1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 1 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ G0101 34.76 33.02 37.97 G0270 25.15 23.89 27.47 G0102 18.76 17.82 20.49 # G0270 23.30 22.14 25.46 # G0102 8.41 7.99 9.19 G0271 12.72 12.08 13.89 G0104 126.37 120.05 138.06 G0275 13.46 12.79 14.71 # G0104 57.95 55.05 63.31 G0278 13.46 12.79 14.71 G0105 366.29 347.98 400.18 G0281 11.72 11.13 12.80 # G0105 202.07 191.97 220.77 G0283 11.72 11.13 12.80 G0105 53 126.19 119.88 137.86 G0288 103.74 98.55 113.33 # G0105 53 57.77 54.88 63.11 G0289 81.59 77.51 89.14 G0106 198.83 188.89 217.22 G0329 8.22 7.81 8.98 G0106 TC 149.97 142.47 163.84 G0339 3,958.14 3,760.23 4,324.26 G0106 26 48.86 46.42 53.38 G0340 2,687.41 2,553.04 2,936.00 G0108 23.85 22.66 26.06 G0341 787.87 748.48 860.75 G0109 13.12 12.46 14.33 G0342 643.74 611.55 703.28 G0117 45.86 43.57 50.11 G0343 1,076.63 1,022.80 1,176.22 G0118 32.45 30.83 35.45 G0364 11.75 11.16 12.83 C G0120 135.21 128.45 147.72 # G0364 8.42 8.00 9.20 C G0120 TC 86.36 82.04 94.35 C G0365 170.81 162.27 186.61 G0120 26 48.86 46.42 53.38 C G0365 TC 158.85 150.91 173.55 G0121 366.46 348.14 400.36 G0365 26 11.96 11.36 13.06 # G0121 202.24 192.13 220.95 G0372 10.63 10.10 11.62 G0121 53 126.73 120.39 138.45 # G0372 8.04 7.64 8.79 # G0121 53 58.30 55.39 63.70 G0389 107.96 102.56 117.94 G0124 27.04 25.69 29.54 G0389 TC 78.96 75.01 86.26 G0127 19.50 18.53 21.31 G0389 26 29.00 27.55 31.68 # G0127 8.04 7.64 8.79 G0396 31.66 30.08 34.59 G0128 8.55 8.12 9.34 # G0396 30.18 28.67 32.97 G0130 31.44 29.87 34.35 G0397 63.12 59.96 68.95 G0130 TC 20.89 19.85 22.83 # G0397 61.64 58.56 67.34 G0130 26 10.55 10.02 11.52 G0398 289.45 274.98 316.23 G0141 27.04 25.69 29.54 G0398 TC 205.81 195.52 224.85 G0166 148.75 141.31 162.51 G0398 26 83.64 79.46 91.38 G0168 79.69 75.71 87.07 G0399 207.56 197.18 226.76 # G0168 24.95 23.70 27.26 G0399 TC 129.59 123.11 141.58 G0179 38.83 36.89 42.42 G0399 26 77.97 74.07 85.18 G0180 51.40 48.83 56.15 G0400 186.80 177.46 204.08 G0181 99.95 94.95 109.19 G0400 TC 116.63 110.80 127.42 G0182 101.80 96.71 111.22 G0400 26 70.17 66.66 76.66 G0202 130.51 123.98 142.58 G0402 131.40 124.83 143.55 G0202 TC 96.34 91.52 105.25 G0403 19.68 18.70 21.51 G0202 26 34.16 32.45 37.32 # G0403 18.94 17.99 20.69 G0204 155.56 147.78 169.95 G0404 10.90 10.36 11.91 G0204 TC 112.99 107.34 123.44 G0405 8.78 8.34 9.59 G0204 26 42.57 40.44 46.51 # G0405 8.04 7.64 8.79 G0206 122.74 116.60 134.09 G0406 37.20 35.34 40.64 G0206 TC 88.58 84.15 96.77 G0407 67.04 63.69 73.24 G0206 26 34.16 32.45 37.32 G0408 96.17 91.36 105.06 G0237 9.79 9.30 10.70 G0409 8.68 8.25 9.49 G0238 10.53 10.00 11.50 G0412 640.08 608.08 699.29 G0239 11.27 10.71 12.32 G0413 939.97 892.97 1,026.92 G0245 64.38 61.16 70.33 G0414 891.45 846.88 973.91 # G0245 44.77 42.53 48.91 G0415 1,216.12 1,155.31 1,328.61 G0246 37.35 35.48 40.80 G0416 627.38 596.01 685.41 # G0246 22.56 21.43 24.64 G0416 TC 449.20 426.74 490.75 G0247 42.63 40.50 46.58 G0416 26 178.19 169.28 194.67 # G0247 24.50 23.28 26.77 G0417 1,218.68 1,157.75 1,331.41 G0248 142.21 135.10 155.37 G0417 TC 877.13 833.27 958.26 G0249 123.71 117.52 135.15 G0417 26 341.55 324.47 373.14 G0250 9.50 9.03 10.38 G0418 2,091.67 1,987.09 2,285.15 G0268 47.82 45.43 52.24 G0418 TC 1,498.14 1,423.23 1,636.71 # G0268 30.80 29.26 33.65 G0418 26 593.53 563.85 648.43 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 2 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ G0419 2,482.68 2,358.55 2,712.33 # 10160 87.76 83.37 95.88 G0419 TC 1,797.73 1,707.84 1,964.02 10180 211.10 200.55 230.63 G0419 26 684.95 650.70 748.31 # 10180 159.32 151.35 174.05 G0420 107.13 101.77 117.04 11000 48.19 45.78 52.65 G0421 25.26 24.00 27.60 # 11000 28.59 27.16 31.23 G0422 49.14 46.68 53.68 11001 19.84 18.85 21.68 G0423 49.14 46.68 53.68 # 11001 14.29 13.58 15.62 G0424 23.73 22.54 25.92 11004 542.92 515.77 593.14 # G0424 9.31 8.84 10.17 11005 716.15 680.34 782.39 G0425 96.47 91.65 105.40 11006 660.81 627.77 721.94 G0426 131.58 125.00 143.75 11008 251.53 238.95 274.79 G0427 193.68 184.00 211.60 11010 425.53 404.25 464.89 G9041 35.29 33.53 38.56 # 11010 255.39 242.62 279.01 G9042 18.26 17.35 19.95 11011 470.26 446.75 513.76 G9043 18.26 17.35 19.95 # 11011 273.86 260.17 299.20 G9044 15.69 14.91 17.15 11012 635.05 603.30 693.80 M0064 42.48 40.36 46.41 # 11012 393.15 373.49 429.51 # M0064 16.22 15.41 17.72 11040 42.63 40.50 46.58 P3001 27.04 25.69 29.54 # 11040 24.50 23.28 26.77 Q0035 18.20 17.29 19.88 11041 48.56 46.13 53.05 Q0035 TC 10.16 9.65 11.10 # 11041 30.06 28.56 32.84 Q0035 26 8.04 7.64 8.79 11042 66.70 63.37 72.88 Q0091 40.81 38.77 44.59 # 11042 40.81 38.77 44.59 # Q0091 17.88 16.99 19.54 11043 252.62 239.99 275.99 Q0092 18.30 17.39 20.00 # 11043 218.97 208.02 239.22 R0070 149.59 142.11 163.43 11044 347.03 329.68 379.13 R0075 149.59 142.11 163.43 # 11044 303.02 287.87 331.05 0073T 513.55 487.87 561.05 11055 44.04 41.84 48.12 0075T 1,099.30 1,044.34 1,200.99 # 11055 20.37 19.35 22.25 0075T 26 914.45 868.73 999.04 11056 53.17 50.51 58.09 0076T 362.78 344.64 396.34 # 11056 28.39 26.97 31.02 0076T 26 91.44 86.87 99.90 11057 63.78 60.59 69.68 0078T 1,243.36 1,181.19 1,358.37 # 11057 36.78 34.94 40.18 0079T 1,142.94 1,085.79 1,248.66 11100 94.79 90.05 103.56 0080T 222.15 211.04 242.70 # 11100 45.97 43.67 50.22 0081T 222.15 211.04 242.70 11101 30.37 28.85 33.18 0171T 706.18 670.87 771.50 # 11101 23.35 22.18 25.51 0172T 353.09 335.44 385.76 11200 76.28 72.47 83.34 0177T 1,221.08 1,160.03 1,334.03 # 11200 64.45 61.23 70.41 0187T 42.55 40.42 46.48 11201 17.08 16.23 18.66 10021 130.05 123.55 142.08 # 11201 15.60 14.82 17.04 # 10021 64.59 61.36 70.56 11300 62.20 59.09 67.95 10022 129.71 123.22 141.70 # 11300 27.80 26.41 30.37 # 10022 62.77 59.63 68.57 11301 84.92 80.67 92.77 10040 93.37 88.70 102.01 # 11301 47.56 45.18 51.96 # 10040 81.54 77.46 89.08 11302 101.59 96.51 110.99 10060 100.22 95.21 109.49 # 11302 58.69 55.76 64.12 # 10060 85.43 81.16 93.33 11303 119.02 113.07 130.03 10061 168.22 159.81 183.78 # 11303 68.72 65.28 75.07 # 10061 148.61 141.18 162.36 11305 63.05 59.90 68.89 10080 151.41 143.84 165.42 # 11305 33.09 31.44 36.16 # 10080 88.90 84.46 97.13 11306 87.10 82.75 95.16 10081 235.56 223.78 257.35 # 11306 51.59 49.01 56.36 # 10081 153.07 145.42 167.23 11307 103.29 98.13 112.85 10120 123.27 117.11 134.68 # 11307 61.87 58.78 67.60 # 10120 83.69 79.51 91.44 11308 114.32 108.60 124.89 10121 237.04 225.19 258.97 # 11308 72.16 68.55 78.83 # 10121 167.51 159.13 183.00 11310 77.17 73.31 84.31 10140 140.84 133.80 153.87 # 11310 40.18 38.17 43.90 # 10140 107.92 102.52 117.90 11311 97.52 92.64 106.54 10160 114.76 109.02 125.37 # 11311 59.06 56.11 64.53 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 3 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 11312 112.80 107.16 123.23 # 11604 193.01 183.36 210.86 # 11312 68.05 64.65 74.35 11606 391.94 372.34 428.19 11313 140.20 133.19 153.17 # 11606 284.68 270.45 311.02 # 11313 90.27 85.76 98.62 11620 168.64 160.21 184.24 11400 107.21 101.85 117.13 # 11620 106.88 101.54 116.77 # 11400 70.22 66.71 76.72 11621 204.33 194.11 223.23 11401 130.60 124.07 142.68 # 11621 136.27 129.46 148.88 # 11401 92.13 87.52 100.65 11622 230.21 218.70 251.51 11402 145.28 138.02 158.72 # 11622 156.61 148.78 171.10 # 11402 101.27 96.21 110.64 11623 268.58 255.15 293.42 11403 166.62 158.29 182.03 # 11623 192.39 182.77 210.19 # 11403 128.89 122.45 140.82 11624 301.17 286.11 329.03 11404 189.27 179.81 206.78 # 11624 217.58 206.70 237.71 # 11404 142.67 135.54 155.87 11626 363.62 345.44 397.26 11406 268.74 255.30 293.60 # 11626 268.94 255.49 293.81 # 11406 214.74 204.00 234.60 11640 175.43 166.66 191.66 11420 107.19 101.83 117.10 # 11640 111.81 106.22 122.15 # 11420 74.27 70.56 81.14 11641 213.60 202.92 233.36 11421 138.24 131.33 151.03 # 11641 144.07 136.87 157.40 # 11421 99.77 94.78 109.00 11642 245.57 233.29 268.28 11422 153.96 146.26 168.20 # 11642 169.75 161.26 185.45 # 11422 120.67 114.64 131.84 11643 288.39 273.97 315.07 11423 179.19 170.23 195.76 # 11643 211.46 200.89 231.02 # 11423 140.73 133.69 153.74 11644 354.31 336.59 387.08 11424 206.21 195.90 225.29 # 11644 261.85 248.76 286.07 # 11424 161.45 153.38 176.39 11646 464.00 440.80 506.92 11426 293.87 279.18 321.06 # 11646 365.62 347.34 399.44 # 11426 245.05 232.80 267.72 11719 19.50 18.53 21.31 11440 117.87 111.98 128.78 # 11719 8.04 7.64 8.79 # 11440 90.50 85.98 98.88 11720 27.95 26.55 30.53 11441 148.48 141.06 162.22 # 11720 15.00 14.25 16.39 # 11441 117.41 111.54 128.27 11721 39.23 37.27 42.86 11442 166.75 158.41 182.17 # 11721 25.55 24.27 27.91 # 11442 130.50 123.98 142.58 11730 87.68 83.30 95.80 11443 198.87 188.93 217.27 # 11730 51.43 48.86 56.19 # 11443 160.41 152.39 175.25 11732 40.29 38.28 44.02 11444 250.86 238.32 274.07 # 11732 26.98 25.63 29.47 # 11444 204.99 194.74 223.95 11740 41.55 39.47 45.39 11446 342.41 325.29 374.08 # 11740 28.97 27.52 31.65 # 11446 290.63 276.10 317.52 11750 196.67 186.84 214.87 11450 321.76 305.67 351.52 # 11750 160.80 152.76 175.67 # 11450 215.98 205.18 235.96 11752 280.92 266.87 306.90 11451 415.09 394.34 453.49 # 11752 241.71 229.62 264.06 # 11451 281.20 267.14 307.21 11755 120.24 114.23 131.36 11462 318.08 302.18 347.51 # 11755 76.60 72.77 83.69 # 11462 208.23 197.82 227.49 11760 188.07 178.67 205.47 11463 426.01 404.71 465.42 # 11760 119.65 113.67 130.72 # 11463 286.20 271.89 312.67 11762 243.61 231.43 266.14 11470 351.77 334.18 384.31 # 11762 177.78 168.89 194.22 # 11470 244.50 232.28 267.12 11765 120.82 114.78 132.00 11471 437.08 415.23 477.51 # 11765 62.76 59.62 68.56 # 11471 303.56 288.38 331.64 11770 236.01 224.21 257.84 11600 165.33 157.06 180.62 # 11770 161.66 153.58 176.62 # 11600 105.04 99.79 114.76 11771 487.12 462.76 532.17 11601 202.49 192.37 221.23 # 11771 378.38 359.46 413.38 # 11601 134.81 128.07 147.28 11772 589.44 559.97 643.97 11602 221.76 210.67 242.27 # 11772 495.86 471.07 541.73 # 11602 148.52 141.09 162.25 11900 51.45 48.88 56.21 11603 252.06 239.46 275.38 # 11900 29.26 27.80 31.97 # 11603 176.24 167.43 192.54 11901 65.22 61.96 71.25 11604 278.08 264.18 303.81 # 11901 45.61 43.33 49.83 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 4 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 11920 161.44 153.37 176.38 # 12034 185.76 176.47 202.94 # 11920 104.85 99.61 114.55 12035 333.56 316.88 364.41 11921 184.74 175.50 201.83 # 12035 215.21 204.45 235.12 # 11921 123.35 117.18 134.76 12036 363.36 345.19 396.97 11922 55.19 52.43 60.29 # 12036 245.74 233.45 268.47 # 11922 27.82 26.43 30.39 12037 407.79 387.40 445.51 11950 68.48 65.06 74.82 # 12037 285.36 271.09 311.75 # 11950 47.40 45.03 51.78 12041 227.96 216.56 249.04 11951 93.18 88.52 101.80 # 12041 155.84 148.05 170.26 # 11951 66.55 63.22 72.70 12042 263.77 250.58 288.17 11952 124.18 117.97 135.67 # 12042 182.40 173.28 199.27 # 11952 91.26 86.70 99.71 12044 308.01 292.61 336.50 11954 146.05 138.75 159.56 # 12044 194.09 184.39 212.05 # 11954 105.37 100.10 115.12 12045 334.89 318.15 365.87 11960 838.87 796.93 916.47 # 12045 222.45 211.33 243.03 11970 548.19 520.78 598.90 12046 408.69 388.26 446.50 11971 422.07 400.97 461.12 # 12046 267.40 254.03 292.13 # 11971 282.63 268.50 308.78 12047 435.74 413.95 476.04 11976 134.17 127.46 146.58 # 12047 294.08 279.38 321.29 # 11976 88.67 84.24 96.88 12051 242.77 230.63 265.22 11980 95.86 91.07 104.73 # 12051 166.21 157.90 181.59 # 11980 75.52 71.74 82.50 12052 277.50 263.63 303.17 11981 124.15 117.94 135.63 # 12052 198.35 188.43 216.69 # 11981 78.66 74.73 85.94 12053 304.90 289.66 333.11 11982 140.48 133.46 153.48 # 12053 197.64 187.76 215.92 # 11982 94.62 89.89 103.37 12054 322.27 306.16 352.08 11983 214.71 203.97 234.57 # 12054 208.35 197.93 227.62 # 11983 172.18 163.57 188.11 12055 385.88 366.59 421.58 12001 135.71 128.92 148.26 # 12055 251.99 239.39 275.30 # 12001 95.40 90.63 104.22 12056 453.04 430.39 494.95 12002 144.12 136.91 157.45 # 12056 292.14 277.53 319.16 # 12002 105.65 100.37 115.43 12057 501.56 476.48 547.95 12004 168.99 160.54 184.62 # 12057 346.22 328.91 378.25 # 12004 123.50 117.33 134.93 13100 285.67 271.39 312.10 12005 210.09 199.59 229.53 # 13100 215.40 204.63 235.32 # 12005 152.76 145.12 166.89 13101 362.00 343.90 395.49 12006 259.94 246.94 283.98 # 13101 262.88 249.74 287.20 # 12006 192.62 182.99 210.44 13102 97.36 92.49 106.36 12007 291.71 277.12 318.69 # 13102 68.88 65.44 75.26 # 12007 218.11 207.20 238.28 13120 296.65 281.82 324.09 12011 144.11 136.90 157.44 # 13120 225.27 214.01 246.11 # 12011 98.24 93.33 107.33 13121 403.21 383.05 440.51 12013 158.69 150.76 173.37 # 13121 300.76 285.72 328.58 # 12013 112.09 106.49 122.46 13122 108.12 102.71 118.12 12014 185.81 176.52 203.00 # 13122 78.53 74.60 85.79 # 12014 133.66 126.98 146.03 13131 327.65 311.27 357.96 12015 232.83 221.19 254.37 # 13131 254.42 241.70 277.96 # 12015 166.99 158.64 182.44 13132 529.93 503.43 578.94 12016 277.06 263.21 302.69 # 13132 433.76 412.07 473.88 # 12016 202.72 192.58 221.47 13133 153.64 145.96 167.85 12017 237.43 225.56 259.39 # 13133 122.94 116.79 134.31 12018 287.81 273.42 314.43 13150 325.56 309.28 355.67 12020 242.69 230.56 265.14 # 13150 252.33 239.71 275.67 # 12020 170.20 161.69 185.94 13151 371.47 352.90 405.84 12021 142.50 135.38 155.69 # 13151 294.17 279.46 321.38 # 12021 123.63 117.45 135.07 13152 512.89 487.25 560.34 12031 217.98 207.08 238.14 # 13152 394.90 375.16 431.43 # 12031 146.22 138.91 159.75 13153 168.29 159.88 183.86 12032 278.28 264.37 304.03 # 13153 132.41 125.79 144.66 # 12032 179.15 170.19 195.72 13160 734.55 697.82 802.49 12034 274.90 261.16 300.33 14000 562.57 534.44 614.61 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 5 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 14000 460.85 437.81 503.48 15155 628.36 596.94 686.48 14001 727.64 691.26 794.95 # 15155 585.09 555.84 639.22 # 14001 607.80 577.41 664.02 15156 159.44 151.47 174.19 14020 632.70 601.07 691.23 # 15156 150.94 143.39 164.90 # 14020 526.55 500.22 575.25 15157 167.56 159.18 183.06 14021 797.30 757.44 871.06 # 15157 156.09 148.29 170.53 # 14021 675.25 641.49 737.71 15170 388.61 369.18 424.56 14040 700.86 665.82 765.69 # 15170 334.60 317.87 365.55 # 14040 596.18 566.37 651.33 15171 85.53 81.25 93.44 14041 870.73 827.19 951.27 # 15171 80.72 76.68 88.18 # 14041 735.36 698.59 803.38 15175 479.32 455.35 523.65 14060 711.80 676.21 777.64 # 15175 428.65 407.22 468.30 # 14060 629.32 597.85 687.53 15176 135.06 128.31 147.56 14061 934.34 887.62 1,020.76 # 15176 126.56 120.23 138.26 # 14061 786.03 746.73 858.74 15200 733.63 696.95 801.49 14301 1,004.54 954.31 1,097.46 # 15200 603.07 572.92 658.86 # 14301 842.54 800.41 920.47 15201 133.09 126.44 145.41 14302 216.83 205.99 236.89 # 15201 72.07 68.47 78.74 14350 678.27 644.36 741.01 15220 694.63 659.90 758.89 15002 301.45 286.38 329.34 # 15220 566.28 537.97 618.67 # 15002 206.39 196.07 225.48 15221 124.07 117.87 135.55 15003 65.38 62.11 71.43 # 15221 66.74 63.40 72.91 # 15003 41.71 39.62 45.56 15240 840.30 798.29 918.03 15004 360.03 342.03 393.33 # 15240 732.30 695.69 800.04 # 15004 254.25 241.54 277.77 15241 166.57 158.24 181.98 15005 109.31 103.84 119.42 # 15241 104.43 99.21 114.09 # 15005 82.68 78.55 90.33 15260 914.47 868.75 999.06 15040 230.49 218.97 251.82 # 15260 796.11 756.30 869.75 # 15040 117.31 111.44 128.16 15261 194.98 185.23 213.01 15050 497.58 472.70 543.61 # 15261 132.85 126.21 145.14 # 15050 405.12 384.86 442.59 15300 311.93 296.33 340.78 15100 778.12 739.21 850.09 # 15300 264.58 251.35 289.05 # 15100 650.51 617.98 710.68 15301 57.45 54.58 62.77 15101 169.94 161.44 185.66 # 15301 52.64 50.01 57.51 # 15101 102.25 97.14 111.71 15320 344.12 326.91 375.95 15110 767.58 729.20 838.58 # 15320 292.71 278.07 319.78 # 15110 668.82 635.38 730.69 15321 85.43 81.16 93.33 15111 108.86 103.42 118.93 # 15321 79.14 75.18 86.46 # 15111 97.39 92.52 106.40 15330 287.89 273.50 314.53 15115 777.40 738.53 849.31 # 15330 239.81 227.82 261.99 # 15115 690.48 655.96 754.35 15331 57.45 54.58 62.77 15116 151.21 143.65 165.20 # 15331 53.01 50.36 57.91 # 15116 137.53 130.65 150.25 15335 293.68 279.00 320.85 15120 856.16 813.35 935.35 # 15335 247.07 234.72 269.93 # 15120 718.56 682.63 785.02 15336 75.29 71.53 82.26 15121 240.80 228.76 263.07 # 15336 68.26 64.85 74.58 # 15121 156.47 148.65 170.95 15340 286.64 272.31 313.16 15130 606.16 575.85 662.23 # 15340 245.59 233.31 268.31 # 15130 508.89 483.45 555.97 15341 42.61 40.48 46.55 15131 87.46 83.09 95.55 # 15341 24.49 23.27 26.76 # 15131 78.95 75.00 86.25 15360 326.78 310.44 357.01 15135 781.86 742.77 854.19 # 15360 278.33 264.41 304.07 # 15135 697.53 662.65 762.05 15361 64.24 61.03 70.18 15136 79.25 75.29 86.58 # 15361 57.58 54.70 62.91 # 15136 73.70 70.02 80.52 15365 316.25 300.44 345.51 15150 629.12 597.66 687.31 # 15365 272.61 258.98 297.83 # 15150 576.97 548.12 630.34 15366 76.53 72.70 83.61 15151 113.59 107.91 124.10 # 15366 69.87 66.38 76.34 # 15151 104.71 99.47 114.39 15400 362.43 344.31 395.96 15152 145.66 138.38 159.14 # 15400 323.23 307.07 353.13 # 15152 135.68 128.90 148.24 15401 83.15 78.99 90.84 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 6 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 15401 52.08 49.48 56.90 # 15788 220.75 209.71 241.17 15420 401.56 381.48 438.70 15789 512.06 486.46 559.43 # 15420 355.33 337.56 388.19 # 15789 389.63 370.15 425.67 15421 103.92 98.72 113.53 15792 385.74 366.45 421.42 # 15421 78.03 74.13 85.25 # 15792 238.90 226.96 261.00 15430 485.39 461.12 530.29 15793 436.94 415.09 477.35 # 15430 466.90 443.56 510.09 # 15793 330.79 314.25 361.39 15570 799.94 759.94 873.93 15819 679.55 645.57 742.41 # 15570 652.36 619.74 712.70 15820 500.34 475.32 546.62 15572 777.46 738.59 849.38 # 15820 453.74 431.05 495.71 # 15572 663.18 630.02 724.52 15821 533.01 506.36 582.31 15574 819.25 778.29 895.03 # 15821 481.60 457.52 526.15 # 15574 698.67 663.74 763.30 15822 388.76 369.32 424.72 15576 729.64 693.16 797.13 # 15822 344.00 326.80 375.82 # 15576 616.09 585.29 673.08 15823 620.56 589.53 677.96 15600 295.20 280.44 322.51 # 15823 571.37 542.80 624.22 # 15600 184.98 175.73 202.09 15830 1,050.65 998.12 1,147.84 15610 302.10 287.00 330.05 15832 812.22 771.61 887.35 # 15610 217.03 206.18 237.11 15833 775.60 736.82 847.34 15620 397.30 377.44 434.06 15834 774.39 735.67 846.02 # 15620 292.26 277.65 319.30 15835 820.13 779.12 895.99 15630 419.86 398.87 458.70 15836 665.01 631.76 726.52 # 15630 318.52 302.59 347.98 15837 705.60 670.32 770.87 15650 464.90 441.66 507.91 # 15837 606.11 575.80 662.17 # 15650 355.42 337.65 388.30 15838 531.61 505.03 580.78 15731 1,035.80 984.01 1,131.61 15839 778.82 739.88 850.86 # 15731 937.05 890.20 1,023.73 # 15839 661.94 628.84 723.17 15732 1,362.26 1,294.15 1,488.27 15840 934.58 887.85 1,021.03 # 15732 1,213.95 1,153.25 1,326.24 15841 1,527.05 1,450.70 1,668.31 15734 1,386.89 1,317.55 1,515.18 15842 2,333.11 2,216.45 2,548.92 # 15734 1,229.32 1,167.85 1,343.03 15845 893.07 848.42 975.68 15736 1,217.02 1,156.17 1,329.60 15851 85.64 81.36 93.56 # 15736 1,052.43 999.81 1,149.78 # 15851 42.74 40.60 46.69 15738 1,298.04 1,233.14 1,418.11 15852 43.83 41.64 47.89 # 15738 1,145.66 1,088.38 1,251.64 15860 105.00 99.75 114.71 15740 933.44 886.77 1,019.79 15920 536.74 509.90 586.39 # 15740 801.03 760.98 875.13 15922 664.66 631.43 726.14 15750 837.33 795.46 914.78 15931 606.34 576.02 662.42 15756 2,165.11 2,056.85 2,365.38 15933 750.24 712.73 819.64 15757 2,153.17 2,045.51 2,352.34 15934 830.34 788.82 907.14 15758 2,143.39 2,036.22 2,341.65 15935 990.40 940.88 1,082.01 15760 771.17 732.61 842.50 15936 802.03 761.93 876.22 # 15760 651.70 619.12 711.99 15937 937.13 890.27 1,023.81 15770 604.68 574.45 660.62 15940 621.47 590.40 678.96 15775 280.09 266.09 306.00 15941 811.86 771.27 886.96 # 15775 205.00 194.75 223.96 15944 798.86 758.92 872.76 15776 388.05 368.65 423.95 15945 887.22 842.86 969.29 # 15776 290.41 275.89 317.27 15946 1,479.03 1,405.08 1,615.84 15780 755.27 717.51 825.14 15950 516.70 490.87 564.50 # 15780 589.20 559.74 643.70 15951 730.65 694.12 798.24 15781 490.40 465.88 535.76 15952 765.34 727.07 836.13 # 15781 394.60 374.87 431.10 15953 872.94 829.29 953.68 15782 522.85 496.71 571.22 15956 1,034.14 982.43 1,129.79 # 15782 381.93 362.83 417.25 15958 1,056.04 1,003.24 1,153.73 15783 443.38 421.21 484.39 16000 62.66 59.53 68.46 # 15783 342.41 325.29 374.08 # 16000 43.06 40.91 47.05 15786 220.78 209.74 241.20 16020 74.64 70.91 81.55 # 15786 128.68 122.25 140.59 # 16020 52.08 49.48 56.90 15787 44.75 42.51 48.89 16025 133.68 127.00 146.05 # 15787 17.01 16.16 18.58 # 16025 105.94 100.64 115.74 15788 397.17 377.31 433.91 16030 160.46 152.44 175.31 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 7 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 16030 120.14 114.13 131.25 17313 570.32 541.80 623.07 16035 191.29 181.73 208.99 # 17313 320.66 304.63 350.32 16036 77.13 73.27 84.26 17314 346.73 329.39 378.80 17000 73.24 69.58 80.02 # 17314 176.22 167.41 192.52 # 17000 51.05 48.50 55.78 17315 74.90 71.16 81.83 17003 6.72 6.38 7.34 # 17315 50.12 47.61 54.75 # 17003 4.13 3.92 4.51 17340 45.29 43.03 49.48 17004 159.60 151.62 174.36 # 17340 43.44 41.27 47.46 # 17004 124.47 118.25 135.99 17360 120.87 114.83 132.05 17106 313.11 297.45 342.07 # 17360 93.13 88.47 101.74 # 17106 255.42 242.65 279.05 19000 102.51 97.38 111.99 17107 407.94 387.54 445.67 # 19000 42.22 40.11 46.13 # 17107 331.75 315.16 362.43 19001 25.18 23.92 27.51 17108 570.53 542.00 623.30 # 19001 21.11 20.05 23.06 # 17108 479.17 455.21 523.49 19020 399.67 379.69 436.64 17110 100.53 95.50 109.83 # 19020 263.19 250.03 287.53 # 17110 63.18 60.02 69.02 19030 155.55 147.77 169.94 17111 119.49 113.52 130.55 # 19030 76.40 72.58 83.47 # 17111 78.43 74.51 85.69 19100 128.92 122.47 140.84 17250 68.13 64.72 74.43 # 19100 63.08 59.93 68.92 # 17250 32.99 31.34 36.04 19101 293.81 279.12 320.99 17260 87.51 83.13 95.60 # 19101 195.43 185.66 213.51 # 17260 63.09 59.94 68.93 19102 203.95 193.75 222.81 17261 130.34 123.82 142.39 # 19102 99.65 94.67 108.87 # 17261 84.85 80.61 92.70 19103 518.97 493.02 566.97 17262 158.50 150.58 173.17 # 19103 183.87 174.68 200.88 # 17262 108.56 103.13 118.60 19105 1,988.30 1,888.89 2,172.22 17263 174.79 166.05 190.96 # 19105 184.46 175.24 201.53 # 17263 119.67 113.69 130.74 19110 413.95 393.25 452.24 17264 187.10 177.75 204.41 # 19110 295.59 280.81 322.93 # 17264 127.92 121.52 139.75 19112 388.96 369.51 424.94 17266 212.31 201.69 231.94 # 19112 267.65 254.27 292.41 # 17266 149.07 141.62 162.86 19120 423.03 401.88 462.16 17270 136.00 129.20 148.58 # 19120 359.41 341.44 392.66 # 17270 91.99 87.39 100.50 19125 469.22 445.76 512.62 17271 149.22 141.76 163.02 # 19125 399.69 379.71 436.67 # 17271 102.99 97.84 112.52 19126 145.63 138.35 159.10 17272 170.75 162.21 186.54 19260 1,090.32 1,035.80 1,191.17 # 17272 119.34 113.37 130.38 19271 1,489.80 1,415.31 1,627.61 17273 190.43 180.91 208.05 19272 1,645.75 1,563.46 1,797.98 # 17273 134.58 127.85 147.03 19290 152.29 144.68 166.38 17274 225.39 214.12 246.24 # 19290 63.52 60.34 69.39 # 17274 165.10 156.85 180.38 19291 65.33 62.06 71.37 17276 260.41 247.39 284.50 # 19291 31.30 29.74 34.20 # 17276 197.53 187.65 215.80 19295 85.99 81.69 93.94 17280 127.38 121.01 139.16 19296 3,678.69 3,494.76 4,018.97 # 17280 83.74 79.55 91.48 # 19296 190.48 180.96 208.10 17281 161.95 153.85 176.93 19297 85.61 81.33 93.53 # 17281 116.09 110.29 126.83 19298 1,196.72 1,136.88 1,307.41 17282 187.49 178.12 204.84 # 19298 310.52 294.99 339.24 # 17282 134.60 127.87 147.05 19300 451.66 429.08 493.44 17283 226.04 214.74 246.95 # 19300 352.16 334.55 384.73 # 17283 167.98 159.58 183.52 19301 566.45 538.13 618.85 17284 262.80 249.66 287.11 19302 787.03 747.68 859.83 # 17284 199.92 189.92 218.41 19303 876.83 832.99 957.94 17286 331.54 314.96 362.20 19304 499.03 474.08 545.19 # 17286 267.55 254.17 292.30 19305 994.42 944.70 1,086.41 17311 624.71 593.47 682.49 19306 1,045.04 992.79 1,141.71 # 17311 357.30 339.44 390.36 19307 1,048.21 995.80 1,145.17 17312 373.87 355.18 408.46 19316 699.86 664.87 764.60 # 17312 190.05 180.55 207.63 19318 1,014.97 964.22 1,108.85 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 8 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 19324 435.37 413.60 475.64 # 20551 39.79 37.80 43.47 19325 583.53 554.35 637.50 20552 48.27 45.86 52.74 19328 444.49 422.27 485.61 # 20552 34.21 32.50 37.38 19330 568.54 540.11 621.13 20553 54.96 52.21 60.04 19340 703.60 668.42 768.68 # 20553 38.31 36.39 41.85 19342 836.12 794.31 913.46 20555 313.43 297.76 342.42 19350 758.41 720.49 828.56 20600 49.75 47.26 54.35 # 19350 611.57 580.99 668.14 # 20600 36.43 34.61 39.80 19355 638.23 606.32 697.27 20605 53.59 50.91 58.55 # 19355 512.47 486.85 559.88 # 20605 38.06 36.16 41.58 19357 1,413.36 1,342.69 1,544.09 20610 70.22 66.71 76.72 19361 1,521.78 1,445.69 1,662.54 # 20610 45.81 43.52 50.05 19364 2,533.52 2,406.84 2,767.87 20612 53.37 50.70 58.31 19366 1,250.43 1,187.91 1,366.10 # 20612 39.31 37.34 42.94 19367 1,642.16 1,560.05 1,794.06 20615 197.28 187.42 215.53 19368 2,028.04 1,926.64 2,215.64 # 20615 145.49 138.22 158.95 19369 1,867.57 1,774.19 2,040.32 20650 178.30 169.39 194.80 19370 618.87 587.93 676.12 # 20650 141.32 134.25 154.39 19371 709.57 674.09 775.20 20660 217.81 206.92 237.96 19380 698.09 663.19 762.67 20661 427.78 406.39 467.35 19396 211.31 200.74 230.85 20662 420.95 399.90 459.89 # 19396 120.69 114.66 131.86 20663 406.94 386.59 444.58 20000 185.15 175.89 202.27 20664 717.45 681.58 783.82 # 20000 140.40 133.38 153.39 20665 107.39 102.02 117.32 20005 275.34 261.57 300.81 # 20665 90.01 85.51 98.34 # 20005 215.43 204.66 235.36 20670 355.52 337.74 388.40 20100 541.53 514.45 591.62 # 20670 135.45 128.68 147.98 20101 357.22 339.36 390.26 20680 545.49 518.22 595.95 # 20101 183.02 173.87 199.95 # 20680 383.12 363.96 418.55 20102 423.46 402.29 462.63 20690 514.36 488.64 561.94 # 20102 227.06 215.71 248.07 20692 966.14 917.83 1,055.50 20103 510.47 484.95 557.69 20693 414.03 393.33 452.33 # 20103 318.88 302.94 348.38 20694 382.67 363.54 418.07 20150 865.17 821.91 945.20 # 20694 304.63 289.40 332.81 20200 174.81 166.07 190.98 20696 954.50 906.78 1,042.80 # 20200 84.19 79.98 91.98 20697 1,297.30 1,232.44 1,417.31 20205 240.37 228.35 262.60 20802 2,211.11 2,100.55 2,415.63 # 20205 136.07 129.27 148.66 20805 2,849.50 2,707.03 3,113.08 20206 237.27 225.41 259.22 20808 3,793.47 3,603.80 4,144.37 # 20206 58.62 55.69 64.04 20816 1,997.86 1,897.97 2,182.67 20220 159.32 151.35 174.05 20822 1,718.77 1,632.83 1,877.75 # 20220 72.77 69.13 79.50 20824 2,019.94 1,918.94 2,206.78 20225 600.65 570.62 656.21 20827 1,794.48 1,704.76 1,960.47 # 20225 109.09 103.64 119.19 20838 2,300.18 2,185.17 2,512.95 20240 206.89 196.55 226.03 20900 373.21 354.55 407.73 20245 571.22 542.66 624.06 # 20900 222.30 211.19 242.87 20250 338.60 321.67 369.92 20902 308.70 293.27 337.26 20251 373.38 354.71 407.92 20910 391.59 372.01 427.81 20500 104.19 98.98 113.83 20912 446.21 423.90 487.49 # 20500 84.96 80.71 92.82 20920 371.65 353.07 406.03 20501 118.38 112.46 129.33 20922 554.90 527.16 606.23 # 20501 38.12 36.21 41.64 # 20922 457.99 435.09 500.35 20520 174.85 166.11 191.03 20924 457.33 434.46 499.63 # 20520 130.84 124.30 142.95 20926 397.96 378.06 434.77 20525 423.70 402.52 462.90 20931 101.07 96.02 110.42 # 20525 225.08 213.83 245.90 20937 154.70 146.97 169.02 20526 68.11 64.70 74.41 20938 168.12 159.71 183.67 # 20526 52.58 49.95 57.44 20950 223.08 211.93 243.72 20550 52.74 50.10 57.62 # 20950 82.17 78.06 89.77 # 20550 38.31 36.39 41.85 20955 2,341.53 2,224.45 2,558.12 20551 53.11 50.45 58.02 20956 2,410.10 2,289.60 2,633.04 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 9 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 20957 2,345.88 2,228.59 2,562.88 # 21082 1,203.05 1,142.90 1,314.34 20962 2,375.94 2,257.14 2,595.71 21083 1,339.27 1,272.31 1,463.16 20969 2,602.96 2,472.81 2,843.73 # 21083 1,100.34 1,045.32 1,202.12 20970 2,597.86 2,467.97 2,838.17 21084 1,564.78 1,486.54 1,709.52 20972 2,254.06 2,141.36 2,462.56 # 21084 1,301.44 1,236.37 1,421.83 20973 2,417.91 2,297.01 2,641.56 21085 653.28 620.62 713.71 20974 61.06 58.01 66.71 # 21085 542.32 515.20 592.48 # 20974 43.67 41.49 47.71 21086 1,558.70 1,480.77 1,702.89 20975 160.06 152.06 174.87 # 21086 1,397.44 1,327.57 1,526.71 20979 47.77 45.38 52.19 21087 1,557.59 1,479.71 1,701.67 # 20979 31.87 30.28 34.82 # 21087 1,396.70 1,326.87 1,525.90 20982 3,419.39 3,248.42 3,735.68 21100 654.97 622.22 715.55 # 20982 372.80 354.16 407.28 # 21100 366.11 347.80 399.97 20985 136.05 129.25 148.64 21110 693.55 658.87 757.70 21010 676.68 642.85 739.28 # 21110 587.40 558.03 641.73 21011 303.01 287.86 331.04 21116 139.75 132.76 152.67 # 21011 234.58 222.85 256.28 # 21116 40.63 38.60 44.39 21012 318.98 303.03 348.48 21120 575.96 547.16 629.23 21013 467.53 444.15 510.77 # 21120 461.67 438.59 504.38 # 21013 375.43 356.66 410.16 21121 695.14 660.38 759.44 21014 491.77 467.18 537.26 # 21121 588.25 558.84 642.67 21015 566.48 538.16 618.88 21122 631.14 599.58 689.52 21016 979.01 930.06 1,069.57 21123 782.11 743.00 854.45 21025 805.17 764.91 879.65 21125 2,918.28 2,772.37 3,188.23 # 21025 683.12 648.96 746.30 # 21125 711.65 676.07 777.48 21026 545.49 518.22 595.95 21127 3,390.80 3,221.26 3,704.45 # 21026 448.58 426.15 490.07 # 21127 785.83 746.54 858.52 21029 690.29 655.78 754.15 21137 668.60 635.17 730.45 # 21029 581.92 552.82 635.74 21138 816.27 775.46 891.78 21030 455.25 432.49 497.36 21139 898.43 853.51 981.54 # 21030 372.40 353.78 406.85 21141 1,246.69 1,184.36 1,362.01 21031 345.79 328.50 377.78 21142 1,251.94 1,189.34 1,367.74 # 21031 262.20 249.09 286.45 21143 1,287.04 1,222.69 1,406.09 21032 351.28 333.72 383.78 21145 1,411.05 1,340.50 1,541.58 # 21032 259.18 246.22 283.15 21146 1,541.01 1,463.96 1,683.55 21034 1,215.29 1,154.53 1,327.71 21147 1,563.11 1,484.95 1,707.69 # 21034 1,077.70 1,023.82 1,177.39 21150 1,496.09 1,421.29 1,634.48 21040 458.96 436.01 501.41 21151 1,851.66 1,759.08 2,022.94 # 21040 370.93 352.38 405.24 21154 1,894.99 1,800.24 2,070.28 21044 813.44 772.77 888.69 21155 2,054.93 1,952.18 2,245.01 21045 1,133.20 1,076.54 1,238.02 21159 2,485.95 2,361.65 2,715.90 21046 996.81 946.97 1,089.02 21160 2,575.23 2,446.47 2,813.44 21047 1,197.35 1,137.48 1,308.10 21172 1,636.11 1,554.30 1,787.45 21048 1,015.01 964.26 1,108.90 21175 2,034.63 1,932.90 2,222.84 21049 1,160.52 1,102.49 1,267.86 21179 1,344.54 1,277.31 1,468.91 21050 796.92 757.07 870.63 21180 1,498.53 1,423.60 1,637.14 21060 736.98 700.13 805.15 21181 636.54 604.71 695.42 21070 582.21 553.10 636.07 21182 1,860.98 1,767.93 2,033.12 21073 338.95 322.00 370.30 21183 2,110.18 2,004.67 2,305.37 # 21073 225.77 214.48 246.65 21184 2,218.87 2,107.93 2,424.12 21076 869.64 826.16 950.08 21188 1,531.30 1,454.74 1,672.95 # 21076 754.61 716.88 824.41 21193 1,124.15 1,067.94 1,228.13 21077 2,146.65 2,039.32 2,345.22 21194 1,299.80 1,234.81 1,420.03 # 21077 1,915.12 1,819.36 2,092.26 21195 1,239.94 1,177.94 1,354.63 21079 1,470.39 1,396.87 1,606.40 21196 1,346.05 1,278.75 1,470.56 # 21079 1,266.59 1,203.26 1,383.75 21198 1,062.43 1,009.31 1,160.71 21080 1,664.54 1,581.31 1,818.51 21199 949.08 901.63 1,036.87 # 21080 1,418.21 1,347.30 1,549.40 21206 1,080.28 1,026.27 1,180.21 21081 1,525.14 1,448.88 1,666.21 21208 1,635.81 1,554.02 1,787.12 # 21081 1,296.56 1,231.73 1,416.49 # 21208 772.91 734.26 844.40 21082 1,423.13 1,351.97 1,554.77 21209 771.55 732.97 842.92 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 10 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 21209 603.26 573.10 659.07 21365 1,018.77 967.83 1,113.00 21210 1,936.28 1,839.47 2,115.39 21366 1,131.85 1,075.26 1,236.55 # 21210 765.65 727.37 836.48 21385 648.28 615.87 708.25 21215 3,347.83 3,180.44 3,657.51 21386 609.28 578.82 665.64 # 21215 804.62 764.39 879.05 21387 683.62 649.44 746.86 21230 712.68 677.05 778.61 21390 718.29 682.38 784.74 21235 666.71 633.37 728.38 21395 872.98 829.33 953.73 # 21235 525.42 499.15 574.02 21400 164.24 156.03 179.43 21240 1,008.65 958.22 1,101.95 # 21400 134.65 127.92 147.11 21242 929.22 882.76 1,015.17 21401 431.58 410.00 471.50 21243 1,533.98 1,457.28 1,675.87 # 21401 272.53 258.90 297.74 21244 970.34 921.82 1,060.09 21406 489.92 465.42 535.23 21245 1,040.26 988.25 1,136.49 21407 589.44 559.97 643.97 # 21245 841.27 799.21 919.09 21408 811.24 770.68 886.28 21246 777.43 738.56 849.34 21421 683.49 649.32 746.72 21247 1,485.66 1,411.38 1,623.09 # 21421 579.19 550.23 632.76 21248 979.51 930.53 1,070.11 21422 609.95 579.45 666.37 # 21248 807.52 767.14 882.21 21423 729.69 693.21 797.19 21249 1,345.83 1,278.54 1,470.32 21431 693.00 658.35 757.10 # 21249 1,138.70 1,081.77 1,244.04 21432 614.64 583.91 671.50 21255 1,294.58 1,229.85 1,414.33 21433 1,550.37 1,472.85 1,693.78 21256 1,089.36 1,034.89 1,190.12 21435 1,218.11 1,157.20 1,330.78 21260 1,177.34 1,118.47 1,286.24 21436 1,843.23 1,751.07 2,013.73 21261 2,083.60 1,979.42 2,276.33 21440 495.98 471.18 541.86 21263 1,815.03 1,724.28 1,982.92 # 21440 410.54 390.01 448.51 21267 1,453.91 1,381.21 1,588.39 21445 686.62 652.29 750.13 21268 1,813.31 1,722.64 1,981.04 # 21445 564.56 536.33 616.78 21270 850.58 808.05 929.26 21450 517.56 491.68 565.43 # 21270 657.88 624.99 718.74 # 21450 429.16 407.70 468.86 21275 751.41 713.84 820.92 21451 670.64 637.11 732.68 21280 503.66 478.48 550.25 # 21451 568.56 540.13 621.15 21282 333.12 316.46 363.93 21452 540.31 513.29 590.28 21295 163.35 155.18 178.46 # 21452 307.29 291.93 335.72 21296 396.37 376.55 433.03 21453 783.90 744.71 856.42 21310 100.17 95.16 109.43 # 21453 689.95 655.45 753.77 # 21310 26.56 25.23 29.01 21454 509.81 484.32 556.97 21315 242.66 230.53 265.11 21461 1,797.62 1,707.74 1,963.90 # 21315 137.25 130.39 149.95 # 21461 846.32 804.00 924.60 21320 230.38 218.86 251.69 21462 1,924.86 1,828.62 2,102.91 # 21320 126.08 119.78 137.75 # 21462 930.65 884.12 1,016.74 21325 433.93 412.23 474.06 21465 845.99 803.69 924.24 21330 524.30 498.09 572.80 21470 1,095.71 1,040.92 1,197.06 21335 677.66 643.78 740.35 21480 82.73 78.59 90.38 21336 593.64 563.96 648.55 # 21480 29.84 28.35 32.60 21337 361.88 343.79 395.36 21485 605.92 575.62 661.96 # 21337 266.08 252.78 290.70 # 21485 514.57 488.84 562.17 21338 676.65 642.82 739.24 21490 842.95 800.80 920.92 21339 757.05 719.20 827.08 21495 639.50 607.53 698.66 21340 728.44 692.02 795.82 21497 609.86 579.37 666.28 21343 1,076.18 1,022.37 1,175.73 # 21497 520.35 494.33 568.48 21344 1,438.35 1,366.43 1,571.39 21501 402.40 382.28 439.62 21345 731.44 694.87 799.10 # 21501 291.07 276.52 318.00 # 21345 597.92 568.02 653.22 21502 478.82 454.88 523.11 21346 865.36 822.09 945.40 21510 420.07 399.07 458.93 21347 992.59 942.96 1,084.40 21550 233.87 222.18 255.51 21348 1,036.69 984.86 1,132.59 # 21550 146.21 138.90 159.74 21355 401.55 381.47 438.69 21552 420.98 399.93 459.92 # 21355 300.58 285.55 328.38 21554 690.24 655.73 754.09 21356 449.68 427.20 491.28 21555 371.86 353.27 406.26 # 21356 344.27 327.06 376.12 # 21555 283.09 268.94 309.28 21360 486.61 462.28 531.62 21556 456.55 433.72 498.78 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 11 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 21557 770.92 732.37 842.23 # 22315 682.06 647.96 745.15 21558 1,292.49 1,227.87 1,412.05 22318 1,425.04 1,353.79 1,556.86 21600 507.80 482.41 554.77 22319 1,571.15 1,492.59 1,716.48 21610 994.95 945.20 1,086.98 22325 1,261.89 1,198.80 1,378.62 21615 613.46 582.79 670.21 22326 1,305.27 1,240.01 1,426.01 21616 762.67 724.54 833.22 22327 1,302.07 1,236.97 1,422.52 21620 477.59 453.71 521.77 22328 256.08 243.28 279.77 21627 503.43 478.26 550.00 22505 107.58 102.20 117.53 21630 1,157.34 1,099.47 1,264.39 22520 2,083.65 1,979.47 2,276.39 21632 1,149.40 1,091.93 1,255.72 # 22520 502.10 477.00 548.55 21685 929.20 882.74 1,015.15 22521 2,038.38 1,936.46 2,226.93 21700 388.06 368.66 423.96 # 22521 474.21 450.50 518.08 21705 573.52 544.84 626.57 22522 220.38 209.36 240.76 21720 386.18 366.87 421.90 22523 543.06 515.91 593.30 21725 480.62 456.59 525.08 22524 522.11 496.00 570.40 21740 976.98 928.13 1,067.35 22525 242.64 230.51 265.09 21750 654.14 621.43 714.64 22532 1,579.21 1,500.25 1,725.29 21800 91.11 86.55 99.53 22533 1,504.09 1,428.89 1,643.22 # 21800 92.96 88.31 101.56 22534 332.30 315.69 363.04 21805 238.16 226.25 260.19 22548 1,679.34 1,595.37 1,834.68 21810 458.57 435.64 500.99 22554 1,130.16 1,073.65 1,234.70 21820 120.28 114.27 131.41 22556 1,490.80 1,416.26 1,628.70 # 21820 122.13 116.02 133.42 22558 1,386.88 1,317.54 1,515.17 21825 518.69 492.76 566.67 22585 306.24 290.93 334.57 21920 234.59 222.86 256.29 22590 1,381.06 1,312.01 1,508.81 # 21920 148.04 140.64 161.74 22595 1,314.71 1,248.97 1,436.32 21925 383.68 364.50 419.18 22600 1,126.83 1,070.49 1,231.06 # 21925 308.60 293.17 337.15 22610 1,110.44 1,054.92 1,213.16 21930 418.44 397.52 457.15 22612 1,429.29 1,357.83 1,561.50 # 21930 331.89 315.30 362.60 22614 358.12 340.21 391.24 21931 439.50 417.53 480.16 22630 1,372.05 1,303.45 1,498.97 21932 630.60 599.07 688.93 22632 290.88 276.34 317.79 21933 693.79 659.10 757.97 22800 1,215.54 1,154.76 1,327.97 21935 951.53 903.95 1,039.54 22802 1,911.23 1,815.67 2,088.02 21936 1,341.32 1,274.25 1,465.39 22804 2,205.59 2,095.31 2,409.61 22010 830.69 789.16 907.53 22808 1,645.86 1,563.57 1,798.11 22015 824.50 783.28 900.77 22810 1,841.73 1,749.64 2,012.09 22100 754.78 717.04 824.60 22812 2,008.02 1,907.62 2,193.76 22101 766.47 728.15 837.37 22818 1,986.79 1,887.45 2,170.57 22102 735.15 698.39 803.15 22819 2,193.12 2,083.46 2,395.98 22103 130.49 123.97 142.57 22830 722.77 686.63 789.62 22110 927.97 881.57 1,013.81 22840 697.40 662.53 761.91 22112 920.08 874.08 1,005.19 22842 699.03 664.08 763.69 22114 898.52 853.59 981.63 22843 744.17 706.96 813.00 22116 128.14 121.73 139.99 22844 910.85 865.31 995.11 22206 2,139.61 2,032.63 2,337.52 22845 666.45 633.13 728.10 22207 2,139.99 2,032.99 2,337.94 22846 691.71 657.12 755.69 22208 531.27 504.71 580.42 22847 778.53 739.60 850.54 22210 1,573.97 1,495.27 1,719.56 22848 332.96 316.31 363.76 22212 1,314.63 1,248.90 1,436.24 22849 1,167.85 1,109.46 1,275.88 22214 1,323.56 1,257.38 1,445.99 22850 640.67 608.64 699.94 22216 334.87 318.13 365.85 22851 372.41 353.79 406.86 22220 1,424.42 1,353.20 1,556.18 22852 613.40 582.73 670.14 22222 1,319.56 1,253.58 1,441.62 22855 990.55 941.02 1,082.17 22224 1,413.45 1,342.78 1,544.20 22856 1,470.97 1,397.42 1,607.03 22226 334.27 317.56 365.19 22857 1,549.61 1,472.13 1,692.95 22305 167.02 158.67 182.47 22861 1,727.91 1,641.51 1,887.74 # 22305 153.34 145.67 167.52 22862 1,770.40 1,681.88 1,934.16 22310 265.88 252.59 290.48 22864 1,533.28 1,456.62 1,675.11 # 22310 247.38 235.01 270.26 22865 1,901.37 1,806.30 2,077.25 22315 772.30 733.69 843.74 22900 463.31 440.14 506.16 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 12 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 22901 619.21 588.25 676.49 23405 568.54 540.11 621.13 22902 402.27 382.16 439.48 23406 706.66 671.33 772.03 # 22902 318.31 302.39 347.75 23410 746.70 709.37 815.78 22903 412.49 391.87 450.65 23412 778.14 739.23 850.11 22904 964.50 916.28 1,053.72 23415 625.24 593.98 683.08 22905 1,250.97 1,188.42 1,366.68 23420 880.58 836.55 962.03 23000 486.60 462.27 531.61 23430 666.88 633.54 728.57 # 23000 324.97 308.72 355.03 23440 686.22 651.91 749.70 23020 621.89 590.80 679.42 23450 859.58 816.60 939.09 23030 382.00 362.90 417.34 23455 914.69 868.96 999.30 # 23030 229.99 218.49 251.26 23460 991.65 942.07 1,083.38 23031 350.26 332.75 382.66 23462 973.51 924.83 1,063.55 # 23031 191.59 182.01 209.31 23465 1,013.95 963.25 1,107.74 23035 616.67 585.84 673.72 23466 1,013.71 963.02 1,107.47 23040 647.64 615.26 707.55 23470 1,103.31 1,048.14 1,205.36 23044 515.80 490.01 563.51 23472 1,367.50 1,299.13 1,494.00 23065 194.87 185.13 212.90 23480 740.70 703.67 809.22 # 23065 153.07 145.42 167.23 23485 872.36 828.74 953.05 23066 463.41 440.24 506.28 23490 771.62 733.04 843.00 # 23066 308.81 293.37 337.38 23491 919.89 873.90 1,004.99 23071 391.44 371.87 427.65 23500 188.34 178.92 205.76 23073 647.12 614.76 706.97 23505 305.76 290.47 334.04 23075 325.04 308.79 355.11 # 23505 289.48 275.01 316.26 # 23075 241.82 229.73 264.19 23515 644.97 612.72 704.63 23076 490.51 465.98 535.88 23520 195.97 186.17 214.10 23077 1,057.52 1,004.64 1,155.34 # 23520 197.44 187.57 215.71 23078 1,301.25 1,236.19 1,421.62 23525 311.92 296.32 340.77 23100 440.90 418.86 481.69 # 23525 290.83 276.29 317.73 23101 402.54 382.41 439.77 23530 491.95 467.35 537.45 23105 572.71 544.07 625.68 23532 558.03 530.13 609.65 23106 432.70 411.07 472.73 23540 193.09 183.44 210.96 23107 594.78 565.04 649.80 # 23540 191.98 182.38 209.74 23120 520.22 494.21 568.34 23545 280.77 266.73 306.74 23125 633.39 601.72 691.98 # 23545 257.83 244.94 281.68 23130 544.17 516.96 594.50 23550 514.34 488.62 561.91 23140 464.83 441.59 507.83 23552 592.47 562.85 647.28 23145 622.90 591.76 680.52 23570 200.29 190.28 218.82 23146 544.36 517.14 594.71 # 23570 203.99 193.79 222.86 23150 592.32 562.70 647.11 23575 343.34 326.17 375.10 23155 712.10 676.50 777.98 # 23575 323.36 307.19 353.27 23156 606.39 576.07 662.48 23585 877.18 833.32 958.32 23170 483.91 459.71 528.67 23600 280.37 266.35 306.30 23172 497.05 472.20 543.03 # 23600 260.40 247.38 284.49 23174 679.10 645.15 741.92 23605 408.49 388.07 446.28 23180 613.98 583.28 670.77 # 23605 376.31 357.49 411.11 23182 597.26 567.40 652.51 23615 796.18 756.37 869.83 23184 669.58 636.10 731.52 23616 1,145.76 1,088.47 1,251.74 23190 504.54 479.31 551.21 23620 231.58 220.00 253.00 23195 677.64 643.76 740.32 # 23620 219.01 208.06 239.27 23200 1,205.67 1,145.39 1,317.20 23625 332.66 316.03 363.43 23210 1,400.99 1,330.94 1,530.58 # 23625 311.58 296.00 340.40 23220 1,556.60 1,478.77 1,700.59 23630 691.53 656.95 755.49 23330 205.89 195.60 224.94 23650 263.40 250.23 287.76 # 23330 135.98 129.18 148.56 # 23650 241.58 229.50 263.93 23331 529.24 502.78 578.20 23655 344.84 327.60 376.74 23332 798.65 758.72 872.53 23660 522.35 496.23 570.66 23350 142.39 135.27 155.56 23665 371.09 352.54 405.42 # 23350 49.92 47.42 54.53 # 23665 348.53 331.10 380.77 23395 1,166.02 1,107.72 1,273.88 23670 776.98 738.13 848.85 23397 1,037.01 985.16 1,132.93 23675 480.75 456.71 525.22 23400 880.74 836.70 962.21 # 23675 443.02 420.87 484.00 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 13 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 23680 830.41 788.89 907.22 24332 545.95 518.65 596.45 23700 174.77 166.03 190.93 24340 550.84 523.30 601.80 23800 928.81 882.37 1,014.73 24341 661.61 628.53 722.81 23802 1,141.96 1,084.86 1,247.59 24342 705.29 670.03 770.53 23900 1,215.65 1,154.87 1,328.10 24343 634.66 602.93 693.37 23920 988.74 939.30 1,080.20 24344 986.80 937.46 1,078.08 23921 367.27 348.91 401.25 24345 629.85 598.36 688.11 23930 317.17 301.31 346.51 24346 989.02 939.57 1,080.51 # 23930 195.48 185.71 213.57 24357 398.77 378.83 435.65 23931 249.08 236.63 272.12 24358 468.25 444.84 511.57 # 23931 141.82 134.73 154.94 24359 588.89 559.45 643.37 23935 446.51 424.18 487.81 24360 813.28 772.62 888.51 24000 424.85 403.61 464.15 24361 914.20 868.49 998.76 24006 640.49 608.47 699.74 24362 960.52 912.49 1,049.36 24065 229.56 218.08 250.79 24363 1,362.25 1,294.14 1,488.26 # 24065 153.00 145.35 167.15 24365 575.42 546.65 628.65 24066 530.58 504.05 579.66 24366 615.42 584.65 672.35 # 24066 360.81 342.77 394.19 24400 741.83 704.74 810.45 24071 380.17 361.16 415.33 24410 947.58 900.20 1,035.23 24073 651.21 618.65 711.45 24420 893.93 849.23 976.61 24075 433.76 412.07 473.88 24430 954.22 906.51 1,042.49 # 24075 291.73 277.14 318.71 24435 970.01 921.51 1,059.74 24076 467.94 444.54 511.22 24470 575.44 546.67 628.67 24077 885.65 841.37 967.58 24495 593.84 564.15 648.77 24079 1,200.69 1,140.66 1,311.76 24498 786.21 746.90 858.94 24100 364.82 346.58 398.57 24500 306.48 291.16 334.83 24101 446.66 424.33 487.98 # 24500 278.00 264.10 303.72 24102 552.41 524.79 603.51 24505 438.43 416.51 478.99 24105 304.73 289.49 332.91 # 24505 399.97 379.97 436.97 24110 523.41 497.24 571.83 24515 791.50 751.93 864.72 24115 646.99 614.64 706.84 24516 780.45 741.43 852.64 24116 777.97 739.07 849.93 24530 328.56 312.13 358.95 24120 469.44 445.97 512.87 # 24530 297.49 282.62 325.01 24125 549.44 521.97 600.27 24535 545.50 518.23 595.96 24126 580.23 551.22 633.90 # 24535 506.67 481.34 553.54 24130 453.68 431.00 495.65 24538 668.49 635.07 730.33 24134 677.14 643.28 739.77 24545 832.82 791.18 909.86 24136 543.07 515.92 593.31 24546 947.40 900.03 1,035.03 24138 599.30 569.34 654.74 24560 275.79 262.00 301.30 24140 643.77 611.58 703.32 # 24560 245.09 232.84 267.77 24145 540.39 513.37 590.38 24565 454.95 432.20 497.03 24147 563.48 535.31 615.61 # 24565 420.18 399.17 459.05 24149 1,051.57 998.99 1,148.84 24566 636.99 605.14 695.91 24150 1,266.10 1,202.80 1,383.22 24575 659.74 626.75 720.76 24152 1,061.83 1,008.74 1,160.05 24576 290.63 276.10 317.52 24155 767.49 729.12 838.49 # 24576 261.04 247.99 285.19 24160 543.62 516.44 593.91 24577 472.49 448.87 516.20 24164 445.31 423.04 486.50 # 24577 434.76 413.02 474.97 24200 179.05 170.10 195.62 24579 752.18 714.57 821.76 # 24200 123.94 117.74 135.40 24582 712.99 677.34 778.94 24201 494.53 469.80 540.27 24586 988.26 938.85 1,079.68 # 24201 327.72 311.33 358.03 24587 987.56 938.18 1,078.91 24220 156.29 148.48 170.75 24600 319.64 303.66 349.21 # 24220 66.42 63.10 72.57 # 24600 291.90 277.31 318.91 24300 356.65 338.82 389.64 24605 411.38 390.81 449.43 24301 678.72 644.78 741.50 24615 643.66 611.48 703.20 24305 520.63 494.60 568.79 24620 493.37 468.70 539.01 24310 427.19 405.83 466.70 24635 648.93 616.48 708.95 24320 700.26 665.25 765.04 24640 109.00 103.55 119.08 24330 645.34 613.07 705.03 # 24640 78.31 74.39 85.55 24331 711.76 676.17 777.60 24650 223.87 212.68 244.58 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 14 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 24650 203.15 192.99 221.94 25210 443.52 421.34 484.54 24655 382.63 363.50 418.03 25215 567.30 538.94 619.78 # 24655 350.09 332.59 382.48 25230 391.74 372.15 427.97 24665 583.48 554.31 637.46 25240 395.35 375.58 431.92 24666 659.87 626.88 720.91 25246 158.27 150.36 172.91 24670 250.40 237.88 273.56 # 25246 73.20 69.54 79.97 # 24670 225.25 213.99 246.09 25248 393.62 373.94 430.03 24675 400.61 380.58 437.67 25250 472.84 449.20 516.58 # 24675 368.06 349.66 402.11 25251 647.51 615.13 707.40 24685 584.38 555.16 638.43 25259 358.68 340.75 391.86 24800 727.24 690.88 794.51 25260 605.33 575.06 661.32 24802 903.63 858.45 987.22 25263 603.79 573.60 659.64 24900 652.06 619.46 712.38 25265 716.56 680.73 782.84 24920 646.78 614.44 706.61 25270 482.60 458.47 527.24 24925 503.36 478.19 549.92 25272 542.03 514.93 592.17 24930 685.89 651.60 749.34 25274 644.59 612.36 704.21 24931 735.35 698.58 803.37 25275 607.20 576.84 663.37 24935 957.11 909.25 1,045.64 25280 550.82 523.28 601.77 25000 311.80 296.21 340.64 25290 458.37 435.45 500.77 25001 300.13 285.12 327.89 25295 512.02 486.42 559.38 25020 517.41 491.54 565.27 25300 619.11 588.15 676.37 25023 999.16 949.20 1,091.58 25301 586.08 556.78 640.30 25024 699.65 664.67 764.37 25310 597.74 567.85 653.03 25025 1,089.89 1,035.40 1,190.71 25312 691.98 657.38 755.99 25028 463.95 440.75 506.86 25315 741.08 704.03 809.63 25031 336.81 319.97 367.97 25316 859.60 816.62 939.11 25035 566.76 538.42 619.18 25320 885.04 840.79 966.91 25040 512.69 487.06 560.12 25332 761.87 723.78 832.35 25065 228.24 216.83 249.35 25335 817.54 776.66 893.16 # 25065 150.94 143.39 164.90 25337 805.45 765.18 879.96 25066 335.52 318.74 366.55 25350 653.12 620.46 713.53 25071 398.87 378.93 435.77 25355 735.42 698.65 803.45 25073 498.50 473.58 544.62 25360 634.61 602.88 693.31 25075 332.90 316.26 363.70 25365 865.39 822.12 945.44 # 25075 298.87 283.93 326.52 25370 947.10 899.75 1,034.71 25076 462.72 439.58 505.52 25375 859.63 816.65 939.15 25077 787.03 747.68 859.83 25390 740.97 703.92 809.51 25078 1,049.50 997.03 1,146.58 25391 944.38 897.16 1,031.73 25085 414.32 393.60 452.64 25392 961.62 913.54 1,050.57 25100 311.14 295.58 339.92 25393 1,071.20 1,017.64 1,170.29 25101 364.88 346.64 398.64 25394 704.91 669.66 770.11 25105 441.82 419.73 482.69 25400 774.89 736.15 846.57 25107 557.31 529.44 608.86 25405 988.00 938.60 1,079.39 25109 475.39 451.62 519.36 25415 931.72 885.13 1,017.90 25110 320.74 304.70 350.41 25420 1,107.72 1,052.33 1,210.18 25111 284.45 270.23 310.76 25425 950.16 902.65 1,038.05 25112 345.18 327.92 377.11 25426 1,014.98 964.23 1,108.86 25115 721.31 685.24 788.03 25430 646.03 613.73 705.79 25116 579.19 550.23 632.76 25431 705.39 670.12 770.64 25118 345.29 328.03 377.23 25440 700.13 665.12 764.89 25119 454.57 431.84 496.62 25441 845.99 803.69 924.24 25120 488.53 464.10 533.72 25442 724.28 688.07 791.28 25125 574.29 545.58 627.42 25443 705.23 669.97 770.47 25126 575.83 547.04 629.10 25444 703.20 668.04 768.25 25130 405.48 385.21 442.99 25445 650.27 617.76 710.42 25135 509.29 483.83 556.40 25446 1,067.94 1,014.54 1,166.72 25136 444.52 422.29 485.63 25447 741.34 704.27 809.91 25145 503.75 478.56 550.34 25449 938.62 891.69 1,025.44 25150 518.81 492.87 566.80 25450 540.51 513.48 590.50 25151 567.98 539.58 620.52 25455 602.67 572.54 658.42 25170 1,223.26 1,162.10 1,336.42 25490 664.65 631.42 726.13 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 15 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 25491 711.85 676.26 777.70 25905 661.40 628.33 722.58 25492 856.58 813.75 935.81 25907 579.85 550.86 633.49 25500 230.04 218.54 251.32 25909 647.65 615.27 707.56 # 25500 210.06 199.56 229.49 25915 1,066.95 1,013.60 1,165.64 25505 441.12 419.06 481.92 25920 620.95 589.90 678.39 # 25505 406.35 386.03 443.93 25922 498.08 473.18 544.16 25515 599.73 569.74 655.20 25924 606.35 576.03 662.43 25520 487.36 462.99 532.44 25927 712.58 676.95 778.49 # 25520 463.69 440.51 506.59 25929 513.74 488.05 561.26 25525 714.51 678.78 780.60 25931 637.57 605.69 696.54 25526 882.00 837.90 963.59 26010 227.89 216.50 248.98 25530 223.06 211.91 243.70 # 26010 120.63 114.60 131.79 # 25530 200.87 190.83 219.45 26011 344.75 327.51 376.64 25535 427.40 406.03 466.93 # 26011 165.36 157.09 180.65 # 25535 399.29 379.33 436.23 26020 384.43 365.21 419.99 25545 559.62 531.64 611.39 26025 373.90 355.21 408.49 25560 233.56 221.88 255.16 26030 439.94 417.94 480.63 # 25560 209.52 199.04 228.90 26034 477.93 454.03 522.13 25565 460.22 437.21 502.79 26035 752.84 715.20 822.48 # 25565 420.27 399.26 459.15 26037 511.79 486.20 559.13 25574 600.28 570.27 655.81 26040 274.81 261.07 300.23 25575 809.34 768.87 884.20 26045 415.85 395.06 454.32 25600 252.28 239.67 275.62 26055 503.78 478.59 550.38 # 25600 228.24 216.83 249.35 # 26055 268.55 255.12 293.39 25605 547.50 520.13 598.15 26060 235.41 223.64 257.19 # 25605 517.54 491.66 565.41 26070 269.76 256.27 294.71 25606 597.62 567.74 652.90 26075 284.94 270.69 311.29 25607 650.04 617.54 710.17 26080 343.33 326.16 375.08 25608 732.88 696.24 800.68 26100 290.09 275.59 316.93 25609 933.76 887.07 1,020.13 26105 295.02 280.27 322.31 25622 260.40 247.38 284.49 26110 283.53 269.35 309.75 # 25622 235.25 223.49 257.01 26111 389.22 369.76 425.22 25624 406.22 385.91 443.80 26113 512.42 486.80 559.82 # 25624 370.72 352.18 405.01 26115 523.03 496.88 571.41 25628 647.11 614.75 706.96 # 26115 314.05 298.35 343.10 25630 264.61 251.38 289.09 26116 467.32 443.95 510.54 # 25630 240.20 228.19 262.42 26117 643.11 610.95 702.59 25635 387.25 367.89 423.07 26118 997.85 947.96 1,090.15 # 25635 347.68 330.30 379.85 26121 535.78 508.99 585.34 25645 508.15 482.74 555.15 26123 742.71 705.57 811.41 25650 276.48 262.66 302.06 26125 255.45 242.68 279.08 # 25650 255.76 242.97 279.42 26130 406.85 386.51 444.49 25651 427.17 405.81 466.68 26135 493.56 468.88 539.21 25652 556.85 529.01 608.36 26140 451.08 428.53 492.81 25660 361.31 343.24 394.73 26145 457.65 434.77 499.99 25670 546.62 519.29 597.18 26160 507.06 481.71 553.97 25671 468.01 444.61 511.30 # 26160 291.06 276.51 317.99 25675 380.15 361.14 415.31 26170 362.00 343.90 395.49 # 25675 349.82 332.33 382.18 26180 395.47 375.70 432.06 25676 566.06 537.76 618.42 26185 481.60 457.52 526.15 25680 413.38 392.71 451.62 26200 402.87 382.73 440.14 25685 659.24 626.28 720.22 26205 540.92 513.87 590.95 25690 417.33 396.46 455.93 26210 393.10 373.45 429.47 25695 569.51 541.03 622.18 26215 500.64 475.61 546.95 25800 669.00 635.55 730.88 26230 448.29 425.88 489.76 25805 772.00 733.40 843.41 26235 442.42 420.30 483.35 25810 786.36 747.04 859.10 26236 393.79 374.10 430.22 25820 552.04 524.44 603.11 26250 834.44 792.72 911.63 25825 681.69 647.61 744.75 26260 655.04 622.29 715.63 25830 857.99 815.09 937.35 26262 515.40 489.63 563.07 25900 671.40 637.83 733.50 26320 307.73 292.34 336.19 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 16 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 26340 286.83 272.49 313.36 26541 720.75 684.71 787.42 26350 639.57 607.59 698.73 26542 609.25 578.79 665.61 26352 727.99 691.59 795.33 26545 623.22 592.06 680.87 26356 969.50 921.03 1,059.18 26546 880.24 836.23 961.66 26357 778.22 739.31 850.21 26548 684.00 649.80 747.27 26358 823.26 782.10 899.42 26550 1,382.84 1,313.70 1,510.76 26370 688.37 653.95 752.04 26551 2,905.32 2,760.05 3,174.06 26372 797.41 757.54 871.17 26553 2,555.66 2,427.88 2,792.06 26373 761.27 723.21 831.69 26554 3,140.36 2,983.34 3,430.84 26390 745.64 708.36 814.61 26555 1,241.18 1,179.12 1,355.99 26392 871.21 827.65 951.80 26556 2,541.53 2,414.45 2,776.62 26410 508.13 482.72 555.13 26560 511.99 486.39 559.35 26412 615.25 584.49 672.16 26561 808.13 767.72 882.88 26415 643.01 610.86 702.49 26562 1,123.88 1,067.69 1,227.84 26416 726.74 690.40 793.96 26565 608.34 577.92 664.61 26418 514.39 488.67 561.97 26567 611.59 581.01 668.16 26420 641.01 608.96 700.30 26568 803.26 763.10 877.57 26426 499.93 474.93 546.17 26580 1,291.12 1,226.56 1,410.54 26428 674.62 640.89 737.02 26587 869.91 826.41 950.37 26432 445.76 423.47 486.99 26590 1,167.96 1,109.56 1,275.99 26433 476.45 452.63 520.52 26591 391.07 371.52 427.25 26434 573.77 545.08 626.84 26593 535.77 508.98 585.33 26437 556.92 529.07 608.43 26596 662.00 628.90 723.24 26440 560.00 532.00 611.80 26600 246.86 234.52 269.70 26442 858.74 815.80 938.17 # 26600 229.47 218.00 250.70 26445 521.27 495.21 569.49 26605 277.92 264.02 303.62 26449 674.15 640.44 736.51 # 26605 253.14 240.48 276.55 26450 361.32 343.25 394.74 26607 393.52 373.84 429.92 26455 358.41 340.49 391.56 26608 424.49 403.27 463.76 26460 348.56 331.13 380.80 26615 501.04 475.99 547.39 26471 549.50 522.03 600.33 26641 321.91 305.81 351.68 26474 531.09 504.54 580.22 # 26641 294.54 279.81 321.78 26476 517.83 491.94 565.73 26645 364.74 346.50 398.48 26477 519.56 493.58 567.62 # 26645 336.26 319.45 367.37 26478 560.45 532.43 612.29 26650 424.65 403.42 463.93 26479 556.43 528.61 607.90 26665 555.02 527.27 606.36 26480 676.67 642.84 739.27 26670 289.51 275.03 316.28 26483 758.99 721.04 829.20 # 26670 261.77 248.68 285.98 26485 728.59 692.16 795.98 26675 387.97 368.57 423.86 26489 803.33 763.16 877.63 # 26675 358.01 340.11 391.13 26490 705.28 670.02 770.52 26676 445.44 423.17 486.65 26492 786.91 747.56 859.69 26685 507.83 482.44 554.81 26494 713.87 678.18 779.91 26686 556.97 529.12 608.49 26496 771.06 732.51 842.39 26700 276.76 262.92 302.36 26497 773.92 735.22 845.50 # 26700 258.64 245.71 282.57 26498 1,028.28 976.87 1,123.40 26705 356.60 338.77 389.59 26499 739.99 702.99 808.44 # 26705 327.01 310.66 357.26 26500 560.90 532.86 612.79 26706 387.19 367.83 423.00 26502 632.05 600.45 690.52 26715 499.80 474.81 546.03 26508 560.66 532.63 612.52 26720 168.60 160.17 184.20 26510 535.59 508.81 585.13 # 26720 154.91 147.16 169.23 26516 628.61 597.18 686.76 26725 296.38 281.56 323.79 26517 738.85 701.91 807.20 # 26725 266.42 253.10 291.07 26518 747.78 710.39 816.95 26727 417.51 396.63 456.12 26520 586.65 557.32 640.92 26735 520.96 494.91 569.15 26525 588.27 558.86 642.69 26740 195.63 185.85 213.73 26530 479.75 455.76 524.12 # 26740 183.42 174.25 200.39 26531 559.00 531.05 610.71 26742 323.62 307.44 353.56 26535 363.79 345.60 397.44 # 26742 294.03 279.33 321.23 26536 610.52 579.99 666.99 26746 646.15 613.84 705.92 26540 591.18 561.62 645.86 26750 157.44 149.57 172.01 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 17 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 26750 154.48 146.76 168.77 27075 1,931.44 1,834.87 2,110.10 26755 273.52 259.84 298.82 27076 2,079.80 1,975.81 2,272.18 # 26755 238.38 226.46 260.43 27077 2,537.85 2,410.96 2,772.60 26756 369.95 351.45 404.17 27078 1,627.22 1,545.86 1,777.74 26765 429.89 408.40 469.66 27080 451.32 428.75 493.06 26770 236.13 224.32 257.97 27086 220.49 209.47 240.89 # 26770 216.89 206.05 236.96 # 27086 133.57 126.89 145.92 26775 333.03 316.38 363.84 27087 571.74 543.15 624.62 # 26775 299.74 284.75 327.46 27090 751.54 713.96 821.05 26776 392.54 372.91 428.85 27091 1,455.34 1,382.57 1,589.96 26785 469.30 445.84 512.72 27093 177.75 168.86 194.19 26820 704.80 669.56 769.99 # 27093 67.16 63.80 73.37 26841 653.47 620.80 713.92 27095 215.33 204.56 235.24 26842 708.06 672.66 773.56 # 27095 77.00 73.15 84.12 26843 658.25 625.34 719.14 27096 167.98 159.58 183.52 26844 732.92 696.27 800.71 # 27096 66.27 62.96 72.40 26850 622.27 591.16 679.83 27097 602.79 572.65 658.55 26852 713.73 678.04 779.75 27098 567.38 539.01 619.86 26860 503.16 478.00 549.70 27100 741.96 704.86 810.59 26861 96.14 91.33 105.03 27105 781.45 742.38 853.74 26862 650.39 617.87 710.55 27110 868.15 824.74 948.45 26863 215.38 204.61 235.30 27111 782.70 743.57 855.11 26910 640.31 608.29 699.53 27120 1,172.14 1,113.53 1,280.56 26951 567.72 539.33 620.23 27122 1,001.56 951.48 1,094.20 26952 580.08 551.08 633.74 27125 1,026.32 975.00 1,121.25 26990 556.60 528.77 608.09 27130 1,315.15 1,249.39 1,436.80 26991 626.38 595.06 684.32 27132 1,536.43 1,459.61 1,678.55 # 26991 468.45 445.03 511.78 27134 1,770.58 1,682.05 1,934.36 26992 867.52 824.14 947.76 27137 1,354.08 1,286.38 1,479.34 27000 397.53 377.65 434.30 27138 1,408.57 1,338.14 1,538.86 27001 485.33 461.06 530.22 27140 813.09 772.44 888.31 27003 528.55 502.12 577.44 27146 1,154.04 1,096.34 1,260.79 27005 656.14 623.33 716.83 27147 1,336.12 1,269.31 1,459.71 27006 664.04 630.84 725.47 27151 1,402.49 1,332.37 1,532.23 27025 816.23 775.42 891.73 27156 1,558.06 1,480.16 1,702.18 27027 771.52 732.94 842.88 27158 1,260.59 1,197.56 1,377.19 27030 853.75 811.06 932.72 27161 1,107.00 1,051.65 1,209.40 27033 884.95 840.70 966.81 27165 1,246.56 1,184.23 1,361.86 27035 1,019.67 968.69 1,113.99 27170 1,073.64 1,019.96 1,172.95 27036 910.77 865.23 995.01 27175 600.01 570.01 655.51 27040 308.65 293.22 337.20 27176 825.42 784.15 901.77 # 27040 184.75 175.51 201.84 27177 1,007.65 957.27 1,100.86 27041 620.00 589.00 677.35 27178 821.36 780.29 897.33 27043 438.76 416.82 479.34 27179 881.49 837.42 963.03 27045 696.61 661.78 761.05 27181 1,009.53 959.05 1,102.91 27047 455.16 432.40 497.26 27185 577.19 548.33 630.58 # 27047 363.43 345.26 397.05 27187 901.38 856.31 984.76 27048 522.72 496.58 571.07 27193 418.91 397.96 457.65 27049 1,154.54 1,096.81 1,261.33 # 27193 422.97 401.82 462.09 27050 328.39 311.97 358.77 27194 637.04 605.19 695.97 27052 507.78 482.39 554.75 27200 155.19 147.43 169.54 27054 614.54 583.81 671.38 # 27200 159.25 151.29 173.98 27057 872.54 828.91 953.25 27202 555.86 528.07 607.28 27059 1,700.98 1,615.93 1,858.32 27220 472.00 448.40 515.66 27060 387.47 368.10 423.32 # 27220 468.30 444.89 511.62 27062 405.08 384.83 442.55 27222 886.25 841.94 968.23 27065 453.43 430.76 495.37 27226 945.49 898.22 1,032.95 27066 730.93 694.38 798.54 27227 1,520.64 1,444.61 1,661.30 27067 935.86 889.07 1,022.43 27228 1,738.74 1,651.80 1,899.57 27070 768.59 730.16 839.68 27230 420.88 399.84 459.82 27071 822.45 781.33 898.53 # 27230 415.71 394.92 454.16 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 18 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 27232 697.33 662.46 761.83 27357 733.03 696.38 800.84 27235 824.55 783.32 900.82 27358 261.27 248.21 285.44 27236 1,084.36 1,030.14 1,184.66 27360 767.09 728.74 838.05 27238 407.30 386.94 444.98 27364 1,466.32 1,393.00 1,601.95 27240 866.07 822.77 946.19 27365 1,681.60 1,597.52 1,837.15 27244 1,115.38 1,059.61 1,218.55 27370 154.64 146.91 168.95 27245 1,133.50 1,076.83 1,238.35 # 27370 49.60 47.12 54.19 27246 342.48 325.36 374.16 27372 535.26 508.50 584.78 # 27246 343.59 326.41 375.37 # 27372 363.64 345.46 397.28 27248 680.06 646.06 742.97 27380 532.14 505.53 581.36 27250 199.83 189.84 218.32 27381 721.89 685.80 788.67 27252 685.19 650.93 748.57 27385 568.72 540.28 621.32 27253 856.09 813.29 935.28 27386 749.55 712.07 818.88 27254 1,153.26 1,095.60 1,259.94 27390 395.83 376.04 432.45 27256 264.50 251.28 288.97 27391 514.50 488.78 562.10 # 27256 221.97 210.87 242.50 27392 633.60 601.92 692.21 27257 303.85 288.66 331.96 27393 455.39 432.62 497.51 27258 1,004.72 954.48 1,097.65 27394 587.16 557.80 641.47 27259 1,410.07 1,339.57 1,540.51 27395 793.12 753.46 866.48 27265 354.58 336.85 387.38 27396 552.56 524.93 603.67 27266 521.03 494.98 569.23 27397 821.07 780.02 897.02 27267 379.43 360.46 414.53 27400 620.99 589.94 678.43 27268 466.50 443.18 509.66 27403 577.64 548.76 631.07 27269 1,109.35 1,053.88 1,211.96 27405 609.03 578.58 665.37 27275 160.25 152.24 175.08 27407 698.99 664.04 763.65 27280 930.38 883.86 1,016.44 27409 872.14 828.53 952.81 27282 741.46 704.39 810.05 27412 1,500.16 1,425.15 1,638.92 27284 1,425.45 1,354.18 1,557.31 27415 1,239.47 1,177.50 1,354.13 27286 1,512.36 1,436.74 1,652.25 27416 876.91 833.06 958.02 27290 1,445.74 1,373.45 1,579.47 27418 753.55 715.87 823.25 27295 1,153.06 1,095.41 1,259.72 27420 674.12 640.41 736.47 27301 593.19 563.53 648.06 27422 671.80 638.21 733.94 # 27301 447.46 425.09 488.85 27424 673.41 639.74 735.70 27303 575.04 546.29 628.23 27425 396.81 376.97 433.52 27305 422.62 401.49 461.71 27427 647.93 615.53 707.86 27306 342.08 324.98 373.73 27428 1,002.99 952.84 1,095.77 27307 420.43 399.41 459.32 27429 1,125.92 1,069.62 1,230.06 27310 656.82 623.98 717.58 27430 667.82 634.43 729.59 27323 241.96 229.86 264.34 27435 724.09 687.89 791.07 # 27323 162.80 154.66 177.86 27437 594.30 564.59 649.28 27324 346.34 329.02 378.37 27438 760.62 722.59 830.98 27325 481.71 457.62 526.26 27440 700.42 665.40 765.21 27326 443.39 421.22 484.40 27441 722.95 686.80 789.82 27327 389.21 369.75 425.21 27442 786.24 746.93 858.97 # 27327 290.82 276.28 317.72 27443 736.67 699.84 804.82 27328 507.65 482.27 554.61 27445 1,143.94 1,086.74 1,249.75 27329 942.96 895.81 1,030.18 27446 1,011.04 960.49 1,104.56 27330 358.30 340.39 391.45 27447 1,406.95 1,336.60 1,537.09 27331 424.57 403.34 463.84 27448 740.96 703.91 809.50 27332 574.78 546.04 627.95 27450 923.65 877.47 1,009.09 27333 521.98 495.88 570.26 27454 1,168.96 1,110.51 1,277.09 27334 612.36 581.74 669.00 27455 852.58 809.95 931.44 27335 690.26 655.75 754.11 27457 876.20 832.39 957.25 27337 392.37 372.75 428.66 27465 1,123.52 1,067.34 1,227.44 27339 704.38 669.16 769.53 27466 1,076.05 1,022.25 1,175.59 27340 327.64 311.26 357.95 27468 1,214.74 1,154.00 1,327.10 27345 431.48 409.91 471.40 27470 1,072.05 1,018.45 1,171.22 27347 467.55 444.17 510.80 27472 1,155.31 1,097.54 1,262.17 27350 585.89 556.60 640.09 27475 594.30 564.59 649.28 27355 541.91 514.81 592.03 27477 660.45 627.43 721.54 27356 664.05 630.85 725.48 27479 788.15 748.74 861.05 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 19 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 27485 603.95 573.75 659.81 27603 474.78 451.04 518.70 27486 1,285.98 1,221.68 1,404.93 # 27603 353.83 336.14 386.56 27487 1,615.91 1,535.11 1,765.38 27604 416.19 395.38 454.69 27488 1,091.97 1,037.37 1,192.98 # 27604 307.82 292.43 336.29 27495 1,028.33 976.91 1,123.45 27605 323.15 306.99 353.04 27496 463.20 440.04 506.05 # 27605 179.27 170.31 195.86 27497 499.73 474.74 545.95 27606 266.16 252.85 290.78 27498 550.38 522.86 601.29 27607 557.36 529.49 608.91 27499 602.50 572.38 658.24 27610 594.23 564.52 649.20 27500 458.67 435.74 501.10 27612 516.00 490.20 563.73 # 27500 426.12 404.81 465.53 27613 226.66 215.33 247.63 27501 449.91 427.41 491.52 # 27613 151.95 144.35 166.00 # 27501 443.99 421.79 485.06 27614 509.71 484.22 556.85 27502 711.08 675.53 776.86 # 27614 374.34 355.62 408.96 27503 724.72 688.48 791.75 27615 909.42 863.95 993.54 27506 1,214.74 1,154.00 1,327.10 27616 1,199.03 1,139.08 1,309.94 27507 890.59 846.06 972.97 27618 397.32 377.45 434.07 27508 464.96 441.71 507.97 # 27618 297.82 282.93 325.37 # 27508 438.33 416.41 478.87 27619 467.33 443.96 510.55 27509 579.40 550.43 632.99 27620 418.51 397.58 457.22 27510 629.62 598.14 687.86 27625 534.80 508.06 584.27 27511 923.91 877.71 1,009.37 27626 579.17 550.21 632.74 27513 1,156.06 1,098.26 1,263.00 27630 486.64 462.31 531.66 27514 912.77 867.13 997.20 # 27630 336.10 319.30 367.20 27516 440.49 418.47 481.24 27632 388.17 368.76 424.07 # 27516 414.97 394.22 453.35 27634 632.48 600.86 690.99 27517 613.40 582.73 670.14 27635 537.28 510.42 586.98 27519 831.69 790.11 908.63 27637 684.20 649.99 747.49 27520 278.83 264.89 304.62 27638 707.43 672.06 772.87 # 27520 252.94 240.29 276.33 27640 780.10 741.10 852.27 27524 680.77 646.73 743.74 27641 626.16 594.85 684.08 27530 347.84 330.45 380.02 27645 1,444.65 1,372.42 1,578.28 # 27530 323.80 307.61 353.75 27646 1,245.66 1,183.38 1,360.89 27532 547.32 519.95 597.94 27647 998.53 948.60 1,090.89 # 27532 516.62 490.79 564.41 27648 149.47 142.00 163.30 27535 828.83 787.39 905.50 # 27648 49.23 46.77 53.79 27536 1,081.42 1,027.35 1,181.45 27650 611.56 580.98 668.13 27538 413.80 393.11 452.08 27652 660.05 627.05 721.11 # 27538 387.91 368.51 423.79 27654 655.65 622.87 716.30 27540 742.04 704.94 810.68 27656 505.80 480.51 552.59 27550 438.75 416.81 479.33 # 27656 329.74 313.25 360.24 # 27550 408.42 388.00 446.20 27658 347.82 330.43 379.99 27552 559.36 531.39 611.10 27659 450.66 428.13 492.35 27556 818.07 777.17 893.75 27664 331.83 315.24 362.53 27557 979.13 930.17 1,069.70 27665 380.51 361.48 415.70 27558 1,108.16 1,052.75 1,210.66 27675 459.68 436.70 502.21 27560 328.22 311.81 358.58 27676 565.24 536.98 617.53 # 27560 300.11 285.10 327.87 27680 392.73 373.09 429.05 27562 418.91 397.96 457.65 27681 476.42 452.60 520.49 27566 808.59 768.16 883.38 27685 575.82 547.03 629.08 27570 133.20 126.54 145.52 # 27685 432.68 411.05 472.71 27580 1,313.02 1,247.37 1,434.48 27686 508.99 483.54 556.07 27590 760.51 722.48 830.85 27687 420.71 399.67 459.62 27591 834.67 792.94 911.88 27690 582.68 553.55 636.58 27592 644.84 612.60 704.49 27691 685.33 651.06 748.72 27594 469.29 445.83 512.70 27692 100.72 95.68 110.03 27596 675.57 641.79 738.06 27695 448.13 425.72 489.58 27598 685.15 650.89 748.52 27696 526.58 500.25 575.29 27600 386.78 367.44 422.56 27698 597.03 567.18 652.26 27601 405.06 384.81 442.53 27700 562.53 534.40 614.56 27602 474.06 450.36 517.91 27702 901.89 856.80 985.32 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 20 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 27703 1,045.65 993.37 1,142.38 27827 985.88 936.59 1,077.08 27704 517.34 491.47 565.19 27828 1,181.54 1,122.46 1,290.83 27705 695.51 660.73 759.84 27829 609.35 578.88 665.71 27707 360.52 342.49 393.86 27830 321.24 305.18 350.96 27709 1,046.54 994.21 1,143.34 # 27830 300.53 285.50 328.33 27712 998.60 948.67 1,090.97 27831 344.88 327.64 376.79 27715 970.20 921.69 1,059.94 27832 658.74 625.80 719.67 27720 797.74 757.85 871.53 27840 320.27 304.26 349.90 27722 798.12 758.21 871.94 27842 438.45 416.53 479.01 27724 1,164.65 1,106.42 1,272.38 27846 669.31 635.84 731.22 27725 1,098.03 1,043.13 1,199.60 27848 754.72 716.98 824.53 27726 858.86 815.92 938.31 27860 160.50 152.48 175.35 27727 896.44 851.62 979.36 27870 955.69 907.91 1,044.10 27730 523.57 497.39 572.00 27871 628.97 597.52 687.15 27732 374.69 355.96 409.35 27880 859.32 816.35 938.80 27734 521.27 495.21 569.49 27881 818.29 777.38 893.99 27740 609.59 579.11 665.98 27882 579.20 550.24 632.78 27742 648.14 615.73 708.09 27884 539.97 512.97 589.92 27745 685.00 650.75 748.36 27886 616.38 585.56 673.39 27750 300.26 285.25 328.04 27888 644.57 612.34 704.19 # 27750 275.11 261.35 300.55 27889 631.88 600.29 690.33 27752 477.04 453.19 521.17 27892 502.58 477.45 549.07 # 27752 443.75 421.56 484.79 27893 506.51 481.18 553.36 27756 515.13 489.37 562.78 27894 782.87 743.73 855.29 27758 806.29 765.98 880.88 28001 243.92 231.72 266.48 27759 909.52 864.04 993.65 # 28001 164.03 155.83 179.20 27760 290.39 275.87 317.25 28002 460.31 437.29 502.88 # 27760 263.75 250.56 288.14 # 28002 356.75 338.91 389.75 27762 427.41 406.04 466.95 28003 619.24 588.28 676.52 # 27762 394.13 374.42 430.58 # 28003 513.83 488.14 561.36 27766 549.53 522.05 600.36 28005 562.61 534.48 614.65 27767 237.35 225.48 259.30 28008 385.32 366.05 420.96 # 27767 238.46 226.54 260.52 # 28008 280.64 266.61 306.60 27768 371.91 353.31 406.31 28010 212.70 202.07 232.38 27769 639.19 607.23 698.31 # 28010 197.17 187.31 215.41 27780 261.62 248.54 285.82 28011 300.16 285.15 327.92 # 27780 237.21 225.35 259.15 # 28011 276.49 262.67 302.07 27781 373.05 354.40 407.56 28020 461.58 438.50 504.28 # 27781 347.16 329.80 379.27 # 28020 332.12 315.51 362.84 27784 636.88 605.04 695.80 28022 424.12 402.91 463.35 27786 275.35 261.58 300.82 # 28022 305.39 290.12 333.64 # 27786 247.98 235.58 270.92 28024 402.62 382.49 439.86 27788 374.09 355.39 408.70 # 28024 288.70 274.27 315.41 # 27788 344.14 326.93 375.97 28035 464.40 441.18 507.36 27792 639.61 607.63 698.77 # 28035 335.69 318.91 366.75 27808 288.65 274.22 315.35 28039 458.61 435.68 501.03 # 27808 259.43 246.46 283.43 # 28039 323.61 307.43 353.54 27810 418.78 397.84 457.52 28041 425.40 404.13 464.75 # 27810 384.38 365.16 419.93 28043 329.41 312.94 359.88 27814 701.63 666.55 766.53 # 28043 251.37 238.80 274.62 27816 273.79 260.10 299.12 28045 452.85 430.21 494.74 # 27816 246.42 234.10 269.22 # 28045 328.57 312.14 358.96 27818 430.92 409.37 470.78 28046 688.55 654.12 752.24 # 27818 392.08 372.48 428.35 28047 895.07 850.32 977.87 27822 769.41 730.94 840.58 28050 402.28 382.17 439.50 27823 874.05 830.35 954.90 # 28050 284.30 270.09 310.60 27824 273.56 259.88 298.86 28052 382.26 363.15 417.62 # 27824 263.95 250.75 288.36 # 28052 265.01 251.76 289.52 27825 488.53 464.10 533.72 28054 347.10 329.75 379.21 # 27825 447.85 425.46 489.28 # 28054 235.03 223.28 256.77 27826 751.30 713.74 820.80 28055 362.70 344.57 396.26 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 21 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 28060 455.31 432.54 497.42 # 28160 256.84 244.00 280.60 # 28060 335.47 318.70 366.51 28171 796.65 756.82 870.34 28062 529.57 503.09 578.55 28173 708.81 673.37 774.38 # 28062 389.76 370.27 425.81 28175 448.00 425.60 489.44 28070 450.57 428.04 492.25 28190 221.51 210.43 241.99 # 28070 325.93 309.63 356.07 # 28190 125.72 119.43 137.34 28072 450.63 428.10 492.32 28192 419.18 398.22 457.95 # 28072 319.70 303.72 349.28 # 28192 298.98 284.03 326.63 28080 449.57 427.09 491.15 28193 479.09 455.14 523.41 # 28080 333.07 316.42 363.88 # 28193 354.81 337.07 387.63 28086 479.30 455.34 523.64 28200 419.07 398.12 457.84 # 28086 333.95 317.25 364.84 # 28200 297.38 282.51 324.89 28088 408.05 387.65 445.80 28202 547.79 520.40 598.46 # 28088 276.75 262.91 302.35 # 28202 411.68 391.10 449.77 28090 411.79 391.20 449.88 28208 407.42 387.05 445.11 # 28090 290.10 275.60 316.94 # 28208 288.69 274.26 315.40 28092 373.69 355.01 408.26 28210 515.22 489.46 562.88 # 28092 255.70 242.92 279.36 # 28210 387.61 368.23 423.46 28100 527.55 501.17 576.35 28220 399.05 379.10 435.97 # 28100 377.01 358.16 411.88 # 28220 288.83 274.39 315.55 28102 488.92 464.47 534.14 28222 456.98 434.13 499.25 28103 400.93 380.88 438.01 # 28222 340.84 323.80 372.37 28104 452.95 430.30 494.85 28225 349.30 331.84 381.62 # 28104 327.19 310.83 357.45 # 28225 240.56 228.53 262.81 28106 426.80 405.46 466.28 28226 409.63 389.15 447.52 28107 490.34 465.82 535.69 # 28226 293.86 279.17 321.05 # 28107 350.90 333.36 383.36 28230 382.55 363.42 417.93 28108 383.21 364.05 418.66 # 28230 273.07 259.42 298.33 # 28108 271.51 257.93 296.62 28232 342.54 325.41 374.22 28110 403.30 383.14 440.61 # 28232 234.17 222.46 255.83 # 28110 271.63 258.05 296.76 28234 358.20 340.29 391.33 28111 454.77 432.03 496.83 # 28234 248.72 236.28 271.72 # 28111 316.44 300.62 345.71 28238 605.03 574.78 661.00 28112 432.73 411.09 472.75 # 28238 464.85 441.61 507.85 # 28112 296.62 281.79 324.06 28240 393.99 374.29 430.43 28113 524.40 498.18 572.91 # 28240 280.81 266.77 306.79 # 28113 397.17 377.31 433.91 28250 502.57 477.44 549.06 28114 950.75 903.21 1,038.69 # 28250 375.71 356.92 410.46 # 28114 769.88 731.39 841.10 28260 611.42 580.85 667.98 28116 669.47 636.00 731.40 # 28260 483.45 459.28 528.17 # 28116 534.10 507.40 583.51 28261 869.97 826.47 950.44 28118 519.49 493.52 567.55 # 28261 727.94 691.54 795.27 # 28118 384.86 365.62 420.46 28262 1,234.69 1,172.96 1,348.90 28119 463.01 439.86 505.84 # 28262 1,038.66 986.73 1,134.74 # 28119 339.85 322.86 371.29 28264 750.12 712.61 819.50 28120 617.15 586.29 674.23 # 28264 617.71 586.82 674.84 # 28120 472.16 448.55 515.83 28270 429.28 407.82 468.99 28122 592.14 562.53 646.91 # 28270 314.25 298.54 343.32 # 28122 469.71 446.22 513.15 28272 348.91 331.46 381.18 28124 424.03 402.83 463.25 # 28272 243.13 230.97 265.62 # 28124 313.81 298.12 342.84 28280 465.57 442.29 508.63 28126 345.66 328.38 377.64 # 28280 337.97 321.07 369.23 # 28126 236.17 224.36 258.01 28285 414.97 394.22 453.35 28130 597.22 567.36 652.46 # 28285 302.16 287.05 330.11 28140 556.97 529.12 608.49 28286 403.08 382.93 440.37 # 28140 426.77 405.43 466.24 # 28286 287.31 272.94 313.88 28150 384.41 365.19 419.97 28288 528.59 502.16 577.48 # 28150 270.12 256.61 295.10 # 28288 401.35 381.28 438.47 28153 360.37 342.35 393.70 28289 655.08 622.33 715.68 # 28153 247.19 234.83 270.05 # 28289 514.16 488.45 561.72 28160 370.02 351.52 404.25 28290 512.05 486.45 559.42 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 22 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 28290 371.87 353.28 406.27 28450 189.43 179.96 206.95 28292 703.32 668.15 768.37 # 28450 169.46 160.99 185.14 # 28292 561.29 533.23 613.21 28455 262.29 249.18 286.56 28293 934.02 887.32 1,020.42 # 28455 242.31 230.19 264.72 # 28293 672.52 638.89 734.72 28456 260.45 247.43 284.54 28294 666.97 633.62 728.66 28465 562.23 534.12 614.24 # 28294 503.86 478.67 550.47 28470 186.83 177.49 204.11 28296 648.47 616.05 708.46 # 28470 168.34 159.92 183.91 # 28296 497.94 473.04 544.00 28475 232.73 221.09 254.25 28297 737.31 700.44 805.51 # 28475 212.76 202.12 232.44 # 28297 560.51 532.48 612.35 28476 307.71 292.32 336.17 28298 639.16 607.20 698.28 28485 488.78 464.34 533.99 # 28298 478.26 454.35 522.50 28490 123.77 117.58 135.22 28299 813.19 772.53 888.41 # 28490 108.23 102.82 118.24 # 28299 646.01 613.71 705.77 28495 154.18 146.47 168.44 28300 610.28 579.77 666.74 # 28495 134.95 128.20 147.43 28302 621.20 590.14 678.66 28496 376.20 357.39 411.00 28304 708.85 673.41 774.42 # 28496 206.80 196.46 225.93 # 28304 553.50 525.83 604.70 28505 597.34 567.47 652.59 28305 632.31 600.69 690.79 # 28505 455.31 432.54 497.42 28306 539.26 512.30 589.15 28510 106.77 101.43 116.64 # 28306 378.37 359.45 413.37 # 28510 104.55 99.32 114.22 28307 649.73 617.24 709.83 28515 139.78 132.79 152.71 # 28307 440.39 418.37 481.13 # 28515 127.57 121.19 139.37 28308 489.00 464.55 534.23 28525 505.36 480.09 552.10 # 28308 347.71 330.32 379.87 # 28525 363.33 345.16 396.93 28309 825.13 783.87 901.45 28530 101.70 96.62 111.11 28310 476.49 452.67 520.57 # 28530 92.82 88.18 101.41 # 28310 334.46 317.74 365.40 28531 354.52 336.79 387.31 28312 440.03 418.03 480.73 # 28531 189.19 179.73 206.69 # 28312 299.48 284.51 327.19 28540 179.79 170.80 196.42 28313 463.59 440.41 506.47 # 28540 166.48 158.16 181.88 # 28313 343.75 326.56 375.54 28545 231.31 219.74 252.70 28315 421.78 400.69 460.79 # 28545 210.97 200.42 230.48 # 28315 305.65 290.37 333.93 28546 441.68 419.60 482.54 28320 575.11 546.35 628.30 # 28546 281.16 267.10 307.17 28322 693.94 659.24 758.13 28555 779.26 740.30 851.35 # 28322 535.64 508.86 585.19 # 28555 607.65 577.27 663.86 28340 540.87 513.83 590.90 28570 151.86 144.27 165.91 # 28340 407.72 387.33 445.43 # 28570 134.85 128.11 147.33 28341 622.96 591.81 680.58 28575 302.45 287.33 330.43 # 28341 482.78 458.64 527.44 # 28575 280.26 266.25 306.19 28344 413.96 393.26 452.25 28576 330.31 313.79 360.86 # 28344 285.98 271.68 312.43 28585 832.68 791.05 909.71 28345 497.51 472.63 543.52 # 28585 679.93 645.93 742.82 # 28345 370.65 352.12 404.94 28600 189.64 180.16 207.18 28360 900.63 855.60 983.94 # 28600 168.56 160.13 184.15 28400 218.17 207.26 238.35 28605 254.85 242.11 278.43 # 28400 200.05 190.05 218.56 # 28605 235.62 223.84 257.42 28405 347.04 329.69 379.14 28606 353.95 336.25 386.69 # 28405 322.25 306.14 352.06 28615 715.35 679.58 781.52 28406 474.38 450.66 518.26 28630 133.89 127.20 146.28 28415 1,033.57 981.89 1,129.17 # 28630 100.97 95.92 110.31 28420 1,107.09 1,051.74 1,209.50 28635 156.30 148.49 170.76 28430 205.00 194.75 223.96 # 28635 124.13 117.92 135.61 # 28430 182.44 173.32 199.32 28636 262.15 249.04 286.40 28435 293.67 278.99 320.84 # 28636 183.73 174.54 200.72 # 28435 269.26 255.80 294.17 28645 567.26 538.90 619.74 28436 389.15 369.69 425.14 # 28645 441.14 419.08 481.94 28445 978.07 929.17 1,068.55 28660 98.42 93.50 107.53 28446 1,091.04 1,036.49 1,191.96 # 28660 78.82 74.88 86.11 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 23 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 28665 139.82 132.83 152.75 # 29105 53.80 51.11 58.78 # 28665 124.29 118.08 135.79 29125 60.20 57.19 65.77 28666 181.44 172.37 198.23 # 29125 38.75 36.81 42.33 28675 519.58 493.60 567.64 29126 68.97 65.52 75.35 # 28675 374.22 355.51 408.84 # 29126 47.88 45.49 52.31 28705 1,201.09 1,141.04 1,312.20 29130 36.13 34.32 39.47 28715 894.85 850.11 977.63 # 29130 26.51 25.18 28.96 28725 731.73 695.14 799.41 29131 45.30 43.04 49.50 28730 773.86 735.17 845.45 # 29131 30.50 28.98 33.33 28735 735.78 698.99 803.84 29200 48.11 45.70 52.56 28737 645.88 613.59 705.63 # 29200 37.38 35.51 40.84 28740 765.19 726.93 835.97 29240 52.45 49.83 57.30 # 28740 582.84 553.70 636.76 # 29240 40.61 38.58 44.37 28750 745.11 707.85 814.03 29260 46.23 43.92 50.51 # 28750 556.48 528.66 607.96 # 29260 34.39 32.67 37.57 28755 447.29 424.93 488.67 29280 45.01 42.76 49.17 # 28755 310.44 294.92 339.16 # 29280 32.80 31.16 35.83 28760 704.93 669.68 770.13 29305 208.61 198.18 227.91 # 28760 544.04 516.84 594.37 # 29305 142.03 134.93 155.17 28800 527.08 500.73 575.84 29325 231.78 220.19 253.22 28805 705.96 670.66 771.26 # 29325 160.39 152.37 175.23 28810 410.81 390.27 448.81 29345 118.72 112.78 129.70 28820 476.02 452.22 520.05 # 29345 91.35 86.78 99.80 # 28820 324.38 308.16 354.38 29355 122.75 116.61 134.10 28825 522.78 496.64 571.14 # 29355 96.86 92.02 105.82 # 28825 377.42 358.55 412.33 29358 135.49 128.72 148.03 28890 310.63 295.10 339.37 # 29358 93.33 88.66 101.96 # 28890 210.77 200.23 230.26 29365 106.71 101.37 116.58 29000 227.97 216.57 249.06 # 29365 79.34 75.37 86.68 # 29000 148.08 140.68 161.78 29405 78.79 74.85 86.08 29010 200.42 190.40 218.96 # 29405 58.08 55.18 63.46 # 29010 130.89 124.35 143.00 29425 84.47 80.25 92.29 29015 214.09 203.39 233.90 # 29425 63.75 60.56 69.64 # 29015 144.18 136.97 157.52 29435 104.12 98.91 113.75 29020 197.17 187.31 215.41 # 29435 77.49 73.62 84.66 # 29020 125.79 119.50 137.43 29440 46.74 44.40 51.06 29025 235.53 223.75 257.31 # 29440 31.58 30.00 34.50 # 29025 159.70 151.72 174.48 29445 128.10 121.70 139.96 29035 212.39 201.77 232.04 # 29445 101.10 96.05 110.46 # 29035 126.21 119.90 137.89 29450 134.29 127.58 146.72 29040 207.54 197.16 226.73 # 29450 110.99 105.44 121.26 # 29040 140.97 133.92 154.01 29505 68.53 65.10 74.87 29044 230.46 218.94 251.78 # 29505 44.12 41.91 48.20 # 29044 146.13 138.82 159.64 29515 63.67 60.49 69.56 29046 248.82 236.38 271.84 # 29515 45.18 42.92 49.36 # 29046 165.23 156.97 180.52 29520 44.78 42.54 48.92 29049 78.90 74.96 86.20 # 29520 33.68 32.00 36.80 # 29049 57.08 54.23 62.36 29530 46.94 44.59 51.28 29055 185.74 176.45 202.92 # 29530 34.73 32.99 37.94 # 29055 122.12 116.01 133.41 29540 38.17 36.26 41.70 29058 98.91 93.96 108.05 # 29540 30.03 28.53 32.81 # 29058 74.49 70.77 81.39 29550 37.13 35.27 40.56 29065 83.20 79.04 90.90 # 29550 28.25 26.84 30.87 # 29065 61.01 57.96 66.65 29580 47.34 44.97 51.72 29075 77.46 73.59 84.63 # 29580 33.28 31.62 36.36 # 29075 55.27 52.51 60.39 29581 86.64 82.31 94.66 29085 82.28 78.17 89.90 # 29581 30.79 29.25 33.64 # 29085 59.72 56.73 65.24 29590 49.41 46.94 53.98 29086 64.79 61.55 70.78 # 29590 37.57 35.69 41.04 # 29086 44.81 42.57 48.96 29700 57.28 54.42 62.58 29105 76.36 72.54 83.42 # 29700 31.76 30.17 34.70 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 24 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 29705 59.35 56.38 64.84 29879 596.98 567.13 652.20 # 29705 43.45 41.28 47.47 29880 622.45 591.33 680.03 29710 105.87 100.58 115.67 29881 581.74 552.65 635.55 # 29710 75.54 71.76 82.52 29882 628.29 596.88 686.41 29715 78.11 74.20 85.33 29883 762.31 724.19 832.82 # 29715 51.11 48.55 55.83 29884 558.07 530.17 609.70 29720 71.14 67.58 77.72 29885 675.50 641.73 737.99 # 29720 40.07 38.07 43.78 29886 570.47 541.95 623.24 29730 57.71 54.82 63.04 29887 671.71 638.12 733.84 # 29730 41.81 39.72 45.68 29888 899.79 854.80 983.02 29740 81.68 77.60 89.24 29889 1,105.08 1,049.83 1,207.30 # 29740 60.23 57.22 65.80 29891 632.36 600.74 690.85 29750 91.40 86.83 99.85 29892 660.98 627.93 722.12 # 29750 70.68 67.15 77.22 29893 541.88 514.79 592.01 29800 472.16 448.55 515.83 # 29893 399.48 379.51 436.44 29804 586.65 557.32 640.92 29894 469.17 445.71 512.57 29805 423.44 402.27 462.61 29895 451.66 429.08 493.44 29806 964.00 915.80 1,053.17 29897 474.58 450.85 518.48 29807 939.48 892.51 1,026.39 29898 529.24 502.78 578.20 29819 529.15 502.69 578.09 29899 957.51 909.63 1,046.07 29820 487.98 463.58 533.12 29900 395.06 375.31 431.61 29821 533.97 507.27 583.36 29901 459.65 436.67 502.17 29822 518.94 492.99 566.94 29902 515.58 489.80 563.27 29823 567.74 539.35 620.25 29904 566.50 538.18 618.91 29824 609.21 578.75 665.56 29905 611.09 580.54 667.62 29825 528.78 502.34 577.69 29906 643.55 611.37 703.08 29826 604.83 574.59 660.78 29907 781.21 742.15 853.47 29827 983.00 933.85 1,073.93 30000 209.80 199.31 229.21 29828 830.20 788.69 906.99 # 30000 108.82 103.38 118.89 29830 408.17 387.76 445.92 30020 204.99 194.74 223.95 29834 444.42 422.20 485.53 # 30020 109.56 104.08 119.69 29835 455.71 432.92 497.86 30100 127.68 121.30 139.50 29836 526.30 499.99 574.99 # 30100 64.80 61.56 70.79 29837 477.24 453.38 521.39 30110 205.95 195.65 225.00 29838 534.19 507.48 583.60 # 30110 120.51 114.48 131.65 29840 404.08 383.88 441.46 30115 394.35 374.63 430.82 29843 433.59 411.91 473.70 30117 766.03 727.73 836.89 29844 447.81 425.42 489.23 # 30117 307.76 292.37 336.23 29845 515.52 489.74 563.20 30118 708.70 673.27 774.26 29846 470.29 446.78 513.80 30120 473.11 449.45 516.87 29847 489.99 465.49 535.31 # 30120 409.86 389.37 447.78 29848 453.57 430.89 495.52 30124 250.35 237.83 273.50 29850 528.68 502.25 577.59 30125 564.65 536.42 616.88 29851 844.99 802.74 923.15 30130 345.87 328.58 377.87 29855 711.54 675.96 777.35 30140 397.12 377.26 433.85 29856 906.66 861.33 990.53 30150 720.90 684.86 787.59 29860 593.08 563.43 647.94 30160 724.87 688.63 791.92 29861 654.79 622.05 715.36 30200 102.06 96.96 111.50 29862 735.43 698.66 803.46 # 30200 55.83 53.04 61.00 29863 733.58 696.90 801.44 30210 134.94 128.19 147.42 29866 947.60 900.22 1,035.25 # 30210 91.67 87.09 100.15 29867 1,152.74 1,095.10 1,259.37 30220 267.32 253.95 292.04 29868 1,521.18 1,445.12 1,661.89 # 30220 116.04 110.24 126.78 29870 531.05 504.50 580.18 30300 206.39 196.07 225.48 # 29870 368.67 350.24 402.78 # 30300 113.18 107.52 123.65 29871 461.32 438.25 503.99 30310 188.19 178.78 205.60 29873 465.99 442.69 509.09 30320 414.91 394.16 453.28 29874 485.06 460.81 529.93 30400 947.93 900.53 1,035.61 29875 446.39 424.07 487.68 30410 1,116.64 1,060.81 1,219.93 29876 589.97 560.47 644.54 30420 1,267.31 1,203.94 1,384.53 29877 559.15 531.19 610.87 30430 834.64 792.91 911.85 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 25 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 30435 1,081.24 1,027.18 1,181.26 # 31235 153.47 145.80 167.67 30450 1,432.37 1,360.75 1,564.86 31237 300.46 285.44 328.26 30460 714.69 678.96 780.80 # 31237 171.75 163.16 187.63 30462 1,384.71 1,315.47 1,512.79 31238 309.61 294.13 338.25 30465 903.50 858.33 987.08 # 31238 186.82 177.48 204.10 30520 562.92 534.77 614.99 31239 622.59 591.46 680.18 30540 621.67 590.59 679.18 31240 152.41 144.79 166.51 30545 839.53 797.55 917.18 31254 260.12 247.11 284.18 30560 244.12 231.91 266.70 31255 382.15 363.04 417.50 # 30560 127.24 120.88 139.01 31256 188.25 178.84 205.67 30580 573.87 545.18 626.96 31267 302.58 287.45 330.57 # 30580 456.99 434.14 499.26 31276 481.77 457.68 526.33 30600 526.63 500.30 575.35 31287 221.22 210.16 241.68 # 30600 403.09 382.94 440.38 31288 256.53 243.70 280.26 30620 567.82 539.43 620.34 31290 1,089.09 1,034.64 1,189.84 30630 574.08 545.38 627.19 31291 1,145.91 1,088.61 1,251.90 30801 205.20 194.94 224.18 31292 941.22 894.16 1,028.28 # 30801 122.72 116.58 134.07 31293 1,025.31 974.04 1,120.15 30802 263.71 250.52 288.10 31294 1,174.74 1,116.00 1,283.40 # 30802 173.46 164.79 189.51 31300 1,170.54 1,112.01 1,278.81 30901 95.40 90.63 104.22 31320 600.22 570.21 655.74 # 30901 58.04 55.14 63.41 31360 1,891.74 1,797.15 2,066.72 30903 177.88 168.99 194.34 31365 2,355.28 2,237.52 2,573.15 # 30903 75.79 72.00 82.80 31367 2,027.86 1,926.47 2,215.44 30905 220.97 209.92 241.41 31368 2,256.43 2,143.61 2,465.15 # 30905 96.69 91.86 105.64 31370 1,905.72 1,810.43 2,081.99 30906 252.35 239.73 275.69 31375 1,805.06 1,714.81 1,972.03 # 30906 126.97 120.62 138.71 31380 1,777.07 1,688.22 1,941.45 30915 532.96 506.31 582.26 31382 1,950.45 1,852.93 2,130.87 30920 767.67 729.29 838.68 31390 2,616.46 2,485.64 2,858.49 30930 112.44 106.82 122.84 31395 2,770.20 2,631.69 3,026.44 31000 162.94 154.79 178.01 31400 927.98 881.58 1,013.82 # 31000 96.73 91.89 105.67 31420 776.62 737.79 848.46 31002 184.58 175.35 201.65 31500 104.05 98.85 113.68 31020 438.28 416.37 478.83 31502 33.30 31.64 36.39 # 31020 323.25 307.09 353.15 31505 77.01 73.16 84.13 31030 631.19 599.63 689.57 # 31505 45.94 43.64 50.19 # 31030 477.33 453.46 521.48 31510 195.37 185.60 213.44 31032 524.25 498.04 572.75 # 31510 114.37 108.65 124.95 31040 689.49 655.02 753.27 31511 194.95 185.20 212.98 31050 452.33 429.71 494.17 # 31511 122.08 115.98 133.38 31051 592.47 562.85 647.28 31512 192.71 183.07 210.53 31070 400.70 380.67 437.77 # 31512 123.18 117.02 134.57 31075 722.35 686.23 789.16 31513 125.53 119.25 137.14 31080 934.75 888.01 1,021.21 31515 193.17 183.51 211.04 31081 1,182.65 1,123.52 1,292.05 # 31515 104.03 98.83 113.65 31084 1,083.58 1,029.40 1,183.81 31520 146.94 139.59 160.53 31085 1,229.03 1,167.58 1,342.72 31525 231.90 220.31 253.36 31086 1,033.73 982.04 1,129.35 # 31525 151.27 143.71 165.27 31087 1,010.43 959.91 1,103.90 31526 150.25 142.74 164.15 31090 929.82 883.33 1,015.83 31527 184.58 175.35 201.65 31200 499.10 474.15 545.27 31528 137.28 130.42 149.98 31201 673.03 639.38 735.29 31529 154.32 146.60 168.59 31205 799.95 759.95 873.94 31530 188.46 179.04 205.90 31225 1,713.13 1,627.47 1,871.59 31531 203.47 193.30 222.30 31230 1,915.58 1,819.80 2,092.77 31535 181.06 172.01 197.81 31231 174.94 166.19 191.12 31536 202.04 191.94 220.73 # 31231 72.48 68.86 79.19 31540 231.96 220.36 253.41 31233 243.75 231.56 266.29 31541 253.48 240.81 276.93 # 31233 129.46 122.99 141.44 31545 347.00 329.65 379.10 31235 278.48 264.56 304.24 31546 524.28 498.07 572.78 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 26 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 31560 300.73 285.69 328.54 31637 74.49 70.77 81.39 31561 328.66 312.23 359.06 31638 245.64 233.36 268.36 31570 319.85 303.86 349.44 31640 247.97 235.57 270.91 # 31570 217.77 206.88 237.91 31641 247.49 235.12 270.39 31571 239.31 227.34 261.44 31643 168.76 160.32 184.37 31575 107.25 101.89 117.17 31645 289.50 275.03 316.28 # 31575 72.11 68.50 78.78 # 31645 154.50 146.78 168.80 31576 208.79 198.35 228.10 31646 263.23 250.07 287.58 # 31576 117.07 111.22 127.90 # 31646 133.78 127.09 146.15 31577 224.58 213.35 245.35 31656 297.46 282.59 324.98 # 31577 141.73 134.64 154.84 # 31656 106.98 101.63 116.87 31578 260.95 247.90 285.09 31715 52.52 49.89 57.37 # 31578 161.83 153.74 176.80 31717 274.06 260.36 299.41 31579 201.27 191.21 219.89 # 31717 104.66 99.43 114.34 # 31579 133.58 126.90 145.94 31720 49.65 47.17 54.25 31580 1,121.61 1,065.53 1,225.36 31725 89.92 85.42 98.23 31582 1,770.31 1,681.79 1,934.06 31730 893.35 848.68 975.98 31584 1,405.09 1,334.84 1,535.07 # 31730 140.30 133.29 153.28 31587 927.51 881.13 1,013.30 31750 1,253.18 1,190.52 1,369.10 31588 1,059.10 1,006.15 1,157.07 31755 1,590.00 1,510.50 1,737.08 31590 824.11 782.90 900.34 31760 1,302.89 1,237.75 1,423.41 31595 710.17 674.66 775.86 31766 1,706.89 1,621.55 1,864.78 31600 372.16 353.55 406.58 31770 1,261.16 1,198.10 1,377.82 31601 247.51 235.13 270.40 31775 1,308.15 1,242.74 1,429.15 31603 210.02 199.52 229.45 31780 1,121.00 1,064.95 1,224.69 31605 171.59 163.01 187.46 31781 1,386.11 1,316.80 1,514.32 31610 658.34 625.42 719.23 31785 1,019.80 968.81 1,114.13 31611 497.12 472.26 543.10 31786 1,391.96 1,322.36 1,520.71 31612 74.83 71.09 81.75 31800 650.63 618.10 710.82 # 31612 45.24 42.98 49.43 31805 782.86 743.72 855.28 31613 412.70 392.07 450.88 31820 398.42 378.50 435.28 31614 688.31 653.89 751.97 # 31820 305.58 290.30 333.85 31615 170.12 161.61 185.85 31825 555.94 528.14 607.36 # 31615 120.93 114.88 132.11 # 31825 450.53 428.00 492.20 31620 263.59 250.41 287.97 31830 400.46 380.44 437.51 # 31620 66.45 63.13 72.60 # 31830 316.13 300.32 345.37 31622 296.75 281.91 324.20 32035 669.95 636.45 731.92 # 31622 139.56 132.58 152.47 32036 725.27 689.01 792.36 31623 322.52 306.39 352.35 32095 593.68 564.00 648.60 # 31623 140.92 133.87 153.95 32100 904.57 859.34 988.24 31624 300.70 285.67 328.52 32110 1,369.55 1,301.07 1,496.23 # 31624 141.66 134.58 154.77 32120 823.51 782.33 899.68 31625 323.37 307.20 353.28 32124 873.25 829.59 954.03 # 31625 164.33 156.11 179.53 32140 935.33 888.56 1,021.84 31626 422.13 401.02 461.17 32141 1,436.38 1,364.56 1,569.24 # 31626 205.02 194.77 223.99 32150 941.34 894.27 1,028.41 31627 1,188.94 1,129.49 1,298.91 32151 955.93 908.13 1,044.35 # 31627 99.68 94.70 108.91 32160 729.28 692.82 796.74 31628 383.88 364.69 419.39 32200 1,061.68 1,008.60 1,159.89 # 31628 183.04 173.89 199.97 32201 878.78 834.84 960.07 31629 592.17 562.56 646.94 # 32201 199.70 189.72 218.18 # 31629 197.16 187.30 215.40 32215 755.41 717.64 825.29 31630 194.75 185.01 212.76 32220 1,505.00 1,429.75 1,644.21 31631 221.00 209.95 241.44 32225 939.60 892.62 1,026.51 31632 68.56 65.13 74.90 32310 866.14 822.83 946.25 # 31632 47.48 45.11 51.88 32320 1,509.37 1,433.90 1,648.99 31633 83.98 79.78 91.75 32400 143.52 136.34 156.79 # 31633 61.41 58.34 67.09 # 32400 86.19 81.88 94.16 31635 331.33 314.76 361.97 32402 534.54 507.81 583.98 # 31635 181.90 172.81 198.73 32405 96.82 91.98 105.78 31636 215.38 204.61 235.30 # 32405 96.45 91.63 105.37 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 27 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 32420 107.85 102.46 117.83 32854 3,201.02 3,040.97 3,497.12 32421 149.99 142.49 163.86 32855 257.29 244.43 281.09 # 32421 74.91 71.16 81.83 32856 310.42 294.90 339.14 32422 189.22 179.76 206.72 32900 1,297.55 1,232.67 1,417.57 # 32422 120.05 114.05 131.16 32905 1,267.16 1,203.80 1,384.37 32440 1,496.17 1,421.36 1,634.56 32906 1,570.12 1,491.61 1,715.35 32442 2,723.88 2,587.69 2,975.84 32940 1,164.04 1,105.84 1,271.72 32445 3,105.36 2,950.09 3,392.60 32960 136.04 129.24 148.63 32480 1,412.89 1,342.25 1,543.59 # 32960 97.94 93.04 107.00 32482 1,510.85 1,435.31 1,650.61 32997 342.34 325.22 374.00 32484 1,370.22 1,301.71 1,496.97 32998 2,722.48 2,586.36 2,974.31 32486 2,225.38 2,114.11 2,431.23 # 32998 291.72 277.13 318.70 32488 2,253.71 2,141.02 2,462.17 33010 120.02 114.02 131.12 32491 1,410.23 1,339.72 1,540.68 33011 118.34 112.42 129.28 32500 1,370.75 1,302.21 1,497.54 33015 510.49 484.97 557.72 32501 235.39 223.62 257.16 33020 831.60 790.02 908.52 32503 1,719.13 1,633.17 1,878.15 33025 762.75 724.61 833.30 32504 1,969.33 1,870.86 2,151.49 33030 1,224.31 1,163.09 1,337.55 32540 1,621.91 1,540.81 1,771.93 33031 1,365.50 1,297.23 1,491.81 32550 752.57 714.94 822.18 33050 948.66 901.23 1,036.41 # 32550 217.37 206.50 237.48 33120 1,487.46 1,413.09 1,625.05 32551 165.08 156.83 180.35 33130 1,385.26 1,316.00 1,513.40 32552 173.12 164.46 189.13 33140 1,514.95 1,439.20 1,655.08 # 32552 152.03 144.43 166.09 33141 134.62 127.89 147.07 32553 577.38 548.51 630.79 33202 742.71 705.57 811.41 # 32553 193.45 183.78 211.35 33203 786.16 746.85 858.88 32560 252.87 240.23 276.26 33206 457.44 434.57 499.76 # 32560 82.36 78.24 89.98 33207 487.17 462.81 532.23 32561 90.82 86.28 99.22 33208 526.42 500.10 575.12 # 32561 68.25 64.84 74.57 33210 180.49 171.47 197.19 32562 80.72 76.68 88.18 33211 181.99 172.89 198.82 # 32562 61.12 58.06 66.77 33212 338.99 322.04 370.35 32601 293.95 279.25 321.14 33213 386.89 367.55 422.68 32602 318.43 302.51 347.89 33214 482.54 458.41 527.17 32603 413.87 393.18 452.16 33215 306.58 291.25 334.94 32604 462.36 439.24 505.13 33216 380.19 361.18 415.36 32605 365.91 347.61 399.75 33217 376.91 358.06 411.77 32606 442.32 420.20 483.23 33218 395.19 375.43 431.74 32650 634.11 602.40 692.76 33220 399.31 379.34 436.24 32651 1,023.20 972.04 1,117.85 33222 346.94 329.59 379.03 32652 1,555.30 1,477.54 1,699.17 33223 417.83 396.94 456.48 32653 987.67 938.29 1,079.03 33224 509.66 484.18 556.81 32654 1,103.98 1,048.78 1,206.10 33225 459.50 436.53 502.01 32655 898.65 853.72 981.78 33226 490.69 466.16 536.08 32656 758.61 720.68 828.78 33233 242.29 230.18 264.71 32657 746.55 709.22 815.60 33234 489.44 464.97 534.72 32658 681.91 647.81 744.98 33235 637.38 605.51 696.34 32659 697.78 662.89 762.32 33236 750.68 713.15 820.12 32660 991.30 941.74 1,083.00 33237 818.38 777.46 894.08 32661 761.38 723.31 831.81 33238 893.48 848.81 976.13 32662 854.46 811.74 933.50 33240 467.73 444.34 510.99 32663 1,331.19 1,264.63 1,454.32 33241 228.59 217.16 249.73 32664 804.10 763.90 878.49 33243 1,326.94 1,260.59 1,449.68 32665 1,169.68 1,111.20 1,277.88 33244 860.01 817.01 939.56 32800 869.48 826.01 949.91 33249 914.95 869.20 999.58 32810 851.39 808.82 930.14 33250 1,408.10 1,337.70 1,538.36 32815 2,606.60 2,476.27 2,847.71 33251 1,563.62 1,485.44 1,708.26 32820 1,272.78 1,209.14 1,390.51 33254 1,307.46 1,242.09 1,428.40 32851 2,458.70 2,335.77 2,686.14 33255 1,594.55 1,514.82 1,742.04 32852 2,724.76 2,588.52 2,976.80 33256 1,894.39 1,799.67 2,069.62 32853 2,924.00 2,777.80 3,194.47 33257 561.41 533.34 613.34 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 28 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 33258 631.52 599.94 689.93 33512 2,341.73 2,224.64 2,558.34 33259 815.01 774.26 890.40 33513 2,394.76 2,275.02 2,616.27 33261 1,555.56 1,477.78 1,699.45 33514 2,542.98 2,415.83 2,778.20 33265 1,300.58 1,235.55 1,420.88 33516 2,637.99 2,506.09 2,882.00 33266 1,776.87 1,688.03 1,941.23 33517 180.83 171.79 197.56 33282 327.32 310.95 357.59 33518 395.00 375.25 431.54 33284 236.63 224.80 258.52 33519 524.23 498.02 572.72 33300 2,296.21 2,181.40 2,508.61 33521 631.32 599.75 689.71 33305 3,684.76 3,500.52 4,025.60 33522 712.19 676.58 778.07 33310 1,118.03 1,062.13 1,221.45 33523 809.40 768.93 884.27 33315 1,424.77 1,353.53 1,556.56 33530 503.58 478.40 550.16 33320 1,018.60 967.67 1,112.82 33533 1,829.27 1,737.81 1,998.48 33321 1,136.85 1,080.01 1,242.01 33534 2,144.39 2,037.17 2,342.75 33322 1,337.04 1,270.19 1,460.72 33535 2,387.00 2,267.65 2,607.80 33330 1,374.96 1,306.21 1,502.14 33536 2,562.31 2,434.19 2,799.32 33332 1,342.03 1,274.93 1,466.17 33542 2,502.04 2,376.94 2,733.48 33335 1,812.51 1,721.88 1,980.16 33545 2,942.82 2,795.68 3,215.03 33400 2,200.96 2,090.91 2,404.55 33548 2,871.13 2,727.57 3,136.71 33401 1,407.25 1,336.89 1,537.42 33572 224.50 213.28 245.27 33403 1,443.58 1,371.40 1,577.11 33600 1,632.89 1,551.25 1,783.94 33404 1,701.12 1,616.06 1,858.47 33602 1,583.87 1,504.68 1,730.38 33405 2,216.95 2,106.10 2,422.02 33606 1,710.45 1,624.93 1,868.67 33406 2,770.85 2,632.31 3,027.16 33608 1,731.87 1,645.28 1,892.07 33410 2,450.30 2,327.79 2,676.96 33610 1,695.53 1,610.75 1,852.36 33411 3,042.21 2,890.10 3,323.62 33611 1,883.23 1,789.07 2,057.43 33412 2,378.40 2,259.48 2,598.40 33612 1,911.67 1,816.09 2,088.50 33413 2,941.97 2,794.87 3,214.10 33615 1,929.95 1,833.45 2,108.47 33414 2,088.86 1,984.42 2,282.08 33617 2,055.66 1,952.88 2,245.81 33415 1,942.06 1,844.96 2,121.70 33619 2,545.65 2,418.37 2,781.13 33416 1,946.96 1,849.61 2,127.05 33641 1,566.19 1,487.88 1,711.06 33417 1,610.65 1,530.12 1,759.64 33645 1,520.00 1,444.00 1,660.60 33420 1,333.45 1,266.78 1,456.80 33647 1,712.97 1,627.32 1,871.42 33422 1,619.97 1,538.97 1,769.82 33660 1,687.84 1,603.45 1,843.97 33425 2,591.30 2,461.74 2,831.00 33665 1,939.97 1,842.97 2,119.42 33426 2,306.35 2,191.03 2,519.68 33670 1,905.58 1,810.30 2,081.85 33427 2,378.91 2,259.96 2,598.95 33675 1,894.58 1,799.85 2,069.83 33430 2,693.70 2,559.02 2,942.87 33676 1,892.63 1,798.00 2,067.70 33460 2,427.54 2,306.16 2,652.08 33677 1,966.52 1,868.19 2,148.42 33463 2,934.60 2,787.87 3,206.05 33681 1,764.23 1,676.02 1,927.42 33464 2,337.29 2,220.43 2,553.49 33684 1,910.85 1,815.31 2,087.61 33465 2,623.19 2,492.03 2,865.83 33688 1,801.25 1,711.19 1,967.87 33468 1,802.42 1,712.30 1,969.15 33690 1,131.37 1,074.80 1,236.02 33470 1,184.05 1,124.85 1,293.58 33692 1,629.03 1,547.58 1,779.72 33471 1,221.82 1,160.73 1,334.84 33694 1,891.00 1,796.45 2,065.92 33472 1,226.10 1,164.80 1,339.52 33697 2,043.09 1,940.94 2,232.08 33474 2,022.93 1,921.78 2,210.05 33702 1,477.33 1,403.46 1,613.98 33475 2,238.88 2,126.94 2,445.98 33710 1,742.20 1,655.09 1,903.35 33476 1,441.15 1,369.09 1,574.45 33720 1,482.87 1,408.73 1,620.04 33478 1,509.54 1,434.06 1,649.17 33722 1,550.42 1,472.90 1,693.84 33496 1,611.70 1,531.12 1,760.79 33724 1,494.98 1,420.23 1,633.26 33500 1,514.18 1,438.47 1,654.24 33726 1,970.93 1,872.38 2,153.24 33501 1,072.76 1,019.12 1,171.99 33730 1,890.74 1,796.20 2,065.63 33502 1,220.31 1,159.29 1,333.18 33732 1,583.60 1,504.42 1,730.08 33503 1,308.85 1,243.41 1,429.92 33735 1,231.71 1,170.12 1,345.64 33504 1,396.30 1,326.49 1,525.46 33736 1,347.64 1,280.26 1,472.30 33505 1,972.20 1,873.59 2,154.63 33737 1,239.92 1,177.92 1,354.61 33506 1,971.08 1,872.53 2,153.41 33750 1,365.21 1,296.95 1,491.49 33507 1,661.67 1,578.59 1,815.38 33755 1,229.16 1,167.70 1,342.86 33508 15.55 14.77 16.99 33762 1,193.57 1,133.89 1,303.97 33510 1,888.70 1,794.27 2,063.41 33764 1,238.84 1,176.90 1,353.44 33511 2,068.65 1,965.22 2,260.00 33766 1,309.77 1,244.28 1,430.92 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 29 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 33767 1,352.75 1,285.11 1,477.88 33971 692.89 658.25 756.99 33768 393.20 373.54 429.57 33973 511.69 486.11 559.03 33770 2,060.11 1,957.10 2,250.67 33974 879.05 835.10 960.37 33771 2,027.99 1,926.59 2,215.58 33975 1,061.26 1,008.20 1,159.43 33774 1,732.05 1,645.45 1,892.27 33976 1,178.74 1,119.80 1,287.77 33775 1,732.96 1,646.31 1,893.26 33977 1,162.36 1,104.24 1,269.88 33776 1,829.72 1,738.23 1,998.96 33978 1,280.17 1,216.16 1,398.58 33777 1,777.61 1,688.73 1,942.04 33979 2,318.74 2,202.80 2,533.22 33778 2,195.72 2,085.93 2,398.82 33980 3,298.22 3,133.31 3,603.31 33779 2,177.72 2,068.83 2,379.15 34001 948.23 900.82 1,035.94 33780 2,338.80 2,221.86 2,555.14 34051 943.48 896.31 1,030.76 33781 2,155.19 2,047.43 2,354.54 34101 597.15 567.29 652.38 33782 2,889.44 2,744.97 3,156.72 34111 597.34 567.47 652.59 33783 3,137.02 2,980.17 3,427.20 34151 1,374.08 1,305.38 1,501.19 33786 2,124.51 2,018.28 2,321.02 34201 1,001.82 951.73 1,094.49 33788 1,431.53 1,359.95 1,563.94 34203 951.95 904.35 1,040.00 33800 937.04 890.19 1,023.72 34401 1,417.51 1,346.63 1,548.62 33802 1,020.58 969.55 1,114.98 34421 724.98 688.73 792.04 33803 1,089.48 1,035.01 1,190.26 34451 1,468.98 1,395.53 1,604.86 33813 1,225.41 1,164.14 1,338.76 34471 1,098.65 1,043.72 1,200.28 33814 1,462.60 1,389.47 1,597.89 34490 600.52 570.49 656.06 33820 936.79 889.95 1,023.44 34501 917.40 871.53 1,002.26 33822 953.88 906.19 1,042.12 34502 1,493.11 1,418.45 1,631.22 33824 1,132.71 1,076.07 1,237.48 34510 1,071.15 1,017.59 1,170.23 33840 1,158.88 1,100.94 1,266.08 34520 1,009.48 959.01 1,102.86 33845 1,309.02 1,243.57 1,430.11 34530 982.68 933.55 1,073.58 33851 1,207.68 1,147.30 1,319.40 34800 1,126.39 1,070.07 1,230.58 33852 1,409.25 1,338.79 1,539.61 34802 1,241.01 1,178.96 1,355.80 33853 1,888.61 1,794.18 2,063.31 34803 1,280.27 1,216.26 1,398.70 33860 2,892.58 2,747.95 3,160.14 34804 1,242.09 1,179.99 1,356.99 33861 2,337.68 2,220.80 2,553.92 34805 1,173.32 1,114.65 1,281.85 33863 2,858.25 2,715.34 3,122.64 34806 102.38 97.26 111.85 33864 2,940.16 2,793.15 3,212.12 34808 202.17 192.06 220.87 33870 2,436.35 2,314.53 2,661.71 34812 331.29 314.73 361.94 33875 1,897.12 1,802.26 2,072.60 34813 233.91 222.21 255.54 33877 3,284.46 3,120.24 3,588.28 34820 478.65 454.72 522.93 33880 1,781.70 1,692.62 1,946.51 34825 696.79 661.95 761.24 33881 1,530.77 1,454.23 1,672.36 34826 204.03 193.83 222.90 33883 1,108.58 1,053.15 1,211.12 34830 1,791.97 1,702.37 1,957.73 33884 402.92 382.77 440.19 34831 1,904.04 1,808.84 2,080.17 33886 951.84 904.25 1,039.89 34832 1,925.86 1,829.57 2,104.01 33889 778.64 739.71 850.67 34833 601.18 571.12 656.79 33891 974.92 926.17 1,065.10 34834 272.32 258.70 297.51 33910 1,606.88 1,526.54 1,755.52 34900 895.04 850.29 977.83 33915 1,312.00 1,246.40 1,433.36 35001 1,117.84 1,061.95 1,221.24 33916 1,587.32 1,507.95 1,734.14 35002 1,191.40 1,131.83 1,301.60 33917 1,427.87 1,356.48 1,559.95 35005 1,034.25 982.54 1,129.92 33920 1,743.22 1,656.06 1,904.47 35011 979.92 930.92 1,070.56 33922 1,329.14 1,262.68 1,452.08 35013 1,218.90 1,157.96 1,331.65 33924 274.09 260.39 299.45 35021 1,196.06 1,136.26 1,306.70 33925 1,670.91 1,587.36 1,825.46 35022 1,357.45 1,289.58 1,483.02 33926 2,291.19 2,176.63 2,503.12 35045 956.01 908.21 1,044.44 33933 355.82 338.03 388.73 35081 1,724.22 1,638.01 1,883.71 33935 3,150.22 2,992.71 3,441.62 35082 2,150.95 2,043.40 2,349.91 33944 250.75 238.21 273.94 35091 1,788.52 1,699.09 1,953.95 33945 4,411.45 4,190.88 4,819.51 35092 2,571.09 2,442.54 2,808.92 33960 951.91 904.31 1,039.96 35102 1,866.02 1,772.72 2,038.63 33961 536.20 509.39 585.80 35103 2,215.58 2,104.80 2,420.52 33967 264.91 251.66 289.41 35111 1,381.68 1,312.60 1,509.49 33968 34.02 32.32 37.17 35112 1,696.44 1,611.62 1,853.36 33970 352.72 335.08 385.34 35121 1,619.92 1,538.92 1,769.76 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 30 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 35122 1,964.59 1,866.36 2,146.31 35472 2,079.45 1,975.48 2,271.80 35131 1,378.09 1,309.19 1,505.57 # 35472 363.26 345.10 396.87 35132 1,672.13 1,588.52 1,826.80 35473 1,985.91 1,886.61 2,169.60 35141 1,095.10 1,040.35 1,196.40 # 35473 320.77 304.73 350.44 35142 1,313.13 1,247.47 1,434.59 35474 2,631.46 2,499.89 2,874.87 35151 1,236.12 1,174.31 1,350.46 # 35474 388.59 369.16 424.53 35152 1,427.94 1,356.54 1,560.02 35475 2,196.90 2,087.06 2,400.12 35180 844.99 802.74 923.15 # 35475 486.26 461.95 531.24 35182 1,701.07 1,616.02 1,858.42 35476 1,657.13 1,574.27 1,810.41 35184 1,007.58 957.20 1,100.78 # 35476 310.44 294.92 339.16 35188 843.43 801.26 921.45 35480 552.09 524.49 603.16 35189 1,568.50 1,490.08 1,713.59 35481 393.76 374.07 430.18 35190 733.17 696.51 800.99 35482 342.90 325.76 374.62 35201 916.65 870.82 1,001.44 35483 416.99 396.14 455.56 35206 749.87 712.38 819.24 35484 521.04 494.99 569.24 35207 684.33 650.11 747.63 35485 484.46 460.24 529.28 35211 1,334.90 1,268.16 1,458.38 35490 609.73 579.24 666.13 35216 1,915.52 1,819.74 2,092.70 35491 409.84 389.35 447.75 35221 1,373.97 1,305.27 1,501.06 35492 371.45 352.88 405.81 35226 825.29 784.03 901.63 35493 450.69 428.16 492.38 35231 1,149.23 1,091.77 1,255.54 35494 574.26 545.55 627.38 35236 957.12 909.26 1,045.65 35495 522.05 495.95 570.34 35241 1,390.20 1,320.69 1,518.79 35500 316.64 300.81 345.93 35246 1,485.75 1,411.46 1,623.18 35501 1,542.42 1,465.30 1,685.10 35251 1,629.41 1,547.94 1,780.13 35506 1,323.28 1,257.12 1,445.69 35256 1,004.04 953.84 1,096.92 35508 1,382.98 1,313.83 1,510.90 35261 1,023.29 972.13 1,117.95 35509 1,476.01 1,402.21 1,612.54 35266 845.27 803.01 923.46 35510 1,259.64 1,196.66 1,376.16 35271 1,334.97 1,268.22 1,458.45 35511 1,186.35 1,127.03 1,296.08 35276 1,390.14 1,320.63 1,518.72 35512 1,228.52 1,167.09 1,342.15 35281 1,555.79 1,478.00 1,699.70 35515 1,339.52 1,272.54 1,463.42 35286 924.27 878.06 1,009.77 35516 1,216.68 1,155.85 1,329.23 35301 1,035.40 983.63 1,131.17 35518 1,177.44 1,118.57 1,286.36 35302 1,101.00 1,045.95 1,202.84 35521 1,247.70 1,185.32 1,363.12 35303 1,211.74 1,151.15 1,323.82 35522 1,210.59 1,150.06 1,322.57 35304 1,259.19 1,196.23 1,375.66 35523 1,279.65 1,215.67 1,398.02 35305 1,210.26 1,149.75 1,322.21 35525 1,129.54 1,073.06 1,234.02 35306 446.34 424.02 487.62 35526 1,659.30 1,576.34 1,812.79 35311 1,488.48 1,414.06 1,626.17 35531 1,998.61 1,898.68 2,183.48 35321 881.50 837.43 963.04 35533 1,576.75 1,497.91 1,722.60 35331 1,448.81 1,376.37 1,582.83 35535 1,899.92 1,804.92 2,075.66 35341 1,358.26 1,290.35 1,483.90 35536 1,710.44 1,624.92 1,868.66 35351 1,269.71 1,206.22 1,387.15 35537 2,118.38 2,012.46 2,314.33 35355 1,032.41 980.79 1,127.91 35538 2,378.10 2,259.20 2,598.08 35361 1,549.92 1,472.42 1,693.28 35539 2,208.62 2,098.19 2,412.92 35363 1,698.49 1,613.57 1,855.61 35540 2,490.77 2,366.23 2,721.16 35371 813.07 772.42 888.28 35548 1,180.72 1,121.68 1,289.93 35372 973.43 924.76 1,063.47 35549 1,270.57 1,207.04 1,388.10 35390 157.72 149.83 172.30 35551 1,480.70 1,406.67 1,617.67 35400 148.62 141.19 162.37 35556 1,382.12 1,313.01 1,509.96 35450 507.52 482.14 554.46 35558 1,215.52 1,154.74 1,327.95 35452 352.09 334.49 384.66 35560 1,757.08 1,669.23 1,919.61 35454 307.20 291.84 335.62 35563 1,375.35 1,306.58 1,502.57 35456 372.97 354.32 407.47 35565 1,308.96 1,243.51 1,430.04 35458 480.39 456.37 524.83 35566 1,653.42 1,570.75 1,806.36 35459 438.79 416.85 479.38 35570 1,473.96 1,400.26 1,610.30 35460 306.67 291.34 335.04 35571 1,325.81 1,259.52 1,448.45 35470 2,709.51 2,574.03 2,960.13 35572 341.87 324.78 373.50 # 35470 454.06 431.36 496.06 35583 1,427.72 1,356.33 1,559.78 35471 2,934.53 2,787.80 3,205.97 35585 1,661.77 1,578.68 1,815.48 # 35471 542.22 515.11 592.38 35587 1,366.41 1,298.09 1,492.80 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 31 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 35600 251.92 239.32 275.22 # 36002 106.70 101.37 116.58 35601 1,436.01 1,364.21 1,568.84 36005 331.07 314.52 361.70 35606 1,167.27 1,108.91 1,275.25 # 36005 48.86 46.42 53.38 35612 904.13 858.92 987.76 36010 555.29 527.53 606.66 35616 1,140.33 1,083.31 1,245.81 # 36010 121.07 115.02 132.27 35621 1,093.96 1,039.26 1,195.15 36011 894.92 850.17 977.70 35623 1,336.12 1,269.31 1,459.71 # 36011 156.67 148.84 171.17 35626 1,538.86 1,461.92 1,681.21 36012 854.52 811.79 933.56 35631 1,831.69 1,740.11 2,001.13 # 36012 177.67 168.79 194.11 35632 1,803.76 1,713.57 1,970.61 36013 779.23 740.27 851.31 35633 1,946.75 1,849.41 2,126.82 # 36013 127.15 120.79 138.91 35634 1,765.88 1,677.59 1,929.23 36014 817.13 776.27 892.71 35636 1,623.85 1,542.66 1,774.06 # 36014 152.85 145.21 166.99 35637 1,693.81 1,609.12 1,850.49 36015 891.60 847.02 974.07 35638 1,728.32 1,641.90 1,888.19 # 36015 176.64 167.81 192.98 35642 1,020.07 969.07 1,114.43 36100 512.56 486.93 559.97 35645 978.49 929.57 1,069.01 # 36100 157.85 149.96 172.45 35646 1,703.74 1,618.55 1,861.33 36120 432.45 410.83 472.45 35647 1,541.10 1,464.05 1,683.66 # 36120 98.83 93.89 107.97 35650 1,055.58 1,002.80 1,153.22 36140 469.77 446.28 513.22 35651 1,382.96 1,313.81 1,510.88 # 36140 102.49 97.37 111.98 35654 1,362.21 1,294.10 1,488.22 36147 774.11 735.40 845.71 35656 1,072.96 1,019.31 1,172.21 # 36147 182.33 173.21 199.19 35661 1,078.35 1,024.43 1,178.09 36148 244.26 232.05 266.86 35663 1,248.55 1,186.12 1,364.04 # 36148 48.60 46.17 53.10 35665 1,168.07 1,109.67 1,276.12 36160 511.49 485.92 558.81 35666 1,262.12 1,199.01 1,378.86 # 36160 129.05 122.60 140.99 35671 1,112.76 1,057.12 1,215.69 36200 631.70 600.12 690.14 35681 79.13 75.17 86.45 # 36200 152.72 145.08 166.84 35682 351.58 334.00 384.10 36215 1,116.19 1,060.38 1,219.44 35683 414.00 393.30 452.30 # 36215 242.94 230.79 265.41 35685 197.67 187.79 215.96 36216 1,220.94 1,159.89 1,333.87 35686 165.23 156.97 180.52 # 36216 274.08 260.38 299.44 35691 967.55 919.17 1,057.05 36217 1,987.07 1,887.72 2,170.88 35693 859.06 816.11 938.53 # 36217 325.63 309.35 355.75 35694 1,002.46 952.34 1,095.19 36218 185.42 176.15 202.57 35695 1,044.01 991.81 1,140.58 # 36218 51.90 49.31 56.71 35697 147.51 140.13 161.15 36245 1,206.22 1,145.91 1,317.80 35700 151.63 144.05 165.66 # 36245 249.00 236.55 272.03 35701 530.81 504.27 579.91 36246 1,201.87 1,141.78 1,313.05 35721 447.40 425.03 488.78 # 36246 271.65 258.07 296.78 35741 493.44 468.77 539.09 36247 1,890.09 1,795.59 2,064.93 35761 368.06 349.66 402.11 # 36247 323.70 307.52 353.65 35800 471.26 447.70 514.86 36248 158.42 150.50 173.08 35820 1,892.40 1,797.78 2,067.45 # 36248 51.90 49.31 56.71 35840 614.72 583.98 671.58 36260 569.41 540.94 622.08 35860 399.44 379.47 436.39 36261 344.87 327.63 376.77 35870 1,264.44 1,201.22 1,381.40 36262 265.83 252.54 290.42 35875 587.15 557.79 641.46 36400 25.79 24.50 28.18 35876 935.75 888.96 1,022.30 # 36400 18.02 17.12 19.69 35879 919.63 873.65 1,004.70 36405 23.69 22.51 25.89 35881 1,018.48 967.56 1,112.69 # 36405 15.55 14.77 16.99 35883 1,185.34 1,126.07 1,294.98 36406 17.08 16.23 18.66 35884 1,242.91 1,180.76 1,357.87 # 36406 8.94 8.49 9.76 35901 495.63 470.85 541.48 36410 18.56 17.63 20.27 35903 557.98 530.08 609.59 # 36410 8.57 8.14 9.36 35905 1,709.33 1,623.86 1,867.44 36420 48.22 45.81 52.68 35907 1,894.69 1,799.96 2,069.95 36425 37.54 35.66 41.01 36000 24.10 22.90 26.34 36430 33.84 32.15 36.97 # 36000 9.31 8.84 10.17 36440 51.09 48.54 55.82 36002 161.07 153.02 175.97 36450 111.16 105.60 121.44 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 32 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 36455 123.02 116.87 134.40 # 36578 210.34 199.82 229.79 36460 327.55 311.17 357.85 36580 218.05 207.15 238.22 36470 134.77 128.03 147.23 # 36580 65.66 62.38 71.74 # 36470 67.82 64.43 74.09 36581 734.59 697.86 802.54 36471 164.89 156.65 180.15 # 36581 196.80 186.96 215.00 # 36471 95.72 90.93 104.57 36582 1,041.63 989.55 1,137.98 36475 1,744.46 1,657.24 1,905.83 # 36582 295.98 281.18 323.36 # 36475 340.08 323.08 371.54 36583 1,099.68 1,044.70 1,201.41 36476 376.01 357.21 410.79 # 36583 304.10 288.90 332.24 # 36476 166.66 158.33 182.08 36584 212.15 201.54 231.77 36478 1,421.98 1,350.88 1,553.51 # 36584 66.79 63.45 72.97 # 36478 341.23 324.17 372.80 36585 1,054.78 1,002.04 1,152.35 36479 390.11 370.60 426.19 # 36585 274.36 260.64 299.74 # 36479 166.71 158.37 182.13 36589 160.13 152.12 174.94 36481 793.02 753.37 866.38 # 36589 134.98 128.23 147.46 # 36481 347.33 329.96 379.45 36590 265.16 251.90 289.69 36500 178.76 169.82 195.29 # 36590 191.55 181.97 209.27 36510 102.22 97.11 111.68 36591 22.00 20.90 24.04 # 36510 56.36 53.54 61.57 36592 24.22 23.01 26.46 36511 89.32 84.85 97.58 36593 26.81 25.47 29.29 36512 88.81 84.37 97.03 36595 577.05 548.20 630.43 36513 92.05 87.45 100.57 # 36595 186.47 177.15 203.72 36514 498.02 473.12 544.09 36596 130.96 124.41 143.07 # 36514 87.84 83.45 95.97 # 36596 44.41 42.19 48.52 36515 1,875.05 1,781.30 2,048.50 36597 122.43 116.31 133.76 # 36515 86.37 82.05 94.36 # 36597 61.77 58.68 67.48 36516 2,081.11 1,977.05 2,273.61 36598 109.91 104.41 120.07 # 36516 63.49 60.32 69.37 # 36598 54.06 51.36 59.06 36522 1,311.71 1,246.12 1,433.04 36600 29.42 27.95 32.14 # 36522 97.80 92.91 106.85 # 36600 14.63 13.90 15.99 36555 257.59 244.71 281.42 36620 48.57 46.14 53.06 # 36555 120.74 114.70 131.91 36625 101.57 96.49 110.96 36556 223.42 212.25 244.09 36640 116.38 110.56 127.14 # 36556 116.53 110.70 127.31 36660 64.67 61.44 70.66 36557 852.69 810.06 931.57 36680 56.93 54.08 62.19 # 36557 296.41 281.59 323.83 36800 153.57 145.89 167.77 36558 778.27 739.36 850.26 36810 203.25 193.09 222.05 # 36558 273.77 260.08 299.09 36815 143.77 136.58 157.07 36560 1,072.45 1,018.83 1,171.65 36818 648.38 615.96 708.35 # 36560 336.04 319.24 367.13 36819 770.56 732.03 841.83 36561 1,119.01 1,063.06 1,222.52 36820 774.65 735.92 846.31 # 36561 335.63 318.85 366.68 36821 657.99 625.09 718.85 36563 1,149.64 1,092.16 1,255.98 36822 364.58 346.35 398.30 # 36563 346.66 329.33 378.73 36823 1,241.45 1,179.38 1,356.29 36565 948.21 900.80 1,035.92 36825 755.60 717.82 825.49 # 36565 332.75 316.11 363.53 36830 636.11 604.30 694.95 36566 3,898.76 3,703.82 4,259.39 36831 441.50 419.43 482.34 # 36566 356.91 339.06 389.92 36832 561.79 533.70 613.76 36568 292.13 277.52 319.15 36833 634.16 602.45 692.82 # 36568 93.88 89.19 102.57 36835 452.54 429.91 494.40 36569 253.08 240.43 276.49 36838 1,131.70 1,075.12 1,236.39 # 36569 91.82 87.23 100.31 36860 188.74 179.30 206.20 36570 1,106.92 1,051.57 1,209.31 # 36860 101.08 96.03 110.43 # 36570 298.39 283.47 325.99 36861 146.19 138.88 159.71 36571 1,197.67 1,137.79 1,308.46 36870 1,794.11 1,704.40 1,960.06 # 36571 301.11 286.05 328.96 # 36870 300.22 285.21 327.99 36575 153.65 145.97 167.87 37140 1,340.43 1,273.41 1,464.42 # 36575 34.18 32.47 37.34 37145 1,412.57 1,341.94 1,543.23 36576 354.13 336.42 386.88 37160 1,236.80 1,174.96 1,351.20 # 36576 185.84 176.55 203.03 37180 1,381.38 1,312.31 1,509.16 36578 489.59 465.11 534.88 37181 1,494.75 1,420.01 1,633.01 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 33 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 37182 861.29 818.23 940.96 38101 1,029.79 978.30 1,125.05 37183 5,024.96 4,773.71 5,489.77 38102 238.21 226.30 260.25 # 37183 409.01 388.56 446.84 38115 1,136.54 1,079.71 1,241.67 37184 2,322.70 2,206.57 2,537.56 38120 938.88 891.94 1,025.73 # 37184 451.54 428.96 493.30 38200 138.70 131.77 151.54 37185 767.74 729.35 838.75 38205 77.59 73.71 84.77 # 37185 166.71 158.37 182.13 38206 77.40 73.53 84.56 37186 1,546.24 1,468.93 1,689.27 38220 145.57 138.29 159.03 # 37186 255.40 242.63 279.02 # 38220 58.65 55.72 64.08 37187 2,223.70 2,112.52 2,429.40 38221 159.73 151.74 174.50 # 37187 415.05 394.30 453.45 # 38221 73.18 69.52 79.95 37188 1,879.08 1,785.13 2,052.90 38230 307.78 292.39 336.25 # 37188 299.00 284.05 326.66 38240 119.81 113.82 130.89 37195 322.37 306.25 352.19 38241 120.37 114.35 131.50 37200 228.54 217.11 249.68 38242 91.48 86.91 99.95 37201 275.91 262.11 301.43 38300 249.13 236.67 272.17 37202 334.33 317.61 365.25 # 38300 167.39 159.02 182.87 37203 1,301.74 1,236.65 1,422.15 38305 419.72 398.73 458.54 # 37203 263.89 250.70 288.31 38308 404.10 383.90 441.49 37204 907.58 862.20 991.53 38380 524.60 498.37 573.13 37205 4,152.10 3,944.50 4,536.18 38381 757.78 719.89 827.87 # 37205 434.57 412.84 474.77 38382 628.60 597.17 686.75 37206 2,502.61 2,377.48 2,734.10 38500 290.80 276.26 317.70 # 37206 212.76 202.12 232.44 # 38500 226.45 215.13 247.40 37207 419.43 398.46 458.23 38505 119.58 113.60 130.64 37208 202.34 192.22 221.05 # 38505 70.39 66.87 76.90 37209 113.75 108.06 124.27 38510 468.51 445.08 511.84 37210 3,440.32 3,268.30 3,758.55 # 38510 383.81 364.62 419.31 # 37210 540.93 513.88 590.96 38520 420.96 399.91 459.90 37215 1,099.29 1,044.33 1,200.98 38525 383.87 364.68 419.38 37250 108.23 102.82 118.24 38530 489.27 464.81 534.53 37251 80.25 76.24 87.68 38542 475.91 452.11 519.93 37500 671.70 638.12 733.84 38550 440.94 418.89 481.72 37565 674.07 640.37 736.43 38555 902.24 857.13 985.70 37600 683.10 648.95 746.29 38562 644.18 611.97 703.77 37605 775.43 736.66 847.16 38564 640.36 608.34 699.59 37606 513.07 487.42 560.53 38570 508.58 483.15 555.62 37607 362.88 344.74 396.45 38571 793.02 753.37 866.38 37609 281.72 267.63 307.77 38572 882.57 838.44 964.21 # 37609 190.74 181.20 208.38 38700 742.60 705.47 811.29 37615 463.59 440.41 506.47 38720 1,234.93 1,173.18 1,349.16 37616 1,042.08 989.98 1,138.48 38724 1,337.67 1,270.79 1,461.41 37617 1,239.75 1,177.76 1,354.42 38740 612.07 581.47 668.69 37618 364.93 346.68 398.68 38745 776.70 737.87 848.55 37620 641.44 609.37 700.78 38746 245.94 233.64 268.69 37650 489.35 464.88 534.61 38747 242.86 230.72 265.33 37660 1,175.23 1,116.47 1,283.94 38760 760.17 722.16 830.48 37700 242.64 230.51 265.09 38765 1,177.57 1,118.69 1,286.49 37718 417.75 396.86 456.39 38770 773.30 734.64 844.84 37722 464.78 441.54 507.77 38780 979.47 930.50 1,070.08 37735 605.93 575.63 661.97 38790 77.86 73.97 85.07 37760 607.29 576.93 663.47 38792 37.75 35.86 41.24 37761 546.34 519.02 596.87 38794 291.13 276.57 318.06 37765 441.78 419.69 482.64 39000 463.58 440.40 506.46 37766 539.90 512.91 589.85 39010 755.88 718.09 825.80 37780 250.41 237.89 273.57 39200 835.60 793.82 912.89 37785 339.55 322.57 370.96 39220 1,079.96 1,025.96 1,179.85 # 37785 251.15 238.59 274.38 39400 477.49 453.62 521.66 37788 1,328.18 1,261.77 1,451.04 39501 773.74 735.05 845.31 37790 475.59 451.81 519.58 39502 930.90 884.36 1,017.01 38100 1,024.85 973.61 1,119.65 39503 5,292.48 5,027.86 5,782.04 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 34 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 39520 923.09 876.94 1,008.48 40840 731.11 694.55 798.73 39530 885.94 841.64 967.89 # 40840 576.13 547.32 629.42 39531 930.68 884.15 1,016.77 40842 737.76 700.87 806.00 39540 791.00 751.45 864.17 # 40842 577.98 549.08 631.44 39541 855.88 813.09 935.05 40843 947.53 900.15 1,035.17 39545 839.32 797.35 916.95 # 40843 742.99 705.84 811.72 39560 726.86 690.52 794.10 40844 1,250.18 1,187.67 1,365.82 39561 1,140.86 1,083.82 1,246.39 # 40844 1,034.55 982.82 1,130.24 40490 119.62 113.64 130.69 40845 1,355.00 1,287.25 1,480.34 # 40490 69.68 66.20 76.13 # 40845 1,154.90 1,097.16 1,261.73 40500 458.61 435.68 501.03 41000 146.04 138.74 159.55 # 40500 335.82 319.03 366.88 # 41000 103.13 97.97 112.67 40510 439.89 417.90 480.59 41005 206.76 196.42 225.88 # 40510 328.56 312.13 358.95 # 41005 117.62 111.74 128.50 40520 450.46 427.94 492.13 41006 327.23 310.87 357.50 # 40520 331.73 315.14 362.41 # 41006 237.73 225.84 259.72 40525 513.31 487.64 560.79 41007 327.28 310.92 357.56 40527 598.03 568.13 653.35 # 41007 231.49 219.92 252.91 40530 498.20 473.29 544.28 41008 336.46 319.64 367.59 # 40530 376.88 358.04 411.75 # 41008 245.85 233.56 268.59 40650 377.81 358.92 412.76 41009 357.50 339.63 390.57 # 40650 266.48 253.16 291.13 # 41009 267.25 253.89 291.97 40652 442.91 420.76 483.87 41010 186.02 176.72 203.23 # 40652 323.81 307.62 353.76 # 41010 102.06 96.96 111.50 40654 520.26 494.25 568.39 41015 384.98 365.73 420.59 # 40654 391.92 372.32 428.17 # 41015 309.89 294.40 338.56 40700 862.62 819.49 942.41 41016 392.37 372.75 428.66 40701 1,049.21 996.75 1,146.26 # 41016 319.88 303.89 349.47 40702 800.92 760.87 875.00 41017 397.18 377.32 433.92 40720 922.37 876.25 1,007.69 # 41017 320.99 304.94 350.68 40761 991.25 941.69 1,082.94 41018 451.11 428.55 492.83 40800 185.44 176.17 202.60 # 41018 374.17 355.46 408.78 # 40800 118.12 112.21 129.04 41019 459.80 436.81 502.33 40801 281.25 267.19 307.27 41100 153.50 145.83 167.70 # 40801 202.47 192.35 221.20 # 41100 101.35 96.28 110.72 40804 190.50 180.98 208.13 41105 154.70 146.97 169.02 # 40804 120.23 114.22 131.35 # 41105 103.66 98.48 113.25 40805 291.36 276.79 318.31 41108 133.51 126.83 145.85 # 40805 209.99 199.49 229.41 # 41108 83.58 79.40 91.31 40806 95.45 90.68 104.28 41110 191.91 182.31 209.66 # 40806 31.10 29.55 33.98 # 41110 122.01 115.91 133.30 40808 166.40 158.08 181.79 41112 300.91 285.86 328.74 # 40808 99.08 94.13 108.25 # 41112 231.75 220.16 253.18 40810 184.29 175.08 201.34 41113 328.97 312.52 359.40 # 40810 116.98 111.13 127.80 # 41113 256.48 243.66 280.21 40812 256.75 243.91 280.50 41114 590.35 560.83 644.95 # 40812 179.81 170.82 196.44 41115 221.48 210.41 241.97 40814 345.04 327.79 376.96 # 41115 137.52 130.64 150.24 # 40814 278.46 264.54 304.22 41116 296.80 281.96 324.25 40816 364.03 345.83 397.70 # 41116 203.23 193.07 222.03 # 40816 291.90 277.31 318.91 41120 977.56 928.68 1,067.98 40818 323.48 307.31 353.41 41130 1,208.70 1,148.27 1,320.51 # 40818 252.46 239.84 275.82 41135 2,003.01 1,902.86 2,188.29 40819 275.93 262.13 301.45 41140 2,045.82 1,943.53 2,235.06 # 40819 214.90 204.16 234.78 41145 2,571.89 2,443.30 2,809.80 40820 240.18 228.17 262.40 41150 2,039.38 1,937.41 2,228.02 # 40820 158.81 150.87 173.50 41153 2,213.20 2,102.54 2,417.92 40830 223.24 212.08 243.89 41155 2,761.82 2,623.73 3,017.29 # 40830 147.42 140.05 161.06 41250 212.83 202.19 232.52 40831 294.09 279.39 321.30 # 41250 132.94 126.29 145.23 # 40831 205.32 195.05 224.31 41251 220.77 209.73 241.19 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 35 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 41251 152.35 144.73 166.44 42227 827.67 786.29 904.23 41252 281.86 267.77 307.94 42235 689.76 655.27 753.56 # 41252 196.42 186.60 214.59 42260 758.88 720.94 829.08 41500 417.45 396.58 456.07 # 42260 625.36 594.09 683.20 41510 389.82 370.33 425.88 42280 145.56 138.28 159.02 41512 579.66 550.68 633.28 # 42280 98.95 94.00 108.10 41520 314.97 299.22 344.10 42281 187.13 177.77 204.44 # 41520 234.71 222.97 256.42 # 42281 141.64 134.56 154.74 41530 2,929.26 2,782.80 3,200.22 42300 191.01 181.46 208.68 # 41530 378.66 359.73 413.69 # 42300 142.19 135.08 155.34 41800 215.32 204.55 235.23 42305 403.37 383.20 440.68 # 41800 123.22 117.06 134.62 42310 148.37 140.95 162.09 41805 221.87 210.78 242.40 # 42310 116.19 110.38 126.94 # 41805 156.04 148.24 170.48 42320 229.33 217.86 250.54 41806 312.71 297.07 341.63 # 42320 165.34 157.07 180.63 # 41806 236.15 224.34 257.99 42330 213.47 202.80 233.22 41822 259.64 246.66 283.66 # 42330 153.92 146.22 168.15 # 41822 162.73 154.59 177.78 42335 341.72 324.63 373.32 41823 386.62 367.29 422.38 # 42335 241.86 229.77 264.24 # 41823 294.15 279.44 321.36 42340 427.54 406.16 467.08 41825 188.28 178.87 205.70 # 42340 316.58 300.75 345.86 # 41825 116.16 110.35 126.90 42400 100.58 95.55 109.88 41826 265.93 252.63 290.52 # 42400 54.35 51.63 59.37 # 41826 188.62 179.19 206.07 42405 277.48 263.61 303.15 41827 391.88 372.29 428.13 # 42405 212.38 201.76 232.02 # 41827 280.92 266.87 306.90 42408 417.47 396.60 456.09 41828 273.38 259.71 298.67 # 42408 306.51 291.18 334.86 # 41828 196.45 186.63 214.62 42409 304.48 289.26 332.65 41830 349.06 331.61 381.35 # 42409 208.69 198.26 228.00 # 41830 256.22 243.41 279.92 42410 581.04 551.99 634.79 41872 332.68 316.05 363.46 42415 1,046.90 994.56 1,143.74 # 41872 243.91 231.71 266.47 42420 1,198.47 1,138.55 1,309.33 41874 331.37 314.80 362.02 42425 790.78 751.24 863.93 # 41874 232.25 220.64 253.74 42426 1,279.59 1,215.61 1,397.95 42000 143.56 136.38 156.84 42440 438.42 416.50 478.98 # 42000 95.85 91.06 104.72 42450 417.50 396.63 456.12 42100 136.40 129.58 149.02 # 42450 336.13 319.32 367.22 # 42100 101.27 96.21 110.64 42500 398.63 378.70 435.51 42104 191.51 181.93 209.22 # 42500 319.84 303.85 349.43 # 42104 127.52 121.14 139.31 42505 514.71 488.97 562.32 42106 241.21 229.15 263.52 # 42505 426.31 404.99 465.74 # 42106 165.02 156.77 180.29 42507 481.91 457.81 526.48 42107 417.45 396.58 456.07 42508 674.58 640.85 736.98 # 42107 319.81 303.82 349.39 42509 794.32 754.60 867.79 42120 916.61 870.78 1,001.40 42510 591.17 561.61 645.85 42140 229.96 218.46 251.23 42550 135.50 128.73 148.04 # 42140 144.52 137.29 157.88 # 42550 62.27 59.16 68.03 42145 658.65 625.72 719.58 42600 446.77 424.43 488.09 42160 217.87 206.98 238.03 # 42600 331.00 314.45 361.62 # 42160 140.56 133.53 153.56 42650 76.19 72.38 83.24 42180 222.97 211.82 243.59 # 42650 55.10 52.35 60.20 # 42180 171.56 162.98 187.43 42660 97.96 93.06 107.02 42182 299.52 284.54 327.22 # 42660 73.17 69.51 79.94 # 42182 245.15 232.89 267.82 42665 286.27 271.96 312.75 42200 814.71 773.97 890.07 # 42665 194.54 184.81 212.53 42205 858.47 815.55 937.88 42700 173.60 164.92 189.66 42210 985.44 936.17 1,076.60 # 42700 127.36 120.99 139.14 42215 638.96 607.01 698.06 42720 423.90 402.71 463.12 42220 502.59 477.46 549.08 # 42720 370.64 352.11 404.93 42225 862.84 819.70 942.66 42725 760.73 722.69 831.09 42226 859.08 816.13 938.55 42800 145.70 138.42 159.18 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 36 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 42800 105.01 99.76 114.72 # 43201 122.94 116.79 134.31 42802 220.52 209.49 240.91 43202 264.00 250.80 288.42 # 42802 127.32 120.95 139.09 # 43202 109.03 103.58 119.12 42804 184.97 175.72 202.08 43204 212.74 202.10 232.42 # 42804 108.04 102.64 118.04 43205 213.27 202.61 233.00 42806 207.88 197.49 227.11 43215 146.46 139.14 160.01 # 42806 126.14 119.83 137.80 43216 188.80 179.36 206.26 42808 210.74 200.20 230.23 # 43216 136.28 129.47 148.89 # 42808 153.78 146.09 168.00 43217 351.95 334.35 384.50 42809 156.81 148.97 171.32 # 43217 161.10 153.05 176.01 # 42809 121.67 115.59 132.93 43219 162.75 154.61 177.80 42810 357.50 339.63 390.57 43220 120.88 114.84 132.07 # 42810 268.36 254.94 293.18 43226 134.16 127.45 146.57 42815 520.03 494.03 568.13 43227 199.89 189.90 218.39 42820 273.97 260.27 299.31 43228 211.81 201.22 231.40 42821 285.19 270.93 311.57 43231 181.53 172.45 198.32 42825 246.68 234.35 269.50 43232 249.61 237.13 272.70 42826 237.16 225.30 259.10 43234 261.19 248.13 285.35 42830 194.51 184.78 212.50 # 43234 113.98 108.28 124.52 42831 209.96 199.46 229.38 43235 279.07 265.12 304.89 42835 176.29 167.48 192.60 # 43235 137.78 130.89 150.52 42836 227.87 216.48 248.95 43236 347.33 329.96 379.45 42842 918.41 872.49 1,003.36 # 43236 167.94 159.54 183.47 42844 1,277.78 1,213.89 1,395.97 43237 224.94 213.69 245.74 42845 2,080.17 1,976.16 2,272.58 43238 281.23 267.17 307.25 42860 176.42 167.60 192.74 43239 323.91 307.71 353.87 42870 538.44 511.52 588.25 # 43239 163.76 155.57 178.91 42890 1,307.28 1,241.92 1,428.21 43240 378.54 359.61 413.55 42892 1,719.84 1,633.85 1,878.93 43241 148.15 140.74 161.85 42894 2,192.13 2,082.52 2,394.90 43242 404.42 384.20 441.83 42900 321.35 305.28 351.07 43243 255.39 242.62 279.01 42950 740.88 703.84 809.42 43244 282.69 268.56 308.84 42953 906.97 861.62 990.86 43245 178.57 169.64 195.09 42955 696.78 661.94 761.23 43246 239.49 227.52 261.65 42960 159.08 151.13 173.80 43247 191.00 181.45 208.67 42961 395.25 375.49 431.81 43248 180.68 171.65 197.40 42962 488.28 463.87 533.45 43249 166.30 157.99 181.69 42970 367.18 348.82 401.14 43250 178.91 169.96 195.45 42971 430.09 408.59 469.88 43251 207.50 197.13 226.70 42972 481.49 457.42 526.03 43255 269.77 256.28 294.72 43020 494.46 469.74 540.20 43256 242.81 230.67 265.27 43030 488.88 464.44 534.11 43257 300.96 285.91 328.80 43045 1,225.98 1,164.68 1,339.38 43258 254.69 241.96 278.25 43100 584.70 555.47 638.79 43259 290.57 276.04 317.45 43101 948.11 900.70 1,035.81 43260 331.81 315.22 362.50 43107 2,365.85 2,247.56 2,584.69 43261 348.49 331.07 380.73 43108 3,973.64 3,774.96 4,341.20 43262 408.91 388.46 446.73 43112 2,519.41 2,393.44 2,752.46 43263 404.09 383.89 441.47 43113 3,939.87 3,742.88 4,304.31 43264 491.22 466.66 536.66 43116 4,721.79 4,485.70 5,158.56 43265 551.46 523.89 602.47 43117 2,306.60 2,191.27 2,519.96 43267 407.43 387.06 445.12 43118 3,217.88 3,056.99 3,515.54 43268 414.09 393.39 452.40 43121 2,657.69 2,524.81 2,903.53 43269 453.74 431.05 495.71 43122 2,342.29 2,225.18 2,558.96 43271 408.54 388.11 446.33 43123 4,003.16 3,803.00 4,373.45 43272 408.17 387.76 445.92 43124 3,353.61 3,185.93 3,663.82 43273 120.74 114.70 131.91 43130 739.42 702.45 807.82 43279 1,126.34 1,070.02 1,230.52 43135 1,385.37 1,316.10 1,513.52 43280 970.92 922.37 1,060.73 43200 201.10 191.05 219.71 43281 1,457.33 1,384.46 1,592.13 # 43200 98.64 93.71 107.77 43282 1,638.22 1,556.31 1,789.76 43201 275.69 261.91 301.20 43300 575.82 547.03 629.08 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 37 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 43305 1,034.23 982.52 1,129.90 # 43760 47.46 45.09 51.85 43310 1,418.23 1,347.32 1,549.42 43761 115.52 109.74 126.20 43312 1,545.23 1,467.97 1,688.17 # 43761 101.47 96.40 110.86 43313 2,527.35 2,400.98 2,761.13 43770 994.96 945.21 1,086.99 43314 2,861.91 2,718.81 3,126.63 43771 1,133.42 1,076.75 1,238.26 43320 1,261.46 1,198.39 1,378.15 43772 853.95 811.25 932.94 43324 1,226.09 1,164.79 1,339.51 43773 1,133.79 1,077.10 1,238.67 43325 1,211.65 1,151.07 1,323.73 43774 857.74 814.85 937.08 43326 1,223.52 1,162.34 1,336.69 43775 1,226.96 1,165.61 1,340.45 43330 1,185.15 1,125.89 1,294.77 43800 830.57 789.04 907.40 43331 1,267.93 1,204.53 1,385.21 43810 902.20 857.09 985.65 43340 1,236.49 1,174.67 1,350.87 43820 1,183.50 1,124.33 1,292.98 43341 1,355.94 1,288.14 1,481.36 43825 1,159.11 1,101.15 1,266.32 43350 1,077.07 1,023.22 1,176.70 43830 620.52 589.49 677.91 43351 1,231.79 1,170.20 1,345.73 43831 522.14 496.03 570.43 43352 1,003.96 953.76 1,096.82 43832 946.77 899.43 1,034.34 43360 2,130.99 2,024.44 2,328.11 43840 1,200.00 1,140.00 1,311.00 43361 2,425.61 2,304.33 2,649.98 43843 1,129.00 1,072.55 1,233.43 43400 1,471.79 1,398.20 1,607.93 43845 1,746.22 1,658.91 1,907.75 43401 1,405.92 1,335.62 1,535.96 43846 1,458.53 1,385.60 1,593.44 43405 1,370.52 1,301.99 1,497.29 43847 1,593.71 1,514.02 1,741.12 43410 933.17 886.51 1,019.49 43848 1,723.34 1,637.17 1,882.75 43415 1,583.84 1,504.65 1,730.35 43850 1,444.52 1,372.29 1,578.13 43420 941.23 894.17 1,028.30 43855 1,498.08 1,423.18 1,636.66 43425 1,388.28 1,318.87 1,516.70 43860 1,464.36 1,391.14 1,599.81 43450 147.63 140.25 161.29 43865 1,522.06 1,445.96 1,662.85 # 43450 84.38 80.16 92.18 43870 632.80 601.16 691.33 43453 278.90 264.96 304.70 43880 1,428.81 1,357.37 1,560.98 # 43453 91.75 87.16 100.23 43886 312.81 297.17 341.75 43456 564.85 536.61 617.10 43887 285.25 270.99 311.64 # 43456 147.64 140.26 161.30 43888 402.52 382.39 439.75 43458 363.36 345.19 396.97 44005 977.73 928.84 1,068.17 # 43458 172.88 164.24 188.88 44010 771.41 732.84 842.77 43460 209.92 199.42 229.33 44015 130.45 123.93 142.52 43496 1,968.04 1,869.64 2,150.09 44020 866.03 822.73 946.14 43500 700.34 665.32 765.12 44021 875.47 831.70 956.46 43501 1,199.65 1,139.67 1,310.62 44025 881.63 837.55 963.18 43502 1,356.09 1,288.29 1,481.53 44050 833.59 791.91 910.70 43510 860.82 817.78 940.45 44055 1,335.13 1,268.37 1,458.63 43520 628.92 597.47 687.09 44100 108.64 103.21 118.69 43600 101.23 96.17 110.60 44110 757.77 719.88 827.86 43605 742.38 705.26 811.05 44111 880.68 836.65 962.15 43610 874.12 830.41 954.97 44120 1,091.62 1,037.04 1,192.60 43611 1,090.15 1,035.64 1,190.99 44121 220.14 209.13 240.50 43620 1,767.67 1,679.29 1,931.18 44125 1,056.81 1,003.97 1,154.57 43621 2,027.04 1,925.69 2,214.54 44126 2,189.52 2,080.04 2,392.05 43622 2,052.78 1,950.14 2,242.66 44127 2,537.87 2,410.98 2,772.63 43631 1,296.75 1,231.91 1,416.70 44128 220.87 209.83 241.30 43632 1,798.71 1,708.77 1,965.09 44130 1,160.25 1,102.24 1,267.58 43633 1,704.54 1,619.31 1,862.21 44137 981.03 931.98 1,071.78 43634 1,884.10 1,789.90 2,058.39 44139 110.43 104.91 120.65 43635 102.02 96.92 111.46 44140 1,200.30 1,140.29 1,311.33 43640 1,049.23 996.77 1,146.29 44141 1,614.06 1,533.36 1,763.36 43641 1,060.97 1,007.92 1,159.11 44143 1,487.90 1,413.51 1,625.54 43644 1,552.91 1,475.26 1,696.55 44144 1,574.11 1,495.40 1,719.71 43645 1,659.04 1,576.09 1,812.50 44145 1,493.32 1,418.65 1,631.45 43651 579.18 550.22 632.75 44146 1,889.93 1,795.43 2,064.74 43652 677.43 643.56 740.09 44147 1,720.23 1,634.22 1,879.35 43653 502.18 477.07 548.63 44150 1,662.47 1,579.35 1,816.25 43752 40.07 38.07 43.78 44151 1,900.41 1,805.39 2,076.20 43760 346.32 329.00 378.35 44155 1,858.08 1,765.18 2,029.96 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 38 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 44156 2,043.83 1,941.64 2,232.89 44393 469.06 445.61 512.45 44157 1,937.89 1,841.00 2,117.15 # 44393 263.05 249.90 287.39 44158 1,983.49 1,884.32 2,166.97 44394 471.06 447.51 514.64 44160 1,109.86 1,054.37 1,212.53 # 44394 243.22 231.06 265.72 44180 824.05 782.85 900.28 44397 261.82 248.73 286.04 44186 584.12 554.91 638.15 44500 24.52 23.29 26.78 44187 987.71 938.32 1,079.07 44602 1,251.51 1,188.93 1,367.27 44188 1,092.62 1,037.99 1,193.69 44603 1,436.06 1,364.26 1,568.90 44202 1,241.61 1,179.53 1,356.46 44604 947.23 899.87 1,034.85 44203 220.13 209.12 240.49 44605 1,170.83 1,112.29 1,279.13 44204 1,384.43 1,315.21 1,512.49 44615 964.23 916.02 1,053.42 44205 1,206.98 1,146.63 1,318.62 44620 774.73 735.99 846.39 44206 1,575.30 1,496.54 1,721.02 44625 913.89 868.20 998.43 44207 1,648.15 1,565.74 1,800.60 44626 1,443.72 1,371.53 1,577.26 44208 1,794.65 1,704.92 1,960.66 44640 1,260.24 1,197.23 1,376.81 44210 1,611.74 1,531.15 1,760.82 44650 1,308.22 1,242.81 1,429.23 44211 1,991.34 1,891.77 2,175.54 44660 1,259.41 1,196.44 1,375.91 44212 1,855.29 1,762.53 2,026.91 44661 1,421.45 1,350.38 1,552.94 44213 172.78 164.14 188.76 44680 956.55 908.72 1,045.03 44227 1,500.55 1,425.52 1,639.35 44700 919.29 873.33 1,004.33 44300 751.94 714.34 821.49 44701 152.59 144.96 166.70 44310 936.45 889.63 1,023.07 44715 355.62 337.84 388.52 44312 536.17 509.36 585.76 44720 245.98 233.68 268.73 44314 909.14 863.68 993.23 44721 349.39 331.92 381.71 44316 1,253.76 1,191.07 1,369.73 44800 680.04 646.04 742.95 44320 1,072.00 1,018.40 1,171.16 44820 750.91 713.36 820.36 44322 869.19 825.73 949.59 44850 662.90 629.76 724.22 44340 547.63 520.25 598.29 44900 685.75 651.46 749.18 44345 939.29 892.33 1,026.18 44901 911.06 865.51 995.34 44346 1,056.08 1,003.28 1,153.77 # 44901 168.37 159.95 183.94 44360 150.01 142.51 163.89 44950 573.58 544.90 626.64 44361 165.26 157.00 180.55 44955 76.50 72.68 83.58 44363 195.82 186.03 213.93 44960 776.71 737.87 848.55 44364 211.13 200.57 230.66 44970 531.20 504.64 580.34 44365 187.99 178.59 205.38 45000 376.09 357.29 410.88 44366 248.46 236.04 271.45 45005 229.35 217.88 250.56 44369 254.19 241.48 277.70 # 45005 138.73 131.79 151.56 44370 273.69 260.01 299.01 45020 498.07 473.17 544.15 44372 242.69 230.56 265.14 45100 261.95 248.85 286.18 44373 196.18 186.37 214.33 45108 318.83 302.89 348.32 44376 289.34 274.87 316.10 45110 1,660.94 1,577.89 1,814.57 44377 307.02 291.67 335.42 45111 974.74 926.00 1,064.90 44378 393.44 373.77 429.84 45112 1,704.22 1,619.01 1,861.86 44379 416.36 395.54 454.87 45113 1,766.87 1,678.53 1,930.31 44380 65.71 62.42 71.78 45114 1,608.72 1,528.28 1,757.52 44382 78.47 74.55 85.73 45116 1,423.69 1,352.51 1,555.39 44383 165.75 157.46 181.08 45119 1,756.18 1,668.37 1,918.63 44385 234.37 222.65 256.05 45120 1,410.15 1,339.64 1,540.59 # 44385 100.47 95.45 109.77 45121 1,540.50 1,463.48 1,683.00 44386 323.71 307.52 353.65 45123 999.82 949.83 1,092.30 # 44386 118.44 112.52 129.40 45126 2,607.93 2,477.53 2,849.16 44388 322.87 306.73 352.74 45130 977.31 928.44 1,067.71 # 44388 156.80 148.96 171.30 45135 1,207.64 1,147.26 1,319.35 44389 372.11 353.50 406.53 45136 1,646.80 1,564.46 1,799.13 # 44389 174.97 166.22 191.15 45150 355.31 337.54 388.17 44390 431.05 409.50 470.93 45160 897.25 852.39 980.25 # 44390 210.61 200.08 230.09 45171 561.53 533.45 613.47 44391 477.73 453.84 521.92 45172 766.76 728.42 837.68 # 44391 239.17 227.21 261.29 45190 610.12 579.61 666.55 44392 405.70 385.42 443.23 45300 102.75 97.61 112.25 # 44392 207.08 196.73 226.24 # 45300 47.27 44.91 51.65 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 39 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 45303 797.08 757.23 870.81 45391 282.79 268.65 308.95 # 45303 80.65 76.62 88.11 45392 360.74 342.70 394.11 45305 164.66 156.43 179.89 45395 1,792.60 1,702.97 1,958.42 # 45305 70.72 67.18 77.26 45397 1,941.14 1,844.08 2,120.69 45307 185.52 176.24 202.68 45400 1,036.58 984.75 1,132.46 # 45307 90.83 86.29 99.23 45402 1,381.18 1,312.12 1,508.94 45308 171.80 163.21 187.69 45500 461.72 438.63 504.42 # 45308 77.11 73.25 84.24 45505 511.77 486.18 559.11 45309 186.61 177.28 203.87 45520 121.86 115.77 133.14 # 45309 85.27 81.01 93.16 # 45520 35.68 33.90 38.99 45315 202.18 192.07 220.88 45540 953.52 905.84 1,041.72 # 45315 99.72 94.73 108.94 45541 825.96 784.66 902.36 45317 197.61 187.73 215.89 45550 1,314.23 1,248.52 1,435.80 # 45317 105.51 100.23 115.26 45560 644.48 612.26 704.10 45320 195.37 185.60 213.44 45562 1,000.41 950.39 1,092.95 # 45320 99.58 94.60 108.79 45563 1,449.76 1,377.27 1,583.86 45321 97.41 92.54 106.42 45800 1,109.42 1,053.95 1,212.04 45327 114.33 108.61 124.90 45805 1,287.14 1,222.78 1,406.20 45330 127.26 120.90 139.04 45820 1,082.69 1,028.56 1,182.84 # 45330 58.83 55.89 64.27 45825 1,332.62 1,265.99 1,455.89 45331 160.22 152.21 175.04 45900 178.67 169.74 195.20 # 45331 71.46 67.89 78.07 45905 150.76 143.22 164.70 45332 265.10 251.85 289.63 45910 177.10 168.25 193.49 # 45332 103.84 98.65 113.45 45915 282.67 268.54 308.82 45333 267.87 254.48 292.65 # 45915 200.19 190.18 218.71 # 45333 103.64 98.46 113.23 45990 98.44 93.52 107.55 45334 156.43 148.61 170.90 46020 232.30 220.69 253.79 45335 231.27 219.71 252.67 # 46020 201.97 191.87 220.65 # 45335 86.65 82.32 94.67 46030 116.93 111.08 127.74 45337 134.11 127.40 146.51 # 46030 79.21 75.25 86.54 45338 295.79 281.00 323.15 46040 451.59 429.01 493.36 # 45338 134.16 127.45 146.57 # 46040 359.12 341.16 392.33 45339 308.30 292.89 336.82 46045 372.67 354.04 407.15 # 45339 176.99 168.14 193.36 46050 165.05 156.80 180.32 45340 415.46 394.69 453.89 # 46050 84.42 80.20 92.23 # 45340 109.21 103.75 119.31 46060 409.40 388.93 447.27 45341 149.44 141.97 163.27 46070 200.27 190.26 218.80 45342 228.16 216.75 249.26 46080 210.36 199.84 229.82 45345 165.90 157.61 181.25 # 46080 141.56 134.48 154.65 45355 190.39 180.87 208.00 46083 157.29 149.43 171.84 45378 369.48 351.01 403.66 # 46083 96.27 91.46 105.18 # 45378 205.26 195.00 224.25 46200 361.86 343.77 395.34 45378 53 127.26 120.90 139.04 # 46200 275.68 261.90 301.19 # 45378 53 58.83 55.89 64.27 46220 172.73 164.09 188.70 45379 469.69 446.21 513.14 # 46220 103.94 98.74 113.55 # 45379 257.02 244.17 280.80 46221 225.83 214.54 246.72 45380 442.58 420.45 483.52 # 46221 165.91 157.61 181.25 # 45380 246.92 234.57 269.76 46230 232.95 221.30 254.50 45381 430.97 409.42 470.83 # 46230 153.06 145.41 167.22 # 45381 234.20 222.49 255.86 46250 390.28 370.77 426.39 45382 581.93 552.83 635.75 # 46250 273.40 259.73 298.69 # 45382 315.62 299.84 344.82 46255 432.32 410.70 472.31 45383 528.52 502.09 577.40 # 46255 309.53 294.05 338.16 # 45383 317.70 301.82 347.09 46257 364.21 346.00 397.90 45384 436.57 414.74 476.95 46258 402.76 382.62 440.01 # 45384 257.18 244.32 280.97 46260 411.90 391.31 450.01 45385 498.42 473.50 544.53 46261 461.95 438.85 504.68 # 45385 293.15 278.49 320.26 46262 481.85 457.76 526.42 45386 618.38 587.46 675.58 46270 425.73 404.44 465.11 # 45386 251.84 239.25 275.14 # 46270 334.37 317.65 365.30 45387 328.55 312.12 358.94 46275 449.70 427.22 491.30 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 40 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 46275 355.75 337.96 388.65 # 46922 119.32 113.35 130.35 46280 404.41 384.19 441.82 46924 463.63 440.45 506.52 46285 440.66 418.63 481.42 # 46924 165.89 157.60 181.24 # 46285 353.37 335.70 386.06 46930 189.29 179.83 206.80 46288 476.87 453.03 520.98 # 46930 136.03 129.23 148.61 46320 154.19 146.48 168.45 46940 192.95 183.30 210.80 # 46320 97.60 92.72 106.63 # 46940 131.19 124.63 143.32 46500 192.59 182.96 210.40 46942 180.48 171.46 197.18 # 46500 112.70 107.07 123.13 # 46942 117.23 111.37 128.08 46505 247.71 235.32 270.62 46945 254.58 241.85 278.13 # 46505 209.24 198.78 228.60 # 46945 193.55 183.87 211.45 46600 75.26 71.50 82.23 46946 267.91 254.51 292.69 # 46600 35.31 33.54 38.57 # 46946 198.74 188.80 217.12 46604 486.09 461.79 531.06 46947 334.37 317.65 365.30 # 46604 60.01 57.01 65.56 47000 317.12 301.26 346.45 46606 193.59 183.91 211.50 # 47000 95.94 91.14 104.81 # 46606 67.84 64.45 74.12 47001 94.35 89.63 103.07 46608 198.79 188.85 217.18 47010 1,074.55 1,020.82 1,173.94 # 46608 72.66 69.03 79.38 47011 185.23 175.97 202.37 46610 196.04 186.24 214.18 47015 1,024.97 973.72 1,119.78 # 46610 72.87 69.23 79.61 47100 746.39 709.07 815.43 46611 152.01 144.41 166.07 47120 2,080.12 1,976.11 2,272.53 # 46611 73.59 69.91 80.40 47122 3,079.26 2,925.30 3,364.10 46612 232.07 220.47 253.54 47125 2,757.96 2,620.06 3,013.07 # 46612 86.35 82.03 94.33 47130 2,962.52 2,814.39 3,236.55 46614 114.25 108.54 124.82 47135 4,201.14 3,991.08 4,589.74 # 46614 60.62 57.59 66.23 47136 3,565.12 3,386.86 3,894.89 46615 129.64 123.16 141.63 47140 3,171.10 3,012.55 3,464.43 # 46615 85.99 81.69 93.94 47141 3,644.83 3,462.59 3,981.98 46700 572.04 543.44 624.96 47142 4,013.07 3,812.42 4,384.28 46705 451.66 429.08 493.44 47143 301.07 286.02 328.92 46706 149.86 142.37 163.73 47144 451.59 429.01 493.36 46707 432.25 410.64 472.24 47145 451.59 429.01 493.36 46710 978.13 929.22 1,068.60 47146 298.42 283.50 326.03 46712 1,890.15 1,795.64 2,064.99 47147 347.73 330.34 379.89 46715 444.87 422.63 486.02 47300 1,003.60 953.42 1,096.43 46716 1,086.03 1,031.73 1,186.49 47350 1,222.08 1,160.98 1,335.13 46730 1,751.10 1,663.55 1,913.08 47360 1,663.85 1,580.66 1,817.76 46735 1,936.72 1,839.88 2,115.86 47361 2,714.38 2,578.66 2,965.46 46740 1,880.94 1,786.89 2,054.92 47362 1,275.35 1,211.58 1,393.32 46742 2,202.80 2,092.66 2,406.56 47370 1,110.03 1,054.53 1,212.71 46744 3,038.19 2,886.28 3,319.22 47371 1,130.45 1,073.93 1,235.02 46746 3,393.04 3,223.39 3,706.90 47380 1,296.80 1,231.96 1,416.75 46748 3,661.98 3,478.88 4,000.71 47381 1,329.75 1,263.26 1,452.75 46750 685.86 651.57 749.31 47382 4,333.76 4,117.07 4,734.63 46751 559.78 531.79 611.56 # 47382 791.91 752.31 865.16 46753 517.20 491.34 565.04 47400 1,920.46 1,824.44 2,098.11 46754 256.58 243.75 280.31 47420 1,194.91 1,135.16 1,305.43 # 46754 198.51 188.58 216.87 47425 1,209.94 1,149.44 1,321.86 46760 971.59 923.01 1,061.46 47460 1,143.88 1,086.69 1,249.69 46761 836.61 794.78 914.00 47480 768.37 729.95 839.44 46762 827.37 786.00 903.90 47490 498.10 473.20 544.18 46900 205.34 195.07 224.33 47500 98.25 93.34 107.34 # 46900 123.97 117.77 135.44 47505 38.12 36.21 41.64 46910 215.68 204.90 235.64 47510 471.25 447.69 514.84 # 46910 119.52 113.54 130.57 47511 585.78 556.49 639.96 46916 209.62 199.14 229.01 47525 492.68 468.05 538.26 # 46916 132.31 125.69 144.54 # 47525 100.62 95.59 109.93 46917 405.62 385.34 443.14 47530 1,372.24 1,303.63 1,499.17 # 46917 119.34 113.37 130.38 # 47530 353.99 336.29 386.73 46922 224.74 213.50 245.53 47550 150.66 143.13 164.60 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 41 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 47552 317.02 301.17 346.35 48551 204.63 194.40 223.56 47553 317.45 301.58 346.82 48552 215.19 204.43 235.09 47554 468.66 445.23 512.01 48554 2,252.11 2,139.50 2,460.43 47555 378.87 359.93 413.92 48556 1,119.09 1,063.14 1,222.61 47556 429.53 408.05 469.26 49000 691.40 656.83 755.35 47560 243.59 231.41 266.12 49002 925.93 879.63 1,011.57 47561 265.84 252.55 290.43 49010 858.63 815.70 938.06 47562 662.01 628.91 723.25 49020 1,424.44 1,353.22 1,556.20 47563 672.12 638.51 734.29 49021 854.48 811.76 933.52 47564 771.23 732.67 842.57 # 49021 169.12 160.66 184.76 47570 689.44 654.97 753.22 49040 895.33 850.56 978.14 47600 955.37 907.60 1,043.74 49041 873.79 830.10 954.62 47605 873.26 829.60 954.04 # 49041 199.89 189.90 218.39 47610 1,118.23 1,062.32 1,221.67 49060 998.42 948.50 1,090.78 47612 1,130.29 1,073.78 1,234.85 49061 859.13 816.17 938.60 47620 1,224.88 1,163.64 1,338.19 # 49061 184.86 175.62 201.96 47630 539.23 512.27 589.11 49062 673.47 639.80 735.77 47700 933.19 886.53 1,019.51 49080 159.00 151.05 173.71 47701 1,584.00 1,504.80 1,730.52 # 49080 68.01 64.61 74.30 47711 1,388.84 1,319.40 1,517.31 49081 152.84 145.20 166.98 47712 1,778.94 1,689.99 1,943.49 # 49081 64.44 61.22 70.40 47715 1,174.09 1,115.39 1,282.70 49180 159.47 151.50 174.23 47720 1,016.56 965.73 1,110.59 # 49180 86.98 82.63 95.02 47721 1,196.63 1,136.80 1,307.32 49203 1,080.39 1,026.37 1,180.33 47740 1,157.99 1,100.09 1,265.10 49204 1,376.66 1,307.83 1,504.00 47741 1,307.24 1,241.88 1,428.16 49205 1,577.35 1,498.48 1,723.25 47760 1,991.44 1,891.87 2,175.65 49215 1,975.00 1,876.25 2,157.69 47765 2,664.89 2,531.65 2,911.40 49220 865.44 822.17 945.50 47780 2,184.39 2,075.17 2,386.45 49250 518.13 492.22 566.05 47785 2,860.99 2,717.94 3,125.63 49255 705.25 669.99 770.49 47800 1,404.44 1,334.22 1,534.35 49320 294.96 280.21 322.24 47801 978.02 929.12 1,068.49 49321 310.89 295.35 339.65 47802 1,352.23 1,284.62 1,477.31 49322 336.94 320.09 368.10 47900 1,216.23 1,155.42 1,328.73 49323 575.53 546.75 628.76 48000 1,671.58 1,588.00 1,826.20 49324 354.09 336.39 386.85 48001 2,062.07 1,958.97 2,252.82 49325 378.37 359.45 413.37 48020 1,044.28 992.07 1,140.88 49326 172.19 163.58 188.12 48100 789.58 750.10 862.62 49400 167.15 158.79 182.61 48102 514.01 488.31 561.56 # 49400 94.28 89.57 103.01 # 48102 245.12 232.86 267.79 49402 763.78 725.59 834.43 48105 2,547.67 2,420.29 2,783.33 49411 506.06 480.76 552.87 48120 985.92 936.62 1,077.11 # 49411 192.05 182.45 209.82 48140 1,394.21 1,324.50 1,523.18 49419 404.52 384.29 441.93 48145 1,449.11 1,376.65 1,583.15 49420 127.33 120.96 139.10 48146 1,656.95 1,574.10 1,810.22 49421 348.02 330.62 380.21 48148 1,103.42 1,048.25 1,205.49 49422 348.05 330.65 380.25 48150 2,778.43 2,639.51 3,035.44 49423 542.37 515.25 592.54 48152 2,572.28 2,443.67 2,810.22 # 49423 74.49 70.77 81.39 48153 2,773.53 2,634.85 3,030.08 49424 145.75 138.46 159.23 48154 2,579.65 2,450.67 2,818.27 # 49424 39.23 37.27 42.86 48155 1,610.50 1,529.98 1,759.48 49425 683.35 649.18 746.56 48400 100.80 95.76 110.12 49426 579.34 550.37 632.93 48500 1,013.34 962.67 1,107.07 49427 45.10 42.85 49.28 48510 962.18 914.07 1,051.18 49428 393.82 374.13 430.25 48511 894.68 849.95 977.44 49429 408.72 388.28 446.52 # 48511 200.44 190.42 218.98 49435 109.64 104.16 119.78 48520 974.54 925.81 1,064.68 49436 167.08 158.73 182.54 48540 1,162.31 1,104.19 1,269.82 49440 1,043.01 990.86 1,139.49 48545 1,187.33 1,127.96 1,297.15 # 49440 223.39 212.22 244.05 48547 1,591.86 1,512.27 1,739.11 49441 1,137.07 1,080.22 1,242.25 48548 1,485.08 1,410.83 1,622.45 # 49441 252.71 240.07 276.08 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 42 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 49442 994.72 944.98 1,086.73 # 50021 168.75 160.31 184.36 # 49442 209.49 199.02 228.87 50040 929.79 883.30 1,015.80 49446 958.51 910.58 1,047.17 50045 932.74 886.10 1,019.02 # 49446 166.63 158.30 182.05 50060 1,149.04 1,091.59 1,255.33 49450 701.94 666.84 766.87 50065 1,207.03 1,146.68 1,318.68 # 49450 67.25 63.89 73.47 50070 1,198.94 1,138.99 1,309.84 49451 687.45 653.08 751.04 50075 1,472.93 1,399.28 1,609.17 # 49451 93.07 88.42 101.68 50080 878.13 834.22 959.35 49452 859.96 816.96 939.50 50081 1,289.37 1,224.90 1,408.64 # 49452 144.26 137.05 157.61 50100 969.27 920.81 1,058.93 49460 770.29 731.78 841.55 50120 951.51 903.93 1,039.52 # 49460 47.94 45.54 52.37 50125 995.61 945.83 1,087.70 49465 164.66 156.43 179.89 50130 1,041.29 989.23 1,137.61 # 49465 31.14 29.58 34.02 50135 1,128.38 1,071.96 1,232.75 49491 698.01 663.11 762.58 50200 544.82 517.58 595.22 49492 831.13 789.57 908.01 # 50200 142.77 135.63 155.97 49495 355.78 337.99 388.69 50205 682.08 647.98 745.18 49496 541.68 514.60 591.79 50220 1,032.22 980.61 1,127.70 49500 356.03 338.23 388.96 50225 1,192.46 1,132.84 1,302.77 49501 533.00 506.35 582.30 50230 1,287.86 1,223.47 1,406.99 49505 460.18 437.17 502.75 50234 1,307.63 1,242.25 1,428.59 49507 565.11 536.85 617.38 50236 1,479.09 1,405.14 1,615.91 49520 560.40 532.38 612.24 50240 1,331.80 1,265.21 1,454.99 49521 681.17 647.11 744.18 50250 1,234.19 1,172.48 1,348.35 49525 507.69 482.31 554.66 50280 951.60 904.02 1,039.62 49540 599.41 569.44 654.86 50290 874.68 830.95 955.59 49550 510.17 484.66 557.36 50320 1,319.50 1,253.53 1,441.56 49553 558.49 530.57 610.16 50323 183.98 174.78 201.00 49555 530.93 504.38 580.04 50325 183.98 174.78 201.00 49557 643.56 611.38 703.09 50327 199.48 189.51 217.94 49560 656.38 623.56 717.09 50328 174.83 166.09 191.00 49561 828.09 786.69 904.69 50329 168.90 160.46 184.53 49565 682.59 648.46 745.73 50340 831.88 790.29 908.83 49566 836.51 794.68 913.88 50360 2,285.11 2,170.85 2,496.48 49568 242.67 230.54 265.12 50365 2,565.22 2,436.96 2,802.50 49570 365.10 346.85 398.88 50370 1,067.92 1,014.52 1,166.70 49572 452.75 430.11 494.63 50380 1,814.10 1,723.40 1,981.91 49580 297.20 282.34 324.69 50382 1,242.98 1,180.83 1,357.95 49582 421.85 400.76 460.87 # 50382 278.74 264.80 304.52 49585 391.36 371.79 427.56 50384 1,055.74 1,002.95 1,153.39 49587 462.82 439.68 505.63 # 50384 253.87 241.18 277.36 49590 505.89 480.60 552.69 50385 1,218.86 1,157.92 1,331.61 49600 653.29 620.63 713.72 # 50385 238.34 226.42 260.38 49605 4,300.67 4,085.64 4,698.49 50386 792.09 752.49 865.36 49606 1,011.33 960.76 1,104.87 # 50386 180.33 171.31 197.01 49610 612.79 582.15 669.47 50387 575.86 547.07 629.13 49611 529.86 503.37 578.88 # 50387 100.95 95.90 110.29 49650 377.15 358.29 412.03 50389 327.53 311.15 357.82 49651 489.96 465.46 535.28 # 50389 55.31 52.54 60.42 49652 685.61 651.33 749.03 50390 98.25 93.34 107.34 49653 857.99 815.09 937.35 50391 126.91 120.56 138.64 49654 787.45 748.08 860.29 # 50391 100.65 95.62 109.96 49655 948.03 900.63 1,035.72 50392 180.96 171.91 197.70 49656 789.59 750.11 862.63 50393 220.15 209.14 240.51 49657 1,137.79 1,080.90 1,243.04 50394 102.48 97.36 111.96 49900 725.84 689.55 792.98 # 50394 49.96 47.46 54.58 49904 1,339.72 1,272.73 1,463.64 50395 182.07 172.97 198.92 49905 324.01 307.81 353.98 50396 117.45 111.58 128.32 50010 702.22 667.11 767.18 50398 519.44 493.47 567.49 50020 1,002.04 951.94 1,094.73 # 50398 74.86 71.12 81.79 50021 900.72 855.68 984.03 50400 1,161.98 1,103.88 1,269.46 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 43 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 50405 1,404.72 1,334.48 1,534.65 50780 1,096.88 1,042.04 1,198.35 50500 1,162.27 1,104.16 1,269.78 50782 1,097.30 1,042.44 1,198.81 50520 1,036.56 984.73 1,132.44 50783 1,121.72 1,065.63 1,225.47 50525 1,355.02 1,287.27 1,480.36 50785 1,214.53 1,153.80 1,326.87 50526 1,370.30 1,301.79 1,497.06 50800 924.10 877.90 1,009.59 50540 1,140.47 1,083.45 1,245.97 50810 1,258.62 1,195.69 1,375.04 50541 926.89 880.55 1,012.63 50815 1,228.40 1,166.98 1,342.03 50542 1,177.00 1,118.15 1,285.87 50820 1,308.98 1,243.53 1,430.06 50543 1,501.58 1,426.50 1,640.48 50825 1,660.08 1,577.08 1,813.64 50544 1,259.97 1,196.97 1,376.52 50830 1,798.51 1,708.58 1,964.87 50545 1,353.85 1,286.16 1,479.08 50840 1,237.61 1,175.73 1,352.09 50546 1,204.55 1,144.32 1,315.97 50845 1,255.62 1,192.84 1,371.77 50547 1,476.87 1,403.03 1,613.48 50860 947.84 900.45 1,035.52 50548 1,362.26 1,294.15 1,488.27 50900 839.56 797.58 917.22 50551 368.26 349.85 402.33 50920 886.17 841.86 968.14 # 50551 299.10 284.15 326.77 50930 1,107.47 1,052.10 1,209.92 50553 387.36 367.99 423.19 50940 886.89 842.55 968.93 # 50553 317.09 301.24 346.43 50945 980.93 931.88 1,071.66 50555 419.42 398.45 458.22 50947 1,386.73 1,317.39 1,515.00 # 50555 345.82 328.53 377.81 50948 1,290.70 1,226.17 1,410.10 50557 427.59 406.21 467.14 50951 384.69 365.46 420.28 # 50557 350.66 333.13 383.10 # 50951 311.83 296.24 340.68 50561 485.13 460.87 530.00 50953 406.22 385.91 443.80 # 50561 400.80 380.76 437.87 # 50953 343.71 326.52 375.50 50562 590.73 561.19 645.37 50955 446.05 423.75 487.31 50570 499.63 474.65 545.85 # 50955 370.97 352.42 405.28 50572 541.19 514.13 591.25 50957 437.11 415.25 477.54 50574 574.47 545.75 627.61 # 50957 359.43 341.46 392.68 50575 726.15 689.84 793.32 50961 394.52 374.79 431.01 50576 573.23 544.57 626.26 # 50961 322.39 306.27 352.21 50580 615.04 584.29 671.93 50970 376.78 357.94 411.63 50590 931.23 884.67 1,017.37 50972 363.15 344.99 396.74 # 50590 568.76 540.32 621.37 50974 480.64 456.61 525.10 50592 3,446.51 3,274.18 3,765.31 50976 472.91 449.26 516.65 # 50592 364.40 346.18 398.11 50980 362.10 344.00 395.60 50593 4,589.93 4,360.43 5,014.49 51020 470.52 446.99 514.04 # 50593 468.13 444.72 511.43 51030 461.83 438.74 504.55 50600 941.59 894.51 1,028.69 51040 292.43 277.81 319.48 50605 922.08 875.98 1,007.38 51045 474.63 450.90 518.54 50610 952.55 904.92 1,040.66 51050 475.61 451.83 519.60 50620 910.83 865.29 995.08 51060 585.11 555.85 639.23 50630 889.75 845.26 972.05 51065 581.05 552.00 634.80 50650 1,040.13 988.12 1,136.34 51080 408.19 387.78 445.95 50660 1,148.18 1,090.77 1,254.39 51100 61.20 58.14 66.86 50684 177.19 168.33 193.58 # 51100 39.00 37.05 42.61 # 50684 49.96 47.46 54.58 51101 125.50 119.23 137.11 50686 105.25 99.99 114.99 # 51101 51.90 49.31 56.71 # 50686 91.94 87.34 100.44 51102 231.99 220.39 253.45 50688 80.10 76.10 87.52 # 51102 148.40 140.98 162.13 50690 98.66 93.73 107.79 51500 621.56 590.48 679.05 # 50690 70.18 66.67 76.67 51520 589.86 560.37 644.43 50700 929.82 883.33 1,015.83 51525 864.40 821.18 944.36 50715 1,111.12 1,055.56 1,213.89 51530 773.93 735.23 845.51 50722 974.38 925.66 1,064.51 51535 776.00 737.20 847.78 50725 1,092.41 1,037.79 1,193.46 51550 954.00 906.30 1,042.25 50727 504.29 479.08 550.94 51555 1,262.74 1,199.60 1,379.54 50728 692.70 658.07 756.78 51565 1,291.24 1,226.68 1,410.68 50740 1,113.78 1,058.09 1,216.80 51570 1,475.56 1,401.78 1,612.05 50750 1,166.71 1,108.37 1,274.63 51575 1,836.83 1,744.99 2,006.74 50760 1,100.39 1,045.37 1,202.18 51580 1,914.55 1,818.82 2,091.64 50770 1,135.27 1,078.51 1,240.29 51585 2,131.90 2,025.31 2,329.11 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 44 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 51590 1,944.49 1,847.27 2,124.36 51840 641.72 609.63 701.07 51595 2,208.00 2,097.60 2,412.24 51841 761.68 723.60 832.14 51596 2,373.99 2,255.29 2,593.58 51845 583.74 554.55 637.73 51597 2,295.90 2,181.11 2,508.28 51860 719.04 683.09 785.55 51600 190.86 181.32 208.52 51865 884.50 840.28 966.32 # 51600 44.39 42.17 48.50 51880 461.98 438.88 504.71 51605 38.51 36.58 42.07 51900 817.87 776.98 893.53 51610 110.13 104.62 120.31 51920 753.16 715.50 822.83 # 51610 63.52 60.34 69.39 51925 993.77 944.08 1,085.69 51700 86.36 82.04 94.35 51940 1,614.90 1,534.16 1,764.28 # 51700 44.94 42.69 49.09 51960 1,395.96 1,326.16 1,525.08 51701 59.45 56.48 64.95 51980 714.80 679.06 780.92 # 51701 27.27 25.91 29.80 51990 735.79 699.00 803.85 51702 76.83 72.99 83.94 51992 810.76 770.22 885.75 # 51702 30.23 28.72 33.03 52000 209.30 198.84 228.67 51703 138.27 131.36 151.06 # 52000 126.45 120.13 138.15 # 51703 82.05 77.95 89.64 52001 382.57 363.44 417.96 51705 112.35 106.73 122.74 # 52001 290.48 275.96 317.35 # 51705 67.59 64.21 73.84 52005 288.04 273.64 314.69 51710 157.05 149.20 171.58 # 52005 134.17 127.46 146.58 # 51710 96.02 91.22 104.90 52007 528.84 502.40 577.76 51715 292.40 277.78 319.45 # 52007 167.48 159.11 182.98 # 51715 199.56 189.58 218.02 52010 400.13 380.12 437.14 51720 114.00 108.30 124.55 # 52010 163.42 155.25 178.54 # 51720 82.19 78.08 89.79 52204 430.99 409.44 470.86 51725 215.13 204.37 235.03 # 52204 142.50 135.38 155.69 51725 TC 138.88 131.94 151.73 52214 601.68 571.60 657.34 51725 26 76.26 72.45 83.32 # 52214 215.54 204.76 235.47 51726 316.32 300.50 345.58 52224 791.06 751.51 864.24 51726 TC 230.03 218.53 251.31 # 52224 171.54 162.96 187.40 51726 26 86.29 81.98 94.28 52234 249.32 236.85 272.38 51727 292.35 277.73 319.39 52235 292.70 278.07 319.78 51727 TC 187.33 177.96 204.65 52240 511.16 485.60 558.44 51727 26 105.02 99.77 114.74 52250 245.64 233.36 268.36 51728 292.36 277.74 319.40 52260 212.21 201.60 231.84 51728 TC 188.44 179.02 205.87 52265 415.40 394.63 453.82 51728 26 103.92 98.72 113.53 # 52265 161.30 153.24 176.23 51729 314.28 298.57 343.36 52270 399.56 379.58 436.52 51729 TC 190.66 181.13 208.30 # 52270 183.93 174.73 200.94 51729 26 123.62 117.44 135.06 52275 545.28 518.02 595.72 51736 53.35 50.68 58.28 # 52275 252.34 239.72 275.68 51736 TC 22.37 21.25 24.44 52276 269.22 255.76 294.12 51736 26 30.98 29.43 33.84 52277 331.62 315.04 362.30 51741 83.72 79.53 91.46 52281 302.66 287.53 330.66 51741 TC 26.07 24.77 28.49 # 52281 156.20 148.39 170.65 51741 26 57.65 54.77 62.99 52282 340.27 323.26 371.75 51784 200.13 190.12 218.64 52283 282.79 268.65 308.95 51784 TC 123.34 117.17 134.75 # 52283 203.27 193.11 222.08 51784 26 76.79 72.95 83.89 52285 284.86 270.62 311.21 51785 218.43 207.51 238.64 # 52285 196.83 186.99 215.04 51785 TC 141.10 134.05 154.16 52290 247.90 235.51 270.84 51785 26 77.33 73.46 84.48 52300 285.69 271.41 312.12 51792 224.88 213.64 245.69 52301 297.04 282.19 324.52 51792 TC 169.21 160.75 184.86 52305 282.39 268.27 308.51 51792 26 55.68 52.90 60.84 52310 250.50 237.98 273.68 51797 139.58 132.60 152.49 # 52310 153.22 145.56 167.39 51797 TC 97.45 92.58 106.47 52315 441.97 419.87 482.85 51797 26 42.12 40.01 46.01 # 52315 278.48 264.56 304.24 51798 19.04 18.09 20.80 52317 931.73 885.14 1,017.91 51800 1,048.13 995.72 1,145.08 # 52317 352.89 335.25 385.54 51820 1,063.66 1,010.48 1,162.05 52318 480.98 456.93 525.47 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 45 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 52320 250.12 237.61 273.25 53420 817.70 776.82 893.34 52325 324.98 308.73 355.04 53425 948.97 901.52 1,036.75 52327 265.75 252.46 290.33 53430 956.90 909.06 1,045.42 52330 723.16 687.00 790.05 53431 1,162.34 1,104.22 1,269.85 # 52330 267.49 254.12 292.24 53440 887.17 842.81 969.23 52332 491.99 467.39 537.50 53442 782.79 743.65 855.20 # 52332 157.63 149.75 172.21 53444 801.41 761.34 875.54 52334 259.71 246.72 283.73 53445 887.24 842.88 969.31 52341 294.32 279.60 321.54 53446 648.78 616.34 708.79 52342 319.93 303.93 349.52 53447 818.26 777.35 893.95 52343 355.93 338.13 388.85 53448 1,292.63 1,228.00 1,412.20 52344 386.35 367.03 422.08 53449 617.37 586.50 674.48 52345 412.14 391.53 450.26 53450 411.97 391.37 450.08 52346 464.97 441.72 507.98 53460 461.38 438.31 504.06 52351 318.45 302.53 347.91 53500 744.84 707.60 813.74 52352 373.52 354.84 408.07 53502 486.78 462.44 531.81 52353 429.76 408.27 469.51 53505 490.11 465.60 535.44 52354 397.35 377.48 434.10 53510 636.50 604.68 695.38 52355 473.46 449.79 517.26 53515 799.51 759.53 873.46 52400 476.81 452.97 520.92 53520 560.19 532.18 612.01 52402 271.34 257.77 296.44 53600 85.81 81.52 93.75 52450 472.06 448.46 515.73 # 53600 64.73 61.49 70.71 52500 491.61 467.03 537.08 53601 83.98 79.78 91.75 52601 837.71 795.82 915.19 # 53601 54.39 51.67 59.42 52630 446.42 424.10 487.72 53605 65.36 62.09 71.40 52640 300.63 285.60 328.44 53620 122.49 116.37 133.83 52647 2,112.81 2,007.17 2,308.25 # 53620 88.46 84.04 96.65 # 52647 650.36 617.84 710.52 53621 115.91 110.11 126.63 52648 2,160.39 2,052.37 2,360.23 # 53621 73.01 69.36 79.76 # 52648 693.86 659.17 758.05 53660 72.97 69.32 79.72 52649 981.88 932.79 1,072.71 # 53660 41.53 39.45 45.37 52700 438.32 416.40 478.86 53661 72.21 68.60 78.89 53000 149.77 142.28 163.62 # 53661 40.77 38.73 44.54 53010 296.39 281.57 323.81 53665 38.47 36.55 42.03 53020 98.19 93.28 107.27 53850 2,411.66 2,291.08 2,634.74 53025 65.81 62.52 71.90 # 53850 571.94 543.34 624.84 53040 393.48 373.81 429.88 53852 2,323.30 2,207.14 2,538.21 53060 176.65 167.82 192.99 # 53852 625.24 593.98 683.08 # 53060 156.67 148.84 171.17 53855 663.20 630.04 724.55 53080 433.73 412.04 473.85 # 53855 79.92 75.92 87.31 53085 624.47 593.25 682.24 54000 156.19 148.38 170.64 53200 155.25 147.49 169.61 # 54000 108.11 102.70 118.11 # 53200 141.20 134.14 154.26 54001 192.27 182.66 210.06 53210 775.01 736.26 846.70 # 54001 139.01 132.06 151.87 53215 937.68 890.80 1,024.42 54015 311.31 295.74 340.10 53220 454.37 431.65 496.40 54050 123.20 117.04 134.60 53230 606.04 575.74 662.10 # 54050 98.42 93.50 107.53 53235 640.52 608.49 699.76 54055 115.51 109.73 126.19 53240 429.95 408.45 469.72 # 54055 88.88 84.44 97.11 53250 407.36 386.99 445.04 54056 130.41 123.89 142.47 53260 199.62 189.64 218.09 # 54056 102.67 97.54 112.17 # 53260 177.05 168.20 193.43 54057 137.64 130.76 150.37 53265 220.84 209.80 241.27 # 54057 92.89 88.25 101.49 # 53265 185.33 176.06 202.47 54060 184.38 175.16 201.43 53270 205.81 195.52 224.85 # 54060 128.90 122.46 140.83 # 53270 184.36 175.14 201.41 54065 208.13 197.72 227.38 53275 265.85 252.56 290.44 # 54065 161.53 153.45 176.47 53400 805.19 764.93 879.67 54100 189.30 179.84 206.82 53405 883.28 839.12 964.99 # 54100 119.03 113.08 130.04 53410 987.88 938.49 1,079.26 54105 275.35 261.58 300.82 53415 1,139.07 1,082.12 1,244.44 # 54105 215.80 205.01 235.76 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 46 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 54110 628.06 596.66 686.16 54411 1,033.75 982.06 1,129.37 54111 808.79 768.35 883.60 54415 531.98 505.38 581.19 54112 948.94 901.49 1,036.71 54416 714.51 678.78 780.60 54115 455.13 432.37 497.23 54417 905.29 860.03 989.03 # 54115 425.54 404.26 464.90 54420 713.99 678.29 780.03 54120 636.22 604.41 695.07 54430 647.80 615.41 707.72 54125 818.50 777.58 894.22 54435 421.15 400.09 460.10 54130 1,204.88 1,144.64 1,316.34 54450 72.84 69.20 79.58 54135 1,528.63 1,452.20 1,670.03 # 54450 58.78 55.84 64.22 54150 165.83 157.54 181.17 54500 75.66 71.88 82.66 # 54150 97.40 92.53 106.41 54505 213.47 202.80 233.22 54160 231.56 219.98 252.98 54512 539.16 512.20 589.03 # 54160 145.38 138.11 158.83 54520 325.25 308.99 355.34 54161 198.23 188.32 216.57 54522 582.94 553.79 636.86 54162 269.98 256.48 294.95 54530 509.54 484.06 556.67 # 54162 198.60 188.67 216.97 54535 740.02 703.02 808.47 54163 219.50 208.53 239.81 54550 492.26 467.65 537.80 54164 193.89 184.20 211.83 54560 672.31 638.69 734.49 54200 110.95 105.40 121.21 54600 455.64 432.86 497.79 # 54200 85.43 81.16 93.33 54620 304.18 288.97 332.32 54205 540.52 513.49 590.51 54640 471.89 448.30 515.55 54220 211.20 200.64 230.74 54650 709.55 674.07 775.18 # 54220 135.38 128.61 147.90 54660 357.48 339.61 390.55 54230 97.81 92.92 106.86 54670 406.81 386.47 444.44 # 54230 80.42 76.40 87.86 54680 784.83 745.59 857.43 54231 141.20 134.14 154.26 54690 664.69 631.46 726.18 # 54231 117.90 112.01 128.81 54692 767.58 729.20 838.58 54235 90.85 86.31 99.26 54700 212.56 201.93 232.22 # 54235 73.83 70.14 80.66 54800 138.07 131.17 150.85 54240 100.27 95.26 109.55 54830 372.91 354.26 407.40 54240 TC 33.84 32.15 36.97 54840 324.23 308.02 354.22 54240 26 66.43 63.11 72.58 54860 421.10 400.05 460.06 54250 124.65 118.42 136.18 54861 568.70 540.27 621.31 54250 TC 12.01 11.41 13.12 54865 359.09 341.14 392.31 54250 26 112.64 107.01 123.06 54900 770.71 732.17 842.00 54300 652.19 619.58 712.52 54901 1,068.82 1,015.38 1,167.69 54304 763.35 725.18 833.96 55000 120.95 114.90 132.14 54308 726.92 690.57 794.16 # 55000 84.70 80.47 92.54 54312 833.42 791.75 910.51 55040 338.50 321.58 369.82 54316 1,014.46 963.74 1,108.30 55041 510.50 484.98 557.73 54318 722.42 686.30 789.25 55060 380.24 361.23 415.41 54322 794.54 754.81 868.03 55100 217.60 206.72 237.73 54324 986.82 937.48 1,078.10 # 55100 163.60 155.42 178.73 54326 934.62 887.89 1,021.07 55110 386.97 367.62 422.76 54328 946.12 898.81 1,033.63 55120 356.01 338.21 388.94 54332 1,028.54 977.11 1,123.68 55150 489.91 465.41 535.22 54336 1,159.76 1,101.77 1,267.04 55175 364.46 346.24 398.18 54340 570.16 541.65 622.90 55180 688.86 654.42 752.58 54344 964.52 916.29 1,053.73 55200 481.16 457.10 525.67 54348 1,034.42 982.70 1,130.11 # 55200 277.36 263.49 303.01 54352 1,442.36 1,370.24 1,575.78 55250 425.44 404.17 464.80 54360 733.13 696.47 800.94 # 55250 227.56 216.18 248.61 54380 812.52 771.89 887.67 55300 182.03 172.93 198.87 54385 1,012.27 961.66 1,105.91 55400 505.06 479.81 551.78 54390 1,202.21 1,142.10 1,313.42 55450 379.27 360.31 414.36 54400 536.48 509.66 586.11 # 55450 256.85 244.01 280.61 54401 661.40 628.33 722.58 55500 381.12 362.06 416.37 54405 816.94 776.09 892.50 55520 401.25 381.19 438.37 54406 736.82 699.98 804.98 55530 353.92 336.22 386.65 54408 796.14 756.33 869.78 55535 430.14 408.63 469.92 54410 869.47 826.00 949.90 55540 482.57 458.44 527.21 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 47 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 55550 424.20 402.99 463.44 56810 243.80 231.61 266.35 55600 424.71 403.47 463.99 56820 103.21 98.05 112.76 55605 508.69 483.26 555.75 # 56820 79.17 75.21 86.49 55650 717.62 681.74 784.00 56821 137.59 130.71 150.32 55680 340.95 323.90 372.49 # 56821 106.89 101.55 116.78 55700 230.17 218.66 251.46 57000 178.65 169.72 195.18 # 55700 138.82 131.88 151.66 57010 404.39 384.17 441.80 55705 270.23 256.72 295.23 57020 87.68 83.30 95.80 55706 383.67 364.49 419.16 # 57020 75.84 72.05 82.86 55720 454.38 431.66 496.41 57022 156.77 148.93 171.27 55725 592.53 562.90 647.34 57023 291.09 276.54 318.02 55801 1,095.85 1,041.06 1,197.22 57061 106.70 101.37 116.58 55810 1,324.61 1,258.38 1,447.14 # 57061 91.17 86.61 99.60 55812 1,622.66 1,541.53 1,772.76 57065 179.64 170.66 196.26 55815 1,779.91 1,690.91 1,944.55 # 57065 159.66 151.68 174.43 55821 881.62 837.54 963.17 57100 82.28 78.17 89.90 55831 954.50 906.78 1,042.80 # 57100 61.20 58.14 66.86 55840 1,350.17 1,282.66 1,475.06 57105 126.85 120.51 138.59 55842 1,446.00 1,373.70 1,579.76 # 57105 116.86 111.02 127.67 55845 1,651.47 1,568.90 1,804.24 57106 448.23 425.82 489.69 55860 883.16 839.00 964.85 57107 1,306.10 1,240.80 1,426.92 55862 1,110.24 1,054.73 1,212.94 57109 1,496.29 1,421.48 1,634.70 55865 1,349.55 1,282.07 1,474.38 57110 839.36 797.39 917.00 55866 1,756.49 1,668.67 1,918.97 57111 1,509.60 1,434.12 1,649.24 55870 176.54 167.71 192.87 57112 1,576.76 1,497.92 1,722.61 # 55870 144.73 137.49 158.11 57120 479.06 455.11 523.38 55873 5,945.77 5,648.48 6,495.75 57130 168.51 160.08 184.09 # 55873 881.55 837.47 963.09 # 57130 150.02 142.52 163.90 55875 768.61 730.18 839.71 57135 180.50 171.48 197.20 55876 138.39 131.47 151.19 # 57135 161.64 153.56 176.59 # 55876 102.88 97.74 112.40 57150 46.58 44.25 50.89 55920 435.47 413.70 475.76 # 57150 27.72 26.33 30.28 56405 102.12 97.01 111.56 57155 397.24 377.38 433.99 # 56405 100.27 95.26 109.55 57160 72.08 68.48 78.75 56420 117.19 111.33 128.03 # 57160 44.71 42.47 48.84 # 56420 86.49 82.17 94.50 57170 62.98 59.83 68.80 56440 171.29 162.73 187.14 # 57170 45.23 42.97 49.42 56441 139.34 132.37 152.23 57180 133.51 126.83 145.85 # 56441 132.31 125.69 144.54 # 57180 99.85 94.86 109.09 56442 45.44 43.17 49.65 57200 278.73 264.79 304.51 56501 122.32 116.20 133.63 57210 343.83 326.64 375.64 # 56501 106.41 101.09 116.25 57220 300.36 285.34 328.14 56515 208.89 198.45 228.22 57230 375.91 357.11 410.68 # 56515 184.84 175.60 201.94 57240 629.76 598.27 688.01 56605 77.82 73.93 85.02 57250 622.62 591.49 680.21 # 56605 56.37 53.55 61.58 57260 770.52 731.99 841.79 56606 35.86 34.07 39.18 57265 851.20 808.64 929.94 # 56606 27.72 26.33 30.28 57267 246.90 234.56 269.74 56620 464.80 441.56 507.79 57268 451.25 428.69 492.99 56625 558.57 530.64 610.24 57270 747.23 709.87 816.35 56630 816.26 775.45 891.77 57280 902.99 857.84 986.52 56631 1,037.33 985.46 1,133.28 57282 473.34 449.67 517.12 56632 1,201.99 1,141.89 1,313.17 57283 648.03 615.63 707.97 56633 1,063.61 1,010.43 1,161.99 57284 780.23 741.22 852.40 56634 1,122.67 1,066.54 1,226.52 57285 637.86 605.97 696.87 56637 1,322.24 1,256.13 1,444.55 57287 660.02 627.02 721.07 56640 1,312.38 1,246.76 1,433.77 57288 686.65 652.32 750.17 56700 174.89 166.15 191.07 57289 713.12 677.46 779.08 56740 277.54 263.66 303.21 57291 506.17 480.86 552.99 56800 226.86 215.52 247.85 57292 774.92 736.17 846.60 56805 1,072.04 1,018.44 1,171.21 57295 456.78 433.94 499.03 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 48 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 57296 889.46 844.99 971.74 58110 45.47 43.20 49.68 57300 506.20 480.89 553.02 # 58110 38.81 36.87 42.40 57305 838.08 796.18 915.61 58120 235.93 224.13 257.75 57307 943.69 896.51 1,030.99 # 58120 202.64 192.51 221.39 57308 594.37 564.65 649.35 58140 852.42 809.80 931.27 57310 457.10 434.25 499.39 58145 507.00 481.65 553.90 57311 520.09 494.09 568.20 58146 1,080.12 1,026.11 1,180.03 57320 521.34 495.27 569.56 58150 924.79 878.55 1,010.33 57330 731.48 694.91 799.15 58152 1,162.75 1,104.61 1,270.30 57335 1,092.51 1,037.88 1,193.56 58180 890.69 846.16 973.08 57400 125.75 119.46 137.38 58200 1,218.91 1,157.96 1,331.65 57410 99.83 94.84 109.07 58210 1,626.79 1,545.45 1,777.27 57415 150.19 142.68 164.08 58240 2,584.48 2,455.26 2,823.55 57420 108.23 102.82 118.24 58260 771.91 733.31 843.31 # 57420 83.82 79.63 91.57 58262 860.94 817.89 940.57 57421 145.84 138.55 159.33 58263 927.15 880.79 1,012.91 # 57421 114.40 108.68 124.98 58267 985.13 935.87 1,076.25 57423 865.31 822.04 945.35 58270 823.76 782.57 899.96 57425 912.43 866.81 996.83 58275 918.61 872.68 1,003.58 57426 817.52 776.64 893.14 58280 982.43 933.31 1,073.31 57452 101.93 96.83 111.35 58285 1,225.83 1,164.54 1,339.22 # 57452 85.65 81.37 93.58 58290 1,075.62 1,021.84 1,175.12 57454 143.96 136.76 157.27 58291 1,167.61 1,109.23 1,275.61 # 57454 127.31 120.94 139.08 58292 1,230.14 1,168.63 1,343.92 57455 133.81 127.12 146.19 58293 1,277.83 1,213.94 1,396.03 # 57455 103.48 98.31 113.06 58294 1,137.78 1,080.89 1,243.02 57456 126.66 120.33 138.38 58301 89.74 85.25 98.04 # 57456 96.70 91.87 105.65 # 58301 63.48 60.31 69.36 57460 276.62 262.79 302.21 58321 73.00 69.35 79.75 # 57460 152.72 145.08 166.84 # 58321 45.26 43.00 49.45 57461 310.55 295.02 339.27 58322 81.52 77.44 89.06 # 57461 175.92 167.12 192.19 # 58322 54.89 52.15 59.97 57500 123.33 117.16 134.73 58323 17.17 16.31 18.76 # 57500 70.07 66.57 76.56 # 58323 11.63 11.05 12.71 57505 95.61 90.83 104.45 58340 119.07 113.12 130.09 # 57505 85.62 81.34 93.54 # 58340 55.46 52.69 60.59 57510 123.42 117.25 134.84 58345 262.50 249.38 286.79 # 57510 107.89 102.50 117.88 58346 426.80 405.46 466.28 57511 136.29 129.48 148.90 58350 91.03 86.48 99.45 # 57511 123.34 117.17 134.75 # 58350 73.64 69.96 80.45 57513 134.44 127.72 146.88 58353 1,051.47 998.90 1,148.74 # 57513 123.71 117.52 135.15 # 58353 205.59 195.31 224.61 57520 287.19 272.83 313.75 58356 1,936.38 1,839.56 2,115.49 # 57520 254.64 241.91 278.20 # 58356 324.87 308.63 354.92 57522 246.70 234.37 269.53 58400 416.89 396.05 455.46 # 57522 227.10 215.75 248.11 58410 750.13 712.62 819.51 57530 322.02 305.92 351.81 58520 745.36 708.09 814.30 57531 1,588.69 1,509.26 1,735.65 58540 846.53 804.20 924.83 57540 726.96 690.61 794.20 58541 801.11 761.05 875.21 57545 767.55 729.17 838.55 58542 893.90 849.21 976.59 57550 381.39 362.32 416.67 58543 908.90 863.46 992.98 57555 560.53 532.50 612.38 58544 981.79 932.70 1,072.61 57556 534.78 508.04 584.25 58545 833.66 791.98 910.78 57558 117.27 111.41 128.12 58546 1,052.89 1,000.25 1,150.29 # 57558 106.17 100.86 115.99 58548 1,655.00 1,572.25 1,808.09 57700 290.86 276.32 317.77 58550 823.73 782.54 899.92 57720 287.82 273.43 314.44 58552 913.82 868.13 998.35 57800 56.20 53.39 61.40 58553 1,058.96 1,006.01 1,156.91 # 57800 45.47 43.20 49.68 58554 1,223.69 1,162.51 1,336.89 58100 102.79 97.65 112.30 58555 238.41 226.49 260.46 # 58100 81.71 77.62 89.26 # 58555 177.38 168.51 193.79 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 49 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 58558 318.66 302.73 348.14 59001 167.03 158.68 182.48 # 58558 249.86 237.37 272.98 59012 184.56 175.33 201.63 58559 321.40 305.33 351.13 59015 142.01 134.91 155.15 58560 363.25 345.09 396.85 # 59015 120.56 114.53 131.71 58561 513.46 487.79 560.96 59020 63.00 59.85 68.83 58562 334.88 318.14 365.86 59020 TC 29.40 27.93 32.12 # 58562 272.37 258.75 297.56 59020 26 33.61 31.93 36.72 58563 1,715.62 1,629.84 1,874.32 59025 42.89 40.75 46.86 # 58563 321.22 305.16 350.93 59025 TC 15.71 14.92 17.16 58565 1,840.66 1,748.63 2,010.92 59025 26 27.18 25.82 29.69 # 58565 405.57 385.29 443.08 59030 96.93 92.08 105.89 58570 860.10 817.10 939.67 59050 45.76 43.47 49.99 58571 950.95 903.40 1,038.91 59051 38.08 36.18 41.61 58572 1,067.05 1,013.70 1,165.76 59070 383.49 364.32 418.97 58573 1,218.16 1,157.25 1,330.84 # 59070 285.48 271.21 311.89 58600 339.22 322.26 370.60 59072 479.47 455.50 523.83 58605 307.93 292.53 336.41 59074 370.55 352.02 404.82 58611 72.42 68.80 79.12 # 59074 285.11 270.85 311.48 58615 231.26 219.70 252.66 59076 471.70 448.12 515.34 58660 625.33 594.06 683.17 59100 751.33 713.76 820.82 58661 599.71 569.72 655.18 59120 718.91 682.96 785.40 58662 657.51 624.63 718.32 59121 720.63 684.60 787.29 58670 341.44 324.37 373.03 59130 796.25 756.44 869.91 58671 340.70 323.67 372.22 59135 803.91 763.71 878.27 58672 687.66 653.28 751.27 59136 794.33 754.61 867.80 58673 749.16 711.70 818.46 59140 345.21 327.95 377.14 58700 715.21 679.45 781.37 59150 695.54 660.76 759.87 58720 669.11 635.65 731.00 59151 678.66 644.73 741.44 58740 815.12 774.36 890.51 59160 193.72 184.03 211.63 58750 843.14 800.98 921.13 # 59160 162.28 154.17 177.30 58752 827.87 786.48 904.45 59200 67.76 64.37 74.03 58760 759.52 721.54 829.77 # 59200 40.76 38.72 44.53 58770 786.01 746.71 858.72 59300 175.84 167.05 192.11 58800 301.12 286.06 328.97 # 59300 133.31 126.64 145.64 # 58800 280.77 266.73 306.74 59320 138.92 131.97 151.77 58805 378.85 359.91 413.90 59325 209.26 198.80 228.62 58820 293.03 278.38 320.14 59350 251.61 239.03 274.88 58822 672.64 639.01 734.86 59400 1,636.91 1,555.06 1,788.32 58823 867.77 824.38 948.04 59409 694.23 659.52 758.45 # 58823 169.09 160.64 184.74 59410 814.05 773.35 889.35 58825 648.91 616.46 708.93 59412 94.05 89.35 102.75 58900 397.26 377.40 434.01 59414 83.14 78.98 90.83 58920 651.58 619.00 711.85 59425 417.59 396.71 456.22 58925 684.53 650.30 747.85 # 59425 326.23 309.92 356.41 58940 472.78 449.14 516.51 59426 749.69 712.21 819.04 58943 1,042.94 990.79 1,139.41 # 59426 579.18 550.22 632.75 58950 997.25 947.39 1,089.50 59430 126.79 120.45 138.52 58951 1,282.90 1,218.76 1,401.57 # 59430 113.85 108.16 124.38 58952 1,447.27 1,374.91 1,581.15 59510 1,852.74 1,760.10 2,024.12 58953 1,792.29 1,702.68 1,958.08 59514 823.69 782.51 899.89 58954 1,943.99 1,846.79 2,123.81 59515 984.71 935.47 1,075.79 58956 1,224.17 1,162.96 1,337.40 59525 440.52 418.49 481.26 58957 1,388.13 1,318.72 1,516.53 59610 1,721.99 1,635.89 1,881.27 58958 1,536.31 1,459.49 1,678.41 59612 779.60 740.62 851.71 58960 860.03 817.03 939.58 59614 877.73 833.84 958.92 58970 204.61 194.38 223.54 59618 1,935.02 1,838.27 2,114.01 # 58970 181.67 172.59 198.48 59620 904.86 859.62 988.56 58976 233.15 221.49 254.71 59622 1,067.00 1,013.65 1,165.70 # 58976 202.08 191.98 220.78 59812 288.95 274.50 315.68 59000 118.45 112.53 129.41 # 59812 267.13 253.77 291.84 # 59000 73.70 70.02 80.52 59820 346.50 329.18 378.56 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 50 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ # 59820 322.46 306.34 352.29 61151 854.90 812.16 933.98 59821 349.01 331.56 381.29 61154 1,095.88 1,041.09 1,197.25 # 59821 323.86 307.67 353.82 61156 1,085.91 1,031.61 1,186.35 59830 397.01 377.16 433.73 61210 326.56 310.23 356.76 59840 196.63 186.80 214.82 61215 431.22 409.66 471.11 # 59840 189.23 179.77 206.74 61250 741.83 704.74 810.45 59841 345.97 328.67 377.97 61253 784.42 745.20 856.98 # 59841 326.00 309.70 356.16 61304 1,431.42 1,359.85 1,563.83 59850 335.28 318.52 366.30 61305 1,748.77 1,661.33 1,910.53 59851 363.05 344.90 396.64 61312 1,812.21 1,721.60 1,979.84 59852 484.36 460.14 529.16 61313 1,724.45 1,638.23 1,883.96 59855 376.94 358.09 411.80 61314 1,588.42 1,509.00 1,735.35 59856 442.95 420.80 483.92 61315 1,805.18 1,714.92 1,972.16 59857 502.87 477.73 549.39 61316 77.19 73.33 84.33 59866 207.16 196.80 226.32 61320 1,664.88 1,581.64 1,818.89 59870 431.46 409.89 471.37 61321 1,839.29 1,747.33 2,009.43 59871 121.97 115.87 133.25 61322 2,050.97 1,948.42 2,240.68 60000 149.33 141.86 163.14 61323 2,073.21 1,969.55 2,264.98 # 60000 135.64 128.86 148.19 61330 1,507.02 1,431.67 1,646.42 60100 107.60 102.22 117.55 61332 1,698.53 1,613.60 1,855.64 # 60100 77.64 73.76 84.82 61333 1,757.05 1,669.20 1,919.58 60200 603.09 572.94 658.88 61334 1,167.64 1,109.26 1,275.65 60210 641.81 609.72 701.18 61340 1,249.38 1,186.91 1,364.95 60212 917.28 871.42 1,002.13 61343 1,919.41 1,823.44 2,096.96 60220 702.80 667.66 767.81 61345 1,778.22 1,689.31 1,942.71 60225 845.08 802.83 923.25 61440 1,742.08 1,654.98 1,903.23 60240 887.71 843.32 969.82 61450 1,670.41 1,586.89 1,824.92 60252 1,206.26 1,145.95 1,317.84 61458 1,753.64 1,665.96 1,915.85 60254 1,553.72 1,476.03 1,697.43 61460 1,816.51 1,725.68 1,984.53 60260 1,004.51 954.28 1,097.42 61470 1,671.27 1,587.71 1,825.87 60270 1,269.16 1,205.70 1,386.56 61480 1,476.34 1,402.52 1,612.90 60271 972.69 924.06 1,062.67 61490 1,653.33 1,570.66 1,806.26 60280 409.35 388.88 447.21 61500 1,181.00 1,121.95 1,290.24 60281 544.70 517.47 595.09 61501 1,019.02 968.07 1,113.28 60300 103.41 98.24 112.98 61510 1,901.67 1,806.59 2,077.58 # 60300 47.93 45.53 52.36 61512 2,230.86 2,119.32 2,437.22 60500 923.83 877.64 1,009.29 61514 1,661.67 1,578.59 1,815.38 60502 1,160.36 1,102.34 1,267.69 61516 1,617.11 1,536.25 1,766.69 60505 1,273.85 1,210.16 1,391.68 61517 77.21 73.35 84.35 60512 223.14 211.98 243.78 61518 2,229.93 2,118.43 2,436.19 60520 944.72 897.48 1,032.10 61519 2,402.74 2,282.60 2,624.99 60521 1,072.73 1,019.09 1,171.95 61520 3,151.36 2,993.79 3,442.86 60522 1,297.73 1,232.84 1,417.77 61521 2,600.94 2,470.89 2,841.52 60540 993.50 943.83 1,085.40 61522 1,909.58 1,814.10 2,086.22 60545 1,133.60 1,076.92 1,238.46 61524 1,808.08 1,717.68 1,975.33 60600 1,332.74 1,266.10 1,456.02 61526 2,962.77 2,814.63 3,236.82 60605 1,701.88 1,616.79 1,859.31 61530 2,491.28 2,366.72 2,721.73 60650 1,106.70 1,051.37 1,209.08 61531 1,058.22 1,005.31 1,156.11 61000 102.21 97.10 111.67 61533 1,323.88 1,257.69 1,446.34 61001 110.11 104.60 120.29 61534 1,429.62 1,358.14 1,561.86 61020 118.97 113.02 129.97 61535 862.93 819.78 942.75 61026 116.15 110.34 126.89 61536 2,258.99 2,146.04 2,467.95 61050 99.93 94.93 109.17 61537 2,129.83 2,023.34 2,326.84 61055 129.03 122.58 140.97 61538 2,117.33 2,011.46 2,313.18 61070 75.38 71.61 82.35 61539 2,051.81 1,949.22 2,241.60 61105 390.71 371.17 426.85 61540 1,906.82 1,811.48 2,083.20 61107 279.46 265.49 305.31 61541 1,870.17 1,776.66 2,043.16 61108 778.40 739.48 850.40 61542 2,000.96 1,900.91 2,186.05 61120 640.04 608.04 699.25 61543 1,877.63 1,783.75 2,051.31 61140 1,092.47 1,037.85 1,193.53 61544 1,580.95 1,501.90 1,727.19 61150 1,173.54 1,114.86 1,282.09 61545 2,595.31 2,465.54 2,835.37 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 51 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 61546 2,009.14 1,908.68 2,194.98 61705 2,249.05 2,136.60 2,457.09 61548 1,388.81 1,319.37 1,517.28 61708 1,949.87 1,852.38 2,130.24 61550 884.54 840.31 966.36 61710 1,735.16 1,648.40 1,895.66 61552 1,155.98 1,098.18 1,262.91 61711 2,269.89 2,156.40 2,479.86 61556 1,462.04 1,388.94 1,597.28 61720 1,067.48 1,014.11 1,166.23 61557 1,467.73 1,394.34 1,603.49 61735 1,332.42 1,265.80 1,455.67 61558 1,635.96 1,554.16 1,787.28 61750 1,224.02 1,162.82 1,337.24 61559 1,910.82 1,815.28 2,087.57 61751 1,194.47 1,134.75 1,304.96 61563 1,728.22 1,641.81 1,888.08 61760 1,352.33 1,284.71 1,477.42 61564 2,103.14 1,997.98 2,297.68 61770 1,377.57 1,308.69 1,504.99 61566 1,969.87 1,871.38 2,152.09 61790 746.33 709.01 815.36 61567 2,248.47 2,136.05 2,456.46 61791 960.90 912.86 1,049.79 61570 1,614.30 1,533.59 1,763.63 61795 220.18 209.17 240.55 61571 1,736.40 1,649.58 1,897.02 61796 779.96 740.96 852.10 61575 2,154.94 2,047.19 2,354.27 61797 178.78 169.84 195.32 61576 3,321.04 3,154.99 3,628.24 61798 1,014.09 963.39 1,107.90 61580 2,232.36 2,120.74 2,438.85 61799 246.48 234.16 269.28 61581 2,493.29 2,368.63 2,723.92 61800 124.42 118.20 135.93 61582 2,584.92 2,455.67 2,824.02 61850 853.70 811.02 932.67 61583 2,530.25 2,403.74 2,764.30 61860 1,364.76 1,296.52 1,491.00 61584 2,483.23 2,359.07 2,712.93 61863 1,308.41 1,242.99 1,429.44 61585 2,549.59 2,422.11 2,785.43 61864 252.61 239.98 275.98 61586 2,001.66 1,901.58 2,186.82 61867 1,995.84 1,896.05 2,180.46 61590 2,817.26 2,676.40 3,077.86 61868 444.47 422.25 485.59 61591 2,838.50 2,696.58 3,101.07 61870 1,033.74 982.05 1,129.36 61592 2,596.71 2,466.87 2,836.90 61875 939.50 892.53 1,026.41 61595 2,146.41 2,039.09 2,344.95 61880 483.97 459.77 528.74 61596 2,337.06 2,220.21 2,553.24 61885 570.59 542.06 623.37 61597 2,375.05 2,256.30 2,594.75 61886 719.01 683.06 785.52 61598 2,351.21 2,233.65 2,568.70 61888 344.01 326.81 375.83 61600 1,934.36 1,837.64 2,113.29 62000 839.87 797.88 917.56 61601 2,080.59 1,976.56 2,273.04 62005 1,093.73 1,039.04 1,194.90 61605 2,027.04 1,925.69 2,214.54 62010 1,319.86 1,253.87 1,441.95 61606 2,652.08 2,519.48 2,897.40 62100 1,413.27 1,342.61 1,544.00 61607 2,350.99 2,233.44 2,568.46 62115 1,166.24 1,107.93 1,274.12 61608 2,661.59 2,528.51 2,907.79 62116 1,544.70 1,467.47 1,687.59 61609 543.54 516.36 593.81 62117 1,624.95 1,543.70 1,775.26 61610 1,654.47 1,571.75 1,807.51 62120 1,596.36 1,516.54 1,744.02 61611 383.27 364.11 418.73 62121 1,515.57 1,439.79 1,655.76 61612 1,413.62 1,342.94 1,544.38 62140 911.12 865.56 995.39 61613 2,658.67 2,525.74 2,904.60 62141 1,001.93 951.83 1,094.60 61615 2,177.75 2,068.86 2,379.19 62142 770.35 731.83 841.60 61616 2,746.34 2,609.02 3,000.37 62143 899.80 854.81 983.03 61618 1,147.04 1,089.69 1,253.14 62145 1,232.77 1,171.13 1,346.80 61619 1,323.91 1,257.71 1,446.37 62146 1,071.44 1,017.87 1,170.55 61623 523.24 497.08 571.64 62147 1,267.60 1,204.22 1,384.85 61624 1,043.86 991.67 1,140.42 62148 111.22 105.66 121.51 61626 841.66 799.58 919.52 62160 168.40 159.98 183.98 61630 1,195.45 1,135.68 1,306.03 62161 1,320.78 1,254.74 1,442.95 61635 1,300.85 1,235.81 1,421.18 62162 1,651.51 1,568.93 1,804.27 61680 1,976.55 1,877.72 2,159.38 62163 1,065.95 1,012.65 1,164.55 61682 3,501.73 3,326.64 3,825.64 62164 1,797.09 1,707.24 1,963.33 61684 2,292.20 2,177.59 2,504.23 62165 1,394.37 1,324.65 1,523.35 61686 3,775.24 3,586.48 4,124.45 62180 1,394.14 1,324.43 1,523.09 61690 1,901.25 1,806.19 2,077.12 62190 796.27 756.46 869.93 61692 3,022.31 2,871.19 3,301.87 62192 846.93 804.58 925.27 61697 3,503.55 3,328.37 3,827.63 62194 349.89 332.40 382.26 61698 3,834.81 3,643.07 4,189.53 62200 1,196.50 1,136.68 1,307.18 61700 2,829.86 2,688.37 3,091.63 62201 1,038.74 986.80 1,134.82 61702 3,314.06 3,148.36 3,620.61 62220 883.32 839.15 965.02 61703 1,182.41 1,123.29 1,291.78 62223 915.78 869.99 1,000.49 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 52 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 62225 442.62 420.49 483.56 63012 1,052.00 999.40 1,149.31 62230 731.12 694.56 798.74 63015 1,297.86 1,232.97 1,417.92 62252 92.61 87.98 101.18 63016 1,334.72 1,267.98 1,458.18 62252 TC 51.59 49.01 56.36 63017 1,095.37 1,040.60 1,196.69 62252 26 41.02 38.97 44.82 63020 1,028.30 976.89 1,123.42 62256 513.70 488.02 561.22 63030 854.81 812.07 933.88 62258 980.38 931.36 1,071.06 63035 175.28 166.52 191.50 62263 629.90 598.41 688.17 63040 1,241.97 1,179.87 1,356.85 # 62263 362.49 344.37 396.03 63042 1,159.25 1,101.29 1,266.48 62264 377.48 358.61 412.40 63043 389.76 370.27 425.81 # 62264 216.59 205.76 236.62 63044 354.43 336.71 387.22 62267 243.38 231.21 265.89 63045 1,118.12 1,062.21 1,221.54 # 62267 155.36 147.59 169.73 63046 1,071.29 1,017.73 1,170.39 62268 421.11 400.05 460.06 63047 976.36 927.54 1,066.67 # 62268 245.80 233.51 268.54 63048 192.45 182.83 210.25 62269 451.86 429.27 493.66 63050 1,356.16 1,288.35 1,481.60 # 62269 251.39 238.82 274.64 63051 1,525.02 1,448.77 1,666.09 62270 145.23 137.97 158.67 63055 1,433.68 1,362.00 1,566.30 # 62270 73.48 69.81 80.28 63056 1,317.18 1,251.32 1,439.02 62272 174.62 165.89 190.77 63057 291.93 277.33 318.93 # 62272 76.97 73.12 84.09 63064 1,565.30 1,487.04 1,710.10 62273 154.71 146.97 169.02 63066 183.83 174.64 200.84 # 62273 104.04 98.84 113.67 63075 1,217.51 1,156.63 1,330.12 62280 288.03 273.63 314.67 63076 225.79 214.50 246.68 # 62280 144.15 136.94 157.48 63077 1,347.87 1,280.48 1,472.55 62281 269.80 256.31 294.76 63078 179.21 170.25 195.79 # 62281 139.60 132.62 152.51 63081 1,571.81 1,493.22 1,717.20 62282 274.02 260.32 299.37 63082 243.36 231.19 265.87 # 62282 129.40 122.93 141.37 63085 1,705.76 1,620.47 1,863.54 62284 204.71 194.47 223.64 63086 175.58 166.80 191.82 # 62284 83.77 79.58 91.52 63087 2,157.94 2,050.04 2,357.55 62287 511.97 486.37 559.33 63088 237.84 225.95 259.84 62290 306.96 291.61 335.35 63090 1,781.82 1,692.73 1,946.64 # 62290 159.75 151.76 174.52 63091 165.04 156.79 180.31 62291 287.88 273.49 314.51 63101 2,051.35 1,948.78 2,241.10 # 62291 153.62 145.94 167.83 63102 2,017.45 1,916.58 2,204.07 62292 457.29 434.43 499.59 63103 267.59 254.21 292.34 62294 684.65 650.42 747.98 63170 1,367.45 1,299.08 1,493.94 62310 207.63 197.25 226.84 63172 1,220.98 1,159.93 1,333.92 # 62310 95.93 91.13 104.80 63173 1,501.97 1,426.87 1,640.90 62311 181.25 172.19 198.02 63180 1,223.47 1,162.30 1,336.65 # 62311 79.54 75.56 86.89 63182 1,335.09 1,268.34 1,458.59 62318 216.67 205.84 236.72 63185 1,034.40 982.68 1,130.08 # 62318 93.87 89.18 102.56 63190 1,145.83 1,088.54 1,251.82 62319 197.71 187.82 215.99 63191 1,050.28 997.77 1,147.44 # 62319 88.60 84.17 96.80 63194 1,278.61 1,214.68 1,396.88 62350 352.65 335.02 385.27 63195 1,325.20 1,258.94 1,447.78 62351 755.83 718.04 825.75 63196 1,415.68 1,344.90 1,546.64 62355 266.80 253.46 291.48 63197 1,485.37 1,411.10 1,622.77 62360 268.43 255.01 293.26 63198 1,526.34 1,450.02 1,667.52 62361 354.94 337.19 387.77 63199 1,717.91 1,632.01 1,876.81 62362 368.19 349.78 402.25 63200 1,324.89 1,258.65 1,447.45 62365 293.05 278.40 320.16 63250 2,406.33 2,286.01 2,628.91 62367 36.92 35.07 40.33 63251 2,472.24 2,348.63 2,700.92 # 62367 22.86 21.72 24.98 63252 2,469.30 2,345.84 2,697.72 62368 52.74 50.10 57.62 63265 1,461.31 1,388.24 1,596.48 # 62368 35.72 33.93 39.02 63266 1,504.87 1,429.63 1,644.07 63001 1,082.44 1,028.32 1,182.57 63267 1,210.46 1,149.94 1,322.43 63003 1,089.11 1,034.65 1,189.85 63268 1,248.25 1,185.84 1,363.72 63005 1,039.57 987.59 1,135.73 63270 1,803.06 1,712.91 1,969.85 63011 969.03 920.58 1,058.67 63271 1,808.31 1,717.89 1,975.57 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 53 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 63272 1,668.38 1,584.96 1,822.70 64412 133.91 127.21 146.29 63273 1,594.21 1,514.50 1,741.68 # 64412 66.97 63.62 73.16 63275 1,571.53 1,492.95 1,716.89 64413 107.84 102.45 117.82 63276 1,562.43 1,484.31 1,706.96 # 64413 72.34 68.72 79.03 63277 1,368.22 1,299.81 1,494.78 64415 119.40 113.43 130.44 63278 1,366.50 1,298.18 1,492.91 # 64415 67.62 64.24 73.88 63280 1,850.10 1,757.60 2,021.24 64416 78.91 74.96 86.20 63281 1,828.67 1,737.24 1,997.83 64417 119.84 113.85 130.93 63282 1,726.25 1,639.94 1,885.93 # 64417 66.58 63.25 72.74 63283 1,645.11 1,562.85 1,797.28 64418 126.50 120.18 138.21 63285 2,269.49 2,156.02 2,479.42 # 64418 68.80 65.36 75.16 63286 2,251.57 2,138.99 2,459.84 64420 150.59 143.06 164.52 63287 2,213.46 2,102.79 2,418.21 # 64420 61.82 58.73 67.54 63290 2,253.92 2,141.22 2,462.40 64421 222.79 211.65 243.40 63295 290.62 276.09 317.50 # 64421 84.83 80.59 92.68 63300 1,613.90 1,533.21 1,763.19 64425 119.85 113.86 130.94 63301 1,874.95 1,781.20 2,048.38 # 64425 87.30 82.94 95.38 63302 1,856.66 1,763.83 2,028.40 64430 140.13 133.12 153.09 63303 1,954.39 1,856.67 2,135.17 # 64430 80.58 76.55 88.03 63304 2,038.91 1,936.96 2,227.50 64435 132.14 125.53 144.36 63305 2,122.23 2,016.12 2,318.54 # 64435 78.14 74.23 85.36 63306 2,142.17 2,035.06 2,340.32 64445 125.11 118.85 136.68 63307 2,032.83 1,931.19 2,220.87 # 64445 74.81 71.07 81.73 63308 290.43 275.91 317.30 64446 81.12 77.06 88.62 63600 752.26 714.65 821.85 64447 63.89 60.70 69.81 63610 1,142.78 1,085.64 1,248.49 64448 71.81 68.22 78.45 # 63610 384.56 365.33 420.13 64449 81.86 77.77 89.44 63615 1,021.99 970.89 1,116.52 64450 95.15 90.39 103.95 63620 846.05 803.75 924.31 # 64450 65.19 61.93 71.22 63621 205.29 195.03 224.28 64455 47.58 45.20 51.98 63650 382.99 363.84 418.42 # 64455 36.48 34.66 39.86 63655 753.64 715.96 823.35 64479 260.75 247.71 284.87 63661 539.70 512.72 589.63 # 64479 116.87 111.03 127.68 # 63661 297.81 282.92 325.36 64480 131.45 124.88 143.61 63662 665.03 631.78 726.55 # 64480 75.97 72.17 83.00 63663 784.46 745.24 857.03 64483 252.77 240.13 276.15 # 63663 445.67 423.39 486.90 # 64483 101.87 96.78 111.30 63664 692.25 657.64 756.29 64484 127.97 121.57 139.81 63685 357.44 339.57 390.51 # 64484 63.99 60.79 69.91 63688 323.19 307.03 353.08 64490 180.77 171.73 197.49 63700 1,105.67 1,050.39 1,207.95 # 64490 104.57 99.34 114.24 63702 1,231.06 1,169.51 1,344.94 64491 90.33 85.81 98.68 63704 1,388.51 1,319.08 1,516.94 # 64491 59.63 56.65 65.15 63706 1,578.88 1,499.94 1,724.93 64492 91.44 86.87 99.90 63707 802.80 762.66 877.06 # 64492 60.74 57.70 66.36 63709 974.56 925.83 1,064.70 64493 162.23 154.12 177.24 63710 970.90 922.36 1,060.71 # 64493 88.99 84.54 97.22 63740 825.54 784.26 901.90 64494 82.47 78.35 90.10 63741 535.33 508.56 584.84 # 64494 51.03 48.48 55.75 63744 571.97 543.37 624.88 64495 83.58 79.40 91.31 63746 504.34 479.12 550.99 # 64495 52.14 49.53 56.96 64400 102.04 96.94 111.48 64505 92.24 87.63 100.77 # 64400 60.25 57.24 65.83 # 64505 77.08 73.23 84.21 64402 103.84 98.65 113.45 64508 139.90 132.91 152.85 # 64402 67.96 64.56 74.24 # 64508 67.78 64.39 74.05 64405 99.81 94.82 109.04 64510 127.98 121.58 139.82 # 64405 70.96 67.41 77.52 # 64510 63.99 60.79 69.91 64408 111.91 106.31 122.26 64517 160.74 152.70 175.61 # 64408 83.43 79.26 91.15 # 64517 112.28 106.67 122.67 64410 133.98 127.28 146.37 64520 174.55 165.82 190.69 # 64410 75.54 71.76 82.52 # 64520 72.09 68.49 78.76 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 54 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 64530 179.51 170.53 196.11 64702 432.39 410.77 472.39 # 64530 84.83 80.59 92.68 64704 302.60 287.47 330.59 64550 14.68 13.95 16.04 64708 436.43 414.61 476.80 # 64550 8.39 7.97 9.17 64712 497.53 472.65 543.55 64553 192.18 182.57 209.96 64713 690.39 655.87 754.25 # 64553 149.28 141.82 163.09 64714 604.26 574.05 660.16 64555 193.98 184.28 211.92 64716 484.06 459.86 528.84 # 64555 141.83 134.74 154.95 64718 520.24 494.23 568.36 64560 192.40 182.78 210.20 64719 355.57 337.79 388.46 # 64560 145.05 137.80 158.47 64721 379.42 360.45 414.52 64561 1,028.41 976.99 1,123.54 # 64721 377.57 358.69 412.49 # 64561 395.94 376.14 432.56 64722 309.82 294.33 338.48 64565 162.08 153.98 177.08 64726 261.19 248.13 285.35 # 64565 113.63 107.95 124.14 64727 169.23 160.77 184.89 64573 531.43 504.86 580.59 64732 358.79 340.85 391.98 64575 259.26 246.30 283.25 64734 380.46 361.44 415.66 64577 334.56 317.83 365.50 64736 382.59 363.46 417.98 64580 276.23 262.42 301.78 64738 439.53 417.55 480.18 64581 763.32 725.15 833.92 64740 421.12 400.06 460.07 64585 293.62 278.94 320.78 64742 434.85 413.11 475.08 # 64585 146.04 138.74 159.55 64744 390.02 370.52 426.10 64590 281.59 267.51 307.64 64746 414.27 393.56 452.59 # 64590 163.23 155.07 178.33 64752 457.42 434.55 499.73 64595 285.31 271.04 311.70 64755 815.69 774.91 891.15 # 64595 128.12 121.71 139.97 64760 443.43 421.26 484.45 64600 375.19 356.43 409.89 64761 414.68 393.95 453.04 # 64600 199.88 189.89 218.37 64763 489.16 464.70 534.41 64605 561.29 533.23 613.21 64766 559.84 531.85 611.63 # 64605 312.37 296.75 341.26 64771 524.01 497.81 572.48 64610 640.35 608.33 699.58 64772 512.84 487.20 560.28 # 64610 431.38 409.81 471.28 64774 374.52 355.79 409.16 64612 150.81 143.27 164.76 64776 355.52 337.74 388.40 # 64612 134.90 128.16 147.38 64778 169.20 160.74 184.85 64613 146.04 138.74 159.55 64782 418.16 397.25 456.84 # 64613 126.07 119.77 137.74 64783 201.78 191.69 220.44 64614 160.23 152.22 175.05 64784 658.37 625.45 719.27 # 64614 136.56 129.73 149.19 64786 971.13 922.57 1,060.96 64620 257.40 244.53 281.21 64787 229.57 218.09 250.80 # 64620 156.79 148.95 171.29 64788 353.22 335.56 385.89 64622 307.08 291.73 335.49 64790 742.87 705.73 811.59 # 64622 168.01 159.61 183.55 64792 1,002.08 951.98 1,094.78 64623 114.12 108.41 124.67 64795 176.10 167.30 192.40 # 64623 46.43 44.11 50.73 64802 557.51 529.63 609.07 64626 362.95 344.80 396.52 64804 779.07 740.12 851.14 # 64626 226.10 214.80 247.02 64809 737.98 701.08 806.24 64627 155.81 148.02 170.22 64818 607.98 577.58 664.22 # 64627 54.47 51.75 59.51 64820 684.12 649.91 747.40 64630 213.09 202.44 232.81 64821 622.10 591.00 679.65 # 64630 177.21 168.35 193.60 64822 615.07 584.32 671.97 64632 81.55 77.47 89.09 64823 696.98 662.13 761.45 # 64632 68.97 65.52 75.35 64831 613.78 583.09 670.55 64640 207.25 196.89 226.42 64832 313.01 297.36 341.96 # 64640 159.91 151.91 174.70 64834 673.12 639.46 735.38 64650 63.71 60.52 69.60 64835 732.42 695.80 800.17 # 64650 37.08 35.23 40.51 64836 733.16 696.50 800.98 64653 75.37 71.60 82.34 64837 344.88 327.64 376.79 # 64653 47.26 44.90 51.64 64840 789.83 750.34 862.89 64680 287.89 273.50 314.53 64856 920.72 874.68 1,005.88 # 64680 151.04 143.49 165.01 64857 961.81 913.72 1,050.78 64681 352.47 334.85 385.08 64858 1,082.88 1,028.74 1,183.05 # 64681 191.95 182.35 209.70 64859 234.55 222.82 256.24 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 55 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 64861 1,225.71 1,164.42 1,339.08 65285 919.60 873.62 1,004.66 64862 1,252.61 1,189.98 1,368.48 65286 614.40 583.68 671.23 64864 801.93 761.83 876.10 # 65286 433.53 411.85 473.63 64865 1,061.12 1,008.06 1,159.27 65290 435.90 414.11 476.23 64866 1,092.97 1,038.32 1,194.07 65400 589.43 559.96 643.95 64868 964.93 916.68 1,054.18 # 65400 524.34 498.12 572.84 64870 976.20 927.39 1,066.50 65410 126.71 120.37 138.43 64872 110.18 104.67 120.37 # 65410 93.42 88.75 102.06 64874 159.74 151.75 174.51 65420 449.23 426.77 490.79 64876 182.80 173.66 199.71 # 65420 327.92 311.52 358.25 64885 1,039.70 987.72 1,135.88 65426 567.48 539.11 619.98 64886 1,232.50 1,170.88 1,346.51 # 65426 418.05 397.15 456.72 64890 987.42 938.05 1,078.76 65430 101.07 96.02 110.42 64891 1,040.98 988.93 1,137.27 # 65430 91.83 87.24 100.33 64892 956.10 908.30 1,044.55 65435 70.54 67.01 77.06 64893 1,009.63 959.15 1,103.02 # 65435 62.03 58.93 67.77 64895 1,196.26 1,136.45 1,306.92 65436 340.51 323.48 372.00 64896 1,365.50 1,297.23 1,491.81 # 65436 327.20 310.84 357.47 64897 1,153.42 1,095.75 1,260.11 65450 281.32 267.25 307.34 64898 1,255.72 1,192.93 1,371.87 # 65450 277.99 264.09 303.70 64901 566.76 538.42 619.18 65600 341.11 324.05 372.66 64902 652.93 620.28 713.32 # 65600 297.09 282.24 324.58 64905 933.70 887.02 1,020.07 65710 971.01 922.46 1,060.83 64907 1,131.45 1,074.88 1,236.11 65730 1,078.01 1,024.11 1,177.73 64910 744.98 707.73 813.89 65750 1,086.76 1,032.42 1,187.28 64911 912.20 866.59 996.58 65755 1,082.62 1,028.49 1,182.76 65091 562.42 534.30 614.45 65756 1,027.26 975.90 1,122.29 65093 558.55 530.62 610.21 65757 144.26 137.05 157.61 65101 651.07 618.52 711.30 65770 1,297.62 1,232.74 1,417.65 65103 679.72 645.73 742.59 65772 392.33 372.71 428.62 65105 750.52 712.99 819.94 # 65772 353.49 335.82 386.19 65110 1,071.59 1,018.01 1,170.71 65775 477.12 453.26 521.25 65112 1,253.81 1,191.12 1,369.79 65780 776.52 737.69 848.34 65114 1,312.54 1,246.91 1,433.95 65781 1,165.29 1,107.03 1,273.08 65125 400.66 380.63 437.72 65782 1,028.59 977.16 1,123.73 # 65125 256.41 243.59 280.13 65800 132.31 125.69 144.54 65130 644.94 612.69 704.59 # 65800 116.04 110.24 126.78 65135 656.28 623.47 716.99 65805 145.41 138.14 158.86 65140 707.09 671.74 772.50 # 65805 117.30 111.44 128.16 65150 503.44 478.27 550.01 65810 411.38 390.81 449.43 65155 751.34 713.77 820.84 65815 559.31 531.34 611.04 65175 573.91 545.21 626.99 # 65815 418.76 397.82 457.49 65205 49.83 47.34 54.44 65820 648.75 616.31 708.76 # 65205 39.84 37.85 43.53 65850 747.19 709.83 816.30 65210 61.26 58.20 66.93 65855 299.08 284.13 326.75 # 65210 47.95 45.55 52.38 # 65855 263.57 250.39 287.95 65220 50.94 48.39 55.65 65860 283.63 269.45 309.87 # 65220 38.36 36.44 41.91 # 65860 235.92 224.12 257.74 65222 67.39 64.02 73.62 65865 411.14 390.58 449.17 # 65222 52.59 49.96 57.45 65870 520.86 494.82 569.04 65235 616.84 586.00 673.90 65875 550.26 522.75 601.16 65260 829.50 788.03 906.23 65880 572.18 543.57 625.11 65265 959.90 911.91 1,048.70 65900 836.58 794.75 913.96 65270 232.85 221.21 254.39 65920 687.52 653.14 751.11 # 65270 124.48 118.26 136.00 65930 566.30 537.99 618.69 65272 431.55 409.97 471.47 66020 161.13 153.07 176.03 # 65272 302.46 287.34 330.44 # 66020 113.79 108.10 124.32 65273 330.79 314.25 361.39 66030 144.45 137.23 157.81 65275 491.99 467.39 537.50 # 66030 96.73 91.89 105.67 # 65275 400.26 380.25 437.29 66130 621.47 590.40 678.96 65280 595.13 565.37 650.18 # 66130 510.88 485.34 558.14 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 56 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 66150 752.03 714.43 821.59 67030 454.41 431.69 496.44 66155 751.31 713.74 820.80 67031 337.53 320.65 368.75 66160 851.02 808.47 929.74 # 67031 310.16 294.65 338.85 66165 736.42 699.60 804.54 67036 846.24 803.93 924.52 66170 1,042.80 990.66 1,139.26 67039 1,095.13 1,040.37 1,196.43 66172 1,312.97 1,247.32 1,434.42 67040 1,252.23 1,189.62 1,368.06 66180 1,026.00 974.70 1,120.91 67041 1,167.39 1,109.02 1,275.37 66185 658.21 625.30 719.10 67042 1,335.36 1,268.59 1,458.88 66220 640.54 608.51 699.79 67043 1,414.44 1,343.72 1,545.28 66225 827.23 785.87 903.75 67101 683.77 649.58 747.02 66250 658.69 625.76 719.62 # 67101 593.15 563.49 648.01 # 66250 490.40 465.88 535.76 67105 627.63 596.25 685.69 66500 304.88 289.64 333.09 # 67105 563.64 535.46 615.78 66505 333.82 317.13 364.70 67107 1,076.31 1,022.49 1,175.86 66600 711.81 676.22 777.65 67108 1,417.18 1,346.32 1,548.27 66605 913.44 867.77 997.94 67110 757.55 719.67 827.62 66625 375.49 356.72 410.23 # 67110 676.55 642.72 739.13 66630 499.81 474.82 546.04 67112 1,168.62 1,110.19 1,276.72 66635 495.59 470.81 541.43 67113 1,537.09 1,460.24 1,679.28 66680 455.14 432.38 497.24 67115 432.59 410.96 472.60 66682 553.43 525.76 604.62 67120 577.68 548.80 631.12 66700 388.82 369.38 424.79 # 67120 491.87 467.28 537.37 # 66700 342.21 325.10 373.87 67121 802.31 762.19 876.52 66710 388.36 368.94 424.28 67141 457.90 435.01 500.26 # 66710 348.04 330.64 380.24 # 67141 427.20 405.84 466.72 66711 551.44 523.87 602.45 67145 458.46 435.54 500.87 66720 406.15 385.84 443.72 # 67145 433.68 412.00 473.80 # 66720 365.83 347.54 399.67 67208 517.69 491.81 565.58 66740 377.43 358.56 412.34 # 67208 499.56 474.58 545.77 # 66740 340.81 323.77 372.34 67210 608.62 578.19 664.92 66761 396.65 376.82 433.34 # 67210 589.02 559.57 643.51 # 66761 361.88 343.79 395.36 67218 1,210.79 1,150.25 1,322.79 66762 412.56 391.93 450.72 67220 941.04 893.99 1,028.09 # 66762 370.76 352.22 405.05 # 67220 898.14 853.23 981.21 66770 454.38 431.66 496.41 67221 258.97 246.02 282.92 # 66770 416.28 395.47 454.79 # 67221 193.13 183.47 210.99 66820 346.73 329.39 378.80 67225 26.59 25.26 29.05 66821 285.07 270.82 311.44 # 67225 25.11 23.85 27.43 # 66821 269.17 255.71 294.07 67227 526.95 500.60 575.69 66825 664.21 631.00 725.65 # 67227 493.29 468.63 538.92 66830 617.30 586.44 674.41 67228 1,057.39 1,004.52 1,155.20 66840 615.52 584.74 672.45 # 67228 930.90 884.36 1,017.01 66850 694.85 660.11 759.13 67229 999.87 949.88 1,092.36 66852 747.72 710.33 816.88 67250 690.55 656.02 754.42 66920 653.75 621.06 714.22 67255 745.29 708.03 814.23 66930 742.84 705.70 811.56 67311 526.71 500.37 575.43 66940 689.25 654.79 753.01 67312 632.44 600.82 690.94 66982 938.26 891.35 1,025.05 67314 591.91 562.31 646.66 66983 647.66 615.28 707.57 67316 709.77 674.28 775.42 66984 675.37 641.60 737.84 67318 608.27 577.86 664.54 66985 671.26 637.70 733.36 67320 284.15 269.94 310.43 66986 802.40 762.28 876.62 67331 275.64 261.86 301.14 66990 80.71 76.67 88.17 67332 299.50 284.53 327.21 67005 416.98 396.13 455.55 67334 265.87 252.58 290.47 67010 474.78 451.04 518.70 67335 135.54 128.76 148.07 67015 507.37 482.00 554.30 67340 316.26 300.45 345.52 67025 637.06 605.21 695.99 67343 576.98 548.13 630.35 # 67025 554.95 527.20 606.28 67345 209.77 199.28 229.17 67027 754.20 716.49 823.96 # 67345 190.91 181.36 208.56 67028 186.76 177.42 204.03 67346 181.06 172.01 197.81 # 67028 149.40 141.93 163.22 67400 824.59 783.36 900.86 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 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 57 FSY10 LOCALITY FEE SCHEDULE FOR AREA 03 DATE 12/24/09 0 PAR NON-PAR LIMITING PAR NON-PAR LIMITING NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE ---- --------- --- ------------ ------------ ------------ ---- --------- --- ------------ ------------ ------------ 67405 695.89 661.10 760.27 67908 434.88 413.14 475.11 67412 759.02 721.07 829.23 # 67908 381.25 362.19 416.52 67413 762.55 724.42 833.08 67909 474.92 451.17 518.85 67414 1,160.26 1,102.25 1,267.59 # 67909 390.59 371.06 426.72 67415 94.48 89.76 103.22 67911 493.99 469.29 539.68 67420 1,451.13 1,378.57 1,585.36 67912 791.80 752.21 865.04 67430 1,084.03 1,029.83 1,184.30 # 67912 437.83 415.94 478.33 67440 1,058.99 1,006.04 1,156.95 67914 343.63 326.45 375.42 67445 1,252.26 1,189.65 1,368.10 # 67914 256.34 243.52 280.05 67450 1,100.75 1,045.71 1,202.57 67915 305.90 290.61 334.20 67500 77.86 73.97 85.07 # 67915 224.53 213.30 245.30 # 67500 70.84 67.30 77.40 67916 475.12 451.36 519.06 67505 79.18 75.22 86.50 # 67916 383.03 363.88 418.46 # 67505 71.41 67.84 78.02 67917 518.44 492.52 566.40 67515 84.51 80.28 92.32 # 67917 422.65 401.52 461.75 # 67515 78.22 74.31 85.46 67921 328.00 311.60 358.34 67550 858.30 815.39 937.70 # 67921 240.71 228.67 262.97 67560 867.09 823.74 947.30 67922 296.30 281.49 323.71 67570 1,053.55 1,000.87 1,151.00 # 67922 216.41 205.59 236.43 67700 232.67 221.04 254.20 67923 501.86 476.77 548.29 # 67700 100.99 95.94 110.33 # 67923 413.84 393.15 452.12 67710 196.59 186.76 214.77 67924 517.96 492.06 565.87 # 67710 85.63 81.35 93.55 # 67924 399.61 379.63 436.57 67715 207.52 197.14 226.71 67930 324.54 308.31 354.56 # 67715 96.19 91.38 105.09 # 67930 218.76 207.82 238.99 67800 111.69 106.11 122.03 67935 527.36 500.99 576.14 # 67800 92.09 87.49 100.61 # 67935 400.12 380.11 437.13 67801 143.72 136.53 157.01 67938 212.73 202.09 232.40 # 67801 120.05 114.05 131.16 # 67938 101.77 96.68 111.18 67805 178.05 169.15 194.52 67950 508.81 483.37 555.88 # 67805 147.72 140.33 161.38 # 67950 413.76 393.07 452.03 67808 324.39 308.17 354.40 67961 509.39 483.92 556.51 67810 196.66 186.83 214.85 # 67961 405.83 385.54 443.37 # 67810 83.48 79.31 91.21 67966 677.49 643.62 740.16 67820 45.76 43.47 49.99 # 67966 580.58 551.55 634.28 # 67820 47.61 45.23 52.01 67971 649.40 616.93 709.47 67825 113.49 107.82 123.99 67973 838.75 796.81 916.33 # 67825 107.20 101.84 117.12 67974 835.84 794.05 913.16 67830 234.07 222.37 255.73 67975 613.56 582.88 670.31 # 67830 122.37 116.25 133.69 68020 104.85 99.61 114.55 67835 389.99 370.49 426.06 # 68020 97.45 92.58 106.47 67840 243.50 231.33 266.03 68040 58.08 55.18 63.46 # 67840 140.68 133.65 153.70 # 68040 48.09 45.69 52.54 67850 194.74 185.00 212.75 68100 149.72 142.23 163.56 # 67850 124.47 118.25 135.99 # 68100 87.21 82.85 95.28 67875 151.91 144.31 165.96 68110 198.25 188.34 216.59 # 67875 87.18 82.82 95.24 # 68110 131.31 124.74 143.45 67880 401.37 381.30 438.50 68115 272.21 258.60 297.39 # 67880 323.32 307.15 353.22 # 68115 161.62 153.54 176.57 67882 496.14 471.33 542.03 68130 467.74 444.35 511.00 # 67882 417.36 396.49 455.96 # 68130 357.15 339.29 390.18 67900 566.94 538.59 619.38 68135 137.35 130.48 150.05 # 67900 454.50 431.78 496.55 # 68135 132.54 125.91 144.80 67901 624.17 592.96 681.90 68200 37.43 35.56 40.89 # 67901 509.51 484.03 556.63 # 68200 31.15 29.59