1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 1 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 32.09 30.49 35.06 G0270 23.71 22.52 25.90 G0102 17.03 16.18 18.61 # G0270 22.10 21.00 24.15 # G0102 8.01 7.61 8.75 G0271 12.08 11.48 13.20 G0104 113.98 108.28 124.52 G0275 12.72 12.08 13.89 # G0104 54.37 51.65 59.40 G0278 12.72 12.08 13.89 G0105 334.07 317.37 364.98 G0281 10.94 10.39 11.95 # G0105 191.00 181.45 208.67 G0283 10.94 10.39 11.95 G0105 53 113.80 108.11 124.33 G0288 90.40 85.88 98.76 # G0105 53 54.19 51.48 59.20 G0289 77.34 73.47 84.49 G0106 177.18 168.32 193.57 G0329 7.42 7.05 8.11 G0106 TC 130.68 124.15 142.77 G0339 3,958.14 3,760.23 4,324.26 G0106 26 46.50 44.18 50.81 G0340 2,687.41 2,553.04 2,936.00 G0108 20.80 19.76 22.72 G0341 714.47 678.75 780.56 G0109 11.46 10.89 12.52 G0342 608.75 578.31 665.06 G0117 41.75 39.66 45.61 G0343 1,017.77 966.88 1,111.91 G0118 28.96 27.51 31.64 G0364 10.89 10.35 11.90 C G0120 121.76 115.67 133.02 # G0364 7.99 7.59 8.73 C G0120 TC 75.26 71.50 82.23 C G0365 149.88 142.39 163.75 G0120 26 46.50 44.18 50.81 C G0365 TC 138.42 131.50 151.23 G0121 334.25 317.54 365.17 G0365 26 11.47 10.90 12.54 # G0121 191.18 181.62 208.86 G0372 9.95 9.45 10.87 G0121 53 114.34 108.62 124.91 # G0372 7.69 7.31 8.41 # G0121 53 54.72 51.98 59.78 G0389 96.39 91.57 105.31 G0124 25.25 23.99 27.59 G0389 TC 68.81 65.37 75.18 G0127 17.68 16.80 19.32 G0389 26 27.58 26.20 30.13 # G0127 7.69 7.31 8.41 G0396 30.19 28.68 32.98 G0128 7.79 7.40 8.51 # G0396 28.90 27.46 31.58 G0130 28.29 26.88 30.91 G0397 60.23 57.22 65.80 G0130 TC 18.22 17.31 19.91 # G0397 58.94 55.99 64.39 G0130 26 10.07 9.57 11.01 G0398 260.34 247.32 284.42 G0141 25.25 23.99 27.59 G0398 TC 179.69 170.71 196.32 G0166 129.89 123.40 141.91 G0398 26 80.66 76.63 88.12 G0168 71.26 67.70 77.86 G0399 189.20 179.74 206.70 # G0168 23.57 22.39 25.75 G0399 TC 113.81 108.12 124.34 G0179 35.63 33.85 38.93 G0399 26 75.40 71.63 82.37 G0180 47.49 45.12 51.89 G0400 170.28 161.77 186.04 G0181 94.02 89.32 102.72 G0400 TC 102.42 97.30 111.90 G0182 95.63 90.85 104.48 G0400 26 67.86 64.47 74.14 G0202 116.52 110.69 127.29 G0402 123.62 117.44 135.06 G0202 TC 83.96 79.76 91.72 G0403 17.86 16.97 19.52 G0202 26 32.57 30.94 35.58 # G0403 17.21 16.35 18.80 G0204 139.04 132.09 151.90 G0404 9.52 9.04 10.40 G0204 TC 98.46 93.54 107.57 G0405 8.33 7.91 9.10 G0204 26 40.58 38.55 44.33 # G0405 7.69 7.31 8.41 G0206 109.76 104.27 119.91 G0406 35.47 33.70 38.76 G0206 TC 77.19 73.33 84.33 G0407 63.99 60.79 69.91 G0206 26 32.57 30.94 35.58 G0408 91.83 87.24 100.33 G0237 8.56 8.13 9.35 G0409 7.59 7.21 8.29 G0238 9.20 8.74 10.05 G0412 599.66 569.68 655.13 G0239 9.84 9.35 10.75 G0413 882.12 838.01 963.71 G0245 59.61 56.63 65.12 G0414 835.55 793.77 912.84 # G0245 42.54 40.41 46.47 G0415 1,143.65 1,086.47 1,249.44 G0246 34.34 32.62 37.51 G0416 558.88 530.94 610.58 # G0246 21.45 20.38 23.44 G0416 TC 391.37 371.80 427.57 G0247 39.16 37.20 42.78 G0416 26 167.51 159.13 183.00 # G0247 23.37 22.20 25.53 G0417 1,085.03 1,030.78 1,185.40 G0248 123.92 117.72 135.38 G0417 TC 764.20 725.99 834.89 G0249 107.80 102.41 117.77 G0417 26 320.83 304.79 350.51 G0250 9.00 8.55 9.83 G0418 1,863.20 1,770.04 2,035.55 G0268 44.09 41.89 48.17 G0418 TC 1,305.23 1,239.97 1,425.97 # G0268 29.26 27.80 31.97 G0418 26 557.97 530.07 609.58 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 99 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 2,209.07 2,098.62 2,413.41 # 10160 81.61 77.53 89.16 G0419 TC 1,566.24 1,487.93 1,711.12 10180 193.65 183.97 211.57 G0419 26 642.82 610.68 702.28 # 10180 148.54 141.11 162.28 G0420 101.66 96.58 111.07 11000 44.42 42.20 48.53 G0421 23.98 22.78 26.20 # 11000 27.34 25.97 29.87 G0422 45.17 42.91 49.35 11001 18.50 17.58 20.22 G0423 45.17 42.91 49.35 # 11001 13.67 12.99 14.94 G0424 21.43 20.36 23.41 11004 518.28 492.37 566.23 # G0424 8.86 8.42 9.68 11005 684.37 650.15 747.67 G0425 91.84 87.25 100.34 11006 630.72 599.18 689.06 G0426 125.17 118.91 136.75 11008 240.37 228.35 262.60 G0427 184.27 175.06 201.32 11010 388.37 368.95 424.29 G9041 33.51 31.83 36.60 # 11010 240.14 228.13 262.35 G9042 16.91 16.06 18.47 11011 430.57 409.04 470.40 G9043 16.91 16.06 18.47 # 11011 259.46 246.49 283.46 G9044 14.63 13.90 15.99 11012 582.24 553.13 636.10 M0064 38.48 36.56 42.04 # 11012 371.50 352.93 405.87 # M0064 15.60 14.82 17.04 11040 39.16 37.20 42.78 P3001 25.25 23.99 27.59 # 11040 23.37 22.20 25.53 Q0035 16.57 15.74 18.10 11041 44.74 42.50 48.88 Q0035 TC 8.88 8.44 9.71 # 11041 28.63 27.20 31.28 Q0035 26 7.69 7.31 8.41 11042 61.41 58.34 67.09 Q0091 37.04 35.19 40.47 # 11042 38.86 36.92 42.46 # Q0091 17.07 16.22 18.65 11043 233.15 221.49 254.71 Q0092 15.97 15.17 17.45 # 11043 203.83 193.64 222.69 R0070 149.59 142.11 163.43 11044 320.16 304.15 349.77 R0075 149.59 142.11 163.43 # 11044 281.82 267.73 307.89 0073T 447.44 425.07 488.83 11055 40.09 38.09 43.80 0075T 1,061.50 1,008.43 1,159.69 # 11055 19.47 18.50 21.28 0075T 26 914.45 868.73 999.04 11056 48.78 46.34 53.29 0076T 350.29 332.78 382.70 # 11056 27.19 25.83 29.70 0076T 26 91.44 86.87 99.90 11057 58.75 55.81 64.18 0078T 1,197.48 1,137.61 1,308.25 # 11057 35.22 33.46 38.48 0079T 1,100.29 1,045.28 1,202.07 11100 85.93 81.63 93.87 0080T 215.11 204.35 235.00 # 11100 43.39 41.22 47.40 0081T 215.11 204.35 235.00 11101 28.15 26.74 30.75 0171T 677.73 643.84 740.42 # 11101 22.03 20.93 24.07 0172T 338.87 321.93 370.22 11200 69.84 66.35 76.30 0177T 1,145.82 1,088.53 1,251.81 # 11200 59.53 56.55 65.03 0187T 38.74 36.80 42.32 11201 16.08 15.28 17.57 10021 118.61 112.68 129.58 # 11201 14.79 14.05 16.16 # 10021 61.57 58.49 67.26 11300 56.29 53.48 61.50 10022 118.22 112.31 129.16 # 11300 26.33 25.01 28.76 # 10022 59.90 56.91 65.45 11301 77.51 73.63 84.67 10040 86.35 82.03 94.33 # 11301 44.96 42.71 49.12 # 10040 76.03 72.23 83.06 11302 92.86 88.22 101.45 10060 92.28 87.67 100.82 # 11302 55.48 52.71 60.62 # 10060 79.39 75.42 86.73 11303 108.83 103.39 118.90 10061 156.62 148.79 171.11 # 11303 65.01 61.76 71.02 # 10061 139.54 132.56 152.44 11305 57.66 54.78 63.00 10080 137.00 130.15 149.67 # 11305 31.56 29.98 34.48 # 10080 82.54 78.41 90.17 11306 79.93 75.93 87.32 10081 215.74 204.95 235.69 # 11306 49.00 46.55 53.53 # 10081 143.88 136.69 157.19 11307 94.70 89.97 103.47 10120 112.55 106.92 122.96 # 11307 58.60 55.67 64.02 # 10120 78.07 74.17 85.30 11308 105.36 100.09 115.10 10121 217.88 206.99 238.04 # 11308 68.62 65.19 74.97 # 10121 157.30 149.44 171.86 11310 70.26 66.75 76.76 10140 129.19 122.73 141.14 # 11310 38.04 36.14 41.56 # 10140 100.51 95.48 109.80 11311 89.32 84.85 97.58 10160 105.14 99.88 114.86 # 11311 55.80 53.01 60.96 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 3 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 103.26 98.10 112.82 # 11604 181.38 172.31 198.16 # 11312 64.26 61.05 70.21 11606 362.53 344.40 396.06 11313 128.86 122.42 140.78 # 11606 269.08 255.63 293.97 # 11313 85.35 81.08 93.24 11620 153.72 146.03 167.93 11400 97.14 92.28 106.12 # 11620 99.91 94.91 109.15 # 11400 64.92 61.67 70.92 11621 186.64 177.31 203.91 11401 119.10 113.15 130.12 # 11621 127.35 120.98 139.13 # 11401 85.59 81.31 93.51 11622 210.55 200.02 230.02 11402 132.62 125.99 144.89 # 11622 146.42 139.10 159.97 # 11402 94.28 89.57 103.01 11623 246.93 234.58 269.77 11403 152.85 145.21 166.99 # 11623 180.55 171.52 197.25 # 11403 119.98 113.98 131.08 11624 277.48 263.61 303.15 11404 173.71 165.02 189.77 # 11624 204.66 194.43 223.59 # 11404 133.11 126.45 145.42 11626 336.10 319.30 367.20 11406 248.97 236.52 272.00 # 11626 253.61 240.93 277.07 # 11406 201.93 191.83 220.60 11640 159.77 151.78 174.55 11420 97.61 92.73 106.64 # 11640 104.35 99.13 114.00 # 11420 68.93 65.48 75.30 11641 195.09 185.34 213.14 11421 126.52 120.19 138.22 # 11641 134.51 127.78 146.95 # 11421 93.00 88.35 101.60 11642 224.81 213.57 245.61 11422 141.11 134.05 154.16 # 11642 158.76 150.82 173.44 # 11422 112.11 106.50 122.48 11643 265.49 252.22 290.05 11423 164.71 156.47 179.94 # 11643 198.47 188.55 216.83 # 11423 131.19 124.63 143.32 11644 326.77 310.43 356.99 11424 190.02 180.52 207.60 # 11644 246.21 233.90 268.99 # 11424 151.03 143.48 165.00 11646 430.41 408.89 470.22 11426 273.16 259.50 298.43 # 11646 344.69 327.46 376.58 # 11426 230.62 219.09 251.95 11719 17.68 16.80 19.32 11440 107.04 101.69 116.94 # 11719 7.69 7.31 8.41 # 11440 83.19 79.03 90.88 11720 25.64 24.36 28.01 11441 135.72 128.93 148.27 # 11720 14.36 13.64 15.69 # 11441 108.65 103.22 118.70 11721 36.36 34.54 39.72 11442 152.64 145.01 166.76 # 11721 24.43 23.21 26.69 # 11442 121.06 115.01 132.26 11730 80.82 76.78 88.30 11443 183.02 173.87 199.95 # 11730 49.24 46.78 53.80 # 11443 149.50 142.03 163.33 11732 37.40 35.53 40.86 11444 231.88 220.29 253.33 # 11732 25.80 24.51 28.19 # 11444 191.92 182.32 209.67 11740 37.69 35.81 41.18 11446 318.38 302.46 347.83 # 11740 26.73 25.39 29.20 # 11446 273.27 259.61 298.55 11750 181.43 172.36 198.21 11450 293.95 279.25 321.14 # 11750 150.17 142.66 164.06 # 11450 201.79 191.70 220.46 11752 259.55 246.57 283.56 11451 380.40 361.38 415.59 # 11752 225.40 214.13 246.25 # 11451 263.75 250.56 288.14 11755 110.05 104.55 120.23 11462 289.79 275.30 316.60 # 11755 72.03 68.43 78.69 # 11462 194.09 184.39 212.05 11760 170.63 162.10 186.42 11463 389.89 370.40 425.96 # 11760 111.01 105.46 121.28 # 11463 268.08 254.68 292.88 11762 224.22 213.01 244.96 11470 322.23 306.12 352.04 # 11762 166.87 158.53 182.31 # 11470 228.79 217.35 249.95 11765 108.25 102.84 118.27 11471 401.38 381.31 438.51 # 11765 57.65 54.77 62.99 # 11471 285.05 270.80 311.42 11770 216.84 206.00 236.90 11600 150.79 143.25 164.74 # 11770 152.08 144.48 166.15 # 11600 98.27 93.36 107.36 11771 450.16 427.65 491.80 11601 185.00 175.75 202.11 # 11771 355.42 337.65 388.30 # 11601 126.03 119.73 137.69 11772 544.61 517.38 594.99 11602 202.61 192.48 221.35 # 11772 463.08 439.93 505.92 # 11602 138.81 131.87 151.65 11900 46.97 44.62 51.31 11603 231.32 219.75 252.71 # 11900 27.64 26.26 30.20 # 11603 165.26 157.00 180.55 11901 60.13 57.12 65.69 11604 255.49 242.72 279.13 # 11901 43.05 40.90 47.04 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 4 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 147.44 140.07 161.08 # 12034 174.26 165.55 190.38 # 11920 98.14 93.23 107.21 12035 305.21 289.95 333.44 11921 169.11 160.65 184.75 # 12035 202.09 191.99 220.79 # 11921 115.61 109.83 126.30 12036 333.84 317.15 364.72 11922 50.15 47.64 54.79 # 12036 231.37 219.80 252.77 # 11922 26.31 24.99 28.74 12037 375.15 356.39 409.85 11950 63.13 59.97 68.97 # 12037 268.49 255.07 293.33 # 11950 44.76 42.52 48.90 12041 208.67 198.24 227.98 11951 86.22 81.91 94.20 # 12041 145.84 138.55 159.33 # 11951 63.02 59.87 68.85 12042 241.38 229.31 263.71 11952 115.17 109.41 125.82 # 12042 170.49 161.97 186.27 # 11952 86.50 82.18 94.51 12044 281.64 267.56 307.69 11954 135.04 128.29 147.53 # 12044 182.40 173.28 199.27 # 11954 99.59 94.61 108.80 12045 307.16 291.80 335.57 11960 778.59 739.66 850.61 # 12045 209.20 198.74 228.55 11970 511.40 485.83 558.70 12046 374.18 355.47 408.79 11971 382.04 362.94 417.38 # 12046 251.09 238.54 274.32 # 11971 260.56 247.53 284.66 12047 399.44 379.47 436.39 11976 124.34 118.12 135.84 # 12047 276.03 262.23 301.56 # 11976 84.71 80.47 92.54 12051 221.99 210.89 242.52 11980 89.66 85.18 97.96 # 12051 155.28 147.52 169.65 # 11980 71.94 68.34 78.59 12052 253.68 241.00 277.15 11981 114.33 108.61 124.90 # 12052 184.72 175.48 201.80 # 11981 74.69 70.96 81.60 12053 278.84 264.90 304.64 11982 129.75 123.26 141.75 # 12053 185.39 176.12 202.54 # 11982 89.80 85.31 98.11 12054 295.37 280.60 322.69 11983 200.52 190.49 219.06 # 12054 196.12 186.31 214.26 # 11983 163.46 155.29 178.58 12055 354.87 337.13 387.70 12001 125.52 119.24 137.13 # 12055 238.23 226.32 260.27 # 12001 90.40 85.88 98.76 12056 416.41 395.59 454.93 12002 133.54 126.86 145.89 # 12056 276.23 262.42 301.78 # 12002 100.03 95.03 109.28 12057 461.65 438.57 504.36 12004 156.79 148.95 171.29 # 12057 326.32 310.00 356.50 # 12004 117.16 111.30 128.00 13100 262.08 248.98 286.33 12005 195.20 185.44 213.26 # 13100 200.86 190.82 219.44 # 12005 145.25 137.99 158.69 13101 331.85 315.26 362.55 12006 242.00 229.90 264.39 # 13101 245.49 233.22 268.20 # 12006 183.36 174.19 200.32 13102 90.03 85.53 98.36 12007 271.58 258.00 296.70 # 13102 65.22 61.96 71.25 # 12007 207.45 197.08 226.64 13120 272.38 258.76 297.57 12011 133.12 126.46 145.43 # 13120 210.18 199.67 229.62 # 12011 93.16 88.50 101.78 13121 369.62 351.14 403.81 12013 146.79 139.45 160.37 # 13121 280.36 266.34 306.29 # 12013 106.19 100.88 116.01 13122 100.23 95.22 109.50 12014 172.37 163.75 188.31 # 13122 74.45 70.73 81.34 # 12014 126.94 120.59 138.68 13131 301.35 286.28 329.22 12015 216.39 205.57 236.41 # 13131 237.55 225.67 259.52 # 12015 159.03 151.08 173.74 13132 488.93 464.48 534.15 12016 258.00 245.10 281.87 # 13132 405.15 384.89 442.62 # 12016 193.24 183.58 211.12 13133 142.97 135.82 156.19 12017 226.78 215.44 247.76 # 13133 116.23 110.42 126.98 12018 274.10 260.40 299.46 13150 299.68 284.70 327.41 12020 222.57 211.44 243.16 # 13150 235.87 224.08 257.69 # 12020 159.41 151.44 174.16 13151 342.26 325.15 373.92 12021 132.03 125.43 144.24 # 13151 274.91 261.16 300.33 # 12021 115.59 109.81 126.28 13152 473.26 449.60 517.04 12031 199.07 189.12 217.49 # 13152 370.47 351.95 404.74 # 12031 136.55 129.72 149.18 13153 156.55 148.72 171.03 12032 252.92 240.27 276.31 # 13153 125.29 119.03 136.88 # 12032 166.56 158.23 181.96 13160 690.58 656.05 754.46 12034 251.92 239.32 275.22 14000 516.75 490.91 564.55 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 5 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 428.14 406.73 467.74 15155 588.29 558.88 642.71 14001 670.68 637.15 732.72 # 15155 550.59 523.06 601.52 # 14001 566.28 537.97 618.67 15156 150.61 143.08 164.54 14020 581.33 552.26 635.10 # 15156 143.20 136.04 156.45 # 14020 488.85 464.41 534.07 15157 158.04 150.14 172.66 14021 735.07 698.32 803.07 # 15157 148.05 140.65 161.75 # 14021 628.73 597.29 686.88 15170 363.71 345.52 397.35 14040 646.30 613.99 706.09 # 15170 316.66 300.83 345.95 # 14040 555.11 527.35 606.45 15171 81.09 77.04 88.60 14041 803.49 763.32 877.82 # 15171 76.90 73.06 84.02 # 14041 685.55 651.27 748.96 15175 450.50 427.98 492.18 14060 658.46 625.54 719.37 # 15175 406.36 386.04 443.95 # 14060 586.60 557.27 640.86 15176 127.90 121.51 139.74 14061 861.63 818.55 941.33 # 15176 120.49 114.47 131.64 # 14061 732.42 695.80 800.17 15200 677.54 643.66 740.21 14301 928.02 881.62 1,013.86 # 15200 563.79 535.60 615.94 # 14301 786.88 747.54 859.67 15201 121.52 115.44 132.76 14302 204.50 194.28 223.42 # 15201 68.35 64.93 74.67 14350 636.56 604.73 695.44 15220 638.98 607.03 698.08 15002 277.98 264.08 303.69 # 15220 527.16 500.80 575.92 # 15002 195.16 185.40 213.21 15221 113.11 107.45 123.57 15003 60.34 57.32 65.92 # 15221 63.16 60.00 69.00 # 15003 39.71 37.72 43.38 15240 775.48 736.71 847.22 15004 332.67 316.04 363.45 # 15240 681.38 647.31 744.41 # 15004 240.51 228.48 262.75 15241 152.93 145.28 167.07 15005 101.98 96.88 111.41 # 15241 98.80 93.86 107.94 # 15005 78.78 74.84 86.07 15260 844.98 802.73 923.14 15040 209.24 198.78 228.60 # 15260 741.87 704.78 810.50 # 15040 110.63 105.10 120.87 15261 179.20 170.24 195.78 15050 456.67 433.84 498.92 # 15261 125.06 118.81 136.63 # 15050 376.11 357.30 410.90 15300 291.33 276.76 318.27 15100 719.72 683.73 786.29 # 15300 250.08 237.58 273.22 # 15100 608.55 578.12 664.84 15301 54.28 51.57 59.31 15101 155.34 147.57 169.71 # 15301 50.09 47.59 54.73 # 15101 96.37 91.55 105.28 15320 321.97 305.87 351.75 15110 715.06 679.31 781.21 # 15320 277.18 263.32 302.82 # 15110 629.02 597.57 687.21 15321 80.79 76.75 88.26 15111 102.70 97.57 112.21 # 15321 75.31 71.54 82.27 # 15111 92.71 88.07 101.28 15330 267.68 254.30 292.45 15115 724.35 688.13 791.35 # 15330 225.78 214.49 246.66 # 15115 648.62 616.19 708.62 15331 54.28 51.57 59.31 15116 142.30 135.19 155.47 # 15331 50.41 47.89 55.07 # 15116 130.38 123.86 142.44 15335 274.27 260.56 299.64 15120 792.61 752.98 865.93 # 15335 233.67 221.99 255.29 # 15120 672.73 639.09 734.95 15336 71.36 67.79 77.96 15121 221.06 210.01 241.51 # 15336 65.24 61.98 71.28 # 15121 147.59 140.21 161.24 15340 265.49 252.22 290.05 15130 559.88 531.89 611.67 # 15340 229.72 218.23 250.96 # 15130 475.13 451.37 519.08 15341 39.19 37.23 42.81 15131 82.58 78.45 90.22 # 15341 23.40 22.23 25.56 # 15131 75.17 71.41 82.12 15360 301.36 286.29 329.23 15135 727.30 690.94 794.58 # 15360 259.14 246.18 283.11 # 15135 653.83 621.14 714.31 15361 60.77 57.73 66.39 15136 75.08 71.33 82.03 # 15361 54.97 52.22 60.05 # 15136 70.25 66.74 76.75 15365 292.98 278.33 320.08 15150 588.01 558.61 642.40 # 15365 254.95 242.20 278.53 # 15150 542.58 515.45 592.77 15366 72.59 68.96 79.30 15151 107.48 102.11 117.43 # 15366 66.79 63.45 72.97 # 15151 99.74 94.75 108.96 15400 334.33 317.61 365.25 15152 137.47 130.60 150.19 # 15400 300.17 285.16 327.93 # 15152 128.77 122.33 140.68 15401 76.69 72.86 83.79 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 6 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 49.62 47.14 54.21 # 15788 201.05 191.00 219.65 15420 370.37 351.85 404.63 15789 466.43 443.11 509.58 # 15420 330.09 313.59 360.63 # 15789 359.77 341.78 393.05 15421 96.90 92.06 105.87 15792 343.81 326.62 375.61 # 15421 74.34 70.62 81.21 # 15792 215.88 205.09 235.85 15430 448.74 426.30 490.25 15793 397.02 377.17 433.75 # 15430 432.63 411.00 472.65 # 15793 304.54 289.31 332.71 15570 740.10 703.10 808.57 15819 637.01 605.16 695.93 # 15570 611.53 580.95 668.09 15820 462.35 439.23 505.11 15572 719.78 683.79 786.36 # 15820 421.75 400.66 460.76 # 15572 620.21 589.20 677.58 15821 493.23 468.57 538.86 15574 758.43 720.51 828.59 # 15821 448.44 426.02 489.92 # 15574 653.38 620.71 713.82 15822 358.04 340.14 391.16 15576 674.73 640.99 737.14 # 15822 319.05 303.10 348.57 # 15576 575.80 547.01 629.06 15823 575.62 546.84 628.87 15600 265.65 252.37 290.23 # 15823 532.76 506.12 582.04 # 15600 169.63 161.15 185.32 15830 987.61 938.23 1,078.96 15610 273.79 260.10 299.12 15832 761.91 723.81 832.38 # 15610 199.67 189.69 218.14 15833 725.95 689.65 793.10 15620 361.76 343.67 395.22 15834 726.04 689.74 793.20 # 15620 270.25 256.74 295.25 15835 769.35 730.88 840.51 15630 382.77 363.63 418.17 15836 624.16 592.95 681.89 # 15630 294.48 279.76 321.72 15837 655.29 622.53 715.91 15650 424.94 403.69 464.24 # 15837 568.61 540.18 621.21 # 15650 329.55 313.07 360.03 15838 497.05 472.20 543.03 15731 962.44 914.32 1,051.47 15839 722.65 686.52 789.50 # 15731 876.41 832.59 957.48 # 15839 620.82 589.78 678.25 15732 1,270.27 1,206.76 1,387.77 15840 876.64 832.81 957.73 # 15732 1,141.05 1,084.00 1,246.60 15841 1,437.30 1,365.44 1,570.26 15734 1,292.25 1,227.64 1,411.79 15842 2,201.35 2,091.28 2,404.97 # 15734 1,154.98 1,097.23 1,261.81 15845 836.90 795.06 914.32 15736 1,132.27 1,075.66 1,237.01 15851 78.18 74.27 85.41 # 15736 988.87 939.43 1,080.34 # 15851 40.80 38.76 44.57 15738 1,211.42 1,150.85 1,323.48 15852 41.80 39.71 45.67 # 15738 1,078.66 1,024.73 1,178.44 15860 99.73 94.74 108.95 15740 862.14 819.03 941.88 15920 502.77 477.63 549.27 # 15740 746.78 709.44 815.86 15922 622.91 591.76 680.52 15750 783.80 744.61 856.30 15931 570.94 542.39 623.75 15756 2,040.90 1,938.86 2,229.69 15933 703.49 668.32 768.57 15757 2,030.58 1,929.05 2,218.41 15934 781.35 742.28 853.62 15758 2,021.12 1,920.06 2,208.07 15935 929.61 883.13 1,015.60 15760 712.89 677.25 778.84 15936 754.47 716.75 824.26 # 15760 608.81 578.37 665.13 15937 880.52 836.49 961.96 15770 564.42 536.20 616.63 15940 584.65 555.42 638.73 15775 259.90 246.91 283.95 15941 759.79 721.80 830.07 # 15775 194.48 184.76 212.47 15944 748.58 711.15 817.82 15776 360.31 342.29 393.63 15945 831.09 789.54 907.97 # 15776 275.24 261.48 300.70 15946 1,390.49 1,320.97 1,519.12 15780 694.01 659.31 758.21 15950 484.10 459.90 528.89 # 15780 549.33 521.86 600.14 15951 685.45 651.18 748.86 15781 448.08 425.68 489.53 15952 719.10 683.15 785.62 # 15781 364.62 346.39 398.35 15953 817.83 776.94 893.48 15782 473.86 450.17 517.70 15956 972.03 923.43 1,061.94 # 15782 351.09 333.54 383.57 15958 990.91 941.36 1,082.56 15783 404.51 384.28 441.92 16000 58.27 55.36 63.66 # 15783 316.54 300.71 345.82 # 16000 41.19 39.13 45.00 15786 200.99 190.94 219.58 16020 68.36 64.94 74.68 # 15786 120.76 114.72 131.93 # 16020 48.70 46.27 53.21 15787 40.34 38.32 44.07 16025 124.19 117.98 135.68 # 15787 16.18 15.37 17.68 # 16025 100.03 95.03 109.28 15788 354.76 337.02 387.57 16030 148.53 141.10 162.27 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 7 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 113.41 107.74 123.90 17313 519.88 493.89 567.97 16035 182.29 173.18 199.16 # 17313 302.37 287.25 330.34 16036 73.49 69.82 80.29 17314 314.73 298.99 343.84 17000 66.49 63.17 72.65 # 17314 166.18 157.87 181.55 # 17000 47.15 44.79 51.51 17315 68.86 65.42 75.23 17003 6.15 5.84 6.72 # 17315 47.27 44.91 51.65 # 17003 3.90 3.71 4.27 17340 42.65 40.52 46.60 17004 146.69 139.36 160.26 # 17340 41.04 38.99 44.84 # 17004 116.07 110.27 126.81 17360 111.35 105.78 121.65 17106 288.05 273.65 314.70 # 17360 87.18 82.82 95.24 # 17106 237.78 225.89 259.77 19000 92.77 88.13 101.35 17107 375.29 356.53 410.01 # 19000 40.25 38.24 43.98 # 17107 308.91 293.46 337.48 19001 23.67 22.49 25.86 17108 528.13 501.72 576.98 # 19001 20.12 19.11 21.98 # 17108 448.54 426.11 490.03 19020 364.41 346.19 398.12 17110 90.46 85.94 98.83 # 19020 245.51 233.23 268.21 # 17110 57.91 55.01 63.26 19030 141.75 134.66 154.86 17111 108.10 102.70 118.11 # 19030 72.79 69.15 79.52 # 17111 72.33 68.71 79.02 19100 117.71 111.82 128.59 17250 61.42 58.35 67.10 # 19100 60.35 57.33 65.93 # 17250 30.81 29.27 33.66 19101 269.66 256.18 294.61 17260 80.21 76.20 87.63 # 19101 183.95 174.75 200.96 # 17260 58.95 56.00 64.40 19102 185.84 176.55 203.03 17261 118.59 112.66 129.56 # 19102 94.97 90.22 103.75 # 17261 78.96 75.01 86.26 19103 467.32 443.95 510.54 17262 144.82 137.58 158.22 # 19103 175.37 166.60 191.59 # 17262 101.31 96.24 110.68 19105 1,747.32 1,659.95 1,908.94 17263 159.87 151.88 174.66 # 19105 175.78 166.99 192.04 # 17263 111.86 106.27 122.21 19110 379.49 360.52 414.60 17264 171.23 162.67 187.07 # 19110 276.37 262.55 301.93 # 17264 119.68 113.70 130.76 19112 355.05 337.30 387.90 17266 194.85 185.11 212.88 # 19112 249.36 236.89 272.42 # 17266 139.75 132.76 152.67 19120 393.70 374.02 430.12 17270 124.16 117.95 135.64 # 19120 338.28 321.37 369.58 # 17270 85.81 81.52 93.75 19125 437.20 415.34 477.64 17271 136.36 129.54 148.97 # 19125 376.62 357.79 411.46 # 17271 96.08 91.28 104.97 19126 139.35 132.38 152.24 17272 156.28 148.47 170.74 19260 1,025.71 974.42 1,120.58 # 17272 111.49 105.92 121.81 19271 1,392.75 1,323.11 1,521.58 17273 174.59 165.86 190.74 19272 1,541.71 1,464.62 1,684.31 # 17273 125.93 119.63 137.57 19290 137.84 130.95 150.59 17274 207.29 196.93 226.47 # 19290 60.51 57.48 66.10 # 17274 154.76 147.02 169.07 19291 59.49 56.52 65.00 17276 240.34 228.32 262.57 # 19291 29.85 28.36 32.61 # 17276 185.56 176.28 202.72 19295 74.94 71.19 81.87 17280 116.02 110.22 126.75 19296 3,220.36 3,059.34 3,518.24 # 17280 77.99 74.09 85.20 # 19296 181.35 172.28 198.12 17281 148.42 141.00 162.15 19297 81.87 77.78 89.45 # 17281 108.46 103.04 118.50 19298 1,067.31 1,013.94 1,166.03 17282 171.98 163.38 187.89 # 19298 295.24 280.48 322.55 # 17282 125.90 119.61 137.55 19300 416.01 395.21 454.49 17283 208.05 197.65 227.30 # 19300 329.33 312.86 359.79 # 17283 157.46 149.59 172.03 19301 536.53 509.70 586.16 17284 242.44 230.32 264.87 19302 745.12 707.86 814.04 # 17284 187.66 178.28 205.02 19303 831.24 789.68 908.13 17286 307.43 292.06 335.87 19304 468.53 445.10 511.87 # 17286 251.69 239.11 274.98 19305 940.54 893.51 1,027.54 17311 569.91 541.41 622.62 19306 987.49 938.12 1,078.84 # 17311 336.93 320.08 368.09 19307 990.64 941.11 1,082.28 17312 339.39 322.42 370.78 19316 656.60 623.77 717.34 # 17312 179.24 170.28 195.82 19318 951.97 904.37 1,040.03 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 8 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 408.19 387.78 445.95 # 20551 37.73 35.84 41.22 19325 544.86 517.62 595.26 20552 44.74 42.50 48.88 19328 414.61 393.88 452.96 # 20552 32.50 30.88 35.51 19330 531.37 504.80 580.52 20553 50.95 48.40 55.66 19340 669.65 636.17 731.60 # 20553 36.45 34.63 39.82 19342 781.71 742.62 854.01 20555 297.91 283.01 325.46 19350 699.19 664.23 763.86 20600 46.03 43.73 50.29 # 19350 571.26 542.70 624.11 # 20600 34.43 32.71 37.62 19355 592.21 562.60 646.99 20605 49.48 47.01 54.06 # 19355 482.65 458.52 527.30 # 20605 35.95 34.15 39.27 19357 1,320.17 1,254.16 1,442.28 20610 64.47 61.25 70.44 19361 1,424.49 1,353.27 1,556.26 # 20610 43.20 41.04 47.20 19364 2,386.93 2,267.58 2,607.72 20612 49.39 46.92 53.96 19366 1,181.95 1,122.85 1,291.28 # 20612 37.14 35.28 40.57 19367 1,543.87 1,466.68 1,686.68 20615 181.43 172.36 198.21 19368 1,910.10 1,814.60 2,086.79 # 20615 136.31 129.49 148.91 19369 1,759.31 1,671.34 1,922.04 20650 164.72 156.48 179.95 19370 577.86 548.97 631.32 # 20650 132.50 125.88 144.76 19371 663.00 629.85 724.33 20660 207.16 196.80 226.32 19380 652.13 619.52 712.45 20661 395.88 376.09 432.50 19396 193.32 183.65 211.20 20662 392.66 373.03 428.98 # 19396 114.38 108.66 124.96 20663 378.73 359.79 413.76 20000 170.22 161.71 185.97 20664 670.14 636.63 732.12 # 20000 131.23 124.67 143.37 20665 99.08 94.13 108.25 20005 254.82 242.08 278.39 # 20665 83.93 79.73 91.69 # 20005 202.62 192.49 221.36 20670 317.21 301.35 346.55 20100 515.54 489.76 563.22 # 20670 125.48 119.21 137.09 20101 324.98 308.73 355.04 20680 500.23 475.22 546.50 # 20101 173.20 164.54 189.22 # 20680 358.77 340.83 391.95 20102 385.77 366.48 421.45 20690 485.03 460.78 529.90 # 20102 214.66 203.93 234.52 20692 909.75 864.26 993.90 20103 467.19 443.83 510.40 20693 386.09 366.79 421.81 # 20103 300.27 285.26 328.05 20694 351.36 333.79 383.86 20150 816.05 775.25 891.54 # 20694 283.37 269.20 309.58 20200 158.52 150.59 173.18 20696 902.14 857.03 985.58 # 20200 79.58 75.60 86.94 20697 1,130.26 1,073.75 1,234.81 20205 219.51 208.53 239.81 20802 2,097.65 1,992.77 2,291.69 # 20205 128.64 122.21 140.54 20805 2,700.00 2,565.00 2,949.75 20206 210.76 200.22 230.25 20808 3,571.54 3,392.96 3,901.90 # 20206 55.12 52.36 60.21 20816 1,871.80 1,778.21 2,044.94 20220 143.97 136.77 157.29 20822 1,610.05 1,529.55 1,758.98 # 20220 68.56 65.13 74.90 20824 1,894.82 1,800.08 2,070.09 20225 530.98 504.43 580.09 20827 1,679.46 1,595.49 1,834.81 # 20225 102.73 97.59 112.23 20838 2,176.31 2,067.49 2,377.61 20240 193.90 184.21 211.84 20900 337.77 320.88 369.01 20245 535.25 508.49 584.76 # 20900 206.30 195.99 225.39 20250 317.27 301.41 346.62 20902 288.29 273.88 314.96 20251 349.80 332.31 382.16 20910 363.89 345.70 397.56 20500 95.98 91.18 104.86 20912 415.86 395.07 454.33 # 20500 79.22 75.26 86.55 20920 346.44 329.12 378.49 20501 106.22 100.91 116.05 20922 512.57 486.94 559.98 # 20501 36.29 34.48 39.65 # 20922 428.15 406.74 467.75 20520 160.23 152.22 175.05 20924 426.46 405.14 465.91 # 20520 121.89 115.80 133.17 20926 371.19 352.63 405.52 20525 384.01 364.81 419.53 20931 96.03 91.23 104.91 # 20525 210.97 200.42 230.48 20937 146.80 139.46 160.38 20526 63.26 60.10 69.12 20938 159.63 151.65 174.40 # 20526 49.73 47.24 54.33 20950 199.64 189.66 218.11 20550 49.01 46.56 53.54 # 20950 76.87 73.03 83.98 # 20550 36.45 34.63 39.82 20955 2,208.06 2,097.66 2,412.31 20551 49.33 46.86 53.89 20956 2,273.75 2,160.06 2,484.07 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 99 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 2,223.80 2,112.61 2,429.50 # 21082 1,133.88 1,077.19 1,238.77 20962 2,235.73 2,123.94 2,442.53 21083 1,244.26 1,182.05 1,359.36 20969 2,455.99 2,333.19 2,683.17 # 21083 1,036.10 984.30 1,131.95 20970 2,451.68 2,329.10 2,678.47 21084 1,455.78 1,382.99 1,590.44 20972 2,143.12 2,035.96 2,341.35 # 21084 1,226.35 1,165.03 1,339.78 20973 2,296.51 2,181.68 2,508.93 21085 609.71 579.22 666.10 20974 55.84 53.05 61.01 # 21085 513.04 487.39 560.50 # 20974 40.70 38.67 44.47 21086 1,460.33 1,387.31 1,595.41 20975 150.56 143.03 164.48 # 21086 1,319.83 1,253.84 1,441.92 20979 44.18 41.97 48.27 21087 1,459.36 1,386.39 1,594.35 # 20979 30.32 28.80 33.12 # 21087 1,319.19 1,253.23 1,441.21 20982 3,008.75 2,858.31 3,287.06 21100 590.12 560.61 644.70 # 20982 354.50 336.78 387.30 # 21100 338.46 321.54 369.77 20985 129.09 122.64 141.04 21110 628.84 597.40 687.01 21010 634.93 603.18 693.66 # 21110 536.36 509.54 585.97 21011 276.39 262.57 301.96 21116 125.03 118.78 136.60 # 21011 216.78 205.94 236.83 # 21116 38.67 36.74 42.25 21012 296.47 281.65 323.90 21120 523.30 497.14 571.71 21013 429.81 408.32 469.57 # 21120 423.73 402.54 462.92 # 21013 349.57 332.09 381.90 21121 637.01 605.16 695.93 21014 458.13 435.22 500.50 # 21121 543.88 516.69 594.19 21015 533.86 507.17 583.25 21122 584.85 555.61 638.95 21016 917.18 871.32 1,002.02 21123 726.97 690.62 794.21 21025 742.98 705.83 811.70 21125 2,588.08 2,458.68 2,827.48 # 21025 636.64 604.81 695.53 # 21125 665.62 632.34 727.19 21026 498.82 473.88 544.96 21127 3,005.29 2,855.03 3,283.28 # 21026 414.39 393.67 452.72 # 21127 735.79 699.00 803.85 21029 636.83 604.99 695.74 21137 625.75 594.46 683.63 # 21029 542.42 515.30 592.60 21138 764.33 726.11 835.03 21030 417.05 396.20 455.63 21139 843.09 800.94 921.08 # 21030 344.87 327.63 376.77 21141 1,168.77 1,110.33 1,276.88 21031 314.83 299.09 343.95 21142 1,176.33 1,117.51 1,285.14 # 21031 242.01 229.91 264.40 21143 1,210.74 1,150.20 1,322.73 21032 319.77 303.78 349.35 21145 1,325.53 1,259.25 1,448.14 # 21032 239.53 227.55 261.68 21146 1,447.59 1,375.21 1,581.49 21034 1,130.60 1,074.07 1,235.18 21147 1,468.19 1,394.78 1,604.00 # 21034 1,010.73 960.19 1,104.22 21150 1,407.74 1,337.35 1,537.95 21040 420.24 399.23 459.11 21151 1,732.59 1,645.96 1,892.85 # 21040 343.55 326.37 375.33 21154 1,779.64 1,690.66 1,944.26 21044 761.55 723.47 831.99 21155 1,931.84 1,835.25 2,110.54 21045 1,063.06 1,009.91 1,161.40 21159 2,343.28 2,226.12 2,560.04 21046 926.85 880.51 1,012.59 21160 2,433.27 2,311.61 2,658.35 21047 1,125.68 1,069.40 1,229.81 21172 1,541.44 1,464.37 1,684.03 21048 944.77 897.53 1,032.16 21175 1,923.29 1,827.13 2,101.20 21049 1,090.52 1,035.99 1,191.39 21179 1,267.10 1,203.75 1,384.31 21050 743.94 706.74 812.75 21180 1,410.75 1,340.21 1,541.24 21060 689.11 654.65 752.85 21181 596.85 567.01 652.06 21070 542.65 515.52 592.85 21182 1,755.37 1,667.60 1,917.74 21073 309.85 294.36 338.51 21183 1,989.30 1,889.84 2,173.32 # 21073 211.24 200.68 230.78 21184 2,096.33 1,991.51 2,290.24 21076 812.78 772.14 887.96 21188 1,429.33 1,357.86 1,561.54 # 21076 712.56 676.93 778.47 21193 1,059.67 1,006.69 1,157.69 21077 2,008.88 1,908.44 2,194.71 21194 1,222.14 1,161.03 1,335.18 # 21077 1,807.16 1,716.80 1,974.32 21195 1,159.05 1,101.10 1,266.27 21079 1,372.83 1,304.19 1,499.82 21196 1,258.35 1,195.43 1,374.74 # 21079 1,195.28 1,135.52 1,305.85 21198 990.45 940.93 1,082.07 21080 1,553.29 1,475.63 1,696.97 21199 895.67 850.89 978.52 # 21080 1,338.68 1,271.75 1,462.51 21206 1,006.99 956.64 1,100.14 21081 1,422.75 1,351.61 1,554.35 21208 1,473.35 1,399.68 1,609.63 # 21081 1,223.61 1,162.43 1,336.79 # 21208 721.58 685.50 788.33 21082 1,325.62 1,259.34 1,448.24 21209 705.17 669.91 770.40 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 10 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 558.55 530.62 610.21 21365 957.58 909.70 1,046.16 21210 1,734.97 1,648.22 1,895.45 21366 1,064.65 1,011.42 1,163.13 # 21210 715.10 679.35 781.25 21385 604.15 573.94 660.03 21215 2,968.31 2,819.89 3,242.87 21386 571.25 542.69 624.09 # 21215 752.62 714.99 822.24 21387 638.28 606.37 697.33 21230 668.08 634.68 729.88 21390 672.70 639.07 734.93 21235 611.87 581.28 668.47 21395 821.04 779.99 896.99 # 21235 488.77 464.33 533.98 21400 149.36 141.89 163.17 21240 944.81 897.57 1,032.21 # 21400 123.58 117.40 135.01 21242 869.54 826.06 949.97 21401 391.51 371.93 427.72 21243 1,437.27 1,365.41 1,570.22 # 21401 252.95 240.30 276.35 21244 901.67 856.59 985.08 21406 457.33 434.46 499.63 21245 960.24 912.23 1,049.06 21407 551.33 523.76 602.32 # 21245 786.88 747.54 859.67 21408 760.74 722.70 831.11 21246 730.46 693.94 798.03 21421 620.85 589.81 678.28 21247 1,397.24 1,327.38 1,526.49 # 21421 529.98 503.48 579.00 21248 905.74 860.45 989.52 21422 567.27 538.91 619.75 # 21248 755.90 718.11 825.83 21423 681.54 647.46 744.58 21249 1,249.71 1,187.22 1,365.30 21431 637.09 605.24 696.03 # 21249 1,069.26 1,015.80 1,168.17 21432 572.76 544.12 625.74 21255 1,203.76 1,143.57 1,315.11 21433 1,461.80 1,388.71 1,597.02 21256 1,021.68 970.60 1,116.19 21435 1,144.55 1,087.32 1,250.42 21260 1,097.64 1,042.76 1,199.17 21436 1,733.86 1,647.17 1,894.25 21261 1,959.21 1,861.25 2,140.44 21440 446.59 424.26 487.90 21263 1,705.92 1,620.62 1,863.71 # 21440 372.16 353.55 406.58 21267 1,354.06 1,286.36 1,479.31 21445 623.92 592.72 681.63 21268 1,694.13 1,609.42 1,850.83 # 21445 517.58 491.70 565.46 21270 784.99 745.74 857.60 21450 466.42 443.10 509.57 # 21270 617.11 586.25 674.19 # 21450 389.41 369.94 425.43 21275 704.33 669.11 769.48 21451 607.48 577.11 663.68 21280 468.88 445.44 512.26 # 21451 518.54 492.61 566.50 21282 308.15 292.74 336.65 21452 480.83 456.79 525.31 21295 150.31 142.79 164.21 # 21452 277.82 263.93 303.52 21296 364.97 346.72 398.73 21453 710.52 674.99 776.24 21310 89.69 85.21 97.99 # 21453 628.67 597.24 686.83 # 21310 25.57 24.29 27.93 21454 474.41 450.69 518.29 21315 218.99 208.04 239.25 21461 1,604.71 1,524.47 1,753.14 # 21315 127.16 120.80 138.92 # 21461 775.92 737.12 847.69 21320 208.48 198.06 227.77 21462 1,722.22 1,636.11 1,881.53 # 21320 117.61 111.73 128.49 # 21462 856.06 813.26 935.25 21325 395.44 375.67 432.02 21465 792.41 752.79 865.71 21330 480.58 456.55 525.03 21470 1,027.73 976.34 1,122.79 21335 627.59 596.21 685.64 21480 74.62 70.89 81.52 21336 545.08 517.83 595.50 # 21480 28.54 27.11 31.18 21337 329.33 312.86 359.79 21485 547.48 520.11 598.13 # 21337 245.87 233.58 268.62 # 21485 467.88 444.49 511.16 21338 618.51 587.58 675.72 21490 789.05 749.60 862.04 21339 695.46 660.69 759.79 21495 585.03 555.78 639.15 21340 681.88 647.79 744.96 21497 550.88 523.34 601.84 21343 998.06 948.16 1,090.38 # 21497 472.90 449.26 516.65 21344 1,349.89 1,282.40 1,474.76 21501 367.33 348.96 401.30 21345 674.50 640.78 736.90 # 21501 270.34 256.82 295.34 # 21345 558.17 530.26 609.80 21502 449.24 426.78 490.80 21346 801.00 760.95 875.09 21510 392.52 372.89 428.82 21347 920.40 874.38 1,005.54 21550 212.49 201.87 232.15 21348 975.25 926.49 1,065.46 # 21550 136.12 129.31 148.71 21355 368.13 349.72 402.18 21552 394.19 374.48 430.65 # 21355 280.16 266.15 306.07 21554 648.19 615.78 708.15 21356 411.77 391.18 449.86 21555 340.85 323.81 372.38 # 21356 319.94 303.94 349.53 # 21555 263.51 250.33 287.88 21360 453.50 430.83 495.45 21556 429.38 407.91 469.10 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 11 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 732.00 695.40 799.71 # 22315 637.76 605.87 696.75 21558 1,216.93 1,156.08 1,329.49 22318 1,342.70 1,275.57 1,466.91 21600 473.27 449.61 517.05 22319 1,482.49 1,408.37 1,619.63 21610 938.23 891.32 1,025.02 22325 1,186.15 1,126.84 1,295.87 21615 579.29 550.33 632.88 22326 1,228.81 1,167.37 1,342.48 21616 718.89 682.95 785.39 22327 1,224.56 1,163.33 1,337.83 21620 447.14 424.78 488.50 22328 243.28 231.12 265.79 21627 469.78 446.29 513.23 22505 101.51 96.43 110.89 21630 1,089.73 1,035.24 1,190.53 22520 1,853.04 1,760.39 2,024.45 21632 1,086.22 1,031.91 1,186.70 # 22520 475.16 451.40 519.11 21685 872.27 828.66 952.96 22521 1,811.27 1,720.71 1,978.82 21700 365.14 346.88 398.91 # 22521 448.54 426.11 490.03 21705 542.21 515.10 592.37 22522 209.68 199.20 229.08 21720 362.45 344.33 395.98 22523 512.23 486.62 559.61 21725 449.08 426.63 490.62 22524 492.30 467.69 537.84 21740 925.41 879.14 1,011.01 22525 230.40 218.88 251.71 21750 618.83 587.89 676.07 22532 1,489.59 1,415.11 1,627.38 21800 83.59 79.41 91.32 22533 1,417.59 1,346.71 1,548.72 # 21800 85.20 80.94 93.08 22534 315.50 299.73 344.69 21805 219.81 208.82 240.14 22548 1,584.51 1,505.28 1,731.07 21810 429.61 408.13 469.35 22554 1,062.56 1,009.43 1,160.84 21820 110.49 104.97 120.72 22556 1,406.03 1,335.73 1,536.09 # 21820 112.10 106.50 122.48 22558 1,309.34 1,243.87 1,430.45 21825 485.12 460.86 529.99 22585 290.98 276.43 317.89 21920 213.17 202.51 232.89 22590 1,299.63 1,234.65 1,419.85 # 21920 137.76 130.87 150.50 22595 1,236.67 1,174.84 1,351.07 21925 353.86 336.17 386.60 22600 1,058.27 1,005.36 1,156.16 # 21925 288.45 274.03 315.13 22610 1,042.77 990.63 1,139.22 21930 385.55 366.27 421.21 22612 1,347.23 1,279.87 1,471.85 # 21930 310.15 294.64 338.84 22614 339.99 322.99 371.44 21931 412.08 391.48 450.20 22630 1,291.83 1,227.24 1,411.33 21932 591.11 561.55 645.78 22632 276.25 262.44 301.81 21933 651.74 619.15 712.02 22800 1,143.10 1,085.95 1,248.84 21935 896.50 851.68 979.43 22802 1,802.69 1,712.56 1,969.44 21936 1,264.08 1,200.88 1,381.01 22804 2,081.88 1,977.79 2,274.46 22010 778.77 739.83 850.80 22808 1,553.16 1,475.50 1,696.83 22015 772.61 733.98 844.08 22810 1,740.44 1,653.42 1,901.43 22100 706.86 671.52 772.25 22812 1,894.13 1,799.42 2,069.33 22101 717.40 681.53 783.76 22818 1,876.00 1,782.20 2,049.53 22102 688.03 653.63 751.67 22819 2,064.61 1,961.38 2,255.59 22103 123.88 117.69 135.34 22830 678.19 644.28 740.92 22110 871.25 827.69 951.84 22840 662.17 629.06 723.42 22112 864.69 821.46 944.68 22842 663.67 630.49 725.06 22114 842.23 800.12 920.14 22843 706.53 671.20 771.88 22116 121.68 115.60 132.94 22844 863.70 820.52 943.60 22206 2,021.20 1,920.14 2,208.16 22845 633.21 601.55 691.78 22207 2,022.62 1,921.49 2,209.71 22846 657.22 624.36 718.01 22208 504.80 479.56 551.49 22847 740.20 703.19 808.67 22210 1,481.32 1,407.25 1,618.34 22848 315.74 299.95 344.94 22212 1,235.31 1,173.54 1,349.57 22849 1,100.72 1,045.68 1,202.53 22214 1,243.46 1,181.29 1,358.48 22850 600.76 570.72 656.33 22216 317.75 301.86 347.14 22851 353.72 336.03 386.43 22220 1,340.98 1,273.93 1,465.02 22852 574.92 546.17 628.10 22222 1,247.17 1,184.81 1,362.53 22855 932.62 885.99 1,018.89 22224 1,330.29 1,263.78 1,453.35 22856 1,387.33 1,317.96 1,515.65 22226 317.35 301.48 346.70 22857 1,465.40 1,392.13 1,600.95 22305 154.49 146.77 168.79 22861 1,639.46 1,557.49 1,791.11 # 22305 142.57 135.44 155.76 22862 1,680.28 1,596.27 1,835.71 22310 248.06 235.66 271.01 22864 1,453.98 1,381.28 1,588.47 # 22310 231.95 220.35 253.40 22865 1,790.68 1,701.15 1,956.32 22315 716.39 680.57 782.66 22900 438.23 416.32 478.77 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 12 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 582.35 553.23 636.21 23405 531.37 504.80 580.52 22902 368.86 350.42 402.98 23406 662.17 629.06 723.42 # 22902 295.72 280.93 323.07 23410 698.63 663.70 763.26 22903 386.28 366.97 422.02 23412 728.28 691.87 795.65 22904 911.22 865.66 995.51 23415 583.66 554.48 637.65 22905 1,181.61 1,122.53 1,290.91 23420 824.34 783.12 900.59 23000 442.82 420.68 483.78 23430 623.93 592.73 681.64 # 23000 302.01 286.91 329.95 23440 642.78 610.64 702.24 23020 581.23 552.17 635.00 23450 806.76 766.42 881.38 23030 347.45 330.08 379.59 23455 858.82 815.88 938.26 # 23030 215.01 204.26 234.90 23460 930.79 884.25 1,016.89 23031 316.92 301.07 346.23 23462 914.58 868.85 999.18 # 23031 178.68 169.75 195.21 23465 952.21 904.60 1,040.29 23035 575.90 547.11 629.18 23466 949.87 902.38 1,037.74 23040 605.39 575.12 661.39 23470 1,036.77 984.93 1,132.67 23044 481.43 457.36 525.96 23472 1,287.01 1,222.66 1,406.06 23065 179.37 170.40 195.96 23480 694.05 659.35 758.25 # 23065 142.96 135.81 156.18 23485 818.74 777.80 894.47 23066 421.90 400.81 460.93 23490 723.62 687.44 790.56 # 23066 287.20 272.84 313.77 23491 862.86 819.72 942.68 23071 366.07 347.77 399.94 23500 173.38 164.71 189.42 23073 606.68 576.35 662.80 23505 282.50 268.38 308.64 23075 300.44 285.42 328.23 # 23505 268.32 254.90 293.14 # 23075 227.94 216.54 249.02 23515 602.81 572.67 658.57 23076 458.88 435.94 501.33 23520 180.38 171.36 197.06 23077 996.32 946.50 1,088.48 # 23520 181.67 172.59 198.48 23078 1,229.54 1,168.06 1,343.27 23525 287.73 273.34 314.34 23100 410.30 389.79 448.26 # 23525 269.37 255.90 294.29 23101 374.82 356.08 409.49 23530 460.18 437.17 502.75 23105 534.76 508.02 584.22 23532 520.79 494.75 568.96 23106 402.86 382.72 440.13 23540 178.12 169.21 194.59 23107 555.63 527.85 607.03 # 23540 177.15 168.29 193.53 23120 484.42 460.20 529.23 23545 258.96 246.01 282.91 23125 592.55 562.92 647.36 # 23545 238.98 227.03 261.08 23130 506.87 481.53 553.76 23550 480.11 456.10 524.52 23140 435.05 413.30 475.30 23552 553.40 525.73 604.59 23145 582.36 553.24 636.23 23570 184.42 175.20 201.48 23146 508.39 482.97 555.42 # 23570 187.64 178.26 205.00 23150 553.62 525.94 604.83 23575 316.96 301.11 346.28 23155 666.27 632.96 727.90 # 23575 299.56 284.58 327.27 23156 566.75 538.41 619.17 23585 824.26 783.05 900.51 23170 452.03 429.43 493.84 23600 257.34 244.47 281.14 23172 463.92 440.72 506.83 # 23600 239.94 227.94 262.13 23174 634.09 602.39 692.75 23605 377.20 358.34 412.09 23180 572.90 544.26 625.90 # 23605 349.16 331.70 381.46 23182 556.71 528.87 608.20 23615 745.56 708.28 814.52 23184 625.10 593.85 682.93 23616 1,075.76 1,021.97 1,175.27 23190 471.11 447.55 514.68 23620 212.49 201.87 232.15 23195 634.14 602.43 692.79 # 23620 201.54 191.46 220.18 23200 1,143.14 1,085.98 1,248.88 23625 307.08 291.73 335.49 23210 1,331.07 1,264.52 1,454.20 # 23625 288.72 274.28 315.42 23220 1,479.06 1,405.11 1,615.88 23630 647.08 614.73 706.94 23330 187.37 178.00 204.70 23650 244.24 232.03 266.83 # 23330 126.46 120.14 138.16 # 23650 225.23 213.97 246.07 23331 493.28 468.62 538.91 23655 320.46 304.44 350.11 23332 747.99 710.59 817.18 23660 487.41 463.04 532.50 23350 128.12 121.71 139.97 23665 342.91 325.76 374.62 # 23350 47.56 45.18 51.96 # 23665 323.26 307.10 353.17 23395 1,094.05 1,039.35 1,195.25 23670 728.75 692.31 796.16 23397 974.25 925.54 1,064.37 23675 445.24 422.98 486.43 23400 825.91 784.61 902.30 # 23675 412.37 391.75 450.51 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 99 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 778.95 740.00 851.00 24332 509.04 483.59 556.13 23700 163.10 154.95 178.19 24340 514.01 488.31 561.56 23800 871.43 827.86 952.04 24341 616.39 585.57 673.41 23802 1,072.70 1,019.07 1,171.93 24342 660.23 627.22 721.30 23900 1,146.65 1,089.32 1,252.72 24343 591.41 561.84 646.12 23920 929.95 883.45 1,015.97 24344 923.95 877.75 1,009.41 23921 344.50 327.28 376.37 24345 587.22 557.86 641.54 23930 288.98 274.53 315.71 24346 925.89 879.60 1,011.54 # 23930 182.96 173.81 199.88 24357 370.33 351.81 404.58 23931 224.74 213.50 245.53 24358 435.97 414.17 476.30 # 23931 131.29 124.73 143.44 24359 550.86 523.32 601.82 23935 415.94 395.14 454.41 24360 762.04 723.94 832.53 24000 395.76 375.97 432.37 24361 857.35 814.48 936.65 24006 598.97 569.02 654.37 24362 901.56 856.48 984.95 24065 208.88 198.44 228.21 24363 1,282.09 1,217.99 1,400.69 # 24065 142.18 135.07 155.33 24365 537.72 510.83 587.45 24066 484.85 460.61 529.70 24366 575.57 546.79 628.81 # 24066 336.95 320.10 368.12 24400 694.08 659.38 758.29 24071 355.32 337.55 388.18 24410 889.37 844.90 971.64 24073 610.19 579.68 666.63 24420 836.80 794.96 914.20 24075 395.76 375.97 432.37 24430 895.63 850.85 978.48 # 24075 272.02 258.42 297.18 24435 908.31 862.89 992.32 24076 438.69 416.76 479.27 24470 539.06 512.11 588.93 24077 836.95 795.10 914.37 24495 553.09 525.44 604.26 24079 1,133.67 1,076.99 1,238.54 24498 736.84 700.00 805.00 24100 339.23 322.27 370.61 24500 281.36 267.29 307.38 24101 415.70 394.92 454.16 # 24500 256.54 243.71 280.27 24102 516.04 490.24 563.78 24505 404.68 384.45 442.12 24105 281.41 267.34 307.44 # 24505 371.17 352.61 405.50 24110 488.00 463.60 533.14 24515 740.71 703.67 809.22 24115 606.41 576.09 662.50 24516 731.43 694.86 799.09 24116 729.45 692.98 796.93 24530 301.78 286.69 329.69 24120 437.72 415.83 478.20 # 24530 274.71 260.97 300.12 24125 513.05 487.40 560.51 24535 505.21 479.95 551.94 24126 541.91 514.81 592.03 # 24535 471.38 447.81 514.98 24130 422.27 401.16 461.33 24538 623.66 592.48 681.35 24134 633.11 601.45 691.67 24545 781.03 741.98 853.28 24136 508.61 483.18 555.66 24546 888.27 843.86 970.44 24138 558.01 530.11 609.63 24560 252.80 240.16 276.18 24140 601.04 570.99 656.64 # 24560 226.05 214.75 246.96 24145 503.78 478.59 550.38 24565 420.75 399.71 459.67 24147 523.95 497.75 572.41 # 24565 390.46 370.94 426.58 24149 984.26 935.05 1,075.31 24566 593.19 563.53 648.06 24150 1,199.09 1,139.14 1,310.01 24575 615.71 584.92 672.66 24152 1,006.45 956.13 1,099.55 24576 266.06 252.76 290.67 24155 719.72 683.73 786.29 # 24576 240.29 228.28 262.52 24160 507.27 481.91 554.20 24577 437.01 415.16 477.43 24164 415.13 394.37 453.53 # 24577 404.14 383.93 441.52 24200 163.59 155.41 178.72 24579 703.55 668.37 768.63 # 24200 115.57 109.79 126.26 24582 663.96 630.76 725.37 24201 450.70 428.17 492.40 24586 927.52 881.14 1,013.31 # 24201 305.38 290.11 333.63 24587 926.77 880.43 1,012.49 24220 141.49 134.42 154.58 24600 296.80 281.96 324.25 # 24220 63.18 60.02 69.02 # 24600 272.63 259.00 297.85 24300 327.64 311.26 357.95 24605 382.14 363.03 417.48 24301 635.16 603.40 693.91 24615 602.12 572.01 657.81 24305 485.53 461.25 530.44 24620 460.19 437.18 502.76 24310 397.97 378.07 434.78 24635 602.44 572.32 658.17 24320 655.96 623.16 716.63 24640 100.19 95.18 109.46 24330 603.59 573.41 659.42 # 24640 73.44 69.77 80.24 24331 666.35 633.03 727.98 24650 204.74 194.50 223.68 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 99 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 186.70 177.37 203.98 25210 412.01 391.41 450.12 24655 352.77 335.13 385.40 25215 528.29 501.88 577.16 # 24655 324.41 308.19 354.42 25230 363.72 345.53 397.36 24665 543.56 516.38 593.84 25240 366.65 348.32 400.57 24666 616.41 585.59 673.43 25246 143.80 136.61 157.10 24670 229.45 217.98 250.68 # 25246 69.69 66.21 76.14 # 24670 207.54 197.16 226.73 25248 365.35 347.08 399.14 24675 369.70 351.22 403.90 25250 440.53 418.50 481.28 # 24675 341.34 324.27 372.91 25251 605.60 575.32 661.62 24685 544.41 517.19 594.77 25259 329.43 312.96 359.90 24800 681.77 647.68 744.83 25260 561.15 533.09 613.05 24802 847.75 805.36 926.16 25263 559.99 531.99 611.79 24900 611.10 580.55 667.63 25265 666.94 633.59 728.63 24920 606.29 575.98 662.38 25270 446.39 424.07 487.68 24925 469.37 445.90 512.79 25272 502.53 477.40 549.01 24930 643.32 611.15 702.82 25274 599.34 569.37 654.78 24931 694.66 659.93 758.92 25275 566.84 538.50 619.28 24935 903.31 858.14 986.86 25280 510.82 485.28 558.07 25000 286.54 272.21 313.04 25290 422.12 401.01 461.16 25001 277.32 263.45 302.97 25295 474.22 450.51 518.09 25020 476.13 452.32 520.17 25300 577.48 548.61 630.90 25023 928.92 882.47 1,014.84 25301 546.68 519.35 597.25 25024 655.11 622.35 715.70 25310 554.53 526.80 605.82 25025 1,025.32 974.05 1,120.16 25312 644.07 611.87 703.65 25028 426.92 405.57 466.41 25315 690.75 656.21 754.64 25031 311.42 295.85 340.23 25316 801.88 761.79 876.06 25035 526.02 499.72 574.68 25320 824.46 783.24 900.73 25040 478.15 454.24 522.38 25332 713.14 677.48 779.10 25065 207.34 196.97 226.52 25335 766.07 727.77 836.94 # 25065 139.99 132.99 152.94 25337 750.77 713.23 820.21 25066 310.26 294.75 338.96 25350 607.11 576.75 663.26 25071 372.45 353.83 406.90 25355 685.19 650.93 748.57 25073 464.34 441.12 507.29 25360 589.69 560.21 644.24 25075 306.70 291.37 335.08 25365 808.46 768.04 883.25 # 25075 277.06 263.21 302.69 25370 884.69 840.46 966.53 25076 431.00 409.45 470.87 25375 803.39 763.22 877.70 25077 739.43 702.46 807.83 25390 690.39 655.87 754.25 25078 989.52 940.04 1,081.05 25391 883.10 838.95 964.79 25085 384.75 365.51 420.34 25392 899.38 854.41 982.57 25100 288.05 273.65 314.70 25393 1,003.19 953.03 1,095.98 25101 338.21 321.30 369.50 25394 659.95 626.95 720.99 25105 410.19 389.68 448.13 25400 722.50 686.38 789.34 25107 517.78 491.89 565.67 25405 923.81 877.62 1,009.26 25109 443.25 421.09 484.25 25415 870.02 826.52 950.50 25110 296.45 281.63 323.87 25420 1,037.06 985.21 1,132.99 25111 262.68 249.55 286.98 25425 885.76 841.47 967.69 25112 320.38 304.36 350.01 25426 953.76 906.07 1,041.98 25115 670.70 637.17 732.75 25430 602.71 572.57 658.46 25116 536.27 509.46 585.88 25431 660.55 627.52 721.65 25118 319.74 303.75 349.31 25440 654.75 622.01 715.31 25119 422.25 401.14 461.31 25441 791.64 752.06 864.87 25120 451.98 429.38 493.79 25442 676.67 642.84 739.27 25125 532.72 506.08 581.99 25443 659.44 626.47 720.44 25126 534.37 507.65 583.80 25444 658.53 625.60 719.44 25130 376.04 357.24 410.83 25445 607.98 577.58 664.22 25135 473.59 449.91 517.40 25446 1,002.74 952.60 1,095.49 25136 413.19 392.53 451.41 25447 692.52 657.89 756.57 25145 466.49 443.17 509.65 25449 880.86 836.82 962.34 25150 483.00 458.85 527.68 25450 504.94 479.69 551.64 25151 527.27 500.91 576.05 25455 564.06 535.86 616.24 25170 1,156.10 1,098.30 1,263.05 25490 619.08 588.13 676.35 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 15 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 663.05 629.90 724.39 25905 616.74 585.90 673.79 25492 799.72 759.73 873.69 25907 539.35 512.38 589.24 25500 211.30 200.74 230.85 25909 603.55 573.37 659.38 # 25500 193.90 184.21 211.84 25915 1,002.98 952.83 1,095.75 25505 407.23 386.87 444.90 25920 579.12 550.16 632.68 # 25505 376.94 358.09 411.80 25922 464.68 441.45 507.67 25515 559.58 531.60 611.34 25924 565.47 537.20 617.78 25520 452.04 429.44 493.86 25927 659.18 626.22 720.15 # 25520 431.41 409.84 471.32 25929 480.61 456.58 525.07 25525 666.98 633.63 728.67 25931 589.62 560.14 644.16 25526 823.92 782.72 900.13 26010 205.18 194.92 224.16 25530 203.74 193.55 222.58 # 26010 111.74 106.15 122.07 # 25530 184.41 175.19 201.47 26011 309.76 294.27 338.41 25535 394.91 375.16 431.43 # 26011 153.48 145.81 167.68 # 25535 370.42 351.90 404.69 26020 356.27 338.46 389.23 25545 520.97 494.92 569.16 26025 347.07 329.72 379.18 25560 214.35 203.63 234.17 26030 409.54 389.06 447.42 # 25560 193.40 183.73 211.29 26034 444.24 422.03 485.33 25565 425.55 404.27 464.91 26035 703.88 668.69 768.99 # 25565 390.75 371.21 426.89 26037 477.77 453.88 521.96 25574 560.08 532.08 611.89 26040 253.85 241.16 277.33 25575 756.92 719.07 826.93 26045 386.41 367.09 422.15 25600 231.47 219.90 252.89 26055 451.94 429.34 493.74 # 25600 210.52 199.99 229.99 # 26055 247.00 234.65 269.85 25605 507.49 482.12 554.44 26060 217.32 206.45 237.42 # 25605 481.39 457.32 525.92 26070 250.95 238.40 274.16 25606 555.68 527.90 607.09 26075 264.59 251.36 289.06 25607 606.54 576.21 662.64 26080 317.85 301.96 347.25 25608 685.06 650.81 748.43 26100 268.72 255.28 293.57 25609 873.98 830.28 954.82 26105 273.19 259.53 298.46 25622 238.58 226.65 260.65 26110 262.30 249.19 286.57 # 25622 216.67 205.84 236.72 26111 361.84 343.75 395.31 25624 373.98 355.28 408.57 26113 476.30 452.49 520.36 # 25624 343.04 325.89 374.77 26115 472.30 448.69 515.99 25628 604.35 574.13 660.25 # 26115 290.24 275.73 317.09 25630 243.26 231.10 265.77 26116 435.08 413.33 475.33 # 25630 221.99 210.89 242.52 26117 602.43 572.31 658.16 25635 356.82 338.98 389.83 26118 931.88 885.29 1,018.08 # 25635 322.34 306.22 352.15 26121 499.23 474.27 545.41 25645 474.03 450.33 517.88 26123 692.63 658.00 756.70 25650 254.42 241.70 277.96 26125 241.84 229.75 264.21 # 25650 236.37 224.55 258.23 26130 377.97 359.07 412.93 25651 396.62 376.79 433.31 26135 459.87 436.88 502.41 25652 518.98 493.03 566.98 26140 419.57 398.59 458.38 25660 335.69 318.91 366.75 26145 425.96 404.66 465.36 25670 510.21 484.70 557.41 26160 456.73 433.89 498.97 25671 435.00 413.25 475.24 # 26160 268.54 255.11 293.38 25675 351.69 334.11 384.23 26170 335.95 319.15 367.02 # 25675 325.26 309.00 355.35 26180 366.90 348.56 400.84 25676 528.00 501.60 576.84 26185 447.07 424.72 488.43 25680 386.19 366.88 421.91 26200 374.72 355.98 409.38 25685 616.97 586.12 674.04 26205 504.76 479.52 551.45 25690 387.70 368.32 423.57 26210 364.78 346.54 398.52 25695 532.11 505.50 581.33 26215 466.86 443.52 510.05 25800 625.07 593.82 682.89 26230 417.61 396.73 456.24 25805 722.13 686.02 788.92 26235 411.92 391.32 450.02 25810 735.16 698.40 803.16 26236 365.95 347.65 399.80 25820 512.97 487.32 560.42 26250 788.84 749.40 861.81 25825 634.48 602.76 693.17 26260 616.54 585.71 673.57 25830 793.43 753.76 866.82 26262 483.25 459.09 527.95 25900 625.39 594.12 683.24 26320 285.25 270.99 311.64 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 16 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 261.63 248.55 285.83 26541 664.78 631.54 726.27 26350 583.23 554.07 637.18 26542 559.96 531.96 611.75 26352 667.48 634.11 729.23 26545 572.78 544.14 625.76 26356 889.16 844.70 971.41 26546 812.10 771.50 887.23 26357 715.03 679.28 781.17 26548 630.41 598.89 688.72 26358 756.74 718.90 826.74 26550 1,296.36 1,231.54 1,416.27 26370 630.34 598.82 688.64 26551 2,736.03 2,599.23 2,989.11 26372 732.78 696.14 800.56 26553 2,420.16 2,299.15 2,644.02 26373 698.75 663.81 763.38 26554 2,965.06 2,816.81 3,239.33 26390 689.45 654.98 753.23 26555 1,153.49 1,095.82 1,260.19 26392 803.37 763.20 877.68 26556 2,414.90 2,294.16 2,638.28 26410 462.74 439.60 505.54 26560 469.34 445.87 512.75 26412 563.17 535.01 615.26 26561 751.24 713.68 820.73 26415 595.32 565.55 650.38 26562 1,046.17 993.86 1,142.94 26416 673.52 639.84 735.82 26565 559.17 531.21 610.89 26418 466.90 443.56 510.09 26567 562.14 534.03 614.13 26420 587.78 558.39 642.15 26568 738.93 701.98 807.28 26426 462.06 438.96 504.80 26580 1,208.28 1,147.87 1,320.05 26428 618.99 588.04 676.25 26587 819.52 778.54 895.32 26432 405.81 385.52 443.35 26590 1,096.44 1,041.62 1,197.86 26433 434.82 413.08 475.04 26591 354.86 337.12 387.69 26434 526.31 499.99 574.99 26593 489.75 465.26 535.05 26437 510.26 484.75 557.46 26596 615.34 584.57 672.26 26440 509.50 484.03 556.63 26600 225.97 214.67 246.87 26442 789.01 749.56 861.99 # 26600 210.83 200.29 230.33 26445 472.80 449.16 516.53 26605 254.86 242.12 278.44 26449 623.28 592.12 680.94 # 26605 233.27 221.61 254.85 26450 330.70 314.17 361.30 26607 365.95 347.65 399.80 26455 328.05 311.65 358.40 26608 393.16 373.50 429.53 26460 318.66 302.73 348.14 26615 466.20 442.89 509.32 26471 503.41 478.24 549.98 26641 297.75 282.86 325.29 26474 485.85 461.56 530.79 # 26641 273.90 260.21 299.24 26476 473.72 450.03 517.53 26645 337.09 320.24 368.28 26477 475.05 451.30 519.00 # 26645 312.28 296.67 341.17 26478 513.32 487.65 560.80 26650 392.45 372.83 428.75 26479 509.73 484.24 556.88 26665 516.90 491.06 564.72 26480 618.42 587.50 675.63 26670 268.26 254.85 293.08 26483 696.89 662.05 761.36 # 26670 244.09 231.89 266.67 26485 667.84 634.45 729.62 26675 358.40 340.48 391.55 26489 741.53 704.45 810.12 # 26675 332.30 315.69 363.04 26490 650.78 618.24 710.98 26676 412.18 391.57 450.31 26492 727.13 690.77 794.39 26685 472.28 448.67 515.97 26494 658.51 625.58 719.42 26686 519.75 493.76 567.82 26496 712.65 677.02 778.57 26700 257.12 244.26 280.90 26497 715.47 679.70 781.66 # 26700 241.33 229.26 263.65 26498 955.89 908.10 1,044.32 26705 329.08 312.63 359.52 26499 683.41 649.24 746.63 # 26705 303.30 288.14 331.36 26500 514.43 488.71 562.02 26706 359.60 341.62 392.86 26502 581.53 552.45 635.32 26715 464.99 441.74 508.00 26508 514.34 488.62 561.91 26720 154.26 146.55 168.53 26510 490.03 465.53 535.36 # 26720 142.34 135.22 155.50 26516 578.31 549.39 631.80 26725 272.83 259.19 298.07 26517 682.04 647.94 745.13 # 26725 246.73 234.39 269.55 26518 690.60 656.07 754.48 26727 386.50 367.18 422.26 26520 534.03 507.33 583.43 26735 485.04 460.79 529.91 26525 535.54 508.76 585.07 26740 179.09 170.14 195.66 26530 446.79 424.45 488.12 # 26740 168.45 160.03 184.03 26531 520.99 494.94 569.18 26742 298.69 283.76 326.32 26535 339.41 322.44 370.81 # 26742 272.91 259.26 298.15 26536 559.29 531.33 611.03 26746 604.06 573.86 659.94 26540 542.73 515.59 592.93 26750 144.69 137.46 158.08 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 17 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 142.12 135.01 155.26 27075 1,822.32 1,731.20 1,990.88 26755 251.84 239.25 275.14 27076 1,976.81 1,877.97 2,159.67 # 26755 221.23 210.17 241.70 27077 2,401.27 2,281.21 2,623.39 26756 341.54 324.46 373.13 27078 1,548.14 1,470.73 1,691.34 26765 399.12 379.16 436.03 27080 422.41 401.29 461.48 26770 218.89 207.95 239.14 27086 200.09 190.09 218.60 # 26770 202.13 192.02 220.82 # 27086 124.37 118.15 135.87 26775 306.49 291.17 334.85 27087 535.38 508.61 584.90 # 26775 277.49 263.62 303.16 27090 704.13 668.92 769.26 26776 362.96 344.81 396.53 27091 1,370.80 1,302.26 1,497.60 26785 436.57 414.74 476.95 27093 160.18 152.17 175.00 26820 649.72 617.23 709.81 # 27093 63.84 60.65 69.75 26841 600.26 570.25 655.79 27095 193.73 184.04 211.65 26842 652.72 620.08 713.09 # 27095 73.21 69.55 79.98 26843 606.32 576.00 662.40 27096 152.02 144.42 166.08 26844 676.45 642.63 739.02 # 27096 63.41 60.24 69.28 26850 572.00 543.40 624.91 27097 564.28 536.07 616.48 26852 658.20 625.29 719.08 27098 533.65 506.97 583.02 26860 458.79 435.85 501.23 27100 694.34 659.62 758.56 26861 91.05 86.50 99.48 27105 731.66 695.08 799.34 26862 598.28 568.37 653.63 27110 814.52 773.79 889.86 26863 204.09 193.89 222.97 27111 735.12 698.36 803.11 26910 590.67 561.14 645.31 27120 1,102.53 1,047.40 1,204.51 26951 519.97 493.97 568.07 27122 940.52 893.49 1,027.51 26952 532.62 505.99 581.89 27125 964.40 916.18 1,053.61 26990 518.52 492.59 566.48 27130 1,237.84 1,175.95 1,352.34 26991 575.54 546.76 628.77 27132 1,447.11 1,374.75 1,580.96 # 26991 437.95 416.05 478.46 27134 1,670.51 1,586.98 1,825.03 26992 812.80 772.16 887.98 27137 1,275.60 1,211.82 1,393.59 27000 370.47 351.95 404.74 27138 1,327.30 1,260.94 1,450.08 27001 452.97 430.32 494.87 27140 762.35 724.23 832.86 27003 493.47 468.80 539.12 27146 1,085.35 1,031.08 1,185.74 27005 614.16 583.45 670.97 27147 1,257.29 1,194.43 1,373.59 27006 621.17 590.11 678.63 27151 1,323.76 1,257.57 1,446.21 27025 765.56 727.28 836.37 27156 1,468.24 1,394.83 1,604.05 27027 724.57 688.34 791.59 27158 1,187.15 1,127.79 1,296.96 27030 801.45 761.38 875.59 27161 1,039.99 987.99 1,136.19 27033 830.58 789.05 907.41 27165 1,171.69 1,113.11 1,280.08 27035 961.76 913.67 1,050.72 27170 1,009.76 959.27 1,103.16 27036 854.13 811.42 933.13 27175 562.33 534.21 614.34 27040 281.08 267.03 307.08 27176 773.69 735.01 845.26 # 27040 173.14 164.48 189.15 27177 945.85 898.56 1,033.34 27041 582.80 553.66 636.71 27178 770.14 731.63 841.37 27043 411.43 390.86 449.49 27179 826.98 785.63 903.47 27045 654.04 621.34 714.54 27181 947.87 900.48 1,035.55 27047 418.37 397.45 457.07 27185 542.21 515.10 592.37 # 27047 338.45 321.53 369.76 27187 845.41 803.14 923.61 27048 492.11 467.50 537.63 27193 390.66 371.13 426.80 27049 1,095.01 1,040.26 1,196.30 # 27193 394.20 374.49 430.66 27050 306.12 290.81 334.43 27194 597.55 567.67 652.82 27052 473.71 450.02 517.52 27200 143.27 136.11 156.53 27054 574.27 545.56 627.39 # 27200 146.81 139.47 160.39 27057 820.08 779.08 895.94 27202 515.15 489.39 562.80 27059 1,605.95 1,525.65 1,754.50 27220 440.03 418.03 480.73 27060 362.36 344.24 395.88 # 27220 436.81 414.97 477.22 27062 377.15 358.29 412.03 27222 831.69 790.11 908.63 27065 422.69 401.56 461.79 27226 889.50 845.03 971.78 27066 684.12 649.91 747.40 27227 1,432.17 1,360.56 1,564.64 27067 877.52 833.64 958.69 27228 1,638.77 1,556.83 1,790.35 27070 718.45 682.53 784.91 27230 391.15 371.59 427.33 27071 768.87 730.43 839.99 # 27230 386.64 367.31 422.41 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 18 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 656.94 624.09 717.70 27357 685.77 651.48 749.20 27235 773.24 734.58 844.77 27358 247.63 235.25 270.54 27236 1,019.10 968.15 1,113.37 27360 716.73 680.89 783.02 27238 379.08 360.13 414.15 27364 1,381.15 1,312.09 1,508.90 27240 812.80 772.16 887.98 27365 1,596.62 1,516.79 1,744.31 27244 1,048.51 996.08 1,145.49 27370 138.68 131.75 151.51 27245 1,064.30 1,011.09 1,162.75 # 27370 47.17 44.81 51.53 27246 318.77 302.83 348.25 27372 488.34 463.92 533.51 # 27246 319.73 303.74 349.30 # 27372 338.82 321.88 370.16 27248 638.01 606.11 697.03 27380 495.05 470.30 540.85 27250 190.11 180.60 207.69 27381 674.37 640.65 736.75 27252 643.49 611.32 703.02 27385 529.73 503.24 578.73 27253 803.21 763.05 877.51 27386 700.02 665.02 764.77 27254 1,084.76 1,030.52 1,185.10 27390 368.19 349.78 402.25 27256 248.39 235.97 271.37 27391 479.86 455.87 524.25 # 27256 211.33 200.76 230.87 27392 592.67 563.04 647.50 27257 287.30 272.94 313.88 27393 424.58 403.35 463.85 27258 943.68 896.50 1,030.98 27394 548.63 521.20 599.38 27259 1,326.75 1,260.41 1,449.47 27395 742.68 705.55 811.38 27265 330.89 314.35 361.50 27396 515.83 490.04 563.55 27266 486.77 462.43 531.79 27397 768.79 730.35 839.90 27267 353.76 336.07 386.48 27400 580.40 551.38 634.09 27268 436.49 414.67 476.87 27403 539.65 512.67 589.57 27269 1,046.25 993.94 1,143.03 27405 568.93 540.48 621.55 27275 149.31 141.84 163.12 27407 654.79 622.05 715.36 27280 872.62 828.99 953.34 27409 817.74 776.85 893.38 27282 696.04 661.24 760.43 27412 1,411.50 1,340.93 1,542.07 27284 1,347.77 1,280.38 1,472.44 27415 1,164.32 1,106.10 1,272.02 27286 1,423.95 1,352.75 1,555.66 27416 823.79 782.60 899.99 27290 1,363.30 1,295.14 1,489.41 27418 705.48 670.21 770.74 27295 1,087.84 1,033.45 1,188.47 27420 630.64 599.11 688.98 27301 545.49 518.22 595.95 27422 628.40 596.98 686.53 # 27301 418.53 397.60 457.24 27424 629.94 598.44 688.21 27303 537.42 510.55 587.13 27425 368.45 350.03 402.53 27305 394.31 374.59 430.78 27427 605.84 575.55 661.88 27306 318.04 302.14 347.46 27428 939.62 892.64 1,026.54 27307 391.87 372.28 428.12 27429 1,054.99 1,002.24 1,152.58 27310 614.45 583.73 671.29 27430 624.73 593.49 682.51 27323 220.58 209.55 240.98 27435 676.78 642.94 739.38 # 27323 151.62 144.04 165.65 27437 555.49 527.72 606.88 27324 323.11 306.95 352.99 27438 712.89 677.25 778.84 27325 450.08 427.58 491.72 27440 657.07 624.22 717.85 27326 413.61 392.93 451.87 27441 678.59 644.66 741.36 27327 356.06 338.26 389.00 27442 737.24 700.38 805.44 # 27327 270.34 256.82 295.34 27443 690.01 655.51 753.84 27328 478.70 454.77 522.99 27445 1,075.47 1,021.70 1,174.96 27329 888.07 843.67 970.22 27446 950.01 902.51 1,037.89 27330 333.64 316.96 364.50 27447 1,323.97 1,257.77 1,446.44 27331 395.32 375.55 431.88 27448 694.56 659.83 758.80 27332 536.47 509.65 586.10 27450 866.44 823.12 946.59 27333 486.64 462.31 531.66 27454 1,099.40 1,044.43 1,201.09 27334 572.28 543.67 625.22 27455 799.23 759.27 873.16 27335 645.92 613.62 705.66 27457 822.65 781.52 898.75 27337 366.86 348.52 400.80 27465 1,057.42 1,004.55 1,155.23 27339 660.81 627.77 721.94 27466 1,010.48 959.96 1,103.95 27340 303.69 288.51 331.79 27468 1,142.65 1,085.52 1,248.35 27345 401.61 381.53 438.76 27470 1,006.38 956.06 1,099.47 27347 435.74 413.95 476.04 27472 1,085.61 1,031.33 1,186.03 27350 547.02 519.67 597.62 27475 555.49 527.72 606.88 27355 505.90 480.61 552.70 27477 618.24 587.33 675.43 27356 621.16 590.10 678.62 27479 739.55 702.57 807.96 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 19 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 564.72 536.48 616.95 27603 435.66 413.88 475.96 27486 1,209.58 1,149.10 1,321.47 # 27603 330.28 313.77 360.84 27487 1,522.33 1,446.21 1,663.14 27604 381.77 362.68 417.08 27488 1,025.67 974.39 1,120.55 # 27604 287.36 272.99 313.94 27495 965.76 917.47 1,055.09 27605 293.49 278.82 320.64 27496 432.17 410.56 472.14 # 27605 168.14 159.73 183.69 27497 468.29 444.88 511.61 27606 249.39 236.92 272.46 27498 516.09 490.29 563.83 27607 521.80 495.71 570.07 27499 564.75 536.51 616.99 27610 556.00 528.20 607.43 27500 426.19 404.88 465.61 27612 483.22 459.06 527.92 # 27500 397.84 377.95 434.64 27613 206.64 196.31 225.76 27501 419.19 398.23 457.96 # 27613 141.55 134.47 154.64 # 27501 414.03 393.33 452.33 27614 468.36 444.94 511.68 27502 667.41 634.04 729.15 # 27614 350.43 332.91 382.85 27503 678.96 645.01 741.76 27615 857.92 815.02 937.27 27506 1,141.29 1,084.23 1,246.86 27616 1,127.60 1,071.22 1,231.90 27507 837.08 795.23 914.51 27618 363.21 345.05 396.81 27508 431.21 409.65 471.10 # 27618 276.53 262.70 302.11 # 27508 408.01 387.61 445.75 27619 436.60 414.77 476.99 27509 539.15 512.19 589.02 27620 390.32 370.80 426.42 27510 589.87 560.38 644.44 27625 501.14 476.08 547.49 27511 868.75 825.31 949.11 27626 542.59 515.46 592.78 27513 1,088.49 1,034.07 1,189.18 27630 444.52 422.29 485.63 27514 856.89 814.05 936.16 # 27630 313.37 297.70 342.36 27516 407.33 386.96 445.00 27632 363.04 344.89 396.62 # 27516 385.09 365.84 420.72 27634 593.46 563.79 648.36 27517 572.90 544.26 625.90 27635 501.86 476.77 548.29 27519 780.55 741.52 852.75 27637 639.64 607.66 698.81 27520 255.70 242.92 279.36 27638 662.76 629.62 724.06 # 27520 233.15 221.49 254.71 27640 731.00 694.45 798.62 27524 636.89 605.05 695.81 27641 586.66 557.33 640.93 27530 320.27 304.26 349.90 27645 1,369.63 1,301.15 1,496.32 # 27530 299.33 284.36 327.01 27646 1,180.14 1,121.13 1,289.30 27532 508.69 483.26 555.75 27647 951.17 903.61 1,039.15 # 27532 481.95 457.85 526.53 27648 134.17 127.46 146.58 27535 778.73 739.79 850.76 # 27648 46.85 44.51 51.19 27536 1,015.59 964.81 1,109.53 27650 571.18 542.62 624.01 27538 381.96 362.86 417.29 27652 619.56 588.58 676.87 # 27538 359.40 341.43 392.64 27654 614.75 584.01 671.61 27540 694.21 659.50 758.43 27656 460.54 437.51 503.14 27550 407.33 386.96 445.00 # 27656 307.16 291.80 335.57 # 27550 380.91 361.86 416.14 27658 324.30 308.09 354.30 27552 521.85 495.76 570.12 27659 421.94 400.84 460.97 27556 767.62 729.24 838.63 27664 308.80 293.36 337.36 27557 920.21 874.20 1,005.33 27665 354.70 336.97 387.52 27558 1,043.15 990.99 1,139.64 27675 430.80 409.26 470.65 27560 302.77 287.63 330.77 27676 529.33 502.86 578.29 # 27560 278.28 264.37 304.03 27680 366.67 348.34 400.59 27562 390.21 370.70 426.31 27681 444.84 422.60 485.99 27566 758.13 720.22 828.25 27685 529.27 502.81 578.23 27570 123.61 117.43 135.04 # 27685 404.57 384.34 441.99 27580 1,233.06 1,171.41 1,347.12 27686 475.80 452.01 519.81 27590 719.95 683.95 786.54 27687 393.16 373.50 429.53 27591 786.32 747.00 859.05 27690 545.57 518.29 596.03 27592 608.51 578.08 664.79 27691 640.93 608.88 700.21 27594 439.83 417.84 480.52 27692 95.60 90.82 104.44 27596 636.56 604.73 695.44 27695 418.29 397.38 456.99 27598 644.52 612.29 704.13 27696 494.14 469.43 539.84 27600 362.57 344.44 396.11 27698 560.11 532.10 611.92 27601 378.56 359.63 413.57 27700 529.73 503.24 578.73 27602 446.36 424.04 487.65 27702 846.37 804.05 924.66 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 20 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 982.30 933.19 1,073.17 27827 921.31 875.24 1,006.53 27704 483.50 459.33 528.23 27828 1,107.17 1,051.81 1,209.58 27705 651.64 619.06 711.92 27829 567.96 539.56 620.49 27707 334.22 317.51 365.14 27830 296.57 281.74 324.00 27709 985.46 936.19 1,076.62 # 27830 278.52 264.59 304.28 27712 937.04 890.19 1,023.72 27831 320.42 304.40 350.06 27715 910.74 865.20 994.98 27832 616.84 586.00 673.90 27720 747.17 709.81 816.28 27840 298.97 284.02 326.62 27722 747.93 710.53 817.11 27842 409.16 388.70 447.01 27724 1,096.23 1,041.42 1,197.63 27846 626.43 595.11 684.38 27725 1,030.14 978.63 1,125.42 27848 706.79 671.45 772.17 27726 808.78 768.34 883.59 27860 149.81 142.32 163.67 27727 843.70 801.52 921.75 27870 897.33 852.46 980.33 27730 488.65 464.22 533.85 27871 588.19 558.78 642.60 27732 349.47 332.00 381.80 27880 814.04 773.34 889.34 27734 489.63 465.15 534.92 27881 770.05 731.55 841.28 27740 571.67 543.09 624.55 27882 546.31 518.99 596.84 27742 609.57 579.09 665.95 27884 507.65 482.27 554.61 27745 641.09 609.04 700.40 27886 579.58 550.60 633.19 27750 275.78 261.99 301.29 27888 605.21 574.95 661.19 # 27750 253.87 241.18 277.36 27889 596.82 566.98 652.03 27752 442.05 419.95 482.94 27892 471.51 447.93 515.12 # 27752 413.05 392.40 451.26 27893 474.85 451.11 518.78 27756 480.23 456.22 524.65 27894 735.82 699.03 803.88 27758 755.42 717.65 825.30 28001 223.73 212.54 244.42 27759 853.41 810.74 932.35 # 28001 154.12 146.41 168.37 27760 266.44 253.12 291.09 28002 425.26 404.00 464.60 # 27760 243.24 231.08 265.74 # 28002 335.03 318.28 366.02 27762 395.33 375.56 431.89 28003 576.58 547.75 629.91 # 27762 366.33 348.01 400.21 # 28003 484.75 460.51 529.59 27766 511.97 486.37 559.33 28005 528.66 502.23 577.56 27767 217.87 206.98 238.03 28008 354.28 336.57 387.06 # 27767 218.84 207.90 239.09 # 28008 263.09 249.94 287.43 27768 345.70 328.42 377.68 28010 197.34 187.47 215.59 27769 599.69 569.71 655.17 # 28010 183.81 174.62 200.81 27780 239.82 227.83 262.00 28011 278.99 265.04 304.80 # 27780 218.56 207.63 238.77 # 28011 258.37 245.45 282.27 27781 344.35 327.13 376.20 28020 423.32 402.15 462.47 # 27781 321.79 305.70 351.56 # 28020 310.53 295.00 339.25 27784 595.63 565.85 650.73 28022 389.08 369.63 425.07 27786 252.58 239.95 275.94 # 28022 285.65 271.37 312.08 # 27786 228.73 217.29 249.88 28024 369.11 350.65 403.25 27788 345.41 328.14 377.36 # 28024 269.86 256.37 294.83 # 27788 319.31 303.34 348.84 28035 426.09 404.79 465.51 27792 598.10 568.20 653.43 # 28035 313.96 298.26 343.00 27808 264.20 250.99 288.64 28039 421.60 400.52 460.60 # 27808 238.74 226.80 260.82 # 28039 303.99 288.79 332.11 27810 387.22 367.86 423.04 28041 399.67 379.69 436.64 # 27810 357.25 339.39 390.30 28043 303.02 287.87 331.05 27814 656.05 623.25 716.74 # 28043 235.03 223.28 256.77 27816 251.41 238.84 274.67 28045 416.63 395.80 455.17 # 27816 227.57 216.19 248.62 # 28045 308.36 292.94 336.88 27818 399.31 379.34 436.24 28046 650.55 618.02 710.72 # 27818 365.47 347.20 399.28 28047 850.11 807.60 928.74 27822 717.59 681.71 783.97 28050 368.28 349.87 402.35 27823 816.97 776.12 892.54 # 28050 265.49 252.22 290.05 27824 252.22 239.61 275.55 28052 349.66 332.18 382.01 # 27824 243.84 231.65 266.40 # 28052 247.51 235.13 270.40 27825 453.80 431.11 495.78 28054 316.77 300.93 346.07 # 27825 418.35 397.43 457.04 # 28054 219.14 208.18 239.41 27826 701.32 666.25 766.19 28055 341.42 324.35 373.00 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 21 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 418.65 397.72 457.38 # 28160 239.55 227.57 261.71 # 28060 314.25 298.54 343.32 28171 759.36 721.39 829.60 28062 488.45 464.03 533.63 28173 674.46 640.74 736.85 # 28062 366.65 348.32 400.57 28175 423.66 402.48 462.85 28070 413.92 393.22 452.20 28190 201.15 191.09 219.75 # 28070 305.33 290.06 333.57 # 28190 117.69 111.81 128.58 28072 412.08 391.48 450.20 28192 384.64 365.41 420.22 # 28072 298.01 283.11 325.58 # 28192 279.92 265.92 305.81 28080 411.41 390.84 449.47 28193 441.34 419.27 482.16 # 28080 309.90 294.41 338.57 # 28193 333.07 316.42 363.88 28086 437.95 416.05 478.46 28200 384.36 365.14 419.91 # 28086 311.32 295.75 340.11 # 28200 278.35 264.43 304.09 28088 371.94 353.34 406.34 28202 505.90 480.61 552.70 # 28088 257.54 244.66 281.36 # 28202 387.32 367.95 423.14 28090 377.30 358.44 412.21 28208 373.34 354.67 407.87 # 28090 271.29 257.73 296.39 # 28208 269.90 256.41 294.87 28092 340.98 323.93 372.52 28210 475.35 451.58 519.32 # 28092 238.19 226.28 260.22 # 28210 364.18 345.97 397.87 28100 483.61 459.43 528.34 28220 366.58 348.25 400.49 # 28100 352.46 334.84 385.07 # 28220 270.55 257.02 295.57 28102 457.86 434.97 500.22 28222 421.42 400.35 460.40 28103 376.17 357.36 410.96 # 28222 320.23 304.22 349.85 28104 416.05 395.25 454.54 28225 319.65 303.67 349.22 # 28104 306.49 291.17 334.85 # 28225 224.91 213.66 245.71 28106 401.45 381.38 438.59 28226 375.68 356.90 410.44 28107 450.28 427.77 491.94 # 28226 274.82 261.08 300.24 # 28107 328.79 312.35 359.20 28230 350.95 333.40 383.41 28108 351.27 333.71 383.77 # 28230 255.57 242.79 279.21 # 28108 253.95 241.25 277.44 28232 312.68 297.05 341.61 28110 368.50 350.08 402.59 # 28232 218.26 207.35 238.45 # 28110 253.79 241.10 277.27 28234 326.47 310.15 356.67 28111 417.27 396.41 455.87 # 28234 231.08 219.53 252.46 # 28111 296.76 281.92 324.21 28238 559.61 531.63 611.37 28112 395.90 376.11 432.53 # 28238 437.49 415.62 477.96 # 28112 277.32 263.45 302.97 28240 361.45 343.38 394.89 28113 481.71 457.62 526.26 # 28240 262.85 249.71 287.17 # 28113 370.86 352.32 405.17 28250 462.77 439.63 505.57 28114 877.80 833.91 959.00 # 28250 352.24 334.63 384.82 # 28114 720.22 684.21 786.84 28260 566.33 538.01 618.71 28116 620.48 589.46 677.88 # 28260 454.84 432.10 496.92 # 28116 502.54 477.41 549.02 28261 811.21 770.65 886.25 28118 477.74 453.85 521.93 # 28261 687.47 653.10 751.07 # 28118 360.44 342.42 393.78 28262 1,147.73 1,090.34 1,253.89 28119 425.96 404.66 465.36 # 28262 976.95 928.10 1,067.32 # 28119 318.66 302.73 348.14 28264 696.43 661.61 760.85 28120 571.24 542.68 624.08 # 28264 581.07 552.02 634.82 # 28120 444.93 422.68 486.08 28270 394.07 374.37 430.53 28122 547.35 519.98 597.98 # 28270 293.86 279.17 321.05 # 28122 440.69 418.66 481.46 28272 319.79 303.80 349.37 28124 389.64 370.16 425.68 # 28272 227.63 216.25 248.69 # 28124 293.61 278.93 320.77 28280 427.39 406.02 466.92 28126 315.90 300.11 345.13 # 28280 316.22 300.41 345.47 # 28126 220.52 209.49 240.91 28285 380.87 361.83 416.10 28130 560.38 532.36 612.21 # 28285 282.59 268.46 308.73 28140 514.60 488.87 562.20 28286 370.17 351.66 404.41 # 28140 401.18 381.12 438.29 # 28286 269.31 255.84 294.22 28150 352.13 334.52 384.70 28288 485.10 460.85 529.98 # 28150 252.56 239.93 275.92 # 28288 374.25 355.54 408.87 28153 329.37 312.90 359.84 28289 604.76 574.52 660.70 # 28153 230.76 219.22 252.10 # 28289 481.99 457.89 526.57 28160 338.16 321.25 369.44 28290 470.01 446.51 513.49 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 22 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 347.88 330.49 380.06 28450 173.44 164.77 189.49 28292 649.48 617.01 709.56 # 28450 156.04 148.24 170.48 # 28292 525.74 499.45 574.37 28455 241.89 229.80 264.27 28293 860.07 817.07 939.63 # 28455 224.49 213.27 245.26 # 28293 632.25 600.64 690.74 28456 238.97 227.02 261.07 28294 616.75 585.91 673.80 28465 526.22 499.91 574.90 # 28294 474.64 450.91 518.55 28470 171.22 162.66 187.06 28296 598.80 568.86 654.19 # 28470 155.11 147.35 169.45 # 28296 467.65 444.27 510.91 28475 215.15 204.39 235.05 28297 681.07 647.02 744.07 # 28475 197.75 187.86 216.04 # 28297 527.05 500.70 575.81 28476 282.99 268.84 309.17 28298 590.01 560.51 644.59 28485 456.41 433.59 498.63 # 28298 449.83 427.34 491.44 28490 112.67 107.04 123.10 28299 755.47 717.70 825.36 # 28490 99.14 94.18 108.31 # 28299 609.82 579.33 666.23 28495 141.19 134.13 154.25 28300 572.29 543.68 625.23 # 28495 124.43 118.21 135.94 28302 582.34 553.22 636.20 28496 338.00 321.10 369.27 28304 656.25 623.44 716.96 # 28496 190.42 180.90 208.04 # 28304 520.91 494.86 569.09 28505 550.97 523.42 601.93 28305 594.26 564.55 649.23 # 28505 427.24 405.88 466.76 28306 494.59 469.86 540.34 28510 97.81 92.92 106.86 # 28306 354.42 336.70 387.21 # 28510 95.88 91.09 104.75 28307 593.50 563.83 648.40 28515 128.14 121.73 139.99 # 28307 411.11 390.55 449.13 # 28515 117.51 111.63 128.37 28308 448.39 425.97 489.87 28525 463.37 440.20 506.23 # 28308 325.29 309.03 355.38 # 28525 339.63 322.65 371.05 28309 777.54 738.66 849.46 28530 93.12 88.46 101.73 28310 437.77 415.88 478.26 # 28530 85.39 81.12 93.29 # 28310 314.03 298.33 343.08 28531 319.70 303.72 349.28 28312 402.50 382.38 439.74 # 28531 175.66 166.88 191.91 # 28312 280.05 266.05 305.96 28540 165.51 157.23 180.81 28313 425.14 403.88 464.46 # 28540 153.91 146.21 168.14 # 28313 320.73 304.69 350.39 28545 212.47 201.85 232.13 28315 387.77 368.38 423.64 # 28545 194.75 185.01 212.76 # 28315 286.59 272.26 313.10 28546 399.13 379.17 436.05 28320 539.87 512.88 589.81 # 28546 259.28 246.32 283.27 28322 640.01 608.01 699.21 28555 719.17 683.21 785.69 # 28322 502.09 476.99 548.54 # 28555 569.65 541.17 622.35 28340 500.02 475.02 546.27 28570 139.39 132.42 152.28 # 28340 384.02 364.82 419.54 # 28570 124.56 118.33 136.08 28341 577.86 548.97 631.32 28575 278.22 264.31 303.96 # 28341 455.73 432.94 497.88 # 28575 258.89 245.95 282.84 28344 378.38 359.46 413.38 28576 307.17 291.81 335.58 # 28344 266.88 253.54 291.57 28585 771.58 733.00 842.95 28345 457.97 435.07 500.33 # 28585 638.50 606.58 697.57 # 28345 347.45 330.08 379.59 28600 173.56 164.88 189.61 28360 848.03 805.63 926.47 # 28600 155.20 147.44 169.56 28400 199.66 189.68 218.13 28605 234.21 222.50 255.88 # 28400 183.87 174.68 200.88 # 28605 217.45 206.58 237.57 28405 321.90 305.81 351.68 28606 329.59 313.11 360.08 # 28405 300.31 285.29 328.08 28615 667.81 634.42 729.58 28406 440.77 418.73 481.54 28630 123.85 117.66 135.31 28415 968.23 919.82 1,057.79 # 28630 95.17 90.41 103.97 28420 1,038.50 986.58 1,134.57 28635 144.17 136.96 157.50 28430 187.84 178.45 205.22 # 28635 116.14 110.33 126.88 # 28430 168.18 159.77 183.74 28636 239.87 227.88 262.06 28435 270.79 257.25 295.84 # 28636 171.55 162.97 187.42 # 28435 249.52 237.04 272.60 28645 524.56 498.33 573.08 28436 359.72 341.73 392.99 # 28645 414.68 393.95 453.04 28445 918.15 872.24 1,003.08 28660 91.06 86.51 99.49 28446 1,025.33 974.06 1,120.17 # 28660 73.99 70.29 80.83 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 23 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 129.87 123.38 141.89 # 29105 50.52 47.99 55.19 # 28665 116.34 110.52 127.10 29125 54.91 52.16 59.98 28666 169.33 160.86 184.99 # 29125 36.22 34.41 39.57 28675 475.82 452.03 519.83 29126 63.27 60.11 69.13 # 28675 349.18 331.72 381.48 # 29126 44.91 42.66 49.06 28705 1,131.39 1,074.82 1,236.04 29130 33.57 31.89 36.67 28715 840.64 798.61 918.40 # 29130 25.19 23.93 27.52 28725 688.10 653.70 751.76 29131 41.75 39.66 45.61 28730 725.79 689.50 792.93 # 29131 28.86 27.42 31.53 28735 691.64 657.06 755.62 29200 44.54 42.31 48.66 28737 607.85 577.46 664.08 # 29200 35.20 33.44 38.46 28740 705.09 669.84 770.32 29240 48.56 46.13 53.05 # 28740 546.23 518.92 596.76 # 29240 38.25 36.34 41.79 28750 684.72 650.48 748.05 29260 42.54 40.41 46.47 # 28750 520.38 494.36 568.51 # 29260 32.22 30.61 35.20 28755 409.59 389.11 447.48 29280 41.29 39.23 45.11 # 28755 290.36 275.84 317.22 # 29280 30.66 29.13 33.50 28760 651.51 618.93 711.77 29305 190.33 180.81 207.93 # 28760 511.34 485.77 558.64 # 29305 132.33 125.71 144.57 28800 495.65 470.87 541.50 29325 211.74 201.15 231.32 28805 668.12 634.71 729.92 # 29325 149.55 142.07 163.38 28810 385.73 366.44 421.41 29345 109.33 103.86 119.44 28820 435.43 413.66 475.71 # 29345 85.48 81.21 93.39 # 28820 303.31 288.14 331.36 29355 113.38 107.71 123.87 28825 480.29 456.28 524.72 # 29355 90.82 86.28 99.22 # 28825 353.65 335.97 386.37 29358 124.08 117.88 135.56 28890 284.67 270.44 311.01 # 29358 87.35 82.98 95.43 # 28890 197.67 187.79 215.96 29365 97.94 93.04 107.00 29000 207.70 197.32 226.92 # 29365 74.09 70.39 80.95 # 29000 138.09 131.19 150.87 29405 72.23 68.62 78.91 29010 183.32 174.15 200.27 # 29405 54.19 51.48 59.20 # 29010 122.74 116.60 134.09 29425 77.76 73.87 84.95 29015 196.61 186.78 214.80 # 29425 59.71 56.72 65.23 # 29015 135.71 128.92 148.26 29435 95.68 90.90 104.54 29020 180.18 171.17 196.85 # 29435 72.48 68.86 79.19 # 29020 117.99 112.09 128.90 29440 43.09 40.94 47.08 29025 215.34 204.57 235.26 # 29440 29.87 28.38 32.64 # 29025 149.28 141.82 163.09 29445 118.94 112.99 129.94 29035 192.52 182.89 210.32 # 29445 95.42 90.65 104.25 # 29035 117.44 111.57 128.31 29450 125.46 119.19 137.07 29040 190.19 180.68 207.78 # 29450 105.16 99.90 114.89 # 29040 132.19 125.58 144.42 29505 62.61 59.48 68.40 29044 209.75 199.26 229.15 # 29505 41.34 39.27 45.16 # 29044 136.28 129.47 148.89 29515 58.48 55.56 63.89 29046 226.97 215.62 247.96 # 29515 42.37 40.25 46.29 # 29046 154.14 146.43 168.39 29520 41.19 39.13 45.00 29049 72.52 68.89 79.22 # 29520 31.52 29.94 34.43 # 29049 53.50 50.83 58.45 29530 43.23 41.07 47.23 29055 169.34 160.87 185.00 # 29530 32.60 30.97 35.62 # 29055 113.92 108.22 124.45 29540 35.31 33.54 38.57 29058 91.67 87.09 100.15 # 29540 28.23 26.82 30.84 # 29058 70.40 66.88 76.91 29550 34.25 32.54 37.42 29065 76.16 72.35 83.20 # 29550 26.51 25.18 28.96 # 29065 56.82 53.98 62.08 29580 43.50 41.33 47.53 29075 70.72 67.18 77.26 # 29580 31.26 29.70 34.16 # 29075 51.38 48.81 56.13 29581 77.96 74.06 85.17 29085 75.33 71.56 82.29 # 29581 29.30 27.84 32.02 # 29085 55.68 52.90 60.84 29590 46.10 43.80 50.37 29086 59.00 56.05 64.46 # 29590 35.79 34.00 39.10 # 29086 41.60 39.52 45.45 29700 52.29 49.68 57.13 29105 70.18 66.67 76.67 # 29700 30.05 28.55 32.83 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 24 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 54.90 52.16 59.98 29879 558.04 530.14 609.66 # 29705 41.05 39.00 44.85 29880 582.16 553.05 636.01 29710 97.90 93.01 106.96 29881 543.60 516.42 593.88 # 29710 71.48 67.91 78.10 29882 587.90 558.51 642.29 29715 71.93 68.33 78.58 29883 713.85 678.16 779.88 # 29715 48.41 45.99 52.89 29884 521.16 495.10 569.37 29720 64.84 61.60 70.84 29885 631.62 600.04 690.05 # 29720 37.77 35.88 41.26 29886 532.85 506.21 582.14 29730 53.41 50.74 58.35 29887 628.10 596.70 686.21 # 29730 39.56 37.58 43.22 29888 844.30 802.09 922.40 29740 75.81 72.02 82.82 29889 1,036.23 984.42 1,132.08 # 29740 57.12 54.26 62.40 29891 591.36 561.79 646.06 29750 84.96 80.71 92.82 29892 619.20 588.24 676.48 # 29750 66.91 63.56 73.09 29893 497.57 472.69 543.59 29800 440.24 418.23 480.96 # 29893 373.51 354.83 408.05 29804 548.54 521.11 599.28 29894 439.44 417.47 480.09 29805 394.38 374.66 430.86 29895 423.12 401.96 462.25 29806 903.77 858.58 987.37 29897 444.05 421.85 485.13 29807 880.41 836.39 961.85 29898 496.34 471.52 542.25 29819 493.89 469.20 539.58 29899 899.01 854.06 982.17 29820 455.58 432.80 497.72 29900 367.80 349.41 401.82 29821 498.50 473.58 544.62 29901 428.27 406.86 467.89 29822 484.18 459.97 528.97 29902 481.26 457.20 525.78 29823 529.92 503.42 578.93 29904 530.06 503.56 579.09 29824 568.65 540.22 621.25 29905 571.11 542.55 623.93 29825 493.57 468.89 539.22 29906 601.42 571.35 657.05 29826 565.59 537.31 617.91 29907 732.05 695.45 799.77 29827 922.24 876.13 1,007.55 30000 188.88 179.44 206.36 29828 778.83 739.89 850.87 # 30000 100.91 95.86 110.24 29830 380.43 361.41 415.62 30020 184.69 175.46 201.78 29834 414.25 393.54 452.57 # 30020 101.55 96.47 110.94 29835 424.98 403.73 464.29 30100 115.11 109.35 125.75 29836 491.14 466.58 536.57 # 30100 60.33 57.31 65.91 29837 445.35 423.08 486.54 30110 186.33 177.01 203.56 29838 498.59 473.66 544.71 # 30110 111.89 106.30 122.25 29840 376.00 357.20 410.78 30115 361.84 343.75 395.31 29843 403.73 383.54 441.07 30117 680.79 646.75 743.76 29844 417.48 396.61 456.10 # 30117 281.54 267.46 307.58 29845 481.38 457.31 525.91 30118 658.29 625.38 719.19 29846 438.62 416.69 479.19 30120 434.60 412.87 474.80 29847 457.39 434.52 499.70 # 30120 379.50 360.53 414.61 29848 421.98 400.88 461.01 30124 231.27 219.71 252.67 29850 495.54 470.76 541.37 30125 521.95 495.85 570.23 29851 792.18 752.57 865.46 30130 315.61 299.83 344.80 29855 665.35 632.08 726.89 30140 360.65 342.62 394.01 29856 850.23 807.72 928.88 30150 667.64 634.26 729.40 29860 554.70 526.97 606.02 30160 672.61 638.98 734.83 29861 613.13 582.47 669.84 30200 92.12 87.51 100.64 29862 687.88 653.49 751.51 # 30200 51.84 49.25 56.64 29863 686.27 651.96 749.75 30210 122.20 116.09 133.50 29866 887.53 843.15 969.62 # 30210 84.50 80.28 92.32 29867 1,081.97 1,027.87 1,182.05 30220 239.42 227.45 261.57 29868 1,431.33 1,359.76 1,563.72 # 30220 107.63 102.25 117.59 29870 484.57 460.34 529.39 30300 184.30 175.09 201.35 # 29870 343.11 325.95 374.84 # 30300 103.09 97.94 112.63 29871 430.16 408.65 469.95 30310 172.22 163.61 188.15 29873 432.31 410.69 472.29 30320 380.56 361.53 415.76 29874 452.95 430.30 494.85 30400 870.47 826.95 950.99 29875 416.14 395.33 454.63 30410 1,030.38 978.86 1,125.69 29876 551.44 523.87 602.45 30420 1,173.98 1,115.28 1,282.57 29877 522.18 496.07 570.48 30430 761.89 723.80 832.37 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 25 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 994.33 944.61 1,086.30 # 31235 144.56 137.33 157.93 30450 1,328.71 1,262.27 1,451.61 31237 274.05 260.35 299.40 30460 666.26 632.95 727.89 # 31237 161.91 153.81 176.88 30462 1,292.04 1,227.44 1,411.56 31238 283.15 268.99 309.34 30465 838.22 796.31 915.76 # 31238 176.17 167.36 192.46 30520 519.26 493.30 567.30 31239 580.85 551.81 634.58 30540 574.18 545.47 627.29 31240 143.52 136.34 156.79 30545 778.11 739.20 850.08 31254 245.72 233.43 268.44 30560 218.07 207.17 238.25 31255 361.54 343.46 394.98 # 30560 116.24 110.43 126.99 31256 177.54 168.66 193.96 30580 528.25 501.84 577.12 31267 286.04 271.74 312.50 # 30580 426.42 405.10 465.87 31276 456.12 433.31 498.31 30600 484.14 459.93 528.92 31287 208.82 198.38 228.14 # 30600 376.52 357.69 411.34 31288 242.32 230.20 264.73 30620 520.19 494.18 568.31 31290 1,025.80 974.51 1,120.69 30630 530.19 503.68 579.23 31291 1,079.81 1,025.82 1,179.69 30801 183.45 174.28 200.42 31292 885.45 841.18 967.36 # 30801 111.60 106.02 121.92 31293 965.14 916.88 1,054.41 30802 238.31 226.39 260.35 31294 1,107.01 1,051.66 1,209.41 # 30802 159.68 151.70 174.46 31300 1,085.23 1,030.97 1,185.62 30901 88.14 83.73 96.29 31320 546.49 519.17 597.05 # 30901 55.59 52.81 60.73 31360 1,771.24 1,682.68 1,935.08 30903 161.35 153.28 176.27 31365 2,211.75 2,101.16 2,416.33 # 30903 72.41 68.79 79.11 31367 1,892.50 1,797.88 2,067.56 30905 200.69 190.66 219.26 31368 2,106.48 2,001.16 2,301.33 # 30905 92.41 87.79 100.96 31370 1,773.69 1,685.01 1,937.76 30906 229.95 218.45 251.22 31375 1,679.82 1,595.83 1,835.20 # 30906 120.71 114.67 131.87 31380 1,653.34 1,570.67 1,806.27 30915 494.97 470.22 540.75 31382 1,816.76 1,725.92 1,984.81 30920 714.66 678.93 780.77 31390 2,455.00 2,332.25 2,682.09 30930 103.35 98.18 112.91 31395 2,593.61 2,463.93 2,833.52 31000 146.87 139.53 160.46 31400 856.19 813.38 935.39 # 31000 89.19 84.73 97.44 31420 723.62 687.44 790.56 31002 168.87 160.43 184.49 31500 100.26 95.25 109.54 31020 394.46 374.74 430.95 31502 31.68 30.10 34.62 # 31020 294.25 279.54 321.47 31505 69.61 66.13 76.05 31030 574.61 545.88 627.76 # 31505 42.54 40.41 46.47 # 31030 440.56 418.53 481.31 31510 178.12 169.21 194.59 31032 484.27 460.06 529.07 # 31510 107.55 102.17 117.50 31040 641.08 609.03 700.38 31511 178.78 169.84 195.32 31050 416.16 395.35 454.65 # 31511 115.30 109.54 125.97 31051 545.99 518.69 596.49 31512 176.41 167.59 192.73 31070 367.22 348.86 401.19 # 31512 115.83 110.04 126.55 31075 668.45 635.03 730.28 31513 118.02 112.12 128.94 31080 866.75 823.41 946.92 31515 175.71 166.92 191.96 31081 1,093.98 1,039.28 1,195.17 # 31515 98.05 93.15 107.12 31084 1,005.52 955.24 1,098.53 31520 138.56 131.63 151.37 31085 1,140.90 1,083.86 1,246.44 31525 212.85 202.21 232.54 31086 959.63 911.65 1,048.40 # 31525 142.60 135.47 155.79 31087 940.24 893.23 1,027.21 31526 141.49 134.42 154.58 31090 856.02 813.22 935.20 31527 174.26 165.55 190.38 31200 456.08 433.28 498.27 31528 129.36 122.89 141.32 31201 621.76 590.67 679.27 31529 145.48 138.21 158.94 31205 740.82 703.78 809.35 31530 178.11 169.20 194.58 31225 1,602.52 1,522.39 1,750.75 31531 192.00 182.40 209.76 31230 1,795.63 1,705.85 1,961.73 31535 170.77 162.23 186.56 31231 156.93 149.08 171.44 31536 190.64 181.11 208.28 # 31231 67.67 64.29 73.93 31540 219.05 208.10 239.32 31233 221.33 210.26 241.80 31541 239.44 227.47 261.59 # 31233 121.76 115.67 133.02 31545 328.24 311.83 358.60 31235 253.48 240.81 276.93 31546 496.81 471.97 542.77 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 26 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 284.42 270.20 310.73 31637 71.27 67.71 77.87 31561 311.00 295.45 339.77 31638 234.14 222.43 255.79 31570 294.62 279.89 321.87 31640 236.34 224.52 258.20 # 31570 205.69 195.41 224.72 31641 236.18 224.37 258.03 31571 226.02 214.72 246.93 31643 161.11 153.05 176.01 31575 97.96 93.06 107.02 31645 265.02 251.77 289.54 # 31575 67.35 63.98 73.58 # 31645 147.40 140.03 161.03 31576 189.99 180.49 207.56 31646 240.37 228.35 262.60 # 31576 110.07 104.57 120.26 # 31646 127.58 121.20 139.38 31577 205.83 195.54 224.87 31656 267.90 254.51 292.69 # 31577 133.65 126.97 146.02 # 31656 101.95 96.85 111.38 31578 239.01 227.06 261.12 31715 50.23 47.72 54.88 # 31578 152.65 145.02 166.77 31717 247.30 234.94 270.18 31579 184.65 175.42 201.73 # 31717 99.71 94.72 108.93 # 31579 125.68 119.40 137.31 31720 47.53 45.15 51.92 31580 1,037.45 985.58 1,133.42 31725 86.31 81.99 94.29 31582 1,637.82 1,555.93 1,789.32 31730 790.19 750.68 863.28 31584 1,308.34 1,242.92 1,429.36 # 31730 134.12 127.41 146.52 31587 870.86 827.32 951.42 31750 1,155.59 1,097.81 1,262.48 31588 984.35 935.13 1,075.40 31755 1,457.34 1,384.47 1,592.14 31590 750.24 712.73 819.64 31760 1,235.72 1,173.93 1,350.02 31595 655.08 622.33 715.68 31766 1,622.83 1,541.69 1,772.94 31600 354.31 336.59 387.08 31770 1,199.67 1,139.69 1,310.64 31601 233.91 222.21 255.54 31775 1,245.12 1,182.86 1,360.29 31603 200.28 190.27 218.81 31780 1,059.34 1,006.37 1,157.33 31605 164.46 156.24 179.68 31781 1,314.14 1,248.43 1,435.69 31610 612.33 581.71 668.97 31785 964.39 916.17 1,053.60 31611 457.79 434.90 500.14 31786 1,321.67 1,255.59 1,443.93 31612 68.96 65.51 75.34 31800 600.49 570.47 656.04 # 31612 43.18 41.02 47.17 31805 739.56 702.58 807.97 31613 379.11 360.15 414.17 31820 366.30 347.99 400.19 31614 635.26 603.50 694.03 # 31820 285.42 271.15 311.82 31615 156.81 148.97 171.32 31825 513.53 487.85 561.03 # 31615 113.95 108.25 124.49 # 31825 421.69 400.61 460.70 31620 235.34 223.57 257.11 31830 368.07 349.67 402.12 # 31620 63.59 60.41 69.47 # 31830 294.60 279.87 321.85 31622 269.94 256.44 294.91 32035 631.89 600.30 690.35 # 31622 132.99 126.34 145.29 32036 684.60 650.37 747.93 31623 292.64 278.01 319.71 32095 560.66 532.63 612.52 # 31623 134.43 127.71 146.87 32100 857.35 814.48 936.65 31624 273.63 259.95 298.94 32110 1,301.26 1,236.20 1,421.63 # 31624 135.07 128.32 147.57 32120 779.15 740.19 851.22 31625 295.37 280.60 322.69 32124 827.06 785.71 903.57 # 31625 156.81 148.97 171.32 32140 886.26 841.95 968.24 31626 384.51 365.28 420.07 32141 1,368.00 1,299.60 1,494.54 # 31626 195.36 185.59 213.43 32150 892.17 847.56 974.69 31627 1,043.89 991.70 1,140.46 32151 905.39 860.12 989.14 # 31627 94.90 90.16 103.68 32160 691.38 656.81 755.33 31628 349.78 332.29 382.13 32200 1,004.82 954.58 1,097.77 # 31628 174.81 166.07 190.98 32201 781.83 742.74 854.15 31629 532.45 505.83 581.70 # 32201 190.20 180.69 207.79 # 31629 188.31 178.89 205.72 32215 714.02 678.32 780.07 31630 185.37 176.10 202.52 32220 1,425.49 1,354.22 1,557.35 31631 210.54 200.01 230.01 32225 890.38 845.86 972.74 31632 63.89 60.70 69.81 32310 820.16 779.15 896.02 # 31632 45.52 43.24 49.73 32320 1,431.70 1,360.12 1,564.14 31633 78.50 74.58 85.77 32400 132.18 125.57 144.41 # 31633 58.84 55.90 64.29 # 32400 82.24 78.13 89.85 31635 303.65 288.47 331.74 32402 504.04 478.84 550.67 # 31635 173.47 164.80 189.52 32405 92.18 87.57 100.71 31636 205.35 195.08 224.34 # 32405 91.86 87.27 100.36 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 27 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 102.86 97.72 112.38 32854 3,023.29 2,872.13 3,302.95 32421 136.94 130.09 149.60 32855 257.29 244.43 281.09 # 32421 71.52 67.94 78.13 32856 310.42 294.90 339.14 32422 173.74 165.05 189.81 32900 1,232.36 1,170.74 1,346.35 # 32422 113.49 107.82 123.99 32905 1,203.78 1,143.59 1,315.13 32440 1,420.39 1,349.37 1,551.78 32906 1,493.50 1,418.83 1,631.65 32442 2,600.56 2,470.53 2,841.11 32940 1,105.60 1,050.32 1,207.87 32445 2,956.25 2,808.44 3,229.71 32960 126.41 120.09 138.10 32480 1,341.63 1,274.55 1,465.73 # 32960 93.22 88.56 101.84 32482 1,433.92 1,362.22 1,566.55 32997 328.31 311.89 358.67 32484 1,302.53 1,237.40 1,423.01 32998 2,395.04 2,275.29 2,616.58 32486 2,122.84 2,016.70 2,319.21 # 32998 277.31 263.44 302.96 32488 2,147.86 2,040.47 2,346.54 33010 114.08 108.38 124.64 32491 1,336.77 1,269.93 1,460.42 33011 112.65 107.02 123.07 32500 1,299.88 1,234.89 1,420.12 33015 480.76 456.72 525.23 32501 225.11 213.85 245.93 33020 788.59 749.16 861.53 32503 1,633.88 1,552.19 1,785.02 33025 723.31 687.14 790.21 32504 1,872.29 1,778.68 2,045.48 33030 1,162.71 1,104.57 1,270.26 32540 1,543.13 1,465.97 1,685.87 33031 1,298.71 1,233.77 1,418.84 32550 673.08 639.43 735.34 33050 899.20 854.24 982.38 # 32550 206.80 196.46 225.93 33120 1,413.81 1,343.12 1,544.59 32551 157.51 149.63 172.07 33130 1,311.07 1,245.52 1,432.35 32552 161.66 153.58 176.62 33140 1,442.10 1,370.00 1,575.50 # 32552 143.29 136.13 156.55 33141 128.21 121.80 140.07 32553 519.32 493.35 567.35 33202 703.75 668.56 768.84 # 32553 184.84 175.60 201.94 33203 744.79 707.55 813.68 32560 226.96 215.61 247.95 33206 430.01 408.51 469.79 # 32560 78.41 74.49 85.66 33207 458.74 435.80 501.17 32561 84.96 80.71 92.82 33208 496.00 471.20 541.88 # 32561 65.30 62.04 71.35 33210 171.30 162.74 187.15 32562 75.53 71.75 82.51 33211 173.02 164.37 189.03 # 32562 58.45 55.53 63.86 33212 318.88 302.94 348.38 32601 279.46 265.49 305.31 33213 364.23 346.02 397.92 32602 302.89 287.75 330.91 33214 453.82 431.13 495.80 32603 394.22 374.51 430.69 33215 288.04 273.64 314.69 32604 440.42 418.40 481.16 33216 356.23 338.42 389.18 32605 348.46 331.04 380.70 33217 353.25 335.59 385.93 32606 421.29 400.23 460.26 33218 370.15 351.64 404.39 32650 598.78 568.84 654.17 33220 374.07 355.37 408.68 32651 971.80 923.21 1,061.69 33222 324.00 307.80 353.97 32652 1,479.70 1,405.72 1,616.58 33223 391.95 372.35 428.20 32653 938.15 891.24 1,024.93 33224 482.59 458.46 527.23 32654 1,049.49 997.02 1,146.57 33225 435.80 414.01 476.11 32655 852.18 809.57 931.01 33226 464.52 441.29 507.48 32656 717.56 681.68 783.93 33233 225.51 214.23 246.36 32657 705.81 670.52 771.10 33234 460.15 437.14 502.71 32658 644.30 612.09 703.90 33235 598.55 568.62 653.91 32659 659.12 626.16 720.08 33236 708.88 673.44 774.46 32660 940.27 893.26 1,027.25 33237 772.29 733.68 843.73 32661 720.47 684.45 787.12 33238 844.51 802.28 922.62 32662 808.67 768.24 883.48 33240 440.04 418.04 480.75 32663 1,265.36 1,202.09 1,382.40 33241 213.17 202.51 232.89 32664 761.77 723.68 832.23 33243 1,257.14 1,194.28 1,373.42 32665 1,110.59 1,055.06 1,213.32 33244 808.91 768.46 883.73 32800 824.84 783.60 901.14 33249 861.70 818.62 941.41 32810 805.81 765.52 880.35 33250 1,338.46 1,271.54 1,462.27 32815 2,485.65 2,361.37 2,715.58 33251 1,486.63 1,412.30 1,624.15 32820 1,205.33 1,145.06 1,316.82 33254 1,241.33 1,179.26 1,356.15 32851 2,320.31 2,204.29 2,534.93 33255 1,514.44 1,438.72 1,654.53 32852 2,568.56 2,440.13 2,806.15 33256 1,800.94 1,710.89 1,967.52 32853 2,765.18 2,626.92 3,020.96 33257 530.53 504.00 579.60 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 28 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 597.46 567.59 652.73 33512 2,229.19 2,117.73 2,435.39 33259 770.86 732.32 842.17 33513 2,281.41 2,167.34 2,492.44 33261 1,479.95 1,405.95 1,616.84 33514 2,422.11 2,301.00 2,646.15 33265 1,234.88 1,173.14 1,349.11 33516 2,512.88 2,387.24 2,745.33 33266 1,690.06 1,605.56 1,846.39 33517 173.06 164.41 189.07 33282 305.58 290.30 333.85 33518 378.23 359.32 413.22 33284 219.49 208.52 239.80 33519 501.79 476.70 548.21 33300 2,193.65 2,083.97 2,396.57 33521 604.14 573.93 660.02 33305 3,517.90 3,342.01 3,843.31 33522 681.28 647.22 744.30 33310 1,060.80 1,007.76 1,158.92 33523 774.29 735.58 845.92 33315 1,353.76 1,286.07 1,478.98 33530 482.29 458.18 526.91 33320 966.83 918.49 1,056.26 33533 1,738.71 1,651.77 1,899.54 33321 1,079.66 1,025.68 1,179.53 33534 2,039.60 1,937.62 2,228.26 33322 1,269.78 1,206.29 1,387.23 33535 2,271.91 2,158.31 2,482.06 33330 1,306.95 1,241.60 1,427.84 33536 2,440.55 2,318.52 2,666.30 33332 1,275.11 1,211.35 1,393.05 33542 2,387.09 2,267.74 2,607.90 33335 1,724.85 1,638.61 1,884.40 33545 2,809.01 2,668.56 3,068.84 33400 2,095.70 1,990.92 2,289.56 33548 2,734.17 2,597.46 2,987.08 33401 1,330.90 1,264.36 1,454.01 33572 214.67 203.94 234.53 33403 1,368.07 1,299.67 1,494.62 33600 1,552.52 1,474.89 1,696.12 33404 1,616.54 1,535.71 1,766.07 33602 1,504.66 1,429.43 1,643.84 33405 2,109.00 2,003.55 2,304.08 33606 1,624.24 1,543.03 1,774.48 33406 2,640.56 2,508.53 2,884.81 33608 1,645.47 1,563.20 1,797.68 33410 2,334.18 2,217.47 2,550.09 33610 1,611.78 1,531.19 1,760.87 33411 2,894.34 2,749.62 3,162.06 33611 1,794.11 1,704.40 1,960.06 33412 2,261.60 2,148.52 2,470.80 33612 1,821.33 1,730.26 1,989.80 33413 2,796.91 2,657.06 3,055.62 33615 1,835.24 1,743.48 2,005.00 33414 1,989.65 1,890.17 2,173.70 33617 1,958.49 1,860.57 2,139.66 33415 1,851.41 1,758.84 2,022.67 33619 2,426.86 2,305.52 2,651.35 33416 1,853.33 1,760.66 2,024.76 33641 1,491.63 1,417.05 1,629.61 33417 1,529.25 1,452.79 1,670.71 33645 1,445.45 1,373.18 1,579.16 33420 1,268.21 1,204.80 1,385.52 33647 1,619.72 1,538.73 1,769.54 33422 1,539.55 1,462.57 1,681.96 33660 1,607.77 1,527.38 1,756.49 33425 2,472.25 2,348.64 2,700.94 33665 1,840.45 1,748.43 2,010.69 33426 2,195.32 2,085.55 2,398.38 33670 1,818.20 1,727.29 1,986.38 33427 2,265.19 2,151.93 2,474.72 33675 1,805.64 1,715.36 1,972.66 33430 2,565.69 2,437.41 2,803.02 33676 1,797.42 1,707.55 1,963.68 33460 2,307.72 2,192.33 2,521.18 33677 1,867.81 1,774.42 2,040.58 33463 2,802.07 2,661.97 3,061.27 33681 1,676.02 1,592.22 1,831.05 33464 2,228.05 2,116.65 2,434.15 33684 1,813.03 1,722.38 1,980.74 33465 2,503.51 2,378.33 2,735.08 33688 1,719.19 1,633.23 1,878.21 33468 1,712.34 1,626.72 1,870.73 33690 1,072.90 1,019.26 1,172.15 33470 1,123.85 1,067.66 1,227.81 33692 1,546.01 1,468.71 1,689.02 33471 1,156.75 1,098.91 1,263.75 33694 1,800.88 1,710.84 1,967.47 33472 1,160.87 1,102.83 1,268.25 33697 1,940.05 1,843.05 2,119.51 33474 1,931.32 1,834.75 2,109.96 33702 1,404.52 1,334.29 1,534.43 33475 2,133.42 2,026.75 2,330.76 33710 1,648.19 1,565.78 1,800.65 33476 1,370.11 1,301.60 1,496.84 33720 1,408.77 1,338.33 1,539.08 33478 1,433.87 1,362.18 1,566.51 33722 1,476.72 1,402.88 1,613.31 33496 1,532.07 1,455.47 1,673.79 33724 1,420.92 1,349.87 1,552.35 33500 1,439.69 1,367.71 1,572.87 33726 1,877.23 1,783.37 2,050.88 33501 1,018.74 967.80 1,112.97 33730 1,803.10 1,712.95 1,969.89 33502 1,157.34 1,099.47 1,264.39 33732 1,504.54 1,429.31 1,643.71 33503 1,236.16 1,174.35 1,350.50 33735 1,168.80 1,110.36 1,276.91 33504 1,326.27 1,259.96 1,448.95 33736 1,278.93 1,214.98 1,397.23 33505 1,883.86 1,789.67 2,058.12 33737 1,176.55 1,117.72 1,285.38 33506 1,879.52 1,785.54 2,053.37 33750 1,289.14 1,224.68 1,408.38 33507 1,582.31 1,503.19 1,728.67 33755 1,167.14 1,108.78 1,275.10 33508 14.87 14.13 16.25 33762 1,130.69 1,074.16 1,235.28 33510 1,795.77 1,705.98 1,961.88 33764 1,175.39 1,116.62 1,284.11 33511 1,967.51 1,869.13 2,149.50 33766 1,241.50 1,179.43 1,356.34 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 29 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,287.64 1,223.26 1,406.75 33971 655.05 622.30 715.65 33768 374.71 355.97 409.37 33973 487.59 463.21 532.69 33770 1,962.34 1,864.22 2,143.85 33974 830.65 789.12 907.49 33771 1,930.15 1,833.64 2,108.69 33975 1,014.63 963.90 1,108.49 33774 1,645.80 1,563.51 1,798.04 33976 1,126.04 1,069.74 1,230.20 33775 1,642.37 1,560.25 1,794.29 33977 1,099.65 1,044.67 1,201.37 33776 1,733.75 1,647.06 1,894.12 33978 1,213.26 1,152.60 1,325.49 33777 1,686.01 1,601.71 1,841.97 33979 2,217.46 2,106.59 2,422.58 33778 2,084.79 1,980.55 2,277.63 33980 3,130.84 2,974.30 3,420.45 33779 2,071.05 1,967.50 2,262.63 34001 902.56 857.43 986.04 33780 2,214.07 2,103.37 2,418.88 34051 895.24 850.48 978.05 33781 2,051.34 1,948.77 2,241.09 34101 566.95 538.60 619.39 33782 2,752.06 2,614.46 3,006.63 34111 567.09 538.74 619.55 33783 2,989.20 2,839.74 3,265.70 34151 1,310.41 1,244.89 1,431.62 33786 2,019.20 1,918.24 2,205.98 34201 956.16 908.35 1,044.60 33788 1,357.37 1,289.50 1,482.93 34203 905.76 860.47 989.54 33800 890.90 846.36 973.31 34401 1,347.75 1,280.36 1,472.41 33802 968.35 919.93 1,057.92 34421 688.62 654.19 752.32 33803 1,036.75 984.91 1,132.65 34451 1,402.20 1,332.09 1,531.90 33813 1,159.14 1,101.18 1,266.36 34471 1,046.93 994.58 1,143.77 33814 1,388.80 1,319.36 1,517.26 34490 569.77 541.28 622.47 33820 888.13 843.72 970.28 34501 871.54 827.96 952.15 33822 902.22 857.11 985.68 34502 1,420.01 1,349.01 1,551.36 33824 1,073.51 1,019.83 1,172.80 34510 1,017.87 966.98 1,112.03 33840 1,101.63 1,046.55 1,203.53 34520 961.78 913.69 1,050.74 33845 1,239.31 1,177.34 1,353.94 34530 932.36 885.74 1,018.60 33851 1,146.92 1,089.57 1,253.01 34800 1,072.91 1,019.26 1,172.15 33852 1,333.00 1,266.35 1,456.30 34802 1,182.40 1,123.28 1,291.77 33853 1,785.57 1,696.29 1,950.73 34803 1,221.00 1,159.95 1,333.94 33860 2,752.65 2,615.02 3,007.27 34804 1,183.43 1,124.26 1,292.90 33861 2,226.08 2,114.78 2,432.00 34805 1,118.97 1,063.02 1,222.47 33863 2,719.85 2,583.86 2,971.44 34806 97.99 93.09 107.05 33864 2,796.68 2,656.85 3,055.38 34808 193.73 184.04 211.65 33870 2,320.37 2,204.35 2,535.00 34812 317.48 301.61 346.85 33875 1,806.48 1,716.16 1,973.58 34813 224.27 213.06 245.02 33877 3,134.83 2,978.09 3,424.80 34820 458.61 435.68 501.03 33880 1,699.89 1,614.90 1,857.14 34825 661.51 628.43 722.69 33881 1,459.92 1,386.92 1,594.96 34826 195.31 185.54 213.37 33883 1,055.78 1,002.99 1,153.44 34830 1,712.40 1,626.78 1,870.80 33884 386.07 366.77 421.79 34831 1,821.83 1,730.74 1,990.35 33886 906.89 861.55 990.78 34832 1,840.84 1,748.80 2,011.12 33889 746.72 709.38 815.79 34833 575.11 546.35 628.30 33891 935.26 888.50 1,021.78 34834 260.14 247.13 284.20 33910 1,528.05 1,451.65 1,669.40 34900 851.42 808.85 930.18 33915 1,249.31 1,186.84 1,364.87 35001 1,062.98 1,009.83 1,161.30 33916 1,505.46 1,430.19 1,644.72 35002 1,132.48 1,075.86 1,237.24 33917 1,352.42 1,284.80 1,477.52 35005 983.85 934.66 1,074.86 33920 1,659.89 1,576.90 1,813.44 35011 933.18 886.52 1,019.50 33922 1,262.39 1,199.27 1,379.16 35013 1,161.22 1,103.16 1,268.63 33924 262.33 249.21 286.59 35021 1,137.07 1,080.22 1,242.25 33925 1,589.94 1,510.44 1,737.01 35022 1,292.79 1,228.15 1,412.37 33926 2,189.07 2,079.62 2,391.56 35045 909.73 864.24 993.88 33933 355.82 338.03 388.73 35081 1,645.76 1,563.47 1,797.99 33935 2,989.05 2,839.60 3,265.54 35082 2,054.02 1,951.32 2,244.02 33944 250.75 238.21 273.94 35091 1,709.64 1,624.16 1,867.78 33945 4,204.75 3,994.51 4,593.69 35092 2,458.25 2,335.34 2,685.64 33960 911.06 865.51 995.34 35102 1,782.08 1,692.98 1,946.93 33961 512.49 486.87 559.90 35103 2,116.90 2,011.06 2,312.72 33967 251.43 238.86 274.69 35111 1,315.51 1,249.73 1,437.19 33968 32.37 30.75 35.36 35112 1,616.46 1,535.64 1,765.99 33970 336.20 319.39 367.30 35121 1,546.24 1,468.93 1,689.27 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 30 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,872.73 1,779.09 2,045.95 35472 1,840.95 1,748.90 2,011.24 35131 1,313.64 1,247.96 1,435.15 # 35472 345.78 328.49 377.76 35132 1,596.10 1,516.30 1,743.75 35473 1,755.74 1,667.95 1,918.14 35141 1,043.61 991.43 1,140.14 # 35473 305.04 289.79 333.26 35142 1,251.72 1,189.13 1,367.50 35474 2,323.70 2,207.52 2,538.65 35151 1,178.46 1,119.54 1,287.47 # 35474 369.67 351.19 403.87 35152 1,362.77 1,294.63 1,488.82 35475 1,953.49 1,855.82 2,134.19 35180 800.99 760.94 875.08 # 35475 463.15 439.99 505.99 35182 1,616.84 1,536.00 1,766.40 35476 1,468.64 1,395.21 1,604.49 35184 957.83 909.94 1,046.43 # 35476 295.38 280.61 322.70 35188 799.24 759.28 873.17 35480 528.48 502.06 577.37 35189 1,495.77 1,420.98 1,634.13 35481 375.63 356.85 410.38 35190 696.11 661.30 760.50 35482 327.25 310.89 357.52 35201 870.83 827.29 951.38 35483 397.83 377.94 434.63 35206 712.30 676.69 778.19 35484 498.65 473.72 544.78 35207 642.07 609.97 701.47 35485 462.58 439.45 505.37 35211 1,268.63 1,205.20 1,385.98 35490 578.31 549.39 631.80 35216 1,825.87 1,734.58 1,994.77 35491 389.66 370.18 425.71 35221 1,310.53 1,245.00 1,431.75 35492 351.90 334.31 384.46 35226 784.48 745.26 857.05 35493 427.05 405.70 466.56 35231 1,090.66 1,036.13 1,191.55 35494 544.58 517.35 594.95 35236 910.69 865.16 994.93 35495 495.18 470.42 540.98 35241 1,321.38 1,255.31 1,443.61 35500 303.45 288.28 331.52 35246 1,415.59 1,344.81 1,546.53 35501 1,468.32 1,394.90 1,604.14 35251 1,555.62 1,477.84 1,699.52 35506 1,261.58 1,198.50 1,378.28 35256 956.27 908.46 1,044.73 35508 1,317.41 1,251.54 1,439.27 35261 973.11 924.45 1,063.12 35509 1,406.51 1,336.18 1,536.61 35266 804.13 763.92 878.51 35510 1,202.12 1,142.01 1,313.31 35271 1,269.04 1,205.59 1,386.43 35511 1,128.87 1,072.43 1,233.29 35276 1,321.82 1,255.73 1,444.09 35512 1,172.85 1,114.21 1,281.34 35281 1,483.87 1,409.68 1,621.13 35515 1,278.99 1,215.04 1,397.30 35286 878.77 834.83 960.05 35516 1,163.90 1,105.71 1,271.57 35301 986.08 936.78 1,077.30 35518 1,123.00 1,066.85 1,226.88 35302 1,050.60 998.07 1,147.78 35521 1,190.59 1,131.06 1,300.72 35303 1,156.69 1,098.86 1,263.69 35522 1,154.02 1,096.32 1,260.77 35304 1,202.30 1,142.19 1,313.52 35523 1,218.01 1,157.11 1,330.68 35305 1,155.40 1,097.63 1,262.27 35525 1,076.63 1,022.80 1,176.22 35306 428.56 407.13 468.20 35526 1,581.70 1,502.62 1,728.01 35311 1,419.41 1,348.44 1,550.71 35531 1,908.47 1,813.05 2,085.01 35321 838.91 796.96 916.50 35533 1,502.11 1,427.00 1,641.05 35331 1,380.98 1,311.93 1,508.72 35535 1,808.52 1,718.09 1,975.80 35341 1,295.56 1,230.78 1,415.40 35536 1,634.95 1,553.20 1,786.18 35351 1,211.52 1,150.94 1,323.58 35537 2,025.35 1,924.08 2,212.69 35355 984.45 935.23 1,075.51 35538 2,273.68 2,160.00 2,484.00 35361 1,480.12 1,406.11 1,617.03 35539 2,113.52 2,007.84 2,309.02 35363 1,618.42 1,537.50 1,768.13 35540 2,381.14 2,262.08 2,601.39 35371 773.88 735.19 845.47 35548 1,125.97 1,069.67 1,230.12 35372 927.59 881.21 1,013.39 35549 1,210.92 1,150.37 1,322.93 35390 151.08 143.53 165.06 35551 1,408.38 1,337.96 1,538.65 35400 142.34 135.22 155.50 35556 1,318.59 1,252.66 1,440.56 35450 485.08 460.83 529.95 35558 1,157.96 1,100.06 1,265.07 35452 336.28 319.47 367.39 35560 1,676.86 1,593.02 1,831.97 35454 293.42 278.75 320.56 35563 1,310.32 1,244.80 1,431.52 35456 356.34 338.52 389.30 35565 1,247.86 1,185.47 1,363.29 35458 459.04 436.09 501.50 35566 1,579.01 1,500.06 1,725.07 35459 419.14 398.18 457.91 35570 1,401.30 1,331.24 1,530.93 35460 292.89 278.25 319.99 35571 1,264.32 1,201.10 1,381.27 35470 2,397.12 2,277.26 2,618.85 35572 327.06 310.71 357.32 # 35470 432.13 410.52 472.10 35583 1,362.59 1,294.46 1,488.63 35471 2,599.15 2,469.19 2,839.57 35585 1,586.18 1,506.87 1,732.90 # 35471 514.93 489.18 562.56 35587 1,302.61 1,237.48 1,423.10 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 31 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 240.71 228.67 262.97 # 36002 101.09 96.04 110.45 35601 1,367.21 1,298.85 1,493.68 36005 292.40 277.78 319.45 35606 1,113.19 1,057.53 1,216.16 # 36005 46.53 44.20 50.83 35612 859.86 816.87 939.40 36010 493.84 469.15 539.52 35616 1,086.24 1,031.93 1,186.72 # 36010 115.54 109.76 126.22 35621 1,043.15 990.99 1,139.64 36011 792.66 753.03 865.98 35623 1,275.28 1,211.52 1,393.25 # 36011 149.48 142.01 163.31 35626 1,465.88 1,392.59 1,601.48 36012 759.03 721.08 829.24 35631 1,750.23 1,662.72 1,912.13 # 36012 169.34 160.87 185.00 35632 1,716.66 1,630.83 1,875.45 36013 689.47 655.00 753.25 35633 1,853.23 1,760.57 2,024.66 # 36013 121.37 115.30 132.60 35634 1,680.44 1,596.42 1,835.88 36014 724.24 688.03 791.23 35636 1,550.98 1,473.43 1,694.44 # 36014 145.51 138.23 158.96 35637 1,617.18 1,536.32 1,766.77 36015 791.05 751.50 864.23 35638 1,649.72 1,567.23 1,802.31 # 36015 168.17 159.76 183.72 35642 969.99 921.49 1,059.71 36100 459.44 436.47 501.94 35645 931.94 885.34 1,018.14 # 36100 150.41 142.89 164.32 35646 1,625.50 1,544.23 1,775.86 36120 385.14 365.88 420.76 35647 1,469.97 1,396.47 1,605.94 # 36120 94.48 89.76 103.22 35650 1,005.85 955.56 1,098.89 36140 417.78 396.89 456.42 35651 1,315.77 1,249.98 1,437.48 # 36140 97.80 92.91 106.85 35654 1,299.28 1,234.32 1,419.47 36147 689.77 655.28 753.57 35656 1,022.37 971.25 1,116.94 # 36147 174.19 165.48 190.30 35661 1,026.55 975.22 1,121.50 36148 216.94 206.09 237.00 35663 1,190.09 1,130.59 1,300.18 # 36148 46.48 44.16 50.78 35665 1,113.26 1,057.60 1,216.24 36160 456.08 433.28 498.27 35666 1,200.84 1,140.80 1,311.92 # 36160 122.88 116.74 134.25 35671 1,058.30 1,005.39 1,156.20 36200 563.10 534.95 615.19 35681 75.80 72.01 82.81 # 36200 145.80 138.51 159.29 35682 337.10 320.25 368.29 36215 992.03 942.43 1,083.79 35683 397.15 377.29 433.88 # 36215 231.23 219.67 252.62 35685 189.52 180.04 207.05 36216 1,085.82 1,031.53 1,186.26 35686 158.25 150.34 172.89 # 36216 260.89 247.85 285.03 35691 921.96 875.86 1,007.24 36217 1,757.45 1,669.58 1,920.02 35693 815.93 775.13 891.40 # 36217 309.97 294.47 338.64 35694 956.12 908.31 1,044.56 36218 165.76 157.47 181.09 35695 995.63 945.85 1,087.73 # 36218 49.44 46.97 54.02 35697 141.37 134.30 154.45 36245 1,070.58 1,017.05 1,169.61 35700 145.30 138.04 158.75 # 36245 236.63 224.80 258.52 35701 501.21 476.15 547.57 36246 1,069.27 1,015.81 1,168.18 35721 422.76 401.62 461.86 # 36246 258.85 245.91 282.80 35741 466.98 443.63 510.17 36247 1,673.19 1,589.53 1,827.96 35761 345.92 328.62 377.91 # 36247 308.52 293.09 337.05 35800 444.87 422.63 486.02 36248 142.24 135.13 155.40 35820 1,807.14 1,716.78 1,974.30 # 36248 49.44 46.97 54.02 35840 582.21 553.10 636.07 36260 538.20 511.29 587.98 35860 377.06 358.21 411.94 36261 324.58 308.35 354.60 35870 1,206.76 1,146.42 1,318.38 36262 249.06 236.61 272.10 35875 557.37 529.50 608.93 36400 24.07 22.87 26.30 35876 891.45 846.88 973.91 # 36400 17.30 16.44 18.91 35879 875.69 831.91 956.70 36405 21.96 20.86 23.99 35881 970.19 921.68 1,059.93 # 36405 14.87 14.13 16.25 35883 1,131.77 1,075.18 1,236.46 36406 15.63 14.85 17.08 35884 1,188.65 1,129.22 1,298.60 # 36406 8.54 8.11 9.33 35901 467.61 444.23 510.86 36410 16.92 16.07 18.48 35903 526.83 500.49 575.56 # 36410 8.21 7.80 8.97 35905 1,633.07 1,551.42 1,784.13 36420 46.18 43.87 50.45 35907 1,810.23 1,719.72 1,977.68 36425 35.86 34.07 39.18 36000 21.75 20.66 23.76 36430 29.50 28.03 32.23 # 36000 8.86 8.42 9.68 36440 48.94 46.49 53.46 36002 148.46 141.04 162.20 36450 105.75 100.46 115.53 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 32 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 116.92 111.07 127.73 # 36578 197.95 188.05 216.26 36460 313.37 297.70 342.36 36580 195.33 185.56 213.39 36470 122.05 115.95 133.34 # 36580 62.57 59.44 68.36 # 36470 63.73 60.54 69.62 36581 654.31 621.59 714.83 36471 150.62 143.09 164.55 # 36581 185.78 176.49 202.96 # 36471 90.36 85.84 98.72 36582 929.39 882.92 1,015.36 36475 1,548.38 1,470.96 1,691.60 # 36582 279.76 265.77 305.64 # 36475 324.85 308.61 354.90 36583 980.55 931.52 1,071.25 36476 341.99 324.89 373.62 # 36583 287.42 273.05 314.01 # 36476 159.61 151.63 174.37 36584 189.69 180.21 207.24 36478 1,267.29 1,203.93 1,384.52 # 36584 63.05 59.90 68.89 # 36478 325.72 309.43 355.84 36585 938.94 891.99 1,025.79 36479 354.14 336.43 386.89 # 36585 259.03 246.08 282.99 # 36479 159.51 151.53 174.26 36589 149.03 141.58 162.82 36481 719.61 683.63 786.17 # 36589 127.12 120.76 138.87 # 36481 331.32 314.75 361.96 36590 245.12 232.86 267.79 36500 170.34 161.82 186.09 # 36590 180.99 171.94 197.73 36510 93.70 89.02 102.37 36591 19.19 18.23 20.96 # 36510 53.75 51.06 58.72 36592 21.12 20.06 23.07 36511 85.04 80.79 92.91 36593 23.38 22.21 25.54 36512 84.44 80.22 92.25 36595 517.42 491.55 565.28 36513 87.54 83.16 95.63 # 36595 177.14 168.28 193.52 36514 441.11 419.05 481.91 36596 117.18 111.32 128.02 # 36514 83.75 79.56 91.49 # 36596 41.78 39.69 45.64 36515 1,640.76 1,558.72 1,792.53 36597 111.59 106.01 121.91 # 36515 82.43 78.31 90.06 # 36597 58.75 55.81 64.18 36516 1,818.44 1,727.52 1,986.65 36598 98.76 93.82 107.89 # 36516 60.64 57.61 66.25 # 36598 50.10 47.60 54.74 36522 1,149.58 1,092.10 1,255.92 36600 26.93 25.58 29.42 # 36522 92.00 87.40 100.51 # 36600 14.04 13.34 15.34 36555 235.22 223.46 256.98 36620 46.96 44.61 51.30 # 36555 116.00 110.20 126.73 36625 97.44 92.57 106.46 36556 204.94 194.69 223.89 36640 110.30 104.79 120.51 # 36556 111.81 106.22 122.15 36660 62.38 59.26 68.15 36557 764.71 726.47 835.44 36680 54.63 51.90 59.69 # 36557 280.07 266.07 305.98 36800 143.99 136.79 157.31 36558 698.15 663.24 762.73 36810 193.78 184.09 211.70 # 36558 258.63 245.70 282.56 36815 136.40 129.58 149.02 36560 959.86 911.87 1,048.65 36818 615.65 584.87 672.60 # 36560 318.29 302.38 347.74 36819 733.11 696.45 800.92 36561 1,000.25 950.24 1,092.78 36820 736.62 699.79 804.76 # 36561 317.75 301.86 347.14 36821 624.93 593.68 682.73 36563 1,028.08 976.68 1,123.18 36822 341.48 324.41 373.07 # 36563 328.50 312.08 358.89 36823 1,179.46 1,120.49 1,288.56 36565 851.78 809.19 930.57 36825 721.00 684.95 787.69 # 36565 315.58 299.80 344.77 36830 605.57 575.29 661.58 36566 3,424.29 3,253.08 3,741.04 36831 418.94 397.99 457.69 # 36566 338.56 321.63 369.87 36832 534.42 507.70 583.86 36568 262.30 249.19 286.57 36833 603.66 573.48 659.50 # 36568 89.58 85.10 97.87 36835 426.46 405.14 465.91 36569 227.89 216.50 248.98 36838 1,078.69 1,024.76 1,178.47 # 36569 87.40 83.03 95.48 36860 172.72 164.08 188.69 36570 986.12 936.81 1,077.33 # 36860 96.35 91.53 105.26 # 36570 281.71 267.62 307.76 36861 137.98 131.08 150.74 36571 1,065.93 1,012.63 1,164.52 36870 1,584.49 1,505.27 1,731.06 # 36571 284.83 270.59 311.18 # 36870 282.98 268.83 309.15 36575 136.64 129.81 149.28 37140 1,275.07 1,211.32 1,393.02 # 36575 32.56 30.93 35.57 37145 1,342.46 1,275.34 1,466.64 36576 322.11 306.00 351.90 37160 1,176.36 1,117.54 1,285.17 # 36576 175.50 166.73 191.74 37180 1,315.09 1,249.34 1,436.74 36578 441.23 419.17 482.05 37181 1,422.89 1,351.75 1,554.51 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 99 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 819.31 778.34 895.09 38101 980.32 931.30 1,071.00 37183 4,410.27 4,189.76 4,818.22 38102 227.86 216.47 248.94 # 37183 388.77 369.33 424.73 38115 1,082.60 1,028.47 1,182.74 37184 2,059.86 1,956.87 2,250.40 38120 890.49 845.97 972.87 # 37184 429.67 408.19 469.42 38200 132.18 125.57 144.41 37185 682.68 648.55 745.83 38205 73.61 69.93 80.42 # 37185 159.05 151.10 173.77 38206 73.47 69.80 80.27 37186 1,367.90 1,299.51 1,494.44 38220 131.25 124.69 143.39 # 37186 243.30 231.14 265.81 # 38220 55.52 52.74 60.65 37187 1,970.51 1,871.98 2,152.78 38221 144.65 137.42 158.03 # 37187 394.78 375.04 431.30 # 38221 69.25 65.79 75.66 37188 1,660.55 1,577.52 1,814.15 38230 288.87 274.43 315.59 # 37188 283.96 269.76 310.22 38240 113.40 107.73 123.89 37195 294.68 279.95 321.94 38241 113.87 108.18 124.41 37200 217.59 206.71 237.72 38242 86.56 82.23 94.56 37201 261.14 248.08 285.29 38300 226.92 215.57 247.91 37202 315.35 299.58 344.52 # 38300 155.71 147.92 170.11 37203 1,154.82 1,097.08 1,261.64 38305 393.90 374.21 430.34 # 37203 250.63 238.10 273.82 38308 381.00 361.95 416.24 37204 865.05 821.80 945.07 38380 491.81 467.22 537.30 37205 3,652.27 3,469.66 3,990.11 38381 717.55 681.67 783.92 # 37205 413.48 392.81 451.73 38382 592.91 563.26 647.75 37206 2,197.76 2,087.87 2,401.05 38500 269.43 255.96 294.35 # 37206 202.80 192.66 221.56 # 38500 213.36 202.69 233.09 37207 400.77 380.73 437.84 38505 108.84 103.40 118.91 37208 193.90 184.21 211.84 # 38505 65.98 62.68 72.08 37209 108.52 103.09 118.55 38510 436.46 414.64 476.84 37210 3,040.33 2,888.31 3,321.56 # 38510 362.66 344.53 396.21 # 37210 514.33 488.61 561.90 38520 396.48 376.66 433.16 37215 1,041.40 989.33 1,137.73 38525 361.73 343.64 395.19 37250 103.25 98.09 112.80 38530 461.75 438.66 504.46 37251 76.74 72.90 83.84 38542 447.83 425.44 489.26 37500 635.01 603.26 693.75 38550 414.36 393.64 452.69 37565 638.47 606.55 697.53 38555 852.29 809.68 931.13 37600 647.74 615.35 707.65 38562 607.60 577.22 663.80 37605 736.81 699.97 804.97 38564 606.01 575.71 662.07 37606 484.43 460.21 529.24 38570 481.79 457.70 526.36 37607 342.77 325.63 374.47 38571 750.95 713.40 820.41 37609 258.40 245.48 282.30 38572 838.99 797.04 916.60 # 37609 179.13 170.17 195.70 38700 699.85 664.86 764.59 37615 437.04 415.19 477.47 38720 1,167.08 1,108.73 1,275.04 37616 988.55 939.12 1,079.99 38724 1,264.33 1,201.11 1,381.28 37617 1,181.19 1,122.13 1,290.45 38740 578.68 549.75 632.21 37618 343.63 326.45 375.42 38745 735.59 698.81 803.63 37620 606.82 576.48 662.95 38746 235.19 223.43 256.94 37650 462.55 439.42 505.33 38747 232.31 220.69 253.79 37660 1,118.60 1,062.67 1,222.07 38760 719.98 683.98 786.58 37700 227.68 216.30 248.75 38765 1,118.38 1,062.46 1,221.83 37718 394.35 374.63 430.82 38770 731.49 694.92 799.16 37722 439.71 417.72 480.38 38780 926.58 880.25 1,012.29 37735 574.36 545.64 627.49 38790 73.25 69.59 80.03 37760 574.90 546.16 628.08 38792 35.08 33.33 38.33 37761 514.83 489.09 562.45 38794 272.36 258.74 297.55 37765 417.53 396.65 456.15 39000 436.18 414.37 476.53 37766 511.38 485.81 558.68 39010 715.11 679.35 781.25 37780 234.90 223.16 256.63 39200 792.70 753.07 866.03 37785 312.56 296.93 341.47 39220 1,024.44 973.22 1,119.20 # 37785 235.55 223.77 257.34 39400 450.49 427.97 492.17 37788 1,256.35 1,193.53 1,372.56 39501 733.46 696.79 801.31 37790 448.58 426.15 490.07 39502 884.07 839.87 965.85 38100 975.85 927.06 1,066.12 39503 5,051.27 4,798.71 5,518.52 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 34 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 875.59 831.81 956.58 40840 674.58 640.85 736.98 39530 841.39 799.32 919.22 # 40840 539.56 512.58 589.47 39531 884.42 840.20 966.23 40842 680.38 646.36 743.31 39540 751.10 713.55 820.58 # 40842 541.17 514.11 591.23 39541 812.69 772.06 887.87 40843 879.49 835.52 960.85 39545 794.06 754.36 867.51 # 40843 701.30 666.24 766.18 39560 688.79 654.35 752.50 40844 1,160.11 1,102.10 1,267.42 39561 1,079.10 1,025.15 1,178.92 # 40844 972.24 923.63 1,062.17 40490 109.25 103.79 119.36 40845 1,260.12 1,197.11 1,376.68 # 40490 65.75 62.46 71.83 # 40845 1,085.79 1,031.50 1,186.23 40500 418.08 397.18 456.76 41000 132.77 126.13 145.05 # 40500 311.10 295.55 339.88 # 41000 95.40 90.63 104.22 40510 403.23 383.07 440.53 41005 185.52 176.24 202.68 # 40510 306.23 290.92 334.56 # 41005 107.86 102.47 117.84 40520 412.38 391.76 450.52 41006 298.82 283.88 326.46 # 40520 308.95 293.50 337.53 # 41006 220.84 209.80 241.27 40525 479.38 455.41 523.72 41007 298.29 283.38 325.89 40527 559.35 531.38 611.09 # 41007 214.84 204.10 234.72 40530 457.06 434.21 499.34 41008 307.35 291.98 335.78 # 40530 351.37 333.80 383.87 # 41008 228.41 216.99 249.54 40650 344.97 327.72 376.88 41009 326.70 310.37 356.93 # 40650 247.98 235.58 270.92 # 41009 248.07 235.67 271.02 40652 404.40 384.18 441.81 41010 166.62 158.29 182.03 # 40652 300.64 285.61 328.45 # 41010 93.48 88.81 102.13 40654 476.17 452.36 520.21 41015 352.17 334.56 384.74 # 40654 364.35 346.13 398.05 # 41015 286.76 272.42 313.28 40700 809.78 769.29 884.68 41016 359.07 341.12 392.29 40701 984.96 935.71 1,076.07 # 41016 295.91 281.11 323.28 40702 755.12 717.36 824.96 41017 363.26 345.10 396.87 40720 865.74 822.45 945.82 # 41017 296.88 282.04 324.35 40761 930.52 883.99 1,016.59 41018 414.47 393.75 452.81 40800 166.63 158.30 182.05 # 41018 347.44 330.07 379.58 # 40800 107.99 102.59 117.98 41019 436.29 414.48 476.65 40801 255.92 243.12 279.59 41100 139.57 132.59 152.48 # 40801 187.28 177.92 204.61 # 41100 94.14 89.43 102.84 40804 171.32 162.75 187.16 41105 140.84 133.80 153.87 # 40804 110.09 104.59 120.28 # 41105 96.37 91.55 105.28 40805 265.31 252.04 289.85 41108 120.84 114.80 132.02 # 40805 194.41 184.69 212.39 # 41108 77.34 73.47 84.49 40806 84.44 80.22 92.25 41110 173.61 164.93 189.67 # 40806 28.37 26.95 30.99 # 41110 112.71 107.07 123.13 40808 149.12 141.66 162.91 41112 273.78 260.09 299.10 # 40808 90.47 85.95 98.84 # 41112 213.53 202.85 233.28 40810 166.17 157.86 181.54 41113 300.16 285.15 327.92 # 40810 107.52 102.14 117.46 # 41113 237.00 225.15 258.92 40812 233.44 221.77 255.04 41114 550.66 523.13 601.60 # 40812 166.41 158.09 181.80 41115 200.32 190.30 218.85 40814 315.12 299.36 344.26 # 41115 127.17 120.81 138.93 # 40814 257.12 244.26 280.90 41116 268.97 255.52 293.85 40816 332.71 316.07 363.48 # 41116 187.44 178.07 204.78 # 40816 269.88 256.39 294.85 41120 897.55 852.67 980.57 40818 293.44 278.77 320.59 41130 1,117.89 1,062.00 1,221.30 # 40818 231.57 219.99 252.99 41135 1,869.26 1,775.80 2,042.17 40819 250.72 238.18 273.91 41140 1,902.23 1,807.12 2,078.19 # 40819 197.55 187.67 215.82 41145 2,396.69 2,276.86 2,618.39 40820 214.78 204.04 234.65 41150 1,899.72 1,804.73 2,075.44 # 40820 143.88 136.69 157.19 41153 2,066.49 1,963.17 2,257.65 40830 202.10 192.00 220.80 41155 2,588.77 2,459.33 2,828.23 # 40830 136.04 129.24 148.63 41250 193.60 183.92 211.51 40831 266.94 253.59 291.63 # 41250 124.00 117.80 135.47 # 40831 189.60 180.12 207.14 41251 201.88 191.79 220.56 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 35 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 142.27 135.16 155.43 42227 761.79 723.70 832.26 41252 258.13 245.22 282.00 42235 633.87 602.18 692.51 # 41252 183.70 174.52 200.70 42260 703.18 668.02 768.22 41500 379.30 360.34 414.39 # 42260 586.86 557.52 641.15 41510 354.06 336.36 386.81 42280 133.57 126.89 145.92 41512 532.57 505.94 581.83 # 42280 92.97 88.32 101.57 41520 286.03 271.73 312.49 42281 171.18 162.62 187.01 # 41520 216.10 205.30 236.10 # 42281 131.54 124.96 143.70 41530 2,570.14 2,441.63 2,807.87 42300 174.58 165.85 190.73 # 41530 348.00 330.60 380.19 # 42300 132.04 125.44 144.26 41800 192.87 183.23 210.71 42305 377.46 358.59 412.38 # 41800 112.63 107.00 123.05 42310 135.89 129.10 148.47 41805 198.81 188.87 217.20 # 42310 107.85 102.46 117.83 # 41805 141.45 134.38 154.54 42320 209.67 199.19 229.07 41806 284.23 270.02 310.52 # 42320 153.92 146.22 168.15 # 41806 217.52 206.64 237.64 42330 195.29 185.53 213.36 41822 236.12 224.31 257.96 # 42330 143.41 136.24 156.68 # 41822 151.69 144.11 165.73 42335 311.74 296.15 340.57 41823 352.30 334.69 384.89 # 42335 224.74 213.50 245.53 # 41823 271.74 258.15 296.87 42340 391.89 372.30 428.15 41825 169.84 161.35 185.55 # 42340 295.22 280.46 322.53 # 41825 107.00 101.65 116.90 42400 90.83 86.29 99.23 41826 241.59 229.51 263.94 # 42400 50.55 48.02 55.22 # 41826 174.25 165.54 190.37 42405 255.50 242.73 279.14 41827 357.14 339.28 390.17 # 42405 198.78 188.84 217.17 # 41827 260.47 247.45 284.57 42408 382.86 363.72 418.28 41828 251.10 238.55 274.33 # 42408 286.19 271.88 312.66 # 41828 184.07 174.87 201.10 42409 277.21 263.35 302.85 41830 318.28 302.37 347.73 # 42409 193.75 184.06 211.67 # 41830 237.40 225.53 259.36 42410 545.91 518.61 596.40 41872 302.53 287.40 330.51 42415 986.79 937.45 1,078.07 # 41872 225.19 213.93 246.02 42420 1,130.73 1,074.19 1,235.32 41874 301.81 286.72 329.73 42425 744.29 707.08 813.14 # 41874 215.46 204.69 235.39 42426 1,208.33 1,147.91 1,320.10 42000 130.34 123.82 142.39 42440 411.35 390.78 449.40 # 42000 88.78 84.34 96.99 42450 383.27 364.11 418.73 42100 124.42 118.20 135.93 # 42450 312.38 296.76 341.27 # 42100 93.81 89.12 102.49 42500 365.51 347.23 399.31 42104 173.79 165.10 189.87 # 42500 296.87 282.03 324.33 # 42104 118.04 112.14 128.96 42505 474.41 450.69 518.29 42106 219.00 208.05 239.26 # 42505 397.39 377.52 434.15 # 42106 152.62 144.99 166.74 42507 445.55 423.27 486.76 42107 382.44 363.32 417.82 42508 626.08 594.78 684.00 # 42107 297.37 282.50 324.88 42509 741.71 704.62 810.31 42120 847.41 805.04 925.80 42510 549.36 521.89 600.17 42140 207.33 196.96 226.50 42550 123.12 116.96 134.50 # 42140 132.89 126.25 145.19 # 42550 59.31 56.34 64.79 42145 614.05 583.35 670.85 42600 409.55 389.07 447.43 42160 197.42 187.55 215.68 # 42600 308.69 293.26 337.25 # 42160 130.07 123.57 142.11 42650 69.54 66.06 75.97 42180 204.74 194.50 223.68 # 42650 51.17 48.61 55.90 # 42180 159.95 151.95 174.74 42660 89.98 85.48 98.30 42182 276.86 263.02 302.47 # 42660 68.39 64.97 74.72 # 42182 229.49 218.02 250.72 42665 260.22 247.21 284.29 42200 761.32 723.25 831.74 # 42665 180.31 171.29 196.98 42205 804.11 763.90 878.49 42700 158.13 150.22 172.75 42210 922.04 875.94 1,007.33 # 42700 117.85 111.96 128.75 42215 594.63 564.90 649.64 42720 395.32 375.55 431.88 42220 466.65 443.32 509.82 # 42720 348.92 331.47 381.19 42225 791.90 752.31 865.16 42725 713.80 678.11 779.83 42226 791.01 751.46 864.18 42800 132.85 126.21 145.14 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 36 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 97.41 92.54 106.42 # 43201 115.77 109.98 126.48 42802 198.67 188.74 217.05 43202 237.87 225.98 259.88 # 42802 117.47 111.60 128.34 # 43202 102.85 97.71 112.37 42804 166.46 158.14 181.86 43204 200.96 190.91 219.55 # 42804 99.44 94.47 108.64 43205 201.48 191.41 220.12 42806 187.82 178.43 205.19 43215 138.44 131.52 151.25 # 42806 116.60 110.77 127.39 43216 174.43 165.71 190.57 42808 193.25 183.59 211.13 # 43216 128.67 122.24 140.58 # 42808 143.63 136.45 156.92 43217 318.77 302.83 348.25 42809 144.31 137.09 157.65 # 43217 152.50 144.88 166.61 # 42809 113.70 108.02 124.22 43219 153.50 145.83 167.70 42810 325.34 309.07 355.43 43220 114.04 108.34 124.59 # 42810 247.68 235.30 270.60 43226 126.59 120.26 138.30 42815 483.22 459.06 527.92 43227 189.08 179.63 206.57 42820 256.03 243.23 279.71 43228 200.17 190.16 218.68 42821 266.40 253.08 291.04 43231 171.41 162.84 187.27 42825 229.35 217.88 250.56 43232 236.08 224.28 257.92 42826 220.82 209.78 241.25 43234 235.97 224.17 257.80 42830 180.35 171.33 197.03 # 43234 107.72 102.33 117.68 42831 194.46 184.74 212.45 43235 253.03 240.38 276.44 42835 163.36 155.19 178.47 # 43235 129.94 123.44 141.96 42836 211.94 201.34 231.54 43236 314.71 298.97 343.82 42842 850.45 807.93 929.12 # 43236 158.42 150.50 173.08 42844 1,186.35 1,127.03 1,296.08 43237 212.50 201.88 232.16 42845 1,946.23 1,848.92 2,126.26 43238 265.87 252.58 290.47 42860 163.16 155.00 178.25 43239 294.14 279.43 321.34 42870 491.80 467.21 537.29 # 43239 154.61 146.88 168.91 42890 1,217.69 1,156.81 1,330.33 43240 358.23 340.32 391.37 42892 1,605.52 1,525.24 1,754.03 43241 139.85 132.86 152.79 42894 2,049.45 1,946.98 2,239.03 43242 382.58 363.45 417.97 42900 301.72 286.63 329.62 43243 241.43 229.36 263.76 42950 679.59 645.61 742.45 43244 267.18 253.82 291.89 42953 829.19 787.73 905.89 43245 168.84 160.40 184.46 42955 640.00 608.00 699.20 43246 226.69 215.36 247.66 42960 148.39 140.97 162.12 43247 180.47 171.45 197.17 42961 368.07 349.67 402.12 43248 170.49 161.97 186.27 42962 455.85 433.06 498.02 43249 156.94 149.09 171.45 42970 344.01 326.81 375.83 43250 169.21 160.75 184.86 42971 401.84 381.75 439.01 43251 196.10 186.30 214.25 42972 450.70 428.17 492.40 43255 254.97 242.22 278.55 43020 464.64 441.41 507.62 43256 229.60 218.12 250.84 43030 459.01 436.06 501.47 43257 285.00 270.75 311.36 43045 1,161.85 1,103.76 1,269.32 43258 240.73 228.69 262.99 43100 549.13 521.67 599.92 43259 274.67 260.94 300.08 43101 899.15 854.19 982.32 43260 313.76 298.07 342.78 43107 2,249.75 2,137.26 2,457.85 43261 329.56 313.08 360.04 43108 3,791.49 3,601.92 4,142.21 43262 386.83 367.49 422.61 43112 2,397.93 2,278.03 2,619.73 43263 382.21 363.10 417.57 43113 3,750.12 3,562.61 4,097.00 43264 464.82 441.58 507.82 43116 4,496.30 4,271.49 4,912.21 43265 521.91 495.81 570.18 43117 2,196.08 2,086.28 2,399.22 43267 385.54 366.26 421.20 43118 3,065.86 2,912.57 3,349.46 43268 391.34 371.77 427.54 43121 2,535.88 2,409.09 2,770.45 43269 429.31 407.84 469.02 43122 2,228.86 2,117.42 2,435.03 43271 386.50 367.18 422.26 43123 3,818.28 3,627.37 4,171.48 43272 386.18 366.87 421.90 43124 3,195.04 3,035.29 3,490.58 43273 114.19 108.48 124.75 43130 696.37 661.55 760.78 43279 1,070.12 1,016.61 1,169.10 43135 1,318.88 1,252.94 1,440.88 43280 922.82 876.68 1,008.18 43200 181.77 172.68 198.58 43281 1,382.75 1,313.61 1,510.65 # 43200 92.51 87.88 101.06 43282 1,555.22 1,477.46 1,699.08 43201 248.85 236.41 271.87 43300 540.04 513.04 590.00 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 37 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 975.51 926.73 1,065.74 # 43760 45.12 42.86 49.29 43310 1,348.16 1,280.75 1,472.86 43761 108.88 103.44 118.96 43312 1,471.64 1,398.06 1,607.77 # 43761 96.64 91.81 105.58 43313 2,409.53 2,289.05 2,632.41 43770 943.31 896.14 1,030.56 43314 2,713.13 2,577.47 2,964.09 43771 1,075.86 1,022.07 1,175.38 43320 1,198.12 1,138.21 1,308.94 43772 810.74 770.20 885.73 43324 1,166.10 1,107.80 1,273.97 43773 1,076.18 1,022.37 1,175.73 43325 1,151.72 1,094.13 1,258.25 43774 814.26 773.55 889.58 43326 1,161.17 1,103.11 1,268.58 43775 1,160.61 1,102.58 1,267.97 43330 1,126.96 1,070.61 1,231.20 43800 789.20 749.74 862.20 43331 1,203.47 1,143.30 1,314.80 43810 857.80 814.91 937.15 43340 1,175.02 1,116.27 1,283.71 43820 1,126.81 1,070.47 1,231.04 43341 1,285.19 1,220.93 1,404.07 43825 1,102.35 1,047.23 1,204.31 43350 1,021.20 970.14 1,115.66 43830 586.61 557.28 640.87 43351 1,167.64 1,109.26 1,275.65 43831 490.95 466.40 536.36 43352 951.00 903.45 1,038.97 43832 898.40 853.48 981.50 43360 2,028.49 1,927.07 2,216.13 43840 1,142.45 1,085.33 1,248.13 43361 2,307.49 2,192.12 2,520.94 43843 1,073.78 1,020.09 1,173.10 43400 1,388.34 1,318.92 1,516.76 43845 1,662.91 1,579.76 1,816.72 43401 1,337.51 1,270.63 1,461.22 43846 1,387.19 1,317.83 1,515.50 43405 1,299.15 1,234.19 1,419.32 43847 1,517.21 1,441.35 1,657.55 43410 883.31 839.14 965.01 43848 1,640.57 1,558.54 1,792.32 43415 1,503.48 1,428.31 1,642.56 43850 1,375.79 1,307.00 1,503.05 43420 889.03 844.58 971.27 43855 1,427.15 1,355.79 1,559.16 43425 1,315.96 1,250.16 1,437.68 43860 1,394.28 1,324.57 1,523.26 43450 134.35 127.63 146.77 43865 1,449.55 1,377.07 1,583.63 # 43450 79.25 75.29 86.58 43870 599.84 569.85 655.33 43453 249.24 236.78 272.30 43880 1,360.24 1,292.23 1,486.06 # 43453 86.19 81.88 94.16 43886 292.22 277.61 319.25 43456 502.78 477.64 549.29 43887 266.87 253.53 291.56 # 43456 139.30 132.34 152.19 43888 378.05 359.15 413.02 43458 329.27 312.81 359.73 44005 930.16 883.65 1,016.20 # 43458 163.32 155.15 178.42 44010 732.61 695.98 800.38 43460 198.60 188.67 216.97 44015 124.80 118.56 136.34 43496 1,881.92 1,787.82 2,055.99 44020 823.35 782.18 899.51 43500 664.50 631.28 725.97 44021 832.01 790.41 908.97 43501 1,141.20 1,084.14 1,246.76 44025 838.13 796.22 915.65 43502 1,290.67 1,226.14 1,410.06 44050 792.12 752.51 865.39 43510 812.69 772.06 887.87 44055 1,272.09 1,208.49 1,389.76 43520 596.06 566.26 651.20 44100 103.00 97.85 112.53 43600 96.13 91.32 105.02 44110 719.69 683.71 786.27 43605 705.04 669.79 770.26 44111 837.37 795.50 914.83 43610 830.98 789.43 907.84 44120 1,039.42 987.45 1,135.57 43611 1,036.33 984.51 1,132.19 44121 210.64 200.11 230.13 43620 1,684.78 1,600.54 1,840.62 44125 1,005.55 955.27 1,098.56 43621 1,934.06 1,837.36 2,112.96 44126 2,087.12 1,982.76 2,280.17 43622 1,958.67 1,860.74 2,139.85 44127 2,420.68 2,299.65 2,644.60 43631 1,233.92 1,172.22 1,348.05 44128 211.31 200.74 230.85 43632 1,716.39 1,630.57 1,875.16 44130 1,104.59 1,049.36 1,206.76 43633 1,625.85 1,544.56 1,776.24 44137 951.62 904.04 1,039.65 43634 1,797.28 1,707.42 1,963.53 44139 105.65 100.37 115.43 43635 97.64 92.76 106.67 44140 1,141.47 1,084.40 1,247.06 43640 997.18 947.32 1,089.42 44141 1,533.04 1,456.39 1,674.85 43641 1,008.57 958.14 1,101.86 44143 1,414.17 1,343.46 1,544.98 43644 1,477.85 1,403.96 1,614.55 44144 1,498.24 1,423.33 1,636.83 43645 1,579.45 1,500.48 1,725.55 44145 1,421.84 1,350.75 1,553.36 43651 547.69 520.31 598.36 44146 1,795.55 1,705.77 1,961.64 43652 641.78 609.69 701.14 44147 1,641.28 1,559.22 1,793.10 43653 473.52 449.84 517.32 44150 1,576.19 1,497.38 1,721.99 43752 38.21 36.30 41.75 44151 1,804.14 1,713.93 1,971.02 43760 305.48 290.21 333.74 44155 1,763.75 1,675.56 1,926.89 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 38 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,939.74 1,842.75 2,119.16 44393 428.77 407.33 468.43 44157 1,840.11 1,748.10 2,010.32 # 44393 249.29 236.83 272.35 44158 1,884.11 1,789.90 2,058.39 44394 428.80 407.36 468.46 44160 1,055.47 1,002.70 1,153.11 # 44394 230.30 218.79 251.61 44180 782.69 743.56 855.09 44397 247.58 235.20 270.48 44186 553.04 525.39 604.20 44500 23.34 22.17 25.50 44187 933.78 887.09 1,020.15 44602 1,195.20 1,135.44 1,305.76 44188 1,033.71 982.02 1,129.32 44603 1,370.48 1,301.96 1,497.25 44202 1,180.93 1,121.88 1,290.16 44604 902.19 857.08 985.64 44203 210.67 200.14 230.16 44605 1,113.72 1,058.03 1,216.73 44204 1,317.83 1,251.94 1,439.73 44615 917.04 871.19 1,001.87 44205 1,148.54 1,091.11 1,254.78 44620 735.92 699.12 803.99 44206 1,498.60 1,423.67 1,637.22 44625 869.13 825.67 949.52 44207 1,570.59 1,492.06 1,715.87 44626 1,376.06 1,307.26 1,503.35 44208 1,706.69 1,621.36 1,864.56 44640 1,200.41 1,140.39 1,311.45 44210 1,531.13 1,454.57 1,672.76 44650 1,246.08 1,183.78 1,361.35 44211 1,892.57 1,797.94 2,067.63 44660 1,196.87 1,137.03 1,307.58 44212 1,761.77 1,673.68 1,924.73 44661 1,353.53 1,285.85 1,478.73 44213 165.32 157.05 180.61 44680 909.73 864.24 993.88 44227 1,428.61 1,357.18 1,560.76 44700 874.07 830.37 954.93 44300 713.52 677.84 779.52 44701 146.00 138.70 159.51 44310 890.16 845.65 972.50 44715 355.62 337.84 388.52 44312 506.76 481.42 553.63 44720 234.40 222.68 256.08 44314 862.55 819.42 942.33 44721 334.17 317.46 365.08 44316 1,192.61 1,132.98 1,302.93 44800 643.50 611.33 703.03 44320 1,018.25 967.34 1,112.44 44820 712.41 676.79 778.31 44322 813.86 773.17 889.15 44850 628.89 597.45 687.07 44340 516.36 490.54 564.12 44900 650.82 618.28 711.02 44345 891.14 846.58 973.57 44901 807.46 767.09 882.15 44346 1,003.03 952.88 1,095.81 # 44901 160.41 152.39 175.25 44360 141.43 134.36 154.51 44950 544.74 517.50 595.13 44361 155.87 148.08 170.29 44955 73.13 69.47 79.89 44363 185.08 175.83 202.20 44960 738.29 701.38 806.59 44364 199.42 189.45 217.87 44970 502.91 477.76 549.42 44365 177.51 168.63 193.92 45000 353.99 336.29 386.73 44366 234.70 222.97 256.42 45005 208.32 197.90 227.59 44369 240.16 228.15 262.37 # 45005 129.37 122.90 141.34 44370 258.29 245.38 282.19 45020 469.98 446.48 513.45 44372 229.78 218.29 251.03 45100 245.18 232.92 267.86 44373 185.43 176.16 202.58 45108 299.50 284.53 327.21 44376 273.92 260.22 299.25 45110 1,576.66 1,497.83 1,722.50 44377 290.39 275.87 317.25 45111 925.32 879.05 1,010.91 44378 372.29 353.68 406.73 45112 1,624.22 1,543.01 1,774.46 44379 393.65 373.97 430.07 45113 1,680.61 1,596.58 1,836.07 44380 61.60 58.52 67.30 45114 1,532.47 1,455.85 1,674.23 44382 73.64 69.96 80.45 45116 1,355.00 1,287.25 1,480.34 44383 156.41 148.59 170.88 45119 1,670.32 1,586.80 1,824.82 44385 211.70 201.12 231.29 45120 1,340.80 1,273.76 1,464.82 # 44385 95.05 90.30 103.85 45121 1,465.74 1,392.45 1,601.32 44386 290.85 276.31 317.76 45123 949.85 902.36 1,037.71 # 44386 112.01 106.41 122.37 45126 2,480.87 2,356.83 2,710.35 44388 293.08 278.43 320.19 45130 928.77 882.33 1,014.68 # 44388 148.40 140.98 162.13 45135 1,147.16 1,089.80 1,253.27 44389 337.21 320.35 368.40 45136 1,562.24 1,484.13 1,706.75 # 44389 165.46 157.19 180.77 45150 333.74 317.05 364.61 44390 391.37 371.80 427.57 45160 851.11 808.55 929.83 # 44390 199.32 189.35 217.75 45171 523.38 497.21 571.79 44391 434.11 412.40 474.26 45172 719.01 683.06 785.52 # 44391 226.27 214.96 247.20 45190 575.30 546.54 628.52 44392 369.36 350.89 403.52 45300 92.85 88.21 101.44 # 44392 196.32 186.50 214.48 # 45300 44.51 42.28 48.62 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 39 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 700.70 665.67 765.52 45391 267.48 254.11 292.23 # 45303 76.53 72.70 83.61 45392 341.49 324.42 373.08 45305 148.70 141.27 162.46 45395 1,700.34 1,615.32 1,857.62 # 45305 66.86 63.52 73.05 45397 1,843.46 1,751.29 2,013.98 45307 168.79 160.35 184.40 45400 984.80 935.56 1,075.89 # 45307 86.30 81.99 94.29 45402 1,314.66 1,248.93 1,436.27 45308 155.55 147.77 169.94 45500 434.41 412.69 474.59 # 45308 73.06 69.41 79.82 45505 480.95 456.90 525.44 45309 168.87 160.43 184.49 45520 108.45 103.03 118.48 # 45309 80.58 76.55 88.03 # 45520 33.37 31.70 36.46 45315 183.72 174.53 200.71 45540 906.55 861.22 990.40 # 45315 94.46 89.74 103.20 45541 781.78 742.69 854.09 45317 180.49 171.47 197.19 45550 1,249.11 1,186.65 1,364.65 # 45317 100.26 95.25 109.54 45560 609.29 578.83 665.65 45320 177.69 168.81 194.13 45562 947.24 899.88 1,034.86 # 45320 94.23 89.52 102.95 45563 1,375.22 1,306.46 1,502.43 45321 92.22 87.61 100.75 45800 1,051.36 998.79 1,148.61 45327 108.12 102.71 118.12 45805 1,220.56 1,159.53 1,333.46 45330 114.87 109.13 125.50 45820 1,026.02 974.72 1,120.93 # 45330 55.26 52.50 60.38 45825 1,261.00 1,197.95 1,377.64 45331 144.38 137.16 157.73 45900 168.25 159.84 183.82 # 45331 67.04 63.69 73.24 45905 141.18 134.12 154.24 45332 238.41 226.49 260.46 45910 166.19 157.88 181.56 # 45332 97.91 93.01 106.96 45915 259.59 246.61 283.60 45333 240.84 228.80 263.12 # 45915 187.73 178.34 205.09 # 45333 97.77 92.88 106.81 45990 93.31 88.64 101.94 45334 147.61 140.23 161.26 46020 214.97 204.22 234.85 45335 207.55 197.17 226.75 # 46020 188.55 179.12 205.99 # 45335 81.56 77.48 89.10 46030 107.16 101.80 117.07 45337 126.67 120.34 138.39 # 46030 74.29 70.58 81.17 45338 267.41 254.04 292.15 46040 416.09 395.29 454.58 # 45338 126.59 120.26 138.30 # 46040 335.53 318.75 366.56 45339 281.63 267.55 307.68 46045 349.48 332.01 381.81 # 45339 167.24 158.88 182.71 46050 149.00 141.55 162.78 45340 369.84 351.35 404.05 # 46050 78.75 74.81 86.03 # 45340 103.03 97.88 112.56 46060 383.44 364.27 418.91 45341 140.98 133.93 154.02 46070 185.69 176.41 202.87 45342 215.57 204.79 235.51 46080 193.91 184.21 211.84 45345 156.67 148.84 171.17 # 46080 133.97 127.27 146.36 45355 180.54 171.51 197.24 46083 143.11 135.95 156.34 45378 337.27 320.41 368.47 # 46083 89.94 85.44 98.26 # 45378 194.20 184.49 212.16 46200 330.29 313.78 360.85 45378 53 114.87 109.13 125.50 # 46200 255.20 242.44 278.81 # 45378 53 55.26 52.50 60.38 46220 157.25 149.39 171.80 45379 428.69 407.26 468.35 # 46220 97.32 92.45 106.32 # 45379 243.40 231.23 265.91 46221 206.62 196.29 225.73 45380 403.98 383.78 441.35 # 46221 154.42 146.70 168.71 # 45380 233.52 221.84 255.12 46230 213.96 203.26 233.75 45381 392.86 373.22 429.20 # 46230 144.35 137.13 157.70 # 45381 221.43 210.36 241.91 46250 357.94 340.04 391.05 45382 530.56 504.03 579.63 # 46250 256.11 243.30 279.80 # 45382 298.55 283.62 326.16 46255 397.57 377.69 434.34 45383 484.85 460.61 529.70 # 46255 290.59 276.06 317.47 # 45383 301.17 286.11 329.03 46257 341.51 324.43 373.09 45384 399.89 379.90 436.89 46258 378.12 359.21 413.09 # 45384 243.61 231.43 266.14 46260 387.19 367.83 423.00 45385 456.26 433.45 498.47 46261 435.00 413.25 475.24 # 45385 277.41 263.54 303.07 46262 452.99 430.34 494.89 45386 557.78 529.89 609.37 46270 391.67 372.09 427.90 # 45386 238.44 226.52 260.50 # 46270 312.08 296.48 340.95 45387 310.76 295.22 339.50 46275 414.51 393.78 452.85 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 40 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 332.66 316.03 363.43 # 46922 111.99 106.39 122.35 46280 379.06 360.11 414.13 46924 415.65 394.87 454.10 46285 406.56 386.23 444.16 # 46924 156.25 148.44 170.71 # 46285 330.51 313.98 361.08 46930 171.38 162.81 187.23 46288 448.13 425.72 489.58 # 46930 124.98 118.73 136.54 46320 141.22 134.16 154.28 46940 177.85 168.96 194.30 # 46320 91.92 87.32 100.42 # 46940 124.04 117.84 135.52 46500 174.82 166.08 190.99 46942 165.84 157.55 181.18 # 46500 105.22 99.96 114.95 # 46942 110.74 105.20 120.98 46505 229.16 217.70 250.36 46945 230.99 219.44 252.36 # 46505 195.65 185.87 213.75 # 46945 177.83 168.94 194.28 46600 67.85 64.46 74.13 46946 244.38 232.16 266.98 # 46600 33.05 31.40 36.11 # 46946 184.13 174.92 201.16 46604 427.79 406.40 467.36 46947 314.80 299.06 343.92 # 46604 56.57 53.74 61.80 47000 284.02 269.82 310.29 46606 173.71 165.02 189.77 # 47000 91.32 86.75 99.76 # 46606 64.15 60.94 70.08 47001 90.26 85.75 98.61 46608 178.65 169.72 195.18 47010 1,018.32 967.40 1,112.51 # 46608 68.77 65.33 75.13 47011 176.35 167.53 192.66 46610 176.20 167.39 192.50 47015 971.61 923.03 1,061.48 # 46610 68.90 65.46 75.28 47100 705.05 669.80 770.27 46611 137.87 130.98 150.63 47120 1,978.00 1,879.10 2,160.97 # 46611 69.56 66.08 75.99 47122 2,935.60 2,788.82 3,207.14 46612 208.57 198.14 227.86 47125 2,628.20 2,496.79 2,871.31 # 46612 81.61 77.53 89.16 47130 2,824.01 2,682.81 3,085.23 46614 103.69 98.51 113.29 47135 3,992.73 3,793.09 4,362.05 # 46614 56.97 54.12 62.24 47136 3,383.94 3,214.74 3,696.95 46615 119.28 113.32 130.32 47140 3,015.34 2,864.57 3,294.26 # 46615 81.25 77.19 88.77 47141 3,462.82 3,289.68 3,783.13 46700 539.33 512.36 589.21 47142 3,811.24 3,620.68 4,163.78 46705 423.35 402.18 462.51 47143 301.07 286.02 328.92 46706 140.80 133.76 153.82 47144 451.59 429.01 493.36 46707 403.00 382.85 440.28 47145 451.59 429.01 493.36 46710 925.04 878.79 1,010.61 47146 285.52 271.24 311.93 46712 1,793.21 1,703.55 1,959.08 47147 332.70 316.07 363.48 46715 418.20 397.29 456.88 47300 951.42 903.85 1,039.43 46716 1,016.62 965.79 1,110.66 47350 1,160.13 1,102.12 1,267.44 46730 1,648.74 1,566.30 1,801.25 47360 1,582.73 1,503.59 1,729.13 46735 1,832.51 1,740.88 2,002.01 47361 2,587.67 2,458.29 2,827.03 46740 1,782.76 1,693.62 1,947.66 47362 1,211.05 1,150.50 1,323.08 46742 2,089.71 1,985.22 2,283.00 47370 1,055.18 1,002.42 1,152.78 46744 2,890.74 2,746.20 3,158.13 47371 1,073.31 1,019.64 1,172.59 46746 3,219.07 3,058.12 3,516.84 47380 1,233.74 1,172.05 1,347.86 46748 3,477.42 3,303.55 3,799.08 47381 1,264.29 1,201.08 1,381.24 46750 648.20 615.79 708.16 47382 3,837.50 3,645.63 4,192.47 46751 526.54 500.21 575.24 # 47382 751.78 714.19 821.32 46753 487.75 463.36 532.86 47400 1,827.78 1,736.39 1,996.85 46754 235.95 224.15 257.77 47420 1,134.64 1,077.91 1,239.60 # 46754 185.36 176.09 202.50 47425 1,148.96 1,091.51 1,255.24 46760 918.63 872.70 1,003.61 47460 1,083.82 1,029.63 1,184.07 46761 792.52 752.89 865.82 47480 725.61 689.33 792.73 46762 782.11 743.00 854.45 47490 466.96 443.61 510.15 46900 186.86 177.52 204.15 47500 93.55 88.87 102.20 # 46900 115.97 110.17 126.70 47505 36.29 34.48 39.65 46910 195.91 186.11 214.03 47510 443.22 421.06 484.22 # 46910 112.13 106.52 122.50 47511 554.06 526.36 605.31 46916 190.51 180.98 208.13 47525 435.47 413.70 475.76 # 46916 123.17 117.01 134.56 # 47525 93.90 89.21 102.59 46917 361.36 343.29 394.78 47530 1,220.12 1,159.11 1,332.98 # 46917 111.95 106.35 122.30 # 47530 333.01 316.36 363.81 46922 203.82 193.63 222.67 47550 144.08 136.88 157.41 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 41 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 300.77 285.73 328.59 48551 204.63 194.40 223.56 47553 302.33 287.21 330.29 48552 205.78 195.49 224.81 47554 446.11 423.80 487.37 48554 2,122.34 2,016.22 2,318.65 47555 360.72 342.68 394.08 48556 1,057.71 1,004.82 1,155.54 47556 408.92 388.47 446.74 49000 655.48 622.71 716.12 47560 232.99 221.34 254.54 49002 881.47 837.40 963.01 47561 253.57 240.89 277.02 49010 815.95 775.15 891.42 47562 626.69 595.36 684.66 49020 1,353.92 1,286.22 1,479.15 47563 637.01 605.16 695.93 49021 758.13 720.22 828.25 47564 732.45 695.83 800.20 # 49021 161.02 152.97 175.92 47570 654.08 621.38 714.59 49040 850.02 807.52 928.65 47600 906.58 861.25 990.44 49041 777.46 738.59 849.38 47605 828.73 787.29 905.38 # 49041 190.35 180.83 207.95 47610 1,063.15 1,009.99 1,161.49 49060 948.19 900.78 1,035.90 47612 1,074.93 1,021.18 1,174.36 49061 763.47 725.30 834.10 47620 1,165.27 1,107.01 1,273.06 # 49061 176.03 167.23 192.31 47630 509.44 483.97 556.57 49062 638.47 606.55 697.53 47700 883.18 839.02 964.87 49080 144.02 136.82 157.34 47701 1,502.18 1,427.07 1,641.13 # 49080 64.75 61.51 70.74 47711 1,320.05 1,254.05 1,442.16 49081 138.35 131.43 151.14 47712 1,693.26 1,608.60 1,849.89 # 49081 61.34 58.27 67.01 47715 1,114.51 1,058.78 1,217.60 49180 145.97 138.67 159.47 47720 963.59 915.41 1,052.72 # 49180 82.81 78.67 90.47 47721 1,136.00 1,079.20 1,241.08 49203 1,026.26 974.95 1,121.19 47740 1,099.14 1,044.18 1,200.81 49204 1,309.68 1,244.20 1,430.83 47741 1,241.84 1,179.75 1,356.71 49205 1,501.67 1,426.59 1,640.58 47760 1,897.82 1,802.93 2,073.37 49215 1,880.57 1,786.54 2,054.52 47765 2,543.64 2,416.46 2,778.93 49220 821.13 780.07 897.08 47780 2,082.98 1,978.83 2,275.65 49250 489.55 465.07 534.83 47785 2,731.52 2,594.94 2,984.18 49255 667.57 634.19 729.32 47800 1,334.86 1,268.12 1,458.34 49320 278.71 264.77 304.49 47801 924.77 878.53 1,010.31 49321 293.88 279.19 321.07 47802 1,284.07 1,219.87 1,402.85 49322 318.89 302.95 348.39 47900 1,154.88 1,097.14 1,261.71 49323 544.83 517.59 595.23 48000 1,591.15 1,511.59 1,738.33 49324 335.36 318.59 366.38 48001 1,965.31 1,867.04 2,147.10 49325 358.65 340.72 391.83 48020 990.96 941.41 1,082.62 49326 164.92 156.67 180.17 48100 749.22 711.76 818.52 49400 153.35 145.68 167.53 48102 466.90 443.56 510.09 # 49400 89.87 85.38 98.19 # 48102 232.64 221.01 254.16 49402 725.15 688.89 792.22 48105 2,428.69 2,307.26 2,653.35 49411 456.38 433.56 498.59 48120 937.19 890.33 1,023.88 # 49411 182.80 173.66 199.71 48140 1,326.53 1,260.20 1,449.23 49419 382.05 362.95 417.39 48145 1,378.97 1,310.02 1,506.52 49420 120.17 114.16 131.28 48146 1,573.68 1,495.00 1,719.25 49421 328.14 311.73 358.49 48148 1,048.02 995.62 1,144.96 49422 329.92 313.42 360.43 48150 2,645.28 2,513.02 2,889.97 49423 478.45 454.53 522.71 48152 2,447.90 2,325.51 2,674.34 # 49423 70.82 67.28 77.37 48153 2,640.79 2,508.75 2,885.06 49424 130.06 123.56 142.09 48154 2,455.30 2,332.54 2,682.42 # 49424 37.26 35.40 40.71 48155 1,528.31 1,451.89 1,669.67 49425 647.40 615.03 707.28 48400 95.91 91.11 104.78 49426 548.76 521.32 599.52 48500 960.06 912.06 1,048.87 49427 42.95 40.80 46.92 48510 911.24 865.68 995.53 49428 372.31 353.69 406.74 48511 795.68 755.90 869.29 49429 387.74 368.35 423.60 # 48511 190.85 181.31 208.51 49435 105.09 99.84 114.82 48520 926.17 879.86 1,011.84 49436 157.12 149.26 171.65 48540 1,105.91 1,050.61 1,208.20 49440 925.79 879.50 1,011.43 48545 1,128.93 1,072.48 1,233.35 # 49440 211.72 201.13 231.30 48547 1,516.06 1,440.26 1,656.30 49441 1,010.17 959.66 1,103.61 48548 1,413.24 1,342.58 1,543.97 # 49441 239.71 227.72 261.88 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 42 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 882.86 838.72 964.53 # 50021 160.70 152.67 175.57 # 49442 198.75 188.81 217.13 50040 877.95 834.05 959.16 49446 848.53 806.10 927.02 50045 880.95 836.90 962.44 # 49446 158.62 150.69 173.29 50060 1,086.18 1,031.87 1,186.65 49450 617.09 586.24 674.18 50065 1,142.28 1,085.17 1,247.95 # 49450 64.13 60.92 70.06 50070 1,133.31 1,076.64 1,238.14 49451 606.42 576.10 662.52 50075 1,393.31 1,323.64 1,522.19 # 49451 88.59 84.16 96.78 50080 829.04 787.59 905.73 49452 760.84 722.80 831.22 50081 1,218.85 1,157.91 1,331.60 # 49452 137.31 130.44 150.01 50100 918.64 872.71 1,003.62 49460 675.03 641.28 737.47 50120 898.89 853.95 982.04 # 49460 45.70 43.42 49.93 50125 939.79 892.80 1,026.72 49465 145.97 138.67 159.47 50130 983.62 934.44 1,074.61 # 49465 29.64 28.16 32.38 50135 1,066.71 1,013.37 1,165.38 49491 661.39 628.32 722.57 50200 485.43 461.16 530.33 49492 789.67 750.19 862.72 # 50200 135.16 128.40 147.66 49495 336.32 319.50 367.43 50205 646.14 613.83 705.90 49496 512.27 486.66 559.66 50220 975.89 927.10 1,066.17 49500 335.00 318.25 365.99 50225 1,128.23 1,071.82 1,232.59 49501 504.16 478.95 550.79 50230 1,219.00 1,158.05 1,331.76 49505 434.72 412.98 474.93 50234 1,237.14 1,175.28 1,351.57 49507 535.01 508.26 584.50 50236 1,398.10 1,328.20 1,527.43 49520 530.67 504.14 579.76 50240 1,258.77 1,195.83 1,375.20 49521 646.27 613.96 706.05 50250 1,165.55 1,107.27 1,273.36 49525 480.22 456.21 524.64 50280 898.82 853.88 981.96 49540 567.86 539.47 620.39 50290 827.66 786.28 904.22 49550 482.66 458.53 527.31 50320 1,243.48 1,181.31 1,358.51 49553 528.71 502.27 577.61 50323 183.98 174.78 201.00 49555 502.44 477.32 548.92 50325 183.98 174.78 201.00 49557 610.06 579.56 666.49 50327 190.69 181.16 208.33 49560 622.44 591.32 680.02 50328 167.08 158.73 182.54 49561 786.76 747.42 859.53 50329 160.97 152.92 175.86 49565 647.21 614.85 707.08 50340 784.41 745.19 856.97 49566 794.75 755.01 868.26 50360 2,163.95 2,055.75 2,364.11 49568 232.16 220.55 253.63 50365 2,430.94 2,309.39 2,655.80 49570 343.79 326.60 375.59 50370 1,010.17 959.66 1,103.61 49572 427.87 406.48 467.45 50380 1,708.42 1,623.00 1,866.45 49580 277.91 264.01 303.61 50382 1,105.23 1,049.97 1,207.47 49582 397.83 377.94 434.63 # 50382 265.16 251.90 289.69 49585 368.93 350.48 403.05 50384 940.08 893.08 1,027.04 49587 437.35 415.48 477.80 # 50384 241.47 229.40 263.81 49590 478.53 454.60 522.79 50385 1,079.94 1,025.94 1,179.83 49600 618.26 587.35 675.45 # 50385 225.69 214.41 246.57 49605 4,094.35 3,889.63 4,473.07 50386 703.49 668.32 768.57 49606 961.88 913.79 1,050.86 # 50386 170.52 161.99 186.29 49610 580.27 551.26 633.95 50387 509.83 484.34 556.99 49611 499.16 474.20 545.33 # 50387 96.08 91.28 104.97 49650 355.58 337.80 388.47 50389 289.80 275.31 316.61 49651 462.46 439.34 505.24 # 50389 52.64 50.01 57.51 49652 649.09 616.64 709.14 50390 93.55 88.87 102.20 49653 812.64 772.01 887.81 50391 118.54 112.61 129.50 49654 746.44 709.12 815.49 # 50391 95.66 90.88 104.51 49655 898.74 853.80 981.87 50392 171.34 162.77 187.19 49656 748.50 711.08 817.74 50393 208.65 198.22 227.95 49657 1,080.13 1,026.12 1,180.04 50394 92.36 87.74 100.90 49900 684.91 650.66 748.26 # 50394 46.60 44.27 50.91 49904 1,262.14 1,199.03 1,378.88 50395 172.30 163.69 188.24 49905 309.85 294.36 338.51 50396 110.80 105.26 121.05 50010 662.61 629.48 723.90 50398 458.47 435.55 500.88 50020 947.52 900.14 1,035.16 # 50398 71.15 67.59 77.73 50021 798.41 758.49 872.26 50400 1,098.82 1,043.88 1,200.46 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 99 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 1,328.86 1,262.42 1,451.78 50780 1,037.29 985.43 1,133.24 50500 1,102.81 1,047.67 1,204.82 50782 1,039.56 987.58 1,135.72 50520 979.76 930.77 1,070.39 50783 1,061.36 1,008.29 1,159.53 50525 1,284.21 1,220.00 1,403.00 50785 1,148.60 1,091.17 1,254.85 50526 1,299.58 1,234.60 1,419.79 50800 872.01 828.41 952.67 50540 1,079.32 1,025.35 1,179.15 50810 1,192.63 1,133.00 1,302.95 50541 876.17 832.36 957.21 50815 1,160.64 1,102.61 1,268.00 50542 1,112.26 1,056.65 1,215.15 50820 1,238.71 1,176.77 1,353.29 50543 1,419.66 1,348.68 1,550.98 50825 1,571.23 1,492.67 1,716.57 50544 1,192.78 1,133.14 1,303.11 50830 1,704.08 1,618.88 1,861.71 50545 1,281.47 1,217.40 1,400.01 50840 1,169.20 1,110.74 1,277.35 50546 1,138.57 1,081.64 1,243.89 50845 1,185.16 1,125.90 1,294.79 50547 1,397.41 1,327.54 1,526.67 50860 895.17 850.41 977.97 50548 1,289.92 1,225.42 1,409.23 50900 792.54 752.91 865.85 50551 343.58 326.40 375.36 50920 836.27 794.46 913.63 # 50551 283.32 269.15 309.52 50930 1,050.68 998.15 1,147.87 50553 361.90 343.81 395.38 50940 837.39 795.52 914.85 # 50553 300.68 285.65 328.50 50945 927.63 881.25 1,013.44 50555 391.89 372.30 428.15 50947 1,312.87 1,247.23 1,434.31 # 50555 327.77 311.38 358.09 50948 1,221.26 1,160.20 1,334.23 50557 399.38 379.41 436.32 50951 358.85 340.91 392.05 # 50557 332.36 315.74 363.10 # 50951 295.37 280.60 322.69 50561 453.49 430.82 495.44 50953 379.22 360.26 414.30 # 50561 380.02 361.02 415.17 # 50953 324.76 308.52 354.80 50562 558.93 530.98 610.63 50955 416.00 395.20 454.48 50570 474.01 450.31 517.86 # 50955 350.58 333.05 383.01 50572 513.48 487.81 560.98 50957 408.36 387.94 446.13 50574 545.18 517.92 595.61 # 50957 340.69 323.66 372.21 50575 689.36 654.89 753.12 50961 368.25 349.84 402.32 50576 543.96 516.76 594.27 # 50961 305.42 290.15 333.67 50580 583.96 554.76 637.97 50970 357.24 339.38 390.29 50590 851.01 808.46 929.73 50972 344.34 327.12 376.19 # 50590 535.22 508.46 584.73 50974 455.98 433.18 498.16 50592 3,030.27 2,878.76 3,310.57 50976 448.71 426.27 490.21 # 50592 345.08 327.83 377.00 50980 343.28 326.12 375.04 50593 4,035.90 3,834.11 4,409.23 51020 441.23 419.17 482.05 # 50593 444.91 422.66 486.06 51030 434.08 412.38 474.24 50600 890.09 845.59 972.43 51040 273.04 259.39 298.30 50605 873.21 829.55 953.98 51045 445.69 423.41 486.92 50610 899.96 854.96 983.20 51050 446.76 424.42 488.08 50620 860.29 817.28 939.87 51060 550.17 522.66 601.06 50630 841.02 798.97 918.82 51065 546.62 519.29 597.18 50650 982.75 933.61 1,073.65 51080 382.88 363.74 418.30 50660 1,085.71 1,031.42 1,186.13 51100 56.50 53.68 61.73 50684 157.45 149.58 172.02 # 51100 37.16 35.30 40.60 # 50684 46.60 44.27 50.91 51101 113.55 107.87 124.05 50686 97.94 93.04 107.00 # 51101 49.43 46.96 54.00 # 50686 86.34 82.02 94.32 51102 213.14 202.48 232.85 50688 74.66 70.93 81.57 # 51102 140.31 133.29 153.28 50690 90.67 86.14 99.06 51500 586.37 557.05 640.61 # 50690 65.86 62.57 71.96 51520 555.36 527.59 606.73 50700 877.87 833.98 959.08 51525 815.85 775.06 891.32 50715 1,053.51 1,000.83 1,150.95 51530 730.49 693.97 798.07 50722 923.90 877.71 1,009.37 51535 732.54 695.91 800.30 50725 1,033.80 982.11 1,129.43 51550 901.90 856.81 985.33 50727 473.05 449.40 516.81 51555 1,194.86 1,135.12 1,305.39 50728 652.98 620.33 713.38 51565 1,221.36 1,160.29 1,334.33 50740 1,055.68 1,002.90 1,153.34 51570 1,397.33 1,327.46 1,526.58 50750 1,102.67 1,047.54 1,204.67 51575 1,739.18 1,652.22 1,900.05 50760 1,041.39 989.32 1,137.72 51580 1,811.70 1,721.12 1,979.29 50770 1,075.28 1,021.52 1,174.75 51585 2,018.42 1,917.50 2,205.13 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 44 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,841.92 1,749.82 2,012.29 51840 605.86 575.57 661.91 51595 2,091.71 1,987.12 2,285.19 51841 719.98 683.98 786.58 51596 2,248.17 2,135.76 2,456.12 51845 550.14 522.63 601.02 51597 2,174.99 2,066.24 2,376.18 51860 678.65 644.72 741.43 51600 169.85 161.36 185.56 51865 835.42 793.65 912.70 # 51600 42.25 40.14 46.16 51880 434.82 413.08 475.04 51605 36.14 34.33 39.48 51900 771.98 733.38 843.39 51610 100.21 95.20 109.48 51920 710.63 675.10 776.37 # 51610 59.60 56.62 65.11 51925 939.04 892.09 1,025.90 51700 78.84 74.90 86.14 51940 1,531.49 1,454.92 1,673.16 # 51700 42.75 40.61 46.70 51960 1,319.68 1,253.70 1,441.76 51701 53.83 51.14 58.81 51980 673.81 640.12 736.14 # 51701 25.80 24.51 28.19 51990 696.06 661.26 760.45 51702 68.98 65.53 75.36 51992 768.05 729.65 839.10 # 51702 28.38 26.96 31.00 52000 191.42 181.85 209.13 51703 126.45 120.13 138.15 # 52000 119.24 113.28 130.27 # 51703 77.47 73.60 84.64 52001 355.42 337.65 388.30 51705 102.14 97.03 111.58 # 52001 275.18 261.42 300.63 # 51705 63.15 59.99 68.99 52005 260.58 247.55 284.68 51710 143.01 135.86 156.24 # 52005 126.53 120.20 138.23 # 51710 89.84 85.35 98.15 52007 473.01 449.36 516.76 51715 269.97 256.47 294.94 # 52007 158.19 150.28 172.82 # 51715 189.09 179.64 206.59 52010 360.87 342.83 394.25 51720 105.40 100.13 115.15 # 52010 154.64 146.91 168.95 # 51720 77.69 73.81 84.88 52204 386.02 366.72 421.73 51725 193.58 183.90 211.49 # 52204 134.67 127.94 147.13 51725 TC 121.02 114.97 132.22 52214 539.22 512.26 589.10 51725 26 72.56 68.93 79.27 # 52214 202.80 192.66 221.56 51726 282.58 268.45 308.72 52224 701.95 666.85 766.88 51726 TC 200.50 190.48 219.05 # 52224 162.21 154.10 177.22 51726 26 82.08 77.98 89.68 52234 235.98 224.18 257.81 51727 263.30 250.14 287.66 52235 277.11 263.25 302.74 51727 TC 163.23 155.07 178.33 52240 484.80 460.56 529.64 51727 26 100.08 95.08 109.34 52250 232.29 220.68 253.78 51728 263.27 250.11 287.63 52260 200.81 190.77 219.39 51728 TC 164.20 155.99 179.39 52265 373.95 355.25 408.54 51728 26 99.08 94.13 108.25 # 52265 152.58 144.95 166.69 51729 283.92 269.72 310.18 52270 361.75 343.66 395.21 51729 TC 166.13 157.82 181.49 # 52270 173.89 165.20 189.98 51729 26 117.80 111.91 128.70 52275 494.12 469.41 539.82 51736 48.95 46.50 53.48 # 52275 238.91 226.96 261.00 51736 TC 19.51 18.53 21.31 52276 254.84 242.10 278.42 51736 26 29.44 27.97 32.17 52277 313.95 298.25 342.99 51741 77.55 73.67 84.72 52281 275.08 261.33 300.53 51741 TC 22.73 21.59 24.83 # 52281 147.47 140.10 161.12 51741 26 54.82 52.08 59.89 52282 322.50 306.38 352.34 51784 180.56 171.53 197.26 52283 261.56 248.48 285.75 51784 TC 107.48 102.11 117.43 # 52283 192.28 182.67 210.07 51784 26 73.08 69.43 79.84 52285 262.84 249.70 287.16 51785 196.53 186.70 214.71 # 52285 186.15 176.84 203.37 51785 TC 122.95 116.80 134.32 52290 234.59 222.86 256.29 51785 26 73.58 69.90 80.39 52300 270.53 257.00 295.55 51792 200.40 190.38 218.94 52301 281.13 267.07 307.13 51792 TC 147.44 140.07 161.08 52305 267.56 254.18 292.31 51792 26 52.96 50.31 57.86 52310 229.67 218.19 250.92 51797 124.86 118.62 136.41 # 52310 144.92 137.67 158.32 51797 TC 84.93 80.68 92.78 52315 406.20 385.89 443.77 51797 26 39.94 37.94 43.63 # 52315 263.77 250.58 288.17 51798 16.61 15.78 18.15 52317 839.02 797.07 916.63 51800 990.08 940.58 1,081.67 # 52317 334.72 317.98 365.68 51820 1,006.26 955.95 1,099.34 52318 456.35 433.53 498.56 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 45 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 236.98 225.13 258.90 53420 774.03 735.33 845.63 52325 308.12 292.71 336.62 53425 896.11 851.30 979.00 52327 252.62 239.99 275.99 53430 904.95 859.70 988.66 52330 650.50 617.98 710.68 53431 1,098.71 1,043.77 1,200.34 # 52330 253.50 240.83 276.95 53440 836.06 794.26 913.40 52332 440.14 418.13 480.85 53442 736.78 699.94 804.93 # 52332 148.84 141.40 162.61 53444 755.85 718.06 825.77 52334 245.86 233.57 268.61 53445 835.51 793.73 912.79 52341 278.18 264.27 303.91 53446 610.00 579.50 666.43 52342 302.51 287.38 330.49 53447 770.93 732.38 842.24 52343 336.72 319.88 367.86 53448 1,221.39 1,160.32 1,334.37 52344 365.24 346.98 399.03 53449 580.79 551.75 634.51 52345 389.76 370.27 425.81 53450 386.43 367.11 422.18 52346 439.97 417.97 480.67 53460 433.43 411.76 473.52 52351 301.22 286.16 329.08 53500 702.10 667.00 767.05 52352 353.34 335.67 386.02 53502 457.65 434.77 499.99 52353 406.78 386.44 444.41 53505 460.55 437.52 503.15 52354 375.96 357.16 410.73 53510 599.04 569.09 654.45 52355 448.30 425.89 489.77 53515 754.31 716.59 824.08 52400 450.73 428.19 492.42 53520 526.55 500.22 575.25 52402 257.82 244.93 281.67 53600 79.69 75.71 87.07 52450 442.85 420.71 483.82 # 53600 61.32 58.25 66.99 52500 461.36 438.29 504.03 53601 77.15 73.29 84.28 52601 791.83 752.24 865.08 # 53601 51.37 48.80 56.12 52630 420.35 399.33 459.23 53605 62.14 59.03 67.88 52640 281.37 267.30 307.40 53620 113.29 107.63 123.77 52647 1,886.60 1,792.27 2,061.11 # 53620 83.65 79.47 91.39 # 52647 612.48 581.86 669.14 53621 106.46 101.14 116.31 52648 1,931.53 1,834.95 2,110.19 # 53621 69.08 65.63 75.47 # 52648 653.87 621.18 714.36 53660 66.46 63.14 72.61 52649 925.69 879.41 1,011.32 # 53660 39.07 37.12 42.69 52700 412.31 391.69 450.44 53661 65.84 62.55 71.93 53000 139.97 132.97 152.92 # 53661 38.45 36.53 42.01 53010 276.31 262.49 301.86 53665 36.65 34.82 40.04 53020 92.75 88.11 101.33 53850 2,142.05 2,034.95 2,340.19 53025 61.88 58.79 67.61 # 53850 539.25 512.29 589.13 53040 369.41 350.94 403.58 53852 2,068.11 1,964.70 2,259.41 53060 165.09 156.84 180.37 # 53852 588.72 559.28 643.17 # 53060 147.69 140.31 161.36 53855 584.45 555.23 638.51 53080 405.99 385.69 443.54 # 53855 76.28 72.47 83.34 53085 590.06 560.56 644.64 54000 142.54 135.41 155.72 53200 145.81 138.52 159.30 # 54000 100.65 95.62 109.96 # 53200 133.56 126.88 145.91 54001 176.62 167.79 192.96 53210 730.94 694.39 798.55 # 54001 130.22 123.71 142.27 53215 885.39 841.12 967.29 54015 293.06 278.41 320.17 53220 426.83 405.49 466.31 54050 112.65 107.02 123.07 53230 570.63 542.10 623.42 # 54050 91.06 86.51 99.49 53235 602.66 572.53 658.41 54055 105.75 100.46 115.53 53240 403.34 383.17 440.65 # 54055 82.55 78.42 90.18 53250 382.65 363.52 418.05 54056 118.95 113.00 129.95 53260 186.31 176.99 203.54 # 54056 94.78 90.04 103.55 # 53260 166.66 158.33 182.08 54057 125.18 118.92 136.76 53265 205.35 195.08 224.34 # 54057 86.19 81.88 94.16 # 53265 174.42 165.70 190.56 54060 168.71 160.27 184.31 53270 192.44 182.82 210.24 # 54060 120.38 114.36 131.51 # 53270 173.75 165.06 189.82 54065 191.47 181.90 209.19 53275 250.21 237.70 273.36 # 54065 150.87 143.33 164.83 53400 758.95 721.00 829.15 54100 172.73 164.09 188.70 53405 833.14 791.48 910.20 # 54100 111.51 105.93 121.82 53410 932.53 885.90 1,018.79 54105 254.28 241.57 277.81 53415 1,076.57 1,022.74 1,176.15 # 54105 202.40 192.28 221.12 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 99 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 591.53 561.95 646.24 54411 975.15 926.39 1,065.35 54111 763.22 725.06 833.82 54415 499.54 474.56 545.74 54112 895.71 850.92 978.56 54416 671.56 637.98 733.68 54115 424.75 403.51 464.04 54417 854.10 811.40 933.11 # 54115 398.97 379.02 435.87 54420 672.37 638.75 734.56 54120 599.02 569.07 654.43 54430 609.28 578.82 665.64 54125 772.37 733.75 843.81 54435 394.58 374.85 431.08 54130 1,138.44 1,081.52 1,243.75 54450 68.01 64.61 74.30 54135 1,446.22 1,373.91 1,580.00 # 54450 55.77 52.98 60.93 54150 152.26 144.65 166.35 54500 71.24 67.68 77.83 # 54150 92.64 88.01 101.21 54505 200.19 190.18 218.71 54160 212.00 201.40 231.61 54512 507.67 482.29 554.63 # 54160 136.92 130.07 149.58 54520 305.04 289.79 333.26 54161 186.21 176.90 203.44 54522 549.51 522.03 600.33 54162 248.73 236.29 271.73 54530 478.37 454.45 522.62 # 54162 186.53 177.20 203.78 54535 698.30 663.39 762.90 54163 204.72 194.48 223.65 54550 463.03 439.88 505.86 54164 180.39 171.37 197.08 54560 634.88 603.14 693.61 54200 101.18 96.12 110.54 54600 428.00 406.60 467.59 # 54200 78.94 74.99 86.24 54620 286.17 271.86 312.64 54205 507.35 481.98 554.28 54640 442.72 420.58 483.67 54220 193.86 184.17 211.80 54650 668.50 635.08 730.34 # 54220 127.80 121.41 139.62 54660 334.75 318.01 365.71 54230 90.65 86.12 99.04 54670 381.44 362.37 416.73 # 54230 75.50 71.73 82.49 54680 740.80 703.76 809.32 54231 131.30 124.74 143.45 54690 628.80 597.36 686.96 # 54231 111.00 105.45 121.27 54692 724.55 688.32 791.57 54235 83.98 79.78 91.75 54700 199.40 189.43 217.84 # 54235 69.15 65.69 75.54 54800 129.93 123.43 141.94 54240 92.65 88.02 101.22 54830 349.38 331.91 381.70 54240 TC 29.50 28.03 32.23 54840 303.90 288.71 332.02 54240 26 63.15 59.99 68.99 54860 395.11 375.35 431.65 54250 117.54 111.66 128.41 54861 534.87 508.13 584.35 54250 TC 10.49 9.97 11.47 54865 336.29 319.48 367.40 54250 26 107.05 101.70 116.96 54900 728.52 692.09 795.90 54300 613.67 582.99 670.44 54901 1,007.93 957.53 1,101.16 54304 719.00 683.05 785.51 55000 111.21 105.65 121.50 54308 684.57 650.34 747.89 # 55000 79.63 75.65 87.00 54312 785.03 745.78 857.65 55040 317.19 301.33 346.53 54316 957.15 909.29 1,045.68 55041 479.57 455.59 523.93 54318 679.34 645.37 742.18 55060 356.38 338.56 389.34 54322 749.02 711.57 818.31 55100 199.63 189.65 218.10 54324 931.03 884.48 1,017.15 # 55100 152.58 144.95 166.69 54326 883.42 839.25 965.14 55110 362.95 344.80 396.52 54328 892.90 848.26 975.50 55120 333.48 316.81 364.33 54332 970.69 922.16 1,060.48 55150 459.99 436.99 502.54 54336 1,098.23 1,043.32 1,199.82 55175 341.41 324.34 372.99 54340 536.18 509.37 585.78 55180 648.24 615.83 708.20 54344 909.62 864.14 993.76 55200 437.67 415.79 478.16 54348 974.84 926.10 1,065.02 # 55200 260.12 247.11 284.18 54352 1,362.76 1,294.62 1,488.81 55250 384.33 365.11 419.88 54360 690.63 656.10 754.52 # 55250 211.94 201.34 231.54 54380 765.49 727.22 836.30 55300 172.80 164.16 188.78 54385 950.50 902.98 1,038.43 55400 474.99 451.24 518.93 54390 1,139.89 1,082.90 1,245.34 55450 348.44 331.02 380.67 54400 504.66 479.43 551.34 # 55450 241.78 229.69 264.14 54401 618.66 587.73 675.89 55500 357.78 339.89 390.87 54405 770.74 732.20 842.03 55520 377.77 358.88 412.71 54406 694.30 659.59 758.53 55530 331.80 315.21 362.49 54408 750.14 712.63 819.52 55535 403.94 383.74 441.30 54410 819.17 778.21 894.94 55540 455.51 432.73 497.64 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 47 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 398.81 378.87 435.70 56810 230.30 218.79 251.61 55600 398.48 378.56 435.34 56820 96.19 91.38 105.09 55605 478.76 454.82 523.04 # 56820 75.24 71.48 82.20 55650 676.59 642.76 739.17 56821 128.45 122.03 140.33 55680 320.08 304.08 349.69 # 56821 101.70 96.62 111.11 55700 211.02 200.47 230.54 57000 168.26 159.85 183.83 # 55700 131.42 124.85 143.58 57010 380.89 361.85 416.13 55705 254.18 241.47 277.69 57020 82.66 78.53 90.31 55706 359.49 341.52 392.75 # 57020 72.34 68.72 79.03 55720 427.26 405.90 466.79 57022 147.99 140.59 161.68 55725 557.04 529.19 608.57 57023 275.25 261.49 300.71 55801 1,035.17 983.41 1,130.92 57061 98.38 93.46 107.48 55810 1,252.92 1,190.27 1,368.81 # 57061 84.85 80.61 92.70 55812 1,535.13 1,458.37 1,677.13 57065 167.62 159.24 183.13 55815 1,684.54 1,600.31 1,840.36 # 57065 150.22 142.71 164.12 55821 832.13 790.52 909.10 57100 76.69 72.86 83.79 55831 901.42 856.35 984.80 # 57100 58.32 55.40 63.71 55840 1,276.40 1,212.58 1,394.47 57105 117.77 111.88 128.66 55842 1,367.44 1,299.07 1,493.93 # 57105 109.06 103.61 119.15 55845 1,563.48 1,485.31 1,708.11 57106 421.74 400.65 460.75 55860 833.77 792.08 910.89 57107 1,240.56 1,178.53 1,355.31 55862 1,048.69 996.26 1,145.70 57109 1,422.30 1,351.19 1,553.87 55865 1,275.57 1,211.79 1,393.56 57110 795.92 756.12 869.54 55866 1,662.20 1,579.09 1,815.95 57111 1,433.90 1,362.21 1,566.54 55870 164.29 156.08 179.49 57112 1,496.83 1,421.99 1,635.29 # 55870 136.58 129.75 149.21 57120 451.91 429.31 493.71 55873 5,236.46 4,974.64 5,720.84 57130 157.10 149.25 171.64 # 55873 824.41 783.19 900.67 # 57130 140.99 133.94 154.03 55875 724.29 688.08 791.29 57135 168.51 160.08 184.09 55876 127.60 121.22 139.40 # 57135 152.08 144.48 166.15 # 55876 96.66 91.83 105.60 57150 42.89 40.75 46.86 55920 413.16 392.50 451.38 # 57150 26.46 25.14 28.91 56405 95.20 90.44 104.01 57155 373.86 355.17 408.45 # 56405 93.59 88.91 102.25 57160 66.51 63.18 72.66 56420 108.11 102.70 118.11 # 57160 42.66 40.53 46.61 # 56420 81.36 77.29 88.88 57170 58.68 55.75 64.11 56440 161.32 153.25 176.24 # 57170 43.21 41.05 47.21 56441 129.74 123.25 141.74 57180 123.11 116.95 134.49 # 56441 123.62 117.44 135.06 # 57180 93.79 89.10 102.47 56442 42.43 40.31 46.36 57200 261.24 248.18 285.41 56501 113.15 107.49 123.61 57210 323.36 307.19 353.27 # 56501 99.29 94.33 108.48 57220 281.92 267.82 307.99 56515 194.83 185.09 212.85 57230 353.81 336.12 386.54 # 56515 173.89 165.20 189.98 57240 596.24 566.43 651.39 56605 72.39 68.77 79.09 57250 590.38 560.86 644.99 # 56605 53.70 51.02 58.67 57260 731.52 694.94 799.18 56606 33.55 31.87 36.65 57265 807.99 767.59 882.73 # 56606 26.46 25.14 28.91 57267 235.35 223.58 257.12 56620 436.38 414.56 476.74 57268 424.67 403.44 463.96 56625 527.08 500.73 575.84 57270 708.06 672.66 773.56 56630 773.07 734.42 844.58 57280 856.22 813.41 935.42 56631 983.08 933.93 1,074.02 57282 445.50 423.23 486.71 56632 1,138.54 1,081.61 1,243.85 57283 613.25 582.59 669.98 56633 1,008.62 958.19 1,101.92 57284 739.25 702.29 807.63 56634 1,064.43 1,011.21 1,162.89 57285 603.89 573.70 659.76 56637 1,255.39 1,192.62 1,371.51 57287 620.92 589.87 678.35 56640 1,246.94 1,184.59 1,362.28 57288 648.19 615.78 708.15 56700 164.24 156.03 179.43 57289 673.27 639.61 735.55 56740 262.22 249.11 286.48 57291 477.07 453.22 521.20 56800 214.02 203.32 233.82 57292 733.67 696.99 801.54 56805 1,017.07 966.22 1,111.15 57295 430.41 408.89 470.22 0 # - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. 0 LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. 0 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2009 BY THE AMERICAN MEDICAL ASSOCIATION. 1HNPRDS10 MAINE - MEDICARE CARRIER 14102 PAGE 48 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 844.13 801.92 922.21 58110 42.83 40.69 46.79 57300 477.49 453.62 521.66 # 58110 37.03 35.18 40.46 57305 794.91 755.16 868.43 58120 220.55 209.52 240.95 57307 895.14 850.38 977.94 # 58120 191.55 181.97 209.27 57308 562.06 533.96 614.05 58140 808.87 768.43 883.69 57310 429.32 407.85 469.03 58145 478.92 454.97 523.22 57311 489.30 464.84 534.57 58146 1,026.04 974.74 1,120.95 57320 490.57 466.04 535.95 58150 878.06 834.16 959.28 57330 690.94 656.39 754.85 58152 1,104.45 1,049.23 1,206.61 57335 1,035.49 983.72 1,131.28 58180 845.37 803.10 923.57 57400 119.04 113.09 130.05 58200 1,158.47 1,100.55 1,265.63 57410 94.27 89.56 102.99 58210 1,546.55 1,469.22 1,689.60 57415 141.14 134.08 154.19 58240 2,457.79 2,334.90 2,685.14 57420 100.95 95.90 110.29 58260 731.62 695.04 799.30 # 57420 79.68 75.70 87.06 58262 816.67 775.84 892.22 57421 136.27 129.46 148.88 58263 879.76 835.77 961.14 # 57421 108.88 103.44 118.96 58267 935.01 888.26 1,021.50 57423 821.10 780.05 897.06 58270 781.58 742.50 853.88 57425 865.79 822.50 945.88 58275 871.50 827.93 952.12 57426 771.98 733.38 843.39 58280 932.47 885.85 1,018.73 57452 95.05 90.30 103.85 58285 1,165.68 1,107.40 1,273.51 # 57452 80.87 76.83 88.35 58290 1,021.83 970.74 1,116.35 57454 135.16 128.40 147.66 58291 1,109.46 1,053.99 1,212.09 # 57454 120.65 114.62 131.81 58292 1,169.29 1,110.83 1,277.45 57455 124.90 118.66 136.46 58293 1,214.96 1,154.21 1,327.34 # 57455 98.47 93.55 107.58 58294 1,081.34 1,027.27 1,181.36 57456 118.07 112.17 129.00 58301 83.48 79.31 91.21 # 57456 91.97 87.37 100.48 # 58301 60.61 57.58 66.22 57460 252.83 240.19 276.22 58321 67.30 63.94 73.53 # 57460 144.88 137.64 158.29 # 58321 43.14 40.98 47.13 57461 284.89 270.65 311.25 58322 75.62 71.84 82.62 # 57461 167.59 159.21 183.09 # 58322 52.42 49.80 57.27 57500 112.46 106.84 122.87 58323 15.93 15.13 17.40 # 57500 66.05 62.75 72.16 # 58323 11.09 10.54 12.12 57505 88.26 83.85 96.43 58340 107.40 102.03 117.33 # 57505 79.56 75.58 86.92 # 58340 51.98 49.38 56.79 57510 115.47 109.70 126.16 58345 248.35 235.93 271.32 # 57510 101.94 96.84 111.37 58346 402.36 382.24 439.58 57511 126.88 120.54 138.62 58350 83.72 79.53 91.46 # 57511 115.60 109.82 126.29 # 58350 68.57 65.14 74.91 57513 125.27 119.01 136.86 58353 931.10 884.55 1,017.23 # 57513 115.92 110.12 126.64 # 58353 194.15 184.44 212.11 57520 267.38 254.01 292.11 58356 1,713.78 1,628.09 1,872.30 # 57520 239.02 227.07 261.13 # 58356 309.80 294.31 338.46 57522 230.27 218.76 251.57 58400 392.82 373.18 429.16 # 57522 213.19 202.53 232.91 58410 711.20 675.64 776.99 57530 302.54 287.41 330.52 58520 706.70 671.37 772.08 57531 1,509.27 1,433.81 1,648.88 58540 803.18 763.02 877.47 57540 688.89 654.45 752.62 58541 759.36 721.39 829.60 57545 727.63 691.25 794.94 58542 847.99 805.59 926.43 57550 358.75 340.81 391.93 58543 862.36 819.24 942.13 57555 529.87 503.38 578.89 58544 932.13 885.52 1,018.35 57556 504.79 479.55 551.48 58545 791.36 751.79 864.56 57558 109.34 103.87 119.45 58546 1,000.64 950.61 1,093.20 # 57558 99.67 94.69 108.89 58548 1,574.01 1,495.31 1,719.61 57700 271.55 257.97 296.67 58550 780.73 741.69 852.94 57720 270.01 256.51 294.99 58552 866.83 823.49 947.01 57800 52.17 49.56 56.99 58553 1,006.45 956.13 1,099.55 # 57800 42.83 40.69 46.79 58554 1,162.72 1,104.58 1,270.27 58100 95.94 91.14 104.81 58555 221.62 210.54 242.12 # 58100 77.57 73.69 84.74 # 58555 168.45 160.03 184.03 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 49 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 297.43 282.56 324.94 59001 158.65 150.72 173.33 # 58558 237.50 225.63 259.47 59012 175.84 167.05 192.11 58559 305.78 290.49 334.06 59015 133.34 126.67 145.67 58560 345.71 328.42 377.68 # 59015 114.65 108.92 125.26 58561 489.11 464.65 534.35 59020 57.76 54.87 63.10 58562 313.50 297.83 342.50 59020 TC 25.63 24.35 28.00 # 58562 259.04 246.09 283.00 59020 26 32.13 30.52 35.10 58563 1,520.43 1,444.41 1,661.07 59025 39.69 37.71 43.37 # 58563 305.60 290.32 333.87 59025 TC 13.71 13.02 14.97 58565 1,633.36 1,551.69 1,784.44 59025 26 25.97 24.67 28.37 # 58565 383.09 363.94 418.53 59030 92.44 87.82 100.99 58570 815.73 774.94 891.18 59050 43.76 41.57 47.81 58571 902.45 857.33 985.93 59051 36.41 34.59 39.78 58572 1,013.61 962.93 1,107.37 59070 357.03 339.18 390.06 58573 1,157.85 1,099.96 1,264.95 # 59070 271.64 258.06 296.77 58600 320.23 304.22 349.85 59072 457.06 434.21 499.34 58605 290.35 275.83 317.20 59074 345.76 328.47 377.74 58611 69.14 65.68 75.53 # 59074 271.32 257.75 296.41 58615 217.94 207.04 238.10 59076 450.29 427.78 491.95 58660 593.41 563.74 648.30 59100 713.02 677.37 778.98 58661 569.95 541.45 622.67 59120 681.72 647.63 744.77 58662 623.66 592.48 681.35 59121 683.54 649.36 746.76 58670 322.17 306.06 351.97 59130 754.30 716.59 824.08 58671 321.52 305.44 351.26 59135 760.35 722.33 830.68 58672 653.07 620.42 713.48 59136 754.35 716.63 824.12 58673 711.37 675.80 777.17 59140 324.63 308.40 354.66 58700 677.60 643.72 740.28 59150 659.70 626.72 720.73 58720 633.92 602.22 692.55 59151 644.22 612.01 703.81 58740 772.63 734.00 844.10 59160 180.83 171.79 197.56 58750 799.93 759.93 873.92 # 59160 153.44 145.77 167.64 58752 784.09 744.89 856.62 59200 62.49 59.37 68.28 58760 719.94 683.94 786.53 # 59200 38.96 37.01 42.56 58770 746.50 709.18 815.56 59300 163.75 155.56 178.89 58800 281.63 267.55 307.68 # 59300 126.69 120.36 138.41 # 58800 263.91 250.71 288.32 59320 131.88 125.29 144.08 58805 356.87 339.03 389.88 59325 198.62 188.69 216.99 58820 274.92 261.17 300.35 59350 240.83 228.79 263.11 58822 636.20 604.39 695.05 59400 1,545.62 1,468.34 1,688.59 58823 769.79 731.30 841.00 59409 663.57 630.39 724.95 # 58823 161.09 153.04 176.00 59410 776.20 737.39 848.00 58825 614.59 583.86 671.44 59412 89.42 84.95 97.69 58900 374.12 355.41 408.72 59414 79.47 75.50 86.83 58920 617.62 586.74 674.75 59425 391.98 372.38 428.24 58925 648.55 616.12 708.54 # 59425 312.39 296.77 341.29 58940 446.48 424.16 487.78 59426 703.22 668.06 768.27 58943 990.59 941.06 1,082.22 # 59426 554.66 526.93 605.97 58950 945.83 898.54 1,033.32 59430 119.74 113.75 130.81 58951 1,219.22 1,158.26 1,332.00 # 59430 108.46 103.04 118.50 58952 1,375.15 1,306.39 1,502.35 59510 1,749.63 1,662.15 1,911.47 58953 1,704.34 1,619.12 1,861.99 59514 787.32 747.95 860.14 58954 1,849.00 1,756.55 2,020.03 59515 938.19 891.28 1,024.97 58956 1,162.01 1,103.91 1,269.50 59525 421.12 400.06 460.07 58957 1,319.56 1,253.58 1,441.62 59610 1,626.18 1,544.87 1,776.60 58958 1,460.60 1,387.57 1,595.71 59612 745.01 707.76 813.92 58960 815.43 774.66 890.86 59614 837.49 795.62 914.96 58970 192.41 182.79 210.21 59618 1,827.74 1,736.35 1,996.80 # 58970 172.43 163.81 188.38 59620 864.92 821.67 944.92 58976 218.47 207.55 238.68 59622 1,016.30 965.49 1,110.31 # 58976 191.40 181.83 209.10 59812 271.11 257.55 296.18 59000 108.89 103.45 118.97 # 59812 252.10 239.50 275.43 # 59000 69.90 66.41 76.37 59820 322.97 306.82 352.84 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 50 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 302.03 286.93 329.97 61151 805.37 765.10 879.87 59821 326.27 309.96 356.45 61154 1,031.30 979.74 1,126.70 # 59821 304.36 289.14 332.51 61156 1,024.42 973.20 1,119.18 59830 374.68 355.95 409.34 61210 310.68 295.15 339.42 59840 184.39 175.17 201.45 61215 401.89 381.80 439.07 # 59840 177.94 169.04 194.40 61250 697.88 662.99 762.44 59841 326.11 309.80 356.27 61253 738.89 701.95 807.24 # 59841 308.71 293.27 337.26 61304 1,351.77 1,284.18 1,476.81 59850 315.83 300.04 345.05 61305 1,652.15 1,569.54 1,804.97 59851 342.20 325.09 373.85 61312 1,714.26 1,628.55 1,872.83 59852 455.05 432.30 497.15 61313 1,628.43 1,547.01 1,779.06 59855 356.52 338.69 389.49 61314 1,500.10 1,425.10 1,638.87 59856 419.98 398.98 458.83 61315 1,705.86 1,620.57 1,863.66 59857 475.61 451.83 519.60 61316 73.48 69.81 80.28 59866 196.51 186.68 214.68 61320 1,573.34 1,494.67 1,718.87 59870 404.56 384.33 441.98 61321 1,739.49 1,652.52 1,900.40 59871 115.59 109.81 126.28 61322 1,940.55 1,843.52 2,120.05 60000 137.53 130.65 150.25 61323 1,963.46 1,865.29 2,145.08 # 60000 125.61 119.33 137.23 61330 1,426.52 1,355.19 1,558.47 60100 100.11 95.10 109.37 61332 1,608.22 1,527.81 1,756.98 # 60100 74.01 70.31 80.86 61333 1,662.21 1,579.10 1,815.97 60200 567.34 538.97 619.82 61334 1,105.27 1,050.01 1,207.51 60210 606.37 576.05 662.46 61340 1,178.78 1,119.84 1,287.82 60212 868.27 824.86 948.59 61343 1,815.12 1,724.36 1,983.01 60220 664.09 630.89 725.52 61345 1,680.45 1,596.43 1,835.89 60225 798.28 758.37 872.13 61440 1,646.40 1,564.08 1,798.69 60240 841.54 799.46 919.38 61450 1,579.64 1,500.66 1,725.76 60252 1,143.19 1,086.03 1,248.93 61458 1,657.12 1,574.26 1,810.40 60254 1,472.00 1,398.40 1,608.16 61460 1,718.37 1,632.45 1,877.32 60260 951.55 903.97 1,039.57 61470 1,580.08 1,501.08 1,726.24 60270 1,203.46 1,143.29 1,314.78 61480 1,398.96 1,329.01 1,528.36 60271 921.14 875.08 1,006.34 61490 1,562.63 1,484.50 1,707.18 60280 382.06 362.96 417.40 61500 1,113.24 1,057.58 1,216.22 60281 510.82 485.28 558.07 61501 959.20 911.24 1,047.93 60300 94.06 89.36 102.76 61510 1,795.05 1,705.30 1,961.10 # 60300 45.73 43.44 49.96 61512 2,110.23 2,004.72 2,305.43 60500 875.63 831.85 956.63 61514 1,569.82 1,491.33 1,715.03 60502 1,100.27 1,045.26 1,202.05 61516 1,527.69 1,451.31 1,669.01 60505 1,206.91 1,146.56 1,318.54 61517 73.45 69.78 80.25 60512 213.11 202.45 232.82 61518 2,098.94 1,993.99 2,293.09 60520 895.71 850.92 978.56 61519 2,265.31 2,152.04 2,474.85 60521 1,016.88 966.04 1,110.95 61520 2,974.86 2,826.12 3,250.04 60522 1,231.18 1,169.62 1,345.06 61521 2,454.15 2,331.44 2,681.16 60540 940.83 893.79 1,027.86 61522 1,805.27 1,715.01 1,972.26 60545 1,075.32 1,021.55 1,174.78 61524 1,709.45 1,623.98 1,867.58 60600 1,267.71 1,204.32 1,384.97 61526 2,801.19 2,661.13 3,060.30 60605 1,614.20 1,533.49 1,763.51 61530 2,352.19 2,234.58 2,569.77 60650 1,051.22 998.66 1,148.46 61531 995.59 945.81 1,087.68 61000 95.47 90.70 104.31 61533 1,249.69 1,187.21 1,365.29 61001 102.62 97.49 112.11 61534 1,348.80 1,281.36 1,473.56 61020 110.37 104.85 120.58 61535 810.80 770.26 885.80 61026 108.43 103.01 118.46 61536 2,137.46 2,030.59 2,335.18 61050 93.18 88.52 101.80 61537 2,019.14 1,918.18 2,205.91 61055 121.09 115.04 132.30 61538 1,998.97 1,899.02 2,183.87 61070 69.47 66.00 75.90 61539 1,941.52 1,844.44 2,121.11 61105 364.78 346.54 398.52 61540 1,802.38 1,712.26 1,969.10 61107 265.84 252.55 290.43 61541 1,768.24 1,679.83 1,931.80 61108 730.30 693.79 797.86 61542 1,892.16 1,797.55 2,067.18 61120 600.70 570.67 656.27 61543 1,776.42 1,687.60 1,940.74 61140 1,028.98 977.53 1,124.16 61544 1,500.21 1,425.20 1,638.98 61150 1,107.25 1,051.89 1,209.67 61545 2,446.70 2,324.37 2,673.03 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 51 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,900.54 1,805.51 2,076.34 61705 2,130.51 2,023.98 2,327.58 61548 1,312.09 1,246.49 1,433.46 61708 1,849.02 1,756.57 2,020.06 61550 833.26 791.60 910.34 61710 1,644.53 1,562.30 1,796.65 61552 1,089.10 1,034.65 1,189.85 61711 2,149.27 2,041.81 2,348.08 61556 1,381.95 1,312.85 1,509.78 61720 1,009.12 958.66 1,102.46 61557 1,383.33 1,314.16 1,511.28 61735 1,261.18 1,198.12 1,377.84 61558 1,544.25 1,467.04 1,687.10 61750 1,155.36 1,097.59 1,262.23 61559 1,801.47 1,711.40 1,968.11 61751 1,124.92 1,068.67 1,228.97 61563 1,633.39 1,551.72 1,784.48 61760 1,278.68 1,214.75 1,396.96 61564 1,988.27 1,888.86 2,172.19 61770 1,304.07 1,238.87 1,424.70 61566 1,861.92 1,768.82 2,034.14 61790 702.07 666.97 767.02 61567 2,125.03 2,018.78 2,321.60 61791 905.78 860.49 989.56 61570 1,525.44 1,449.17 1,666.55 61795 209.28 198.82 228.64 61571 1,640.40 1,558.38 1,792.14 61796 735.14 698.38 803.14 61575 2,041.60 1,939.52 2,230.45 61797 169.76 161.27 185.46 61576 3,120.93 2,964.88 3,409.61 61798 962.24 914.13 1,051.25 61580 2,089.25 1,984.79 2,282.51 61799 234.07 222.37 255.73 61581 2,333.17 2,216.51 2,548.99 61800 117.44 111.57 128.31 61582 2,409.76 2,289.27 2,632.66 61850 803.64 763.46 877.98 61583 2,375.88 2,257.09 2,595.65 61860 1,288.95 1,224.50 1,408.18 61584 2,331.38 2,214.81 2,547.03 61863 1,232.85 1,171.21 1,346.89 61585 2,389.57 2,270.09 2,610.60 61864 240.26 228.25 262.49 61586 1,867.21 1,773.85 2,039.93 61867 1,887.08 1,792.73 2,061.64 61590 2,651.87 2,519.28 2,897.17 61868 422.76 401.62 461.86 61591 2,672.21 2,538.60 2,919.39 61870 973.97 925.27 1,064.06 61592 2,431.32 2,309.75 2,656.21 61875 884.65 840.42 966.48 61595 2,013.37 1,912.70 2,199.61 61880 452.78 430.14 494.66 61596 2,198.33 2,088.41 2,401.67 61885 530.76 504.22 579.85 61597 2,229.64 2,118.16 2,435.88 61886 670.83 637.29 732.88 61598 2,212.45 2,101.83 2,417.10 61888 322.94 306.79 352.81 61600 1,812.56 1,721.93 1,980.22 62000 794.24 754.53 867.71 61601 1,950.86 1,853.32 2,131.32 62005 1,032.02 980.42 1,127.48 61605 1,901.24 1,806.18 2,077.11 62010 1,246.07 1,183.77 1,361.34 61606 2,497.06 2,372.21 2,728.04 62100 1,335.35 1,268.58 1,458.87 61607 2,209.18 2,098.72 2,413.53 62115 1,108.11 1,052.70 1,210.61 61608 2,498.93 2,373.98 2,730.08 62116 1,458.09 1,385.19 1,592.97 61609 517.92 492.02 565.82 62117 1,532.33 1,455.71 1,674.07 61610 1,574.55 1,495.82 1,720.19 62120 1,491.94 1,417.34 1,629.94 61611 363.69 345.51 397.34 62121 1,423.78 1,352.59 1,555.48 61612 1,343.48 1,276.31 1,467.76 62140 858.32 815.40 937.71 61613 2,495.68 2,370.90 2,726.54 62141 944.29 897.08 1,031.64 61615 2,044.44 1,942.22 2,233.55 62142 723.94 687.74 790.90 61616 2,575.85 2,447.06 2,814.12 62143 847.31 804.94 925.68 61618 1,081.70 1,027.62 1,181.76 62145 1,164.23 1,106.02 1,271.92 61619 1,250.06 1,187.56 1,365.69 62146 1,011.01 960.46 1,104.53 61623 497.73 472.84 543.77 62147 1,197.16 1,137.30 1,307.90 61624 994.17 944.46 1,086.13 62148 105.87 100.58 115.67 61626 801.58 761.50 875.73 62160 160.17 152.16 174.98 61630 1,134.53 1,077.80 1,239.47 62161 1,245.97 1,183.67 1,361.22 61635 1,234.78 1,173.04 1,349.00 62162 1,559.13 1,481.17 1,703.35 61680 1,868.14 1,774.73 2,040.94 62163 1,002.87 952.73 1,095.64 61682 3,312.74 3,147.10 3,619.17 62164 1,697.77 1,612.88 1,854.81 61684 2,161.12 2,053.06 2,361.02 62165 1,315.89 1,250.10 1,437.62 61686 3,569.36 3,390.89 3,899.52 62180 1,315.98 1,250.18 1,437.71 61690 1,797.11 1,707.25 1,963.34 62190 748.35 710.93 817.57 61692 2,855.39 2,712.62 3,119.51 62192 797.49 757.62 871.26 61697 3,313.86 3,148.17 3,620.40 62194 328.13 311.72 358.48 61698 3,630.82 3,449.28 3,966.67 62200 1,129.01 1,072.56 1,233.44 61700 2,669.66 2,536.18 2,916.61 62201 976.93 928.08 1,067.29 61702 3,134.02 2,977.32 3,423.92 62220 832.49 790.87 909.50 61703 1,114.52 1,058.79 1,217.61 62223 860.54 817.51 940.14 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 52 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 413.36 392.69 451.59 63012 990.61 941.08 1,082.24 62230 688.02 653.62 751.66 63015 1,223.54 1,162.36 1,336.71 62252 83.99 79.79 91.76 63016 1,259.87 1,196.88 1,376.41 62252 TC 44.97 42.72 49.13 63017 1,031.00 979.45 1,126.37 62252 26 39.02 37.07 42.63 63020 967.34 918.97 1,056.82 62256 480.61 456.58 525.07 63030 802.48 762.36 876.71 62258 924.01 877.81 1,009.48 63035 166.47 158.15 181.87 62263 575.16 546.40 628.36 63040 1,171.57 1,112.99 1,279.94 # 62263 342.19 325.08 373.84 63042 1,091.67 1,037.09 1,192.65 62264 346.70 329.37 378.78 63043 389.76 370.27 425.81 # 62264 206.53 196.20 225.63 63044 354.43 336.71 387.22 62267 224.10 212.90 244.84 63045 1,053.54 1,000.86 1,150.99 # 62267 147.40 140.03 161.03 63046 1,009.08 958.63 1,102.42 62268 386.13 366.82 421.84 63047 917.79 871.90 1,002.69 # 62268 233.39 221.72 254.98 63048 182.86 173.72 199.78 62269 414.17 393.46 452.48 63050 1,280.32 1,216.30 1,398.75 # 62269 239.52 227.54 261.67 63051 1,440.05 1,368.05 1,573.26 62270 132.25 125.64 144.49 63055 1,353.46 1,285.79 1,478.66 # 62270 69.73 66.24 76.18 63056 1,242.97 1,180.82 1,357.94 62272 157.93 150.03 172.53 63057 277.32 263.45 302.97 # 62272 72.86 69.22 79.60 63064 1,479.06 1,405.11 1,615.88 62273 143.50 136.33 156.78 63066 174.80 166.06 190.97 # 62273 99.35 94.38 108.54 63075 1,147.19 1,089.83 1,253.30 62280 262.03 248.93 286.27 63076 214.54 203.81 234.38 # 62280 136.68 129.85 149.33 63077 1,273.18 1,209.52 1,390.95 62281 245.87 233.58 268.62 63078 170.17 161.66 185.91 # 62281 132.45 125.83 144.70 63081 1,484.17 1,409.96 1,621.45 62282 248.31 235.89 271.27 63082 231.20 219.64 252.59 # 62282 122.31 116.19 133.62 63085 1,614.08 1,533.38 1,763.39 62284 184.66 175.43 201.74 63086 166.89 158.55 182.33 # 62284 79.29 75.33 86.63 63087 2,042.44 1,940.32 2,231.37 62287 482.62 458.49 527.26 63088 225.79 214.50 246.68 62290 279.62 265.64 305.49 63090 1,684.85 1,600.61 1,840.70 # 62290 151.37 143.80 165.37 63091 156.74 148.90 171.24 62291 262.61 249.48 286.90 63101 1,937.60 1,840.72 2,116.83 # 62291 145.64 138.36 159.11 63102 1,904.80 1,809.56 2,080.99 62292 435.71 413.92 476.01 63103 254.08 241.38 277.59 62294 648.37 615.95 708.34 63170 1,291.05 1,226.50 1,410.48 62310 188.63 179.20 206.08 63172 1,152.46 1,094.84 1,259.07 # 62310 91.31 86.74 99.75 63173 1,417.68 1,346.80 1,548.82 62311 164.15 155.94 179.33 63180 1,158.08 1,100.18 1,265.21 # 62311 75.53 71.75 82.51 63182 1,265.59 1,202.31 1,382.66 62318 197.01 187.16 215.23 63185 975.20 926.44 1,065.41 # 62318 90.02 85.52 98.35 63190 1,079.02 1,025.07 1,178.83 62319 179.83 170.84 196.47 63191 994.98 945.23 1,087.01 # 62319 84.77 80.53 92.61 63194 1,204.86 1,144.62 1,316.31 62350 332.57 315.94 363.33 63195 1,251.70 1,189.12 1,367.49 62351 709.49 674.02 775.12 63196 1,334.92 1,268.17 1,458.40 62355 250.64 238.11 273.83 63197 1,402.19 1,332.08 1,531.89 62360 252.19 239.58 275.52 63198 1,449.95 1,377.45 1,584.07 62361 333.07 316.42 363.88 63199 1,623.17 1,542.01 1,773.31 62362 346.60 329.27 378.66 63200 1,250.33 1,187.81 1,365.98 62365 274.93 261.18 300.36 63250 2,270.57 2,157.04 2,480.60 62367 34.13 32.42 37.28 63251 2,331.46 2,214.89 2,547.12 # 62367 21.88 20.79 23.91 63252 2,328.85 2,212.41 2,544.27 62368 49.01 46.56 53.54 63265 1,379.30 1,310.34 1,506.89 # 62368 34.19 32.48 37.35 63266 1,421.11 1,350.05 1,552.56 63001 1,021.09 970.04 1,115.55 63267 1,140.72 1,083.68 1,246.23 63003 1,027.29 975.93 1,122.32 63268 1,177.38 1,118.51 1,286.29 63005 978.08 929.18 1,068.56 63270 1,704.69 1,619.46 1,862.38 63011 912.88 867.24 997.33 63271 1,709.48 1,624.01 1,867.61 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 53 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 1,576.35 1,497.53 1,722.16 64412 121.57 115.49 132.81 63273 1,507.76 1,432.37 1,647.23 # 64412 63.25 60.09 69.10 63275 1,484.48 1,410.26 1,621.80 64413 99.74 94.75 108.96 63276 1,475.72 1,401.93 1,612.22 # 64413 68.81 65.37 75.18 63277 1,290.85 1,226.31 1,410.26 64415 110.01 104.51 120.19 63278 1,289.83 1,225.34 1,409.14 # 64415 64.90 61.66 70.91 63280 1,747.78 1,660.39 1,909.45 64416 76.06 72.26 83.10 63281 1,727.65 1,641.27 1,887.46 64417 110.23 104.72 120.43 63282 1,630.09 1,548.59 1,780.88 # 64417 63.83 60.64 69.74 63283 1,553.37 1,475.70 1,697.06 64418 115.59 109.81 126.28 63285 2,148.08 2,040.68 2,346.78 # 64418 65.32 62.05 71.36 63286 2,130.02 2,023.52 2,327.05 64420 136.01 129.21 148.59 63287 2,085.55 1,981.27 2,278.46 # 64420 58.67 55.74 64.10 63290 2,124.10 2,017.90 2,320.59 64421 200.98 190.93 219.57 63295 276.78 262.94 302.38 # 64421 80.78 76.74 88.25 63300 1,524.86 1,448.62 1,665.91 64425 111.57 105.99 121.89 63301 1,775.23 1,686.47 1,939.44 # 64425 83.21 79.05 90.91 63302 1,757.41 1,669.54 1,919.97 64430 128.04 121.64 139.89 63303 1,853.34 1,760.67 2,024.77 # 64430 76.16 72.35 83.20 63304 1,928.33 1,831.91 2,106.70 64435 121.20 115.14 132.41 63305 2,011.67 1,911.09 2,197.75 # 64435 74.15 70.44 81.01 63306 2,025.91 1,924.61 2,213.30 64445 115.05 109.30 125.70 63307 1,928.01 1,831.61 2,106.35 # 64445 71.23 67.67 77.82 63308 276.07 262.27 301.61 64446 78.00 74.10 85.22 63600 717.00 681.15 783.32 64447 61.72 58.63 67.42 63610 1,030.81 979.27 1,126.16 64448 69.14 65.68 75.53 # 63610 370.22 351.71 404.47 64449 78.64 74.71 85.92 63615 968.11 919.70 1,057.66 64450 88.04 83.64 96.19 63620 799.24 759.28 873.17 # 64450 61.94 58.84 67.67 63621 194.93 185.18 212.96 64455 44.47 42.25 48.59 63650 362.83 344.69 396.39 # 64455 34.80 33.06 38.02 63655 707.60 672.22 773.05 64479 236.17 224.36 258.01 63661 490.06 465.56 535.39 # 64479 110.82 105.28 121.07 # 63661 279.31 265.34 305.14 64480 120.92 114.87 132.10 63662 624.83 593.59 682.63 # 64480 72.59 68.96 79.30 63663 715.46 679.69 781.64 64483 227.91 216.51 248.99 # 63663 420.29 399.28 459.17 # 64483 96.44 91.62 105.36 63664 650.71 618.17 710.90 64484 116.87 111.03 127.68 63685 336.79 319.95 367.94 # 64484 61.12 58.06 66.77 63688 303.89 288.70 332.01 64490 164.91 156.66 180.16 63700 1,041.69 989.61 1,138.05 # 64490 98.53 93.60 107.64 63702 1,159.63 1,101.65 1,266.90 64491 83.43 79.26 91.15 63704 1,310.36 1,244.84 1,431.57 # 64491 56.69 53.86 61.94 63706 1,489.30 1,414.84 1,627.07 64492 84.40 80.18 92.21 63707 754.48 716.76 824.27 # 64492 57.65 54.77 62.99 63709 917.48 871.61 1,002.35 64493 147.52 140.14 161.16 63710 913.88 868.19 998.42 # 64493 83.72 79.53 91.46 63740 775.47 736.70 847.21 64494 75.91 72.11 82.93 63741 505.54 480.26 552.30 # 64494 48.52 46.09 53.00 63744 538.16 511.25 587.94 64495 76.88 73.04 84.00 63746 472.29 448.68 515.98 # 64495 49.49 47.02 54.07 64400 93.51 88.83 102.15 64505 85.83 81.54 93.77 # 64400 57.10 54.25 62.39 # 64505 72.62 68.99 79.34 64402 95.65 90.87 104.50 64508 126.65 120.32 138.37 # 64402 64.39 61.17 70.35 # 64508 63.81 60.62 69.71 64405 92.52 87.89 101.07 64510 116.42 110.60 127.19 # 64405 67.38 64.01 73.61 # 64510 60.67 57.64 66.29 64408 103.28 98.12 112.84 64517 148.92 141.47 162.69 # 64408 78.47 74.55 85.73 # 64517 106.71 101.37 116.58 64410 122.86 116.72 134.23 64520 157.52 149.64 172.09 # 64410 71.95 68.35 78.60 # 64520 68.26 64.85 74.58 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 54 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 162.82 154.68 177.88 64702 402.84 382.70 440.11 # 64530 80.32 76.30 87.75 64704 282.83 268.69 308.99 64550 13.52 12.84 14.77 64708 406.91 386.56 444.54 # 64550 8.04 7.64 8.79 64712 467.14 443.78 510.35 64553 177.27 168.41 193.67 64713 649.83 617.34 709.94 # 64553 139.89 132.90 152.84 64714 570.45 541.93 623.22 64555 178.47 169.55 194.98 64716 450.80 428.26 492.50 # 64555 133.03 126.38 145.34 64718 483.95 459.75 528.71 64560 177.30 168.44 193.71 64719 330.72 314.18 361.31 # 64560 136.06 129.26 148.65 64721 351.52 333.94 384.03 64561 925.17 878.91 1,010.75 # 64721 349.90 332.41 382.27 # 64561 374.15 355.44 408.76 64722 290.11 275.60 316.94 64565 148.66 141.23 162.41 64726 244.89 232.65 267.55 # 64565 106.45 101.13 116.30 64727 160.50 152.48 175.35 64573 499.16 474.20 545.33 64732 334.51 317.78 365.45 64575 243.86 231.67 266.42 64734 354.28 336.57 387.06 64577 312.50 296.88 341.41 64736 356.76 338.92 389.76 64580 258.46 245.54 282.37 64738 411.44 390.87 449.50 64581 723.16 687.00 790.05 64740 392.46 372.84 428.77 64585 264.48 251.26 288.95 64742 407.01 386.66 444.66 # 64585 135.91 129.11 148.48 64744 365.44 347.17 399.25 64590 255.37 242.60 278.99 64746 389.00 369.55 424.98 # 64590 152.26 144.65 166.35 64752 431.42 409.85 471.33 64595 255.86 243.07 279.53 64755 774.62 735.89 846.27 # 64595 118.91 112.96 129.90 64760 418.59 397.66 457.31 64600 341.39 324.32 372.97 64761 390.39 370.87 426.50 # 64600 188.65 179.22 206.10 64763 458.29 435.38 500.69 64605 511.80 486.21 559.14 64766 526.21 499.90 574.89 # 64605 294.94 280.19 322.22 64771 490.04 465.54 535.37 64610 589.52 560.04 644.05 64772 480.31 456.29 524.73 # 64610 407.46 387.09 445.15 64774 350.60 333.07 383.03 64612 140.31 133.29 153.28 64776 332.97 316.32 363.77 # 64612 126.45 120.13 138.15 64778 160.56 152.53 175.41 64613 136.02 129.22 148.60 64782 392.60 372.97 428.92 # 64613 118.62 112.69 129.59 64783 191.04 181.49 208.71 64614 148.90 141.46 162.68 64784 618.32 587.40 675.51 # 64614 128.27 121.86 140.14 64786 914.71 868.97 999.32 64620 235.99 224.19 257.82 64787 217.88 206.99 238.04 # 64620 148.34 140.92 162.06 64788 329.91 313.41 360.42 64622 279.86 265.87 305.75 64790 698.91 663.96 763.55 # 64622 158.70 150.77 173.39 64792 944.19 896.98 1,031.53 64623 103.42 98.25 112.99 64795 166.52 158.19 181.92 # 64623 44.45 42.23 48.56 64802 527.53 501.15 576.32 64626 332.07 315.47 362.79 64804 742.92 705.77 811.64 # 64626 212.84 202.20 232.53 64809 702.28 667.17 767.25 64627 140.44 133.42 153.43 64818 577.32 548.45 630.72 # 64627 52.14 49.53 56.96 64820 641.04 608.99 700.34 64630 198.11 188.20 216.43 64821 581.37 552.30 635.15 # 64630 166.85 158.51 182.29 64822 575.24 546.48 628.45 64632 75.99 72.19 83.02 64823 653.44 620.77 713.89 # 64632 65.03 61.78 71.05 64831 573.16 544.50 626.18 64640 191.90 182.31 209.66 64832 296.38 281.56 323.79 # 64640 150.65 143.12 164.59 64834 631.66 600.08 690.09 64650 58.44 55.52 63.85 64835 687.65 653.27 751.26 # 64650 35.24 33.48 38.50 64836 688.29 653.88 751.96 64653 69.51 66.03 75.93 64837 326.15 309.84 356.32 # 64653 45.02 42.77 49.19 64840 744.57 707.34 813.44 64680 261.72 248.63 285.92 64856 865.58 822.30 945.65 # 64680 142.49 135.37 155.68 64857 904.43 859.21 988.09 64681 322.34 306.22 352.15 64858 1,018.72 967.78 1,112.95 # 64681 182.49 173.37 199.38 64859 222.31 211.19 242.87 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 99 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 1,156.13 1,098.32 1,263.07 65285 862.75 819.61 942.55 64862 1,185.95 1,126.65 1,295.65 65286 562.60 534.47 614.64 64864 753.83 716.14 823.56 # 65286 405.03 384.78 442.50 64865 990.65 941.12 1,082.29 65290 407.32 386.95 444.99 64866 1,021.45 970.38 1,115.94 65400 544.46 517.24 594.83 64868 901.96 856.86 985.39 # 65400 487.74 463.35 532.85 64870 923.67 877.49 1,009.11 65410 116.66 110.83 127.45 64872 104.18 98.97 113.82 # 65410 87.66 83.28 95.77 64874 151.42 143.85 165.43 65420 409.30 388.84 447.17 64876 173.52 164.84 189.57 # 65420 303.60 288.42 331.68 64885 978.21 929.30 1,068.70 65426 519.35 493.38 567.39 64886 1,159.44 1,101.47 1,266.69 # 65426 389.16 369.70 425.16 64890 928.86 882.42 1,014.78 65430 94.12 89.41 102.82 64891 980.22 931.21 1,070.89 # 65430 86.06 81.76 94.02 64892 899.48 854.51 982.69 65435 65.32 62.05 71.36 64893 950.89 903.35 1,038.85 # 65435 57.91 55.01 63.26 64895 1,128.33 1,071.91 1,232.70 65436 316.85 301.01 346.16 64896 1,288.22 1,223.81 1,407.38 # 65436 305.25 289.99 333.49 64897 1,086.77 1,032.43 1,187.29 65450 259.40 246.43 283.39 64898 1,182.61 1,123.48 1,292.00 # 65450 256.50 243.68 280.23 64901 536.89 510.05 586.56 65600 314.52 298.79 343.61 64902 618.78 587.84 676.02 # 65600 276.17 262.36 301.71 64905 877.30 833.44 958.46 65710 905.56 860.28 989.32 64907 1,066.23 1,012.92 1,164.86 65730 1,006.61 956.28 1,099.72 64910 696.72 661.88 761.16 65750 1,016.29 965.48 1,110.30 64911 855.51 812.73 934.64 65755 1,012.46 961.84 1,106.12 65091 520.65 494.62 568.81 65756 962.65 914.52 1,051.70 65093 516.35 490.53 564.11 65757 144.26 137.05 157.61 65101 602.24 572.13 657.95 65770 1,219.02 1,158.07 1,331.78 65103 629.49 598.02 687.72 65772 362.73 344.59 396.28 65105 695.77 660.98 760.13 # 65772 328.90 312.46 359.33 65110 998.14 948.23 1,090.46 65775 443.44 421.27 484.46 65112 1,168.44 1,110.02 1,276.52 65780 720.63 684.60 787.29 65114 1,224.29 1,163.08 1,337.54 65781 1,088.11 1,033.70 1,188.76 65125 362.86 344.72 396.43 65782 961.27 913.21 1,050.19 # 65125 237.18 225.32 259.12 65800 123.17 117.01 134.56 65130 597.41 567.54 652.67 # 65800 108.99 103.54 119.07 65135 608.06 577.66 664.31 65805 134.69 127.96 147.15 65140 654.94 622.19 715.52 # 65805 110.20 104.69 120.39 65150 464.44 441.22 507.40 65810 382.50 363.38 417.89 65155 697.20 662.34 761.69 65815 512.40 486.78 559.80 65175 530.43 503.91 579.50 # 65815 389.95 370.45 426.02 65205 46.37 44.05 50.66 65820 601.00 570.95 656.59 # 65205 37.67 35.79 41.16 65850 698.68 663.75 763.31 65210 56.86 54.02 62.12 65855 277.15 263.29 302.78 # 65210 45.26 43.00 49.45 # 65855 246.21 233.90 268.99 65220 47.33 44.96 51.70 65860 263.29 250.13 287.65 # 65220 36.38 34.56 39.74 # 65860 221.72 210.63 242.22 65222 62.59 59.46 68.38 65865 381.39 362.32 416.67 # 65222 49.70 47.22 54.30 65870 484.72 460.48 529.55 65235 574.55 545.82 627.69 65875 511.60 486.02 558.92 65260 773.06 734.41 844.57 65880 532.07 505.47 581.29 65265 897.19 852.33 980.18 65900 779.11 740.15 851.17 65270 210.91 200.36 230.41 65920 640.07 608.07 699.28 # 65270 116.50 110.68 127.28 65930 528.51 502.08 577.39 65272 394.54 374.81 431.03 66020 146.96 139.61 160.55 # 65272 282.08 267.98 308.18 # 66020 105.72 100.43 115.49 65273 308.91 293.46 337.48 66030 131.22 124.66 143.36 65275 454.56 431.83 496.60 # 66030 89.65 85.17 97.95 # 65275 374.65 355.92 409.31 66130 574.71 545.97 627.87 65280 556.88 529.04 608.40 # 66130 478.36 454.44 522.61 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 56 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 697.47 662.60 761.99 67030 420.43 399.41 459.32 66155 696.80 661.96 761.25 67031 312.43 296.81 341.33 66160 791.20 751.64 864.39 # 67031 288.59 274.16 315.28 66165 682.71 648.57 745.86 67036 792.20 752.59 865.48 66170 970.21 921.70 1,059.96 67039 1,024.19 972.98 1,118.93 66172 1,221.36 1,160.29 1,334.33 67040 1,171.86 1,113.27 1,280.26 66180 960.92 912.87 1,049.80 67041 1,096.49 1,041.67 1,197.92 66185 613.55 582.87 670.30 67042 1,255.76 1,192.97 1,371.92 66220 596.02 566.22 651.15 67043 1,329.66 1,263.18 1,452.66 66225 774.01 735.31 845.61 67101 632.56 600.93 691.07 66250 603.82 573.63 659.67 # 67101 553.62 525.94 604.83 # 66250 457.20 434.34 499.49 67105 581.99 552.89 635.82 66500 281.01 266.96 307.00 # 67105 526.24 499.93 574.92 66505 307.79 292.40 336.26 67107 1,007.68 957.30 1,100.90 66600 660.89 627.85 722.03 67108 1,329.10 1,262.65 1,452.05 66605 852.95 810.30 931.85 67110 702.11 667.00 767.05 66625 349.00 331.55 381.28 # 67110 631.55 599.97 689.97 66630 465.83 442.54 508.92 67112 1,095.47 1,040.70 1,196.81 66635 461.37 438.30 504.05 67113 1,443.75 1,371.56 1,577.29 66680 423.65 402.47 462.84 67115 401.99 381.89 439.17 66682 513.09 487.44 560.56 67120 533.25 506.59 582.58 66700 359.61 341.63 392.87 # 67120 458.49 435.57 500.91 # 66700 319.01 303.06 348.52 67121 750.29 712.78 819.70 66710 360.06 342.06 393.37 67141 424.66 403.43 463.94 # 66710 324.94 308.69 354.99 # 67141 397.91 378.01 434.71 66711 512.28 486.67 559.67 67145 425.49 404.22 464.85 66720 374.46 355.74 409.10 # 67145 403.90 383.71 441.27 # 66720 339.34 322.37 370.73 67208 481.76 457.67 526.32 66740 349.46 331.99 381.79 # 67208 465.97 442.67 509.07 # 66740 317.56 301.68 346.93 67210 569.43 540.96 622.10 66761 366.38 348.06 400.27 # 67210 552.35 524.73 603.44 # 66761 336.09 319.29 367.18 67218 1,136.69 1,079.86 1,241.84 66762 381.53 362.45 416.82 67220 880.11 836.10 961.52 # 66762 345.12 327.86 377.04 # 67220 842.73 800.59 920.68 66770 420.48 399.46 459.38 67221 239.87 227.88 262.06 # 66770 387.29 367.93 423.12 # 67221 182.51 173.38 199.39 66820 318.83 302.89 348.32 67225 25.05 23.80 27.37 66821 262.56 249.43 286.84 # 67225 23.76 22.57 25.96 # 66821 248.70 236.27 271.71 67227 489.34 464.87 534.60 66825 615.73 584.94 672.68 # 67227 460.01 437.01 502.56 66830 575.86 547.07 629.13 67228 978.59 929.66 1,069.11 66840 574.98 546.23 628.16 # 67228 868.38 824.96 948.70 66850 648.89 616.45 708.92 67229 936.60 889.77 1,023.24 66852 699.20 664.24 763.88 67250 641.77 609.68 701.13 66920 610.26 579.75 666.71 67255 692.25 657.64 756.29 66930 693.81 659.12 757.99 67311 491.32 466.75 536.76 66940 643.79 611.60 703.34 67312 591.78 562.19 646.52 66982 879.87 835.88 961.26 67314 552.38 524.76 603.47 66983 606.30 575.99 662.39 67316 664.51 631.28 725.97 66984 632.14 600.53 690.61 67318 566.57 538.24 618.98 66985 625.86 594.57 683.76 67320 269.26 255.80 294.17 66986 749.52 712.04 818.85 67331 261.59 248.51 285.79 66990 76.39 72.57 83.46 67332 284.17 269.96 310.45 67005 388.29 368.88 424.21 67334 251.92 239.32 275.22 67010 442.76 420.62 483.71 67335 128.50 122.08 140.39 67015 471.49 447.92 515.11 67340 299.64 284.66 327.36 67025 588.97 559.52 643.45 67343 538.43 511.51 588.24 # 67025 517.43 491.56 565.29 67345 195.81 186.02 213.92 67027 705.74 670.45 771.02 # 67345 179.38 170.41 195.97 67028 173.12 164.46 189.13 67346 169.95 161.45 185.67 # 67028 140.57 133.54 153.57 67400 765.45 727.18 836.26 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 57 FSY10 LOCALITY FEE SCHEDULE FOR AREA 99 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 644.09 611.89 703.67 67908 401.24 381.18 438.36 67412 704.51 669.28 769.67 # 67908 354.51 336.78 387.30 67413 707.60 672.22 773.05 67909 437.24 415.38 477.69 67414 1,084.64 1,030.41 1,184.97 # 67909 363.77 345.58 397.42 67415 89.57 85.09 97.85 67911 461.92 438.82 504.64 67420 1,356.62 1,288.79 1,482.11 67912 716.17 680.36 782.41 67430 1,005.85 955.56 1,098.89 # 67912 407.79 387.40 445.51 67440 983.62 934.44 1,074.61 67914 315.14 299.38 344.29 67445 1,171.77 1,113.18 1,280.16 # 67914 239.09 227.14 261.21 67450 1,022.34 971.22 1,116.90 67915 279.96 265.96 305.85 67500 73.64 69.96 80.45 # 67915 209.07 198.62 228.41 # 67500 67.52 64.14 73.76 67916 436.89 415.05 477.31 67505 74.35 70.63 81.22 # 67916 356.65 338.82 389.64 # 67505 67.58 64.20 73.83 67917 477.70 453.82 521.89 67515 79.51 75.53 86.86 # 67917 394.24 374.53 430.71 # 67515 74.03 70.33 80.88 67921 300.41 285.39 328.20 67550 797.45 757.58 871.22 # 67921 224.36 213.14 245.11 67560 805.50 765.23 880.01 67922 271.11 257.55 296.18 67570 982.47 933.35 1,073.35 # 67922 201.51 191.43 220.14 67700 208.51 198.08 227.79 67923 462.64 439.51 505.44 # 67700 93.80 89.11 102.48 # 67923 385.95 366.65 421.65 67710 175.79 167.00 192.05 67924 476.20 452.39 520.25 # 67710 79.12 75.16 86.43 # 67924 373.08 354.43 407.59 67715 186.17 176.86 203.39 67930 298.16 283.25 325.74 # 67715 89.17 84.71 97.42 # 67930 206.01 195.71 225.07 67800 103.20 98.04 112.75 67935 486.31 461.99 531.29 # 67800 86.12 81.81 94.08 # 67935 375.46 356.69 410.19 67801 133.29 126.63 145.62 67938 191.06 181.51 208.74 # 67801 112.66 107.03 123.08 # 67938 94.39 89.67 103.12 67805 164.72 156.48 179.95 67950 468.44 445.02 511.77 # 67805 138.29 131.38 151.09 # 67950 385.62 366.34 421.29 67808 302.02 286.92 329.96 67961 468.43 445.01 511.76 67810 177.46 168.59 193.88 # 67961 378.21 359.30 413.20 # 67810 78.85 74.91 86.15 67966 628.03 596.63 686.12 67820 42.82 40.68 46.78 # 67966 543.60 516.42 593.88 # 67820 44.43 42.21 48.54 67971 608.03 577.63 664.27 67825 104.89 99.65 114.60 67973 786.17 746.86 858.89 # 67825 99.42 94.45 108.62 67974 783.51 744.33 855.98 67830 211.30 200.74 230.85 67975 574.00 545.30 627.10 # 67830 113.99 108.29 124.53 68020 97.21 92.35 106.20 67835 363.81 345.62 397.46 # 68020 90.77 86.23 99.16 67840 220.85 209.81 241.28 68040 54.19 51.48 59.20 # 67840 131.27 124.71 143.42 # 68040 45.49 43.22 49.70 67850 176.85 168.01 193.21 68100 136.03 129.23 148.61 # 67850 115.62 109.84 126.32 # 68100 81.57 77.49 89.11 67875 138.03 131.13 150.80 68110 180.40 171.38 197.09 # 67875 81.64 77.56 89.19 # 68110 122.07 115.97 133.37 67880 368.94 350.49 403.06 68115 247.07 234.72 269.93 # 67880 300.95 285.90 328.79 # 68115 150.72 143.18 164.66 67882 457.65 434.77 499.99 68130 427.99 406.59 467.58 # 67882 389.02 369.57 425.01 # 68130 331.64 315.06 362.32 67900 522.55 496.42 570.88 68135 127.45 121.08 139.24 # 67900 424.59 403.36 463.86 # 68135 123.26 117.10 134.67 67901 575.85 547.06 629.12 68200 34.69 32.96 37.90 # 67901 475.96 452.16 519.98 # 68200 29.21 27.75