1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 1 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 33.95 32.25 37.09 G0270 22.38 21.26 24.45 G0102 18.36 17.44 20.06 # G0270 20.61 19.58 22.52 # G0102 8.43 8.01 9.21 G0271 12.74 12.10 13.92 G0104 122.19 116.08 133.49 G0275 13.80 13.11 15.08 # G0104 57.31 54.44 62.61 G0278 13.80 13.11 15.08 G0105 359.61 341.63 392.87 G0281 11.28 10.72 12.33 # G0105 201.48 191.41 220.12 G0283 11.28 10.72 12.33 G0105 53 122.19 116.08 133.49 G0288 123.72 117.53 135.16 # G0105 53 57.31 54.44 62.61 G0289 81.72 77.63 89.27 G0106 192.57 182.94 210.38 G0329 7.66 7.28 8.37 G0106 TC 143.04 135.89 156.27 G0339 3,958.14 3,760.23 4,324.26 G0106 26 49.53 47.05 54.11 G0340 2,687.41 2,553.04 2,936.00 G0108 22.51 21.38 24.59 G0341 396.00 376.20 432.63 G0109 12.59 11.96 13.75 G0342 642.15 610.04 701.55 G0117 43.00 40.85 46.98 G0343 1,066.90 1,013.56 1,165.59 G0118 29.00 27.55 31.68 G0364 12.15 11.54 13.27 G0120 192.57 182.94 210.38 # G0364 8.96 8.51 9.79 G0120 TC 143.04 135.89 156.27 C G0365 158.96 151.01 173.66 G0120 26 49.53 47.05 54.11 C G0365 TC 147.11 139.75 160.71 G0121 359.61 341.63 392.87 G0365 26 11.85 11.26 12.95 # G0121 201.48 191.41 220.12 G0372 10.92 10.37 11.93 G0121 53 122.19 116.08 133.49 # G0372 8.08 7.68 8.83 # G0121 53 57.31 54.44 62.61 G0389 107.59 102.21 117.54 G0124 26.49 25.17 28.95 G0389 TC 77.99 74.09 85.20 G0127 18.36 17.44 20.06 G0389 26 29.60 28.12 32.34 # G0127 8.08 7.68 8.83 G0392 2,115.24 2,009.48 2,310.90 G0128 8.03 7.63 8.77 # G0392 436.52 414.69 476.89 G0130 30.97 29.42 33.83 G0393 1,598.01 1,518.11 1,745.83 G0130 TC 20.74 19.70 22.66 # G0393 306.79 291.45 335.17 G0130 26 10.24 9.73 11.19 G0396 30.71 29.17 33.55 G0141 26.49 25.17 28.95 # G0396 29.29 27.83 32.00 G0166 147.35 139.98 160.98 G0397 59.82 56.83 65.35 G0168 74.19 70.48 81.05 # G0397 58.41 55.49 63.81 # G0168 24.20 22.99 26.44 G0398 279.21 265.25 305.04 G0179 38.21 36.30 41.75 G0398 TC 196.78 186.94 214.98 G0180 50.57 48.04 55.25 G0398 26 82.43 78.31 90.06 G0181 98.37 93.45 107.47 G0399 200.48 190.46 219.03 G0182 100.50 95.48 109.80 G0399 TC 123.56 117.38 134.99 G0202 126.28 119.97 137.97 G0399 26 76.92 73.07 84.03 G0202 TC 92.00 87.40 100.51 G0400 180.43 171.41 197.12 G0202 26 34.28 32.57 37.46 G0400 TC 111.21 105.65 121.50 G0204 148.54 141.11 162.28 G0400 26 69.22 65.76 75.62 G0204 TC 106.18 100.87 116.00 G0402 90.16 85.65 98.50 G0204 26 42.36 40.24 46.28 G0403 20.13 19.12 21.99 G0206 117.95 112.05 128.86 G0404 13.12 12.46 14.33 G0206 TC 83.66 79.48 91.40 G0405 8.08 7.68 8.83 G0206 26 34.28 32.57 37.46 G0406 36.45 34.63 39.82 G0237 9.93 9.43 10.84 G0407 65.73 62.44 71.81 G0238 10.63 10.10 11.62 G0408 94.11 89.40 102.81 G0239 10.99 10.44 12.01 G0409 8.33 7.91 9.10 G0245 61.87 58.78 67.60 G0412 649.71 617.22 709.80 # G0245 43.79 41.60 47.84 G0413 951.76 904.17 1,039.80 G0246 36.08 34.28 39.42 G0414 901.13 856.07 984.48 # G0246 22.26 21.15 24.32 G0415 1,230.52 1,168.99 1,344.34 G0247 40.37 38.35 44.10 G0416 615.90 585.11 672.88 # G0247 24.41 23.19 26.67 G0416 TC 435.70 413.92 476.01 G0248 145.89 138.60 159.39 G0416 26 180.20 171.19 196.87 G0249 123.91 117.71 135.37 G0417 1,196.51 1,136.68 1,307.18 G0250 9.50 9.03 10.38 G0417 TC 851.18 808.62 929.91 G0268 45.75 43.46 49.98 G0417 26 345.32 328.05 377.26 # G0268 30.15 28.64 32.94 G0418 2,053.95 1,951.25 2,243.94 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 VERMONT - MEDICARE CARRIER 31145 PAGE 2 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 1,454.03 1,381.33 1,588.53 # 10040 77.48 73.61 84.65 G0418 26 599.91 569.91 655.40 10060 95.03 90.28 103.82 G0419 2,437.26 2,315.40 2,662.71 # 10060 81.91 77.81 89.48 G0419 TC 1,744.73 1,657.49 1,906.11 10061 162.42 154.30 177.45 G0419 26 692.53 657.90 756.59 # 10061 145.05 137.80 158.47 G9041 22.43 21.31 24.51 10080 142.00 134.90 155.14 G9042 7.33 6.96 8.00 # 10080 83.86 79.67 91.62 G9043 6.97 6.62 7.61 10081 222.37 211.25 242.94 G9044 6.62 6.29 7.23 # 10081 145.79 138.50 159.28 M0064 39.76 37.77 43.44 10120 116.68 110.85 127.48 # M0064 16.36 15.54 17.87 # 10120 80.16 76.15 87.57 P3001 26.49 25.17 28.95 10121 226.23 214.92 247.16 Q0035 18.36 17.44 20.06 # 10121 163.12 154.96 178.20 Q0035 TC 10.28 9.77 11.24 10140 133.71 127.02 146.07 Q0035 26 8.08 7.68 8.83 # 10140 104.63 99.40 114.31 Q0091 39.22 37.26 42.85 10160 108.87 103.43 118.94 # Q0091 17.60 16.72 19.23 # 10160 84.41 80.19 92.22 Q0092 15.78 14.99 17.24 10180 200.43 190.41 218.97 R0070 117.10 111.25 127.94 # 10180 153.99 146.29 168.23 R0075 117.10 111.25 127.94 11000 46.98 44.63 51.32 0067T 572.43 543.81 625.38 # 11000 29.26 27.80 31.97 C 0067T TC 183.43 174.26 200.40 11001 19.68 18.70 21.51 0067T 26 125.09 118.84 136.67 # 11001 14.72 13.98 16.08 0073T 505.73 480.44 552.51 11004 527.55 501.17 576.35 0075T 1,083.98 1,029.78 1,184.25 11005 687.58 653.20 751.18 0075T 26 914.45 868.73 999.04 11006 648.92 616.47 708.94 0076T 357.71 339.82 390.79 11008 246.40 234.08 269.19 0076T 26 91.44 86.87 99.90 11010 405.62 385.34 443.14 0078T 1,216.61 1,155.78 1,329.15 # 11010 251.04 238.49 274.26 0079T 1,116.70 1,060.87 1,220.00 11011 451.80 429.21 493.59 0080T 217.71 206.82 237.84 # 11011 269.57 256.09 294.50 0081T 217.71 206.82 237.84 11012 616.03 585.23 673.01 0145T 569.85 541.36 622.56 # 11012 390.20 370.69 426.29 C 0145T TC 266.73 253.39 291.40 11040 41.07 39.02 44.87 0145T 26 99.20 94.24 108.38 # 11040 25.12 23.86 27.44 0146T 569.85 541.36 622.56 11041 47.87 45.48 52.30 C 0146T TC 266.73 253.39 291.40 # 11041 31.20 29.64 34.09 0146T 26 99.20 94.24 108.38 11042 64.83 61.59 70.83 0147T 569.85 541.36 622.56 # 11042 41.78 39.69 45.64 C 0147T TC 266.73 253.39 291.40 11043 237.25 225.39 259.20 0147T 26 99.20 94.24 108.38 # 11043 207.11 196.75 226.26 0148T 569.85 541.36 622.56 11044 324.22 308.01 354.21 C 0148T TC 266.73 253.39 291.40 # 11044 285.22 270.96 311.60 0148T 26 99.20 94.24 108.38 11055 42.27 40.16 46.18 0149T 569.85 541.36 622.56 # 11055 21.00 19.95 22.94 C 0149T TC 266.73 253.39 291.40 11056 51.60 49.02 56.37 0149T 26 99.20 94.24 108.38 # 11056 29.62 28.14 32.36 0150T 569.85 541.36 622.56 11057 62.16 59.05 67.91 C 0150T TC 266.73 253.39 291.40 # 11057 38.41 36.49 41.96 0150T 26 99.20 94.24 108.38 11100 90.37 85.85 98.73 0151T 185.57 176.29 202.73 # 11100 43.92 41.72 47.98 C 0151T TC 99.07 94.12 108.24 11101 29.32 27.85 32.03 0151T 26 65.31 62.04 71.35 # 11101 22.59 21.46 24.68 0171T 690.08 655.58 753.92 11200 71.03 67.48 77.60 0172T 345.04 327.79 376.96 # 11200 60.04 57.04 65.60 0177T 1,194.06 1,134.36 1,304.51 11201 16.48 15.66 18.01 10021 123.79 117.60 135.24 # 11201 15.07 14.32 16.47 # 10021 62.81 59.67 68.62 11300 58.99 56.04 64.45 10022 127.34 120.97 139.12 # 11300 26.72 25.38 29.19 # 10022 62.46 59.34 68.24 11301 81.00 76.95 88.49 10040 88.47 84.05 96.66 # 11301 45.54 43.26 49.75 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 VERMONT - MEDICARE CARRIER 31145 PAGE 3 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 96.90 92.06 105.87 # 11462 194.63 184.90 212.64 # 11302 56.48 53.66 61.71 11463 402.53 382.40 439.76 11303 113.67 107.99 124.19 # 11463 272.06 258.46 297.23 # 11303 66.17 62.86 72.29 11470 328.73 312.29 359.13 11305 60.50 57.48 66.10 # 11470 230.17 218.66 251.46 # 11305 33.55 31.87 36.65 11471 412.74 392.10 450.92 11306 83.74 79.55 91.48 # 11471 289.01 274.56 315.74 # 11306 51.12 48.56 55.84 11600 154.12 146.41 168.37 11307 99.08 94.13 108.25 # 11600 98.10 93.20 107.18 # 11307 60.43 57.41 66.02 11601 190.55 181.02 208.17 11308 110.94 105.39 121.20 # 11601 127.09 120.74 138.85 # 11308 72.29 68.68 78.98 11602 209.46 198.99 228.84 11310 73.48 69.81 80.28 # 11602 139.97 132.97 152.92 # 11310 38.73 36.79 42.31 11603 237.80 225.91 259.80 11311 93.35 88.68 101.98 # 11603 166.19 157.88 181.56 # 11311 56.83 53.99 62.09 11604 262.48 249.36 286.76 11312 107.80 102.41 117.77 # 11604 182.35 173.23 199.21 # 11312 65.26 62.00 71.30 11606 368.89 350.45 403.02 11313 134.64 127.91 147.10 # 11606 269.62 256.14 294.56 # 11313 87.14 82.78 95.20 11620 157.49 149.62 172.06 11400 100.15 95.14 109.41 # 11620 99.70 94.72 108.93 # 11400 65.41 62.14 71.46 11621 192.33 182.71 210.12 11401 123.07 116.92 134.46 # 11621 128.51 122.08 140.39 # 11401 86.91 82.56 94.94 11622 217.70 206.82 237.84 11402 137.18 130.32 149.87 # 11622 148.21 140.80 161.92 # 11402 96.05 91.25 104.94 11623 253.93 241.23 277.41 11403 157.62 149.74 172.20 # 11623 182.32 173.20 199.18 # 11403 122.17 116.06 133.47 11624 285.26 271.00 311.65 11404 179.41 170.44 196.01 # 11624 206.91 196.56 226.04 # 11404 135.80 129.01 148.36 11626 346.48 329.16 378.53 11406 252.75 240.11 276.13 # 11626 258.20 245.29 282.08 # 11406 202.77 192.63 221.52 11640 164.60 156.37 179.83 11420 101.12 96.06 110.47 # 11640 105.04 99.79 114.76 # 11420 70.63 67.10 77.17 11641 202.31 192.19 221.02 11421 131.16 124.60 143.29 # 11641 137.07 130.22 149.75 # 11421 95.35 90.58 104.17 11642 233.25 221.59 254.83 11422 146.36 139.04 159.90 # 11642 161.63 153.55 176.58 # 11422 115.16 109.40 125.81 11643 273.97 260.27 299.31 11423 170.34 161.82 186.09 # 11643 201.65 191.57 220.31 # 11423 134.18 127.47 146.59 11644 337.81 320.92 369.06 11424 196.30 186.49 214.46 # 11644 250.95 238.40 274.16 # 11424 154.46 146.74 168.75 11646 444.26 422.05 485.36 11426 280.75 266.71 306.72 # 11646 352.44 334.82 385.04 # 11426 235.37 223.60 257.14 11719 18.54 17.61 20.25 11440 110.88 105.34 121.14 # 11719 8.26 7.85 9.03 # 11440 85.00 80.75 92.86 11720 27.14 25.78 29.65 11441 140.42 133.40 153.41 # 11720 15.44 14.67 16.87 # 11441 111.35 105.78 121.65 11721 38.79 36.85 42.38 11442 158.11 150.20 172.73 # 11721 26.38 25.06 28.82 # 11442 124.08 117.88 135.56 11730 85.75 81.46 93.68 11443 189.65 180.17 207.20 # 11730 53.49 50.82 58.44 # 11443 153.14 145.48 167.30 11732 39.87 37.88 43.56 11444 239.09 227.14 261.21 # 11732 27.82 26.43 30.39 # 11444 196.20 186.39 214.35 11740 39.22 37.26 42.85 11446 325.32 309.05 355.41 # 11740 28.23 26.82 30.84 # 11446 277.46 263.59 303.13 11750 186.16 176.85 203.38 11450 299.70 284.72 327.43 # 11750 154.97 147.22 169.30 # 11450 202.21 192.10 220.92 11752 264.64 251.41 289.12 11451 391.37 371.80 427.57 # 11752 231.66 220.08 253.09 # 11451 266.57 253.24 291.23 11755 116.01 110.21 126.74 11462 296.03 281.23 323.41 # 11755 76.66 72.83 83.75 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 VERMONT - MEDICARE CARRIER 31145 PAGE 4 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 174.15 165.44 190.26 # 12014 128.96 122.51 140.89 # 11760 115.30 109.54 125.97 12015 221.22 210.16 241.68 11762 233.26 221.60 254.84 # 12015 161.66 153.58 176.62 # 11762 176.89 168.05 193.26 12016 264.21 251.00 288.65 11765 111.40 105.83 121.70 # 12016 197.20 187.34 215.44 # 11765 59.64 56.66 65.16 12017 234.54 222.81 256.23 11770 222.99 211.84 243.62 12018 290.16 275.65 317.00 # 11770 154.92 147.17 169.25 12020 230.98 219.43 252.34 11771 457.05 434.20 499.33 # 12020 164.32 156.10 179.52 # 11771 359.20 341.24 392.43 12021 136.55 129.72 149.18 11772 554.77 527.03 606.08 # 12021 119.18 113.22 130.20 # 11772 469.68 446.20 513.13 12031 205.00 194.75 223.96 11900 49.24 46.78 53.80 # 12031 138.34 131.42 151.13 # 11900 27.97 26.57 30.56 12032 264.58 251.35 289.05 11901 62.35 59.23 68.11 # 12032 170.63 162.10 186.42 # 11901 43.56 41.38 47.59 12034 260.06 247.06 284.12 11920 157.67 149.79 172.26 # 12034 177.45 168.58 193.87 # 11920 102.01 96.91 111.45 12035 316.72 300.88 346.01 11921 179.67 170.69 196.29 # 12035 207.53 197.15 226.72 # 11921 120.10 114.10 131.22 12036 346.52 329.19 378.57 11922 52.94 50.29 57.83 # 12036 238.74 226.80 260.82 # 11922 27.06 25.71 29.57 12037 390.67 371.14 426.81 11950 66.10 62.80 72.22 # 12037 277.93 264.03 303.63 # 11950 45.54 43.26 49.75 12041 214.70 203.97 234.57 11951 88.11 83.70 96.26 # 12041 148.05 140.65 161.75 # 11951 63.30 60.14 69.16 12042 250.74 238.20 273.93 11952 124.05 117.85 135.53 # 12042 173.45 164.78 189.50 # 11952 91.43 86.86 99.89 12044 288.91 274.46 315.63 11954 141.33 134.26 154.40 # 12044 186.09 176.79 203.31 # 11954 102.33 97.21 111.79 12045 319.33 303.36 348.86 11960 798.13 758.22 871.95 # 12045 215.45 204.68 235.38 11970 522.52 496.39 570.85 12046 378.02 359.12 412.99 11971 394.05 374.35 430.50 # 12046 253.57 240.89 277.02 # 11971 260.40 247.38 284.49 12047 405.56 385.28 443.07 11976 131.36 124.79 143.51 # 12047 277.57 263.69 303.24 # 11976 87.40 83.03 95.48 12051 230.89 219.35 252.25 11980 93.25 88.59 101.88 # 12051 158.57 150.64 173.24 # 11980 73.75 70.06 80.57 12052 262.11 249.00 286.35 11981 121.08 115.03 132.28 # 12052 186.60 177.27 203.86 # 11981 77.83 73.94 85.03 12053 287.84 273.45 314.47 11982 139.17 132.21 152.04 # 12053 188.92 179.47 206.39 # 11982 94.85 90.11 103.63 12054 304.16 288.95 332.29 11983 215.61 204.83 235.55 # 12054 200.29 190.28 218.82 # 11983 174.13 165.42 190.23 12055 365.90 347.61 399.75 12001 127.43 121.06 139.22 # 12055 243.59 231.41 266.12 # 12001 90.92 86.37 99.33 12056 431.62 410.04 471.55 12002 135.68 128.90 148.24 # 12056 297.25 282.39 324.75 # 12002 100.94 95.89 110.27 12057 482.94 458.79 527.61 12004 160.02 152.02 174.82 # 12057 341.13 324.07 372.68 # 12004 118.54 112.61 129.50 13100 273.83 260.14 299.16 12005 199.39 189.42 217.83 # 13100 207.18 196.82 226.34 # 12005 147.63 140.25 161.29 13101 346.28 328.97 378.32 12006 247.39 235.02 270.27 # 13101 251.98 239.38 275.29 # 12006 186.41 177.09 203.65 13102 93.46 88.79 102.11 12007 279.92 265.92 305.81 # 13102 66.87 63.53 73.06 # 12007 212.91 202.26 232.60 13120 284.58 270.35 310.90 12011 135.45 128.68 147.98 # 13120 216.51 205.68 236.53 # 12011 93.97 89.27 102.66 13121 383.60 364.42 419.08 12013 149.41 141.94 163.23 # 13121 286.10 271.80 312.57 # 12013 107.22 101.86 117.14 13122 104.57 99.34 114.24 12014 176.11 167.30 192.40 # 13122 76.56 72.73 83.64 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 5 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 314.30 298.59 343.38 # 15121 152.99 145.34 167.14 # 13131 244.45 232.23 267.06 15130 580.75 551.71 634.47 13132 503.84 478.65 550.45 # 15130 488.57 464.14 533.76 # 13132 412.72 392.08 450.89 15131 87.23 82.87 95.30 13133 148.10 140.70 161.81 # 15131 78.72 74.78 86.00 # 13133 119.39 113.42 130.43 15135 748.80 711.36 818.06 13150 312.53 296.90 341.44 # 15135 671.86 638.27 734.01 # 13150 242.69 230.56 265.14 15136 80.32 76.30 87.75 13151 356.71 338.87 389.70 # 15136 74.64 70.91 81.55 # 13151 282.97 268.82 309.14 15150 606.89 576.55 663.03 13152 491.69 467.11 537.18 # 15150 557.96 530.06 609.57 # 13152 380.72 361.68 415.93 15151 112.88 107.24 123.33 13153 162.40 154.28 177.42 # 15151 104.02 98.82 113.64 # 13153 129.07 122.62 141.01 15152 147.04 139.69 160.64 13160 709.10 673.65 774.70 # 15152 137.11 130.25 149.79 14000 532.53 505.90 581.79 15155 639.80 607.81 698.98 # 14000 437.16 415.30 477.60 # 15155 599.03 569.08 654.44 14001 691.92 657.32 755.92 15156 156.94 149.09 171.45 # 14001 579.89 550.90 633.54 # 15156 148.79 141.35 162.55 14020 599.86 569.87 655.35 15157 173.22 164.56 189.24 # 14020 500.60 475.57 546.91 # 15157 161.52 153.44 176.46 14021 760.04 722.04 830.35 15170 371.45 352.88 405.81 # 14021 646.94 614.59 706.78 # 15170 321.82 305.73 351.59 14040 667.04 633.69 728.74 15171 83.01 78.86 90.69 # 14040 569.89 541.40 622.61 # 15171 79.11 75.15 86.42 14041 830.21 788.70 907.01 15175 471.75 448.16 515.38 # 14041 704.00 668.80 769.12 # 15175 424.95 403.70 464.26 14060 678.05 644.15 740.77 15176 132.83 126.19 145.12 # 14060 601.47 571.40 657.11 # 15176 125.39 119.12 136.99 14061 889.62 845.14 971.91 15200 694.63 659.90 758.89 # 14061 751.00 713.45 820.47 # 15200 573.02 544.37 626.03 14300 960.31 912.29 1,049.13 15201 128.25 121.84 140.12 # 14300 838.35 796.43 915.89 # 15201 71.17 67.61 77.75 14350 659.57 626.59 720.58 15220 661.75 628.66 722.96 15002 288.48 274.06 315.17 # 15220 542.63 515.50 592.83 # 15002 201.62 191.54 220.27 15221 119.48 113.51 130.54 15003 62.70 59.57 68.51 # 15221 65.24 61.98 71.28 # 15003 40.72 38.68 44.48 15240 794.98 755.23 868.51 15004 349.84 332.35 382.20 # 15240 694.29 659.58 758.52 # 15004 251.99 239.39 275.30 15241 159.77 151.78 174.55 15005 105.19 99.93 114.92 # 15241 101.98 96.88 111.41 # 15005 80.73 76.69 88.19 15260 864.01 820.81 943.93 15040 219.95 208.95 240.29 # 15260 754.46 716.74 824.25 # 15040 113.59 107.91 124.10 15261 186.59 177.26 203.85 15050 466.09 442.79 509.21 # 15261 128.80 122.36 140.71 # 15050 382.77 363.63 418.17 15300 297.96 283.06 325.52 15100 746.48 709.16 815.53 # 15300 255.77 242.98 279.43 # 15100 624.52 593.29 682.28 15301 55.91 53.11 61.08 15101 164.47 156.25 179.69 # 15301 51.65 49.07 56.43 # 15101 99.95 94.95 109.19 15320 335.79 319.00 366.85 15110 736.72 699.88 804.86 # 15320 289.34 274.87 316.10 # 15110 642.77 610.63 702.22 15321 83.33 79.16 91.03 15111 107.12 101.76 117.02 # 15321 77.66 73.78 84.85 # 15111 96.13 91.32 105.02 15330 275.22 261.46 300.68 15115 746.85 709.51 815.94 # 15330 231.96 220.36 253.41 # 15115 667.08 633.73 728.79 15331 55.91 53.11 61.08 15116 145.62 138.34 159.09 # 15331 52.01 49.41 56.82 # 15116 132.86 126.22 145.15 15335 289.71 275.22 316.50 15120 812.47 771.85 887.63 # 15335 247.52 235.14 270.41 # 15120 686.26 651.95 749.74 15336 77.79 73.90 84.99 15121 232.05 220.45 253.52 # 15336 71.41 67.84 78.02 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 VERMONT - MEDICARE CARRIER 31145 PAGE 6 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 275.79 262.00 301.30 15776 390.83 371.29 426.98 # 15340 237.50 225.63 259.47 # 15776 297.23 282.37 324.73 15341 41.07 39.02 44.87 15780 721.84 685.75 788.61 # 15341 24.76 23.52 27.05 # 15780 568.33 539.91 620.90 15360 312.77 297.13 341.70 15781 463.52 440.34 506.39 # 15360 267.74 254.35 292.50 # 15781 374.89 356.15 409.57 15361 62.74 59.60 68.54 15782 490.48 465.96 535.85 # 15361 57.06 54.21 62.34 # 15782 360.01 342.01 393.31 15365 307.44 292.07 335.88 15783 422.04 400.94 461.08 # 15365 267.02 253.67 291.72 # 15783 324.90 308.66 354.96 15366 77.28 73.42 84.43 15786 207.05 196.70 226.21 # 15366 71.25 67.69 77.84 # 15786 121.97 115.87 133.25 15400 342.11 325.00 373.75 15787 42.39 40.27 46.31 # 15400 308.78 293.34 337.34 # 15787 16.86 16.02 18.42 15401 81.79 77.70 89.36 15788 368.75 350.31 402.86 # 15401 51.30 48.74 56.05 # 15788 207.08 196.73 226.24 15420 385.85 366.56 421.54 15789 492.96 468.31 538.56 # 15420 342.60 325.47 374.29 # 15789 374.54 355.81 409.18 15421 100.35 95.33 109.63 15792 362.58 344.45 396.12 # 15421 76.59 72.76 83.67 # 15792 227.50 216.13 248.55 15430 454.19 431.48 496.20 15793 409.86 389.37 447.78 # 15430 437.88 415.99 478.39 # 15793 310.59 295.06 339.32 15570 761.88 723.79 832.36 15819 646.08 613.78 705.85 # 15570 623.96 592.76 681.67 15820 463.17 440.01 506.01 15572 739.87 702.88 808.31 # 15820 419.21 398.25 457.99 # 15572 632.80 601.16 691.33 15821 492.41 467.79 537.96 15574 781.00 741.95 853.24 # 15821 444.20 421.99 485.29 # 15574 668.97 635.52 730.85 15822 362.41 344.29 395.93 15576 695.33 660.56 759.64 # 15822 320.57 304.54 350.22 # 15576 588.62 559.19 643.07 15823 573.25 544.59 626.28 15600 281.79 267.70 307.86 # 15823 527.52 501.14 576.31 # 15600 175.07 166.32 191.27 15830 1,020.34 969.32 1,114.72 15610 282.80 268.66 308.96 15832 778.72 739.78 850.75 # 15610 206.93 196.58 226.07 15833 735.08 698.33 803.08 15620 376.04 357.24 410.83 15834 730.98 694.43 798.59 # 15620 275.00 261.25 300.44 15835 773.49 734.82 845.04 15630 397.70 377.82 434.49 15836 644.78 612.54 704.42 # 15630 300.91 285.86 328.74 15837 668.62 635.19 730.47 15650 443.49 421.32 484.52 # 15837 583.88 554.69 637.89 # 15650 338.91 321.96 370.25 15838 505.85 480.56 552.64 15731 985.29 936.03 1,076.43 15839 740.10 703.10 808.57 # 15731 892.40 847.78 974.95 # 15839 632.68 601.05 691.21 15732 1,302.40 1,237.28 1,422.87 15840 889.95 845.45 972.27 # 15732 1,159.17 1,101.21 1,266.39 15841 1,486.66 1,412.33 1,624.18 15734 1,334.92 1,268.17 1,458.40 15842 2,342.44 2,225.32 2,559.12 # 15734 1,185.30 1,126.04 1,294.95 15845 837.26 795.40 914.71 15736 1,181.89 1,122.80 1,291.22 15851 81.36 77.29 88.88 # 15736 1,022.35 971.23 1,116.91 # 15851 41.29 39.23 45.11 15738 1,261.10 1,198.05 1,377.76 15852 42.89 40.75 46.86 # 15738 1,113.96 1,058.26 1,217.00 15860 100.62 95.59 109.93 15740 884.33 840.11 966.13 15920 511.18 485.62 558.46 # 15740 760.25 722.24 830.58 15922 648.92 616.47 708.94 15750 800.77 760.73 874.84 15931 581.58 552.50 635.38 15756 2,103.94 1,998.74 2,298.55 15933 716.40 680.58 782.67 15757 2,087.11 1,982.75 2,280.16 15934 797.87 757.98 871.68 15758 2,086.58 1,982.25 2,279.59 15935 949.94 902.44 1,037.81 15760 732.12 695.51 799.84 15936 773.45 734.78 845.00 # 15760 620.80 589.76 678.22 15937 904.39 859.17 988.05 15770 573.40 544.73 626.44 15940 597.98 568.08 653.29 15775 282.10 268.00 308.20 15941 777.40 738.53 849.31 # 15775 208.01 197.61 227.25 15944 765.55 727.27 836.36 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 7 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 850.35 807.83 929.00 # 17280 78.90 74.96 86.20 15946 1,421.28 1,350.22 1,552.75 17281 153.69 146.01 167.91 15950 495.79 471.00 541.65 # 17281 110.08 104.58 120.27 15951 706.89 671.55 772.28 17282 178.17 169.26 194.65 15952 742.96 705.81 811.68 # 17282 127.82 121.43 139.64 15953 827.38 786.01 903.91 17283 215.23 204.47 235.14 15956 995.58 945.80 1,087.67 # 17283 159.92 151.92 174.71 15958 1,016.11 965.30 1,110.10 17284 250.32 237.80 273.47 16000 60.10 57.10 65.67 # 17284 190.76 181.22 208.40 # 16000 42.02 39.92 45.91 17286 316.29 300.48 345.55 16020 70.68 67.15 77.22 # 17286 256.02 243.22 279.70 # 16020 50.12 47.61 54.75 17311 605.43 575.16 661.43 16025 127.86 121.47 139.69 # 17311 343.42 326.25 375.19 # 16025 102.34 97.22 111.80 17312 362.75 344.61 396.30 16030 152.99 145.34 167.14 # 17312 182.65 173.52 199.55 # 16030 116.12 110.31 126.86 17313 552.56 524.93 603.67 16035 191.22 181.66 208.91 # 17313 308.29 292.88 336.81 16036 76.06 72.26 83.10 17314 336.19 319.38 367.29 17000 68.63 65.20 74.98 # 17314 169.56 161.08 185.24 # 17000 47.71 45.32 52.12 17315 72.32 68.70 79.01 17003 6.60 6.27 7.21 # 17315 48.22 45.81 52.68 # 17003 4.12 3.91 4.50 17340 42.83 40.69 46.79 17004 153.38 145.71 167.57 # 17340 41.41 39.34 45.24 # 17004 119.70 113.72 130.78 17360 115.39 109.62 126.06 17106 300.52 285.49 328.31 # 17360 88.80 84.36 97.01 # 17106 246.63 234.30 269.45 19000 100.13 95.12 109.39 17107 397.23 377.37 433.98 # 19000 42.34 40.22 46.25 # 17107 325.26 309.00 355.35 19001 25.07 23.82 27.39 17108 509.07 483.62 556.16 # 19001 21.17 20.11 23.13 # 17108 425.75 404.46 465.13 19020 373.63 354.95 408.19 17110 95.24 90.48 104.05 # 19020 247.77 235.38 270.69 # 17110 59.44 56.47 64.94 19030 153.91 146.21 168.14 17111 113.14 107.48 123.60 # 19030 76.98 73.13 84.10 # 17111 74.14 70.43 80.99 19100 122.02 115.92 133.31 17250 64.47 61.25 70.44 # 19100 61.74 58.65 67.45 # 17250 32.21 30.60 35.19 19101 277.93 264.03 303.63 17260 82.82 78.68 90.48 # 19101 187.53 178.15 204.87 # 17260 59.42 56.45 64.92 19102 201.53 191.45 220.17 17261 123.57 117.39 135.00 # 19102 100.48 95.46 109.78 # 17261 80.32 76.30 87.75 19103 507.80 482.41 554.77 17262 150.59 143.06 164.52 # 19103 184.11 174.90 201.14 # 17262 102.73 97.59 112.23 19105 1,954.30 1,856.59 2,135.08 17263 166.14 157.83 181.50 # 19105 184.47 175.25 201.54 # 17263 113.67 107.99 124.19 19110 386.75 367.41 422.52 17264 177.75 168.86 194.19 # 19110 279.33 265.36 305.16 # 17264 121.38 115.31 132.61 19112 362.09 343.99 395.59 17266 201.93 191.83 220.60 # 19112 251.12 238.56 274.34 # 17266 141.30 134.24 154.38 19120 399.71 379.72 436.68 17270 128.27 121.86 140.14 # 19120 342.27 325.16 373.93 # 17270 86.79 82.45 94.82 19125 442.53 420.40 483.46 17271 141.67 134.59 154.78 # 19125 379.78 360.79 414.91 # 17271 97.71 92.82 106.74 19126 142.51 135.38 155.69 17272 162.23 154.12 177.24 19260 1,047.61 995.23 1,144.51 # 17272 113.30 107.64 123.79 19271 1,424.75 1,353.51 1,556.54 17273 181.01 171.96 197.75 19272 1,578.09 1,499.19 1,724.07 # 17273 127.83 121.44 139.66 19290 149.50 142.03 163.33 17274 214.31 203.59 234.13 # 19290 63.70 60.52 69.60 # 17274 156.88 149.04 171.40 19291 64.55 61.32 70.52 17276 248.01 235.61 270.95 # 19291 31.58 30.00 34.50 # 17276 188.45 179.03 205.88 19295 83.49 79.32 91.22 17280 120.38 114.36 131.51 19296 3,487.27 3,312.91 3,809.85 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 8 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 184.07 174.87 201.10 20250 331.02 314.47 361.64 19297 83.11 78.95 90.79 20251 366.96 348.61 400.90 19298 1,184.77 1,125.53 1,294.36 20500 103.22 98.06 112.77 # 19298 304.46 289.24 332.63 # 20500 84.78 80.54 92.62 19300 426.97 405.62 466.46 20501 117.10 111.25 127.94 # 19300 332.67 316.04 363.45 # 20501 38.40 36.48 41.95 19301 531.66 505.08 580.84 20520 165.45 157.18 180.76 19302 757.48 719.61 827.55 # 20520 125.39 119.12 136.99 19303 822.45 781.33 898.53 20525 403.97 383.77 441.34 19304 474.81 451.07 518.73 # 20525 218.90 207.96 239.15 19305 946.54 899.21 1,034.09 20526 66.69 63.36 72.86 19306 991.75 942.16 1,083.48 # 20526 52.15 49.54 56.97 19307 997.31 947.44 1,089.56 20550 51.68 49.10 56.47 19316 677.72 643.83 740.40 # 20550 38.21 36.30 41.75 19318 994.92 945.17 1,086.95 20551 51.15 48.59 55.88 19324 414.55 393.82 452.89 # 20551 39.10 37.15 42.72 19325 561.90 533.81 613.88 20552 46.67 44.34 50.99 19328 424.47 403.25 463.74 # 20552 33.19 31.53 36.26 19330 545.34 518.07 595.78 20553 52.22 49.61 57.05 19340 352.64 335.01 385.26 # 20553 36.97 35.12 40.39 19342 801.95 761.85 876.13 20555 306.59 291.26 334.95 19350 734.13 697.42 802.03 20600 48.61 46.18 53.11 # 19350 590.54 561.01 645.16 # 20600 36.56 34.73 39.94 19355 610.95 580.40 667.46 20605 52.17 49.56 56.99 # 19355 489.70 465.22 535.00 # 20605 37.99 36.09 41.50 19357 1,348.23 1,280.82 1,472.94 20610 67.30 63.94 73.53 19361 1,449.63 1,377.15 1,583.72 # 20610 45.32 43.05 49.51 19364 2,467.47 2,344.10 2,695.72 20612 51.83 49.24 56.63 19366 1,216.48 1,155.66 1,329.01 # 20612 39.06 37.11 42.68 19367 1,596.10 1,516.30 1,743.75 20615 190.36 180.84 207.97 19368 1,975.01 1,876.26 2,157.70 # 20615 141.79 134.70 154.91 19369 1,803.52 1,713.34 1,970.34 20650 172.41 163.79 188.36 19370 591.62 562.04 646.35 # 20650 139.09 132.14 151.96 19371 681.63 647.55 744.68 20660 224.16 212.95 244.89 19380 667.69 634.31 729.46 # 20660 211.40 200.83 230.95 19396 190.62 181.09 208.25 20661 405.80 385.51 443.34 # 19396 118.30 112.39 129.25 20662 423.91 402.71 463.12 20000 178.38 169.46 194.88 20663 389.80 370.31 425.86 # 20000 137.61 130.73 150.34 20664 665.50 632.23 727.06 20005 264.49 251.27 288.96 20665 106.98 101.63 116.87 # 20005 210.60 200.07 230.08 # 20665 89.61 85.13 97.90 20100 524.38 498.16 572.88 20670 342.83 325.69 374.54 20101 341.93 324.83 373.55 # 20670 131.52 124.94 143.68 # 20101 179.20 170.24 195.78 20680 515.87 490.08 563.59 20102 400.34 380.32 437.37 # 20680 365.90 347.61 399.75 # 20102 218.82 207.88 239.06 20690 481.92 457.82 526.49 20103 486.95 462.60 531.99 20692 901.90 856.81 985.33 # 20103 311.46 295.89 340.27 20693 403.84 383.65 441.20 20150 850.43 807.91 929.10 20694 368.92 350.47 403.04 20200 165.91 157.61 181.25 # 20694 295.18 280.42 322.48 # 20200 82.59 78.46 90.23 20696 957.32 909.45 1,045.87 20205 226.36 215.04 247.30 20697 1,172.98 1,114.33 1,281.48 # 20205 131.70 125.12 143.89 # 20697 0.18 0.17 0.20 20206 232.64 221.01 254.16 20802 2,202.43 2,092.31 2,406.16 # 20206 58.57 55.64 63.99 20805 2,697.91 2,563.01 2,947.46 20220 159.96 151.96 174.75 20808 3,655.18 3,472.42 3,993.28 # 20220 73.10 69.45 79.87 20816 2,018.45 1,917.53 2,205.16 20225 605.96 575.66 662.01 20822 1,709.97 1,624.47 1,868.14 # 20225 110.32 104.80 120.52 20824 2,009.76 1,909.27 2,195.66 20240 202.62 192.49 221.36 20827 1,781.78 1,692.69 1,946.59 20245 552.48 524.86 603.59 20838 2,241.84 2,129.75 2,449.21 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 VERMONT - MEDICARE CARRIER 31145 PAGE 9 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 366.22 347.91 400.10 # 21076 742.63 705.50 811.33 # 20900 232.56 220.93 254.07 21077 2,098.89 1,993.95 2,293.04 20902 321.06 305.01 350.76 # 21077 1,880.14 1,786.13 2,054.05 20910 381.01 361.96 416.25 21079 1,435.43 1,363.66 1,568.21 20912 428.07 406.67 467.67 # 21079 1,243.98 1,181.78 1,359.05 20920 360.28 342.27 393.61 21080 1,629.40 1,547.93 1,780.12 20922 534.87 508.13 584.35 # 21080 1,398.24 1,328.33 1,527.58 # 20922 441.98 419.88 482.86 21081 1,488.41 1,413.99 1,626.09 20924 444.63 422.40 485.76 # 21081 1,274.27 1,210.56 1,392.14 20926 384.01 364.81 419.53 21082 1,384.90 1,315.66 1,513.01 20931 100.52 95.49 109.81 # 21082 1,179.98 1,120.98 1,289.13 20937 153.76 146.07 167.98 21083 1,315.71 1,249.92 1,437.41 20938 166.65 158.32 182.07 # 21083 1,092.35 1,037.73 1,193.39 20950 214.89 204.15 234.77 21084 1,504.94 1,429.69 1,644.14 # 20950 80.88 76.84 88.37 # 21084 1,258.18 1,195.27 1,374.56 20955 2,283.19 2,169.03 2,494.38 21085 606.87 576.53 663.01 20956 2,371.66 2,253.08 2,591.04 # 21085 505.47 480.20 552.23 20957 2,260.13 2,147.12 2,469.19 21086 1,529.49 1,453.02 1,670.97 20962 2,325.97 2,209.67 2,541.12 # 21086 1,375.62 1,306.84 1,502.87 20969 2,532.37 2,405.75 2,766.61 21087 1,525.44 1,449.17 1,666.55 20970 2,534.52 2,407.79 2,768.96 # 21087 1,372.28 1,303.67 1,499.22 20972 2,316.20 2,200.39 2,530.45 21100 619.66 588.68 676.98 20973 2,430.61 2,309.08 2,655.44 # 21100 350.92 333.37 383.38 20974 57.27 54.41 62.57 21110 649.81 617.32 709.92 # 20974 42.38 40.26 46.30 # 21110 553.02 525.37 604.18 20975 158.43 150.51 173.09 21116 131.67 125.09 143.85 20979 46.99 44.64 51.34 # 21116 39.49 37.52 43.15 # 20979 32.46 30.84 35.47 21120 539.77 512.78 589.70 20982 3,342.52 3,175.39 3,651.70 # 21120 433.77 412.08 473.89 # 20982 377.54 358.66 412.46 21121 672.23 638.62 734.41 20985 136.21 129.40 148.81 # 21121 574.02 545.32 627.12 21010 644.21 612.00 703.80 21122 632.16 600.55 690.63 21015 375.63 356.85 410.38 21123 755.53 717.75 825.41 21025 773.15 734.49 844.66 21125 2,655.38 2,522.61 2,901.00 # 21025 658.63 625.70 719.56 # 21125 662.54 629.41 723.82 21026 513.16 487.50 560.63 21127 3,157.41 2,999.54 3,449.47 # 21026 424.88 403.64 464.19 # 21127 770.68 732.15 841.97 21029 652.71 620.07 713.08 21137 635.03 603.28 693.77 # 21029 552.74 525.10 603.87 21138 792.41 752.79 865.71 21030 429.05 407.60 468.74 21139 893.59 848.91 976.25 # 21030 352.82 335.18 385.46 21141 1,194.33 1,134.61 1,304.80 21031 329.90 313.41 360.42 21142 1,178.99 1,120.04 1,288.05 # 21031 252.26 239.65 275.60 21143 1,228.63 1,167.20 1,342.28 21032 334.34 317.62 365.26 21145 1,370.16 1,301.65 1,496.90 # 21032 248.55 236.12 271.54 21146 1,463.40 1,390.23 1,598.76 21034 1,167.57 1,109.19 1,275.57 21147 1,513.95 1,438.25 1,653.99 # 21034 1,039.59 987.61 1,135.75 21150 1,498.59 1,423.66 1,637.21 21040 432.59 410.96 472.60 21151 1,819.75 1,728.76 1,988.07 # 21040 350.69 333.16 383.13 21154 1,834.92 1,743.17 2,004.65 21044 778.74 739.80 850.77 21155 2,057.29 1,954.43 2,247.59 21045 1,085.93 1,031.63 1,186.37 21159 2,486.74 2,362.40 2,716.76 21046 957.84 909.95 1,046.44 21160 2,583.19 2,454.03 2,822.13 21047 1,157.65 1,099.77 1,264.74 21172 1,582.87 1,503.73 1,729.29 21048 971.10 922.55 1,060.93 21175 1,908.67 1,813.24 2,085.23 21049 1,122.49 1,066.37 1,226.33 21179 1,311.33 1,245.76 1,432.62 21050 762.63 724.50 833.18 21180 1,493.53 1,418.85 1,631.68 21060 696.13 661.32 760.52 21181 625.49 594.22 683.35 21070 565.08 536.83 617.35 21182 1,824.05 1,732.85 1,992.78 21073 319.13 303.17 348.65 21183 2,032.68 1,931.05 2,220.71 # 21073 210.29 199.78 229.75 21184 2,166.95 2,058.60 2,367.39 21076 850.76 808.22 929.45 21188 1,451.92 1,379.32 1,586.22 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 VERMONT - MEDICARE CARRIER 31145 PAGE 10 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 1,101.78 1,046.69 1,203.69 21345 700.24 665.23 765.01 21194 1,261.16 1,198.10 1,377.82 # 21345 577.57 548.69 630.99 21195 1,188.13 1,128.72 1,298.03 21346 838.37 796.45 915.92 21196 1,292.99 1,228.34 1,412.59 21347 971.51 922.93 1,061.37 21198 1,018.72 967.78 1,112.95 21348 1,023.86 972.67 1,118.57 21199 919.27 873.31 1,004.31 21355 380.55 361.52 415.75 21206 1,003.94 953.74 1,096.80 # 21355 285.54 271.26 311.95 21208 1,503.76 1,428.57 1,642.86 21356 425.80 404.51 465.19 # 21208 729.81 693.32 797.32 # 21356 327.59 311.21 357.89 21209 710.44 674.92 776.16 21360 465.49 442.22 508.55 # 21209 561.19 533.13 613.10 21365 974.31 925.59 1,064.43 21210 1,800.11 1,710.10 1,966.62 21366 1,078.94 1,024.99 1,178.74 # 21210 727.64 691.26 794.95 21385 628.45 597.03 686.58 21215 3,069.83 2,916.34 3,353.79 21386 585.91 556.61 640.10 # 21215 757.56 719.68 827.63 21387 655.19 622.43 715.79 21230 677.98 644.08 740.69 21390 679.26 645.30 742.10 21235 631.78 600.19 690.22 21395 854.75 812.01 933.81 # 21235 499.18 474.22 545.35 21400 153.14 145.48 167.30 21240 978.23 929.32 1,068.72 # 21400 125.84 119.55 137.48 21242 897.97 853.07 981.03 21401 408.45 388.03 446.23 21243 1,471.93 1,398.33 1,608.08 # 21401 257.77 244.88 281.61 21244 922.59 876.46 1,007.93 21406 475.06 451.31 519.01 21245 996.41 946.59 1,088.58 21407 562.00 533.90 613.99 # 21245 811.34 770.77 886.39 21408 772.02 733.42 843.43 21246 755.96 718.16 825.88 21421 630.13 598.62 688.41 21247 1,433.34 1,361.67 1,565.92 # 21421 538.31 511.39 588.10 21248 934.83 888.09 1,021.30 21422 588.58 559.15 643.02 # 21248 775.65 736.87 847.40 21423 698.68 663.75 763.31 21249 1,294.40 1,229.68 1,414.13 21431 645.68 613.40 705.41 # 21249 1,098.70 1,043.77 1,200.34 21432 587.98 558.58 642.37 21255 1,271.81 1,208.22 1,389.45 21433 1,505.35 1,430.08 1,644.59 21256 1,038.70 986.77 1,134.79 21435 1,188.62 1,129.19 1,298.57 21260 1,177.03 1,118.18 1,285.91 21436 1,747.90 1,660.51 1,909.59 21261 1,999.24 1,899.28 2,184.17 21440 458.97 436.02 501.42 21263 1,801.73 1,711.64 1,968.39 # 21440 381.33 362.26 416.60 21267 1,370.43 1,301.91 1,497.20 21445 650.30 617.79 710.46 21268 1,691.62 1,607.04 1,848.10 # 21445 537.21 510.35 586.90 21270 797.35 757.48 871.10 21450 478.46 454.54 522.72 # 21270 620.79 589.75 678.21 # 21450 400.11 380.10 437.12 21275 713.08 677.43 779.04 21451 630.64 599.11 688.98 21280 462.97 439.82 505.79 # 21451 537.04 510.19 586.72 21282 306.33 291.01 334.66 21452 519.89 493.90 567.99 21295 153.20 145.54 167.37 # 21452 288.73 274.29 315.43 21296 372.61 353.98 407.08 21453 729.94 693.44 797.46 21310 92.71 88.07 101.28 # 21453 648.05 615.65 708.00 # 21310 26.05 24.75 28.46 21454 484.72 460.48 529.55 21315 226.56 215.23 247.51 21461 1,657.60 1,574.72 1,810.93 # 21315 130.13 123.62 142.16 # 21461 800.34 760.32 874.37 21320 217.74 206.85 237.88 21462 1,790.33 1,700.81 1,955.93 # 21320 121.31 115.24 132.53 # 21462 885.56 841.28 967.47 21325 410.71 390.17 448.70 21465 802.63 762.50 876.88 21330 502.62 477.49 549.11 21470 1,047.23 994.87 1,144.10 21335 648.88 616.44 708.91 21480 78.72 74.78 86.00 21336 561.48 533.41 613.42 # 21480 29.44 27.97 32.17 21337 338.78 321.84 370.12 21485 564.17 535.96 616.35 # 21337 249.44 236.97 272.52 # 21485 481.92 457.82 526.49 21338 642.23 610.12 701.64 21490 810.81 770.27 885.81 21339 715.19 679.43 781.34 21495 596.40 566.58 651.57 21340 711.48 675.91 777.30 21497 569.94 541.44 622.66 21343 1,012.03 961.43 1,105.64 # 21497 487.33 462.96 532.40 21344 1,325.72 1,259.43 1,448.34 21501 377.61 358.73 412.54 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 VERMONT - MEDICARE CARRIER 31145 PAGE 11 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 275.50 261.73 300.99 22310 247.91 235.51 270.84 21502 458.80 435.86 501.24 # 22310 231.25 219.69 252.64 21510 406.04 385.74 443.60 22315 737.31 700.44 805.51 21550 222.49 211.37 243.08 # 22315 655.06 622.31 715.66 # 21550 140.59 133.56 153.59 22318 1,383.97 1,314.77 1,511.99 21555 371.72 353.13 406.10 22319 1,519.34 1,443.37 1,659.88 # 21555 289.82 275.33 316.63 22325 1,217.10 1,156.25 1,329.69 21556 362.71 344.57 396.26 22326 1,266.07 1,202.77 1,383.19 21557 512.35 486.73 559.74 22327 1,258.94 1,195.99 1,375.39 21600 484.86 460.62 529.71 22328 252.33 239.71 275.67 21610 935.78 888.99 1,022.34 22505 107.83 102.44 117.81 21615 594.19 564.48 649.15 22520 2,031.28 1,929.72 2,219.18 21616 758.60 720.67 828.77 # 22520 519.90 493.91 568.00 21620 460.59 437.56 503.19 22521 1,978.82 1,879.88 2,161.86 21627 484.00 459.80 528.77 # 22521 490.13 465.62 535.46 21630 1,125.19 1,068.93 1,229.27 22522 228.76 217.32 249.92 21632 1,112.20 1,056.59 1,215.08 22523 544.74 517.50 595.13 21685 884.03 839.83 965.80 22524 522.17 496.06 570.47 21700 376.41 357.59 411.23 22525 243.75 231.56 266.29 21705 572.62 543.99 625.59 22526 1,713.18 1,627.52 1,871.65 21720 359.56 341.58 392.82 # 22526 307.10 291.75 335.51 21725 466.73 443.39 509.90 22527 1,331.31 1,264.74 1,454.45 21740 967.92 919.52 1,057.45 # 22527 139.72 132.73 152.64 21750 641.61 609.53 700.96 22532 1,518.48 1,442.56 1,658.94 21800 84.44 80.22 92.25 22533 1,436.84 1,365.00 1,569.75 # 21800 85.86 81.57 93.81 22534 330.26 313.75 360.81 21805 225.39 214.12 246.24 22548 1,610.48 1,529.96 1,759.45 21810 439.88 417.89 480.57 22554 1,110.47 1,054.95 1,213.19 21820 112.47 106.85 122.88 22556 1,447.13 1,374.77 1,580.99 # 21820 113.89 108.20 124.43 22558 1,335.37 1,268.60 1,458.89 21825 499.34 474.37 545.53 22585 304.45 289.23 332.61 21920 222.14 211.03 242.68 22590 1,337.15 1,270.29 1,460.83 # 21920 140.59 133.56 153.59 22595 1,270.56 1,207.03 1,388.08 21925 363.29 345.13 396.90 22600 1,089.59 1,035.11 1,190.38 # 21925 294.16 279.45 321.37 22610 1,076.42 1,022.60 1,175.99 21930 405.44 385.17 442.95 22612 1,394.31 1,324.59 1,523.28 # 21930 326.02 309.72 356.18 22614 355.87 338.08 388.79 21935 1,026.43 975.11 1,121.38 22630 1,338.07 1,271.17 1,461.85 22010 792.14 752.53 865.41 22632 288.85 274.41 315.57 22015 787.82 748.43 860.69 22800 1,185.00 1,125.75 1,294.61 22100 711.95 676.35 777.80 22802 1,882.97 1,788.82 2,057.14 22101 711.49 675.92 777.31 22804 2,176.04 2,067.24 2,377.33 22102 708.83 673.39 774.40 22808 1,604.08 1,523.88 1,752.46 22103 128.67 122.24 140.58 22810 1,791.22 1,701.66 1,956.91 22110 883.73 839.54 965.47 22812 1,962.51 1,864.38 2,144.04 22112 856.50 813.68 935.73 22818 1,970.85 1,872.31 2,153.16 22114 878.65 834.72 959.93 22819 2,269.13 2,155.67 2,479.02 22116 127.59 121.21 139.39 22830 706.11 670.80 771.42 22206 2,105.19 1,999.93 2,299.92 22840 693.98 659.28 758.17 22207 2,078.31 1,974.39 2,270.55 22842 695.78 660.99 760.14 22208 526.37 500.05 575.06 22843 741.16 704.10 809.72 22210 1,541.54 1,464.46 1,684.13 22844 910.12 864.61 994.30 22212 1,278.94 1,214.99 1,397.24 22845 662.60 629.47 723.89 22214 1,286.93 1,222.58 1,405.97 22846 688.04 653.64 751.69 22216 334.54 317.81 365.48 22847 760.86 722.82 831.24 22220 1,386.92 1,317.57 1,515.21 22848 331.69 315.11 362.38 22222 1,267.80 1,204.41 1,385.07 22849 1,144.09 1,086.89 1,249.92 22224 1,378.05 1,309.15 1,505.52 22850 624.63 593.40 682.41 22226 333.12 316.46 363.93 22851 370.03 351.53 404.26 22305 159.89 151.90 174.69 22852 597.60 567.72 652.88 # 22305 147.49 140.12 161.14 22855 967.30 918.94 1,056.78 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 VERMONT - MEDICARE CARRIER 31145 PAGE 12 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 1,444.34 1,372.12 1,577.94 23405 553.68 526.00 604.90 22857 1,521.90 1,445.81 1,662.68 23406 691.83 657.24 755.83 22861 1,774.64 1,685.91 1,938.80 23410 732.95 696.30 800.75 22862 1,750.59 1,663.06 1,912.52 23412 765.71 727.42 836.53 22864 1,612.35 1,531.73 1,761.49 23415 610.59 580.06 667.07 22865 1,875.22 1,781.46 2,048.68 23420 859.92 816.92 939.46 22900 359.65 341.67 392.92 23430 650.90 618.36 711.11 23000 457.50 434.63 499.82 23440 671.22 637.66 733.31 # 23000 312.15 296.54 341.02 23450 842.16 800.05 920.06 23020 605.04 574.79 661.01 23455 898.22 853.31 981.31 23030 364.92 346.67 398.67 23460 972.47 923.85 1,062.43 # 23030 224.88 213.64 245.69 23462 954.17 906.46 1,042.43 23031 333.50 316.83 364.35 23465 995.09 945.34 1,087.14 # 23031 186.36 177.04 203.60 23466 982.33 933.21 1,073.19 23035 600.50 570.48 656.05 23470 1,082.90 1,028.76 1,183.07 23040 630.10 598.60 688.39 23472 1,341.36 1,274.29 1,465.43 23044 499.76 474.77 545.99 23480 723.87 687.68 790.83 23065 185.74 176.45 202.92 23485 855.23 812.47 934.34 # 23065 146.74 139.40 160.31 23490 742.02 704.92 810.66 23066 435.23 413.47 475.49 23491 900.44 855.42 983.73 # 23066 295.19 280.43 322.49 23500 177.48 168.61 193.90 23075 223.03 211.88 243.66 # 23500 176.42 167.60 192.74 # 23075 155.32 147.55 169.68 23505 292.07 277.47 319.09 23076 492.68 468.05 538.26 # 23505 276.83 262.99 302.44 23077 1,046.82 994.48 1,143.65 23515 616.59 585.76 673.62 23100 425.18 403.92 464.51 23520 183.91 174.71 200.92 23101 390.87 371.33 427.03 # 23520 184.97 175.72 202.08 23105 557.01 529.16 608.53 23525 286.55 272.22 313.05 23106 415.04 394.29 453.43 # 23525 268.11 254.70 292.91 23107 578.69 549.76 632.22 23530 470.98 447.43 514.54 23120 500.85 475.81 547.18 23532 541.95 514.85 592.08 23125 615.49 584.72 672.43 23540 182.01 172.91 198.85 23130 526.79 500.45 575.52 # 23540 179.53 170.55 196.13 23140 448.79 426.35 490.30 23545 263.47 250.30 287.85 23145 604.90 574.66 660.86 # 23545 242.91 230.76 265.37 23146 525.04 498.79 573.61 23550 499.94 474.94 546.18 23150 572.88 544.24 625.88 23552 575.65 546.87 628.90 23155 692.97 658.32 757.07 23570 189.62 180.14 207.16 23156 588.94 559.49 643.41 # 23570 192.11 182.50 209.88 23170 463.02 439.87 505.85 23575 324.21 308.00 354.20 23172 475.68 451.90 519.69 # 23575 305.78 290.49 334.06 23174 658.80 625.86 719.74 23585 838.10 796.20 915.63 23180 599.67 569.69 655.14 23600 265.22 251.96 289.75 23182 578.88 549.94 632.43 # 23600 245.36 233.09 268.05 23184 653.04 620.39 713.45 23605 391.52 371.94 427.73 23190 486.40 462.08 531.39 # 23605 361.74 343.65 395.20 23195 659.35 626.38 720.34 23615 765.99 727.69 836.84 23200 778.72 739.78 850.75 23616 1,136.82 1,079.98 1,241.98 23210 814.63 773.90 889.99 23620 218.45 207.53 238.66 23220 942.86 895.72 1,030.08 # 23620 206.04 195.74 225.10 23221 1,099.79 1,044.80 1,201.52 23625 317.39 301.52 346.75 23222 1,498.79 1,423.85 1,637.43 # 23625 298.25 283.34 325.84 23330 192.93 183.28 210.77 23630 658.42 625.50 719.33 # 23330 129.82 123.33 141.83 23650 248.13 235.72 271.08 23331 513.07 487.42 560.53 # 23650 227.21 215.85 248.23 23332 778.96 740.01 851.01 23655 328.42 312.00 358.80 23350 140.29 133.28 153.27 23660 506.71 481.37 553.58 # 23350 50.24 47.73 54.89 23665 353.53 335.85 386.23 23395 1,135.18 1,078.42 1,240.18 # 23665 332.97 316.32 363.77 23397 1,016.11 965.30 1,110.10 23670 740.13 703.12 808.59 23400 861.22 818.16 940.88 23675 461.55 438.47 504.24 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 13 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 427.51 406.13 467.05 24332 526.71 500.37 575.43 23680 799.84 759.85 873.83 24340 535.14 508.38 584.64 23700 170.28 161.77 186.04 24341 631.30 599.74 689.70 23800 906.77 861.43 990.64 24342 689.96 655.46 753.78 23802 1,102.33 1,047.21 1,204.29 24343 612.88 582.24 669.58 23900 1,175.38 1,116.61 1,284.10 24344 956.10 908.30 1,044.55 23920 952.49 904.87 1,040.60 24345 608.80 578.36 665.11 23921 345.50 328.23 377.46 24346 958.41 910.49 1,047.06 23930 303.31 288.14 331.36 24357 383.78 364.59 419.28 # 23930 189.15 179.69 206.64 24358 452.93 430.28 494.82 23931 236.85 225.01 258.76 24359 570.26 541.75 623.01 # 23931 136.52 129.69 149.14 24360 793.85 754.16 867.28 23935 432.20 410.59 472.18 24361 891.17 846.61 973.60 24000 411.12 390.56 449.14 24362 940.97 893.92 1,028.01 24006 622.65 591.52 680.25 24363 1,324.22 1,258.01 1,446.71 24065 217.36 206.49 237.46 24365 560.11 532.10 611.92 # 24065 146.10 138.80 159.62 24366 600.09 570.09 655.60 24066 502.34 477.22 548.80 24400 724.09 687.89 791.07 # 24066 346.34 329.02 378.37 24410 925.06 878.81 1,010.63 24075 407.61 387.23 445.31 24420 870.00 826.50 950.48 # 24075 271.11 257.55 296.18 24430 924.80 878.56 1,010.34 24076 413.48 392.81 451.73 24435 938.07 891.17 1,024.85 24077 715.71 679.92 781.91 24470 551.61 524.03 602.63 24100 350.60 333.07 383.03 24495 576.14 547.33 629.43 24101 432.16 410.55 472.13 24498 769.34 730.87 840.50 24102 536.50 509.68 586.13 24500 288.79 274.35 315.50 24105 290.25 275.74 317.10 # 24500 261.85 248.76 286.07 24110 507.19 481.83 554.10 24505 419.19 398.23 457.96 24115 640.60 608.57 699.86 # 24505 383.73 364.54 419.22 24116 760.63 722.60 830.99 24515 771.36 732.79 842.71 24120 454.27 431.56 496.29 24516 762.91 724.76 833.47 24125 526.34 500.02 575.02 24530 310.76 295.22 339.50 24126 558.54 530.61 610.20 # 24530 281.69 267.61 307.75 24130 438.79 416.85 479.38 24535 524.62 498.39 573.15 24134 659.81 626.82 720.84 # 24535 488.81 464.37 534.03 24136 521.16 495.10 569.37 24538 650.66 618.13 710.85 24138 576.85 548.01 630.21 24545 804.26 764.05 878.66 24140 628.74 597.30 686.90 24546 931.28 884.72 1,017.43 24145 527.02 500.67 575.77 24560 259.47 246.50 283.48 24147 547.39 520.02 598.02 # 24560 230.39 218.87 251.70 24149 1,014.48 963.76 1,108.32 24565 431.47 409.90 471.39 24150 857.83 814.94 937.18 # 24565 399.57 379.59 436.53 24151 986.72 937.38 1,077.99 24566 610.51 579.98 666.98 24152 646.43 614.11 706.23 24575 644.37 612.15 703.97 24153 697.40 662.53 761.91 24576 272.98 259.33 298.23 24155 747.26 709.90 816.39 # 24576 245.33 233.06 268.02 24160 528.01 501.61 576.85 24577 448.99 426.54 490.52 24164 431.54 409.96 471.45 # 24577 414.60 393.87 452.95 24200 169.12 160.66 184.76 24579 732.99 696.34 800.79 # 24200 118.07 112.17 129.00 24582 680.96 646.91 743.95 24201 471.46 447.89 515.07 24586 969.61 921.13 1,059.30 # 24201 315.82 300.03 345.03 24587 966.08 917.78 1,055.45 24220 153.95 146.25 168.19 24600 305.35 290.08 333.59 # 24220 66.38 63.06 72.52 # 24600 278.41 264.49 304.16 24300 337.88 320.99 369.14 24605 394.52 374.79 431.01 24301 660.97 627.92 722.11 24615 628.38 596.96 686.50 24305 504.93 479.68 551.63 24620 477.01 453.16 521.13 24310 413.10 392.45 451.32 24635 656.19 623.38 716.89 24320 680.75 646.71 743.72 24640 101.07 96.02 110.42 24330 627.99 596.59 686.08 # 24640 74.13 70.42 80.98 24331 694.63 659.90 758.89 24650 210.68 200.15 230.17 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 14 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 190.47 180.95 208.09 25246 156.34 148.52 170.80 24655 363.95 345.75 397.61 # 25246 73.03 69.38 79.79 # 24655 333.82 317.13 364.70 25248 384.25 365.04 419.80 24665 565.25 536.99 617.54 25250 456.20 433.39 498.40 24666 642.22 610.11 701.63 25251 624.14 592.93 681.87 24670 236.79 224.95 258.69 25259 339.12 322.16 370.48 # 24670 212.68 202.05 232.36 25260 595.56 565.78 650.65 24675 384.17 364.96 419.70 25263 594.68 564.95 649.69 # 24675 354.03 336.33 386.78 25265 705.65 670.37 770.93 24685 567.19 538.83 619.65 25270 478.17 454.26 522.40 24800 698.28 663.37 762.88 25272 538.01 511.11 587.78 24802 883.12 838.96 964.80 25274 637.42 605.55 696.38 24900 630.53 599.00 688.85 25275 586.90 557.56 641.19 24920 625.90 594.61 683.80 25280 545.39 518.12 595.84 24925 486.12 461.81 531.08 25290 462.68 439.55 505.48 24930 664.08 630.88 725.51 25295 507.76 482.37 554.73 24931 742.59 705.46 811.28 25300 598.47 568.55 653.83 24935 902.16 857.05 985.61 25301 569.32 540.85 621.98 25000 301.82 286.73 329.74 25310 590.27 560.76 644.87 25001 285.66 271.38 312.09 25312 683.51 649.33 746.73 25020 500.10 475.10 546.37 25315 732.42 695.80 800.17 25023 961.91 913.81 1,050.88 25316 847.74 805.35 926.15 25024 673.27 639.61 735.55 25320 843.62 801.44 921.66 25025 1,040.48 988.46 1,136.73 25332 742.61 705.48 811.30 25028 445.46 423.19 486.67 25335 844.12 801.91 922.20 25031 327.44 311.07 357.73 25337 775.68 736.90 847.44 25035 565.74 537.45 618.07 25350 649.20 616.74 709.25 25040 500.26 475.25 546.54 25355 729.48 693.01 796.96 25065 215.89 205.10 235.87 25360 630.03 598.53 688.31 # 25065 144.27 137.06 157.62 25365 856.39 813.57 935.61 25066 327.97 311.57 358.31 25370 933.85 887.16 1,020.23 25075 287.14 272.78 313.70 25375 900.91 855.86 984.24 25076 388.01 368.61 423.90 25390 734.38 697.66 802.31 25077 657.22 624.36 718.01 25391 932.74 886.10 1,019.02 25085 403.42 383.25 440.74 25392 947.65 900.27 1,035.31 25100 299.64 284.66 327.36 25393 1,062.61 1,009.48 1,160.90 25101 352.94 335.29 385.58 25394 682.70 648.57 745.86 25105 428.98 407.53 468.66 25400 769.81 731.32 841.02 25107 534.36 507.64 583.79 25405 978.74 929.80 1,069.27 25109 455.77 432.98 497.93 25415 919.69 873.71 1,004.77 25110 314.01 298.31 343.06 25420 1,094.64 1,039.91 1,195.90 25111 272.39 258.77 297.59 25425 947.48 900.11 1,035.13 25112 332.82 316.18 363.61 25426 989.88 940.39 1,081.45 25115 704.56 669.33 769.73 25430 623.53 592.35 681.20 25116 569.38 540.91 622.05 25431 687.66 653.28 751.27 25118 333.78 317.09 364.65 25440 685.08 650.83 748.45 25119 441.86 419.77 482.74 25441 829.69 788.21 906.44 25120 485.50 461.23 530.41 25442 708.40 672.98 773.93 25125 565.76 537.47 618.09 25443 680.12 646.11 743.03 25126 570.22 541.71 622.97 25444 723.98 687.78 790.95 25130 391.76 372.17 428.00 25445 633.55 601.87 692.15 25135 489.18 464.72 534.43 25446 1,044.12 991.91 1,140.70 25136 431.70 410.12 471.64 25447 715.82 680.03 782.03 25145 498.60 473.67 544.72 25449 914.36 868.64 998.94 25150 506.73 481.39 553.60 25450 530.52 503.99 579.59 25151 561.15 533.09 613.05 25455 608.14 577.73 664.39 25170 780.39 741.37 852.58 25490 668.57 635.14 730.41 25210 429.40 407.93 469.12 25491 705.15 669.89 770.37 25215 553.10 525.45 604.27 25492 848.62 806.19 927.12 25230 380.21 361.20 415.38 25500 216.18 205.37 236.18 25240 385.49 366.22 421.15 # 25500 197.03 187.18 215.26 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 VERMONT - MEDICARE CARRIER 31145 PAGE 15 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 421.16 400.10 460.12 25920 600.08 570.08 655.59 # 25505 389.26 369.80 425.27 25922 507.25 481.89 554.17 25515 583.22 554.06 637.17 25924 585.94 556.64 640.14 25520 464.34 441.12 507.29 25927 682.73 648.59 745.88 # 25520 442.71 420.57 483.66 25929 490.34 465.82 535.69 25525 703.71 668.52 768.80 25931 622.18 591.07 679.73 25526 866.43 823.11 946.58 26010 215.43 204.66 235.36 25530 209.40 198.93 228.77 # 26010 114.39 108.67 124.97 # 25530 188.13 178.72 205.53 26011 328.38 311.96 358.75 25535 408.18 387.77 445.94 # 26011 159.27 151.31 174.01 # 25535 382.65 363.52 418.05 26020 367.62 349.24 401.63 25545 545.47 518.20 595.93 26025 358.94 340.99 392.14 25560 219.01 208.06 239.27 26030 424.17 402.96 463.40 # 25560 195.96 186.16 214.08 26034 459.64 436.66 502.16 25565 441.09 419.04 481.90 26035 717.01 681.16 783.33 # 25565 404.22 384.01 441.61 26037 494.98 470.23 540.76 25574 575.81 547.02 629.07 26040 263.49 250.32 287.87 25575 782.62 743.49 855.01 26045 401.33 381.26 438.45 25600 238.44 226.52 260.50 26055 480.25 456.24 524.68 # 25600 215.40 204.63 235.32 # 26055 252.99 240.34 276.39 25605 519.00 493.05 567.01 26060 225.60 214.32 246.47 # 25605 491.34 466.77 536.79 26070 257.15 244.29 280.93 25606 576.01 547.21 629.29 26075 272.28 258.67 297.47 25607 622.50 591.38 680.09 26080 328.43 312.01 358.81 25608 708.47 673.05 774.01 26100 275.93 262.13 301.45 25609 904.35 859.13 988.00 26105 282.15 268.04 308.25 25622 244.64 232.41 267.27 26110 271.06 257.51 296.14 # 25622 220.18 209.17 240.55 26115 526.53 500.20 575.23 25624 386.73 367.39 422.50 # 26115 307.43 292.06 335.87 # 25624 353.40 335.73 386.09 26116 413.56 392.88 451.81 25628 625.26 594.00 683.10 26117 564.27 536.06 616.47 25630 250.47 237.95 273.64 26121 518.46 492.54 566.42 # 25630 226.36 215.04 247.30 26123 710.67 675.14 776.41 25635 365.72 347.43 399.54 26125 253.41 240.74 276.85 # 25635 326.72 310.38 356.94 26130 392.20 372.59 428.48 25645 492.57 467.94 538.13 26135 478.04 454.14 522.26 25650 261.21 248.15 285.37 26140 434.85 413.11 475.08 # 25650 240.65 228.62 262.91 26145 441.85 419.76 482.72 25651 408.28 387.87 446.05 26160 480.52 456.49 524.96 25652 537.44 510.57 587.16 # 26160 275.60 261.82 301.09 25660 341.85 324.76 373.47 26170 347.68 330.30 379.85 25670 531.62 505.04 580.80 26180 380.01 361.01 415.16 25671 449.08 426.63 490.62 26185 454.95 432.20 497.03 25675 360.94 342.89 394.32 26200 389.77 370.28 425.82 # 25675 332.93 316.28 363.72 26205 523.73 497.54 572.17 25676 550.52 522.99 601.44 26210 378.04 359.14 413.01 25680 394.35 374.63 430.82 26215 480.80 456.76 525.27 25685 640.23 608.22 699.45 26230 436.18 414.37 476.53 25690 397.94 378.04 434.75 26235 428.65 407.22 468.30 25695 552.43 524.81 603.53 26236 379.91 360.91 415.05 25800 653.52 620.84 713.97 26250 506.77 481.43 553.64 25805 753.42 715.75 823.11 26255 771.19 732.63 842.52 25810 761.50 723.43 831.94 26260 474.55 450.82 518.44 25820 534.53 507.80 583.97 26261 588.80 559.36 643.26 25825 659.31 626.34 720.29 26262 395.90 376.11 432.53 25830 825.21 783.95 901.54 26320 295.79 281.00 323.15 25900 657.67 624.79 718.51 26340 266.23 252.92 290.86 25905 649.52 617.04 709.60 26350 616.81 585.97 673.87 25907 567.79 539.40 620.31 26352 701.13 666.07 765.98 25909 638.36 606.44 697.41 26356 917.84 871.95 1,002.74 25915 1,114.77 1,059.03 1,217.88 26357 752.37 714.75 821.96 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 16 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 795.79 756.00 869.40 26550 1,306.33 1,241.01 1,427.16 26370 667.28 633.92 729.01 26551 2,830.38 2,688.86 3,092.19 26372 773.25 734.59 844.78 26553 2,504.88 2,379.64 2,736.59 26373 735.49 698.72 803.53 26554 3,237.15 3,075.29 3,536.58 26390 721.03 684.98 787.73 26555 1,198.03 1,138.13 1,308.85 26392 843.46 801.29 921.48 26556 2,587.33 2,457.96 2,826.65 26410 490.47 465.95 535.84 26560 492.33 467.71 537.87 26412 595.36 565.59 650.43 26561 789.95 750.45 863.02 26415 626.92 595.57 684.91 26562 1,149.33 1,091.86 1,255.64 26416 673.13 639.47 735.39 26565 585.87 556.58 640.07 26418 492.74 468.10 538.32 26567 591.59 562.01 646.31 26420 618.32 587.40 675.51 26568 778.18 739.27 850.16 26426 497.41 472.54 543.42 26580 1,222.31 1,161.19 1,335.37 26428 650.15 617.64 710.29 26587 837.39 795.52 914.85 26432 428.94 407.49 468.61 26590 1,108.74 1,053.30 1,211.30 26433 460.11 437.10 502.67 26591 377.43 358.56 412.34 26434 551.97 524.37 603.03 26593 514.82 489.08 562.44 26437 537.99 511.09 587.75 26596 636.65 604.82 695.54 26440 541.05 514.00 591.10 26600 228.40 216.98 249.53 26442 819.73 778.74 895.55 # 26600 211.02 200.47 230.54 26445 502.33 477.21 548.79 26605 262.86 249.72 287.18 26449 657.72 624.83 718.55 # 26605 239.82 227.83 262.00 26450 347.01 329.66 379.11 26607 376.73 357.89 411.57 26455 344.68 327.45 376.57 26608 408.13 387.72 445.88 26460 335.18 318.42 366.18 26615 474.63 450.90 518.54 26471 529.95 503.45 578.97 26641 303.25 288.09 331.30 26474 508.80 483.36 555.86 # 26641 277.37 263.50 303.03 26476 495.06 470.31 540.86 26645 344.98 327.73 376.89 26477 499.29 474.33 545.48 # 26645 318.39 302.47 347.84 26478 542.05 514.95 592.19 26650 407.98 387.58 445.72 26479 535.98 509.18 585.56 26665 527.27 500.91 576.05 26480 652.50 619.88 712.86 26670 273.65 259.97 298.97 26483 736.42 699.60 804.54 # 26670 247.06 234.71 269.92 26485 705.75 670.46 771.03 26675 367.81 349.42 401.83 26489 763.50 725.33 834.13 # 26675 340.16 323.15 371.62 26490 681.72 647.63 744.77 26676 427.91 406.51 467.49 26492 759.56 721.58 829.82 26685 485.77 461.48 530.70 26494 689.73 655.24 753.53 26686 538.40 511.48 588.20 26496 748.01 710.61 817.20 26700 261.25 248.19 285.42 26497 748.71 711.27 817.96 # 26700 243.52 231.34 266.04 26498 999.54 949.56 1,091.99 26705 337.59 320.71 368.82 26499 715.38 679.61 781.55 # 26705 310.29 294.78 339.00 26500 541.08 514.03 591.13 26706 370.94 352.39 405.25 26502 610.39 579.87 666.85 26715 475.13 451.37 519.08 26508 543.59 516.41 593.87 26720 158.08 150.18 172.71 26510 516.13 490.32 563.87 # 26720 144.61 137.38 157.99 26516 608.80 578.36 665.11 26725 282.29 268.18 308.41 26517 716.39 680.57 782.66 # 26725 253.57 240.89 277.02 26518 723.60 687.42 790.53 26727 401.32 381.25 438.44 26520 565.51 537.23 617.81 26735 494.86 470.12 540.64 26525 567.83 539.44 620.36 26740 183.95 174.75 200.96 26530 463.53 440.35 506.40 # 26740 172.61 163.98 188.58 26531 539.96 512.96 589.90 26742 309.37 293.90 337.99 26535 347.97 330.57 380.16 # 26742 281.36 267.29 307.38 26536 580.69 551.66 634.41 26746 607.62 577.24 663.83 26540 571.68 543.10 624.57 26750 147.82 140.43 161.49 26541 698.68 663.75 763.31 # 26750 143.92 136.72 157.23 26542 591.21 561.65 645.90 26755 259.64 246.66 283.66 26545 601.76 571.67 657.42 # 26755 226.31 214.99 247.24 26546 845.51 803.23 923.71 26756 353.84 336.15 386.57 26548 662.52 629.39 723.80 26765 403.00 382.85 440.28 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 VERMONT - MEDICARE CARRIER 31145 PAGE 17 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 221.85 210.76 242.37 27087 554.93 527.18 606.26 # 26770 203.06 192.91 221.85 27090 733.89 697.20 801.78 26775 315.32 299.55 344.48 27091 1,422.49 1,351.37 1,554.08 # 26775 283.41 269.24 309.63 27093 172.20 163.59 188.13 26776 376.42 357.60 411.24 # 27093 66.91 63.56 73.09 26785 439.96 417.96 480.65 27095 207.96 197.56 227.19 26820 682.51 648.38 745.64 # 27095 76.42 72.60 83.49 26841 631.84 600.25 690.29 27096 158.26 150.35 172.90 26842 686.43 652.11 749.93 # 27096 64.31 61.09 70.25 26843 635.85 604.06 694.67 27097 584.96 555.71 639.07 26844 709.24 673.78 774.85 27098 549.23 521.77 600.04 26850 602.67 572.54 658.42 27100 721.80 685.71 788.57 26852 691.18 656.62 755.11 27105 757.16 719.30 827.20 26860 483.78 459.59 528.53 27110 844.33 802.11 922.43 26861 95.53 90.75 104.36 27111 753.23 715.57 822.91 26862 628.44 597.02 686.57 27120 1,144.70 1,087.47 1,250.59 26863 213.28 202.62 233.01 27122 980.26 931.25 1,070.94 26910 618.30 587.39 675.50 27125 998.84 948.90 1,091.24 26951 535.86 509.07 585.43 27130 1,287.31 1,222.94 1,406.38 26952 560.62 532.59 612.48 27132 1,504.84 1,429.60 1,644.04 26990 537.56 510.68 587.28 27134 1,744.79 1,657.55 1,906.18 26991 601.74 571.65 657.40 27137 1,329.88 1,263.39 1,452.90 # 26991 453.55 430.87 495.50 27138 1,384.19 1,314.98 1,512.23 26992 846.30 803.99 924.59 27140 795.35 755.58 868.92 27000 389.82 370.33 425.88 27146 1,122.50 1,066.38 1,226.34 27001 472.55 448.92 516.26 27147 1,307.49 1,242.12 1,428.44 27003 508.77 483.33 555.83 27151 1,361.54 1,293.46 1,487.48 27005 640.75 608.71 700.02 27156 1,525.54 1,449.26 1,666.65 27006 647.68 615.30 707.60 27158 1,227.34 1,165.97 1,340.87 27025 785.98 746.68 858.68 27161 1,085.03 1,030.78 1,185.40 27027 766.98 728.63 837.92 27165 1,213.36 1,152.69 1,325.59 27030 836.82 794.98 914.23 27170 1,050.30 997.79 1,147.46 27033 866.52 823.19 946.67 27175 584.16 554.95 638.19 27035 972.93 924.28 1,062.92 27176 806.22 765.91 880.80 27036 886.49 842.17 968.50 27177 984.51 935.28 1,075.57 27040 295.13 280.37 322.43 27178 798.44 758.52 872.30 # 27040 179.19 170.23 195.76 27179 860.22 817.21 939.79 27041 607.17 576.81 663.33 27181 963.89 915.70 1,053.06 27047 538.97 512.02 588.82 27185 603.10 572.95 658.89 # 27047 452.82 430.18 494.71 27187 881.64 837.56 963.19 27048 416.19 395.38 454.69 27193 403.85 383.66 441.21 27049 882.53 838.40 964.16 # 27193 407.39 387.02 445.07 27050 304.86 289.62 333.06 27194 629.13 597.67 687.32 27052 485.82 461.53 530.76 27200 146.84 139.50 160.43 27054 595.92 566.12 651.04 # 27200 150.03 142.53 163.91 27057 854.48 811.76 933.52 27202 561.32 533.25 613.24 27060 375.73 356.94 410.48 27220 455.17 432.41 497.27 27062 391.78 372.19 428.02 # 27220 451.98 429.38 493.79 27065 437.28 415.42 477.73 27222 864.92 821.67 944.92 27066 710.37 674.85 776.08 27226 919.87 873.88 1,004.96 27067 904.14 858.93 987.77 27227 1,490.31 1,415.79 1,628.16 27070 744.82 707.58 813.72 27228 1,706.97 1,621.62 1,864.86 27071 799.19 759.23 873.11 27230 404.91 384.66 442.36 27075 2,057.42 1,954.55 2,247.73 # 27230 399.60 379.62 436.56 27076 1,420.09 1,349.09 1,551.45 27232 686.62 652.29 750.13 27077 2,380.35 2,261.33 2,600.53 27235 806.47 766.15 881.07 27078 897.71 852.82 980.74 27236 1,055.96 1,003.16 1,153.63 27079 860.74 817.70 940.36 27238 391.77 372.18 428.01 27080 431.83 410.24 471.78 27240 844.00 801.80 922.07 27086 211.20 200.64 230.74 27244 1,086.44 1,032.12 1,186.94 # 27086 129.66 123.18 141.66 27245 1,122.01 1,065.91 1,225.80 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 18 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 331.32 314.75 361.96 27381 703.38 668.21 768.44 # 27246 332.02 315.42 362.73 27385 552.18 524.57 603.26 27248 665.79 632.50 727.38 27386 729.47 693.00 796.95 27250 209.69 199.21 229.09 27390 382.25 363.14 417.61 27252 667.04 633.69 728.74 27391 498.46 473.54 544.57 27253 837.84 795.95 915.34 27392 614.60 583.87 671.45 27254 1,132.28 1,075.67 1,237.02 27393 441.74 419.65 482.60 27256 257.12 244.26 280.90 27394 571.20 542.64 624.04 # 27256 217.41 206.54 237.52 27395 773.92 735.22 845.50 27257 298.01 283.11 325.58 27396 536.97 510.12 586.64 27258 982.62 933.49 1,073.51 27397 792.59 752.96 865.90 27259 1,378.56 1,309.63 1,506.07 27400 599.55 569.57 655.01 27265 340.42 323.40 371.91 27403 562.06 533.96 614.05 27266 506.43 481.11 553.28 27405 592.29 562.68 647.08 27267 361.48 343.41 394.92 27407 676.65 642.82 739.24 27268 447.71 425.32 489.12 27409 851.38 808.81 930.13 27269 1,078.56 1,024.63 1,178.32 27412 1,473.20 1,399.54 1,609.47 27275 157.19 149.33 171.73 27415 1,228.50 1,167.08 1,342.14 27280 908.46 863.04 992.50 27416 853.23 810.57 932.16 27282 712.71 677.07 778.63 27418 734.54 697.81 802.48 27284 1,383.60 1,314.42 1,511.58 27420 657.34 624.47 718.14 27286 1,467.38 1,394.01 1,603.11 27422 654.65 621.92 715.21 27290 1,398.74 1,328.80 1,528.12 27424 656.44 623.62 717.16 27295 1,128.50 1,072.08 1,232.89 27425 382.51 363.38 417.89 27301 568.06 539.66 620.61 27427 630.29 598.78 688.60 # 27301 431.92 410.32 471.87 27428 971.92 923.32 1,061.82 27303 559.06 531.11 610.78 27429 1,088.64 1,034.21 1,189.34 27305 407.64 387.26 445.35 27430 650.55 618.02 710.72 27306 329.48 313.01 359.96 27435 698.45 663.53 763.06 27307 405.96 385.66 443.51 27437 578.38 549.46 631.88 27310 637.87 605.98 696.88 27438 741.64 704.56 810.24 27323 229.35 217.88 250.56 27440 677.34 643.47 739.99 # 27323 156.32 148.50 170.78 27441 699.42 664.45 764.12 27324 332.51 315.88 363.26 27442 767.80 729.41 838.82 27325 460.71 437.67 503.32 27443 719.19 683.23 785.71 27326 424.64 403.41 463.92 27445 1,121.30 1,065.24 1,225.03 27327 387.74 368.35 423.60 27446 993.73 944.04 1,085.65 # 27327 304.07 288.87 332.20 27447 1,378.03 1,309.13 1,505.50 27328 366.77 348.43 400.69 27448 724.26 688.05 791.26 27329 916.85 871.01 1,001.66 27450 902.97 857.82 986.49 27330 347.96 330.56 380.14 27454 1,139.66 1,082.68 1,245.08 27331 411.26 390.70 449.31 27455 834.16 792.45 911.32 27332 558.24 530.33 609.88 27457 859.38 816.41 938.87 27333 505.75 480.46 552.53 27465 1,086.03 1,031.73 1,186.49 27334 594.48 564.76 649.47 27466 1,050.81 998.27 1,148.01 27335 672.59 638.96 734.80 27468 1,189.80 1,130.31 1,299.86 27340 314.87 299.13 344.00 27470 1,047.52 995.14 1,144.41 27345 416.61 395.78 455.15 27472 1,132.50 1,075.88 1,237.26 27347 447.47 425.10 488.87 27475 576.09 547.29 629.38 27350 568.29 539.88 620.86 27477 644.86 612.62 704.51 27355 526.59 500.26 575.30 27479 827.61 786.23 904.16 27356 646.08 613.78 705.85 27485 588.78 559.34 643.24 27357 715.65 679.87 781.85 27486 1,257.47 1,194.60 1,373.79 27358 260.93 247.88 285.06 27487 1,586.34 1,507.02 1,733.07 27360 745.99 708.69 814.99 27488 1,063.92 1,010.72 1,162.33 27365 1,087.82 1,033.43 1,188.44 27495 1,007.12 956.76 1,100.27 27370 147.36 139.99 160.99 27496 439.54 417.56 480.19 # 27370 48.80 46.36 53.31 27497 477.39 453.52 521.55 27372 510.40 484.88 557.61 27498 520.62 494.59 568.78 # 27372 351.22 333.66 383.71 27499 576.91 548.06 630.27 27380 515.63 489.85 563.33 27500 442.27 420.16 483.18 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 VERMONT - MEDICARE CARRIER 31145 PAGE 19 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 411.78 391.19 449.87 27613 215.46 204.69 235.39 27501 434.73 412.99 474.94 # 27613 147.04 139.69 160.64 # 27501 428.70 407.27 468.36 27614 484.18 459.97 528.97 27502 694.35 659.63 758.57 # 27614 362.93 344.78 396.50 27503 706.33 671.01 771.66 27615 779.94 740.94 852.08 27506 1,182.66 1,123.53 1,292.06 27618 422.50 401.38 461.59 27507 875.26 831.50 956.23 # 27618 336.35 319.53 367.46 27508 446.28 423.97 487.57 27619 673.56 639.88 735.86 # 27508 421.46 400.39 460.45 # 27619 521.11 495.05 569.31 27509 561.77 533.68 613.73 27620 406.90 386.56 444.54 27510 613.65 582.97 670.42 27625 526.89 500.55 575.63 27511 907.35 861.98 991.28 27626 568.37 539.95 620.94 27513 1,140.80 1,083.76 1,246.32 27630 462.38 439.26 505.15 27514 913.19 867.53 997.66 # 27630 327.66 311.28 357.97 27516 417.90 397.01 456.56 27635 523.24 497.08 571.64 # 27516 394.50 374.78 431.00 27637 663.75 630.56 725.14 27517 590.02 560.52 644.60 27638 691.28 656.72 755.23 27519 826.78 785.44 903.26 27640 766.84 728.50 837.78 27520 263.22 250.06 287.57 27641 614.92 584.17 671.80 # 27520 238.41 226.49 260.46 27645 929.57 883.09 1,015.55 27524 663.97 630.77 725.39 27646 822.63 781.50 898.73 27530 330.50 313.98 361.08 27647 728.84 692.40 796.26 # 27530 307.81 292.42 336.28 27648 142.04 134.94 155.18 27532 528.80 502.36 577.71 # 27648 48.44 46.02 52.92 # 27532 500.79 475.75 547.11 27650 597.27 567.41 652.52 27535 810.44 769.92 885.41 27652 658.36 625.44 719.26 27536 1,053.69 1,001.01 1,151.16 27654 643.28 611.12 702.79 27538 395.43 375.66 432.01 27656 465.26 442.00 508.30 # 27538 370.97 352.42 405.28 # 27656 309.62 294.14 338.26 27540 732.01 695.41 799.72 27658 339.29 322.33 370.68 27550 419.38 398.41 458.17 27659 445.76 423.47 486.99 # 27550 391.02 371.47 427.19 27664 323.28 307.12 353.19 27552 541.57 514.49 591.66 27665 370.39 351.87 404.65 27556 812.98 772.33 888.18 27675 454.42 431.70 496.46 27557 973.37 924.70 1,063.41 27676 551.32 523.75 602.31 27558 1,094.19 1,039.48 1,195.40 27680 384.41 365.19 419.97 27560 307.60 292.22 336.05 27681 457.78 434.89 500.12 # 27560 279.23 265.27 305.06 27685 548.68 521.25 599.44 27562 399.88 379.89 436.87 # 27685 424.60 403.37 463.88 27566 790.87 751.33 864.03 27686 499.86 474.87 546.10 27570 128.33 121.91 140.20 27687 411.49 390.92 449.56 27580 1,283.16 1,219.00 1,401.85 27690 567.13 538.77 619.59 27590 736.42 699.60 804.54 27691 664.88 631.64 726.39 27591 814.68 773.95 890.04 27692 101.10 96.05 110.46 27592 624.66 593.43 682.44 27695 438.07 416.17 478.60 27594 451.37 428.80 493.12 27696 523.40 497.23 571.81 27596 653.90 621.21 714.39 27698 587.65 558.27 642.01 27598 664.13 630.92 725.56 27700 556.68 528.85 608.18 27600 374.76 356.02 409.42 27702 887.08 842.73 969.14 27601 388.95 369.50 424.93 27703 1,026.67 975.34 1,121.64 27602 459.50 436.53 502.01 27704 502.54 477.41 549.02 27603 450.50 427.98 492.18 27705 680.57 646.54 743.52 # 27603 339.53 322.55 370.93 27707 345.98 328.68 377.98 27604 395.00 375.25 431.54 27709 999.97 949.97 1,092.47 # 27604 298.92 283.97 326.57 27712 971.24 922.68 1,061.08 27605 315.32 299.55 344.48 27715 948.00 900.60 1,035.69 # 27605 179.18 170.22 195.75 27720 778.95 740.00 851.00 27606 262.89 249.75 287.21 27722 777.06 738.21 848.94 27607 542.04 514.94 592.18 27724 1,144.39 1,087.17 1,250.25 27610 578.68 549.75 632.21 27725 1,065.37 1,012.10 1,163.92 27612 505.59 480.31 552.36 27726 816.38 775.56 891.89 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 VERMONT - MEDICARE CARRIER 31145 PAGE 20 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 863.92 820.72 943.83 27870 933.92 887.22 1,020.30 27730 515.91 490.11 563.63 27871 612.77 582.13 669.45 27732 352.97 335.32 385.62 27880 828.16 786.75 904.76 27734 528.70 502.27 577.61 27881 796.30 756.49 869.96 27740 586.05 556.75 640.26 27882 561.90 533.81 613.88 27742 616.78 585.94 673.83 27884 522.10 496.00 570.40 27745 668.12 634.71 729.92 27886 595.52 565.74 650.60 27750 284.34 270.12 310.64 27888 629.59 598.11 687.83 # 27750 260.94 247.89 285.07 27889 615.18 584.42 672.08 27752 458.37 435.45 500.77 27892 483.32 459.15 528.02 # 27752 427.88 406.49 467.46 27893 489.32 464.85 534.58 27756 497.37 472.50 543.38 27894 751.81 714.22 821.35 27758 785.27 746.01 857.91 28001 234.76 223.02 256.47 27759 889.75 845.26 972.05 # 28001 164.57 156.34 179.79 27760 274.13 260.42 299.48 28002 437.97 416.07 478.48 # 27760 248.96 236.51 271.99 # 28002 347.56 330.18 379.71 27762 410.37 389.85 448.33 28003 602.42 572.30 658.15 # 27762 379.53 360.55 414.63 # 28003 510.95 485.40 558.21 27766 534.28 507.57 583.71 28005 556.90 529.06 608.42 27767 218.13 207.22 238.30 28008 370.54 352.01 404.81 # 27767 219.19 208.23 239.46 # 28008 278.36 264.44 304.11 27768 350.62 333.09 383.05 28010 205.95 195.65 225.00 27769 611.01 580.46 667.53 # 28010 192.83 183.19 210.67 27780 245.37 233.10 268.07 28011 291.28 276.72 318.23 # 27780 222.33 211.21 242.89 # 28011 271.43 257.86 296.54 27781 355.26 337.50 388.13 28020 439.47 417.50 480.13 # 27781 331.51 314.93 362.17 # 28020 326.37 310.05 356.56 27784 608.96 578.51 665.29 28022 405.94 385.64 443.49 27786 259.84 246.85 283.88 # 28022 302.42 287.30 330.40 # 27786 233.96 222.26 255.60 28024 385.92 366.62 421.61 27788 358.30 340.39 391.45 # 28024 286.65 272.32 313.17 # 27788 330.65 314.12 361.24 28035 442.36 420.24 483.28 27792 615.18 584.42 672.08 # 28035 329.61 313.13 360.10 27808 271.90 258.31 297.06 28043 295.00 280.25 322.29 # 27808 244.24 232.03 266.83 # 28043 236.86 225.02 258.77 27810 401.61 381.53 438.76 28045 413.60 392.92 451.86 # 27810 370.06 351.56 404.29 # 28045 300.85 285.81 328.68 27814 684.47 650.25 747.79 28046 752.64 715.01 822.26 27816 257.57 244.69 281.39 # 28046 615.08 584.33 671.98 # 27816 232.05 220.45 253.52 28050 388.67 369.24 424.63 27818 414.25 393.54 452.57 # 28050 284.08 269.88 310.36 # 27818 378.44 359.52 413.45 28052 358.52 340.59 391.68 27822 750.05 712.55 819.43 # 28052 258.54 245.61 282.45 27823 854.38 811.66 933.41 28054 336.78 319.94 367.93 27824 258.78 245.84 282.72 # 28054 235.74 223.95 257.54 # 27824 249.21 236.75 272.26 28055 361.81 343.72 395.28 27825 471.59 448.01 515.21 28060 436.07 414.27 476.41 # 27825 434.01 412.31 474.16 # 28060 331.12 314.56 361.74 27826 721.84 685.75 788.61 28062 513.25 487.59 560.73 27827 959.92 911.92 1,048.71 # 28062 388.45 369.03 424.38 27828 1,148.96 1,091.51 1,255.24 28070 432.26 410.65 472.25 27829 577.96 549.06 631.42 # 28070 323.77 307.58 353.72 27830 300.83 285.79 328.66 28072 426.09 404.79 465.51 # 27830 282.04 267.94 308.13 # 28072 313.35 297.68 342.33 27831 328.05 311.65 358.40 28080 419.21 398.25 457.99 27832 622.40 591.28 679.97 # 28080 317.81 301.92 347.21 27840 303.81 288.62 331.91 28086 457.05 434.20 499.33 27842 423.21 402.05 462.36 # 28086 326.94 310.59 357.18 27846 653.63 620.95 714.09 28088 387.89 368.50 423.78 27848 739.91 702.91 808.35 # 28088 272.31 258.69 297.49 27860 157.94 150.04 172.55 28090 392.14 372.53 428.41 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 VERMONT - MEDICARE CARRIER 31145 PAGE 21 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 285.42 271.15 311.82 # 28202 411.37 390.80 449.42 28092 354.09 336.39 386.85 28208 386.62 367.29 422.38 # 28092 250.57 238.04 273.75 # 28208 283.09 268.94 309.28 28100 505.45 480.18 552.21 28210 497.55 472.67 543.57 # 28100 370.38 351.86 404.64 # 28210 384.45 365.23 420.01 28102 505.28 480.02 552.02 28220 381.93 362.83 417.25 28103 408.29 387.88 446.06 # 28220 285.85 271.56 312.29 28104 433.87 412.18 474.01 28222 441.44 419.37 482.28 # 28104 324.32 308.10 354.32 # 28222 340.40 323.38 371.89 28106 431.38 409.81 471.28 28225 331.94 315.34 362.64 28107 481.65 457.57 526.21 # 28225 236.93 225.08 258.84 # 28107 354.01 336.31 386.76 28226 398.77 378.83 435.65 28108 365.40 347.13 399.20 # 28226 295.60 280.82 322.94 # 28108 267.90 254.51 292.69 28230 366.86 348.52 400.80 28110 383.61 364.43 419.09 # 28230 271.84 258.25 296.99 # 28110 267.32 253.95 292.04 28232 325.40 309.13 355.50 28111 436.46 414.64 476.84 # 28232 231.09 219.54 252.47 # 28111 312.37 296.75 341.26 28234 337.45 320.58 368.67 28112 413.10 392.45 451.32 # 28234 242.08 229.98 264.48 # 28112 292.21 277.60 319.24 28238 585.09 555.84 639.22 28113 494.76 470.02 540.52 # 28238 461.71 438.62 504.41 # 28113 382.72 363.58 418.12 28240 377.39 358.52 412.30 28114 898.29 853.38 981.39 # 28240 278.83 264.89 304.62 # 28114 739.10 702.15 807.47 28250 479.73 455.74 524.10 28116 642.31 610.19 701.72 # 28250 369.82 351.33 404.03 # 28116 524.60 498.37 573.13 28260 585.93 556.63 640.12 28118 497.13 472.27 543.11 # 28260 477.09 453.24 521.23 # 28118 379.07 360.12 414.14 28261 850.68 808.15 929.37 28119 443.26 421.10 484.27 # 28261 727.66 691.28 794.97 # 28119 335.48 318.71 366.52 28262 1,186.54 1,127.21 1,296.29 28120 491.76 467.17 537.25 # 28262 1,017.07 966.22 1,111.15 # 28120 360.94 342.89 394.32 28264 759.70 721.72 829.98 28122 571.80 543.21 624.69 # 28264 639.87 607.88 699.06 # 28122 463.31 440.14 506.16 28270 408.13 387.72 445.88 28124 406.04 385.74 443.60 # 28270 308.86 293.42 337.43 # 28124 309.61 294.13 338.25 28272 333.80 317.11 364.68 28126 328.14 311.73 358.49 # 28272 240.91 228.86 263.19 # 28126 232.77 221.13 254.30 28280 447.56 425.18 488.96 28130 575.68 546.90 628.94 # 28280 335.52 318.74 366.55 28140 538.16 511.25 587.94 28285 395.45 375.68 432.03 # 28140 421.51 400.43 460.49 # 28285 296.53 281.70 323.96 28150 365.71 347.42 399.53 28286 386.56 367.23 422.31 # 28150 265.73 252.44 290.31 # 28286 284.81 270.57 311.16 28153 340.99 323.94 372.53 28288 495.78 470.99 541.64 # 28153 241.72 229.63 264.07 # 28288 386.93 367.58 422.72 28160 349.90 332.41 382.27 28289 626.03 594.73 683.94 # 28160 252.05 239.45 275.37 # 28289 502.29 477.18 548.76 28171 563.78 535.59 615.93 28290 487.73 463.34 532.84 28173 641.48 609.41 700.82 # 28290 366.83 348.49 400.76 # 28173 514.91 489.16 562.53 28292 666.29 632.98 727.93 28175 470.82 447.28 514.37 # 28292 541.85 514.76 591.97 # 28175 363.39 345.22 397.00 28293 889.32 844.85 971.58 28190 209.31 198.84 228.67 # 28293 655.68 622.90 716.34 # 28190 123.51 117.33 134.93 28294 642.82 610.68 702.28 28192 401.49 381.42 438.63 # 28294 498.88 473.94 545.03 # 28192 295.49 280.72 322.83 28296 629.76 598.27 688.01 28193 460.66 437.63 503.27 # 28296 495.39 470.62 541.21 # 28193 351.46 333.89 383.97 28297 711.47 675.90 777.29 28200 401.47 381.40 438.61 # 28297 556.54 528.71 608.02 # 28200 294.76 280.02 322.02 28298 614.79 584.05 671.66 28202 533.68 507.00 583.05 # 28298 474.40 450.68 518.28 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 VERMONT - MEDICARE CARRIER 31145 PAGE 22 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 790.20 750.69 863.29 # 28490 101.01 95.96 110.35 # 28299 642.36 610.24 701.78 28495 145.63 138.35 159.10 28300 599.95 569.95 655.44 # 28495 129.32 122.85 141.28 28302 595.01 565.26 650.05 28496 353.49 335.82 386.19 28304 682.57 648.44 745.71 # 28496 197.85 187.96 216.15 # 28304 547.13 519.77 597.74 28505 566.00 537.70 618.36 28305 630.21 598.70 688.51 # 28505 435.53 413.75 475.81 28306 511.60 486.02 558.92 28510 99.94 94.94 109.18 # 28306 370.49 351.97 404.77 # 28510 98.17 93.26 107.25 28307 603.35 573.18 659.16 28515 131.73 125.14 143.91 # 28307 417.93 397.03 456.58 # 28515 121.45 115.38 132.69 28308 463.76 440.57 506.66 28525 476.08 452.28 520.12 # 28308 340.03 323.03 371.48 # 28525 345.96 328.66 377.96 28309 810.15 769.64 885.09 28530 96.37 91.55 105.28 28310 456.75 433.91 499.00 # 28530 89.28 84.82 97.54 # 28310 331.60 315.02 362.27 28531 312.44 296.82 341.34 28312 418.10 397.20 456.78 # 28531 170.98 162.43 186.79 # 28312 295.43 280.66 322.76 28540 171.09 162.54 186.92 28313 438.94 416.99 479.54 # 28540 160.10 152.10 174.92 # 28313 338.25 321.34 369.54 28545 210.15 199.64 229.59 28315 403.40 383.23 440.71 # 28545 193.84 184.15 211.77 # 28315 302.00 286.90 329.94 28546 396.56 376.73 433.24 28320 567.66 539.28 620.17 # 28546 261.48 248.41 285.67 28322 662.88 629.74 724.20 28555 738.55 701.62 806.86 # 28322 524.26 498.05 572.76 # 28555 583.62 554.44 637.61 28340 529.31 502.84 578.27 28570 147.62 140.24 161.28 # 28340 409.83 389.34 447.74 # 28570 133.09 126.44 145.41 28341 609.84 579.35 666.25 28575 282.10 268.00 308.20 # 28341 485.04 460.79 529.91 # 28575 264.02 250.82 288.44 28344 406.59 386.26 444.20 28576 309.89 294.40 338.56 # 28344 287.82 273.43 314.44 28585 787.45 748.08 860.29 28345 490.02 465.52 535.35 # 28585 655.91 623.11 716.58 # 28345 375.50 356.73 410.24 28600 178.26 169.35 194.75 28360 873.32 829.65 954.10 # 28600 160.53 152.50 175.38 28400 206.43 196.11 225.53 28605 230.34 218.82 251.64 # 28400 189.76 180.27 207.31 # 28605 215.45 204.68 235.38 28405 336.92 320.07 368.08 28606 342.62 325.49 374.31 # 28405 316.00 300.20 345.23 28615 688.78 654.34 752.49 28406 462.08 438.98 504.83 28630 127.25 120.89 139.02 28415 1,015.89 965.10 1,109.87 # 28630 98.53 93.60 107.64 28420 1,069.87 1,016.38 1,168.84 28635 151.84 144.25 165.89 28430 193.26 183.60 211.14 # 28635 123.12 116.96 134.50 # 28430 172.35 163.73 188.29 28636 250.01 237.51 273.14 28435 272.75 259.11 297.98 # 28636 182.30 173.19 199.17 # 28435 252.90 240.26 276.30 28645 535.68 508.90 585.24 28436 370.69 352.16 404.98 # 28645 425.07 403.82 464.39 28445 957.85 909.96 1,046.45 28660 92.76 88.12 101.34 28446 1,051.95 999.35 1,149.25 # 28660 75.38 71.61 82.35 28450 178.79 169.85 195.33 28665 135.18 128.42 147.68 # 28450 160.36 152.34 175.19 # 28665 122.42 116.30 133.75 28455 248.29 235.88 271.26 28666 174.43 165.71 190.57 # 28455 231.98 220.38 253.44 28675 487.42 463.05 532.51 28456 238.12 226.21 260.14 # 28675 354.83 337.09 387.65 28465 546.93 519.58 597.52 28705 1,182.20 1,123.09 1,291.55 28470 178.46 169.54 194.97 28715 875.65 831.87 956.65 # 28470 161.09 153.04 176.00 28725 720.32 684.30 786.95 28475 226.56 215.23 247.51 28730 754.87 717.13 824.70 # 28475 209.54 199.06 228.92 28735 721.79 685.70 788.56 28476 294.92 280.17 322.20 28737 640.24 608.23 699.46 28485 472.55 448.92 516.26 28740 730.13 693.62 797.66 28490 115.19 109.43 125.84 # 28740 566.34 538.02 618.72 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 VERMONT - MEDICARE CARRIER 31145 PAGE 23 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 711.09 675.54 776.87 29240 51.48 48.91 56.25 # 28750 539.14 512.18 589.01 # 29240 40.14 38.13 43.85 28755 428.14 406.73 467.74 29260 44.47 42.25 48.59 # 28755 306.54 291.21 334.89 # 29260 33.13 31.47 36.19 28760 673.15 639.49 735.41 29280 43.03 40.88 47.01 # 28760 532.05 505.45 581.27 # 29280 31.33 29.76 34.22 28800 517.33 491.46 565.18 29305 198.16 188.25 216.49 28805 683.33 649.16 746.53 # 29305 138.60 131.67 151.42 28810 398.52 378.59 435.38 29325 220.49 209.47 240.89 28820 453.38 430.71 495.32 # 29325 156.67 148.84 171.17 # 28820 314.76 299.02 343.87 29345 114.64 108.91 125.25 28825 492.45 467.83 538.00 # 29345 89.82 85.33 98.13 # 28825 359.85 341.86 393.14 29355 118.62 112.69 129.59 28890 298.24 283.33 325.83 # 29355 95.58 90.80 104.42 # 28890 204.99 194.74 223.95 29358 129.02 122.57 140.96 29000 229.49 218.02 250.72 # 29358 91.44 86.87 99.90 # 29000 150.78 143.24 164.73 29365 102.81 97.67 112.32 29010 208.80 198.36 228.11 # 29365 77.99 74.09 85.20 # 29010 138.60 131.67 151.42 29405 75.68 71.90 82.69 29015 203.89 193.70 222.76 # 29405 57.24 54.38 62.54 # 29015 143.27 136.11 156.53 29425 81.97 77.87 89.55 29020 194.84 185.10 212.87 # 29425 63.18 60.02 69.02 # 29020 128.55 122.12 140.44 29435 100.33 95.31 109.61 29025 220.53 209.50 240.93 # 29435 76.22 72.41 83.27 # 29025 156.01 148.21 170.44 29440 45.01 42.76 49.17 29035 204.56 194.33 223.48 # 29440 31.19 29.63 34.07 # 29035 123.73 117.54 135.17 29445 126.04 119.74 137.70 29040 197.39 187.52 215.65 # 29445 101.22 96.16 110.58 # 29040 138.18 131.27 150.96 29450 133.32 126.65 145.65 29044 221.61 210.53 242.11 # 29450 112.75 107.11 123.18 # 29044 143.97 136.77 157.29 29505 64.59 61.36 70.56 29046 241.81 229.72 264.18 # 29505 42.25 40.14 46.16 # 29046 164.88 156.64 180.14 29515 60.53 57.50 66.13 29049 73.39 69.72 80.18 # 29515 44.22 42.01 48.31 # 29049 53.89 51.20 58.88 29520 43.40 41.23 47.41 29055 175.50 166.73 191.74 # 29520 33.12 31.46 36.18 # 29055 118.77 112.83 129.75 29530 45.19 42.93 49.37 29058 94.92 90.17 103.70 # 29530 33.85 32.16 36.98 # 29058 73.64 69.96 80.45 29540 37.18 35.32 40.62 29065 79.76 75.77 87.14 # 29540 30.09 28.59 32.88 # 29065 59.55 56.57 65.06 29550 36.09 34.29 39.43 29075 74.03 70.33 80.88 # 29550 28.29 26.88 30.91 # 29075 53.82 51.13 58.80 29580 45.53 43.25 49.74 29085 78.87 74.93 86.17 # 29580 33.13 31.47 36.19 # 29085 57.96 55.06 63.32 29590 48.85 46.41 53.37 29086 60.47 57.45 66.07 # 29590 38.57 36.64 42.14 # 29086 42.74 40.60 46.69 29700 54.94 52.19 60.02 29105 73.20 69.54 79.97 # 29700 31.54 29.96 34.45 # 29105 52.28 49.67 57.12 29705 57.71 54.82 63.04 29125 56.90 54.06 62.17 # 29705 43.18 41.02 47.17 # 29125 37.40 35.53 40.86 29710 101.14 96.08 110.49 29126 65.52 62.24 71.58 # 29710 74.19 70.48 81.05 # 29126 46.02 43.72 50.28 29715 77.32 73.45 84.47 29130 34.69 32.96 37.90 # 29715 51.09 48.54 55.82 # 29130 25.83 24.54 28.22 29720 67.77 64.38 74.04 29131 43.06 40.91 47.05 # 29720 39.76 37.77 43.44 # 29131 29.23 27.77 31.94 29730 56.11 53.30 61.30 29200 46.13 43.82 50.39 # 29730 41.58 39.50 45.43 # 29200 36.20 34.39 39.55 29740 80.44 76.42 87.88 29220 47.54 45.16 51.93 # 29740 60.59 57.56 66.19 # 29220 37.61 35.73 41.09 29750 87.79 83.40 95.91 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 24 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 69.36 65.89 75.77 # 29893 386.75 367.41 422.52 29800 454.83 432.09 496.90 29894 459.39 436.42 501.88 29804 563.96 535.76 616.12 29895 444.37 422.15 485.47 29805 410.91 390.36 448.91 29897 465.40 442.13 508.45 29806 941.01 893.96 1,028.05 29898 520.52 494.49 568.66 29807 916.62 870.79 1,001.41 29899 935.68 888.90 1,022.24 29819 515.12 489.36 562.76 29900 399.80 379.81 436.78 29820 475.43 451.66 519.41 29901 438.16 416.25 478.69 29821 519.26 493.30 567.30 29902 468.64 445.21 511.99 29822 504.37 479.15 551.02 29904 544.17 516.96 594.50 29823 551.79 524.20 602.83 29905 585.77 556.48 639.95 29824 588.49 559.07 642.93 29906 617.08 586.23 674.16 29825 514.41 488.69 561.99 29907 755.25 717.49 825.11 29826 590.21 560.70 644.81 30000 197.64 187.76 215.92 29827 964.17 915.96 1,053.35 # 30000 103.34 98.17 112.90 29828 807.07 766.72 881.73 30020 191.26 181.70 208.96 29830 396.47 376.65 433.15 # 30020 104.05 98.85 113.68 29834 432.06 410.46 472.03 30100 120.23 114.22 131.35 29835 443.35 421.18 484.36 # 30100 62.79 59.65 68.60 29836 510.12 484.61 557.30 30110 193.51 183.83 211.40 29837 464.85 441.61 507.85 # 30110 115.16 109.40 125.81 29838 519.79 493.80 567.87 30115 375.44 356.67 410.17 29840 389.44 369.97 425.47 30117 710.65 675.12 776.39 29843 418.44 397.52 457.15 # 30117 291.24 276.68 318.18 29844 434.25 412.54 474.42 30118 678.85 644.91 741.65 29845 497.18 472.32 543.17 30120 451.34 428.77 493.09 29846 456.99 434.14 499.26 # 30120 394.62 374.89 431.12 29847 474.74 451.00 518.65 30124 237.85 225.96 259.85 29848 433.09 411.44 473.16 30125 540.95 513.90 590.99 29850 502.85 477.71 549.37 30130 327.70 311.32 358.02 29851 826.96 785.61 903.45 30140 374.19 355.48 408.80 29855 692.89 658.25 756.99 30150 694.03 659.33 758.23 29856 886.98 842.63 969.02 30160 698.03 663.13 762.60 29860 571.50 542.93 624.37 30200 96.20 91.39 105.10 29861 633.66 601.98 692.28 # 30200 53.65 50.97 58.62 29862 708.56 673.13 774.10 30210 126.35 120.03 138.03 29863 702.20 667.09 767.15 # 30210 87.00 82.65 95.05 29866 922.65 876.52 1,008.00 30220 248.77 236.33 271.78 29867 1,119.35 1,063.38 1,222.89 # 30220 110.50 104.98 120.73 29868 1,493.99 1,419.29 1,632.18 30300 193.16 183.50 211.03 29870 356.70 338.87 389.70 # 30300 105.94 100.64 115.74 29871 448.18 425.77 489.64 30310 178.82 169.88 195.36 29873 447.87 425.48 489.30 30320 394.34 374.62 430.81 29874 470.64 447.11 514.18 30400 907.62 862.24 991.58 29875 433.67 411.99 473.79 30410 1,075.43 1,021.66 1,174.91 29876 570.53 542.00 623.30 30420 1,210.16 1,149.65 1,322.10 29877 539.87 512.88 589.81 30430 793.83 754.14 867.26 29879 577.69 548.81 631.13 30435 1,047.73 995.34 1,144.64 29880 603.14 572.98 658.93 30450 1,391.02 1,321.47 1,519.69 29881 562.10 534.00 614.10 30460 673.24 639.58 735.52 29882 608.72 578.28 665.02 30462 1,351.18 1,283.62 1,476.16 29883 742.78 705.64 811.49 30465 863.23 820.07 943.08 29884 538.27 511.36 588.06 30520 528.87 502.43 577.79 29885 653.03 620.38 713.44 30540 589.53 560.05 644.06 29886 550.63 523.10 601.57 30545 848.38 805.96 926.85 29887 649.28 616.82 709.34 30560 228.74 217.30 249.90 29888 879.90 835.91 961.30 # 30560 120.61 114.58 131.77 29889 1,075.82 1,022.03 1,175.33 30580 548.10 520.70 598.81 29891 612.82 582.18 669.51 # 30580 440.32 418.30 481.05 29892 626.66 595.33 684.63 30600 504.97 479.72 551.68 29893 513.31 487.64 560.79 # 30600 391.16 371.60 427.34 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 VERMONT - MEDICARE CARRIER 31145 PAGE 25 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 538.47 511.55 588.28 31290 1,050.71 998.17 1,147.90 30630 547.32 519.95 597.94 31291 1,106.04 1,050.74 1,208.35 30801 192.30 182.69 210.09 31292 909.20 863.74 993.30 # 30801 115.36 109.59 126.03 31293 990.82 941.28 1,082.47 30802 248.71 236.27 271.71 31294 1,137.36 1,080.49 1,242.56 # 30802 164.68 156.45 179.92 31300 1,115.14 1,059.38 1,218.29 30901 91.32 86.75 99.76 31320 567.47 539.10 619.97 # 30901 56.93 54.08 62.19 31360 1,785.72 1,696.43 1,950.89 30903 167.39 159.02 182.87 31365 2,234.29 2,122.58 2,440.97 # 30903 74.14 70.43 80.99 31367 1,927.37 1,831.00 2,105.65 30905 208.42 198.00 227.70 31368 2,152.20 2,044.59 2,351.28 # 30905 95.32 90.55 104.13 31370 1,812.08 1,721.48 1,979.70 30906 239.73 227.74 261.90 31375 1,714.03 1,628.33 1,872.58 # 30906 124.51 118.28 136.02 31380 1,688.54 1,604.11 1,844.73 30915 508.61 483.18 555.66 31382 1,850.81 1,758.27 2,022.01 30920 732.78 696.14 800.56 31390 2,488.96 2,364.51 2,719.19 30930 106.43 101.11 116.28 31395 2,639.52 2,507.54 2,883.67 31000 153.34 145.67 167.52 31400 886.74 842.40 968.76 # 31000 92.00 87.40 100.51 31420 743.77 706.58 812.57 31002 175.78 166.99 192.04 31500 103.34 98.17 112.90 31020 415.02 394.27 453.41 31502 32.83 31.19 35.87 # 31020 305.82 290.53 334.11 31505 73.23 69.57 80.01 31030 604.53 574.30 660.45 # 31505 44.15 41.94 48.23 # 31030 458.11 435.20 500.48 31510 186.94 177.59 204.23 31032 500.88 475.84 547.22 # 31510 111.07 105.52 121.35 31040 659.78 626.79 720.81 31511 187.26 177.90 204.59 31050 432.38 410.76 472.37 # 31511 119.19 113.23 130.21 31051 565.21 536.95 617.49 31512 184.90 175.66 202.01 31070 379.84 360.85 414.98 # 31512 119.67 113.69 130.74 31075 690.48 655.96 754.35 31513 121.99 115.89 133.27 31080 890.55 846.02 972.92 31515 184.74 175.50 201.83 31081 1,081.71 1,027.62 1,181.76 # 31515 101.42 96.35 110.80 31084 1,041.52 989.44 1,137.86 31520 141.95 134.85 155.08 31085 1,098.62 1,043.69 1,200.24 31525 222.29 211.18 242.86 31086 986.21 936.90 1,077.44 # 31525 147.48 140.11 161.13 31087 975.15 926.39 1,065.35 31526 146.38 139.06 159.92 31090 877.32 833.45 958.47 31527 178.89 169.95 195.44 31200 468.03 444.63 511.32 31528 133.50 126.83 145.85 31201 642.58 610.45 702.02 31529 150.53 143.00 164.45 31205 755.67 717.89 825.57 31530 184.10 174.90 201.14 31225 1,629.38 1,547.91 1,780.10 31531 198.40 188.48 216.75 31230 1,827.06 1,735.71 1,996.07 31535 176.35 167.53 192.66 31231 165.35 157.08 180.64 31536 196.97 187.12 215.19 # 31231 69.98 66.48 76.45 31540 226.38 215.06 247.32 31233 232.83 221.19 254.37 31541 247.54 235.16 270.43 # 31233 126.11 119.80 137.77 31545 335.85 319.06 366.92 31235 267.50 254.13 292.25 31546 510.40 484.88 557.61 # 31235 150.50 142.98 164.43 31560 293.13 278.47 320.24 31237 288.27 273.86 314.94 31561 321.11 305.05 350.81 # 31237 167.72 159.33 183.23 31570 309.54 294.06 338.17 31238 297.12 282.26 324.60 # 31570 212.05 201.45 231.67 # 31238 182.26 173.15 199.12 31571 233.56 221.88 255.16 31239 592.00 562.40 646.76 31575 102.95 97.80 112.47 31240 149.07 141.62 162.86 # 31575 69.98 66.48 76.45 31254 255.06 242.31 278.66 31576 200.09 190.09 218.60 31255 376.28 357.47 411.09 # 31576 113.94 108.24 124.48 31256 184.75 175.51 201.84 31577 215.81 205.02 235.77 31267 297.38 282.51 324.89 # 31577 138.17 131.26 150.95 31276 474.39 450.67 518.27 31578 250.78 238.24 273.98 31287 217.03 206.18 237.11 # 31578 157.18 149.32 171.72 31288 251.64 239.06 274.92 31579 194.59 184.86 212.59 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 VERMONT - MEDICARE CARRIER 31145 PAGE 26 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 129.71 123.22 141.70 31750 1,188.93 1,129.48 1,298.90 31580 1,064.93 1,011.68 1,163.43 31755 1,506.38 1,431.06 1,645.72 31582 1,692.23 1,607.62 1,848.76 31760 1,276.02 1,212.22 1,394.05 31584 1,353.17 1,285.51 1,478.34 31766 1,662.05 1,578.95 1,815.79 31587 885.77 841.48 967.70 31770 1,234.45 1,172.73 1,348.64 31588 1,004.40 954.18 1,097.31 31775 1,275.84 1,212.05 1,393.86 31590 783.87 744.68 856.38 31780 1,083.87 1,029.68 1,184.13 31595 678.92 644.97 741.72 31781 1,312.76 1,247.12 1,434.19 31600 365.59 347.31 399.41 31785 991.89 942.30 1,083.65 31601 242.35 230.23 264.76 31786 1,373.46 1,304.79 1,500.51 31603 206.36 196.04 225.45 31800 621.25 590.19 678.72 31605 169.85 161.36 185.56 31805 756.61 718.78 826.60 31610 630.49 598.97 688.82 31820 378.23 359.32 413.22 31611 472.99 449.34 516.74 # 31820 292.78 278.14 319.86 31612 72.17 68.56 78.84 31825 529.47 503.00 578.45 # 31612 44.51 42.28 48.62 # 31825 431.98 410.38 471.94 31613 391.02 371.47 427.19 31830 380.68 361.65 415.90 31614 649.68 617.20 709.78 # 31830 303.03 287.88 331.06 31615 164.35 156.13 179.55 32035 645.98 613.68 705.73 # 31615 117.55 111.67 128.42 32036 700.30 665.29 765.08 31620 257.71 244.82 281.54 32095 574.38 545.66 627.51 # 31620 66.61 63.28 72.77 32100 885.71 841.42 967.63 31622 289.57 275.09 316.35 32110 1,335.77 1,268.98 1,459.33 # 31622 137.48 130.61 150.20 32120 796.20 756.39 869.85 31623 317.47 301.60 346.84 32124 845.58 803.30 923.80 # 31623 139.49 132.52 152.40 32140 904.99 859.74 988.70 31624 295.13 280.37 322.43 32141 1,373.06 1,304.41 1,500.07 # 31624 139.85 132.86 152.79 32150 911.82 866.23 996.16 31625 317.93 302.03 347.33 32151 932.63 886.00 1,018.90 # 31625 162.65 154.52 177.70 32160 701.51 666.43 766.39 31628 382.02 362.92 417.36 32200 1,024.04 972.84 1,118.77 # 31628 181.71 172.62 198.51 32201 858.63 815.70 938.06 31629 584.99 555.74 639.10 # 32201 201.32 191.25 219.94 # 31629 194.65 184.92 212.66 32215 733.69 697.01 801.56 31630 193.40 183.73 211.29 32220 1,465.39 1,392.12 1,600.94 31631 218.20 207.29 238.38 32225 912.48 866.86 996.89 31632 69.75 66.26 76.20 32310 841.21 799.15 919.02 # 31632 49.54 47.06 54.12 32320 1,468.79 1,395.35 1,604.65 31633 84.47 80.25 92.29 32400 142.17 135.06 155.32 # 31633 62.48 59.36 68.26 # 32400 86.51 82.18 94.51 31635 326.27 309.96 356.45 32402 517.48 491.61 565.35 # 31635 180.20 171.19 196.87 32405 97.78 92.89 106.82 31636 213.38 202.71 233.12 # 32405 97.43 92.56 106.44 31637 75.59 71.81 82.58 32420 107.69 102.31 117.66 31638 240.16 228.15 262.37 32421 148.07 140.67 161.77 31640 247.26 234.90 270.14 # 32421 74.68 70.95 81.59 31641 245.02 232.77 267.69 32422 186.75 177.41 204.02 31643 168.40 159.98 183.98 # 32422 119.75 113.76 130.82 31645 284.84 270.60 311.19 32440 1,467.61 1,394.23 1,603.36 # 31645 152.95 145.30 167.10 32442 2,745.87 2,608.58 2,999.87 31646 258.69 245.76 282.62 32445 3,124.18 2,967.97 3,413.17 # 31646 132.48 125.86 144.74 32480 1,385.02 1,315.77 1,513.14 31656 295.40 280.63 322.72 32482 1,477.61 1,403.73 1,614.29 # 31656 107.15 101.79 117.06 32484 1,338.01 1,271.11 1,461.78 31715 52.97 50.32 57.87 32486 2,142.85 2,035.71 2,341.07 31717 277.47 263.60 303.14 32488 2,169.61 2,061.13 2,370.30 # 31717 105.17 99.91 114.90 32491 1,378.12 1,309.21 1,505.59 31720 49.75 47.26 54.35 32500 1,339.61 1,272.63 1,463.52 31725 89.47 85.00 97.75 32501 233.44 221.77 255.04 31730 789.33 749.86 862.34 32503 1,689.91 1,605.41 1,846.22 # 31730 136.98 130.13 149.65 32504 1,940.78 1,843.74 2,120.30 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 VERMONT - MEDICARE CARRIER 31145 PAGE 27 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 1,547.45 1,470.08 1,690.59 33206 449.02 426.57 490.56 32550 730.02 693.52 797.55 33207 480.46 456.44 524.91 # 32550 215.95 205.15 235.92 33208 518.31 492.39 566.25 32551 166.31 157.99 181.69 33210 178.21 169.30 194.70 32560 273.07 259.42 298.33 33211 178.80 169.86 195.34 # 32560 106.09 100.79 115.91 33212 335.36 318.59 366.38 32601 290.44 275.92 317.31 33213 383.03 363.88 418.46 32602 315.03 299.28 344.17 33214 474.83 451.09 518.75 32603 408.14 387.73 445.89 33215 303.43 288.26 331.50 32604 458.54 435.61 500.95 33216 374.37 355.65 409.00 32605 361.88 343.79 395.36 33217 370.98 352.43 405.29 32606 437.92 416.02 478.42 33218 387.06 367.71 422.87 32650 622.29 591.18 679.86 33220 390.65 371.12 426.79 32651 986.44 937.12 1,077.69 33222 340.20 323.19 371.67 32652 1,498.60 1,423.67 1,637.22 33223 412.19 391.58 450.32 32653 955.58 907.80 1,043.97 33224 503.26 478.10 549.82 32654 1,058.79 1,005.85 1,156.73 33225 454.08 431.38 496.09 32655 871.21 827.65 951.80 33226 485.84 461.55 530.78 32656 744.99 707.74 813.90 33233 238.50 226.58 260.57 32657 734.14 697.43 802.04 33234 482.32 458.20 526.93 32658 671.74 638.15 733.87 33235 623.44 592.27 681.11 32659 683.22 649.06 746.42 33236 730.67 694.14 798.26 32660 965.60 917.32 1,054.92 33237 809.00 768.55 883.83 32661 750.18 712.67 819.57 33238 870.88 827.34 951.44 32662 839.62 797.64 917.29 33240 461.80 438.71 504.52 32663 1,296.63 1,231.80 1,416.57 33241 225.69 214.41 246.57 32664 796.11 756.30 869.75 33243 1,286.60 1,222.27 1,405.61 32665 1,123.71 1,067.52 1,227.65 33244 847.40 805.03 925.78 32800 859.02 816.07 938.48 33249 898.49 853.57 981.61 32810 831.08 789.53 907.96 33250 1,372.15 1,303.54 1,499.07 32815 2,474.75 2,351.01 2,703.66 33251 1,520.21 1,444.20 1,660.83 32820 1,240.33 1,178.31 1,355.06 33254 1,277.54 1,213.66 1,395.71 32851 2,394.66 2,274.93 2,616.17 33255 1,563.85 1,485.66 1,708.51 32852 2,651.81 2,519.22 2,897.10 33256 1,863.57 1,770.39 2,035.95 32853 2,859.10 2,716.15 3,123.57 33257 542.06 514.96 592.20 32854 3,116.48 2,960.66 3,404.76 33258 611.66 581.08 668.24 32855 257.29 244.43 281.09 33259 795.93 756.13 869.55 32856 310.42 294.90 339.14 33261 1,513.48 1,437.81 1,653.48 32900 1,263.29 1,200.13 1,380.15 33265 1,274.70 1,210.97 1,392.62 32905 1,244.51 1,182.28 1,359.62 33266 1,748.10 1,660.70 1,909.81 32906 1,545.22 1,467.96 1,688.15 33282 320.70 304.67 350.37 32940 1,140.35 1,083.33 1,245.83 33284 231.24 219.68 252.63 32960 129.46 122.99 141.44 33300 2,183.21 2,074.05 2,385.16 # 32960 94.71 89.97 103.47 33305 3,651.21 3,468.65 3,988.95 32997 339.29 322.33 370.68 33310 1,094.03 1,039.33 1,195.23 32998 2,629.49 2,498.02 2,872.72 33315 1,391.27 1,321.71 1,519.97 # 32998 294.52 279.79 321.76 33320 993.55 943.87 1,085.45 33010 118.71 112.77 129.69 33321 1,116.99 1,061.14 1,220.31 33011 116.05 110.25 126.79 33322 1,300.18 1,235.17 1,420.45 33015 503.41 478.24 549.98 33330 1,312.78 1,247.14 1,434.21 33020 808.79 768.35 883.60 33332 1,310.02 1,244.52 1,431.20 33025 745.82 708.53 814.81 33335 1,768.19 1,679.78 1,931.75 33030 1,194.00 1,134.30 1,304.45 33400 2,136.78 2,029.94 2,334.43 33031 1,333.39 1,266.72 1,456.73 33401 1,407.08 1,336.73 1,537.24 33050 923.24 877.08 1,008.64 33403 1,414.42 1,343.70 1,545.26 33120 1,456.54 1,383.71 1,591.27 33404 1,675.33 1,591.56 1,830.29 33130 1,284.24 1,220.03 1,403.03 33405 2,173.43 2,064.76 2,374.47 33140 1,468.89 1,395.45 1,604.77 33406 2,689.14 2,554.68 2,937.88 33141 140.30 133.29 153.28 33410 2,373.73 2,255.04 2,593.30 33202 728.15 691.74 795.50 33411 3,103.85 2,948.66 3,390.96 33203 770.13 731.62 841.36 33412 2,341.90 2,224.81 2,558.53 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 28 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 33413 3,052.60 2,899.97 3,334.97 33615 1,897.38 1,802.51 2,072.89 33414 2,039.03 1,937.08 2,227.64 33617 2,028.98 1,927.53 2,216.66 33415 1,890.47 1,795.95 2,065.34 33619 2,488.62 2,364.19 2,718.82 33416 1,896.53 1,801.70 2,071.96 33641 1,516.24 1,440.43 1,656.49 33417 1,579.60 1,500.62 1,725.71 33645 1,490.08 1,415.58 1,627.92 33420 1,291.19 1,226.63 1,410.62 33647 1,589.72 1,510.23 1,736.76 33422 1,586.97 1,507.62 1,733.76 33660 1,658.61 1,575.68 1,812.03 33425 2,486.58 2,362.25 2,716.59 33665 1,800.01 1,710.01 1,966.51 33426 2,248.05 2,135.65 2,456.00 33670 1,868.60 1,775.17 2,041.45 33427 2,340.73 2,223.69 2,557.24 33675 1,863.18 1,770.02 2,035.52 33430 2,604.93 2,474.68 2,845.88 33676 1,937.67 1,840.79 2,116.91 33460 2,213.64 2,102.96 2,418.40 33677 2,013.73 1,913.04 2,200.00 33463 2,800.12 2,660.11 3,059.13 33681 1,724.45 1,638.23 1,883.96 33464 2,249.30 2,136.84 2,457.37 33684 1,766.62 1,678.29 1,930.03 33465 2,519.28 2,393.32 2,752.32 33688 1,765.67 1,677.39 1,929.00 33468 1,770.27 1,681.76 1,934.02 33690 1,091.59 1,037.01 1,192.56 33470 1,127.46 1,071.09 1,231.75 33692 1,662.10 1,579.00 1,815.85 33471 1,243.75 1,181.56 1,358.79 33694 1,871.25 1,777.69 2,044.34 33472 1,255.12 1,192.36 1,371.21 33697 2,025.92 1,924.62 2,213.31 33474 1,940.40 1,843.38 2,119.89 33702 1,443.65 1,371.47 1,577.19 33475 2,177.32 2,068.45 2,378.72 33710 1,749.18 1,661.72 1,910.98 33476 1,382.35 1,313.23 1,510.21 33720 1,462.43 1,389.31 1,597.71 33478 1,478.72 1,404.78 1,615.50 33722 1,470.22 1,396.71 1,606.22 33496 1,581.87 1,502.78 1,728.20 33724 1,483.60 1,409.42 1,620.83 33500 1,484.30 1,410.09 1,621.60 33726 1,938.69 1,841.76 2,118.02 33501 1,034.75 983.01 1,130.46 33730 1,845.53 1,753.25 2,016.24 33502 1,190.79 1,131.25 1,300.94 33732 1,544.66 1,467.43 1,687.54 33503 1,284.87 1,220.63 1,403.72 33735 1,181.89 1,122.80 1,291.22 33504 1,359.96 1,291.96 1,485.75 33736 1,312.31 1,246.69 1,433.69 33505 1,885.16 1,790.90 2,059.54 33737 1,221.84 1,160.75 1,334.86 33506 1,939.73 1,842.74 2,119.15 33750 1,244.01 1,181.81 1,359.08 33507 1,640.14 1,558.13 1,791.85 33755 1,214.27 1,153.56 1,326.59 33508 15.43 14.66 16.86 33762 1,212.87 1,152.23 1,325.06 33510 1,849.14 1,756.68 2,020.18 33764 1,195.33 1,135.56 1,305.89 33511 2,019.84 1,918.85 2,206.68 33766 1,314.81 1,249.07 1,436.43 33512 2,277.59 2,163.71 2,488.27 33767 1,328.27 1,261.86 1,451.14 33513 2,325.76 2,209.47 2,540.89 33768 404.54 384.31 441.96 33514 2,467.29 2,343.93 2,695.52 33770 2,019.44 1,918.47 2,206.24 33516 2,564.37 2,436.15 2,801.57 33771 2,070.74 1,967.20 2,262.28 33517 176.08 167.28 192.37 33774 1,703.83 1,618.64 1,861.44 33518 381.84 362.75 417.16 33775 1,772.68 1,684.05 1,936.66 33519 509.07 483.62 556.16 33776 1,866.24 1,772.93 2,038.87 33521 615.45 584.68 672.38 33777 1,824.73 1,733.49 1,993.51 33522 698.79 663.85 763.43 33778 2,244.61 2,132.38 2,452.24 33523 796.91 757.06 870.62 33779 2,170.77 2,062.23 2,371.56 33530 485.82 461.53 530.76 33780 2,253.39 2,140.72 2,461.83 33533 1,799.27 1,709.31 1,965.71 33781 2,200.46 2,090.44 2,404.01 33534 2,095.51 1,990.73 2,289.34 33786 2,165.23 2,056.97 2,365.52 33535 2,327.67 2,211.29 2,542.98 33788 1,461.26 1,388.20 1,596.43 33536 2,493.51 2,368.83 2,724.15 33800 916.89 871.05 1,001.71 33542 2,407.66 2,287.28 2,630.37 33802 988.61 939.18 1,080.06 33545 2,840.40 2,698.38 3,103.14 33803 1,070.73 1,017.19 1,169.77 33548 2,785.02 2,645.77 3,042.64 33813 1,218.68 1,157.75 1,331.41 33572 222.65 211.52 243.25 33814 1,434.16 1,362.45 1,566.82 33600 1,608.53 1,528.10 1,757.32 33820 919.18 873.22 1,004.20 33602 1,534.60 1,457.87 1,676.55 33822 974.90 926.16 1,065.08 33606 1,670.44 1,586.92 1,824.96 33824 1,103.14 1,047.98 1,205.18 33608 1,714.05 1,628.35 1,872.60 33840 1,119.31 1,063.34 1,222.84 33610 1,672.65 1,589.02 1,827.37 33845 1,288.22 1,223.81 1,407.38 33611 1,842.08 1,749.98 2,012.48 33851 1,182.37 1,123.25 1,291.74 33612 1,897.38 1,802.51 2,072.89 33852 1,292.08 1,227.48 1,411.60 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 VERMONT - MEDICARE CARRIER 31145 PAGE 29 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 1,773.67 1,684.99 1,937.74 34803 1,242.92 1,180.77 1,357.89 33860 2,969.63 2,821.15 3,244.32 34804 1,211.95 1,151.35 1,324.05 33861 2,302.66 2,187.53 2,515.66 34805 1,139.14 1,082.18 1,244.51 33863 2,962.26 2,814.15 3,236.27 34806 102.28 97.17 111.75 33864 3,044.94 2,892.69 3,326.59 34808 201.19 191.13 219.80 33870 2,403.66 2,283.48 2,626.00 34812 331.62 315.04 362.30 33875 1,866.97 1,773.62 2,039.66 34813 231.37 219.80 252.77 33877 3,335.31 3,168.54 3,643.82 34820 477.37 453.50 521.53 33880 1,728.86 1,642.42 1,888.78 34825 679.17 645.21 741.99 33881 1,484.40 1,410.18 1,621.71 34826 200.67 190.64 219.24 33883 1,081.78 1,027.69 1,181.84 34830 1,767.02 1,678.67 1,930.47 33884 394.94 375.19 431.47 34831 1,871.84 1,778.25 2,044.99 33886 929.47 883.00 1,015.45 34832 1,898.79 1,803.85 2,074.43 33889 772.52 733.89 843.97 34833 595.01 565.26 650.05 33891 966.25 917.94 1,055.63 34834 269.82 256.33 294.78 33910 1,565.00 1,486.75 1,709.76 34900 879.78 835.79 961.16 33915 1,260.22 1,197.21 1,376.79 35001 1,095.36 1,040.59 1,196.68 33916 1,567.93 1,489.53 1,712.96 35002 1,156.31 1,098.49 1,263.26 33917 1,416.91 1,346.06 1,547.97 35005 1,011.21 960.65 1,104.75 33920 1,710.71 1,625.17 1,868.95 35011 960.73 912.69 1,049.59 33922 1,295.42 1,230.65 1,415.25 35013 1,192.36 1,132.74 1,302.65 33924 272.74 259.10 297.97 35021 1,170.66 1,112.13 1,278.95 33925 1,662.90 1,579.76 1,816.72 35022 1,323.83 1,257.64 1,446.29 33926 2,211.12 2,100.56 2,415.64 35045 934.52 887.79 1,020.96 33933 355.82 338.03 388.73 35081 1,677.02 1,593.17 1,832.15 33935 3,272.13 3,108.52 3,574.80 35082 2,103.85 1,998.66 2,298.46 33944 250.75 238.21 273.94 35091 1,768.71 1,680.27 1,932.31 33945 4,385.76 4,166.47 4,791.44 35092 2,513.38 2,387.71 2,745.87 33960 948.82 901.38 1,036.59 35102 1,818.68 1,727.75 1,986.91 33961 532.38 505.76 581.62 35103 2,173.21 2,064.55 2,374.23 33967 262.63 249.50 286.93 35111 1,339.39 1,272.42 1,463.28 33968 33.54 31.86 36.64 35112 1,642.23 1,560.12 1,794.14 33970 350.44 332.92 382.86 35121 1,589.10 1,509.65 1,736.10 33971 675.31 641.54 737.77 35122 1,904.77 1,809.53 2,080.96 33973 510.37 484.85 557.58 35131 1,354.50 1,286.78 1,479.80 33974 859.53 816.55 939.03 35132 1,638.66 1,556.73 1,790.24 33975 1,052.96 1,000.31 1,150.36 35141 1,075.05 1,021.30 1,174.50 33976 1,170.99 1,112.44 1,279.31 35142 1,286.76 1,222.42 1,405.78 33977 1,135.40 1,078.63 1,240.42 35151 1,212.51 1,151.88 1,324.66 33978 1,248.88 1,186.44 1,364.41 35152 1,408.99 1,338.54 1,539.32 33979 2,307.72 2,192.33 2,521.18 35180 813.20 772.54 888.42 33980 3,401.93 3,231.83 3,716.60 35182 1,655.86 1,573.07 1,809.03 34001 916.39 870.57 1,001.16 35184 975.76 926.97 1,066.02 34051 916.89 871.05 1,001.71 35188 818.08 777.18 893.76 34101 582.11 553.00 635.95 35189 1,527.73 1,451.34 1,669.04 34111 581.94 552.84 635.77 35190 714.95 679.20 781.08 34151 1,345.73 1,278.44 1,470.21 35201 896.45 851.63 979.37 34201 954.64 906.91 1,042.95 35206 732.76 696.12 800.54 34203 930.32 883.80 1,016.37 35207 664.18 630.97 725.62 34401 1,391.15 1,321.59 1,519.83 35211 1,302.76 1,237.62 1,423.26 34421 706.26 670.95 771.59 35216 1,824.04 1,732.84 1,992.77 34451 1,453.29 1,380.63 1,587.72 35221 1,341.04 1,273.99 1,465.09 34471 1,026.74 975.40 1,121.71 35226 809.33 768.86 884.19 34490 585.29 556.03 639.43 35231 1,124.31 1,068.09 1,228.30 34501 906.49 861.17 990.35 35236 937.36 890.49 1,024.06 34502 1,468.40 1,394.98 1,604.23 35241 1,359.53 1,291.55 1,485.28 34510 1,031.39 979.82 1,126.79 35246 1,477.95 1,404.05 1,614.66 34520 990.17 940.66 1,081.76 35251 1,593.81 1,514.12 1,741.24 34530 933.24 886.58 1,019.57 35256 985.13 935.87 1,076.25 34800 1,108.45 1,053.03 1,210.98 35261 996.06 946.26 1,088.20 34802 1,212.48 1,151.86 1,324.64 35266 825.96 784.66 902.36 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 30 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 1,300.99 1,235.94 1,421.33 35511 1,146.92 1,089.57 1,253.01 35276 1,364.64 1,296.41 1,490.87 35512 1,193.93 1,134.23 1,304.36 35281 1,522.82 1,446.68 1,663.68 35515 1,285.63 1,221.35 1,404.55 35286 904.21 859.00 987.85 35516 1,178.51 1,119.58 1,287.52 35301 1,014.00 963.30 1,107.80 35518 1,167.04 1,108.69 1,274.99 35302 1,077.79 1,023.90 1,177.49 35521 1,228.18 1,166.77 1,341.79 35303 1,186.22 1,126.91 1,295.95 35522 1,166.18 1,107.87 1,274.05 35304 1,233.44 1,171.77 1,347.54 35523 1,235.54 1,173.76 1,349.82 35305 1,184.80 1,125.56 1,294.39 35525 1,093.67 1,038.99 1,194.84 35306 442.69 420.56 483.64 35526 1,611.01 1,530.46 1,760.03 35311 1,456.23 1,383.42 1,590.93 35531 1,959.90 1,861.91 2,141.20 35321 862.40 819.28 942.17 35533 1,518.49 1,442.57 1,658.96 35331 1,423.20 1,352.04 1,554.85 35535 1,944.23 1,847.02 2,124.07 35341 1,338.43 1,271.51 1,462.24 35536 1,688.98 1,604.53 1,845.21 35351 1,245.15 1,182.89 1,360.32 35537 2,094.86 1,990.12 2,288.64 35355 1,011.50 960.93 1,105.07 35538 2,351.57 2,233.99 2,569.09 35361 1,532.48 1,455.86 1,674.24 35539 2,179.87 2,070.88 2,381.51 35363 1,669.90 1,586.41 1,824.37 35540 2,441.81 2,319.72 2,667.68 35371 796.92 757.07 870.63 35548 1,164.74 1,106.50 1,272.48 35372 956.12 908.31 1,044.56 35549 1,265.42 1,202.15 1,382.47 35390 156.14 148.33 170.58 35551 1,442.06 1,369.96 1,575.45 35400 147.69 140.31 161.36 35556 1,342.00 1,274.90 1,466.14 35450 501.16 476.10 547.52 35558 1,186.99 1,127.64 1,296.79 35452 347.34 329.97 379.47 35560 1,724.43 1,638.21 1,883.94 35454 304.44 289.22 332.60 35563 1,322.43 1,256.31 1,444.76 35456 368.51 350.08 402.59 35565 1,281.78 1,217.69 1,400.34 35458 473.33 449.66 517.11 35566 1,609.68 1,529.20 1,758.58 35459 434.34 412.62 474.51 35570 1,503.11 1,427.95 1,642.14 35460 301.96 286.86 329.89 35571 1,299.91 1,234.91 1,420.15 35470 2,694.55 2,559.82 2,943.79 35572 338.59 321.66 369.91 # 35470 448.21 425.80 489.67 35583 1,386.04 1,316.74 1,514.25 35471 2,962.03 2,813.93 3,236.02 35585 1,621.18 1,540.12 1,771.14 # 35471 536.66 509.83 586.30 35587 1,340.57 1,273.54 1,464.57 35472 2,053.74 1,951.05 2,243.71 35600 249.19 236.73 272.24 # 35472 358.00 340.10 391.12 35601 1,396.06 1,326.26 1,525.20 35473 1,961.21 1,863.15 2,142.62 35606 1,138.40 1,081.48 1,243.70 # 35473 316.88 301.04 346.20 35612 891.25 846.69 973.69 35474 2,616.49 2,485.67 2,858.52 35616 1,091.98 1,037.38 1,192.99 # 35474 383.28 364.12 418.74 35621 1,073.35 1,019.68 1,172.63 35475 2,115.24 2,009.48 2,310.90 35623 1,318.06 1,252.16 1,439.98 # 35475 480.48 456.46 524.93 35626 1,512.88 1,437.24 1,652.83 35476 1,598.01 1,518.11 1,745.83 35631 1,802.04 1,711.94 1,968.73 # 35476 307.15 291.79 335.56 35632 1,845.88 1,753.59 2,016.63 35480 544.14 516.93 594.47 35633 1,993.03 1,893.38 2,177.39 35481 390.82 371.28 426.97 35634 1,806.58 1,716.25 1,973.69 35482 342.39 325.27 374.06 35636 1,601.66 1,521.58 1,749.82 35483 412.75 392.11 450.93 35637 1,655.61 1,572.83 1,808.75 35484 515.21 489.45 562.87 35638 1,691.74 1,607.15 1,848.22 35485 478.46 454.54 522.72 35642 1,005.11 954.85 1,098.08 35490 598.97 569.02 654.37 35645 950.54 903.01 1,038.46 35491 400.25 380.24 437.28 35646 1,670.80 1,587.26 1,825.35 35492 364.42 346.20 398.13 35647 1,512.70 1,437.07 1,652.63 35493 443.82 421.63 484.87 35650 1,034.54 982.81 1,130.23 35494 563.49 535.32 615.62 35651 1,340.52 1,273.49 1,464.51 35495 513.98 488.28 561.52 35654 1,335.13 1,268.37 1,458.63 35500 312.49 296.87 341.40 35656 1,052.10 999.50 1,149.43 35501 1,510.00 1,434.50 1,649.68 35661 1,053.78 1,001.09 1,151.25 35506 1,288.52 1,224.09 1,407.70 35663 1,222.03 1,160.93 1,335.07 35508 1,332.43 1,265.81 1,455.68 35665 1,144.14 1,086.93 1,249.97 35509 1,451.61 1,379.03 1,585.88 35666 1,234.45 1,172.73 1,348.64 35510 1,225.08 1,163.83 1,338.40 35671 1,087.71 1,033.32 1,188.32 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 31 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 DATE 11/04/08 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 35681 78.07 74.17 85.30 # 36215 239.85 227.86 262.04 35682 348.39 330.97 380.62 36216 1,188.94 1,129.49 1,298.91 35683 411.04 390.49 449.06 # 36216 270.35 256.83 295.35 35685 195.65 185.87 213.75 36217 1,936.39 1,839.57 2,115.51 35686 163.85 155.66 179.01 # 36217 323.25 307.09 353.15 35691 957.78 909.89 1,046.37 36218 182.31 173.19 199.17 35693 849.99 807.49 928.61 # 36218 51.49 48.92 56.26 35694 990.04 940.54 1,081.62 36245 1,199.57 1,139.59 1,310.53 35695 1,031.64 980.06 1,127.07 # 36245 246.93 234.58 269.77 35697 145.92 138.62 159.41 36246 1,178.48 1,119.56 1,287.49 35700 150.04 142.54 163.92 # 36246 269.10 255.65 294.00 35701 514.95 489.20 562.58 36247 1,850.05 1,757.55 2,021.18 35721 436.96 415.11 477.38 # 36247 320.24 304.23 349.86 35741 478.48 454.56 522.74 36248 156.79 148.95 171.29 35761 353.97 336.27 386.71 # 36248 51.49 48.92 56.26 35800 455.25 432.49 497.36 36260 546.39 519.07 596.93 35820 1,794.54 1,704.81 1,960.53 36261 333.41 316.74 364.25 35840 594.36 564.64 649.34 36262 253.80 241.11 277.28 35860 384.82 365.58 420.42 36400 24.16 22.95 26.39 35870 1,242.26 1,180.15 1,357.17 # 36400 17.07 16.22 18.65 35875 572.41 543.79 625.36 36405 21.99 20.89 24.02 35876 915.79 870.00 1,000.50 # 36405 14.90 14.16 16.28 35879 896.73 851.89 979.67 36406 15.89 15.10 17.37 35881 996.81 946.97 1,089.02 # 36406 8.80 8.36 9.61 35883 1,160.95 1,102.90 1,268.34 36410 17.66 16.78 19.30 35884 1,224.25 1,163.04 1,337.50 # 36410 8.44 8.02 9.22 35901 480.57 456.54 525.02 36420 46.53 44.20 50.83 35903 543.50 516.33 593.78 36425 36.62 34.79 40.01 35905 1,687.80 1,603.41 1,843.92 36430 34.38 32.66 37.56 35907 1,859.17 1,766.21 2,031.14 36440 48.84 46.40 53.36 36000 23.69 22.51 25.89 36450 112.49 106.87 122.90 # 36000 9.15 8.69 9.99 36455 123.26 117.10 134.67 36002 159.84 151.85 174.63 36460 319.32 303.35 348.85 # 36002 106.66 101.33 116.53 36470 127.58 121.20 139.38 36005 320.90 304.86 350.59 # 36470 65.18 61.92 71.21 # 36005 48.26 45.85 52.73 36471 157.14 149.28 171.67 36010 553.84 526.15 605.07 # 36471 91.55 86.97 100.02 # 36010 120.95 114.90 132.14 36475 1,667.39 1,584.02 1,821.62 36011 876.72 832.88 957.81 # 36475 326.89 310.55 357.13 # 36011 156.30 148.49 170.76 36476 358.01 340.11 391.13 36012 824.83 783.59 901.13 # 36476 159.82 151.83 174.60 # 36012 176.74 167.90 193.09 36478 1,374.19 1,305.48 1,501.30 36013 761.47 723.40 831.91 # 36478 330.08 313.58 360.62 # 36013 126.50 120.18 138.21 36479 376.44 357.62 411.26 36014 795.11 755.35 868.65 # 36479 160.89 152.85 175.78 # 36014 153.75 146.06 167.97 36481 397.23 377.37 433.98 36015 871.98 828.38 952.64 36500 176.92 168.07 193.28 # 36015 177.81 168.92 194.26 36510 102.41 97.29 111.88 36100 505.27 480.01 552.01 # 36510 54.55 51.82 59.59 # 36100 155.34 147.57 169.71 36511 86.15 81.84 94.12 36120 418.15 397.24 456.83 36512 87.57 83.19 95.67 # 36120 98.01 93.11 107.08 36513 89.86 85.37 98.18 36140 461.76 438.67 504.47 36514 486.42 462.10 531.42 # 36140 100.84 95.80 110.17 # 36514 85.44 81.17 93.35 36145 457.69 434.81 500.03 36515 1,813.80 1,723.11 1,981.58 # 36145 98.90 93.96 108.05 # 36515 83.67 79.49 91.41 36160 507.80 482.41 554.77 36516 2,053.14 1,950.48 2,243.05 # 36160 130.93 124.38 143.04 # 36516 59.95 56.95 65.49 36200 617.30 586.44 674.41 36522 1,280.35 1,216.33 1,398.78 # 36200 150.73 143.19 164.67 # 36522 96.91 92.06 105.87 36215 1,087.89 1,033.50 1,188.53 36555 257.78 244.89 281.62 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 VERMONT - MEDICARE CARRIER 31145 PAGE 32 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 122.35 116.23 133.66 36625 100.54 95.51 109.84 36556 219.38 208.41 239.67 36640 113.48 107.81 123.98 # 36556 115.50 109.73 126.19 36660 63.95 60.75 69.86 36557 788.91 749.46 861.88 36680 56.57 53.74 61.80 # 36557 285.11 270.85 311.48 36800 149.49 142.02 163.32 36558 763.20 725.04 833.80 36810 199.33 189.36 217.76 # 36558 272.52 258.89 297.72 36815 140.73 133.69 153.74 36560 1,084.23 1,030.02 1,184.52 36818 638.14 606.23 697.16 # 36560 337.94 321.04 369.20 36819 753.17 715.51 822.84 36561 1,072.73 1,019.09 1,171.95 36820 755.83 718.04 825.75 # 36561 326.79 310.45 357.02 36821 630.34 598.82 688.64 36563 1,082.94 1,028.79 1,183.11 36822 354.12 336.41 386.87 # 36563 337.70 320.82 368.94 36823 1,204.08 1,143.88 1,315.46 36565 907.17 861.81 991.08 36825 546.14 518.83 596.65 # 36565 321.83 305.74 351.60 36830 623.74 592.55 681.43 36566 3,388.15 3,218.74 3,701.55 36831 431.14 409.58 471.02 # 36566 344.83 327.59 376.73 36832 550.16 522.65 601.05 36568 292.42 277.80 319.47 36833 621.41 590.34 678.89 # 36568 93.88 89.19 102.57 36834 584.40 555.18 638.46 36569 253.70 241.02 277.17 36835 432.39 410.77 472.39 # 36569 93.46 88.79 102.11 36838 1,109.90 1,054.41 1,212.57 36570 1,102.10 1,047.00 1,204.05 36860 179.73 170.74 196.35 # 36570 301.56 286.48 329.45 # 36860 98.54 93.61 107.65 36571 1,143.21 1,086.05 1,248.96 36861 142.80 135.66 156.01 # 36571 293.04 278.39 320.15 36870 1,738.06 1,651.16 1,898.83 36575 150.36 142.84 164.27 # 36870 295.81 281.02 323.17 # 36575 36.56 34.73 39.94 37140 1,277.72 1,213.83 1,395.90 36576 337.16 320.30 368.35 37145 1,372.53 1,303.90 1,499.49 # 36576 178.69 169.76 195.22 37160 1,193.46 1,133.79 1,303.86 36578 471.72 448.13 515.35 37180 1,335.83 1,269.04 1,459.40 # 36578 204.75 194.51 223.69 37181 1,445.26 1,373.00 1,578.95 36580 217.58 206.70 237.71 37182 871.12 827.56 951.69 # 36580 66.91 63.56 73.09 37183 414.17 393.46 452.48 36581 712.05 676.45 777.92 37184 2,285.80 2,171.51 2,497.24 # 36581 193.72 184.03 211.63 # 37184 445.41 423.14 486.61 36582 993.92 944.22 1,085.85 37185 755.56 717.78 825.45 # 36582 284.86 270.62 311.21 # 37185 163.84 155.65 179.00 36583 994.31 944.59 1,086.28 37186 1,540.96 1,463.91 1,683.50 # 36583 285.24 270.98 311.63 # 37186 251.87 239.28 275.17 36584 214.33 203.61 234.15 37187 2,190.41 2,080.89 2,393.02 # 36584 68.97 65.52 75.35 # 37187 413.83 393.14 452.11 36585 1,020.62 969.59 1,115.03 37188 1,861.76 1,768.67 2,033.97 # 36585 267.59 254.21 292.34 # 37188 299.68 284.70 327.41 36589 156.66 148.83 171.15 37195 316.11 300.30 345.35 # 36589 132.55 125.92 144.81 37200 231.26 219.70 252.66 36590 254.42 241.70 277.96 37201 273.72 260.03 299.03 # 36590 187.06 177.71 204.37 37202 329.08 312.63 359.52 36591 21.45 20.38 23.44 37203 1,267.50 1,204.13 1,384.75 36592 23.58 22.40 25.76 # 37203 263.10 249.95 287.44 36593 31.70 30.12 34.64 37204 916.10 870.30 1,000.85 36595 574.58 545.85 627.73 37205 3,143.71 2,986.52 3,434.50 # 36595 186.72 177.38 203.99 # 37205 431.52 409.94 471.43 36596 128.97 122.52 140.90 37206 1,878.52 1,784.59 2,052.28 # 36596 44.24 42.03 48.33 # 37206 210.08 199.58 229.52 36597 121.10 115.05 132.31 37207 414.63 393.90 452.99 # 36597 62.25 59.14 68.01 37208 200.48 190.46 219.03 36598 108.76 103.32 118.82 37209 113.23 107.57 123.71 # 36598 58.77 55.83 64.20 37210 3,336.59 3,169.76 3,645.22 36600 28.91 27.46 31.58 # 37210 547.82 520.43 598.49 # 36600 14.73 13.99 16.09 37215 1,075.33 1,021.56 1,174.79 36620 48.74 46.30 53.25 37250 107.10 101.75 117.01 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 33 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 79.49 75.52 86.85 38550 417.59 396.71 456.22 37500 651.13 618.57 711.36 38555 869.04 825.59 949.43 37565 648.04 615.64 707.99 38562 624.90 593.66 682.71 37600 662.44 629.32 723.72 38564 619.08 588.13 676.35 37605 755.71 717.92 825.61 38570 504.60 479.37 551.28 37606 493.25 468.59 538.88 38571 797.57 757.69 871.34 37607 352.40 334.78 385.00 38572 871.86 828.27 952.51 37609 266.66 253.33 291.33 38700 705.08 669.83 770.30 # 37609 182.28 173.17 199.15 38720 1,170.76 1,112.22 1,279.05 37615 438.98 417.03 479.58 38724 1,269.84 1,206.35 1,387.30 37616 1,016.30 965.49 1,110.31 38740 586.03 556.73 640.24 37617 1,208.34 1,147.92 1,320.11 38745 745.33 708.06 814.27 37618 350.15 332.64 382.54 38746 244.37 232.15 266.97 37620 635.38 603.61 694.15 38747 238.35 226.43 260.39 37650 477.48 453.61 521.65 38760 735.27 698.51 803.29 37660 1,133.18 1,076.52 1,238.00 38765 1,144.10 1,086.90 1,249.94 37700 234.30 222.59 255.98 38770 769.28 730.82 840.44 37718 390.04 370.54 426.12 38780 968.02 919.62 1,057.56 37722 446.98 424.63 488.32 38790 75.76 71.97 82.77 37735 592.54 562.91 647.35 38792 36.83 34.99 40.24 37760 583.61 554.43 637.59 38794 288.85 274.41 315.57 37765 422.99 401.84 462.12 39000 447.15 424.79 488.51 37766 514.94 489.19 562.57 39010 739.28 702.32 807.67 37780 241.81 229.72 264.18 39200 818.62 777.69 894.34 37785 324.95 308.70 355.01 39220 1,055.11 1,002.35 1,152.70 # 37785 242.34 230.22 264.75 39400 461.12 438.06 503.77 37788 1,299.22 1,234.26 1,419.40 39501 750.75 713.21 820.19 37790 472.53 448.90 516.24 39502 900.34 855.32 983.62 38100 981.77 932.68 1,072.58 39503 5,255.32 4,992.55 5,741.43 38101 986.19 936.88 1,077.41 39520 899.17 854.21 982.34 38102 233.86 222.17 255.50 39530 860.82 817.78 940.45 38115 1,092.20 1,037.59 1,193.23 39531 899.18 854.22 982.35 38120 907.35 861.98 991.28 39540 767.08 728.73 838.04 38200 132.43 125.81 144.68 39541 827.52 786.14 904.06 38205 76.61 72.78 83.70 39545 816.05 775.25 891.54 38206 76.61 72.78 83.70 39560 704.65 669.42 769.83 38220 144.42 137.20 157.78 39561 1,096.23 1,041.42 1,197.63 # 38220 57.56 54.68 62.88 40490 114.73 108.99 125.34 38221 160.20 152.19 175.02 # 40490 66.86 63.52 73.05 # 38221 72.98 69.33 79.73 40500 432.33 410.71 472.32 38230 293.26 278.60 320.39 # 40500 318.17 302.26 347.60 38240 118.54 112.61 129.50 40510 418.20 397.29 456.88 38241 119.25 113.29 130.28 # 40510 314.32 298.60 343.39 38242 90.38 85.86 98.74 40520 429.70 408.22 469.45 38300 237.32 225.45 259.27 # 40520 317.67 301.79 347.06 # 38300 159.68 151.70 174.46 40525 493.32 468.65 538.95 38305 403.50 383.33 440.83 40527 582.91 553.76 636.82 38308 387.12 367.76 422.92 40530 474.29 450.58 518.17 38380 501.04 475.99 547.39 # 40530 360.49 342.47 393.84 38381 742.06 704.96 810.70 40650 357.12 339.26 390.15 38382 600.34 570.32 655.87 # 40650 253.24 240.58 276.67 38500 276.85 263.01 302.46 40652 419.89 398.90 458.74 # 38500 218.00 207.10 238.17 # 40652 308.57 293.14 337.11 38505 117.16 111.30 128.00 40654 495.33 470.56 541.14 # 38505 70.00 66.50 76.48 # 40654 374.79 356.05 409.46 38510 448.27 425.86 489.74 40700 828.70 787.27 905.36 # 38510 370.27 351.76 404.52 40701 1,025.86 974.57 1,120.76 38520 404.81 384.57 442.26 40702 796.13 756.32 869.77 38525 366.51 348.18 400.41 40720 875.59 831.81 956.58 38530 470.82 447.28 514.37 40761 948.25 900.84 1,035.97 38542 452.89 430.25 494.79 40800 172.84 164.20 188.83 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 VERMONT - MEDICARE CARRIER 31145 PAGE 34 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 111.16 105.60 121.44 41019 454.39 431.67 496.42 40801 264.79 251.55 289.28 41100 145.31 138.04 158.75 # 40801 192.82 183.18 210.66 # 41100 97.09 92.24 106.08 40804 176.43 167.61 192.75 41105 145.70 138.42 159.18 # 40804 112.62 106.99 123.04 # 41105 98.55 93.62 107.66 40805 277.47 263.60 303.14 41108 125.09 118.84 136.67 # 40805 199.83 189.84 218.32 # 41108 79.35 75.38 86.69 40806 91.66 87.08 100.14 41110 180.14 171.13 196.80 # 40806 29.97 28.47 32.74 # 41110 115.97 110.17 126.70 40808 155.52 147.74 169.90 41112 283.88 269.69 310.14 # 40808 93.48 88.81 102.13 # 41112 220.07 209.07 240.43 40810 172.93 164.28 188.92 41113 311.10 295.55 339.88 # 40810 110.89 105.35 121.15 # 41113 244.45 232.23 267.06 40812 242.84 230.70 265.31 41114 565.61 537.33 617.93 # 40812 171.93 163.33 187.83 41115 209.53 199.05 228.91 40814 326.65 310.32 356.87 # 41115 130.82 124.28 142.92 # 40814 265.67 252.39 290.25 41116 278.21 264.30 303.95 40816 344.36 327.14 376.21 # 41116 192.77 183.13 210.60 # 40816 278.06 264.16 303.78 41120 927.17 880.81 1,012.93 40818 303.54 288.36 331.61 41130 1,145.18 1,087.92 1,251.11 # 40818 238.66 226.73 260.74 41135 1,908.68 1,813.25 2,085.24 40819 260.11 247.10 284.17 41140 1,960.49 1,862.47 2,141.84 # 40819 204.09 193.89 222.97 41145 2,457.23 2,334.37 2,684.53 40820 225.74 214.45 246.62 41150 1,943.58 1,846.40 2,123.36 # 40820 149.87 142.38 163.74 41153 2,108.61 2,003.18 2,303.66 40830 207.59 197.21 226.79 41155 2,623.35 2,492.18 2,866.01 # 40830 139.17 132.21 152.04 41250 195.81 186.02 213.92 40831 275.21 261.45 300.67 # 41250 124.90 118.66 136.46 # 40831 195.44 185.67 213.52 41251 202.41 192.29 221.13 40840 703.87 668.68 768.98 # 41251 145.33 138.06 158.77 # 40840 562.06 533.96 614.05 41252 265.40 252.13 289.95 40842 692.88 658.24 756.98 # 41252 188.12 178.71 205.52 # 40842 550.00 522.50 600.88 41500 392.61 372.98 428.93 40843 904.41 859.19 988.07 41510 360.89 342.85 394.28 # 40843 714.73 678.99 780.84 41512 551.32 523.75 602.31 40844 1,198.73 1,138.79 1,309.61 41520 297.18 282.32 324.67 # 40844 999.13 949.17 1,091.55 # 41520 223.08 211.93 243.72 40845 1,305.42 1,240.15 1,426.17 41530 2,755.80 2,618.01 3,010.71 # 40845 1,120.71 1,064.67 1,224.37 # 41530 360.91 342.86 394.29 41000 137.65 130.77 150.39 41800 194.66 184.93 212.67 # 41000 97.94 93.04 107.00 # 41800 112.76 107.12 123.19 41005 193.29 183.63 211.17 41805 200.91 190.86 219.49 # 41005 111.74 106.15 122.07 # 41805 143.47 136.30 156.75 41006 309.89 294.40 338.56 41806 292.89 278.25 319.99 # 41006 228.35 216.93 249.47 # 41806 222.69 211.56 243.29 41007 310.87 295.33 339.63 41822 245.86 233.57 268.61 # 41007 221.89 210.80 242.42 # 41822 154.39 146.67 168.67 41008 319.36 303.39 348.90 41823 366.11 347.80 399.97 # 41008 236.39 224.57 258.26 # 41823 279.25 265.29 305.08 41009 339.17 322.21 370.54 41825 176.13 167.32 192.42 # 41009 256.56 243.73 280.29 # 41825 110.90 105.36 121.16 41010 173.85 165.16 189.93 41826 247.11 234.75 269.96 # 41010 96.20 91.39 105.10 # 41826 178.33 169.41 194.82 41015 365.10 346.85 398.88 41827 367.24 348.88 401.21 # 41015 294.90 280.16 322.18 # 41827 265.14 251.88 289.66 41016 374.56 355.83 409.20 41828 261.74 248.65 285.95 # 41016 305.78 290.49 334.06 # 41828 191.19 181.63 208.87 41017 377.39 358.52 412.30 41830 331.04 314.49 361.66 # 41017 307.19 291.83 335.60 # 41830 244.89 232.65 267.55 41018 432.08 410.48 472.05 41872 311.26 295.70 340.06 # 41018 359.04 341.09 392.25 # 41872 228.30 216.89 249.42 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 VERMONT - MEDICARE CARRIER 31145 PAGE 35 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 315.11 299.35 344.25 42425 763.05 724.90 833.64 # 41874 223.29 212.13 243.95 42426 1,239.46 1,177.49 1,354.11 42000 135.83 129.04 148.40 42440 421.38 400.31 460.36 # 42000 90.81 86.27 99.21 42450 396.00 376.20 432.63 42100 128.97 122.52 140.90 # 42450 320.84 304.80 350.52 # 42100 96.35 91.53 105.26 42500 377.54 358.66 412.46 42104 179.69 170.71 196.32 # 42500 305.22 289.96 333.45 # 42104 121.19 115.13 132.40 42505 490.01 465.51 535.34 42106 227.65 216.27 248.71 # 42505 408.47 388.05 446.26 # 42106 158.51 150.58 173.17 42507 459.84 436.85 502.38 42107 395.53 375.75 432.11 42508 652.23 619.62 712.56 # 42107 305.48 290.21 333.74 42509 748.57 711.14 817.81 42120 863.68 820.50 943.58 42510 566.23 537.92 618.61 42140 214.96 204.21 234.84 42550 135.66 128.88 148.21 # 42140 136.61 129.78 149.25 # 42550 62.98 59.83 68.80 42145 626.46 595.14 684.41 42600 424.66 403.43 463.94 42160 207.62 197.24 226.83 # 42600 317.95 302.05 347.36 # 42160 135.29 128.53 147.81 42650 72.61 68.98 79.33 42180 210.88 200.34 230.39 # 42650 53.11 50.45 58.02 # 42180 164.08 155.88 179.26 42660 93.40 88.73 102.04 42182 288.07 273.67 314.72 # 42660 70.71 67.17 77.25 # 42182 238.79 226.85 260.88 42665 268.70 255.27 293.56 42200 791.55 751.97 864.77 # 42665 185.03 175.78 202.15 42205 842.40 800.28 920.32 42700 163.55 155.37 178.68 42210 948.29 900.88 1,036.01 # 42700 121.00 114.95 132.19 42215 622.75 591.61 680.35 42720 407.29 386.93 444.97 42220 485.55 461.27 530.46 # 42720 358.36 340.44 391.51 42225 836.87 795.03 914.28 42725 730.88 694.34 798.49 42226 830.30 788.79 907.11 42800 137.17 130.31 149.86 42227 807.17 766.81 881.83 # 42800 99.95 94.95 109.19 42235 659.62 626.64 720.64 42802 209.41 198.94 228.78 42260 732.88 696.24 800.68 # 42802 121.49 115.42 132.73 # 42260 609.50 579.03 665.88 42804 174.84 166.10 191.02 42280 136.19 129.38 148.79 # 42804 102.87 97.73 112.39 # 42280 92.59 87.96 101.15 42806 197.20 187.34 215.44 42281 176.50 167.68 192.83 # 42806 120.62 114.59 131.78 # 42281 135.37 128.60 147.89 42808 200.12 190.11 218.63 42300 180.58 171.55 197.28 # 42808 148.01 140.61 161.70 # 42300 135.55 128.77 148.09 42809 148.95 141.50 162.73 42305 386.49 367.17 422.25 # 42809 115.98 110.18 126.71 42310 140.47 133.45 153.47 42810 336.86 320.02 368.02 # 42310 110.69 105.16 120.93 # 42810 253.89 241.20 277.38 42320 217.17 206.31 237.26 42815 497.00 472.15 542.97 # 42320 158.67 150.74 173.35 42820 262.58 249.45 286.87 42330 202.19 192.08 220.89 42821 274.01 260.31 299.36 # 42330 147.24 139.88 160.86 42825 235.20 223.44 256.96 42335 322.35 306.23 352.16 42826 227.01 215.66 248.01 # 42335 230.88 219.34 252.24 42830 185.23 175.97 202.37 42340 404.85 384.61 442.30 42831 199.85 189.86 218.34 # 42340 303.45 288.28 331.52 42835 166.80 158.46 182.23 42400 95.84 91.05 104.71 42836 217.86 206.97 238.02 # 42400 52.94 50.29 57.83 42842 866.52 823.19 946.67 42405 266.13 252.82 290.74 42844 1,217.15 1,156.29 1,329.73 # 42405 205.15 194.89 224.12 42845 1,990.69 1,891.16 2,174.83 42408 396.12 376.31 432.76 42860 167.64 159.26 183.15 # 42408 294.02 279.32 321.22 42870 511.34 485.77 558.64 42409 286.95 272.60 313.49 42890 1,239.08 1,177.13 1,353.70 # 42409 199.73 189.74 218.20 42892 1,625.98 1,544.68 1,776.38 42410 559.32 531.35 611.05 42894 2,081.88 1,977.79 2,274.46 42415 1,010.87 960.33 1,104.38 42900 311.98 296.38 340.84 42420 1,158.68 1,100.75 1,265.86 42950 706.92 671.57 772.31 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 36 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 869.64 826.16 950.08 43245 175.29 166.53 191.51 42955 664.93 631.68 726.43 43246 234.84 223.10 256.57 42960 152.28 144.67 166.37 43247 187.65 178.27 205.01 42961 378.01 359.11 412.98 43248 177.58 168.70 194.01 42962 468.16 444.75 511.46 43249 163.43 155.26 178.55 42970 350.41 332.89 382.82 43250 175.31 166.54 191.52 42971 412.57 391.94 450.73 43251 204.14 193.93 223.02 42972 463.33 440.16 506.18 43255 265.81 252.52 290.40 43020 474.85 451.11 518.78 43256 238.75 226.81 260.83 43030 471.35 447.78 514.95 43257 293.35 278.68 320.48 43045 1,191.37 1,131.80 1,301.57 43258 250.40 237.88 273.56 43100 562.92 534.77 614.99 43259 285.54 271.26 311.95 43101 928.81 882.37 1,014.73 43260 326.77 310.43 356.99 43107 2,300.12 2,185.11 2,512.88 43261 343.44 326.27 375.21 43108 3,902.33 3,707.21 4,263.29 43262 403.33 383.16 440.63 43112 2,457.20 2,334.34 2,684.49 43263 399.01 379.06 435.92 43113 3,897.21 3,702.35 4,257.70 43264 484.19 459.98 528.98 43116 4,445.04 4,222.79 4,856.21 43265 543.36 516.19 593.62 43117 2,248.26 2,135.85 2,456.23 43267 401.56 381.48 438.70 43118 3,207.86 3,047.47 3,504.59 43268 408.29 387.88 446.06 43121 2,544.53 2,417.30 2,779.90 43269 447.08 424.73 488.44 43122 2,272.45 2,158.83 2,482.65 43271 402.97 382.82 440.24 43123 3,922.69 3,726.56 4,285.54 43272 402.26 382.15 439.47 43124 3,351.80 3,184.21 3,661.84 43273 121.90 115.81 133.18 43130 713.03 677.38 778.99 43279 1,125.78 1,069.49 1,229.91 43135 1,332.17 1,265.56 1,455.39 43280 939.00 892.05 1,025.86 43200 193.30 183.64 211.19 43300 557.91 530.01 609.51 # 43200 95.80 91.01 104.66 43305 1,001.81 951.72 1,094.48 43201 265.93 252.63 290.52 43310 1,388.31 1,318.89 1,516.72 # 43201 120.57 114.54 131.72 43312 1,532.66 1,456.03 1,674.43 43202 254.11 241.40 277.61 43313 2,444.31 2,322.09 2,670.40 # 43202 106.26 100.95 116.09 43314 2,800.73 2,660.69 3,059.79 43204 209.33 198.86 228.69 43320 1,222.22 1,161.11 1,335.28 43205 210.05 199.55 229.48 43324 1,184.44 1,125.22 1,294.00 43215 143.39 136.22 156.65 43325 1,166.49 1,108.17 1,274.40 43216 179.78 170.79 196.41 43326 1,188.07 1,128.67 1,297.97 # 43216 133.69 127.01 146.06 43330 1,143.72 1,086.53 1,249.51 43217 339.98 322.98 371.43 43331 1,239.77 1,177.78 1,354.45 # 43217 157.40 149.53 171.96 43340 1,189.08 1,129.63 1,299.07 43219 159.46 151.49 174.21 43341 1,308.56 1,243.13 1,429.60 43220 118.09 112.19 129.02 43350 1,018.94 967.99 1,113.19 43226 131.71 125.12 143.89 43351 1,191.84 1,132.25 1,302.09 43227 196.11 186.30 214.25 43352 974.63 925.90 1,064.79 43228 208.97 198.52 228.30 43360 2,082.62 1,978.49 2,275.26 43231 178.32 169.40 194.81 43361 2,332.32 2,215.70 2,548.06 43232 245.57 233.29 268.28 43400 1,442.80 1,370.66 1,576.26 43234 252.05 239.45 275.37 43401 1,356.21 1,288.40 1,481.66 # 43234 110.95 105.40 121.21 43405 1,315.23 1,249.47 1,436.89 43235 272.49 258.87 297.70 43410 901.84 856.75 985.26 # 43235 135.64 128.86 148.19 43415 1,531.67 1,455.09 1,673.35 43236 339.47 322.50 370.88 43420 904.04 858.84 987.67 # 43236 165.03 156.78 180.30 43425 1,346.45 1,279.13 1,471.00 43237 223.81 212.62 244.51 43450 144.60 137.37 157.98 43238 277.98 264.08 303.69 # 43450 82.91 78.76 90.57 43239 315.50 299.73 344.69 43453 271.96 258.36 297.11 # 43239 160.57 152.54 175.42 # 43453 90.08 85.58 98.42 43240 373.22 354.56 407.74 43456 550.38 522.86 601.29 43241 145.69 138.41 159.17 # 43456 145.14 137.88 158.56 43242 398.49 378.57 435.36 43458 353.20 335.54 385.87 43243 251.12 238.56 274.34 # 43458 169.55 161.07 185.23 43244 278.35 264.43 304.09 43460 205.62 195.34 224.64 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 37 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 1,938.61 1,841.68 2,117.93 44021 844.18 801.97 922.27 43500 672.59 638.96 734.80 44025 849.44 806.97 928.02 43501 1,155.67 1,097.89 1,262.57 44050 803.81 763.62 878.16 43502 1,308.03 1,242.63 1,429.02 44055 1,287.64 1,223.26 1,406.75 43510 833.72 792.03 910.83 44100 107.40 102.03 117.33 43520 608.40 577.98 664.68 44110 728.30 691.89 795.67 43600 99.72 94.73 108.94 44111 847.50 805.13 925.90 43605 713.74 678.05 779.76 44120 1,050.06 997.56 1,147.19 43610 842.60 800.47 920.54 44121 215.75 204.96 235.70 43611 1,048.86 996.42 1,145.88 44125 1,019.07 968.12 1,113.34 43620 1,708.37 1,622.95 1,866.39 44126 2,104.16 1,998.95 2,298.79 43621 1,947.50 1,850.13 2,127.65 44127 2,448.04 2,325.64 2,674.49 43622 1,975.08 1,876.33 2,157.78 44128 216.63 205.80 236.67 43631 1,252.54 1,189.91 1,368.40 44130 1,102.44 1,047.32 1,204.42 43632 1,712.15 1,626.54 1,870.52 44137 962.77 914.63 1,051.82 43633 1,628.13 1,546.72 1,778.73 44139 108.06 102.66 118.06 43634 1,798.48 1,708.56 1,964.84 44140 1,159.21 1,101.25 1,266.44 43635 99.98 94.98 109.23 44141 1,533.12 1,456.46 1,674.93 43640 1,007.95 957.55 1,101.18 44143 1,430.37 1,358.85 1,562.68 43641 1,016.79 965.95 1,110.84 44144 1,504.19 1,428.98 1,643.33 43644 1,492.86 1,418.22 1,630.95 44145 1,445.04 1,372.79 1,578.71 43645 1,596.24 1,516.43 1,743.89 44146 1,811.46 1,720.89 1,979.02 43651 559.70 531.72 611.48 44147 1,635.25 1,553.49 1,786.51 43652 655.21 622.45 715.82 44150 1,588.35 1,508.93 1,735.27 43653 478.53 454.60 522.79 44151 1,815.81 1,725.02 1,983.77 43752 39.49 37.52 43.15 44155 1,779.89 1,690.90 1,944.54 43760 305.98 290.68 334.28 44156 1,954.15 1,856.44 2,134.91 # 43760 47.17 44.81 51.53 44157 1,854.88 1,762.14 2,026.46 43761 114.85 109.11 125.48 44158 1,901.04 1,805.99 2,076.89 # 43761 101.38 96.31 110.76 44160 1,068.86 1,015.42 1,167.73 43770 956.11 908.30 1,044.55 44180 796.57 756.74 870.25 43771 1,090.03 1,035.53 1,190.86 44186 562.29 534.18 614.31 43772 824.30 783.09 900.55 44187 948.87 901.43 1,036.64 43773 1,090.92 1,036.37 1,191.83 44188 1,049.29 996.83 1,146.35 43774 825.75 784.46 902.13 44202 1,199.39 1,139.42 1,310.33 43800 799.86 759.87 873.85 44203 214.86 204.12 234.74 43810 867.04 823.69 947.24 44204 1,339.49 1,272.52 1,463.40 43820 1,125.73 1,069.44 1,229.86 44205 1,169.37 1,110.90 1,277.54 43825 1,115.28 1,059.52 1,218.45 44206 1,520.37 1,444.35 1,661.00 43830 594.47 564.75 649.46 44207 1,596.66 1,516.83 1,744.35 43831 497.32 472.45 543.32 44208 1,737.07 1,650.22 1,897.75 43832 914.47 868.75 999.06 44210 1,553.15 1,475.49 1,696.81 43840 1,141.86 1,084.77 1,247.49 44211 1,906.76 1,811.42 2,083.13 43843 1,087.30 1,032.94 1,187.88 44212 1,789.51 1,700.03 1,955.03 43845 1,681.64 1,597.56 1,837.19 44213 169.45 160.98 185.13 43846 1,402.11 1,332.00 1,531.80 44227 1,450.19 1,377.68 1,584.33 43847 1,531.29 1,454.73 1,672.94 44300 722.61 686.48 789.45 43848 1,661.82 1,578.73 1,815.54 44310 903.44 858.27 987.01 43850 1,391.42 1,321.85 1,520.13 44312 515.46 489.69 563.14 43855 1,453.95 1,381.25 1,588.44 44314 875.98 832.18 957.01 43860 1,413.06 1,342.41 1,543.77 44316 1,199.02 1,139.07 1,309.93 43865 1,469.41 1,395.94 1,605.33 44320 1,030.48 978.96 1,125.80 43870 606.55 576.22 662.65 44322 821.58 780.50 897.58 43880 1,380.36 1,311.34 1,508.04 44340 518.34 492.42 566.28 43886 288.69 274.26 315.40 44345 902.11 857.00 985.55 43887 269.34 255.87 294.25 44346 1,013.13 962.47 1,106.84 43888 380.34 361.32 415.52 44360 147.82 140.43 161.49 44005 943.68 896.50 1,030.98 44361 162.88 154.74 177.95 44010 742.43 705.31 811.11 44363 192.68 183.05 210.51 44015 128.32 121.90 140.19 44364 207.72 197.33 226.93 44020 834.38 792.66 911.56 44365 184.95 175.70 202.06 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 VERMONT - MEDICARE CARRIER 31145 PAGE 38 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 244.82 232.58 267.47 45005 216.23 205.42 236.23 44369 250.02 237.52 273.15 # 45005 132.56 125.93 144.82 44370 269.34 255.87 294.25 45020 466.90 443.56 510.09 44372 237.90 226.01 259.91 45100 247.73 235.34 270.64 44373 192.68 183.05 210.51 45108 301.02 285.97 328.87 44376 284.68 270.45 311.02 45110 1,599.31 1,519.34 1,747.24 44377 302.22 287.11 330.18 45111 938.78 891.84 1,025.62 44378 387.57 368.19 423.42 45112 1,648.51 1,566.08 1,800.99 44379 410.46 389.94 448.43 45113 1,690.72 1,606.18 1,847.11 44380 64.45 61.23 70.41 45114 1,542.98 1,465.83 1,685.70 44382 77.35 73.48 84.50 45116 1,387.27 1,317.91 1,515.60 44383 166.11 157.80 181.47 45119 1,693.90 1,609.21 1,850.59 44385 224.28 213.07 245.03 45120 1,352.43 1,284.81 1,477.53 # 44385 98.78 93.84 107.92 45121 1,479.37 1,405.40 1,616.21 44386 311.85 296.26 340.70 45123 960.39 912.37 1,049.23 # 44386 115.80 110.01 126.51 45126 2,507.25 2,381.89 2,739.17 44388 310.51 294.98 339.23 45130 939.27 892.31 1,026.16 # 44388 153.80 146.11 168.03 45135 1,149.30 1,091.84 1,255.62 44389 360.86 342.82 394.24 45136 1,594.08 1,514.38 1,741.54 # 44389 171.89 163.30 187.80 45150 342.95 325.80 374.67 44390 416.76 395.92 455.31 45160 854.62 811.89 933.67 # 44390 206.17 195.86 225.24 45170 667.85 634.46 729.63 44391 467.05 443.70 510.26 45190 581.44 552.37 635.23 # 44391 235.19 223.43 256.94 45300 94.79 90.05 103.56 44392 390.88 371.34 427.04 # 45300 44.45 42.23 48.56 # 44392 202.62 192.49 221.36 45303 736.40 699.58 804.52 44393 454.25 431.54 496.27 # 45303 75.90 72.11 82.93 # 44393 258.19 245.28 282.07 45305 154.09 146.39 168.35 44394 457.54 434.66 499.86 # 45305 67.94 64.54 74.22 # 44394 239.15 227.19 261.27 45307 171.74 163.15 187.62 44397 258.29 245.38 282.19 # 45307 85.94 81.64 93.89 44500 24.58 23.35 26.85 45308 157.38 149.51 171.94 44602 1,194.10 1,134.40 1,304.56 # 45308 73.00 69.35 79.75 44603 1,368.81 1,300.37 1,495.43 45309 176.39 167.57 192.71 44604 915.30 869.54 999.97 # 45309 84.22 80.01 92.01 44605 1,129.34 1,072.87 1,233.80 45315 190.59 181.06 208.22 44615 930.38 883.86 1,016.44 # 45315 96.28 91.47 105.19 44620 743.79 706.60 812.59 45317 184.33 175.11 201.38 44625 880.41 836.39 961.85 # 45317 101.37 96.30 110.75 44626 1,397.85 1,327.96 1,527.15 45320 185.43 176.16 202.58 44640 1,219.96 1,158.96 1,332.80 # 45320 96.45 91.63 105.37 44650 1,268.55 1,205.12 1,385.89 45321 93.42 88.75 102.06 44660 1,234.73 1,172.99 1,348.94 45327 108.99 103.54 119.07 44661 1,381.25 1,312.19 1,509.02 45330 122.19 116.08 133.49 44680 919.10 873.15 1,004.12 # 45330 57.31 54.44 62.61 44700 890.46 845.94 972.83 45331 155.45 147.68 169.83 44701 149.53 142.05 163.36 # 45331 69.65 66.17 76.10 44715 355.62 337.84 388.52 45332 255.28 242.52 278.90 44720 246.77 234.43 269.59 # 45332 101.77 96.68 111.18 44721 343.32 326.15 375.07 45333 256.88 244.04 280.65 44800 654.39 621.67 714.92 # 45333 101.24 96.18 110.61 44820 722.78 686.64 789.64 45334 153.75 146.06 167.97 44850 637.79 605.90 696.79 45335 219.81 208.82 240.14 44900 654.00 621.30 714.50 # 45335 84.73 80.49 92.56 44901 900.08 855.08 983.34 45337 131.37 124.80 143.52 # 44901 169.39 160.92 185.06 45338 286.64 272.31 313.16 44950 552.85 525.21 603.99 # 45338 131.71 125.12 143.89 44955 75.02 71.27 81.96 45339 297.23 282.37 324.73 44960 745.22 707.96 814.15 # 45339 174.21 165.50 190.33 44970 508.71 483.27 555.76 45340 392.02 372.42 428.28 45000 357.23 339.37 390.28 # 45340 106.62 101.29 116.48 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 VERMONT - MEDICARE CARRIER 31145 PAGE 39 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 146.76 139.42 160.33 46070 196.29 186.48 214.45 45342 224.39 213.17 245.15 46080 197.56 187.68 215.83 45345 162.91 154.76 177.97 # 46080 136.23 129.42 148.83 45355 186.83 177.49 204.11 46083 149.94 142.44 163.81 45378 359.61 341.63 392.87 # 46083 91.80 87.21 100.29 # 45378 201.48 191.41 220.12 46200 331.99 315.39 362.70 45378 53 122.19 116.08 133.49 # 46200 256.83 243.99 280.59 # 45378 53 57.31 54.44 62.61 46210 304.95 289.70 333.16 45379 456.46 433.64 498.69 # 46210 216.32 205.50 236.33 # 45379 252.25 239.64 275.59 46211 412.44 391.82 450.59 45380 431.85 410.26 471.80 # 46211 314.94 299.19 344.07 # 45380 242.88 230.74 265.35 46220 159.96 151.96 174.75 45381 420.54 399.51 459.44 # 46220 98.27 93.36 107.36 # 45381 230.15 218.64 251.44 46221 209.33 198.86 228.69 45382 569.46 540.99 622.14 # 46221 156.15 148.34 170.59 # 45382 310.65 295.12 339.39 46230 218.89 207.95 239.14 45383 513.73 488.04 561.25 # 46230 146.57 139.24 160.13 # 45383 311.99 296.39 340.85 46250 364.49 346.27 398.21 45384 424.03 402.83 463.25 # 46250 258.84 245.90 282.79 # 45384 252.08 239.48 275.40 46255 406.40 386.08 443.99 45385 486.80 462.46 531.83 # 46255 294.37 279.65 321.60 # 45385 288.26 273.85 314.93 46257 344.49 327.27 376.36 45386 601.04 570.99 656.64 46258 376.76 357.92 411.61 # 45386 247.57 235.19 270.47 46260 391.16 371.60 427.34 45387 323.01 306.86 352.89 46261 437.67 415.79 478.16 45391 278.91 264.96 304.70 46262 456.92 434.07 499.18 45392 353.54 335.86 386.24 46270 394.31 374.59 430.78 45395 1,728.81 1,642.37 1,888.73 # 46270 311.35 295.78 340.15 45397 1,874.19 1,780.48 2,047.55 46275 417.31 396.44 455.91 45400 998.15 948.24 1,090.48 # 46275 333.64 316.96 364.50 45402 1,334.43 1,267.71 1,457.87 46280 381.72 362.63 417.02 45500 440.16 418.15 480.87 46285 405.97 385.67 443.52 45505 482.51 458.38 527.14 # 46285 329.74 313.25 360.24 45520 110.06 104.56 120.24 46288 451.17 428.61 492.90 # 45520 34.19 32.48 37.35 46320 144.21 137.00 157.55 45540 921.15 875.09 1,006.35 # 46320 93.16 88.50 101.78 45541 791.88 752.29 865.13 46500 175.78 166.99 192.04 45550 1,266.40 1,203.08 1,383.54 # 46500 105.93 100.63 115.72 45560 627.51 596.13 685.55 46505 229.87 218.38 251.14 45562 961.27 913.21 1,050.19 # 46505 194.42 184.70 212.41 45563 1,389.44 1,319.97 1,517.97 46600 70.71 67.17 77.25 45800 1,080.77 1,026.73 1,180.74 # 46600 33.84 32.15 36.97 45805 1,221.40 1,160.33 1,334.38 46604 440.95 418.90 481.74 45820 1,074.81 1,021.07 1,174.23 # 46604 58.41 55.49 63.81 45825 1,291.19 1,226.63 1,410.62 46606 181.01 171.96 197.75 45900 170.19 161.68 185.93 # 46606 64.72 61.48 70.70 45905 144.45 137.23 157.81 46608 186.56 177.23 203.81 45910 171.17 162.61 187.00 # 46608 70.98 67.43 77.54 45915 268.17 254.76 292.97 46610 184.60 175.37 201.68 # 45915 191.94 182.34 209.69 # 46610 70.44 66.92 76.96 45990 95.22 90.46 104.03 46611 145.25 137.99 158.69 46020 216.45 205.63 236.47 # 46611 72.57 68.94 79.28 # 46020 189.50 180.03 207.03 46612 220.71 209.67 241.12 46030 108.88 103.44 118.96 # 46612 85.63 81.35 93.55 # 46030 75.20 71.44 82.16 46614 111.21 105.65 121.50 46040 422.23 401.12 461.29 # 46614 61.22 58.16 66.88 # 46040 339.27 322.31 370.66 46615 127.64 121.26 139.45 46045 349.88 332.39 382.25 # 46615 86.86 82.52 94.90 46050 151.76 144.17 165.80 46700 543.32 516.15 593.57 # 46050 79.44 75.47 86.79 46705 447.40 425.03 488.78 46060 384.71 365.47 420.29 46706 143.62 136.44 156.91 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 40 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 926.42 880.10 1,012.12 47142 3,972.97 3,774.32 4,340.47 46712 1,885.20 1,790.94 2,059.58 47143 301.07 286.02 328.92 46715 442.04 419.94 482.93 47144 451.59 429.01 493.36 46716 1,085.67 1,031.39 1,186.10 47145 451.59 429.01 493.36 46730 1,642.93 1,560.78 1,794.90 47146 292.73 278.09 319.80 46735 1,916.74 1,820.90 2,094.04 47147 341.54 324.46 373.13 46740 1,764.23 1,676.02 1,927.42 47300 959.42 911.45 1,048.17 46742 2,083.17 1,979.01 2,275.86 47350 1,176.53 1,117.70 1,285.36 46744 2,960.53 2,812.50 3,234.38 47360 1,601.81 1,521.72 1,749.98 46746 3,418.90 3,247.96 3,735.15 47361 2,631.27 2,499.71 2,874.67 46748 3,598.27 3,418.36 3,931.11 47362 1,221.85 1,160.76 1,334.87 46750 657.13 624.27 717.91 47370 1,074.63 1,020.90 1,174.04 46751 545.86 518.57 596.36 47371 1,094.66 1,039.93 1,195.92 46753 495.64 470.86 541.49 47380 1,257.19 1,194.33 1,373.48 46754 238.05 226.15 260.07 47381 1,282.18 1,218.07 1,400.78 # 46754 183.09 173.94 200.03 47382 800.19 760.18 874.21 46760 929.54 883.06 1,015.52 47400 1,832.19 1,740.58 2,001.67 46761 803.50 763.33 877.83 47420 1,151.44 1,093.87 1,257.95 46762 793.11 753.45 866.47 47425 1,163.13 1,104.97 1,270.72 46900 192.43 182.81 210.23 47460 1,099.85 1,044.86 1,201.59 # 46900 119.04 113.09 130.05 47480 732.59 695.96 800.35 46910 200.56 190.53 219.11 47490 496.10 471.30 542.00 # 46910 113.70 108.02 124.22 47500 99.40 94.43 108.59 46916 199.15 189.19 217.57 47505 38.40 36.48 41.95 # 46916 125.76 119.47 137.39 47510 469.62 446.14 513.06 46917 383.14 363.98 418.58 47511 589.74 560.25 644.29 # 46917 114.41 108.69 124.99 47525 552.04 524.44 603.11 46922 208.89 198.45 228.22 # 47525 120.57 114.54 131.72 # 46922 113.52 107.84 124.02 47530 1,336.49 1,269.67 1,460.12 46924 434.21 412.50 474.38 # 47530 352.66 335.03 385.28 # 46924 158.74 150.80 173.42 47550 147.88 140.49 161.56 46930 184.59 175.36 201.66 47552 319.55 303.57 349.11 # 46930 133.18 126.52 145.50 47553 319.92 303.92 349.51 46937 215.78 204.99 235.74 47554 466.00 442.70 509.11 # 46937 152.32 144.70 166.41 47555 383.76 364.57 419.26 46938 374.74 356.00 409.40 47556 434.18 412.47 474.34 # 46938 309.15 293.69 337.74 47560 238.88 226.94 260.98 46940 180.98 171.93 197.72 47561 259.44 246.47 283.44 # 46940 126.38 120.06 138.07 47562 633.82 602.13 692.45 46942 167.69 159.31 183.21 47563 648.23 615.82 708.19 # 46942 112.39 106.77 122.79 47564 748.63 711.20 817.88 46945 234.04 222.34 255.69 47570 668.58 635.15 730.42 # 46945 180.15 171.14 196.81 47600 910.64 865.11 994.88 46946 253.11 240.45 276.52 47605 841.13 799.07 918.93 # 46946 190.00 180.50 207.58 47610 1,078.46 1,024.54 1,178.22 46947 319.72 303.73 349.29 47612 1,089.81 1,035.32 1,190.62 47000 300.38 285.36 328.16 47620 1,182.75 1,123.61 1,292.15 # 47000 96.52 91.69 105.44 47630 534.60 507.87 584.05 47001 92.44 87.82 100.99 47700 897.79 852.90 980.84 47010 1,029.70 978.22 1,124.95 47701 1,543.84 1,466.65 1,686.65 47011 186.96 177.61 204.25 47711 1,339.18 1,272.22 1,463.05 47015 976.14 927.33 1,066.43 47712 1,714.74 1,629.00 1,873.35 47100 714.11 678.40 780.16 47715 1,125.97 1,069.67 1,230.12 47120 2,007.71 1,907.32 2,193.42 47720 973.00 924.35 1,063.00 47122 2,986.00 2,836.70 3,262.21 47721 1,147.86 1,090.47 1,254.04 47125 2,674.38 2,540.66 2,921.76 47740 1,109.29 1,053.83 1,211.90 47130 2,875.60 2,731.82 3,141.59 47741 1,256.27 1,193.46 1,372.48 47135 4,234.03 4,022.33 4,625.68 47760 1,896.44 1,801.62 2,071.86 47136 3,611.50 3,430.93 3,945.57 47765 2,510.14 2,384.63 2,742.32 47140 3,025.46 2,874.19 3,305.32 47780 2,075.09 1,971.34 2,267.04 47141 3,606.13 3,425.82 3,939.69 47785 2,707.87 2,572.48 2,958.35 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 41 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 1,352.28 1,284.67 1,477.37 49320 285.45 271.18 311.86 47801 962.53 914.40 1,051.56 49321 300.34 285.32 328.12 47802 1,298.72 1,233.78 1,418.85 49322 326.75 310.41 356.97 47900 1,170.11 1,111.60 1,278.34 49323 554.92 527.17 606.25 48000 1,623.11 1,541.95 1,773.24 49324 340.05 323.05 371.51 48001 1,992.74 1,893.10 2,177.07 49325 364.64 346.41 398.37 48020 1,001.12 951.06 1,093.72 49326 167.67 159.29 183.18 48100 759.93 721.93 830.22 49400 165.11 156.85 180.38 48102 502.74 477.60 549.24 # 49400 94.56 89.83 103.30 # 48102 246.76 234.42 269.58 49402 736.66 699.83 804.80 48105 2,457.43 2,334.56 2,684.74 49419 394.76 375.02 431.27 48120 948.79 901.35 1,036.55 49420 125.61 119.33 137.23 48140 1,342.99 1,275.84 1,467.22 49421 338.21 321.30 369.50 48145 1,394.50 1,324.78 1,523.50 49422 338.62 321.69 369.94 48146 1,592.12 1,512.51 1,739.39 49423 527.55 501.17 576.35 48148 1,057.38 1,004.51 1,155.19 # 49423 75.52 71.74 82.50 48150 2,685.39 2,551.12 2,933.79 49424 143.34 136.17 156.60 48152 2,483.28 2,359.12 2,712.99 # 49424 39.46 37.49 43.11 48153 2,681.66 2,547.58 2,929.72 49425 661.77 628.68 722.98 48154 2,489.45 2,364.98 2,719.73 49426 563.90 535.71 616.07 48155 1,545.16 1,467.90 1,688.09 49427 45.39 43.12 49.59 48400 98.15 93.24 107.23 49428 379.90 360.91 415.05 48500 968.29 919.88 1,057.86 49429 400.11 380.10 437.12 48510 920.21 874.20 1,005.33 49435 107.36 101.99 117.29 48511 872.45 828.83 953.15 49436 159.04 151.09 173.75 # 48511 202.38 192.26 221.10 49440 1,025.17 973.91 1,120.00 48520 938.00 891.10 1,024.77 # 49440 227.12 215.76 248.12 48540 1,120.20 1,064.19 1,223.82 49441 1,114.54 1,058.81 1,217.63 48545 1,135.79 1,079.00 1,240.85 # 49441 252.31 239.69 275.64 48547 1,530.68 1,454.15 1,672.27 49442 999.03 949.08 1,091.44 48548 1,433.21 1,361.55 1,565.78 # 49442 208.42 198.00 227.70 48551 204.63 194.40 223.56 49446 933.38 886.71 1,019.72 48552 206.29 195.98 225.38 # 49446 167.94 159.54 183.47 48554 2,132.34 2,025.72 2,329.58 49450 698.20 663.29 762.78 48556 1,062.80 1,009.66 1,161.11 # 49450 67.12 63.76 73.32 49000 667.28 633.92 729.01 49451 664.63 631.40 726.11 49002 879.07 835.12 960.39 # 49451 93.47 88.80 102.12 49010 829.17 787.71 905.87 49452 837.02 795.17 914.45 49020 1,369.76 1,301.27 1,496.46 # 49452 145.68 138.40 159.16 49021 833.79 792.10 910.92 49460 765.49 727.22 836.30 # 49021 170.81 162.27 186.61 # 49460 47.91 45.51 52.34 49040 859.02 816.07 938.48 49465 160.10 152.10 174.92 49041 851.18 808.62 929.91 # 49465 31.40 29.83 34.30 # 49041 202.03 191.93 220.72 49491 666.21 632.90 727.84 49060 962.53 914.40 1,051.56 49492 813.14 772.48 888.35 49061 836.46 794.64 913.84 49495 338.74 321.80 370.07 # 49061 186.96 177.61 204.25 49496 514.20 488.49 561.76 49062 653.09 620.44 713.51 49500 337.26 320.40 368.46 49080 158.23 150.32 172.87 49501 510.09 484.59 557.28 # 49080 68.18 64.77 74.49 49505 441.70 419.62 482.56 49081 147.72 140.33 161.38 49507 543.65 516.47 593.94 # 49081 64.05 60.85 69.98 49520 539.54 512.56 589.44 49180 158.82 150.88 173.51 49521 657.83 624.94 718.68 # 49180 87.56 83.18 95.66 49525 488.02 463.62 533.16 49203 1,046.06 993.76 1,142.82 49540 577.04 548.19 630.42 49204 1,335.61 1,268.83 1,459.15 49550 490.36 465.84 535.72 49205 1,529.11 1,452.65 1,670.55 49553 536.66 509.83 586.30 49215 1,916.62 1,820.79 2,093.91 49555 510.46 484.94 557.68 49220 833.93 792.23 911.06 49557 619.76 588.77 677.09 49250 498.54 473.61 544.65 49560 633.59 601.91 692.20 49255 677.02 643.17 739.65 49561 799.29 759.33 873.23 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 VERMONT - MEDICARE CARRIER 31145 PAGE 42 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 657.26 624.40 718.06 50360 2,176.48 2,067.66 2,377.81 49566 807.54 767.16 882.23 50365 2,451.03 2,328.48 2,677.75 49568 237.64 225.76 259.62 50370 1,018.18 967.27 1,112.36 49570 348.02 330.62 380.21 50380 1,724.51 1,638.28 1,884.02 49572 431.56 409.98 471.48 50382 1,235.00 1,173.25 1,349.24 49580 271.38 257.81 296.48 # 50382 282.01 267.91 308.10 49582 402.39 382.27 439.61 50384 1,062.21 1,009.10 1,160.47 49585 374.05 355.35 408.65 # 50384 256.71 243.87 280.45 49587 443.17 421.01 484.16 50385 1,208.65 1,148.22 1,320.45 49590 486.23 461.92 531.21 # 50385 241.12 229.06 263.42 49600 628.41 596.99 686.54 50386 783.40 744.23 855.86 49605 4,337.84 4,120.95 4,739.09 # 50386 182.11 173.00 198.95 49606 980.32 931.30 1,071.00 50387 571.66 543.08 624.54 49610 585.32 556.05 639.46 # 50387 102.26 97.15 111.72 49611 528.55 502.12 577.44 50389 331.63 315.05 362.31 49650 363.10 344.95 396.69 # 50389 56.15 53.34 61.34 49651 469.78 446.29 513.23 50390 99.40 94.43 108.59 49652 683.09 648.94 746.28 50391 127.76 121.37 139.58 49653 853.66 810.98 932.63 # 50391 101.17 96.11 110.53 49654 784.90 745.66 857.51 50392 182.51 173.38 199.39 49655 944.68 897.45 1,032.07 50393 222.51 211.38 243.09 49656 787.59 748.21 860.44 50394 102.39 97.27 111.86 49657 1,136.59 1,079.76 1,241.72 # 50394 50.27 47.76 54.92 49900 698.00 663.10 762.57 50395 183.75 174.56 200.74 49904 1,303.14 1,237.98 1,423.68 50396 118.80 112.86 129.79 49905 317.88 301.99 347.29 50398 513.01 487.36 560.46 50010 687.53 653.15 751.12 # 50398 75.52 71.74 82.50 50020 980.49 931.47 1,071.19 50400 1,161.52 1,103.44 1,268.96 50021 877.39 833.52 958.55 50405 1,408.37 1,337.95 1,538.64 # 50021 170.45 161.93 186.22 50500 1,120.30 1,064.29 1,223.93 50040 925.60 879.32 1,011.22 50520 1,040.03 988.03 1,136.23 50045 933.32 886.65 1,019.65 50525 1,299.87 1,234.88 1,420.11 50060 1,150.33 1,092.81 1,256.73 50526 1,360.42 1,292.40 1,486.26 50065 1,208.05 1,147.65 1,319.80 50540 1,137.66 1,080.78 1,242.90 50070 1,201.93 1,141.83 1,313.10 50541 927.18 880.82 1,012.94 50075 1,477.20 1,403.34 1,613.84 50542 1,176.62 1,117.79 1,285.46 50080 878.80 834.86 960.09 50543 1,501.12 1,426.06 1,639.97 50081 1,290.48 1,225.96 1,409.85 50544 1,264.92 1,201.67 1,381.92 50100 934.16 887.45 1,020.57 50545 1,357.58 1,289.70 1,483.16 50120 951.82 904.23 1,039.86 50546 1,203.51 1,143.33 1,314.83 50125 983.02 933.87 1,073.95 50547 1,439.47 1,367.50 1,572.63 50130 1,042.32 990.20 1,138.73 50548 1,368.77 1,300.33 1,495.38 50135 1,128.66 1,072.23 1,233.06 50551 371.40 352.83 405.75 50200 142.70 135.57 155.91 # 50551 301.56 286.48 329.45 50205 658.99 626.04 719.95 50553 387.77 368.38 423.64 50220 1,025.03 973.78 1,119.85 # 50553 318.64 302.71 348.12 50225 1,187.76 1,128.37 1,297.63 50555 422.84 401.70 461.96 50230 1,288.40 1,223.98 1,407.58 # 50555 348.74 331.30 381.00 50234 1,308.03 1,242.63 1,429.02 50557 431.40 409.83 471.30 50236 1,480.64 1,406.61 1,617.60 # 50557 354.11 336.40 386.86 50240 1,330.08 1,263.58 1,453.12 50561 489.25 464.79 534.51 50250 1,234.60 1,172.87 1,348.80 # 50561 404.51 384.28 441.92 50280 947.85 900.46 1,035.53 50562 596.03 566.23 651.16 50290 872.44 828.82 953.14 50570 504.97 479.72 551.68 50320 1,286.58 1,222.25 1,405.59 50572 548.87 521.43 599.64 50323 183.98 174.78 201.00 50574 580.49 551.47 634.19 50325 183.98 174.78 201.00 50575 734.03 697.33 801.93 50327 192.99 183.34 210.84 50576 579.58 550.60 633.19 50328 169.46 160.99 185.14 50580 620.71 589.67 678.12 50329 167.42 159.05 182.91 50590 925.69 879.41 1,011.32 50340 792.05 752.45 865.32 # 50590 566.55 538.22 618.95 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 VERMONT - MEDICARE CARRIER 31145 PAGE 43 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 3,507.09 3,331.74 3,831.50 50980 365.78 347.49 399.61 # 50592 366.62 348.29 400.53 51020 466.02 442.72 509.13 50593 4,526.54 4,300.21 4,945.24 51030 460.94 437.89 503.57 # 50593 464.99 441.74 508.00 51040 291.10 276.55 318.03 50600 941.18 894.12 1,028.24 51045 464.14 440.93 507.07 50605 904.40 859.18 988.06 51050 472.94 449.29 516.68 50610 958.93 910.98 1,047.63 51060 582.44 553.32 636.32 50620 911.30 865.74 995.60 51065 578.36 549.44 631.86 50630 888.12 843.71 970.27 51080 405.17 384.91 442.65 50650 1,038.96 987.01 1,135.06 51100 60.57 57.54 66.17 50660 1,148.60 1,091.17 1,254.85 # 51100 38.94 36.99 42.54 50684 176.84 168.00 193.20 51101 123.99 117.79 135.46 # 50684 49.92 47.42 54.53 # 51101 52.02 49.42 56.83 50686 91.14 86.58 99.57 51102 234.20 222.49 255.86 50688 79.60 75.62 86.96 # 51102 151.24 143.68 165.23 50690 99.09 94.14 108.26 51500 620.48 589.46 677.88 # 50690 70.37 66.85 76.88 51520 586.31 556.99 640.54 50700 929.51 883.03 1,015.48 51525 862.47 819.35 942.25 50715 1,093.70 1,039.02 1,194.87 51530 767.47 729.10 838.47 50722 951.14 903.58 1,039.12 51535 778.56 739.63 850.57 50725 1,092.42 1,037.80 1,193.47 51550 946.87 899.53 1,034.46 50727 502.19 477.08 548.64 51555 1,259.45 1,196.48 1,375.95 50728 690.46 655.94 754.33 51565 1,288.28 1,223.87 1,407.45 50740 1,071.92 1,018.32 1,171.07 51570 1,471.95 1,398.35 1,608.10 50750 1,168.93 1,110.48 1,277.05 51575 1,840.30 1,748.29 2,010.53 50760 1,088.62 1,034.19 1,189.32 51580 1,917.93 1,822.03 2,095.33 50770 1,130.81 1,074.27 1,235.41 51585 2,136.43 2,029.61 2,334.05 50780 1,092.09 1,037.49 1,193.11 51590 1,946.02 1,848.72 2,126.03 50782 1,071.34 1,017.77 1,170.44 51595 2,211.75 2,101.16 2,416.33 50783 1,109.16 1,053.70 1,211.76 51596 2,377.65 2,258.77 2,597.59 50785 1,213.33 1,152.66 1,325.56 51597 2,292.06 2,177.46 2,504.08 50800 921.18 875.12 1,006.39 51600 190.21 180.70 207.81 50810 1,206.52 1,146.19 1,318.12 # 51600 44.85 42.61 49.00 50815 1,228.73 1,167.29 1,342.38 51605 38.68 36.75 42.26 50820 1,306.76 1,241.42 1,427.63 51610 110.37 104.85 120.58 50825 1,660.35 1,577.33 1,813.93 # 51610 63.92 60.72 69.83 50830 1,801.55 1,711.47 1,968.19 51700 86.69 82.36 94.71 50840 1,237.15 1,175.29 1,351.58 # 51700 44.85 42.61 49.00 50845 1,254.52 1,191.79 1,370.56 51701 60.22 57.21 65.79 50860 949.60 902.12 1,037.44 # 51701 27.25 25.89 29.77 50900 835.45 793.68 912.73 51702 77.59 73.71 84.77 50920 884.68 840.45 966.52 # 51702 30.08 28.58 32.87 50930 1,070.10 1,016.60 1,169.09 51703 139.87 132.88 152.81 50940 888.45 844.03 970.63 # 51703 82.44 78.32 90.07 50945 986.16 936.85 1,077.38 51705 112.48 106.86 122.89 50947 1,396.61 1,326.78 1,525.80 # 51705 67.10 63.75 73.31 50948 1,298.32 1,233.40 1,418.41 51710 158.50 150.58 173.17 50951 388.03 368.63 423.92 # 51710 95.39 90.62 104.21 # 50951 314.64 298.91 343.75 51715 293.16 278.50 320.28 50953 409.55 389.07 447.43 # 51715 200.62 190.59 219.18 # 50953 346.44 329.12 378.49 51720 116.13 110.32 126.87 50955 452.93 430.28 494.82 # 51720 83.87 79.68 91.63 # 50955 374.22 355.51 408.84 51725 218.24 207.33 238.43 50957 440.55 418.52 481.30 51725 TC 141.46 134.39 154.55 # 50957 362.90 344.76 396.47 51725 26 76.79 72.95 83.89 50961 397.73 377.84 434.52 51726 317.63 301.75 347.01 # 50961 325.05 308.80 355.12 51726 TC 230.27 218.76 251.57 50970 380.84 361.80 416.07 51726 26 87.37 83.00 95.45 50972 366.69 348.36 400.61 51736 53.19 50.53 58.11 50974 485.60 461.32 530.52 51736 TC 21.80 20.71 23.82 50976 478.07 454.17 522.30 51736 26 31.39 29.82 34.29 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 VERMONT - MEDICARE CARRIER 31145 PAGE 44 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 84.18 79.97 91.97 52270 410.11 389.60 448.04 51741 TC 25.52 24.24 27.88 # 52270 185.69 176.41 202.87 51741 26 58.66 55.73 64.09 52275 561.06 533.01 612.96 51772 244.18 231.97 266.77 # 52275 254.39 241.67 277.92 51772 TC 162.90 154.76 177.97 52276 271.59 258.01 296.71 51772 26 81.28 77.22 88.80 52277 331.68 315.10 362.37 51784 200.17 190.16 218.68 52281 308.37 292.95 336.89 51784 TC 122.67 116.54 134.02 # 52281 157.34 149.47 171.89 51784 26 77.51 73.63 84.67 52282 342.28 325.17 373.95 51785 217.37 206.50 237.48 52283 284.47 270.25 310.79 51785 TC 139.68 132.70 152.61 # 52283 204.35 194.13 223.25 51785 26 77.68 73.80 84.87 52285 286.52 272.19 313.02 51792 227.56 216.18 248.61 # 52285 197.89 188.00 216.20 51792 TC 171.76 163.17 187.65 52290 249.89 237.40 273.01 51792 26 55.80 53.01 60.96 52300 286.84 272.50 313.38 51795 299.08 284.13 326.75 52301 301.14 286.08 328.99 51795 TC 221.22 210.16 241.68 52305 285.07 270.82 311.44 51795 26 77.86 73.97 85.07 52310 254.13 241.42 277.63 51797 147.43 140.06 161.07 # 52310 154.51 146.78 168.80 51797 TC 103.34 98.17 112.90 52315 449.69 427.21 491.29 51797 26 44.09 41.89 48.17 # 52315 280.93 266.88 306.91 51798 19.85 18.86 21.69 52317 960.25 912.24 1,049.08 51800 1,047.32 994.95 1,144.19 # 52317 356.48 338.66 389.46 51820 1,064.53 1,011.30 1,163.00 52318 485.79 461.50 530.73 51840 635.77 603.98 694.58 52320 252.26 239.65 275.60 51841 754.52 716.79 824.31 52325 328.13 311.72 358.48 51845 580.63 551.60 634.34 52327 535.12 508.36 584.61 51860 708.47 673.05 774.01 # 52327 268.51 255.08 293.34 51865 879.01 835.06 960.32 52330 781.26 742.20 853.53 51880 459.95 436.95 502.49 # 52330 270.02 256.52 295.00 51900 814.80 774.06 890.17 52332 483.35 459.18 528.06 51920 752.90 715.26 822.55 # 52332 158.95 151.00 173.65 51925 978.33 929.41 1,068.82 52334 262.27 249.16 286.53 51940 1,611.24 1,530.68 1,760.28 52341 298.04 283.14 325.61 51960 1,392.85 1,323.21 1,521.69 52342 324.04 307.84 354.02 51980 713.43 677.76 779.42 52343 360.45 342.43 393.79 51990 730.01 693.51 797.54 52344 390.89 371.35 427.05 51992 796.88 757.04 870.60 52345 416.90 396.06 455.47 52000 210.18 199.67 229.62 52346 470.53 447.00 514.05 # 52000 126.51 120.18 138.21 52351 321.04 304.99 350.74 52001 386.37 367.05 422.11 52352 376.96 358.11 411.83 # 52001 293.13 278.47 320.24 52353 433.64 411.96 473.75 52005 289.85 275.36 316.66 52354 400.82 380.78 437.90 # 52005 134.92 128.17 147.40 52355 477.76 453.87 521.95 52007 542.50 515.38 592.69 52400 490.61 466.08 535.99 # 52007 168.82 160.38 184.44 52402 274.77 261.03 300.18 52010 404.05 383.85 441.43 52450 468.72 445.28 512.07 # 52010 163.68 155.50 178.83 52500 489.49 465.02 534.77 52204 444.56 422.33 485.68 52601 831.54 789.96 908.45 # 52204 143.21 136.05 156.46 52630 445.15 422.89 486.32 52214 584.04 554.84 638.07 52640 303.33 288.16 331.38 # 52214 221.70 210.62 242.21 52647 2,177.76 2,068.87 2,379.20 52224 834.00 792.30 911.15 # 52647 647.95 615.55 707.88 # 52224 172.79 164.15 188.77 52648 2,224.01 2,112.81 2,429.73 52234 251.86 239.27 275.16 # 52648 691.36 656.79 755.31 52235 295.26 280.50 322.58 52649 988.41 938.99 1,079.84 52240 516.24 490.43 563.99 52700 434.89 413.15 475.12 52250 247.35 234.98 270.23 53000 148.88 141.44 162.66 52260 213.32 202.65 233.05 53010 292.30 277.69 319.34 52265 425.10 403.85 464.43 53020 98.75 93.81 107.88 # 52265 160.61 152.58 175.47 53025 64.86 61.62 70.86 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 45 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 393.04 373.39 429.40 53852 2,407.04 2,286.69 2,629.69 53060 172.49 163.87 188.45 # 53852 622.31 591.19 679.87 # 53060 152.63 145.00 166.75 54000 156.76 148.92 171.26 53080 435.60 413.82 475.89 # 54000 107.13 101.77 117.04 53085 615.78 584.99 672.74 54001 192.61 182.98 210.43 53200 155.79 148.00 170.20 # 54001 138.01 131.11 150.78 # 53200 141.97 134.87 155.10 54015 311.32 295.75 340.11 53210 772.81 734.17 844.30 54050 118.12 112.21 129.04 53215 938.68 891.75 1,025.51 # 54050 94.01 89.31 102.71 53220 451.46 428.89 493.22 54055 112.78 107.14 123.21 53230 601.34 571.27 656.96 # 54055 86.54 82.21 94.54 53235 640.15 608.14 699.36 54056 123.44 117.27 134.86 53240 429.67 408.19 469.42 # 54056 97.20 92.34 106.19 53250 398.67 378.74 435.55 54057 135.66 128.88 148.21 53260 198.41 188.49 216.76 # 54057 90.99 86.44 99.41 # 53260 175.36 166.59 191.58 54060 183.24 174.08 200.19 53265 220.65 209.62 241.06 # 54060 126.87 120.53 138.61 # 53265 184.49 175.27 201.56 54065 200.91 190.86 219.49 53270 201.84 191.75 220.51 # 54065 155.18 147.42 169.53 # 53270 180.21 171.20 196.88 54100 184.45 175.23 201.51 53275 266.53 253.20 291.18 # 54100 115.32 109.55 125.98 53400 803.35 763.18 877.66 54105 277.07 263.22 302.70 53405 884.76 840.52 966.60 # 54105 216.09 205.29 236.08 53410 987.74 938.35 1,079.10 54110 626.28 594.97 684.22 53415 1,139.01 1,082.06 1,244.37 54111 809.21 768.75 884.06 53420 809.32 768.85 884.18 54112 949.91 902.41 1,037.77 53425 951.40 903.83 1,039.40 54115 451.39 428.82 493.14 53430 948.78 901.34 1,036.54 # 54115 421.61 400.53 460.61 53431 1,164.12 1,105.91 1,271.80 54120 633.78 602.09 692.40 53440 881.83 837.74 963.40 54125 816.57 775.74 892.10 53442 776.71 737.87 848.55 54130 1,207.93 1,147.53 1,319.66 53444 801.63 761.55 875.78 54135 1,533.69 1,457.01 1,675.56 53445 885.47 841.20 967.38 54150 168.14 159.73 183.69 53446 647.26 614.90 707.14 # 54150 97.94 93.04 107.00 53447 818.52 777.59 894.23 54160 233.20 221.54 254.77 53448 1,293.64 1,228.96 1,413.30 # 54160 145.63 138.35 159.10 53449 615.42 584.65 672.35 54161 197.88 187.99 216.19 53450 409.46 388.99 447.34 54162 270.55 257.02 295.57 53460 459.87 436.88 502.41 # 54162 196.80 186.96 215.00 53500 738.86 701.92 807.21 54163 218.07 207.17 238.25 53502 485.70 461.42 530.63 54164 192.07 182.47 209.84 53505 488.54 464.11 533.73 54200 110.21 104.70 120.41 53510 635.52 603.74 694.30 # 54200 84.33 80.11 92.13 53515 800.75 760.71 874.82 54205 538.59 511.66 588.41 53520 557.87 529.98 609.48 54220 213.30 202.64 233.04 53600 86.71 82.37 94.73 # 54220 136.01 129.21 148.59 # 53600 65.44 62.17 71.50 54230 98.13 93.22 107.20 53601 84.44 80.22 92.25 # 54230 80.76 76.72 88.23 # 53601 54.66 51.93 59.72 54231 141.99 134.89 155.12 53605 65.83 62.54 71.92 # 54231 118.94 112.99 129.94 53620 124.18 117.97 135.67 54235 90.77 86.23 99.16 # 53620 89.09 84.64 97.34 # 54235 74.11 70.40 80.96 53621 117.46 111.59 128.33 54240 101.65 96.57 111.06 # 53621 73.85 70.16 80.68 54240 TC 34.03 32.33 37.18 53660 73.29 69.63 80.07 54240 26 67.62 64.24 73.88 # 53660 41.73 39.64 45.59 54250 126.85 120.51 138.59 53661 72.94 69.29 79.68 54250 TC 12.05 11.45 13.17 # 53661 41.03 38.98 44.83 54250 26 114.80 109.06 125.42 53665 38.40 36.48 41.95 54300 652.68 620.05 713.06 53850 2,501.45 2,376.38 2,732.84 54304 764.56 726.33 835.28 # 53850 571.36 542.79 624.21 54308 728.00 691.60 795.34 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 VERMONT - MEDICARE CARRIER 31145 PAGE 46 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 839.72 797.73 917.39 55040 336.71 319.87 367.85 54316 1,017.57 966.69 1,111.69 55041 506.77 481.43 553.64 54318 730.48 693.96 798.05 55060 376.64 357.81 411.48 54322 796.18 756.37 869.83 55100 215.06 204.31 234.96 54324 989.44 939.97 1,080.97 # 55100 160.11 152.10 174.92 54326 929.37 882.90 1,015.34 55110 383.31 364.14 418.76 54328 943.67 896.49 1,030.96 55120 351.74 334.15 384.27 54332 1,030.88 979.34 1,126.24 55150 485.61 461.33 530.53 54336 1,164.30 1,106.09 1,272.00 55175 361.05 343.00 394.45 54340 566.87 538.53 619.31 55180 685.27 651.01 748.66 54344 974.21 925.50 1,064.33 55200 490.04 465.54 535.37 54348 1,036.52 984.69 1,132.39 # 55200 276.25 262.44 301.81 54352 1,458.13 1,385.22 1,593.00 55250 432.60 410.97 472.62 54360 733.77 697.08 801.64 # 55250 226.61 215.28 247.57 54380 813.13 772.47 888.34 55300 182.05 172.95 198.89 54385 984.58 935.35 1,075.65 55400 506.48 481.16 553.33 54390 1,191.83 1,132.24 1,302.08 55450 382.19 363.08 417.54 54400 537.32 510.45 587.02 # 55450 255.62 242.84 279.27 54401 657.68 624.80 718.52 55500 372.95 354.30 407.45 54405 816.90 776.06 892.47 55520 382.42 363.30 417.80 54406 736.31 699.49 804.41 55530 353.20 335.54 385.87 54408 792.92 753.27 866.26 55535 427.44 406.07 466.98 54410 869.55 826.07 949.98 55540 463.36 440.19 506.22 54411 1,029.78 978.29 1,125.03 55550 422.48 401.36 461.56 54415 529.31 502.84 578.27 55600 425.72 404.43 465.09 54416 709.36 673.89 774.97 55605 503.35 478.18 549.91 54417 903.47 858.30 987.05 55650 716.31 680.49 782.56 54420 713.85 678.16 779.88 55680 338.95 322.00 370.30 54430 646.93 614.58 706.77 55700 231.84 220.25 253.29 54435 419.06 398.11 457.83 # 55700 138.25 131.34 151.04 54450 73.71 70.02 80.52 55705 271.16 257.60 296.24 # 54450 59.53 56.55 65.03 55706 384.33 365.11 419.88 54500 76.31 72.49 83.36 55720 461.79 438.70 504.51 54505 214.29 203.58 234.12 55725 589.22 559.76 643.72 54512 537.93 511.03 587.68 55801 1,094.66 1,039.93 1,195.92 54520 325.45 309.18 355.56 55810 1,324.31 1,258.09 1,446.80 54522 582.79 553.65 636.70 55812 1,627.07 1,545.72 1,777.58 54530 508.50 483.08 555.54 55815 1,785.29 1,696.03 1,950.43 54535 738.09 701.19 806.37 55821 881.12 837.06 962.62 54550 490.58 466.05 535.96 55831 954.84 907.10 1,043.17 54560 668.11 634.70 729.91 55840 1,351.62 1,284.04 1,476.65 54600 453.95 431.25 495.94 55842 1,448.47 1,376.05 1,582.46 54620 304.66 289.43 332.84 55845 1,656.66 1,573.83 1,809.90 54640 465.84 442.55 508.93 55860 883.82 839.63 965.57 54650 711.86 676.27 777.71 55862 1,115.55 1,059.77 1,218.74 54660 355.83 338.04 388.75 55865 1,352.64 1,285.01 1,477.76 54670 405.50 385.23 443.01 55866 1,760.17 1,672.16 1,922.98 54680 786.63 747.30 859.40 55870 176.71 167.87 193.05 54690 634.55 602.82 693.24 # 55870 145.86 138.57 159.36 54692 776.17 737.36 847.96 55873 1,151.77 1,094.18 1,258.31 54700 211.26 200.70 230.81 55875 766.96 728.61 837.90 54800 133.12 126.46 145.43 55876 141.43 134.36 154.51 54830 369.29 350.83 403.45 # 55876 106.33 101.01 116.16 54840 324.20 307.99 354.19 55920 431.19 409.63 471.07 54860 418.79 397.85 457.53 56405 98.91 93.96 108.05 54861 566.15 537.84 618.52 # 56405 96.78 91.94 105.73 54865 356.56 338.73 389.54 56420 114.30 108.59 124.88 54900 758.55 720.62 828.71 # 56420 83.81 79.62 91.56 54901 1,077.70 1,023.82 1,177.39 56440 166.94 158.59 182.38 55000 121.59 115.51 132.84 56441 137.34 130.47 150.04 # 55000 84.71 80.47 92.54 # 56441 129.90 123.41 141.92 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 VERMONT - MEDICARE CARRIER 31145 PAGE 47 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 44.73 42.49 48.86 57200 270.29 256.78 295.30 56501 118.64 112.71 129.62 57210 334.89 318.15 365.87 # 56501 103.04 97.89 112.57 57220 291.29 276.73 318.24 56515 202.32 192.20 221.03 57230 365.04 346.79 398.81 # 56515 178.92 169.97 195.47 57240 608.95 578.50 665.28 56605 76.36 72.54 83.42 57250 595.29 565.53 650.36 # 56605 55.79 53.00 60.95 57260 741.01 703.96 809.55 56606 35.25 33.49 38.51 57265 826.45 785.13 902.90 # 56606 27.45 26.08 29.99 57267 247.92 235.52 270.85 56620 449.01 426.56 490.54 57268 438.99 417.04 479.60 56625 540.76 513.72 590.78 57270 728.61 692.18 796.01 56630 790.79 751.25 863.94 57280 886.45 842.13 968.45 56631 1,005.83 955.54 1,098.87 57282 464.55 441.32 507.52 56632 1,164.03 1,105.83 1,271.70 57283 629.57 598.09 687.80 56633 1,031.40 979.83 1,126.80 57284 768.56 730.13 839.65 56634 1,089.26 1,034.80 1,190.02 57285 616.63 585.80 673.67 56637 1,287.08 1,222.73 1,406.14 57287 647.64 615.26 707.55 56640 1,281.78 1,217.69 1,400.34 57288 679.81 645.82 742.69 56700 169.38 160.91 185.05 57289 714.08 678.38 780.14 56740 270.23 256.72 295.23 57291 495.30 470.54 541.12 56800 222.52 211.39 243.10 57292 757.52 719.64 827.59 56805 1,047.69 995.31 1,144.61 57295 450.49 427.97 492.17 56810 238.87 226.93 260.97 57296 867.21 823.85 947.43 56820 101.24 96.18 110.61 57300 484.69 460.46 529.53 # 56820 77.84 73.95 85.04 57305 808.13 767.72 882.88 56821 135.43 128.66 147.96 57307 903.68 858.50 987.28 # 56821 105.64 100.36 115.41 57308 577.83 548.94 631.28 57000 174.29 165.58 190.42 57310 454.13 431.42 496.13 57010 391.75 372.16 427.98 57311 518.18 492.27 566.11 57020 86.35 82.03 94.33 57320 516.03 490.23 563.76 # 57020 75.00 71.25 81.94 57330 732.26 695.65 800.00 57022 151.95 144.35 166.00 57335 1,065.33 1,012.06 1,163.87 57023 284.24 270.03 310.53 57400 124.39 118.17 135.90 57061 103.40 98.23 112.96 57410 97.84 92.95 106.89 # 57061 88.16 83.75 96.31 57415 146.12 138.81 159.63 57065 175.13 166.37 191.33 57420 106.44 101.12 116.29 # 57065 155.63 147.85 170.03 # 57420 82.68 78.55 90.33 57100 80.85 76.81 88.33 57421 143.32 136.15 156.57 # 57100 60.28 57.27 65.86 # 57421 112.83 107.19 123.27 57105 123.70 117.52 135.15 57423 847.60 805.22 926.00 # 57105 113.77 108.08 124.29 57425 893.72 849.03 976.38 57106 432.19 410.58 472.17 57452 100.17 95.16 109.43 57107 1,276.52 1,212.69 1,394.59 # 57452 84.22 80.01 92.01 57109 1,458.57 1,385.64 1,593.49 57454 141.44 134.37 154.53 57110 821.87 780.78 897.90 # 57454 125.49 119.22 137.10 57111 1,474.53 1,400.80 1,610.92 57455 131.67 125.09 143.85 57112 1,567.31 1,488.94 1,712.28 # 57455 102.24 97.13 111.70 57120 466.72 443.38 509.89 57456 124.49 118.27 136.01 57130 165.09 156.84 180.37 # 57456 95.42 90.65 104.25 # 57130 147.01 139.66 160.61 57460 273.63 259.95 298.94 57135 176.93 168.08 193.29 # 57460 150.61 143.08 164.54 # 57135 158.50 150.58 173.17 57461 306.79 291.45 335.17 57150 46.60 44.27 50.91 # 57461 173.84 165.15 189.92 # 57150 27.45 26.08 29.99 57500 121.27 115.21 132.49 57155 388.62 369.19 424.57 # 57500 68.44 65.02 74.77 57160 70.73 67.19 77.27 57505 92.52 87.89 101.07 # 57160 44.14 41.93 48.22 # 57505 82.60 78.47 90.24 57170 63.48 60.31 69.36 57510 121.51 115.43 132.74 # 57170 44.69 42.46 48.83 # 57510 106.26 100.95 116.09 57180 129.84 123.35 141.85 57511 132.51 125.88 144.76 # 57180 97.57 92.69 106.59 # 57511 119.75 113.76 130.82 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 VERMONT - MEDICARE CARRIER 31145 PAGE 48 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 130.74 124.20 142.83 58353 1,049.27 996.81 1,146.33 # 57513 120.46 114.44 131.61 # 58353 201.58 191.50 220.23 57520 280.58 266.55 306.53 58356 1,922.57 1,826.44 2,100.41 # 57520 248.67 236.24 271.68 # 58356 320.43 304.41 350.07 57522 240.25 228.24 262.48 58400 408.61 388.18 446.41 # 57522 220.75 209.71 241.17 58410 730.99 694.44 798.61 57530 312.99 297.34 341.94 58520 713.42 677.75 779.41 57531 1,549.36 1,471.89 1,692.67 58540 827.85 786.46 904.43 57540 709.75 674.26 775.40 58541 780.96 741.91 853.20 57545 749.07 711.62 818.36 58542 868.43 825.01 948.76 57550 370.18 351.67 404.42 58543 882.79 838.65 964.45 57555 546.07 518.77 596.59 58544 953.90 906.21 1,042.14 57556 522.15 496.04 570.45 58545 815.17 774.41 890.57 57558 114.11 108.40 124.66 58546 1,032.84 981.20 1,128.38 # 57558 103.12 97.96 112.65 58548 1,611.18 1,530.62 1,760.21 57700 278.91 264.96 304.70 58550 805.13 764.87 879.60 57720 278.74 264.80 304.52 58552 889.56 845.08 971.84 57800 55.24 52.48 60.35 58553 1,038.23 986.32 1,134.27 # 57800 44.60 42.37 48.73 58554 1,192.00 1,132.40 1,302.26 58100 100.90 95.86 110.24 58555 220.40 209.38 240.79 # 58100 80.69 76.66 88.16 # 58555 175.02 166.27 191.21 58110 44.96 42.71 49.12 58558 297.65 282.77 325.19 # 58110 38.22 36.31 41.76 # 58558 246.60 234.27 269.41 58120 227.80 216.41 248.87 58559 317.12 301.26 346.45 # 58120 196.60 186.77 214.79 58560 358.39 340.47 391.54 58140 831.62 790.04 908.55 58561 507.15 481.79 554.06 58145 493.69 469.01 539.36 58562 314.59 298.86 343.69 58146 1,059.32 1,006.35 1,157.30 # 58562 268.86 255.42 293.73 58150 901.86 856.77 985.29 58563 1,707.96 1,622.56 1,865.94 58152 1,137.68 1,080.80 1,242.92 # 58563 317.12 301.26 346.45 58180 866.88 823.54 947.07 58565 1,813.94 1,723.24 1,981.73 58200 1,191.81 1,132.22 1,302.05 # 58565 402.90 382.76 440.17 58210 1,587.73 1,508.34 1,734.59 58570 838.39 796.47 915.94 58240 2,502.38 2,377.26 2,733.85 58571 922.29 876.18 1,007.61 58260 753.15 715.49 822.81 58572 1,042.13 990.02 1,138.52 58262 841.27 799.21 919.09 58573 1,181.72 1,122.63 1,291.02 58263 906.40 861.08 990.24 58600 330.77 314.23 361.36 58267 963.09 914.94 1,052.18 58605 300.80 285.76 328.62 58270 806.51 766.18 881.11 58611 71.78 68.19 78.42 58275 897.59 852.71 980.62 58615 227.31 215.94 248.33 58280 960.24 912.23 1,049.06 58660 612.49 581.87 669.15 58285 1,204.04 1,143.84 1,315.42 58661 588.60 559.17 643.05 58290 1,054.49 1,001.77 1,152.04 58662 644.20 611.99 703.79 58291 1,145.80 1,088.51 1,251.79 58670 333.07 316.42 363.88 58292 1,207.38 1,147.01 1,319.06 58671 332.89 316.25 363.69 58293 1,253.53 1,190.85 1,369.48 58672 677.47 643.60 740.14 58294 1,114.12 1,058.41 1,217.17 58673 736.99 700.14 805.16 58301 88.16 83.75 96.31 58700 693.94 659.24 758.13 # 58301 62.63 59.50 68.43 58720 652.36 619.74 712.70 58321 72.17 68.56 78.84 58740 795.27 755.51 868.84 # 58321 45.94 43.64 50.19 58750 827.46 786.09 904.00 58322 80.26 76.25 87.69 58752 833.85 792.16 910.98 # 58322 54.37 51.65 59.40 58760 748.24 710.83 817.45 58323 17.69 16.81 19.33 58770 767.91 729.51 838.94 # 58323 11.66 11.08 12.74 58800 291.87 277.28 318.87 58340 118.06 112.16 128.98 # 58800 271.66 258.08 296.79 # 58340 54.60 51.87 59.65 58805 368.46 350.04 402.55 58345 255.08 242.33 278.68 58820 284.64 270.41 310.97 58346 417.21 396.35 455.80 58822 642.76 610.62 702.21 58350 88.19 83.78 96.35 58823 843.36 801.19 921.37 # 58350 71.17 67.61 77.75 # 58823 170.09 161.59 185.83 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 VERMONT - MEDICARE CARRIER 31145 PAGE 49 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 634.23 602.52 692.90 59412 93.55 88.87 102.20 58900 376.01 357.21 410.79 59414 82.85 78.71 90.52 58920 638.04 606.14 697.06 59425 396.54 376.71 433.22 58925 665.63 632.35 727.20 # 59425 308.97 293.52 337.55 58940 456.04 433.24 498.23 59426 709.99 674.49 775.66 58943 1,016.99 966.14 1,111.06 # 59426 546.90 519.56 597.49 58950 970.19 921.68 1,059.93 59430 126.06 119.76 137.72 58951 1,251.54 1,188.96 1,367.30 # 59430 113.65 107.97 124.17 58952 1,411.29 1,340.73 1,541.84 59510 1,794.79 1,705.05 1,960.81 58953 1,750.26 1,662.75 1,912.16 59514 823.09 781.94 899.23 58954 1,899.91 1,804.91 2,075.65 59515 973.92 925.22 1,064.00 58956 1,218.77 1,157.83 1,331.50 59525 438.47 416.55 479.03 58957 1,347.17 1,279.81 1,471.78 59610 1,668.72 1,585.28 1,823.07 58958 1,497.17 1,422.31 1,635.66 59612 778.77 739.83 850.80 58960 838.35 796.43 915.89 59614 873.29 829.63 954.07 58970 205.45 195.18 224.46 59618 1,877.18 1,783.32 2,050.82 # 58970 183.11 173.95 200.04 59620 903.60 858.42 987.18 58976 235.05 223.30 256.80 59622 1,055.78 1,002.99 1,153.44 # 58976 205.63 195.35 224.65 59812 281.45 267.38 307.49 59000 117.23 111.37 128.08 # 59812 261.95 248.85 286.18 # 59000 73.27 69.61 80.05 59820 334.10 317.40 365.01 59001 167.52 159.14 183.01 # 59820 310.34 294.82 339.04 59012 184.27 175.06 201.32 59821 339.41 322.44 370.81 59015 140.99 133.94 154.03 # 59821 314.23 298.52 343.30 # 59015 120.07 114.07 131.18 59830 389.60 370.12 425.64 59020 63.49 60.32 69.37 59840 194.83 185.09 212.85 59020 TC 29.42 27.95 32.14 # 59840 188.44 179.02 205.87 59020 26 34.07 32.37 37.23 59841 338.69 321.76 370.02 59025 42.32 40.20 46.23 # 59841 319.19 303.23 348.71 59025 TC 14.89 14.15 16.27 59850 348.82 331.38 381.09 59025 26 27.44 26.07 29.98 59851 358.40 340.48 391.55 59030 102.40 97.28 111.87 59852 503.18 478.02 549.72 59050 45.73 43.44 49.96 59855 371.61 353.03 405.98 59051 37.84 35.95 41.34 59856 438.36 416.44 478.91 59070 364.10 345.90 397.79 59857 525.27 499.01 573.86 # 59070 268.73 255.29 293.58 59866 216.68 205.85 236.73 59072 444.41 422.19 485.52 59870 420.02 399.02 458.87 59074 344.96 327.71 376.87 59871 121.09 115.04 132.30 # 59074 266.25 252.94 290.88 60000 142.36 135.24 155.53 59076 434.48 412.76 474.67 # 60000 129.95 123.45 141.97 59100 738.74 701.80 807.07 60100 106.60 101.27 116.46 59120 706.42 671.10 771.77 # 60100 77.88 73.99 85.09 59121 709.30 673.84 774.92 60200 579.09 550.14 632.66 59130 826.97 785.62 903.46 60210 618.48 587.56 675.69 59135 838.22 796.31 915.76 60212 887.13 842.77 969.19 59136 782.70 743.57 855.11 60220 678.20 644.29 740.93 59140 351.81 334.22 384.35 60225 814.70 773.97 890.07 59150 685.98 651.68 749.43 60240 862.05 818.95 941.79 59151 670.10 636.60 732.09 60252 1,165.45 1,107.18 1,273.26 59160 192.71 183.07 210.53 60254 1,504.21 1,429.00 1,643.35 # 59160 161.51 153.43 176.44 60260 973.18 924.52 1,063.20 59200 67.30 63.94 73.53 60270 1,226.98 1,165.63 1,340.47 # 59200 40.71 38.67 44.47 60271 941.07 894.02 1,028.12 59300 173.55 164.87 189.60 60280 390.46 370.94 426.58 # 59300 132.07 125.47 144.29 60281 521.30 495.24 569.53 59320 138.50 131.58 151.32 60300 100.04 95.04 109.30 59325 218.68 207.75 238.91 # 60300 47.92 45.52 52.35 59350 250.57 238.04 273.75 60500 893.38 848.71 976.02 59400 1,585.11 1,505.85 1,731.73 60502 1,121.28 1,065.22 1,225.00 59409 695.06 660.31 759.36 60505 1,232.52 1,170.89 1,346.52 59410 808.18 767.77 882.94 60512 218.41 207.49 238.61 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 VERMONT - MEDICARE CARRIER 31145 PAGE 50 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 919.65 873.67 1,004.72 61519 2,522.03 2,395.93 2,755.32 60521 1,054.15 1,001.44 1,151.66 61520 3,239.04 3,077.09 3,538.65 60522 1,272.10 1,208.50 1,389.78 61521 2,710.28 2,574.77 2,960.99 60540 973.56 924.88 1,063.61 61522 1,860.38 1,767.36 2,032.46 60545 1,107.03 1,051.68 1,209.43 61524 1,756.59 1,668.76 1,919.07 60600 1,287.55 1,223.17 1,406.65 61526 2,960.69 2,812.66 3,234.56 60605 1,621.10 1,540.05 1,771.06 61530 2,513.83 2,388.14 2,746.36 60650 1,082.25 1,028.14 1,182.36 61531 1,020.24 969.23 1,114.61 61000 99.34 94.37 108.53 61533 1,286.12 1,221.81 1,405.08 61001 96.98 92.13 105.95 61534 1,385.94 1,316.64 1,514.14 61020 114.70 108.97 125.32 61535 830.96 789.41 907.82 61026 114.63 108.90 125.24 61536 2,206.33 2,096.01 2,410.41 61050 98.94 93.99 108.09 61537 2,041.80 1,939.71 2,230.67 61055 127.31 120.94 139.08 61538 2,192.19 2,082.58 2,394.97 61070 73.39 69.72 80.18 61539 1,997.43 1,897.56 2,182.19 61105 375.81 357.02 410.57 61540 1,870.53 1,777.00 2,043.55 61107 276.82 262.98 302.43 61541 1,804.44 1,714.22 1,971.35 61108 746.38 709.06 815.42 61542 1,952.27 1,854.66 2,132.86 61120 612.26 581.65 668.90 61543 1,823.37 1,732.20 1,992.03 61140 1,059.18 1,006.22 1,157.15 61544 1,506.46 1,431.14 1,645.81 61150 1,133.95 1,077.25 1,238.84 61545 2,689.41 2,554.94 2,938.18 61151 821.79 780.70 897.81 61546 1,949.29 1,851.83 2,129.60 61154 1,060.66 1,007.63 1,158.77 61548 1,333.71 1,267.02 1,457.07 61156 1,057.03 1,004.18 1,154.81 61550 882.24 838.13 963.85 61210 323.23 307.07 353.13 61552 1,160.32 1,102.30 1,267.65 61215 409.72 389.23 447.61 61556 1,395.39 1,325.62 1,524.46 61250 714.57 678.84 780.67 61557 1,429.33 1,357.86 1,561.54 61253 789.73 750.24 862.78 61558 1,501.18 1,426.12 1,640.04 61304 1,394.87 1,325.13 1,523.90 61559 2,043.83 1,941.64 2,232.89 61305 1,686.26 1,601.95 1,842.24 61563 1,653.63 1,570.95 1,806.59 61312 1,749.06 1,661.61 1,910.85 61564 2,056.15 1,953.34 2,246.34 61313 1,669.57 1,586.09 1,824.00 61566 1,904.96 1,809.71 2,081.17 61314 1,543.28 1,466.12 1,686.04 61567 2,150.98 2,043.43 2,349.94 61315 1,756.80 1,668.96 1,919.30 61570 1,557.16 1,479.30 1,701.20 61316 76.16 72.35 83.20 61571 1,688.90 1,604.46 1,845.13 61320 1,624.68 1,543.45 1,774.97 61575 2,029.94 1,928.44 2,217.71 61321 1,781.45 1,692.38 1,946.24 61576 3,263.45 3,100.28 3,565.32 61322 1,979.54 1,880.56 2,162.64 61580 2,146.36 2,039.04 2,344.90 61323 2,012.29 1,911.68 2,198.43 61581 2,408.79 2,288.35 2,631.60 61330 1,399.68 1,329.70 1,529.16 61582 2,449.51 2,327.03 2,676.08 61332 1,608.37 1,527.95 1,757.14 61583 2,466.35 2,343.03 2,694.48 61333 1,631.02 1,549.47 1,781.89 61584 2,406.92 2,286.57 2,629.56 61334 1,063.53 1,010.35 1,161.90 61585 2,561.92 2,433.82 2,798.89 61340 1,210.51 1,149.98 1,322.48 61586 1,849.10 1,756.65 2,020.15 61343 1,869.44 1,775.97 2,042.37 61590 2,726.80 2,590.46 2,979.03 61345 1,730.32 1,643.80 1,890.37 61591 2,743.96 2,606.76 2,997.77 61440 1,693.82 1,609.13 1,850.50 61592 2,704.13 2,568.92 2,954.26 61450 1,609.14 1,528.68 1,757.98 61595 2,062.70 1,959.57 2,253.51 61458 1,710.40 1,624.88 1,868.61 61596 2,274.38 2,160.66 2,484.76 61460 1,740.60 1,653.57 1,901.61 61597 2,454.16 2,331.45 2,681.17 61470 1,613.52 1,532.84 1,762.77 61598 2,190.50 2,080.98 2,393.13 61480 1,561.77 1,483.68 1,706.23 61600 1,856.04 1,763.24 2,027.73 61490 1,617.08 1,536.23 1,766.66 61601 2,011.10 1,910.55 2,197.13 61500 1,148.13 1,090.72 1,254.33 61605 1,950.76 1,853.22 2,131.20 61501 986.04 936.74 1,077.25 61606 2,577.38 2,448.51 2,815.79 61510 1,846.28 1,753.97 2,017.07 61607 2,399.79 2,279.80 2,621.77 61512 2,177.08 2,068.23 2,378.46 61608 2,773.30 2,634.64 3,029.84 61514 1,617.10 1,536.25 1,766.69 61609 532.67 506.04 581.95 61516 1,577.90 1,499.01 1,723.86 61610 1,633.44 1,551.77 1,784.54 61517 76.15 72.34 83.19 61611 412.62 391.99 450.79 61518 2,343.36 2,226.19 2,560.12 61612 1,467.97 1,394.57 1,603.76 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 VERMONT - MEDICARE CARRIER 31145 PAGE 51 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 2,708.67 2,573.24 2,959.23 62141 975.56 926.78 1,065.80 61615 2,154.83 2,047.09 2,354.15 62142 744.20 706.99 813.04 61616 2,815.89 2,675.10 3,076.37 62143 870.72 827.18 951.26 61618 1,109.76 1,054.27 1,212.41 62145 1,194.22 1,134.51 1,304.69 61619 1,281.84 1,217.75 1,400.41 62146 1,026.30 974.99 1,121.24 61623 519.19 493.23 567.21 62147 1,218.70 1,157.77 1,331.44 61624 1,034.28 982.57 1,129.96 62148 108.96 103.51 119.04 61626 845.00 802.75 923.16 62160 166.81 158.47 182.24 61630 1,179.41 1,120.44 1,288.51 62161 1,282.24 1,218.13 1,400.85 61635 1,291.54 1,226.96 1,411.00 62162 1,597.93 1,518.03 1,745.73 61680 1,926.72 1,830.38 2,104.94 62163 1,033.41 981.74 1,129.00 61682 3,615.35 3,434.58 3,949.77 62164 1,709.66 1,624.18 1,867.81 61684 2,408.22 2,287.81 2,630.98 62165 1,334.00 1,267.30 1,457.40 61686 3,872.47 3,678.85 4,230.68 62180 1,346.37 1,279.05 1,470.91 61690 1,837.25 1,745.39 2,007.20 62190 766.21 727.90 837.09 61692 3,128.14 2,971.73 3,417.49 62192 816.55 775.72 892.08 61697 3,552.64 3,375.01 3,881.26 62194 335.24 318.48 366.25 61698 3,831.78 3,640.19 4,186.22 62200 1,162.34 1,104.22 1,269.85 61700 2,954.66 2,806.93 3,227.97 62201 999.63 949.65 1,092.10 61702 3,335.21 3,168.45 3,643.72 62220 856.86 814.02 936.12 61703 1,139.94 1,082.94 1,245.38 62223 881.46 837.39 963.00 61705 2,180.36 2,071.34 2,382.04 62225 421.09 400.04 460.05 61708 1,920.50 1,824.48 2,098.15 62230 708.52 673.09 774.05 61710 1,731.47 1,644.90 1,891.64 62252 88.89 84.45 97.12 61711 2,219.21 2,108.25 2,424.49 62252 TC 47.86 45.47 52.29 61720 999.82 949.83 1,092.30 62252 26 41.03 38.98 44.83 61735 1,232.45 1,170.83 1,346.45 62256 492.87 468.23 538.46 61750 1,189.08 1,129.63 1,299.07 62258 952.25 904.64 1,040.34 61751 1,159.00 1,101.05 1,266.21 62263 583.73 554.54 637.72 61760 1,307.20 1,241.84 1,428.12 # 62263 343.36 326.19 375.12 61770 1,302.04 1,236.94 1,422.48 62264 357.40 339.53 390.46 61790 720.12 684.11 786.73 # 62264 209.91 199.41 229.32 61791 934.06 887.36 1,020.46 62267 232.09 220.49 253.56 61795 217.78 206.89 237.92 # 62267 153.03 145.38 167.19 61796 678.58 644.65 741.35 62268 422.81 401.67 461.92 61797 185.72 176.43 202.89 # 62268 246.96 234.61 269.80 61798 678.58 644.65 741.35 62269 459.15 436.19 501.62 61799 256.71 243.87 280.45 # 62269 251.74 239.15 275.02 61800 130.56 124.03 142.63 62270 140.52 133.49 153.51 61850 827.88 786.49 904.46 # 62270 71.74 68.15 78.37 61860 1,320.49 1,254.47 1,442.64 62272 164.96 156.71 180.22 61863 1,277.27 1,213.41 1,395.42 # 62272 75.26 71.50 82.23 61864 325.07 308.82 355.14 62273 149.32 141.85 163.13 61867 1,899.59 1,804.61 2,075.30 # 62273 102.17 97.06 111.62 61868 499.47 474.50 545.68 62280 275.29 261.53 300.76 61870 1,003.19 953.03 1,095.98 # 62280 139.14 132.18 152.01 61875 982.43 933.31 1,073.31 62281 255.64 242.86 279.29 61880 462.83 439.69 505.64 # 62281 134.74 128.00 147.20 61885 537.42 510.55 587.13 62282 265.01 251.76 289.52 61886 678.16 644.25 740.89 # 62282 124.26 118.05 135.76 61888 337.57 320.69 368.79 62284 202.13 192.02 220.82 62000 757.16 719.30 827.20 # 62284 84.07 79.87 91.85 62005 1,051.84 999.25 1,149.14 62287 497.13 472.27 543.11 62010 1,282.18 1,218.07 1,400.78 62290 294.84 280.10 322.12 62100 1,369.30 1,300.84 1,495.97 # 62290 156.57 148.74 171.05 62115 1,210.51 1,149.98 1,322.48 62291 275.82 262.03 301.33 62116 1,503.23 1,428.07 1,642.28 # 62291 151.02 143.47 164.99 62117 1,635.90 1,554.11 1,787.23 62292 445.86 423.57 487.11 62120 1,564.00 1,485.80 1,708.67 62294 716.08 680.28 782.32 62121 1,418.88 1,347.94 1,550.13 62310 194.74 185.00 212.75 62140 887.97 843.57 970.11 # 62310 92.63 88.00 101.20 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 VERMONT - MEDICARE CARRIER 31145 PAGE 52 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 172.00 163.40 187.91 63180 1,191.33 1,131.76 1,301.52 # 62311 76.98 73.13 84.10 63182 1,269.19 1,205.73 1,386.59 62318 208.29 197.88 227.56 63185 972.34 923.72 1,062.28 # 62318 93.06 88.41 101.67 63190 1,117.53 1,061.65 1,220.90 62319 188.51 179.08 205.94 63191 1,045.12 992.86 1,141.79 # 62319 87.11 82.75 95.16 63194 1,273.01 1,209.36 1,390.76 62350 343.94 326.74 375.75 63195 1,278.46 1,214.54 1,396.72 62351 723.92 687.72 790.88 63196 1,503.94 1,428.74 1,643.05 62355 258.37 245.45 282.27 63197 1,434.47 1,362.75 1,567.16 62360 250.77 238.23 273.96 63198 1,587.72 1,508.33 1,734.58 62361 343.71 326.52 375.50 63199 1,717.65 1,631.77 1,876.54 62362 360.62 342.59 393.98 63200 1,282.03 1,217.93 1,400.62 62365 285.31 271.04 311.70 63250 2,490.72 2,366.18 2,721.11 62367 34.86 33.12 38.09 63251 2,578.28 2,449.37 2,816.78 # 62367 22.10 21.00 24.15 63252 2,578.78 2,449.84 2,817.32 62368 49.73 47.24 54.33 63265 1,419.94 1,348.94 1,551.28 # 62368 34.49 32.77 37.69 63266 1,459.99 1,386.99 1,595.04 63001 1,049.71 997.22 1,146.80 63267 1,176.81 1,117.97 1,285.67 63003 1,056.53 1,003.70 1,154.26 63268 1,185.73 1,126.44 1,295.41 63005 1,004.33 954.11 1,097.23 63270 1,746.64 1,659.31 1,908.21 63011 947.82 900.43 1,035.49 63271 1,756.99 1,669.14 1,919.51 63012 1,021.25 970.19 1,115.72 63272 1,619.78 1,538.79 1,769.61 63015 1,259.52 1,196.54 1,376.02 63273 1,530.20 1,453.69 1,671.74 63016 1,297.32 1,232.45 1,417.32 63275 1,525.21 1,448.95 1,666.29 63017 1,058.56 1,005.63 1,156.47 63276 1,519.26 1,443.30 1,659.80 63020 999.72 949.73 1,092.19 63277 1,334.37 1,267.65 1,457.80 63030 831.12 789.56 907.99 63278 1,308.54 1,243.11 1,429.58 63035 175.76 166.97 192.02 63280 1,800.95 1,710.90 1,967.54 63040 1,213.47 1,152.80 1,325.72 63281 1,780.57 1,691.54 1,945.27 63042 1,137.03 1,080.18 1,242.21 63282 1,680.39 1,596.37 1,835.83 63043 389.76 370.27 425.81 63283 1,593.07 1,513.42 1,740.43 63044 354.43 336.71 387.22 63285 2,208.65 2,098.22 2,412.95 63045 1,086.40 1,032.08 1,186.89 63286 2,200.76 2,090.72 2,404.33 63046 1,040.10 988.10 1,136.32 63287 2,323.85 2,207.66 2,538.81 63047 949.27 901.81 1,037.08 63290 2,354.30 2,236.59 2,572.08 63048 189.97 180.47 207.54 63295 280.55 266.52 306.50 63050 1,306.51 1,241.18 1,427.36 63300 1,572.75 1,494.11 1,718.23 63051 1,479.55 1,405.57 1,616.41 63301 1,771.77 1,683.18 1,935.66 63055 1,397.10 1,327.25 1,526.34 63302 1,759.80 1,671.81 1,922.58 63056 1,290.99 1,226.44 1,410.41 63303 1,846.45 1,754.13 2,017.25 63057 290.28 275.77 317.14 63304 1,951.41 1,853.84 2,131.92 63064 1,528.46 1,452.04 1,669.85 63305 1,996.55 1,896.72 2,181.23 63066 179.38 170.41 195.97 63306 2,081.68 1,977.60 2,274.24 63075 1,191.94 1,132.34 1,302.19 63307 1,949.43 1,851.96 2,129.75 63076 223.97 212.77 244.69 63308 290.45 275.93 317.32 63077 1,314.20 1,248.49 1,435.76 63600 737.64 700.76 805.87 63078 178.86 169.92 195.41 63610 1,204.66 1,144.43 1,316.09 63081 1,533.54 1,456.86 1,675.39 # 63610 394.55 374.82 431.04 63082 241.89 229.80 264.27 63615 987.22 937.86 1,078.54 63085 1,648.98 1,566.53 1,801.51 63620 678.58 644.65 741.35 63086 172.61 163.98 188.58 63621 213.50 202.83 233.25 63087 2,102.41 1,997.29 2,296.88 63650 367.56 349.18 401.56 63088 236.21 224.40 258.06 63655 724.01 687.81 790.98 63090 1,726.29 1,639.98 1,885.98 63660 386.33 367.01 422.06 63091 162.77 154.63 177.82 63685 349.08 331.63 381.37 63101 1,971.11 1,872.55 2,153.43 63688 313.18 297.52 342.15 63102 1,962.60 1,864.47 2,144.14 63700 1,051.75 999.16 1,149.03 63103 260.46 247.44 284.56 63702 1,181.93 1,122.83 1,291.25 63170 1,313.71 1,248.02 1,435.22 63704 1,316.84 1,251.00 1,438.65 63172 1,182.15 1,123.04 1,291.50 63706 1,528.54 1,452.11 1,669.93 63173 1,456.20 1,383.39 1,590.90 63707 777.50 738.63 849.42 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 VERMONT - MEDICARE CARRIER 31145 PAGE 53 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 944.50 897.28 1,031.87 64484 122.41 116.29 133.73 63710 941.66 894.58 1,028.77 # 64484 62.14 59.03 67.88 63740 798.72 758.78 872.60 64505 91.23 86.67 99.67 63741 520.52 494.49 568.66 # 64505 76.34 72.52 83.40 63744 545.57 518.29 596.03 64508 127.43 121.06 139.22 63746 477.08 453.23 521.21 # 64508 63.26 60.10 69.12 64400 95.87 91.08 104.74 64510 126.78 120.44 138.51 # 64400 57.22 54.36 62.51 # 64510 61.54 58.46 67.23 64402 98.08 93.18 107.16 64517 152.55 144.92 166.66 # 64402 65.11 61.85 71.13 # 64517 108.23 102.82 118.24 64405 92.63 88.00 101.20 64520 166.03 157.73 181.39 # 64405 66.75 63.41 72.92 # 64520 69.60 66.12 76.04 64408 106.86 101.52 116.75 64530 171.49 162.92 187.36 # 64408 80.63 76.60 88.09 # 64530 82.15 78.04 89.75 64410 124.42 118.20 135.93 64550 14.11 13.40 15.41 # 64410 71.60 68.02 78.22 # 64550 8.44 8.02 9.22 64412 123.74 117.55 135.18 64553 181.52 172.44 198.31 # 64412 63.82 60.63 69.72 # 64553 142.52 135.39 155.70 64413 102.96 97.81 112.48 64555 192.66 183.03 210.48 # 64413 69.63 66.15 76.07 # 64555 140.19 133.18 153.16 64415 117.01 111.16 127.83 64560 190.76 181.22 208.40 # 64415 67.37 64.00 73.60 # 64560 144.32 137.10 157.67 64416 83.51 79.33 91.23 64561 1,045.38 993.11 1,142.08 64417 118.05 112.15 128.97 # 64561 393.04 373.39 429.40 # 64417 66.64 63.31 72.81 64565 152.29 144.68 166.38 64418 120.46 114.44 131.61 # 64565 107.26 101.90 117.19 # 64418 66.57 63.24 72.73 64573 510.42 484.90 557.64 64420 143.24 136.08 156.49 64575 252.75 240.11 276.13 # 64420 59.92 56.92 65.46 64577 311.20 295.64 339.99 64421 211.44 200.87 231.00 64580 263.09 249.94 287.43 # 64421 82.03 77.93 89.62 64581 762.50 724.38 833.04 64425 115.04 109.29 125.68 64585 301.90 286.81 329.83 # 64425 84.91 80.66 92.76 # 64585 145.20 137.94 158.63 64430 140.57 133.54 153.57 64590 283.50 269.33 309.73 # 64430 80.66 76.63 88.12 # 64590 162.60 154.47 177.64 64435 129.93 123.43 141.94 64595 292.66 278.03 319.73 # 64435 76.75 72.91 83.85 # 64595 128.16 121.75 140.01 64445 121.44 115.37 132.68 64600 359.11 341.15 392.32 # 64445 73.22 69.56 79.99 # 64600 191.41 181.84 209.12 64446 84.05 79.85 91.83 64605 503.80 478.61 550.40 64447 64.20 60.99 70.14 # 64605 303.13 287.97 331.17 64448 74.37 70.65 81.25 64610 609.09 578.64 665.44 64449 83.53 79.35 91.25 # 64610 422.96 401.81 462.08 64450 92.41 87.79 100.96 64612 138.23 131.32 151.02 # 64450 65.47 62.20 71.53 # 64612 121.57 115.49 132.81 64455 47.07 44.72 51.43 64613 136.10 129.30 148.70 # 64455 37.15 35.29 40.58 # 64613 114.83 109.09 125.45 64470 234.59 222.86 256.29 64614 152.73 145.09 166.85 # 64470 94.54 89.81 103.28 # 64614 127.91 121.51 139.74 64472 101.47 96.40 110.86 64620 242.11 230.00 264.50 # 64472 60.35 57.33 65.93 # 64620 149.93 142.43 163.79 64475 210.03 199.53 229.46 64622 290.07 275.57 316.91 # 64475 74.24 70.53 81.11 # 64622 159.25 151.29 173.98 64476 85.15 80.89 93.02 64623 107.67 102.29 117.63 # 64476 45.09 42.84 49.27 # 64623 44.92 42.67 49.07 64479 248.45 236.03 271.43 64626 337.71 320.82 368.94 # 64479 111.95 106.35 122.30 # 64626 210.44 199.92 229.91 64480 124.67 118.44 136.21 64627 146.95 139.60 160.54 # 64480 72.91 69.26 79.65 # 64627 52.64 50.01 57.51 64483 241.71 229.62 264.06 64630 209.59 199.11 228.98 # 64483 98.47 93.55 107.58 # 64630 174.49 165.77 190.64 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 54 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 77.84 73.95 85.04 64823 671.06 637.51 733.14 # 64632 66.50 63.18 72.66 64831 592.68 563.05 647.51 64640 205.71 195.42 224.73 64832 309.88 294.39 338.55 # 64640 159.27 151.31 174.01 64834 655.58 622.80 716.22 64650 59.99 56.99 65.54 64835 710.35 674.83 776.05 # 64650 35.88 34.09 39.20 64836 710.36 674.84 776.07 64653 69.67 66.19 76.12 64837 343.92 326.72 375.73 # 64653 44.85 42.61 49.00 64840 811.58 771.00 886.65 64680 274.24 260.53 299.61 64856 893.71 849.02 976.37 # 64680 145.54 138.26 159.00 64857 934.40 887.68 1,020.83 64681 353.99 336.29 386.73 64858 1,072.73 1,019.09 1,171.95 # 64681 195.51 185.73 213.59 64859 233.17 221.51 254.74 64702 404.84 384.60 442.29 64861 1,208.02 1,147.62 1,319.76 64704 296.86 282.02 324.32 64862 1,181.35 1,122.28 1,290.62 64708 418.53 397.60 457.24 64864 778.10 739.20 850.08 64712 482.19 458.08 526.79 64865 1,030.36 978.84 1,125.67 64713 671.33 637.76 733.42 64866 1,068.16 1,014.75 1,166.96 64714 575.85 547.06 629.12 64868 936.59 889.76 1,023.22 64716 460.26 437.25 502.84 64870 915.05 869.30 999.70 64718 494.02 469.32 539.72 64872 109.50 104.03 119.63 64719 342.40 325.28 374.07 64874 160.98 152.93 175.87 64721 361.87 343.78 395.35 64876 175.57 166.79 191.81 # 64721 360.45 342.43 393.79 64885 1,013.38 962.71 1,107.12 64722 294.29 279.58 321.52 64886 1,201.45 1,141.38 1,312.59 64726 258.51 245.58 282.42 64890 962.66 914.53 1,051.71 64727 167.78 159.39 183.30 64891 997.97 948.07 1,090.28 64732 333.64 316.96 364.50 64892 935.04 888.29 1,021.53 64734 361.52 343.44 394.96 64893 984.29 935.08 1,075.34 64736 343.45 326.28 375.22 64895 1,157.34 1,099.47 1,264.39 64738 402.95 382.80 440.22 64896 1,275.05 1,211.30 1,393.00 64740 404.49 384.27 441.91 64897 1,120.03 1,064.03 1,223.63 64742 413.74 393.05 452.01 64898 1,221.48 1,160.41 1,334.47 64744 360.02 342.02 393.32 64901 548.04 520.64 598.74 64746 391.04 371.49 427.21 64902 629.84 598.35 688.10 64752 442.60 420.47 483.54 64905 896.23 851.42 979.13 64755 786.15 746.84 858.87 64907 1,174.61 1,115.88 1,283.26 64760 418.44 397.52 457.15 64910 720.04 684.04 786.65 64761 397.56 377.68 434.33 64911 869.88 826.39 950.35 64763 479.57 455.59 523.93 65091 520.19 494.18 568.31 64766 552.68 525.05 603.81 65093 519.00 493.05 567.01 64771 517.29 491.43 565.14 65101 599.67 569.69 655.14 64772 496.00 471.20 541.88 65103 626.23 594.92 684.16 64774 359.74 341.75 393.01 65105 690.87 656.33 754.78 64776 345.44 328.17 377.40 65110 1,006.16 955.85 1,099.23 64778 166.72 158.38 182.14 65112 1,182.77 1,123.63 1,292.17 64782 407.17 386.81 444.83 65114 1,231.71 1,170.12 1,345.64 64783 199.53 189.55 217.98 65125 373.31 354.64 407.84 64784 633.48 601.81 692.08 # 65125 235.75 223.96 257.55 64786 947.57 900.19 1,035.22 65130 593.36 563.69 648.24 64787 229.13 217.67 250.32 65135 604.28 574.07 660.18 64788 337.59 320.71 368.82 65140 658.32 625.40 719.21 64790 721.36 685.29 788.08 65150 476.97 453.12 521.09 64792 937.05 890.20 1,023.73 65155 694.16 659.45 758.37 64795 170.91 162.36 186.71 65175 534.61 507.88 584.06 64802 532.47 505.85 581.73 65205 47.05 44.70 51.41 64804 810.20 769.69 885.14 # 65205 37.48 35.61 40.95 64809 763.98 725.78 834.65 65210 57.59 54.71 62.92 64818 591.93 562.33 646.68 # 65210 45.18 42.92 49.36 64820 663.16 630.00 724.50 65220 48.12 45.71 52.57 64821 599.01 569.06 654.42 # 65220 36.77 34.93 40.17 64822 591.21 561.65 645.90 65222 63.32 60.15 69.17 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 55 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 49.49 47.02 54.07 65875 509.49 484.02 556.62 65235 569.95 541.45 622.67 65880 536.95 510.10 586.62 65260 781.26 742.20 853.53 65900 787.80 748.41 860.67 65265 879.66 835.68 961.03 65920 637.54 605.66 696.51 65270 219.03 208.08 239.29 65930 524.59 498.36 573.11 # 65270 116.22 110.41 126.97 66020 152.37 144.75 166.46 65272 404.25 384.04 441.65 # 66020 107.34 101.97 117.27 # 65272 282.64 268.51 308.79 66030 134.79 128.05 147.26 65273 310.45 294.93 339.17 # 66030 89.76 85.27 98.06 65275 453.29 430.63 495.22 66130 576.93 548.08 630.29 # 65275 369.27 350.81 403.43 # 66130 471.99 448.39 515.65 65280 544.65 517.42 595.03 66150 701.09 666.04 765.95 65285 849.39 806.92 927.96 66155 699.14 664.18 763.81 65286 572.07 543.47 624.99 66160 795.47 755.70 869.06 # 65286 400.48 380.46 437.53 66165 684.96 650.71 748.32 65290 399.70 379.72 436.68 66170 963.29 915.13 1,052.40 65400 544.39 517.17 594.75 66172 1,210.52 1,149.99 1,322.49 # 65400 483.05 458.90 527.74 66180 957.61 909.73 1,046.19 65410 118.42 112.50 129.38 66185 604.86 574.62 660.81 # 65410 86.87 82.53 94.91 66220 590.81 561.27 645.46 65420 419.69 398.71 458.52 66225 760.04 722.04 830.35 # 65420 304.47 289.25 332.64 66250 608.70 578.27 665.01 65426 529.57 503.09 578.55 # 66250 448.80 426.36 490.31 # 65426 388.11 368.70 424.01 66500 286.97 272.62 313.51 65430 95.73 90.94 104.58 66505 314.15 298.44 343.21 # 65430 86.87 82.53 94.91 66600 665.28 632.02 726.82 65435 66.15 62.84 72.27 66605 863.47 820.30 943.35 # 65435 58.00 55.10 63.37 66625 349.54 332.06 381.87 65436 313.98 298.28 343.02 66630 460.08 437.08 502.64 # 65436 301.57 286.49 329.46 66635 464.74 441.50 507.73 65450 259.79 246.80 283.82 66680 415.95 395.15 454.42 # 65450 256.60 243.77 280.34 66682 505.85 480.56 552.64 65600 315.00 299.25 344.14 66700 364.71 346.47 398.44 # 65600 273.17 259.51 298.44 # 66700 321.45 305.38 351.19 65710 899.71 854.72 982.93 66710 358.50 340.58 391.67 65730 1,000.67 950.64 1,093.24 # 66710 320.57 304.54 350.22 65750 1,014.51 963.78 1,108.35 66711 514.16 488.45 561.72 65755 1,008.59 958.16 1,101.88 66720 375.93 357.13 410.70 65756 971.25 922.69 1,061.09 # 66720 339.06 322.11 370.43 65770 1,159.63 1,101.65 1,266.90 66740 356.02 338.22 388.95 65772 364.12 345.91 397.80 # 66740 321.99 305.89 351.77 # 65772 327.24 310.88 357.51 66761 365.66 347.38 399.49 65775 447.27 424.91 488.65 # 66761 332.69 316.06 363.47 65780 720.39 684.37 787.03 66762 383.08 363.93 418.52 65781 1,095.77 1,040.98 1,197.13 # 66762 343.73 326.54 375.52 65782 944.87 897.63 1,032.27 66770 425.54 404.26 464.90 65800 125.07 118.82 136.64 # 66770 389.73 370.24 425.78 # 65800 109.83 104.34 119.99 66820 322.36 306.24 352.18 65805 136.42 129.60 149.04 66821 262.08 248.98 286.33 # 65805 109.83 104.34 119.99 # 66821 247.19 234.83 270.05 65810 379.26 360.30 414.35 66825 619.07 588.12 676.34 65815 518.17 492.26 566.10 66830 579.64 550.66 633.26 # 65815 384.51 365.28 420.07 66840 564.75 536.51 616.99 65820 610.50 579.98 666.98 66850 644.63 612.40 704.26 65850 693.93 659.23 758.11 66852 689.82 655.33 753.63 65855 278.02 264.12 303.74 66920 615.49 584.72 672.43 # 65855 244.70 232.47 267.34 66930 699.52 664.54 764.22 65860 256.72 243.88 280.46 66940 635.30 603.54 694.07 # 65860 212.05 201.45 231.67 66982 874.28 830.57 955.16 65865 388.12 368.71 424.02 66983 604.70 574.47 660.64 65870 479.65 455.67 524.02 66984 627.28 595.92 685.31 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS09 VERMONT - MEDICARE CARRIER 31145 PAGE 56 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 620.70 589.67 678.12 67320 272.38 258.76 297.57 66986 758.72 720.78 828.90 67331 257.86 244.97 281.72 66990 77.68 73.80 84.87 67332 280.46 266.44 306.41 67005 382.51 363.38 417.89 67334 254.44 241.72 277.98 67010 442.78 420.64 483.74 67335 127.91 121.51 139.74 67015 472.60 448.97 516.32 67340 303.06 287.91 331.10 67025 588.03 558.63 642.42 67343 530.29 503.78 579.35 # 67025 510.03 484.53 557.21 67345 193.08 183.43 210.94 67027 698.30 663.39 762.90 # 67345 175.71 166.92 191.96 67028 176.32 167.50 192.63 67346 168.55 160.12 184.14 # 67028 141.22 134.16 154.28 67400 763.96 725.76 834.62 67030 422.66 401.53 461.76 67405 650.38 617.86 710.54 67031 312.51 296.88 341.41 67412 707.46 672.09 772.90 # 67031 286.63 272.30 313.15 67413 707.77 672.38 773.24 67036 789.01 749.56 861.99 67414 1,084.91 1,030.66 1,185.26 67039 1,010.66 960.13 1,104.15 67415 89.53 85.05 97.81 67040 1,165.90 1,107.61 1,273.75 67420 1,350.28 1,282.77 1,475.19 67041 1,090.07 1,035.57 1,190.91 67430 1,026.27 974.96 1,121.20 67042 1,248.68 1,186.25 1,364.19 67440 990.22 940.71 1,081.82 67043 1,310.15 1,244.64 1,431.34 67445 1,163.07 1,104.92 1,270.66 67101 629.75 598.26 688.00 67450 1,027.78 976.39 1,122.85 # 67101 545.73 518.44 596.21 67500 75.15 71.39 82.10 67105 582.80 553.66 636.71 # 67500 68.06 64.66 74.36 # 67105 523.24 497.08 571.64 67505 73.28 69.62 80.06 67107 992.20 942.59 1,083.98 # 67505 65.83 62.54 71.92 67108 1,320.87 1,254.83 1,443.05 67515 77.97 74.07 85.18 67110 705.25 669.99 770.49 # 67515 71.94 68.34 78.59 # 67110 628.31 596.89 686.42 67550 795.48 755.71 869.07 67112 1,089.91 1,035.41 1,190.72 67560 810.64 770.11 885.63 67113 1,434.61 1,362.88 1,567.31 67570 952.78 905.14 1,040.91 67115 399.45 379.48 436.40 67700 218.70 207.77 238.94 67120 531.23 504.67 580.37 # 67700 93.90 89.21 102.59 # 67120 450.04 427.54 491.67 67710 184.46 175.24 201.53 67121 739.60 702.62 808.01 # 67710 78.45 74.53 85.71 67141 421.30 400.24 460.28 67715 194.33 184.61 212.30 # 67141 392.58 372.95 428.89 # 67715 88.68 84.25 96.89 67145 424.77 403.53 464.06 67800 103.84 98.65 113.45 # 67145 401.37 381.30 438.50 # 67800 85.76 81.47 93.69 67208 486.91 462.56 531.94 67801 133.21 126.55 145.53 # 67208 469.90 446.41 513.37 # 67801 111.23 105.67 121.52 67210 568.69 540.26 621.30 67805 164.98 156.73 180.24 # 67210 549.90 522.41 600.77 # 67805 136.62 129.79 149.26 67218 1,153.92 1,096.22 1,260.65 67808 296.81 281.97 324.27 67220 873.17 829.51 953.94 67810 188.10 178.70 205.51 # 67220 832.76 791.12 909.79 # 67810 79.96 75.96 87.35 67221 246.73 234.39 269.55 67820 43.68 41.50 47.73 # 67221 183.97 174.77 200.99 # 67820 45.10 42.85 49.28 67225 25.46 24.19 27.82 67825 105.26 100.00 115.00 # 67225 24.04 22.84 26.27 # 67825 98.88 93.94 108.03 67227 495.70 470.92 541.56 67830 219.09 208.14 239.36 # 67227 464.15 440.94 507.08 # 67830 113.08 107.43 123.54 67228 977.45 928.58 1,067.87 67835 360.79 342.75 394.16 # 67228 862.22 819.11 941.98 67840 229.22 217.76 250.42 67229 944.12 896.91 1,031.45 # 67840 131.01 124.46 143.13 67250 642.32 610.20 701.73 67850 184.51 175.28 201.57 67255 687.13 652.77 750.69 # 67850 117.51 111.63 128.37 67311 486.61 462.28 531.62 67875 143.17 136.01 156.41 67312 582.07 552.97 635.92 # 67875 81.48 77.41 89.02 67314 545.72 518.43 596.19 67880 370.55 352.02 404.82 67316 653.38 620.71 713.82 # 67880 296.81 281.97 324.27 67318 571.09 542.54 623.92 67882 457.20 434.34 499.49 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 VERMONT - MEDICARE CARRIER 31145 PAGE 57 FSY09 LOCALITY FEE SCHEDULE FOR AREA 50 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 382.40 363.28 417.77 # 68130 336.30 319.49 367.41 67900 528.07 501.67 576.92 68135 128.23 121.82 140.09 # 67900 422.06 400.96 461.10 # 68135 123.98 117.78 135.45 67901 569.66 541.18 622.36 68200 35.04 33.29 38.28 # 67901 472.87 449.23 516.61 # 68200 29.02 27.57 31.71 67902 585.90 556.61 640.10 68320 584.83 555.59 638.93 67903 504.32 479.10 550.97 # 68320 432.38 410.76 472.37 # 67903 408.60 388.17 446.40 68325 537.29 510.43 586.99 67904 597.37 567.50 652.63 68326 523.52 497.34 571.94 # 67904 485.34 461.07 530.23 68328 583.87 554.68 637.88 67906 423.57 402.39 462.75 68330 491.27 466.71 536.72 67908 402.36 382.24 439.58 # 68330 371.79 353.20 406.18 # 67908 353.44 335.77 386.14 68335 525.13 498.87 573.70 67909 441.70 419.62 482.56 68340 442.39 420.27 483.31 # 67909 361.58 343.50 395.03 # 68340 321.14 305.08 350.84 67911 454.22 431.51 496.24 68360 431.35 409.78 471.25 67912 747.25 709.89 816.37 # 68360 332.08 315.48 362.80 # 67912 408.67 388.24 446.48 68362 532.32 505.70 581.56 67914 321.51 305.43 351.24 68371 340.88 323.84 372.42 # 67914 238.19 226.28 260.22 68400 231.13 219.57 252.51 67915 288.06 273.66 314.71 # 68400 112.37 106.75 122.76 # 67915 210.42 199.90 229.89 68420 263.59 250.41 287.97 67916 442.54 420.41 483.47 # 68420 144.11 136.90 157.44 # 67916 355.32 337.55 388.18 68440 87.62 83.24 95.73 67917 483.38 459.21 528.09 # 68440 78.76 74.82 86.04 # 67917 392.62 372.99 428.94 68500 793.08 753.43 866.44 67921 306.10 290.80 334.42 68505 797.99 758.09 871.80 # 67921 222.78 211.64 243.39 68510 376.30 357.49 411.11 67922 278.95 265.00 304.75 # 68510 246.54 234.21 269.34 # 67922 202.72 192.58 221.47 68520 561.67 533.59 613.63 67923 466.64 443.31 509.81 68525 226.76 215.42 247.73 # 67923 383.32 364.15 418.77 68530 358.90 340.96 392.10 67924 482.88 458.74 527.55 # 68530 217.44 206.57 237.56 # 67924 370.50 351.98 404.78 68540 758.53 720.60 828.69 67930 303.38 288.21 331.44 68550 931.54 884.96 1,017.70 # 67930 204.11 193.90 222.99 68700 489.68 465.20 534.98 67935 492.18 467.57 537.71 68705 195.55 185.77 213.64 # 67935 372.70 354.07 407.18 # 68705 136.34 129.52 148.95 67938 199.72 189.73 218.19 68720 621.43 590.36 678.91 # 67938 94.42 89.70 103.16 68745 623.50 592.33 681.18 67950 475.46 451.69 519.44 68750 641.52 609.44 700.86 # 67950 385.41 366.14 421.06 68760 165.75 157.46 181.08 67961 474.85 451.11 518.78 # 68760 119.30 113.34 130.34 # 67961 376.64 357.81 411.48 68761 120.67 114.64 131.84 67966 626.35 595.03 684.28 # 68761 96.92 92.07 105.88 # 67966 534.17 507.46 583.58 68770 484.08 459.88 528.86 67971 602.51 572.38 658.24 68801 100.03 95.03 109.28 67973 780.23 741.22 852.40 # 68801 86.56 82.23 94.56 67974 777.02 738.17 848.90 68810 193.78 184.09 211.70 67975 568.96 540.51 621.59 # 68810 155.14 147.38 169.49 68020 97.63 92.75 106.66 68811 168.26 159.85 183.83 # 68020 90.90 86.36 99.31 68815 364.84 346.60 398.59 68040 54.41 51.69 59.44 # 68815 212.03 201.43 231.64 # 68040 45.19 42.93 49.37 68816 559.86 531.87 611.65 68100 142.10 135.00 155.25 # 68816 203.20 193.04 222.00 # 68100 82.19 78.08 89.79 68840 101.82 96.73 111.24 68110 184.92 175.67 202.02 # 68840 91.53