 57.91 54231 136.00 129.20 148.58 53605 64.19 60.98 70.13 # 54231 115.06 109.31 125.71 53620 118.35 112.43 129.29 54235 86.53 82.20 94.53 # 53620 86.47 82.15 94.47 # 54235 71.39 67.82 77.99 53621 111.34 105.77 121.64 54240 96.96 92.11 105.93 # 53621 71.72 68.13 78.35 54240 TC 31.02 29.47 33.89 53660 69.01 65.56 75.39 54240 26 65.95 62.65 72.05 # 53660 40.34 38.32 44.07 54250 122.88 116.74 134.25 53661 68.72 65.28 75.07 54250 TC 10.98 10.43 11.99 # 53661 39.74 37.75 43.41 54250 26 111.89 106.30 122.25 53665 37.49 35.62 40.96 54300 630.79 599.25 689.14 53850 2,306.54 2,191.21 2,519.89 54304 739.50 702.53 807.91 # 53850 553.16 525.50 604.33 54308 704.03 668.83 769.15 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 MAINE - MEDICARE CARRIER 31142 PAGE 46 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 812.40 771.78 887.55 55040 324.42 308.20 354.43 54316 985.60 936.32 1,076.77 55041 489.18 464.72 534.43 54318 706.54 671.21 771.89 55060 362.93 344.78 396.50 54322 770.61 732.08 841.89 55100 203.59 193.41 222.42 54324 958.27 910.36 1,046.91 # 55100 153.67 145.99 167.89 54326 901.90 856.81 985.33 55110 369.53 351.05 403.71 54328 914.23 868.52 998.80 55120 338.77 321.83 370.10 54332 998.75 948.81 1,091.13 55150 468.56 445.13 511.90 54336 1,132.30 1,075.69 1,237.04 55175 347.69 330.31 379.86 54340 547.69 520.31 598.36 55180 662.49 629.37 723.78 54344 943.51 896.33 1,030.78 55200 460.60 437.57 503.21 54348 1,003.74 953.55 1,096.58 # 55200 266.39 253.07 291.03 54352 1,414.20 1,343.49 1,545.01 55250 404.38 384.16 441.78 54360 709.81 674.32 775.47 # 55250 217.26 206.40 237.36 54380 786.62 747.29 859.38 55300 177.37 168.50 193.78 54385 950.01 902.51 1,037.89 55400 489.38 464.91 534.65 54390 1,159.96 1,101.96 1,267.25 55450 362.16 344.05 395.66 54400 519.24 493.28 567.27 # 55450 247.18 234.82 270.04 54401 632.60 600.97 691.12 55500 359.96 341.96 393.25 54405 791.26 751.70 864.46 55520 370.36 351.84 404.62 54406 712.52 676.89 778.42 55530 340.42 323.40 371.91 54408 767.21 728.85 838.18 55535 412.53 391.90 450.69 54410 841.37 799.30 919.20 55540 449.63 427.15 491.22 54411 997.34 947.47 1,089.59 55550 408.22 387.81 445.98 54415 510.75 485.21 557.99 55600 410.63 390.10 448.62 54416 684.94 650.69 748.29 55605 486.87 462.53 531.91 54417 875.11 831.35 956.05 55650 693.65 658.97 757.82 54420 690.38 655.86 754.24 55680 327.19 310.83 357.45 54430 625.03 593.78 682.85 55700 219.32 208.35 239.60 54435 403.59 383.41 440.92 # 55700 134.30 127.59 146.73 54450 70.80 67.26 77.35 55705 262.01 248.91 286.25 # 54450 57.92 55.02 63.27 55706 370.12 351.61 404.35 54500 73.82 70.13 80.65 55720 446.47 424.15 487.77 54505 206.60 196.27 225.71 55725 569.17 540.71 621.82 54512 520.31 494.29 568.43 55801 1,061.53 1,008.45 1,159.72 54520 313.85 298.16 342.88 55810 1,285.53 1,221.25 1,404.44 54522 564.49 536.27 616.71 55812 1,579.68 1,500.70 1,725.81 54530 490.65 466.12 536.04 55815 1,733.72 1,647.03 1,894.08 54535 715.27 679.51 781.44 55821 853.80 811.11 932.78 54550 474.12 450.41 517.97 55831 925.65 879.37 1,011.28 54560 648.02 615.62 707.96 55840 1,311.38 1,245.81 1,432.68 54600 438.16 416.25 478.69 55842 1,405.72 1,335.43 1,535.74 54620 294.44 279.72 321.68 55845 1,609.26 1,528.80 1,758.12 54640 449.25 426.79 490.81 55860 856.54 813.71 935.77 54650 689.10 654.65 752.85 55862 1,081.66 1,027.58 1,181.72 54660 342.63 325.50 374.33 55865 1,312.15 1,246.54 1,433.52 54670 390.88 371.34 427.04 55866 1,709.24 1,623.78 1,867.35 54680 762.54 724.41 833.07 55870 169.32 160.85 184.98 54690 616.51 585.68 673.53 # 55870 141.30 134.24 154.38 54692 752.39 714.77 821.99 55873 1,115.56 1,059.78 1,218.75 54700 203.76 193.57 222.61 55875 742.23 705.12 810.89 54800 129.02 122.57 140.96 55876 134.68 127.95 147.14 54830 355.70 337.92 388.61 # 55876 102.79 97.65 112.30 54840 312.39 296.77 341.29 55920 420.15 399.14 459.01 54860 403.84 383.65 441.20 56405 94.97 90.22 103.75 54861 547.00 519.65 597.60 # 56405 93.03 88.38 101.64 54865 343.32 326.15 375.07 56420 108.77 103.33 118.83 54900 737.10 700.25 805.29 # 56420 81.07 77.02 88.57 54901 1,044.66 992.43 1,141.29 56440 161.68 153.60 176.64 55000 115.37 109.60 126.04 56441 131.68 125.10 143.87 # 55000 81.87 77.78 89.45 # 56441 124.92 118.67 136.47 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 99 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 43.01 40.86 46.99 57200 260.67 247.64 284.79 56501 113.21 107.55 123.68 57210 323.88 307.69 353.84 # 56501 99.03 94.08 108.19 57220 281.25 267.19 307.27 56515 194.37 184.65 212.35 57230 353.08 335.43 385.74 # 56515 173.11 164.45 189.12 57240 591.97 562.37 646.73 56605 73.22 69.56 79.99 57250 579.62 550.64 633.24 # 56605 54.54 51.81 59.58 57260 722.25 686.14 789.06 56606 33.96 32.26 37.10 57265 805.43 765.16 879.93 # 56606 26.88 25.54 29.37 57267 242.44 230.32 264.87 56620 433.72 412.03 473.83 57268 424.83 403.59 464.13 56625 524.54 498.31 573.06 57270 709.15 673.69 774.74 56630 769.39 730.92 840.56 57280 863.06 819.91 942.90 56631 979.23 930.27 1,069.81 57282 449.66 427.18 491.26 56632 1,132.93 1,076.28 1,237.72 57283 611.93 581.33 668.53 56633 1,004.67 954.44 1,097.61 57284 747.67 710.29 816.83 56634 1,060.90 1,007.86 1,159.04 57285 599.30 569.34 654.74 56637 1,254.87 1,192.13 1,370.95 57287 626.12 594.81 684.03 56640 1,250.80 1,188.26 1,366.50 57288 659.12 626.16 720.08 56700 163.60 155.42 178.73 57289 692.69 658.06 756.77 56740 262.40 249.28 286.67 57291 479.75 455.76 524.12 56800 215.78 204.99 235.74 57292 736.82 699.98 804.98 56805 1,020.69 969.66 1,115.11 57295 436.37 414.55 476.73 56810 231.91 220.31 253.36 57296 845.05 802.80 923.22 56820 97.23 92.37 106.23 57300 470.15 446.64 513.64 # 56820 75.97 72.17 83.00 57305 787.45 748.08 860.29 56821 130.23 123.72 142.28 57307 880.63 836.60 962.09 # 56821 103.17 98.01 112.71 57308 561.50 533.43 613.44 57000 168.74 160.30 184.35 57310 438.41 416.49 478.96 57010 379.36 360.39 414.45 57311 500.95 475.90 547.29 57020 83.70 79.52 91.45 57320 498.96 474.01 545.11 # 57020 73.40 69.73 80.19 57330 710.33 674.81 776.03 57022 147.41 140.04 161.05 57335 1,036.72 984.88 1,132.61 57023 276.15 262.34 301.69 57400 120.95 114.90 132.14 57061 98.39 93.47 107.49 57410 94.98 90.23 103.76 # 57061 84.54 80.31 92.36 57415 141.22 134.16 154.28 57065 168.31 159.89 183.87 57420 102.30 97.19 111.77 # 57065 150.60 143.07 164.53 # 57420 80.72 76.68 88.18 57100 77.65 73.77 84.84 57421 137.92 131.02 150.67 # 57100 58.97 56.02 64.42 # 57421 110.23 104.72 120.43 57105 118.37 112.45 129.32 57423 825.68 784.40 902.06 # 57105 109.35 103.88 119.46 57425 870.83 827.29 951.38 57106 418.15 397.24 456.83 57452 96.27 91.46 105.18 57107 1,245.01 1,182.76 1,360.17 # 57452 81.77 77.68 89.33 57109 1,423.86 1,352.67 1,555.57 57454 136.67 129.84 149.32 57110 800.40 760.38 874.44 # 57454 122.18 116.07 133.48 57111 1,438.29 1,366.38 1,571.34 57455 126.60 120.27 138.31 57112 1,529.40 1,452.93 1,670.87 # 57455 99.86 94.87 109.10 57120 452.53 429.90 494.39 57456 119.58 113.60 130.64 57130 158.53 150.60 173.19 # 57456 93.17 88.51 101.79 # 57130 142.10 135.00 155.25 57460 258.51 245.58 282.42 57135 170.12 161.61 185.85 # 57460 146.75 139.41 160.32 # 57135 153.37 145.70 167.56 57461 290.73 276.19 317.62 57150 44.27 42.06 48.37 # 57461 169.95 161.45 185.67 # 57150 26.88 25.54 29.37 57500 114.33 108.61 124.90 57155 376.20 357.39 411.00 # 57500 66.34 63.02 72.47 57160 67.37 64.00 73.60 57505 88.12 83.71 96.27 # 57160 43.21 41.05 47.21 # 57505 79.11 75.15 86.42 57170 60.86 57.82 66.49 57510 117.05 111.20 127.88 # 57170 43.79 41.60 47.84 # 57510 103.20 98.04 112.75 57180 123.56 117.38 134.99 57511 127.12 120.76 138.87 # 57180 94.25 89.54 102.97 # 57511 115.52 109.74 126.20 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 99 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 125.51 119.23 137.11 58353 965.73 917.44 1,055.06 # 57513 116.17 110.36 126.91 # 58353 195.65 185.87 213.75 57520 269.14 255.68 294.03 58356 1,768.96 1,680.51 1,932.59 # 57520 240.15 228.14 262.36 # 58356 313.50 297.83 342.50 57522 230.92 219.37 252.28 58400 395.80 376.01 432.41 # 57522 213.20 202.54 232.92 58410 711.80 676.21 777.64 57530 302.47 287.35 330.45 58520 694.82 660.08 759.09 57531 1,511.59 1,436.01 1,651.41 58540 806.69 766.36 881.31 57540 690.89 656.35 754.80 58541 760.46 722.44 830.81 57545 729.34 692.87 796.80 58542 846.08 803.78 924.35 57550 358.04 340.14 391.16 58543 860.23 817.22 939.80 57555 530.44 503.92 579.51 58544 930.05 883.55 1,016.08 57556 506.51 481.18 553.36 58545 794.62 754.89 868.12 57558 109.59 104.11 119.73 58546 1,007.77 957.38 1,100.99 # 57558 99.61 94.63 108.82 58548 1,573.58 1,494.90 1,719.14 57700 268.02 254.62 292.81 58550 783.83 744.64 856.34 57720 269.02 255.57 293.91 58552 866.50 823.18 946.66 57800 52.88 50.24 57.78 58553 1,013.06 962.41 1,106.77 # 57800 43.22 41.06 47.22 58554 1,162.68 1,104.55 1,270.23 58100 97.02 92.17 106.00 58555 211.91 201.31 231.51 # 58100 78.67 74.74 85.95 # 58555 170.68 162.15 186.47 58110 43.54 41.36 47.56 58558 287.03 272.68 313.58 # 58110 37.42 35.55 40.88 # 58558 240.65 228.62 262.91 58120 219.30 208.34 239.59 58559 309.70 294.22 338.35 # 58120 190.96 181.41 208.62 58560 350.11 332.60 382.49 58140 810.43 769.91 885.40 58561 495.79 471.00 541.65 58145 479.25 455.29 523.58 58562 304.04 288.84 332.17 58146 1,033.18 981.52 1,128.75 # 58562 262.50 249.38 286.79 58150 879.31 835.34 960.64 58563 1,573.20 1,494.54 1,718.72 58152 1,109.55 1,054.07 1,212.18 # 58563 309.70 294.22 338.35 58180 844.82 802.58 922.97 58565 1,673.23 1,589.57 1,828.01 58200 1,163.04 1,104.89 1,270.62 # 58565 391.37 371.80 427.57 58210 1,549.76 1,472.27 1,693.11 58570 816.78 775.94 892.33 58240 2,442.43 2,320.31 2,668.36 58571 898.95 854.00 982.10 58260 733.20 696.54 801.02 58572 1,016.61 965.78 1,110.65 58262 819.55 778.57 895.36 58573 1,153.34 1,095.67 1,260.02 58263 883.23 839.07 964.93 58600 320.97 304.92 350.66 58267 938.68 891.75 1,025.51 58605 291.61 277.03 318.58 58270 785.86 746.57 858.56 58611 70.31 66.79 76.81 58275 874.52 830.79 955.41 58615 220.22 209.21 240.59 58280 935.99 889.19 1,022.57 58660 596.94 567.09 652.15 58285 1,175.41 1,116.64 1,284.14 58661 574.33 545.61 627.45 58290 1,028.51 977.08 1,123.64 58662 627.57 596.19 685.62 58291 1,117.77 1,061.88 1,221.16 58670 323.08 306.93 352.97 58292 1,178.23 1,119.32 1,287.22 58671 322.94 306.79 352.81 58293 1,223.58 1,162.40 1,336.76 58672 660.73 627.69 721.84 58294 1,087.08 1,032.73 1,187.64 58673 718.64 682.71 785.12 58301 84.54 80.31 92.36 58700 675.40 641.63 737.87 # 58301 61.35 58.28 67.02 58720 634.91 603.16 693.63 58321 68.77 65.33 75.13 58740 774.26 735.55 845.88 # 58321 44.94 42.69 49.09 58750 806.27 765.96 880.85 58322 76.76 72.92 83.86 58752 812.00 771.40 887.11 # 58322 53.25 50.59 58.18 58760 728.57 692.14 795.96 58323 16.88 16.04 18.45 58770 749.11 711.65 818.40 # 58323 11.40 10.83 12.45 58800 280.88 266.84 306.87 58340 110.31 104.79 120.51 # 58800 262.52 249.39 286.80 # 58340 52.66 50.03 57.53 58805 356.85 339.01 389.86 58345 247.85 235.46 270.78 58820 274.73 260.99 300.14 58346 404.68 384.45 442.12 58822 624.57 593.34 682.34 58350 83.72 79.53 91.46 58823 777.68 738.80 849.62 # 58350 68.26 64.85 74.58 # 58823 166.06 157.76 181.42 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 99 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 617.07 586.22 674.15 59412 91.32 86.75 99.76 58900 364.27 346.06 397.97 59414 81.24 77.18 88.76 58920 621.29 590.23 678.76 59425 382.73 363.59 418.13 58925 647.83 615.44 707.76 # 59425 303.18 288.02 331.22 58940 442.67 420.54 483.62 59426 684.85 650.61 748.20 58943 991.85 942.26 1,083.60 # 59426 536.70 509.87 586.35 58950 945.13 897.87 1,032.55 59430 122.41 116.29 133.73 58951 1,221.25 1,160.19 1,334.22 # 59430 111.14 105.58 121.42 58952 1,376.95 1,308.10 1,504.32 59510 1,741.42 1,654.35 1,902.50 58953 1,708.80 1,623.36 1,866.86 59514 806.95 766.60 881.59 58954 1,855.24 1,762.48 2,026.85 59515 952.16 904.55 1,040.23 58956 1,188.88 1,129.44 1,298.86 59525 429.85 408.36 469.61 58957 1,314.96 1,249.21 1,436.59 59610 1,619.21 1,538.25 1,768.99 58958 1,461.72 1,388.63 1,596.92 59612 763.32 725.15 833.92 58960 816.48 775.66 892.01 59614 854.82 812.08 933.89 58970 199.00 189.05 217.41 59618 1,821.64 1,730.56 1,990.14 # 58970 178.71 169.77 195.24 59620 885.85 841.56 967.79 58976 226.96 215.61 247.95 59622 1,031.92 980.32 1,127.37 # 58976 200.22 190.21 218.74 59812 271.81 258.22 296.95 59000 111.33 105.76 121.62 # 59812 254.10 241.40 277.61 # 59000 71.39 67.82 77.99 59820 320.60 304.57 350.26 59001 163.31 155.14 178.41 # 59820 299.02 284.07 326.68 59012 180.17 171.16 196.83 59821 326.57 310.24 356.78 59015 136.24 129.43 148.84 # 59821 303.70 288.52 331.80 # 59015 117.24 111.38 128.09 59830 377.90 359.01 412.86 59020 60.30 57.29 65.88 59840 188.15 178.74 205.55 59020 TC 26.90 25.56 29.39 # 59840 182.35 173.23 199.21 59020 26 33.41 31.74 36.50 59841 328.21 311.80 358.57 59025 40.46 38.44 44.21 # 59841 310.50 294.98 339.23 59025 TC 13.56 12.88 14.81 59850 338.57 321.64 369.89 59025 26 26.90 25.56 29.39 59851 347.34 329.97 379.47 59030 100.40 95.38 109.69 59852 487.41 463.04 532.50 59050 44.84 42.60 48.99 59855 361.15 343.09 394.55 59051 37.11 35.25 40.54 59856 426.87 405.53 466.36 59070 348.55 331.12 380.79 59857 511.37 485.80 558.67 # 59070 261.92 248.82 286.14 59866 211.52 200.94 231.08 59072 433.68 412.00 473.80 59870 405.14 384.88 442.61 59074 331.16 314.60 361.79 59871 117.90 112.01 128.81 # 59074 259.66 246.68 283.68 60000 135.46 128.69 147.99 59076 424.67 403.44 463.96 # 60000 124.19 117.98 135.68 59100 719.97 683.97 786.57 60100 102.16 97.05 111.61 59120 687.92 653.52 751.55 # 60100 76.07 72.27 83.11 59121 690.90 656.36 754.81 60200 560.54 532.51 612.39 59130 806.56 766.23 881.16 60210 600.79 570.75 656.36 59135 816.12 775.31 891.61 60212 863.15 819.99 942.99 59136 763.17 725.01 833.76 60220 658.96 626.01 719.91 59140 341.17 324.11 372.73 60225 791.38 751.81 864.58 59150 668.23 634.82 730.04 60240 839.76 797.77 917.44 59151 653.12 620.46 713.53 60252 1,134.95 1,078.20 1,239.93 59160 185.18 175.92 202.31 60254 1,464.40 1,391.18 1,599.86 # 59160 156.84 149.00 171.35 60260 947.45 900.08 1,035.09 59200 64.07 60.87 70.00 60270 1,194.83 1,135.09 1,305.35 # 59200 39.92 37.92 43.61 60271 915.85 870.06 1,000.57 59300 166.60 158.27 182.01 60280 375.62 356.84 410.37 # 59300 128.92 122.47 140.84 60281 503.59 478.41 550.17 59320 135.02 128.27 147.51 60300 94.20 89.49 102.91 59325 213.58 202.90 233.34 # 60300 46.86 44.52 51.20 59350 245.95 233.65 268.70 60500 870.16 826.65 950.65 59400 1,537.95 1,461.05 1,680.21 60502 1,092.38 1,037.76 1,193.42 59409 681.49 647.42 744.53 60505 1,199.89 1,139.90 1,310.89 59410 790.74 751.20 863.88 60512 213.99 203.29 233.78 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 99 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 895.61 850.83 978.45 61519 2,452.36 2,329.74 2,679.20 60521 1,025.60 974.32 1,120.47 61520 3,149.66 2,992.18 3,441.01 60522 1,238.44 1,176.52 1,353.00 61521 2,636.43 2,504.61 2,880.30 60540 946.58 899.25 1,034.14 61522 1,806.90 1,716.56 1,974.04 60545 1,078.01 1,024.11 1,177.73 61524 1,706.37 1,621.05 1,864.21 60600 1,255.98 1,193.18 1,372.16 61526 2,879.79 2,735.80 3,146.17 60605 1,582.19 1,503.08 1,728.54 61530 2,444.28 2,322.07 2,670.38 60650 1,055.23 1,002.47 1,152.84 61531 987.12 937.76 1,078.42 61000 95.69 90.91 104.55 61533 1,247.73 1,185.34 1,363.14 61001 93.29 88.63 101.92 61534 1,343.98 1,276.78 1,468.30 61020 109.77 104.28 119.92 61535 803.18 763.02 877.47 61026 110.29 104.78 120.50 61536 2,144.32 2,037.10 2,342.67 61050 95.06 90.31 103.86 61537 1,986.85 1,887.51 2,170.64 61055 122.88 116.74 134.25 61538 2,133.38 2,026.71 2,330.72 61070 69.90 66.41 76.37 61539 1,941.65 1,844.57 2,121.26 61105 361.51 343.43 394.94 61540 1,816.96 1,726.11 1,985.03 61107 270.18 256.67 295.17 61541 1,752.34 1,664.72 1,914.43 61108 720.60 684.57 787.26 61542 1,896.43 1,801.61 2,071.85 61120 591.25 561.69 645.94 61543 1,772.42 1,683.80 1,936.37 61140 1,025.77 974.48 1,120.65 61544 1,468.84 1,395.40 1,604.71 61150 1,099.65 1,044.67 1,201.37 61545 2,614.15 2,483.44 2,855.96 61151 796.01 756.21 869.64 61546 1,894.03 1,799.33 2,069.23 61154 1,026.67 975.34 1,121.64 61548 1,294.35 1,229.63 1,414.07 61156 1,024.90 973.66 1,119.71 61550 854.14 811.43 933.14 61210 315.47 299.70 344.66 61552 1,122.84 1,066.70 1,226.71 61215 393.43 373.76 429.82 61556 1,354.89 1,287.15 1,480.22 61250 691.60 657.02 755.57 61557 1,384.94 1,315.69 1,513.04 61253 766.23 727.92 837.11 61558 1,453.09 1,380.44 1,587.51 61304 1,353.84 1,286.15 1,479.07 61559 1,983.04 1,883.89 2,166.47 61305 1,636.51 1,554.68 1,787.88 61563 1,604.75 1,524.51 1,753.19 61312 1,699.17 1,614.21 1,856.34 61564 1,997.25 1,897.39 2,182.00 61313 1,620.08 1,539.08 1,769.94 61566 1,849.23 1,756.77 2,020.29 61314 1,497.90 1,423.01 1,636.46 61567 2,086.96 1,982.61 2,280.00 61315 1,705.77 1,620.48 1,863.55 61570 1,511.83 1,436.24 1,651.68 61316 74.38 70.66 81.26 61571 1,639.38 1,557.41 1,791.02 61320 1,577.55 1,498.67 1,723.47 61575 1,973.58 1,874.90 2,156.14 61321 1,731.03 1,644.48 1,891.15 61576 3,156.26 2,998.45 3,448.22 61322 1,923.99 1,827.79 2,101.96 61580 2,069.05 1,965.60 2,260.44 61323 1,957.23 1,859.37 2,138.28 61581 2,323.39 2,207.22 2,538.30 61330 1,358.64 1,290.71 1,484.32 61582 2,353.00 2,235.35 2,570.65 61332 1,563.54 1,485.36 1,708.16 61583 2,383.24 2,264.08 2,603.69 61333 1,584.77 1,505.53 1,731.36 61584 2,324.84 2,208.60 2,539.89 61334 1,033.56 981.88 1,129.16 61585 2,479.68 2,355.70 2,709.06 61340 1,174.10 1,115.40 1,282.71 61586 1,777.41 1,688.54 1,941.82 61343 1,816.22 1,725.41 1,984.22 61590 2,641.06 2,509.01 2,885.36 61345 1,680.12 1,596.11 1,835.53 61591 2,657.26 2,524.40 2,903.06 61440 1,644.84 1,562.60 1,796.99 61592 2,615.83 2,485.04 2,857.80 61450 1,562.90 1,484.76 1,707.47 61595 1,991.55 1,891.97 2,175.77 61458 1,660.72 1,577.68 1,814.33 61596 2,201.81 2,091.72 2,405.48 61460 1,691.07 1,606.52 1,847.50 61597 2,379.19 2,260.23 2,599.26 61470 1,566.83 1,488.49 1,711.76 61598 2,120.00 2,014.00 2,316.10 61480 1,522.67 1,446.54 1,663.52 61600 1,791.17 1,701.61 1,956.85 61490 1,570.50 1,491.98 1,715.78 61601 1,940.89 1,843.85 2,120.43 61500 1,112.99 1,057.34 1,215.94 61605 1,884.07 1,789.87 2,058.35 61501 954.87 907.13 1,043.20 61606 2,495.35 2,370.58 2,726.17 61510 1,791.04 1,701.49 1,956.71 61607 2,326.75 2,210.41 2,541.97 61512 2,115.54 2,009.76 2,311.22 61608 2,687.99 2,553.59 2,936.63 61514 1,569.80 1,491.31 1,715.01 61609 520.93 494.88 569.11 61516 1,531.72 1,455.13 1,673.40 61610 1,594.97 1,515.22 1,742.50 61517 74.34 70.62 81.21 61611 402.57 382.44 439.81 61518 2,276.50 2,162.68 2,487.08 61612 1,432.92 1,361.27 1,565.46 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 99 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 2,623.63 2,492.45 2,866.32 62141 945.45 898.18 1,032.91 61615 2,083.35 1,979.18 2,276.06 62142 719.50 683.53 786.06 61616 2,726.19 2,589.88 2,978.36 62143 843.20 801.04 921.20 61618 1,075.92 1,022.12 1,175.44 62145 1,158.65 1,100.72 1,265.83 61619 1,243.97 1,181.77 1,359.04 62146 995.31 945.54 1,087.37 61623 506.32 481.00 553.15 62147 1,182.49 1,123.37 1,291.88 61624 1,009.40 958.93 1,102.77 62148 106.42 101.10 116.27 61626 824.58 783.35 900.85 62160 162.77 154.63 177.82 61630 1,147.79 1,090.40 1,253.96 62161 1,243.46 1,181.29 1,358.48 61635 1,257.28 1,194.42 1,373.58 62162 1,549.88 1,472.39 1,693.25 61680 1,871.01 1,777.46 2,044.08 62163 999.86 949.87 1,092.35 61682 3,520.79 3,344.75 3,846.46 62164 1,659.05 1,576.10 1,812.52 61684 2,342.50 2,225.38 2,559.19 62165 1,293.33 1,228.66 1,412.96 61686 3,769.01 3,580.56 4,117.64 62180 1,305.81 1,240.52 1,426.60 61690 1,783.96 1,694.76 1,948.97 62190 740.74 703.70 809.26 61692 3,044.61 2,892.38 3,326.24 62192 790.74 751.20 863.88 61697 3,458.27 3,285.36 3,778.16 62194 324.89 308.65 354.95 61698 3,731.90 3,545.31 4,077.11 62200 1,127.30 1,070.94 1,231.58 61700 2,873.14 2,729.48 3,138.90 62201 966.92 918.57 1,056.36 61702 3,246.10 3,083.80 3,546.37 62220 830.41 788.89 907.22 61703 1,104.31 1,049.09 1,206.45 62223 852.06 809.46 930.88 61705 2,121.39 2,015.32 2,317.62 62225 405.10 384.85 442.58 61708 1,871.40 1,777.83 2,044.50 62230 685.80 651.51 749.24 61710 1,683.73 1,599.54 1,839.47 62252 83.56 79.38 91.29 61711 2,158.07 2,050.17 2,357.70 62252 TC 43.51 41.33 47.53 61720 970.94 922.39 1,060.75 62252 26 40.05 38.05 43.76 61735 1,197.68 1,137.80 1,308.47 62256 474.81 451.07 518.73 61750 1,153.50 1,095.83 1,260.20 62258 922.83 876.69 1,008.19 61751 1,122.30 1,066.19 1,226.12 62263 552.16 524.55 603.23 61760 1,270.29 1,206.78 1,387.80 # 62263 333.80 317.11 364.68 61770 1,265.19 1,201.93 1,382.22 62264 339.74 322.75 371.16 61790 697.02 662.17 761.50 # 62264 205.75 195.46 224.78 61791 904.96 859.71 988.67 62267 221.14 210.08 241.59 61795 212.51 201.88 232.16 # 62267 149.32 141.85 163.13 61796 656.63 623.80 717.37 62268 400.46 380.44 437.51 61797 181.45 172.38 198.24 # 62268 240.71 228.67 262.97 61798 656.63 623.80 717.37 62269 434.29 412.58 474.47 61799 250.81 238.27 274.01 # 62269 245.88 233.59 268.63 61800 127.01 120.66 138.76 62270 132.32 125.70 144.56 61850 801.41 761.34 875.54 # 62270 69.83 66.34 76.29 61860 1,281.29 1,217.23 1,399.81 62272 154.63 146.90 168.94 61863 1,237.58 1,175.70 1,352.06 # 62272 73.14 69.48 79.90 61864 319.49 303.52 349.05 62273 142.98 135.83 156.20 61867 1,843.60 1,751.42 2,014.13 # 62273 100.14 95.13 109.40 61868 489.21 464.75 534.46 62280 259.28 246.32 283.27 61870 971.64 923.06 1,061.52 # 62280 135.61 128.83 148.15 61875 951.59 904.01 1,039.61 62281 241.34 229.27 263.66 61880 446.00 423.70 487.26 # 62281 131.52 124.94 143.68 61885 515.29 489.53 562.96 62282 248.73 236.29 271.73 61886 651.60 619.02 711.87 # 62282 120.87 114.83 132.05 61888 326.13 309.82 356.29 62284 188.93 179.48 206.40 62000 735.33 698.56 803.34 # 62284 81.68 77.60 89.24 62005 1,020.10 969.10 1,114.47 62287 481.94 457.84 526.52 62010 1,243.98 1,181.78 1,359.05 62290 278.15 264.24 303.88 62100 1,329.54 1,263.06 1,452.52 # 62290 152.54 144.91 166.65 62115 1,184.17 1,124.96 1,293.70 62291 260.62 247.59 284.73 62116 1,458.35 1,385.43 1,593.24 # 62291 147.25 139.89 160.87 62117 1,587.25 1,507.89 1,734.07 62292 436.63 414.80 477.02 62120 1,506.51 1,431.18 1,645.86 62294 694.82 660.08 759.09 62121 1,371.88 1,303.29 1,498.78 62310 183.42 174.25 200.39 62140 860.37 817.35 939.95 # 62310 90.66 86.13 99.05 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 99 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 161.49 153.42 176.43 63180 1,156.45 1,098.63 1,263.42 # 62311 75.18 71.42 82.13 63182 1,237.08 1,175.23 1,351.51 62318 196.16 186.35 214.30 63185 942.16 895.05 1,029.31 # 62318 91.49 86.92 99.96 63190 1,082.76 1,028.62 1,182.91 62319 177.61 168.73 194.04 63191 1,022.44 971.32 1,117.02 # 62319 85.50 81.23 93.41 63194 1,234.64 1,172.91 1,348.85 62350 334.02 317.32 364.92 63195 1,240.94 1,178.89 1,355.72 62351 699.62 664.64 764.34 63196 1,459.22 1,386.26 1,594.20 62355 250.14 237.63 273.27 63197 1,391.49 1,321.92 1,520.21 62360 242.53 230.40 264.96 63198 1,551.70 1,474.12 1,695.24 62361 332.12 315.51 362.84 63199 1,666.23 1,582.92 1,820.36 62362 349.61 332.13 381.95 63200 1,243.58 1,181.40 1,358.61 62365 275.86 262.07 301.38 63250 2,422.66 2,301.53 2,646.76 62367 33.30 31.64 36.39 63251 2,507.12 2,381.76 2,739.02 # 62367 21.71 20.62 23.71 63252 2,507.94 2,382.54 2,739.92 62368 47.76 45.37 52.18 63265 1,377.55 1,308.67 1,504.97 # 62368 33.91 32.21 37.04 63266 1,416.96 1,346.11 1,548.03 63001 1,017.92 967.02 1,112.07 63267 1,140.41 1,083.39 1,245.90 63003 1,024.48 973.26 1,119.25 63268 1,149.22 1,091.76 1,255.52 63005 971.90 923.31 1,061.81 63270 1,696.48 1,611.66 1,853.41 63011 918.98 873.03 1,003.98 63271 1,706.42 1,621.10 1,864.27 63012 988.97 939.52 1,080.45 63272 1,572.54 1,493.91 1,718.00 63015 1,220.75 1,159.71 1,333.67 63273 1,487.00 1,412.65 1,624.55 63016 1,258.76 1,195.82 1,375.19 63275 1,480.56 1,406.53 1,617.51 63017 1,024.65 973.42 1,119.43 63276 1,474.64 1,400.91 1,611.05 63020 967.60 919.22 1,057.10 63277 1,294.37 1,229.65 1,414.10 63030 803.24 763.08 877.54 63278 1,269.21 1,205.75 1,386.61 63035 171.43 162.86 187.29 63280 1,748.15 1,660.74 1,909.85 63040 1,177.07 1,118.22 1,285.95 63281 1,728.47 1,642.05 1,888.36 63042 1,101.72 1,046.63 1,203.62 63282 1,630.68 1,549.15 1,781.52 63043 389.76 370.27 425.81 63283 1,545.91 1,468.61 1,688.90 63044 354.43 336.71 387.22 63285 2,147.45 2,040.08 2,346.09 63045 1,052.65 1,000.02 1,150.02 63286 2,138.91 2,031.96 2,336.75 63046 1,007.54 957.16 1,100.73 63287 2,259.17 2,146.21 2,468.14 63047 918.20 872.29 1,003.13 63290 2,288.64 2,174.21 2,500.34 63048 185.27 176.01 202.41 63295 273.97 260.27 299.31 63050 1,267.19 1,203.83 1,384.40 63300 1,527.14 1,450.78 1,668.40 63051 1,435.94 1,364.14 1,568.76 63301 1,722.63 1,636.50 1,881.98 63055 1,355.64 1,287.86 1,481.04 63302 1,710.61 1,625.08 1,868.84 63056 1,252.75 1,190.11 1,368.63 63303 1,795.84 1,706.05 1,961.96 63057 283.14 268.98 309.33 63304 1,895.11 1,800.35 2,070.40 63064 1,484.51 1,410.28 1,621.82 63305 1,942.80 1,845.66 2,122.51 63066 174.91 166.16 191.08 63306 2,022.38 1,921.26 2,209.45 63075 1,155.08 1,097.33 1,261.93 63307 1,893.60 1,798.92 2,068.76 63076 218.46 207.54 238.67 63308 283.38 269.21 309.59 63077 1,275.87 1,212.08 1,393.89 63600 722.32 686.20 789.13 63078 174.46 165.74 190.60 63610 1,124.64 1,068.41 1,228.67 63081 1,488.47 1,414.05 1,626.16 # 63610 388.70 369.27 424.66 63082 235.90 224.11 257.73 63615 958.61 910.68 1,047.28 63085 1,602.62 1,522.49 1,750.86 63620 656.63 623.80 717.37 63086 168.36 159.94 183.93 63621 208.59 198.16 227.88 63087 2,044.07 1,941.87 2,233.15 63650 358.43 340.51 391.59 63088 230.26 218.75 251.56 63655 699.67 664.69 764.39 63090 1,677.14 1,593.28 1,832.27 63660 374.99 356.24 409.68 63091 158.70 150.77 173.39 63685 338.74 321.80 370.07 63101 1,912.49 1,816.87 2,089.40 63688 303.38 288.21 331.44 63102 1,904.76 1,809.52 2,080.95 63700 1,018.73 967.79 1,112.96 63103 253.72 241.03 277.18 63702 1,144.43 1,087.21 1,250.29 63170 1,274.73 1,210.99 1,392.64 63704 1,277.57 1,213.69 1,395.74 63172 1,146.57 1,089.24 1,252.63 63706 1,482.41 1,408.29 1,619.53 63173 1,412.55 1,341.92 1,543.21 63707 752.00 714.40 821.56 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 53 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 914.61 868.88 999.21 64484 115.74 109.95 126.44 63710 911.74 866.15 996.07 # 64484 60.98 57.93 66.62 63740 771.93 733.33 843.33 64505 87.54 83.16 95.63 63741 505.51 480.23 552.26 # 64505 74.01 70.31 80.86 63744 528.15 501.74 577.00 64508 119.58 113.60 130.64 63746 459.98 436.98 502.53 # 64508 61.28 58.22 66.95 64400 90.88 86.34 99.29 64510 119.32 113.35 130.35 # 64400 55.77 52.98 60.93 # 64510 60.06 57.06 65.62 64402 93.38 88.71 102.02 64517 146.04 138.74 159.55 # 64402 63.43 60.26 69.30 # 64517 105.78 100.49 115.56 64405 88.64 84.21 96.84 64520 155.43 147.66 169.81 # 64405 65.13 61.87 71.15 # 64520 67.82 64.43 74.09 64408 101.91 96.81 111.33 64530 161.18 153.12 176.09 # 64408 78.07 74.17 85.30 # 64530 80.02 76.02 87.42 64410 117.91 112.01 128.81 64550 13.43 12.76 14.67 # 64410 69.92 66.42 76.38 # 64550 8.28 7.87 9.05 64412 116.44 110.62 127.21 64553 172.90 164.26 188.90 # 64412 62.01 58.91 67.75 # 64553 137.47 130.60 150.19 64413 98.29 93.38 107.39 64555 182.91 173.76 199.82 # 64413 68.02 64.62 74.31 # 64555 135.24 128.48 147.75 64415 111.34 105.77 121.64 64560 181.53 172.45 198.32 # 64415 66.25 62.94 72.38 # 64560 139.34 132.37 152.23 64416 82.38 78.26 90.00 64561 973.89 925.20 1,063.98 64417 112.18 106.57 122.56 # 64561 381.28 362.22 416.55 # 64417 65.48 62.21 71.54 64565 144.45 137.23 157.81 64418 113.91 108.21 124.44 # 64565 103.54 98.36 113.11 # 64418 64.95 61.70 70.96 64573 493.36 468.69 538.99 64420 134.16 127.45 146.57 64575 245.09 232.84 267.77 # 64420 58.47 55.55 63.88 64577 299.82 284.83 327.55 64421 197.82 187.93 216.12 64580 253.29 240.63 276.72 # 64421 80.26 76.25 87.69 64581 741.22 704.16 809.78 64425 110.51 104.98 120.73 64585 281.47 267.40 307.51 # 64425 83.14 78.98 90.83 # 64585 139.12 132.16 151.98 64430 132.70 126.07 144.98 64590 265.86 252.57 290.46 # 64430 78.27 74.36 85.51 # 64590 156.03 148.23 170.46 64435 123.09 116.94 134.48 64595 271.97 258.37 297.13 # 64435 74.78 71.04 81.70 # 64595 122.53 116.40 133.86 64445 115.38 109.61 126.05 64600 338.24 321.33 369.53 # 64445 71.58 68.00 78.20 # 64600 185.90 176.61 203.10 64446 82.68 78.55 90.33 64605 477.59 453.71 521.77 64447 63.43 60.26 69.30 # 64605 295.30 280.54 322.62 64448 73.26 69.60 80.04 64610 579.72 550.73 633.34 64449 82.11 78.00 89.70 # 64610 410.63 390.10 448.62 64450 88.37 83.95 96.54 64612 132.30 125.69 144.54 # 64450 63.89 60.70 69.81 # 64612 117.17 111.31 128.01 64455 45.39 43.12 49.59 64613 130.37 123.85 142.43 # 64455 36.38 34.56 39.74 # 64613 111.05 105.50 121.33 64470 219.41 208.44 239.71 64614 146.18 138.87 159.70 # 64470 92.19 87.58 100.72 # 64614 123.63 117.45 135.07 64472 96.58 91.75 105.51 64620 229.73 218.24 250.98 # 64472 59.22 56.26 64.70 # 64620 145.99 138.69 159.49 64475 195.63 185.85 213.73 64622 273.80 260.11 299.13 # 64475 72.27 68.66 78.96 # 64622 154.95 147.20 169.28 64476 80.71 76.67 88.17 64623 101.19 96.13 110.55 # 64476 44.32 42.10 48.42 # 64623 44.18 41.97 48.27 64479 233.17 221.51 254.74 64626 319.75 303.76 349.32 # 64479 109.17 103.71 119.27 # 64626 204.13 193.92 223.01 64480 118.51 112.58 129.47 64627 137.45 130.58 150.17 # 64480 71.49 67.92 78.11 # 64627 51.78 49.19 56.57 64483 226.04 214.74 246.95 64630 200.75 190.71 219.32 # 64483 95.92 91.12 104.79 # 64630 168.87 160.43 184.49 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 54 FSY09 LOCALITY FEE SCHEDULE FOR AREA 99 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 74.76 71.02 81.67 64823 647.98 615.58 707.92 # 64632 64.46 61.24 70.43 64831 570.56 542.03 623.33 64640 196.56 186.73 214.74 64832 301.63 286.55 329.53 # 64640 154.37 146.65 168.65 64834 633.58 601.90 692.19 64650 56.91 54.06 62.17 64835 686.62 652.29 750.13 # 64650 35.01 33.26 38.25 64836 686.52 652.19 750.02 64653 66.33 63.01 72.46 64837 334.74 318.00 365.70 # 64653 43.79 41.60 47.84 64840 785.43 746.16 858.08 64680 258.16 245.25 282.04 64856 864.89 821.65 944.90 # 64680 141.25 134.19 154.32 64857 904.49 859.27 988.16 64681 334.55 317.82 365.49 64858 1,038.68 986.75 1,134.76 # 64681 190.58 181.05 208.21 64859 227.01 215.66 248.01 64702 388.97 369.52 424.95 64861 1,172.95 1,114.30 1,281.45 64704 285.95 271.65 312.40 64862 1,149.78 1,092.29 1,256.13 64708 402.41 382.29 439.63 64864 752.98 715.33 822.63 64712 466.03 442.73 509.14 64865 991.31 941.74 1,083.00 64713 650.30 617.79 710.46 64866 1,029.04 977.59 1,124.23 64714 559.66 531.68 611.43 64868 902.17 857.06 985.62 64716 441.86 419.77 482.74 64870 889.48 845.01 971.76 64718 473.91 450.21 517.74 64872 106.55 101.22 116.40 64719 328.52 312.09 358.90 64874 156.80 148.96 171.30 64721 345.98 328.68 377.98 64876 171.43 162.86 187.29 # 64721 344.69 327.46 376.58 64885 981.20 932.14 1,071.96 64722 283.83 269.64 310.09 64886 1,163.47 1,105.30 1,271.10 64726 249.67 237.19 272.77 64890 931.68 885.10 1,017.87 64727 163.48 155.31 178.61 64891 966.27 917.96 1,055.65 64732 320.67 304.64 350.34 64892 905.25 859.99 988.99 64734 347.95 330.55 380.13 64893 953.96 906.26 1,042.20 64736 329.84 313.35 360.35 64895 1,122.72 1,066.58 1,226.57 64738 388.59 369.16 424.53 64896 1,235.79 1,174.00 1,350.10 64740 388.86 369.42 424.83 64897 1,085.44 1,031.17 1,185.85 64742 399.40 379.43 436.34 64898 1,183.18 1,124.02 1,292.62 64744 347.68 330.30 379.85 64901 533.90 507.21 583.29 64746 377.98 359.08 412.94 64902 613.84 583.15 670.62 64752 428.74 407.30 468.40 64905 867.10 823.75 947.31 64755 766.78 728.44 837.71 64907 1,138.24 1,081.33 1,243.53 64760 406.26 385.95 443.84 64910 694.13 659.42 758.33 64761 384.99 365.74 420.60 64911 840.45 798.43 918.19 64763 461.91 438.81 504.63 65091 496.66 471.83 542.60 64766 534.75 508.01 584.21 65093 494.95 470.20 540.73 64771 498.53 473.60 544.64 65101 572.11 543.50 625.03 64772 478.56 454.63 522.82 65103 598.06 568.16 653.38 64774 346.90 329.56 378.99 65105 660.37 627.35 721.45 64776 333.35 316.68 364.18 65110 966.35 918.03 1,055.73 64778 162.52 154.39 177.55 65112 1,136.75 1,079.91 1,241.90 64782 393.70 374.02 430.12 65114 1,184.49 1,125.27 1,294.06 64783 194.39 184.67 212.37 65125 349.96 332.46 382.33 64784 612.50 581.88 669.16 # 65125 224.99 213.74 245.80 64786 918.54 872.61 1,003.50 65130 566.78 538.44 619.21 64787 223.31 212.14 243.96 65135 577.31 548.44 630.71 64788 324.91 308.66 354.96 65140 629.22 597.76 687.42 64790 698.48 663.56 763.09 65150 454.71 431.97 496.77 64792 907.42 862.05 991.36 65155 664.06 630.86 725.49 64795 166.10 157.80 181.47 65175 510.03 484.53 557.21 64802 519.75 493.76 567.82 65205 45.14 42.88 49.31 64804 791.83 752.24 865.08 # 65205 36.45 34.63 39.82 64809 744.86 707.62 813.76 65210 55.16 52.40 60.26 64818 577.14 548.28 630.52 # 65210 43.89 41.70 47.96 64820 640.15 608.14 699.36 65220 46.14 43.83 50.40 64821 576.65 547.82 629.99 # 65220 35.83 34.04 39.15 64822 569.67 541.19 622.37 65222 60.66 57.63 66.27 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 99 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 48.10 45.70 52.56 65875 488.53 464.10 533.72 65235 547.39 520.02 598.02 65880 515.34 489.57 563.01 65260 751.29 713.73 820.79 65900 757.09 719.24 827.13 65265 846.61 804.28 924.92 65920 612.04 581.44 668.66 65270 205.47 195.20 224.48 65930 504.41 479.19 551.07 # 65270 112.07 106.47 122.44 66020 143.87 136.68 157.18 65272 382.39 363.27 417.76 # 66020 102.97 97.82 112.49 # 65272 271.92 258.32 297.07 66030 126.74 120.40 138.46 65273 299.01 284.06 326.67 # 66030 85.84 81.55 93.78 65275 432.51 410.88 472.51 66130 550.32 522.80 601.22 # 65275 356.18 338.37 389.13 # 66130 454.99 432.24 497.08 65280 524.73 498.49 573.26 66150 671.31 637.74 733.40 65285 820.38 779.36 896.26 66155 669.42 635.95 731.34 65286 541.46 514.39 591.55 66160 763.26 725.10 833.87 # 65286 385.58 366.30 421.25 66165 655.60 622.82 716.24 65290 384.61 365.38 420.19 66170 924.24 878.03 1,009.73 65400 519.07 493.12 567.09 66172 1,161.26 1,103.20 1,268.68 # 65400 463.35 440.18 506.21 66180 924.06 877.86 1,009.54 65410 112.56 106.93 122.97 66185 581.05 552.00 634.80 # 65410 83.89 79.70 91.66 66220 567.06 538.71 619.52 65420 395.63 375.85 432.23 66225 732.28 695.67 800.02 # 65420 290.95 276.40 317.86 66250 576.33 547.51 629.64 65426 501.09 476.04 547.45 # 66250 431.08 409.53 470.96 # 65426 372.58 353.95 407.04 66500 273.39 259.72 298.68 65430 91.94 87.34 100.44 66505 299.37 284.40 327.06 # 65430 83.89 79.70 91.66 66600 637.77 605.88 696.76 65435 63.20 60.04 69.05 66605 831.94 790.34 908.89 # 65435 55.79 53.00 60.95 66625 335.12 318.36 366.11 65436 301.18 286.12 329.04 66630 441.94 419.84 482.82 # 65436 289.91 275.41 316.72 66635 446.47 424.15 487.77 65450 247.34 234.97 270.22 66680 398.94 378.99 435.84 # 65450 244.44 232.22 267.05 66682 483.68 459.50 528.43 65600 299.89 284.90 327.64 66700 348.44 331.02 380.67 # 65600 261.89 248.80 286.12 # 66700 309.14 293.68 337.73 65710 864.91 821.66 944.91 66710 342.78 325.64 374.49 65730 963.06 914.91 1,052.15 # 66710 308.32 292.90 336.84 65750 977.71 928.82 1,068.14 66711 493.03 468.38 538.64 65755 971.96 923.36 1,061.86 66720 358.00 340.10 391.12 65756 938.42 891.50 1,025.23 # 66720 324.51 308.28 354.52 65770 1,119.05 1,063.10 1,222.57 66740 340.53 323.50 372.03 65772 347.52 330.14 379.66 # 66740 309.61 294.13 338.25 # 65772 314.02 298.32 343.07 66761 348.60 331.17 380.85 65775 429.02 407.57 468.71 # 66761 318.65 302.72 348.13 65780 689.63 655.15 753.42 66762 365.74 347.45 399.57 65781 1,055.12 1,002.36 1,152.71 # 66762 329.99 313.49 360.51 65782 909.18 863.72 993.28 66770 406.77 386.43 444.39 65800 120.08 114.08 131.19 # 66770 374.24 355.53 408.86 # 65800 106.23 100.92 116.06 66820 306.15 290.84 334.47 65805 130.39 123.87 142.45 66821 249.23 236.77 272.29 # 65805 106.23 100.92 116.06 # 66821 235.71 223.92 257.51 65810 363.67 345.49 397.31 66825 592.21 562.60 646.99 65815 490.48 465.96 535.85 66830 557.80 529.91 609.40 # 65815 369.06 350.61 403.20 66840 543.37 516.20 593.63 65820 584.09 554.89 638.12 66850 620.46 589.44 677.86 65850 668.41 634.99 730.24 66852 664.43 631.21 725.89 65855 265.78 252.49 290.36 66920 592.69 563.06 647.52 # 65855 235.50 223.73 257.29 66930 673.89 640.20 736.23 65860 245.28 233.02 267.97 66940 611.36 580.79 667.91 # 65860 204.70 194.47 223.64 66982 844.29 802.08 922.39 65865 371.75 353.16 406.13 66983 583.25 554.09 637.20 65870 460.07 437.07 502.63 66984 604.73 574.49 660.66 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 99 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 596.62 566.79 651.81 67320 265.66 252.38 290.24 66986 730.77 694.23 798.36 67331 251.55 238.97 274.82 66990 75.67 71.89 82.67 67332 273.54 259.86 298.84 67005 367.02 348.67 400.97 67334 248.17 235.76 271.12 67010 425.75 404.46 465.13 67335 124.64 118.41 136.17 67015 453.03 430.38 494.94 67340 295.56 280.78 322.90 67025 560.90 532.86 612.79 67343 509.75 484.26 556.90 # 67025 490.04 465.54 535.37 67345 185.54 176.26 202.70 67027 673.04 639.39 735.30 # 67345 169.76 161.27 185.46 67028 168.70 160.27 184.31 67346 162.86 154.72 177.93 # 67028 136.82 129.98 149.48 67400 731.21 694.65 798.85 67030 403.89 383.70 441.26 67405 621.31 590.24 678.78 67031 298.54 283.61 326.15 67412 677.10 643.25 739.74 # 67031 275.03 261.28 300.47 67413 677.15 643.29 739.78 67036 761.00 722.95 831.39 67414 1,045.41 993.14 1,142.11 67039 973.47 924.80 1,063.52 67415 87.30 82.94 95.38 67040 1,124.12 1,067.91 1,228.10 67420 1,300.03 1,235.03 1,420.28 67041 1,054.49 1,001.77 1,152.04 67430 983.29 934.13 1,074.25 67042 1,209.15 1,148.69 1,320.99 67440 948.84 901.40 1,036.61 67043 1,267.74 1,204.35 1,385.00 67445 1,120.74 1,064.70 1,224.41 67101 601.13 571.07 656.73 67450 984.75 935.51 1,075.84 # 67101 524.80 498.56 573.34 67500 73.11 69.45 79.87 67105 557.65 529.77 609.24 # 67500 66.67 63.34 72.84 # 67105 503.54 478.36 550.11 67505 70.85 67.31 77.41 67107 956.60 908.77 1,045.09 # 67505 64.08 60.88 70.01 67108 1,275.96 1,212.16 1,393.98 67515 75.50 71.73 82.49 67110 674.52 640.79 736.91 # 67515 70.03 66.53 76.51 # 67110 604.63 574.40 660.56 67550 761.93 723.83 832.40 67112 1,052.48 999.86 1,149.84 67560 776.85 738.01 848.71 67113 1,387.76 1,318.37 1,516.13 67570 913.64 867.96 998.15 67115 382.89 363.75 418.31 67700 203.32 193.15 222.12 67120 505.95 480.65 552.75 # 67700 89.95 85.45 98.27 # 67120 432.19 410.58 472.17 67710 171.09 162.54 186.92 67121 712.42 676.80 778.32 # 67710 74.79 71.05 81.71 67141 402.99 382.84 440.27 67715 180.74 171.70 197.46 # 67141 376.90 358.06 411.77 # 67715 84.76 80.52 92.60 67145 406.72 386.38 444.34 67800 99.04 94.09 108.20 # 67145 385.46 366.19 421.12 # 67800 82.62 78.49 90.26 67208 467.67 444.29 510.93 67801 127.41 121.04 139.20 # 67208 452.21 429.60 494.04 # 67801 107.45 102.08 117.39 67210 548.26 520.85 598.98 67805 157.46 149.59 172.03 # 67210 531.19 504.63 580.32 # 67805 131.70 125.12 143.89 67218 1,116.62 1,060.79 1,219.91 67808 284.72 270.48 311.05 67220 841.21 799.15 919.02 67810 175.87 167.08 192.14 # 67220 804.49 764.27 878.91 # 67810 77.63 73.75 84.81 67221 235.87 224.08 257.69 67820 42.10 40.00 46.00 # 67221 178.87 169.93 195.42 # 67820 43.39 41.22 47.40 67225 24.71 23.47 26.99 67825 100.37 95.35 109.65 # 67225 23.43 22.26 25.60 # 67825 94.57 89.84 103.32 67227 475.26 451.50 519.23 67830 204.84 194.60 223.79 # 67227 446.59 424.26 487.90 # 67830 108.54 103.11 118.58 67228 934.18 887.47 1,020.59 67835 346.76 329.42 378.83 # 67228 829.51 788.03 906.23 67840 215.21 204.45 235.12 67229 911.74 866.15 996.07 # 67840 125.99 119.69 137.64 67250 615.56 584.78 672.50 67850 173.39 164.72 189.43 67255 657.90 625.01 718.76 # 67850 112.52 106.89 122.92 67311 467.76 444.37 511.03 67875 134.64 127.91 147.10 67312 560.82 532.78 612.70 # 67875 78.60 74.67 85.87 67314 524.79 498.55 573.33 67880 351.71 334.12 384.24 67316 629.84 598.35 688.10 # 67880 284.72 270.48 311.05 67318 548.97 521.52 599.75 67882 435.16 413.40 475.41 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 99 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 367.20 348.84 401.17 # 68130 322.40 306.28 352.22 67900 502.47 477.35 548.95 68135 122.79 116.65 134.15 # 67900 406.17 385.86 443.74 # 68135 118.92 112.97 129.92 67901 543.10 515.95 593.34 68200 33.49 31.82 36.59 # 67901 455.17 432.41 497.27 # 68200 28.01 26.61 30.60 67902 565.26 537.00 617.55 68320 553.02 525.37 604.18 67903 480.16 456.15 524.57 # 68320 414.52 393.79 452.86 # 67903 393.20 373.54 429.57 68325 516.69 490.86 564.49 67904 569.24 540.78 621.90 68326 503.33 478.16 549.88 # 67904 467.46 444.09 510.70 68328 561.89 533.80 613.87 67906 408.17 387.76 445.92 68330 465.30 442.04 508.35 67908 383.14 363.98 418.58 # 68330 356.76 338.92 389.76 # 67908 338.70 321.77 370.04 68335 504.95 479.70 551.66 67909 419.82 398.83 458.65 68340 418.23 397.32 456.92 # 67909 347.04 329.69 379.14 # 68340 308.08 292.68 336.58 67911 437.54 415.66 478.01 68360 408.88 388.44 446.71 67912 699.89 664.90 764.64 # 68360 318.70 302.77 348.19 # 67912 392.31 372.69 428.59 68362 511.97 486.37 559.33 67914 304.62 289.39 332.80 68371 326.84 310.50 357.08 # 67914 228.93 217.48 250.10 68400 215.76 204.97 235.72 67915 272.56 258.93 297.77 # 68400 107.86 102.47 117.84 # 67915 202.03 191.93 220.72 68420 247.31 234.94 270.18 67916 420.23 399.22 459.10 # 68420 138.77 131.83 151.60 # 67916 341.00 323.95 372.54 68440 82.86 78.72 90.53 67917 459.82 436.83 502.35 # 68440 74.80 71.06 81.72 # 67917 377.37 358.50 412.28 68500 762.66 724.53 833.21 67921 289.66 275.18 316.46 68505 766.86 728.52 837.80 # 67921 213.97 203.27 233.76 68510 357.44 339.57 390.51 67922 263.87 250.68 288.28 # 68510 239.56 227.58 261.72 # 67922 194.63 184.90 212.64 68520 539.21 512.25 589.09 67923 444.05 421.85 485.13 68525 220.97 209.92 241.41 # 67923 368.36 349.94 402.43 68530 338.47 321.55 369.78 67924 458.47 435.55 500.88 # 68530 209.96 199.46 229.38 # 67924 356.38 338.56 389.34 68540 729.37 692.90 796.84 67930 287.88 273.49 314.51 68550 896.70 851.87 979.65 # 67930 197.70 187.82 215.99 68700 470.72 447.18 514.26 67935 468.49 445.07 511.83 68705 184.69 175.46 201.78 # 67935 359.96 341.96 393.25 # 68705 130.90 124.36 143.01 67938 185.99 176.69 203.19 68720 597.59 567.71 652.87 # 67938 90.34 85.82 98.69 68745 599.34 569.37 654.78 67950 451.96 429.36 493.76 68750 616.11 585.30 673.10 # 67950 370.16 351.65 404.40 68760 156.50 148.68 170.98 67961 450.93 428.38 492.64 # 68760 114.31 108.59 124.88 # 67961 361.72 343.63 395.17 68761 114.29 108.58 124.87 67966 598.80 568.86 654.19 # 68761 92.71 88.07 101.28 # 67966 515.06 489.31 562.71 68770 467.08 443.73 510.29 67971 580.85 551.81 634.58 68801 94.13 89.42 102.83 67973 752.88 715.24 822.53 # 68801 81.89 77.80 89.47 67974 749.87 712.38 819.24 68810 183.12 173.96 200.05 67975 548.14 520.73 598.84 # 68810 148.01 140.61 161.70 68020 93.39 88.72 102.03 68811 160.97 152.92 175.86 # 68020 87.27 82.91 95.35 68815 342.43 325.31 374.11 68040 52.30 49.69 57.14 # 68815 203.61 193.43 222.44 # 68040 43.93 41.73 47.99 68816 518.79 492.85 566.78 68100 133.67