appendix 1 table b -...

118
Page 1 Medical Fee Schedule - Rule 40.000 Appendix I, Table B CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08 10040 $35.50 0 $63.06 $90.62 $118.18 10060 $67.30 0 $92.36 $117.41 $142.47 10061 $139.77 0 $174.95 $210.14 $245.32 10080 $84.24 0 $129.50 $174.76 $220.03 10081 $121.90 0 $194.77 $267.64 $340.52 10120 $65.25 0 $102.95 $140.66 $178.36 10121 $144.28 0 $216.79 $289.30 $361.81 10140 $70.90 0 $102.55 $134.19 $165.84 10160 $39.85 0 $73.88 $107.91 $141.94 11000 $59.05 0 $68.18 $77.31 $86.44 11001 $19.85 0 $24.53 $29.21 $33.89 11010 $469.96 $514.13 $558.30 $602.48 11011 $558.87 $623.55 $688.22 $752.90 11012 $773.74 $864.66 $955.58 $1,046.50 11040 $49.58 0 $54.49 $59.40 $64.31 11041 $72.75 0 $84.51 $96.26 $108.02 11042 $106.67 0 $124.91 $143.15 $161.39 11043 $205.74 0 $259.41 $313.07 $366.74 11044 $353.53 0 $384.30 $415.07 $445.83 11055 $27.57 $35.13 $42.69 $50.26 11056 $39.03 $46.86 $54.69 $62.51 11057 $44.56 $55.91 $67.25 $78.60 11100 $62.37 7 $79.23 $96.08 $112.94 11101 $33.74 0 $42.48 $51.22 $59.96 11200 $52.87 0 $69.22 $85.58 $101.93 11201 $33.91 7 $37.99 $42.07 $46.14 11300 $53.44 0 $65.18 $76.92 $88.66 11301 $77.93 0 $91.33 $104.72 $118.12 11302 $98.07 0 $113.36 $128.66 $143.95 11303 $131.03 0 $146.84 $162.65 $178.46 11305 $61.47 0 $72.30 $83.14 $93.97 11306 $87.08 0 $101.21 $115.34 $129.46 11307 $106.18 0 $121.58 $136.99 $152.39 11308 $141.02 0 $153.42 $165.81 $178.21 11310 $70.88 0 $84.16 $97.43 $110.71 11311 $96.34 0 $111.55 $126.76 $141.97 11312 $116.42 0 $128.73 $141.04 $153.35 11313 $156.87 0 $169.73 $182.58 $195.44 11400 $76.75 15 $103.76 $130.76 $157.77 11401 $101.99 15 $130.74 $159.49 $188.24 11402 $127.75 15 $159.22 $190.68 $222.15 11403 $159.27 15 $190.56 $221.86 $253.15 11404 $194.50 15 $229.98 $265.46 $300.94 11420 $88.59 15 $111.55 $134.52 $157.48 11421 $118.19 15 $146.69 $175.19 $203.69 11422 $144.91 15 $175.36 $205.82 $236.27 11423 $189.60 15 $226.77 $263.94 $301.11 11424 $231.46 15 $270.86 $310.26 $349.66 11440 $102.59 15 $133.77 $164.95 $196.13 11441 $137.56 15 $171.51 $205.45 $239.40 11442 $152.72 15 $194.65 $236.57 $278.50 11443 $234.44 15 $264.79 $295.13 $325.48 11444 $277.70 15 $318.78 $359.85 $400.93 11450 $289.97 15 $367.80 $445.64 $523.47 11451 $286.35 15 $400.05 $513.75 $627.45 11462 $318.23 15 $368.05 $417.87 $467.69 11463 $293.25 15 $424.98 $556.71 $688.45 11470 $206.36 15 $293.79 $381.23 $468.66 11471 $246.01 15 $387.14 $528.28 $669.41 4/2006 CPT® Codes/Desc only are copyright 2010 American Medical Assoc. Mod 26 is professional component, TC is technical component

Upload: dinhanh

Post on 21-Aug-2018

218 views

Category:

Documents


0 download

TRANSCRIPT

Page 1 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

10040 $35.50 0 $63.06 $90.62 $118.1810060 $67.30 0 $92.36 $117.41 $142.4710061 $139.77 0 $174.95 $210.14 $245.3210080 $84.24 0 $129.50 $174.76 $220.0310081 $121.90 0 $194.77 $267.64 $340.5210120 $65.25 0 $102.95 $140.66 $178.3610121 $144.28 0 $216.79 $289.30 $361.8110140 $70.90 0 $102.55 $134.19 $165.8410160 $39.85 0 $73.88 $107.91 $141.9411000 $59.05 0 $68.18 $77.31 $86.4411001 $19.85 0 $24.53 $29.21 $33.8911010 $469.96 $514.13 $558.30 $602.4811011 $558.87 $623.55 $688.22 $752.9011012 $773.74 $864.66 $955.58 $1,046.5011040 $49.58 0 $54.49 $59.40 $64.3111041 $72.75 0 $84.51 $96.26 $108.0211042 $106.67 0 $124.91 $143.15 $161.3911043 $205.74 0 $259.41 $313.07 $366.7411044 $353.53 0 $384.30 $415.07 $445.8311055 $27.57 $35.13 $42.69 $50.2611056 $39.03 $46.86 $54.69 $62.5111057 $44.56 $55.91 $67.25 $78.6011100 $62.37 7 $79.23 $96.08 $112.9411101 $33.74 0 $42.48 $51.22 $59.9611200 $52.87 0 $69.22 $85.58 $101.9311201 $33.91 7 $37.99 $42.07 $46.1411300 $53.44 0 $65.18 $76.92 $88.6611301 $77.93 0 $91.33 $104.72 $118.1211302 $98.07 0 $113.36 $128.66 $143.9511303 $131.03 0 $146.84 $162.65 $178.4611305 $61.47 0 $72.30 $83.14 $93.9711306 $87.08 0 $101.21 $115.34 $129.4611307 $106.18 0 $121.58 $136.99 $152.3911308 $141.02 0 $153.42 $165.81 $178.2111310 $70.88 0 $84.16 $97.43 $110.7111311 $96.34 0 $111.55 $126.76 $141.9711312 $116.42 0 $128.73 $141.04 $153.3511313 $156.87 0 $169.73 $182.58 $195.4411400 $76.75 15 $103.76 $130.76 $157.7711401 $101.99 15 $130.74 $159.49 $188.2411402 $127.75 15 $159.22 $190.68 $222.1511403 $159.27 15 $190.56 $221.86 $253.1511404 $194.50 15 $229.98 $265.46 $300.9411420 $88.59 15 $111.55 $134.52 $157.4811421 $118.19 15 $146.69 $175.19 $203.6911422 $144.91 15 $175.36 $205.82 $236.2711423 $189.60 15 $226.77 $263.94 $301.1111424 $231.46 15 $270.86 $310.26 $349.6611440 $102.59 15 $133.77 $164.95 $196.1311441 $137.56 15 $171.51 $205.45 $239.4011442 $152.72 15 $194.65 $236.57 $278.5011443 $234.44 15 $264.79 $295.13 $325.4811444 $277.70 15 $318.78 $359.85 $400.9311450 $289.97 15 $367.80 $445.64 $523.4711451 $286.35 15 $400.05 $513.75 $627.4511462 $318.23 15 $368.05 $417.87 $467.6911463 $293.25 15 $424.98 $556.71 $688.4511470 $206.36 15 $293.79 $381.23 $468.6611471 $246.01 15 $387.14 $528.28 $669.41

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 2 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

11600 $143.51 90 $171.31 $199.11 $226.9211601 $174.68 90 $205.44 $236.20 $266.9711602 $209.35 90 $241.82 $274.29 $306.7611603 $255.54 90 $287.04 $318.54 $350.0411604 $287.29 90 $320.54 $353.78 $387.0311620 $162.26 90 $189.30 $216.34 $243.3811621 $214.90 90 $247.75 $280.61 $313.4611622 $316.38 90 $321.29 $326.20 $331.1111623 $369.52 90 $390.66 $411.79 $432.9311624 $407.08 90 $431.29 $455.49 $479.7011640 $218.71 90 $238.64 $258.56 $278.4911641 $309.75 90 $332.57 $355.40 $378.2211642 $382.30 90 $383.97 $385.65 $387.3211643 $456.81 90 $469.18 $481.55 $493.9211644 $552.53 90 $564.13 $575.73 $587.3311719 $15.10 $17.57 $20.03 $22.5011720 $36.74 $36.57 $36.41 $36.2411721 $62.45 $60.83 $59.21 $57.5911730 $55.12 0 $74.37 $93.62 $112.8711732 $34.08 0 $40.74 $47.40 $54.0611740 $38.15 0 $43.87 $49.59 $55.3111750 $196.05 0 $213.62 $231.19 $248.7611752 $305.78 0 $311.61 $317.44 $323.2711755 $114.49 $129.66 $144.82 $159.9911760 $244.42 60 $264.05 $283.67 $303.3011762 $463.51 90 $467.86 $472.20 $476.5511765 $135.25 60 $137.11 $138.98 $140.8411770 $238.28 30 $289.33 $340.39 $391.4411771 $484.78 60 $572.54 $660.30 $748.0511772 $582.75 60 $671.06 $759.38 $847.6911900 $51.07 0 $58.05 $65.03 $72.0111901 $62.28 0 $75.79 $89.30 $102.8111960 $1,258.81 90 $1,269.51 $1,280.22 $1,290.9211970 $1,301.35 90 $1,351.77 $1,402.18 $1,452.6011975 $116.79 15 $137.78 $158.78 $179.7711976 $161.79 15 $172.90 $184.01 $195.1211977 $231.05 15 $238.75 $246.46 $254.1612001 $77.49 0 $114.95 $152.41 $189.8712002 $93.33 0 $132.28 $171.22 $210.1712004 $150.71 0 $184.71 $218.72 $252.7212005 $188.18 7 $222.03 $255.87 $289.7212006 $238.34 7 $282.87 $327.39 $371.9212011 $118.27 0 $148.58 $178.90 $209.2112013 $146.42 0 $176.06 $205.70 $235.3412014 $179.67 7 $210.84 $242.02 $273.1912015 $209.43 7 $255.08 $300.74 $346.3912016 $247.03 7 $295.81 $344.58 $393.3612017 $285.01 7 $345.90 $406.79 $467.6812020 $154.45 7 $211.60 $268.76 $325.9112021 $88.42 7 $128.40 $168.39 $208.3712031 $100.82 0 $146.60 $192.37 $238.1512032 $150.20 0 $207.67 $265.14 $322.6012034 $202.57 15 $248.66 $294.74 $340.8312035 $236.84 15 $300.56 $364.28 $427.9912036 $291.72 15 $369.23 $446.74 $524.2612041 $133.05 0 $175.96 $218.86 $261.7712042 $195.04 15 $237.15 $279.27 $321.3812044 $250.05 15 $285.11 $320.17 $355.2312045 $306.93 15 $359.46 $412.00 $464.5312046 $361.50 15 $435.14 $508.78 $582.42

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 3 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

12051 $170.17 0 $215.32 $260.46 $305.6112052 $220.05 15 $262.35 $304.65 $346.9612053 $281.33 15 $305.25 $329.16 $353.0812054 $341.86 15 $373.25 $404.64 $436.0312055 $422.21 15 $458.90 $495.59 $532.2812056 $511.38 15 $559.64 $607.90 $656.1613100 $150.64 30 $219.93 $289.22 $358.5113101 $267.38 30 $342.34 $417.30 $492.2713120 $235.58 30 $290.08 $344.57 $399.0713121 $345.15 30 $427.56 $509.96 $592.3713131 $279.38 30 $343.94 $408.49 $473.0513132 $457.30 30 $569.61 $681.92 $794.2413150 $281.60 30 $350.85 $420.10 $489.3513151 $382.44 30 $456.47 $530.49 $604.5213152 $616.77 30 $702.91 $789.04 $875.1814000 $528.96 60 $644.68 $760.40 $876.1214001 $725.70 60 $875.35 $1,025.00 $1,174.6414020 $656.70 90 $708.54 $760.38 $812.2114021 $932.81 90 $1,018.02 $1,103.24 $1,188.4514040 $847.53 60 $947.16 $1,046.78 $1,146.4114041 $1,103.34 60 $1,200.72 $1,298.09 $1,395.4714060 $1,028.75 60 $1,084.15 $1,139.55 $1,194.9514061 $1,351.80 90 $1,423.61 $1,495.42 $1,567.2314300 $1,390.35 90 $1,404.71 $1,419.06 $1,433.4214350 $871.42 60 $903.94 $936.46 $968.9815000 $169.84 0 $257.68 $345.51 $433.3515050 $191.49 30 $311.12 $430.74 $550.3715100 $528.08 45 $759.42 $990.77 $1,222.1115101 $150.04 45 $219.96 $289.88 $359.8015120 $853.20 45 $1,039.22 $1,225.24 $1,411.2615121 $218.50 45 $293.75 $369.00 $444.2515200 $435.27 45 $623.89 $812.51 $1,001.1315201 $178.93 45 $207.44 $235.95 $264.4715220 $512.32 45 $665.38 $818.45 $971.5115221 $244.44 45 $245.00 $245.56 $246.1115240 $633.16 45 $794.94 $956.73 $1,118.5115241 $327.27 45 $338.37 $349.47 $360.5615260 $790.31 45 $920.21 $1,050.10 $1,180.0015261 $412.38 45 $435.68 $458.98 $482.2815400 $316.49 0 $379.65 $442.81 $505.9715570 $747.19 90 $919.96 $1,092.73 $1,265.5015572 $756.47 90 $924.29 $1,092.12 $1,259.9415574 $925.26 90 $1,063.31 $1,201.36 $1,339.4015576 $644.87 90 $853.33 $1,061.80 $1,270.2615600 $438.04 45 $488.66 $539.27 $589.8915610 $484.38 45 $514.41 $544.44 $574.4715620 $541.00 45 $577.31 $613.62 $649.9315630 $608.21 45 $628.54 $648.88 $669.2115650 $491.29 45 $627.53 $763.77 $900.0115732 $1,559.77 90 $1,879.43 $2,199.10 $2,518.7615734 $1,504.12 90 $1,843.78 $2,183.44 $2,523.1115736 $1,373.64 90 $1,674.95 $1,976.27 $2,277.5815738 $1,336.41 90 $1,746.98 $2,157.55 $2,568.1215740 $934.54 90 $1,166.42 $1,398.31 $1,630.1915750 $963.00 90 $1,183.18 $1,403.37 $1,623.5515756 $3,618.64 $3,920.02 $4,221.40 $4,522.7815757 $3,618.64 $3,947.93 $4,277.23 $4,606.5215758 $3,618.64 $3,933.48 $4,248.33 $4,563.1715760 $812.01 45 $948.25 $1,084.50 $1,220.7415770 $939.00 60 $1,038.18 $1,137.36 $1,236.54

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 4 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

15780 $964.31 90 $1,047.27 $1,130.23 $1,213.2015781 $419.16 90 $494.16 $569.17 $644.1715782 $284.05 90 $419.42 $554.80 $690.1715783 $281.51 60 $365.51 $449.50 $533.5015786 $85.04 0 $139.51 $193.99 $248.4615787 $35.59 30 $49.33 $63.07 $76.8115788 $313.99 $408.04 $502.09 $596.1415789 $405.92 $563.42 $720.92 $878.4215792 $210.74 $300.83 $390.92 $481.0115793 $289.81 $399.28 $508.76 $618.2315822 $912.84 30 $869.96 $827.07 $784.1915823 $950.05 60 $991.77 $1,033.49 $1,075.2115831 $2,163.43 60 $2,262.84 $2,362.25 $2,461.6615840 $2,254.78 90 $2,234.42 $2,214.05 $2,193.6915841 $2,632.35 90 $2,577.80 $2,523.26 $2,468.7115842 $4,327.45 90 $4,340.68 $4,353.91 $4,367.1415845 $2,152.80 90 $2,099.42 $2,046.05 $1,992.6715851 $75.64 30 $100.04 $124.44 $148.8515852 $139.95 30 $147.93 $155.91 $163.8915920 $597.03 90 $690.94 $784.84 $878.7515922 $1,199.64 90 $1,232.05 $1,264.47 $1,296.8815931 $720.45 90 $815.35 $910.25 $1,005.1515933 $1,451.64 90 $1,454.78 $1,457.92 $1,461.0615934 $930.76 90 $1,067.35 $1,203.94 $1,340.5315935 $1,451.64 90 $1,541.95 $1,632.26 $1,722.5715936 $1,379.66 90 $1,453.50 $1,527.34 $1,601.1815937 $1,595.35 90 $1,588.82 $1,582.29 $1,575.7715940 $635.28 90 $746.97 $858.66 $970.3415941 $999.37 90 $1,095.19 $1,191.00 $1,286.8215944 $1,167.79 90 $1,220.16 $1,272.53 $1,324.9015945 $1,338.97 90 $1,458.91 $1,578.84 $1,698.7815946 $1,255.47 90 $1,567.16 $1,878.85 $2,190.5415950 $619.11 60 $694.50 $769.88 $845.2715951 $819.91 60 $984.65 $1,149.40 $1,314.1415952 $996.77 90 $1,126.05 $1,255.34 $1,384.6215953 $1,161.79 90 $1,296.10 $1,430.42 $1,564.7316000 $46.32 0 $61.10 $75.89 $90.6716020 $56.47 0 $76.09 $95.71 $115.3216025 $93.50 0 $126.96 $160.42 $193.8816030 $157.00 0 $198.74 $240.48 $282.2316035 $258.16 0 $289.68 $321.20 $352.7317000 $65.11 0 $73.64 $82.17 $90.7017003 $15.13 $17.93 $20.72 $23.5217004 $262.51 $264.90 $267.30 $269.6917106 $339.83 0 $386.70 $433.56 $480.4317107 $664.71 0 $737.86 $811.01 $884.1617108 $1,104.88 0 $1,152.40 $1,199.93 $1,247.4517110 $58.64 0 $77.87 $97.10 $116.3417111 $79.83 $96.04 $112.25 $128.4617250 $51.75 0 $63.54 $75.32 $87.1117260 $109.98 15 $121.27 $132.56 $143.8617261 $136.31 15 $151.57 $166.83 $182.0817262 $177.28 15 $191.87 $206.46 $221.0517263 $215.87 15 $225.55 $235.23 $244.9117264 $244.91 15 $260.38 $275.85 $291.3217270 $136.24 15 $152.42 $168.61 $184.7917271 $175.15 15 $188.02 $200.89 $213.7517272 $219.28 15 $228.79 $238.29 $247.8017273 $296.37 15 $303.01 $309.65 $316.2917274 $386.26 15 $399.39 $412.53 $425.66

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 5 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

17280 $166.42 15 $165.15 $163.88 $162.6217281 $229.78 15 $222.37 $214.97 $207.5617282 $273.76 15 $276.48 $279.20 $281.9217283 $405.53 15 $406.27 $407.01 $407.7517284 $487.57 15 $497.35 $507.12 $516.9017304 $635.13 0 $719.15 $803.17 $887.1917305 $178.69 0 $254.52 $330.35 $406.1917306 $199.27 0 $257.72 $316.18 $374.6317307 $180.31 0 $240.49 $300.67 $360.8517310 $26.59 0 $65.69 $104.78 $143.8817340 $55.28 0 $61.61 $67.94 $74.2717360 $34.01 0 $69.72 $105.43 $141.1419000 $58.57 0 $85.52 $112.46 $139.4119001 $27.92 0 $39.21 $50.50 $61.7919020 $226.14 0 $320.25 $414.37 $508.4819030 $66.88 0 $140.32 $213.76 $287.2019100 $99.58 0 $138.44 $177.30 $216.1719101 $324.41 30 $439.05 $553.69 $668.3419110 $324.73 30 $446.49 $568.24 $690.0019112 $328.90 30 $426.48 $524.06 $621.6519120 $437.14 30 $554.69 $672.24 $789.7919125 $503.82 $593.06 $682.30 $771.5419126 $253.25 $265.35 $277.45 $289.5519140 $648.71 60 $750.37 $852.03 $953.6819160 $625.16 60 $671.89 $718.62 $765.3419162 $1,423.65 60 $1,538.34 $1,653.02 $1,767.7119180 $770.56 60 $891.44 $1,012.31 $1,133.1919182 $869.32 60 $937.86 $1,006.40 $1,074.9419200 $1,454.18 90 $1,522.26 $1,590.33 $1,658.4119220 $1,951.54 90 $2,046.92 $2,142.30 $2,237.6819240 $1,421.06 60 $1,597.55 $1,774.05 $1,950.5419260 $920.00 90 $1,128.36 $1,336.73 $1,545.0919271 $1,604.67 90 $1,971.34 $2,338.02 $2,704.6919272 $1,749.22 90 $2,010.79 $2,272.37 $2,533.9419290 $89.45 0 $138.78 $188.11 $237.4519291 $46.72 0 $67.13 $87.54 $107.9519316 $1,642.39 90 $1,596.55 $1,550.71 $1,504.8719318 $2,077.57 90 $2,228.20 $2,378.84 $2,529.4719325 $966.64 90 $1,023.29 $1,079.94 $1,136.5919328 $439.25 90 $552.55 $665.86 $779.1619330 $468.07 90 $577.63 $687.19 $796.7519340 $890.99 90 $932.22 $973.46 $1,014.6919342 $1,284.31 90 $1,370.03 $1,455.76 $1,541.4819350 $728.00 90 $942.12 $1,156.24 $1,370.3619355 $622.36 90 $762.30 $902.24 $1,042.1919357 $1,370.56 90 $1,761.16 $2,151.77 $2,542.3719361 $2,313.94 90 $2,511.48 $2,709.02 $2,906.5619364 $2,467.90 90 $3,174.26 $3,880.62 $4,586.9719366 $1,575.50 90 $2,055.66 $2,535.81 $3,015.9719367 $2,644.38 $3,161.03 $3,677.68 $4,194.3319368 $3,070.87 $3,501.07 $3,931.26 $4,361.4619369 $2,638.46 $3,126.40 $3,614.34 $4,102.2819370 $801.37 90 $968.68 $1,135.99 $1,303.3019371 $770.99 90 $957.32 $1,143.66 $1,329.9919380 $609.43 90 $746.61 $883.78 $1,020.9620000 $107.07 0 $135.91 $164.75 $193.5920005 $224.25 21 $274.06 $323.86 $373.6720100 $935.35 30 $973.85 $1,012.35 $1,050.8520101 $293.55 30 $386.68 $479.81 $572.9520102 $364.16 30 $503.91 $643.67 $783.42

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 6 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

20103 $486.25 30 $551.10 $615.95 $680.8020150 $1,483.28 $1,547.84 $1,612.41 $1,676.9720200 $113.74 7 $166.07 $218.40 $270.7320205 $226.59 15 $273.33 $320.07 $366.8120206 $99.15 0 $155.76 $212.36 $268.9720220 $121.94 15 $194.78 $267.62 $340.4620225 $321.53 15 $526.09 $730.65 $935.2120240 $282.81 21 $324.62 $366.43 $408.2520245 $416.18 30 $491.27 $566.36 $641.4520250 $669.30 45 $694.02 $718.73 $743.4520251 $1,584.24 45 $1,479.65 $1,375.06 $1,270.4720500 $51.31 0 $124.46 $197.61 $270.7620501 $94.52 0 $168.92 $243.32 $317.7220520 $134.62 0 $197.09 $259.55 $322.0220525 $361.90 30 $426.25 $490.60 $554.9520550 $60.49 0 $76.73 $92.97 $109.2120600 $47.77 0 $61.75 $75.74 $89.7220605 $52.78 0 $68.33 $83.87 $99.4220610 $58.73 0 $79.72 $100.70 $121.6920615 $308.94 60 $337.01 $365.08 $393.1520650 $150.88 0 $212.68 $274.47 $336.2720660 $260.26 21 $296.87 $333.48 $370.0920661 $350.05 21 $477.33 $604.61 $731.8920664 $643.25 $781.50 $919.74 $1,057.9920665 $65.71 0 $109.88 $154.04 $198.2120670 $137.77 0 $242.20 $346.63 $451.0620680 $370.79 21 $442.51 $514.23 $585.9520690 $350.55 21 $416.32 $482.09 $547.8620692 $421.75 21 $536.70 $651.66 $766.6120693 $334.30 21 $515.37 $696.44 $877.5120694 $298.74 21 $391.95 $485.16 $578.3720802 $6,347.23 90 $6,356.33 $6,365.42 $6,374.5220805 $6,267.50 90 $6,211.41 $6,155.33 $6,099.2420808 $5,784.50 90 $6,131.16 $6,477.82 $6,824.4820816 $2,737.00 90 $3,676.36 $4,615.71 $5,555.0720822 $1,567.30 90 $2,616.78 $3,666.27 $4,715.7520824 $3,035.44 90 $3,927.75 $4,820.05 $5,712.3620827 $2,623.98 90 $3,443.74 $4,263.51 $5,083.2720838 $6,267.50 90 $6,127.83 $5,988.17 $5,848.5020900 $308.44 0 $394.65 $480.86 $567.0620902 $480.18 0 $615.44 $750.70 $885.9720910 $358.73 0 $460.50 $562.27 $664.0420924 $475.05 15 $530.42 $585.79 $641.1620926 $267.66 15 $390.25 $512.83 $635.4220937 $321.95 $376.76 $431.58 $486.3920938 $350.15 $419.77 $489.38 $559.0020955 $5,909.68 90 $5,851.08 $5,792.48 $5,733.8820956 $3,935.18 $3,806.91 $3,678.64 $3,550.3720957 $4,441.00 $4,604.27 $4,767.53 $4,930.8020974 $235.75 0 $216.78 $197.82 $178.8520975 $357.86 90 $395.92 $433.99 $472.0521010 $1,224.55 90 $1,259.22 $1,293.89 $1,328.5721015 $537.92 90 $620.95 $703.97 $787.0021025 $751.84 90 $884.36 $1,016.89 $1,149.4121026 $861.35 90 $859.63 $857.90 $856.1821029 $619.15 90 $840.53 $1,061.91 $1,283.3021030 $375.53 90 $489.35 $603.17 $717.0021031 $292.51 90 $343.62 $394.74 $445.8521032 $636.34 90 $645.19 $654.04 $662.8921034 $1,035.41 90 $1,482.70 $1,930.00 $2,377.29

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 7 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

21040 $399.63 90 $454.81 $509.99 $565.1721044 $1,324.28 90 $1,425.45 $1,526.63 $1,627.8021045 $2,141.79 90 $2,394.34 $2,646.89 $2,899.4421050 $1,436.41 90 $1,533.93 $1,631.45 $1,728.9621060 $1,741.85 90 $1,750.39 $1,758.93 $1,767.4721070 $906.10 90 $978.07 $1,050.04 $1,122.0021076 $1,604.17 30 $1,613.91 $1,623.65 $1,633.4021077 $3,918.04 30 $4,113.10 $4,308.16 $4,503.2321085 $460.00 90 $607.03 $754.06 $901.0921100 $179.25 0 $395.20 $611.15 $827.1021110 $671.66 30 $683.21 $694.76 $706.3121116 $119.60 0 $189.75 $259.91 $330.0621121 $2,645.00 90 $2,370.64 $2,096.28 $1,821.9221122 $2,760.00 90 $2,491.04 $2,222.07 $1,953.1121125 $460.00 90 $1,440.48 $2,420.97 $3,401.4521127 $771.65 90 $1,240.35 $1,709.05 $2,177.7621141 $2,847.40 30 $2,932.51 $3,017.63 $3,102.7421142 $2,942.52 30 $3,061.38 $3,180.24 $3,299.1021143 $3,072.69 30 $3,187.31 $3,301.92 $3,416.5421145 $3,070.46 90 $3,235.43 $3,400.39 $3,565.3621146 $3,398.96 90 $3,568.46 $3,737.95 $3,907.4521147 $4,128.50 90 $4,153.56 $4,178.63 $4,203.6921150 $2,587.50 90 $2,855.25 $3,123.01 $3,390.7621151 $2,817.50 90 $3,225.52 $3,633.55 $4,041.5721154 $4,756.40 90 $4,756.17 $4,755.93 $4,755.7021155 $4,945.00 90 $5,018.81 $5,092.61 $5,166.4221193 $2,530.00 90 $2,661.23 $2,792.45 $2,923.6821194 $2,760.00 90 $2,923.66 $3,087.32 $3,250.9921195 $3,624.80 90 $3,521.67 $3,418.54 $3,315.4121196 $3,826.05 90 $3,798.09 $3,770.13 $3,742.1721198 $1,196.00 90 $1,587.99 $1,979.98 $2,371.9721206 $2,188.25 90 $2,387.18 $2,586.12 $2,785.0521208 $1,276.21 90 $1,525.03 $1,773.84 $2,022.6621209 $806.81 90 $979.39 $1,151.96 $1,324.5421210 $1,529.12 90 $1,666.59 $1,804.06 $1,941.5321215 $1,529.12 90 $2,044.34 $2,559.57 $3,074.7921230 $1,385.75 90 $1,525.13 $1,664.51 $1,803.8821235 $844.30 90 $946.80 $1,049.30 $1,151.7921240 $2,443.24 90 $2,547.24 $2,651.25 $2,755.2521242 $2,105.42 90 $2,190.39 $2,275.36 $2,360.3321243 $2,241.34 90 $2,418.37 $2,595.40 $2,772.4221244 $1,906.18 90 $1,967.96 $2,029.73 $2,091.5121245 $1,504.20 90 $1,796.42 $2,088.64 $2,380.8621246 $1,880.25 90 $1,870.17 $1,860.09 $1,850.0221247 $3,659.30 90 $3,809.75 $3,960.19 $4,110.6421248 $1,504.20 90 $1,640.52 $1,776.83 $1,913.1521249 $2,456.40 90 $2,607.94 $2,759.48 $2,911.0221255 $1,300.61 90 $1,976.99 $2,653.37 $3,329.7621256 $1,265.00 90 $1,739.01 $2,213.03 $2,687.0421275 $1,451.00 90 $1,527.17 $1,603.34 $1,679.5121300 $87.40 0 $133.87 $180.35 $226.8221310 $55.27 0 $81.47 $107.66 $133.8621315 $151.62 0 $198.68 $245.74 $292.8021320 $396.03 90 $409.73 $423.44 $437.1421325 $308.58 90 $482.22 $655.86 $829.5021330 $727.27 90 $867.50 $1,007.72 $1,147.9521335 $1,287.42 90 $1,375.12 $1,462.82 $1,550.5121336 $574.19 90 $702.16 $830.13 $958.1121337 $136.43 90 $267.63 $398.83 $530.0421338 $927.16 90 $1,129.87 $1,332.59 $1,535.30

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 8 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

21339 $1,192.64 90 $1,282.93 $1,373.21 $1,463.5021340 $1,102.28 90 $1,331.27 $1,560.27 $1,789.2621343 $1,024.00 90 $1,277.55 $1,531.11 $1,784.6621344 $1,676.77 90 $1,981.26 $2,285.74 $2,590.2321345 $876.74 90 $1,073.63 $1,270.51 $1,467.4021346 $1,470.90 90 $1,587.45 $1,704.00 $1,820.5421347 $1,426.03 90 $1,766.85 $2,107.67 $2,448.4921348 $1,353.23 90 $1,799.83 $2,246.42 $2,693.0221355 $361.36 0 $475.61 $589.86 $704.1121356 $614.37 0 $714.82 $815.27 $915.7121360 $919.69 90 $971.94 $1,024.18 $1,076.4321365 $1,425.33 90 $1,626.80 $1,828.26 $2,029.7321366 $1,528.50 90 $1,864.50 $2,200.49 $2,536.4921385 $1,217.04 90 $1,254.51 $1,291.97 $1,329.4421386 $1,506.43 90 $1,565.08 $1,623.73 $1,682.3921387 $1,637.89 90 $1,672.65 $1,707.41 $1,742.1621390 $1,689.85 90 $1,773.66 $1,857.48 $1,941.2921395 $2,245.93 90 $2,306.96 $2,367.98 $2,429.0121400 $335.24 0 $332.03 $328.82 $325.6121401 $554.71 90 $633.84 $712.97 $792.1021406 $1,045.95 90 $1,073.42 $1,100.90 $1,128.3721407 $1,273.48 90 $1,313.69 $1,353.90 $1,394.1121408 $1,420.46 90 $1,564.94 $1,709.43 $1,853.9121421 $1,047.20 90 $1,082.60 $1,118.01 $1,153.4121422 $1,239.09 90 $1,289.79 $1,340.49 $1,391.1921423 $1,449.52 90 $1,550.43 $1,651.33 $1,752.2421431 $1,059.50 90 $1,090.91 $1,122.32 $1,153.7421432 $1,577.78 90 $1,586.55 $1,595.31 $1,604.0821433 $2,046.67 90 $2,457.07 $2,867.47 $3,277.8721435 $1,887.89 90 $2,143.56 $2,399.22 $2,654.8921436 $2,535.00 90 $2,971.43 $3,407.85 $3,844.2821450 $194.02 90 $330.28 $466.55 $602.8121451 $644.25 90 $785.41 $926.58 $1,067.7421452 $487.64 90 $679.83 $872.02 $1,064.2021453 $1,012.39 90 $1,022.27 $1,032.14 $1,042.0221454 $1,517.92 90 $1,505.90 $1,493.87 $1,481.8521461 $1,258.66 90 $1,537.11 $1,815.56 $2,094.0221462 $1,605.94 90 $1,914.38 $2,222.81 $2,531.2521465 $1,406.23 90 $1,563.58 $1,720.92 $1,878.2721470 $1,830.20 90 $1,905.84 $1,981.48 $2,057.1221480 $102.78 30 $130.17 $157.56 $184.9521485 $396.89 90 $482.68 $568.48 $654.2721490 $1,108.60 90 $1,252.32 $1,396.04 $1,539.7621495 $794.25 90 $867.06 $939.87 $1,012.6921497 $510.41 90 $604.02 $697.64 $791.2521501 $385.44 21 $437.79 $490.14 $542.5021502 $496.22 30 $628.46 $760.70 $892.9421510 $457.70 21 $575.22 $692.73 $810.2521550 $150.41 0 $209.93 $269.44 $328.9621555 $140.28 15 $262.06 $383.84 $505.6221556 $272.16 15 $392.85 $513.55 $634.2421557 $711.85 90 $901.46 $1,091.07 $1,280.6821600 $470.59 60 $576.01 $681.43 $786.8521610 $486.99 60 $785.17 $1,083.35 $1,381.5321615 $1,368.77 60 $1,466.73 $1,564.69 $1,662.6521616 $1,669.64 60 $1,664.40 $1,659.16 $1,653.9221620 $1,768.70 60 $1,692.56 $1,616.42 $1,540.2821627 $396.59 60 $621.47 $846.36 $1,071.2421630 $1,152.30 60 $1,527.32 $1,902.34 $2,277.3621632 $1,986.89 60 $2,143.18 $2,299.46 $2,455.75

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 9 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

21700 $770.57 60 $849.65 $928.73 $1,007.8021705 $926.65 60 $1,031.75 $1,136.84 $1,241.9421720 $617.81 60 $702.43 $787.05 $871.6821725 $713.12 60 $780.47 $847.82 $915.1721740 $1,990.18 90 $2,057.88 $2,125.59 $2,193.2921750 $793.27 90 $987.54 $1,181.81 $1,376.0921800 $57.71 30 $87.14 $116.56 $145.9921805 $395.60 60 $441.23 $486.86 $532.4921810 $977.50 60 $1,011.11 $1,044.72 $1,078.3321820 $83.47 30 $122.42 $161.38 $200.3321825 $680.80 60 $787.48 $894.17 $1,000.8521920 $116.98 30 $178.75 $240.52 $302.2921925 $289.05 60 $422.02 $554.99 $687.9621930 $518.16 60 $582.01 $645.86 $709.7221935 $761.51 90 $1,141.07 $1,520.63 $1,900.1922100 $621.56 90 $809.72 $997.88 $1,186.0422101 $638.33 30 $816.97 $995.62 $1,174.2622102 $619.58 30 $813.37 $1,007.16 $1,200.9622103 $268.92 $283.26 $297.61 $311.9522110 $1,431.78 30 $1,520.61 $1,609.45 $1,698.2822112 $1,349.30 30 $1,458.40 $1,567.51 $1,676.6122114 $1,534.48 30 $1,591.50 $1,648.51 $1,705.5322116 $267.42 $280.36 $293.31 $306.2522210 $2,899.86 90 $2,994.04 $3,088.22 $3,182.3922212 $3,053.08 90 $3,127.41 $3,201.74 $3,276.0722214 $2,259.09 90 $2,493.21 $2,727.33 $2,961.4522216 $676.07 $741.63 $807.19 $872.7422220 $3,340.72 90 $3,232.47 $3,124.23 $3,015.9822222 $2,310.09 90 $2,532.11 $2,754.14 $2,976.1622224 $2,450.83 90 $2,674.64 $2,898.46 $3,122.2722226 $676.07 $734.59 $793.10 $851.6222305 $238.28 90 $259.00 $279.71 $300.4322310 $296.40 90 $353.28 $410.15 $467.0322315 $688.35 90 $860.40 $1,032.45 $1,204.5122325 $2,002.12 90 $2,157.42 $2,312.72 $2,468.0122326 $2,002.12 90 $2,155.97 $2,309.81 $2,463.6622327 $2,002.12 90 $2,208.86 $2,415.60 $2,622.3422328 $538.75 $577.86 $616.97 $656.0822505 $121.21 0 $178.49 $235.77 $293.0422548 $2,901.13 90 $3,046.45 $3,191.76 $3,337.0822554 $2,705.23 90 $2,949.61 $3,193.99 $3,438.3722556 $2,848.27 90 $2,973.34 $3,098.41 $3,223.4822558 $2,734.52 90 $2,938.63 $3,142.74 $3,346.8422585 $512.94 90 $616.24 $719.54 $822.8422590 $2,966.53 90 $3,007.95 $3,049.37 $3,090.7822595 $2,809.71 90 $2,922.78 $3,035.84 $3,148.9122600 $2,263.33 90 $2,335.24 $2,407.14 $2,479.0522610 $2,282.31 90 $2,480.80 $2,679.30 $2,877.7922612 $2,626.98 90 $2,820.08 $3,013.18 $3,206.2922614 $709.82 $761.02 $812.22 $863.4222630 $2,363.97 90 $2,770.28 $3,176.60 $3,582.9122632 $597.64 $680.62 $763.60 $846.5822800 $2,347.74 90 $2,542.56 $2,737.39 $2,932.2122802 $2,950.40 90 $3,506.10 $4,061.79 $4,617.4922804 $4,087.00 30 $4,556.86 $5,026.71 $5,496.5722808 $2,892.25 30 $3,088.69 $3,285.14 $3,481.5822810 $2,600.94 90 $3,098.39 $3,595.83 $4,093.2822812 $3,519.54 90 $3,882.67 $4,245.80 $4,608.9222818 $3,189.65 $3,666.06 $4,142.47 $4,618.8822819 $3,469.69 $3,824.30 $4,178.91 $4,533.52

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 10 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

22830 $1,418.96 90 $1,821.26 $2,223.56 $2,625.8622840 $1,652.64 90 $1,666.84 $1,681.04 $1,695.2422842 $1,815.05 90 $1,879.00 $1,942.96 $2,006.9122843 $1,140.49 $1,607.91 $2,075.33 $2,542.7422844 $1,390.35 $1,876.43 $2,362.52 $2,848.6022845 $1,678.18 90 $1,826.18 $1,974.19 $2,122.1922846 $1,040.43 $1,379.07 $1,717.70 $2,056.3422847 $1,159.24 $1,546.06 $1,932.88 $2,319.7122848 $736.54 $745.06 $753.58 $762.1022849 $1,852.12 90 $2,051.84 $2,251.56 $2,451.2822850 $748.19 90 $964.32 $1,180.46 $1,396.5922851 $823.58 $839.17 $854.76 $870.3522852 $972.88 90 $1,056.10 $1,139.33 $1,222.5522855 $1,339.36 90 $1,664.98 $1,990.60 $2,316.2222900 $417.45 30 $462.43 $507.41 $552.3923000 $463.22 60 $583.19 $703.17 $823.1423020 $888.53 60 $993.78 $1,099.04 $1,204.2923030 $263.45 15 $398.84 $534.23 $669.6123031 $155.25 15 $303.48 $451.72 $599.9523035 $597.41 30 $795.01 $992.61 $1,190.2123040 $874.38 60 $1,001.33 $1,128.28 $1,255.2423044 $579.60 45 $721.39 $863.19 $1,004.9823065 $183.02 0 $232.07 $281.11 $330.1623066 $268.25 0 $412.45 $556.65 $700.8623075 $267.89 7 $302.01 $336.14 $370.2623076 $540.77 15 $658.89 $777.01 $895.1323077 $791.13 90 $1,288.39 $1,785.66 $2,282.9223100 $874.38 60 $922.91 $971.43 $1,019.9623101 $800.49 60 $874.98 $949.46 $1,023.9523105 $1,064.08 90 $1,178.29 $1,292.49 $1,406.7023106 $768.21 90 $831.33 $894.45 $957.5723107 $1,223.17 90 $1,331.65 $1,440.14 $1,548.6223120 $764.45 60 $874.26 $984.06 $1,093.8723125 $1,327.62 60 $1,414.97 $1,502.32 $1,589.6723130 $770.79 60 $843.46 $916.12 $988.7923140 $460.66 60 $580.95 $701.24 $821.5323145 $718.37 90 $872.19 $1,026.00 $1,179.8223146 $542.80 90 $680.11 $817.42 $954.7423150 $722.75 30 $901.22 $1,079.70 $1,258.1723155 $934.95 90 $1,151.67 $1,368.39 $1,585.1123156 $995.90 90 $1,069.69 $1,143.48 $1,217.2723170 $420.90 90 $590.44 $759.99 $929.5323172 $423.02 30 $622.43 $821.84 $1,021.2623174 $840.77 90 $1,064.67 $1,288.57 $1,512.4723180 $606.77 90 $810.91 $1,015.05 $1,219.1923182 $546.77 30 $785.01 $1,023.26 $1,261.5023184 $445.45 30 $741.51 $1,037.57 $1,333.6323190 $585.65 60 $682.69 $779.73 $876.7623195 $1,059.50 30 $1,168.08 $1,276.66 $1,385.2423200 $1,087.28 30 $1,203.77 $1,320.26 $1,436.7523210 $1,389.80 30 $1,524.33 $1,658.85 $1,793.3823220 $1,324.28 30 $1,368.42 $1,412.57 $1,456.7123221 $1,421.30 90 $1,677.91 $1,934.52 $2,191.1323222 $1,727.30 90 $2,038.01 $2,348.72 $2,659.4323330 $213.14 60 $264.88 $316.63 $368.3723331 $835.28 60 $887.41 $939.54 $991.6723332 $1,515.78 60 $1,614.56 $1,713.34 $1,812.1223350 $81.92 0 $157.71 $233.50 $309.3023395 $1,438.60 60 $1,634.30 $1,830.00 $2,025.7123397 $1,774.28 60 $1,771.09 $1,767.90 $1,764.72

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 11 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

23400 $1,396.39 60 $1,570.90 $1,745.41 $1,919.9123405 $438.39 60 $626.11 $813.83 $1,001.5423406 $732.89 60 $897.61 $1,062.32 $1,227.0423410 $1,078.14 90 $1,247.44 $1,416.74 $1,586.0523412 $1,142.20 60 $1,417.54 $1,692.87 $1,968.2123415 $787.83 60 $936.25 $1,084.67 $1,233.0823420 $1,538.77 90 $1,692.47 $1,846.17 $1,999.8723430 $931.81 90 $1,108.84 $1,285.87 $1,462.9023440 $971.43 90 $1,120.16 $1,268.90 $1,417.6323450 $1,307.54 90 $1,498.61 $1,689.68 $1,880.7523455 $1,679.61 90 $1,789.85 $1,900.09 $2,010.3323460 $1,541.43 90 $1,719.73 $1,898.03 $2,076.3323462 $1,445.80 90 $1,669.93 $1,894.07 $2,118.2023465 $1,420.34 90 $1,639.36 $1,858.39 $2,077.4123466 $1,433.10 90 $1,745.17 $2,057.24 $2,369.3123470 $1,653.68 90 $1,773.82 $1,893.96 $2,014.1123472 $3,064.03 90 $3,047.07 $3,030.10 $3,013.1423480 $883.82 90 $1,025.01 $1,166.21 $1,307.4023485 $1,227.11 90 $1,361.55 $1,495.99 $1,630.4323490 $661.25 90 $981.93 $1,302.61 $1,623.3023491 $884.35 90 $1,248.32 $1,612.29 $1,976.2623500 $112.27 0 $183.55 $254.83 $326.1123505 $249.30 90 $328.49 $407.68 $486.8723515 $677.91 90 $764.32 $850.73 $937.1523520 $143.75 0 $205.46 $267.17 $328.8823525 $223.52 90 $314.98 $406.43 $497.8923530 $770.57 90 $874.61 $978.64 $1,082.6823532 $972.01 90 $1,028.68 $1,085.34 $1,142.0123540 $113.48 0 $172.74 $232.00 $291.2623545 $201.41 60 $285.71 $370.02 $454.3223550 $926.31 60 $1,020.25 $1,114.19 $1,208.1323552 $1,049.75 90 $1,218.13 $1,386.51 $1,554.9023570 $118.27 90 $170.11 $221.96 $273.8023575 $266.11 90 $362.56 $459.00 $555.4523585 $910.49 90 $1,108.78 $1,307.07 $1,505.3623600 $143.77 90 $235.88 $327.98 $420.0923605 $423.57 90 $522.98 $622.40 $721.8123615 $906.06 90 $1,065.14 $1,224.23 $1,383.3123616 $1,568.02 90 $1,936.73 $2,305.43 $2,674.1423620 $98.12 90 $192.66 $287.20 $381.7423625 $376.16 90 $470.03 $563.91 $657.7823630 $807.37 90 $948.09 $1,088.82 $1,229.5423650 $235.53 30 $302.57 $369.61 $436.6523655 $331.93 30 $390.92 $449.90 $508.8923660 $926.31 90 $1,032.50 $1,138.69 $1,244.8823665 $279.74 90 $386.63 $493.52 $600.4123670 $929.53 90 $1,076.80 $1,224.07 $1,371.3423675 $375.67 90 $528.89 $682.10 $835.3223680 $1,033.55 90 $1,265.06 $1,496.56 $1,728.0723700 $167.39 0 $221.11 $274.83 $328.5523800 $1,548.40 90 $1,722.72 $1,897.04 $2,071.3623802 $1,522.68 90 $1,797.62 $2,072.56 $2,347.5023900 $1,857.36 90 $2,095.86 $2,334.35 $2,572.8523920 $1,366.25 90 $1,580.84 $1,795.43 $2,010.0223921 $346.32 30 $466.64 $586.96 $707.2923930 $194.39 30 $308.26 $422.13 $536.0023931 $64.95 0 $170.65 $276.35 $382.0523935 $452.11 0 $628.63 $805.15 $981.6824000 $805.08 60 $868.92 $932.77 $996.6124006 $838.35 60 $1,023.36 $1,208.37 $1,393.37

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 12 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

24065 $202.45 0 $258.26 $314.08 $369.8924066 $364.64 0 $511.27 $657.90 $804.5224075 $275.39 21 $373.94 $472.50 $571.0524076 $507.75 30 $568.32 $628.89 $689.4624077 $609.50 90 $905.30 $1,201.10 $1,496.9124100 $706.33 60 $758.70 $811.07 $863.4424101 $874.40 60 $899.77 $925.14 $950.5124102 $1,162.18 90 $1,217.65 $1,273.11 $1,328.5824105 $396.45 60 $447.82 $499.20 $550.5724110 $725.43 60 $866.55 $1,007.67 $1,148.7924115 $952.18 90 $1,100.49 $1,248.81 $1,397.1224116 $995.90 90 $1,177.81 $1,359.72 $1,541.6324120 $656.51 60 $739.44 $822.37 $905.3024125 $731.40 90 $755.78 $780.16 $804.5424126 $783.15 90 $911.29 $1,039.44 $1,167.5824130 $617.81 60 $731.71 $845.61 $959.5124134 $834.91 30 $1,052.40 $1,269.90 $1,487.3924136 $794.25 30 $896.60 $998.95 $1,101.3024138 $839.50 30 $912.08 $984.66 $1,057.2424140 $707.28 60 $908.75 $1,110.21 $1,311.6824145 $655.82 30 $787.59 $919.36 $1,051.1324147 $592.95 60 $762.73 $932.51 $1,102.2824149 $1,504.43 $1,676.81 $1,849.20 $2,021.5824150 $1,336.43 90 $1,469.65 $1,602.87 $1,736.0924151 $1,545.14 90 $1,726.31 $1,907.47 $2,088.6424152 $1,037.30 90 $1,153.56 $1,269.82 $1,386.0824153 $1,545.14 90 $1,531.83 $1,518.51 $1,505.2024155 $1,255.55 60 $1,333.87 $1,412.19 $1,490.5124160 $535.16 60 $699.40 $863.64 $1,027.8924164 $348.14 30 $507.53 $666.92 $826.3124200 $222.89 30 $248.48 $274.08 $299.6724201 $374.76 30 $523.81 $672.85 $821.9024220 $51.13 0 $195.55 $339.98 $484.4024301 $1,038.50 30 $1,158.99 $1,279.47 $1,399.9624305 $522.48 60 $626.06 $729.64 $833.2224310 $395.69 30 $502.85 $610.01 $717.1624320 $1,087.90 90 $1,193.96 $1,300.03 $1,406.0924330 $632.81 90 $832.07 $1,031.34 $1,230.6024331 $667.00 90 $934.42 $1,201.83 $1,469.2524340 $1,121.67 90 $1,195.53 $1,269.38 $1,343.2424341 $867.64 $949.01 $1,030.38 $1,111.7424342 $1,193.42 90 $1,272.15 $1,350.88 $1,429.6024350 $505.22 30 $562.54 $619.85 $677.1724351 $569.99 30 $630.02 $690.06 $750.0924352 $669.28 30 $757.04 $844.80 $932.5624354 $648.96 30 $679.84 $710.72 $741.6124356 $739.11 30 $811.07 $883.03 $954.9924360 $1,132.84 90 $1,369.67 $1,606.50 $1,843.3324361 $1,227.17 90 $1,373.39 $1,519.61 $1,665.8324362 $1,403.00 90 $1,585.28 $1,767.55 $1,949.8324363 $1,856.77 90 $2,238.03 $2,619.28 $3,000.5424365 $757.50 60 $835.59 $913.69 $991.7824366 $957.69 60 $1,066.50 $1,175.30 $1,284.1124400 $1,021.25 90 $1,157.49 $1,293.72 $1,429.9624410 $1,174.14 90 $1,379.42 $1,584.70 $1,789.9824420 $931.50 90 $1,167.06 $1,402.61 $1,638.1724430 $1,365.29 90 $1,497.50 $1,629.71 $1,761.9224435 $1,533.85 90 $1,689.57 $1,845.29 $2,001.0124470 $568.64 90 $805.81 $1,042.98 $1,280.1424495 $912.17 60 $1,026.15 $1,140.12 $1,254.10

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 13 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

24498 $633.79 90 $977.71 $1,321.63 $1,665.5524500 $165.71 90 $261.73 $357.74 $453.7624505 $415.92 90 $527.11 $638.30 $749.4924515 $865.98 90 $1,070.94 $1,275.91 $1,480.8724516 $1,247.02 90 $1,362.57 $1,478.13 $1,593.6824530 $179.96 90 $290.19 $400.41 $510.6424535 $463.50 90 $621.83 $780.15 $938.4824538 $881.25 90 $991.71 $1,102.18 $1,212.6424545 $1,038.29 90 $1,136.72 $1,235.15 $1,333.5924546 $1,545.85 90 $1,647.99 $1,750.12 $1,852.2624560 $143.96 90 $239.32 $334.69 $430.0524565 $315.61 90 $472.40 $629.20 $785.9924566 $704.92 $830.00 $955.09 $1,080.1724575 $874.81 90 $993.45 $1,112.09 $1,230.7324576 $236.95 60 $296.28 $355.62 $414.9524577 $426.77 60 $533.06 $639.35 $745.6424579 $1,035.76 90 $1,147.49 $1,259.21 $1,370.9424582 $771.06 $894.66 $1,018.25 $1,141.8524586 $1,315.18 90 $1,504.80 $1,694.43 $1,884.0524587 $1,394.30 90 $1,612.85 $1,831.40 $2,049.9524600 $267.09 60 $338.39 $409.68 $480.9824605 $321.11 60 $390.83 $460.56 $530.2824615 $761.62 90 $931.20 $1,100.79 $1,270.3724620 $395.67 90 $530.30 $664.92 $799.5524635 $977.75 90 $1,215.62 $1,453.48 $1,691.3524640 $127.18 0 $152.98 $178.77 $204.5724650 $132.24 60 $208.80 $285.37 $361.9324655 $279.30 90 $392.79 $506.27 $619.7624665 $652.50 90 $790.13 $927.77 $1,065.4024666 $826.79 90 $995.24 $1,163.69 $1,332.1324670 $135.06 60 $214.92 $294.79 $374.6524675 $306.73 90 $424.59 $542.44 $660.3024685 $867.36 90 $960.05 $1,052.74 $1,145.4324800 $1,239.20 90 $1,316.25 $1,393.30 $1,470.3524802 $1,320.98 90 $1,482.74 $1,644.49 $1,806.2524900 $757.07 90 $893.41 $1,029.74 $1,166.0824920 $725.87 90 $876.46 $1,027.05 $1,177.6324925 $269.99 30 $482.09 $694.19 $906.2924930 $760.82 90 $919.88 $1,078.93 $1,237.9924931 $764.27 90 $919.79 $1,075.31 $1,230.8424935 $1,081.00 90 $1,352.08 $1,623.16 $1,894.2424940 $1,081.00 90 $1,127.97 $1,174.94 $1,221.9125000 $397.53 30 $462.50 $527.47 $592.4425020 $608.37 30 $779.74 $951.10 $1,122.4725023 $844.64 30 $1,146.38 $1,448.13 $1,749.8725028 $368.98 30 $514.81 $660.64 $806.4725031 $69.00 30 $356.38 $643.76 $931.1425035 $522.21 60 $739.95 $957.70 $1,175.4425040 $445.82 60 $645.05 $844.28 $1,043.5125065 $182.93 0 $239.18 $295.43 $351.6925066 $288.56 0 $410.22 $531.88 $653.5325075 $305.22 30 $387.79 $470.36 $552.9425076 $474.02 60 $634.24 $794.46 $954.6925077 $1,240.85 90 $1,346.01 $1,451.17 $1,556.3225085 $602.66 60 $756.74 $910.81 $1,064.8925100 $479.49 60 $572.99 $666.49 $759.9825101 $555.60 60 $682.17 $808.74 $935.3125105 $878.60 60 $947.15 $1,015.69 $1,084.2425107 $703.81 60 $850.27 $996.73 $1,143.2025110 $306.52 30 $420.67 $534.82 $648.97

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 14 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

25111 $444.25 30 $520.27 $596.29 $672.3125112 $516.15 30 $602.37 $688.60 $774.8225115 $907.82 60 $1,093.26 $1,278.69 $1,464.1325116 $904.44 60 $1,041.07 $1,177.70 $1,314.3425118 $786.32 60 $823.89 $861.46 $899.0325119 $868.92 60 $979.74 $1,090.57 $1,201.3925120 $543.65 60 $748.87 $954.08 $1,159.3025125 $743.07 90 $934.66 $1,126.25 $1,317.8325130 $523.34 60 $655.01 $786.67 $918.3425135 $749.24 90 $855.27 $961.29 $1,067.3225136 $566.05 90 $703.26 $840.47 $977.6825145 $693.65 90 $873.76 $1,053.87 $1,233.9825150 $563.10 60 $728.85 $894.61 $1,060.3625151 $525.64 60 $764.08 $1,002.53 $1,240.9725170 $1,121.25 60 $1,315.52 $1,509.78 $1,704.0525210 $580.18 60 $717.66 $855.13 $992.6125215 $767.05 60 $992.70 $1,218.35 $1,443.9925230 $486.12 60 $590.20 $694.27 $798.3525240 $479.48 60 $602.90 $726.33 $849.7525246 $102.59 0 $210.69 $318.78 $426.8825248 $387.11 60 $516.65 $646.19 $775.7325250 $695.25 30 $750.47 $805.68 $860.9025251 $898.28 30 $1,004.91 $1,111.53 $1,218.1625260 $594.82 60 $839.95 $1,085.08 $1,330.2125263 $650.53 60 $849.84 $1,049.15 $1,248.4725265 $776.18 90 $1,002.50 $1,228.81 $1,455.1325270 $496.88 60 $682.27 $867.66 $1,053.0525272 $555.96 60 $753.86 $951.76 $1,149.6625274 $690.75 90 $929.51 $1,168.26 $1,407.0225280 $578.49 60 $770.72 $962.94 $1,155.1725290 $414.35 60 $644.80 $875.24 $1,105.6925295 $502.72 60 $694.67 $886.62 $1,078.5725300 $632.70 90 $841.89 $1,051.09 $1,260.2825301 $632.70 90 $812.82 $992.94 $1,173.0625310 $734.63 90 $932.75 $1,130.86 $1,328.9825312 $1,007.85 90 $1,200.00 $1,392.15 $1,584.3025315 $836.71 90 $1,107.46 $1,378.21 $1,648.9625316 $990.34 90 $1,305.72 $1,621.10 $1,936.4825320 $834.42 90 $1,076.37 $1,318.32 $1,560.2725332 $989.92 90 $1,199.16 $1,408.39 $1,617.6325335 $1,804.65 90 $1,874.55 $1,944.45 $2,014.3525337 $1,027.10 $1,203.77 $1,380.44 $1,557.1125350 $852.77 90 $1,034.43 $1,216.08 $1,397.7425355 $952.52 90 $1,189.59 $1,426.67 $1,663.7425360 $779.93 90 $989.39 $1,198.85 $1,408.3125365 $1,064.02 90 $1,312.14 $1,560.26 $1,808.3825370 $1,098.70 90 $1,338.62 $1,578.54 $1,818.4625375 $1,470.74 90 $1,643.20 $1,815.65 $1,988.1125390 $1,074.77 90 $1,340.78 $1,606.78 $1,872.7925391 $1,111.97 90 $1,420.47 $1,728.97 $2,037.4825392 $1,123.28 90 $1,384.54 $1,645.80 $1,907.0625393 $1,228.28 90 $1,575.48 $1,922.69 $2,269.8925400 $1,072.28 90 $1,237.51 $1,402.74 $1,567.9725405 $1,336.77 90 $1,623.14 $1,909.51 $2,195.8725415 $1,487.60 90 $1,698.19 $1,908.77 $2,119.3625420 $1,745.16 90 $1,984.12 $2,223.08 $2,462.0425425 $1,200.88 90 $1,486.35 $1,771.82 $2,057.2925426 $1,517.78 90 $1,755.84 $1,993.91 $2,231.9725440 $1,254.42 90 $1,353.07 $1,451.72 $1,550.3725441 $1,219.28 90 $1,346.61 $1,473.94 $1,601.27

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 15 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

25442 $905.65 90 $1,138.77 $1,371.89 $1,605.0125443 $952.83 90 $1,135.90 $1,318.97 $1,502.0425444 $1,019.00 90 $1,192.70 $1,366.40 $1,540.1025445 $1,050.98 90 $1,200.76 $1,350.54 $1,500.3125446 $1,789.79 90 $1,878.14 $1,966.50 $2,054.8525447 $1,067.74 90 $1,183.12 $1,298.49 $1,413.8725449 $935.78 90 $1,164.70 $1,393.63 $1,622.5525450 $617.84 90 $793.15 $968.46 $1,143.7625455 $667.67 90 $858.39 $1,049.12 $1,239.8425490 $759.00 90 $1,106.31 $1,453.61 $1,800.9225491 $805.00 90 $1,165.87 $1,526.73 $1,887.6025492 $989.00 90 $1,366.67 $1,744.34 $2,122.0125500 $141.90 60 $218.20 $294.51 $370.8125505 $406.15 90 $516.52 $626.89 $737.2725515 $681.58 90 $850.79 $1,020.00 $1,189.2225520 $598.70 90 $719.57 $840.43 $961.3025525 $1,100.54 90 $1,261.21 $1,421.88 $1,582.5525526 $1,476.70 90 $1,692.65 $1,908.61 $2,124.5625530 $138.67 60 $218.99 $299.31 $379.6325535 $374.21 90 $469.94 $565.67 $661.4025545 $711.26 90 $850.44 $989.62 $1,128.8125560 $147.02 60 $213.06 $279.11 $345.1525565 $544.23 60 $620.71 $697.20 $773.6825574 $978.65 90 $1,043.36 $1,108.07 $1,172.7925575 $1,139.68 90 $1,260.76 $1,381.83 $1,502.9125600 $210.53 60 $289.48 $368.44 $447.3925605 $476.27 90 $572.79 $669.31 $765.8325611 $661.63 90 $768.50 $875.38 $982.2525620 $894.57 90 $1,016.61 $1,138.65 $1,260.6925622 $149.13 60 $225.91 $302.69 $379.4725624 $371.09 90 $477.38 $583.68 $689.9725628 $812.07 90 $936.55 $1,061.03 $1,185.5125630 $152.88 60 $232.71 $312.54 $392.3825635 $336.79 60 $440.15 $543.51 $646.8625645 $620.84 90 $746.00 $871.15 $996.3125650 $428.38 90 $477.07 $525.76 $574.4525660 $309.41 30 $408.19 $506.97 $605.7625670 $702.92 90 $799.04 $895.16 $991.2825675 $295.42 60 $399.31 $503.20 $607.0925676 $641.78 90 $772.80 $903.82 $1,034.8425680 $458.21 60 $551.47 $644.73 $737.9925685 $919.31 90 $1,063.18 $1,207.04 $1,350.9125690 $528.00 90 $627.59 $727.19 $826.7825695 $735.49 60 $890.20 $1,044.90 $1,199.6125800 $1,077.13 90 $1,169.52 $1,261.91 $1,354.3025805 $1,243.92 90 $1,357.06 $1,470.20 $1,583.3425810 $1,266.75 90 $1,412.06 $1,557.36 $1,702.6725820 $1,377.10 90 $1,433.17 $1,489.23 $1,545.3025825 $1,551.72 90 $1,742.65 $1,933.59 $2,124.5225830 $1,027.10 $1,231.69 $1,436.27 $1,640.8625900 $822.92 90 $1,006.41 $1,189.91 $1,373.4025905 $667.00 90 $903.02 $1,139.04 $1,375.0625907 $398.20 30 $697.63 $997.05 $1,296.4825909 $711.53 90 $944.74 $1,177.95 $1,411.1725915 $1,105.53 60 $1,502.77 $1,900.00 $2,297.2425920 $652.24 90 $814.39 $976.53 $1,138.6825922 $275.39 30 $482.62 $689.84 $897.0725924 $520.64 90 $690.32 $859.99 $1,029.6725927 $692.17 90 $915.42 $1,138.67 $1,361.9325929 $416.00 30 $559.08 $702.15 $845.23

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 16 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

25931 $612.50 90 $791.15 $969.79 $1,148.4426010 $91.04 0 $158.27 $225.49 $292.7226011 $226.62 0 $336.56 $446.50 $556.4526020 $364.03 30 $480.53 $597.04 $713.5426025 $372.04 30 $528.64 $685.23 $841.8326030 $609.50 30 $782.19 $954.87 $1,127.5626034 $515.74 30 $635.82 $755.89 $875.9726035 $1,015.49 60 $1,122.05 $1,228.61 $1,335.1826037 $915.20 30 $960.05 $1,004.90 $1,049.7526040 $331.25 30 $462.39 $593.53 $724.6726045 $528.65 60 $648.75 $768.85 $888.9526055 $367.02 30 $553.88 $740.74 $927.5926060 $145.79 15 $249.82 $353.85 $457.8826070 $417.55 30 $499.48 $581.41 $663.3426075 $427.40 30 $511.19 $594.98 $678.7726080 $361.60 30 $466.63 $571.67 $676.7026100 $445.13 30 $514.94 $584.76 $654.5726105 $438.70 30 $549.15 $659.61 $770.0626110 $343.15 30 $470.08 $597.01 $723.9326115 $301.11 30 $452.87 $604.62 $756.3826116 $485.07 30 $656.84 $828.61 $1,000.3826117 $568.10 90 $823.55 $1,079.00 $1,334.4426121 $1,188.87 90 $1,229.94 $1,271.02 $1,312.0926123 $1,183.30 90 $1,311.80 $1,440.30 $1,568.8126125 $568.16 90 $547.65 $527.15 $506.6426130 $826.82 90 $886.82 $946.82 $1,006.8226135 $542.59 90 $705.46 $868.32 $1,031.1926140 $498.17 90 $677.08 $856.00 $1,034.9126145 $583.63 90 $765.93 $948.24 $1,130.5426160 $290.26 30 $513.62 $736.98 $960.3526170 $357.70 30 $454.98 $552.25 $649.5326180 $405.53 30 $505.74 $605.95 $706.1626185 $499.17 $574.32 $649.47 $724.6326200 $651.35 60 $784.17 $916.99 $1,049.8226205 $786.27 90 $923.76 $1,061.24 $1,198.7326210 $525.12 60 $632.79 $740.47 $848.1426215 $677.05 90 $800.57 $924.08 $1,047.6026230 $484.14 60 $606.42 $728.70 $850.9826235 $459.79 60 $601.19 $742.59 $883.9926236 $449.80 60 $573.40 $697.00 $820.6026250 $724.94 90 $878.66 $1,032.38 $1,186.0926255 $938.46 90 $1,112.58 $1,286.70 $1,460.8326260 $889.07 90 $936.58 $984.08 $1,031.5926261 $922.67 90 $1,036.73 $1,150.79 $1,264.8426262 $764.41 90 $855.50 $946.58 $1,037.6726320 $513.98 30 $583.21 $652.44 $721.6826350 $902.56 90 $1,031.25 $1,159.94 $1,288.6326352 $1,104.07 90 $1,259.77 $1,415.47 $1,571.1726356 $1,223.42 90 $1,353.33 $1,483.23 $1,613.1426357 $1,276.84 90 $1,445.96 $1,615.09 $1,784.2126358 $1,337.39 90 $1,530.99 $1,724.59 $1,918.1826370 $826.52 60 $976.25 $1,125.97 $1,275.7026372 $1,013.14 60 $1,231.93 $1,450.72 $1,669.5026373 $816.14 90 $1,051.79 $1,287.44 $1,523.0926390 $900.92 90 $1,093.23 $1,285.54 $1,477.8526392 $1,027.43 60 $1,256.14 $1,484.85 $1,713.5626410 $471.58 60 $600.14 $728.71 $857.2726412 $661.22 60 $822.95 $984.68 $1,146.4226415 $809.32 60 $974.47 $1,139.61 $1,304.7626416 $1,005.51 60 $1,186.32 $1,367.13 $1,547.95

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 17 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

26418 $387.18 90 $549.62 $712.05 $874.4926420 $614.16 90 $814.75 $1,015.34 $1,215.9326426 $586.28 90 $816.34 $1,046.40 $1,276.4626428 $791.11 90 $966.92 $1,142.73 $1,318.5526432 $456.77 30 $547.79 $638.82 $729.8426433 $459.64 30 $616.01 $772.37 $928.7426434 $661.91 90 $781.52 $901.14 $1,020.7526437 $483.50 60 $629.58 $775.67 $921.7526440 $512.07 60 $720.32 $928.56 $1,136.8126442 $679.71 60 $913.91 $1,148.12 $1,382.3226445 $430.49 60 $647.36 $864.23 $1,081.1126449 $785.63 60 $975.57 $1,165.51 $1,355.4526450 $271.09 30 $408.31 $545.53 $682.7526455 $445.94 30 $528.28 $610.62 $692.9626460 $264.42 30 $396.77 $529.12 $661.4726471 $575.43 90 $760.49 $945.55 $1,130.6126474 $593.53 90 $744.66 $895.80 $1,046.9326476 $417.77 90 $602.63 $787.48 $972.3426477 $410.57 90 $603.26 $795.96 $988.6526478 $483.07 90 $689.55 $896.02 $1,102.5026479 $483.07 90 $677.61 $872.14 $1,066.6826480 $704.51 90 $997.13 $1,289.75 $1,582.3626483 $824.22 90 $1,063.48 $1,302.75 $1,542.0126485 $769.60 90 $992.57 $1,215.55 $1,438.5226489 $983.69 90 $1,216.45 $1,449.21 $1,681.9726490 $919.45 90 $1,105.96 $1,292.47 $1,478.9726492 $1,072.74 90 $1,303.11 $1,533.48 $1,763.8526494 $980.52 90 $1,166.70 $1,352.88 $1,539.0626496 $957.45 90 $1,180.52 $1,403.60 $1,626.6726497 $998.59 90 $1,218.69 $1,438.78 $1,658.8826498 $1,331.03 90 $1,532.72 $1,734.41 $1,936.1126500 $521.36 90 $702.42 $883.48 $1,064.5526502 $572.34 90 $793.60 $1,014.86 $1,236.1226504 $635.98 90 $881.42 $1,126.87 $1,372.3126508 $526.49 90 $709.97 $893.45 $1,076.9226510 $581.31 90 $774.27 $967.23 $1,160.1926516 $550.49 90 $728.21 $905.93 $1,083.6526517 $915.40 90 $1,147.38 $1,379.36 $1,611.3426518 $1,087.90 90 $1,301.47 $1,515.04 $1,728.6226520 $637.85 90 $854.61 $1,071.37 $1,288.1326525 $571.63 90 $808.07 $1,044.52 $1,280.9626530 $675.90 90 $842.66 $1,009.42 $1,176.1726531 $1,051.32 90 $1,144.56 $1,237.79 $1,331.0326535 $729.26 90 $816.08 $902.91 $989.7326536 $795.04 90 $906.01 $1,016.97 $1,127.9426540 $970.15 90 $1,073.31 $1,176.46 $1,279.6226541 $1,077.04 90 $1,188.42 $1,299.80 $1,411.1726542 $858.11 90 $1,037.06 $1,216.00 $1,394.9526545 $735.28 90 $895.43 $1,055.58 $1,215.7326546 $920.31 $1,123.13 $1,325.96 $1,528.7826548 $652.16 90 $829.34 $1,006.51 $1,183.6926550 $1,629.50 90 $1,958.28 $2,287.06 $2,615.8526551 $4,811.82 $5,069.41 $5,327.01 $5,584.6026553 $4,785.29 $4,864.76 $4,944.23 $5,023.6926554 $5,698.20 $5,985.75 $6,273.30 $6,560.8626555 $935.78 90 $1,335.83 $1,735.88 $2,135.9226556 $4,849.42 $5,076.49 $5,303.56 $5,530.6326560 $964.00 45 $1,004.02 $1,044.04 $1,084.0526561 $1,151.09 45 $1,267.59 $1,384.08 $1,500.5826562 $1,285.96 90 $1,590.22 $1,894.49 $2,198.75

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 18 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

26565 $693.23 90 $871.65 $1,050.08 $1,228.5026567 $566.63 90 $782.14 $997.65 $1,213.1526568 $925.89 90 $1,192.81 $1,459.74 $1,726.6626580 $1,324.64 90 $1,553.86 $1,783.08 $2,012.3126587 $974.73 90 $1,130.61 $1,286.50 $1,442.3826590 $856.64 90 $1,262.61 $1,668.59 $2,074.5626591 $492.19 90 $615.27 $738.34 $861.4226593 $627.19 90 $731.00 $834.81 $938.6126600 $135.72 60 $199.22 $262.72 $326.2126605 $258.15 60 $334.33 $410.50 $486.6826607 $355.41 60 $487.20 $618.99 $750.7726608 $370.30 60 $487.08 $603.86 $720.6326615 $559.17 60 $665.67 $772.17 $878.6726641 $186.78 60 $295.59 $404.40 $513.2126645 $280.14 45 $374.02 $467.89 $561.7726650 $508.47 45 $631.70 $754.94 $878.1726665 $704.87 60 $811.71 $918.54 $1,025.3826670 $120.47 30 $235.82 $351.17 $466.5226675 $302.08 45 $396.55 $491.02 $585.5026676 $481.59 45 $583.31 $685.03 $786.7526685 $545.21 60 $653.15 $761.10 $869.0426686 $694.85 60 $859.22 $1,023.59 $1,187.9526700 $228.70 30 $284.34 $339.99 $395.6326705 $290.15 45 $369.94 $449.73 $529.5226706 $385.86 45 $485.04 $584.21 $683.3926715 $501.86 45 $597.18 $692.50 $787.8226720 $107.77 45 $156.58 $205.40 $254.2126725 $238.38 45 $286.91 $335.43 $383.9626727 $345.39 45 $458.67 $571.95 $685.2326735 $453.78 60 $535.09 $616.40 $697.7126740 $186.00 60 $227.08 $268.17 $309.2526742 $325.81 60 $392.79 $459.78 $526.7626746 $564.69 60 $656.07 $747.45 $838.8326750 $85.86 45 $136.82 $187.77 $238.7326755 $179.13 30 $239.83 $300.52 $361.2226756 $275.09 60 $391.04 $506.98 $622.9326765 $337.14 60 $425.11 $513.07 $601.0426770 $182.24 30 $226.48 $270.73 $314.9726775 $226.36 45 $297.07 $367.78 $438.5026776 $266.42 60 $391.21 $516.00 $640.7926785 $319.96 60 $426.81 $533.65 $640.5026820 $953.39 90 $1,077.06 $1,200.72 $1,324.3926841 $773.25 90 $951.95 $1,130.65 $1,309.3426842 $883.80 90 $1,082.61 $1,281.43 $1,480.2426843 $711.00 90 $897.08 $1,083.17 $1,269.2526844 $941.03 90 $1,140.10 $1,339.17 $1,538.2526850 $624.90 90 $808.32 $991.75 $1,175.1726852 $760.71 90 $963.01 $1,165.31 $1,367.6126860 $470.74 90 $577.81 $684.89 $791.9626861 $188.27 90 $204.95 $221.63 $238.3126862 $604.21 90 $821.27 $1,038.33 $1,255.3926863 $213.39 90 $271.83 $330.28 $388.7226910 $533.25 90 $736.48 $939.70 $1,142.9326951 $412.81 45 $534.02 $655.23 $776.4526952 $600.91 45 $759.25 $917.60 $1,075.9426990 $688.32 30 $832.07 $975.83 $1,119.5826991 $98.50 30 $415.94 $733.38 $1,050.8226992 $870.14 30 $1,142.18 $1,414.23 $1,686.2727000 $106.67 30 $303.09 $499.52 $695.9427001 $353.98 30 $529.15 $704.33 $879.50

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 19 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

27003 $697.63 45 $768.98 $840.34 $911.6927005 $512.89 60 $707.43 $901.98 $1,096.5227006 $586.69 60 $802.14 $1,017.60 $1,233.0527025 $835.31 90 $1,001.51 $1,167.71 $1,333.9127030 $1,151.29 90 $1,284.56 $1,417.82 $1,551.0927033 $1,124.64 90 $1,342.98 $1,561.33 $1,779.6727035 $1,342.05 90 $1,592.95 $1,843.86 $2,094.7627036 $1,332.60 $1,458.47 $1,584.34 $1,710.2027040 $181.69 0 $286.62 $391.54 $496.4727041 $318.26 0 $544.07 $769.88 $995.6927047 $368.68 7 $573.87 $779.06 $984.2427048 $718.87 15 $804.68 $890.50 $976.3127049 $980.95 90 $1,295.47 $1,610.00 $1,924.5227050 $482.72 90 $547.35 $611.97 $676.6027052 $1,124.64 90 $1,186.40 $1,248.17 $1,309.9327054 $1,551.16 90 $1,650.78 $1,750.41 $1,850.0327060 $383.07 60 $501.21 $619.36 $737.5027062 $361.17 60 $494.98 $628.78 $762.5927065 $469.40 60 $608.62 $747.84 $887.0627066 $740.43 90 $925.53 $1,110.63 $1,295.7227067 $1,217.17 90 $1,386.92 $1,556.67 $1,726.4227070 $547.22 60 $874.53 $1,201.83 $1,529.1427071 $906.06 60 $1,167.75 $1,429.44 $1,691.1327075 $1,779.05 60 $2,359.77 $2,940.49 $3,521.2127076 $3,499.84 90 $3,418.42 $3,337.01 $3,255.5927077 $3,281.45 90 $3,635.15 $3,988.85 $4,342.5527078 $1,372.77 90 $1,530.34 $1,687.90 $1,845.4727079 $1,590.05 90 $1,697.47 $1,804.89 $1,912.3027080 $482.72 90 $591.66 $700.61 $809.5527086 $353.41 0 $390.70 $428.00 $465.2927087 $484.10 30 $675.22 $866.34 $1,057.4727090 $1,224.02 90 $1,335.72 $1,447.43 $1,559.1327091 $3,456.90 90 $3,285.27 $3,113.64 $2,942.0227093 $112.93 0 $251.42 $389.92 $528.4127095 $207.26 0 $295.80 $384.35 $472.8927097 $847.78 90 $986.11 $1,124.44 $1,262.7727098 $1,210.37 90 $1,256.11 $1,301.86 $1,347.6027100 $1,164.50 90 $1,369.42 $1,574.35 $1,779.2727105 $1,239.20 90 $1,387.35 $1,535.49 $1,683.6427110 $1,380.91 90 $1,566.72 $1,752.54 $1,938.3527111 $1,571.28 90 $1,672.81 $1,774.33 $1,875.8627120 $1,857.36 90 $1,988.17 $2,118.97 $2,249.7827122 $1,524.00 90 $1,687.41 $1,850.81 $2,014.2227125 $2,129.19 90 $2,125.15 $2,121.12 $2,117.0827130 $3,408.98 90 $3,455.21 $3,501.44 $3,547.6727132 $3,647.61 90 $3,717.25 $3,786.88 $3,856.5227134 $3,882.02 90 $3,740.44 $3,598.86 $3,457.2827137 $3,178.24 90 $3,133.55 $3,088.86 $3,044.1727138 $3,131.74 90 $3,362.17 $3,592.61 $3,823.0427140 $960.06 90 $1,143.82 $1,327.59 $1,511.3527146 $1,830.08 90 $1,960.08 $2,090.08 $2,220.0827147 $2,136.52 90 $2,261.11 $2,385.69 $2,510.2827151 $2,150.53 90 $2,229.74 $2,308.95 $2,388.1627156 $2,332.79 90 $2,608.82 $2,884.86 $3,160.8927158 $1,900.10 90 $2,160.95 $2,421.81 $2,682.6627161 $1,510.50 90 $1,742.45 $1,974.41 $2,206.3627165 $1,830.08 90 $2,039.17 $2,248.25 $2,457.3427170 $1,788.80 90 $1,993.23 $2,197.65 $2,402.0827175 $974.86 90 $1,051.82 $1,128.77 $1,205.7327176 $1,560.48 90 $1,708.37 $1,856.26 $2,004.15

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 20 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

27177 $1,913.94 90 $2,065.06 $2,216.19 $2,367.3127178 $1,867.70 90 $1,954.52 $2,041.33 $2,128.1527179 $1,412.72 90 $1,547.44 $1,682.17 $1,816.8927181 $1,787.22 90 $1,951.49 $2,115.76 $2,280.0327185 $449.15 90 $681.88 $914.61 $1,147.3427187 $1,618.67 90 $1,726.92 $1,835.18 $1,943.4327193 $297.85 90 $432.92 $567.98 $703.0527194 $526.70 90 $736.40 $946.10 $1,155.7927200 $134.14 60 $182.13 $230.13 $278.1227202 $542.80 90 $826.27 $1,109.75 $1,393.2227215 $1,270.59 90 $1,391.03 $1,511.47 $1,631.9127216 $1,327.23 90 $1,484.01 $1,640.80 $1,797.5827217 $1,617.43 90 $1,782.06 $1,946.70 $2,111.3327218 $1,985.97 90 $2,192.42 $2,398.87 $2,605.3227220 $277.96 90 $451.43 $624.90 $798.3727222 $918.17 90 $1,112.78 $1,307.39 $1,502.0027226 $1,674.40 90 $1,874.24 $2,074.08 $2,273.9327227 $2,619.74 90 $2,792.89 $2,966.04 $3,139.1927228 $2,499.88 90 $3,047.39 $3,594.90 $4,142.4027230 $303.99 90 $446.15 $588.31 $730.4627232 $906.74 90 $1,021.07 $1,135.41 $1,249.7427235 $1,572.50 90 $1,593.85 $1,615.20 $1,636.5527236 $2,167.83 90 $2,078.76 $1,989.69 $1,900.6127238 $291.76 90 $419.42 $547.09 $674.7527240 $837.18 90 $967.43 $1,097.67 $1,227.9227244 $2,202.89 90 $2,123.70 $2,044.51 $1,965.3227245 $2,374.75 90 $2,342.23 $2,309.71 $2,277.1927246 $243.52 0 $365.95 $488.38 $610.8127248 $840.97 90 $997.33 $1,153.69 $1,310.0527250 $386.54 60 $494.56 $602.59 $710.6127252 $547.56 90 $686.01 $824.46 $962.9127253 $1,018.10 90 $1,290.36 $1,562.62 $1,834.8827254 $1,354.30 90 $1,613.76 $1,873.22 $2,132.6927256 $297.32 0 $388.79 $480.26 $571.7227257 $679.42 0 $769.04 $858.67 $948.2927258 $1,258.04 90 $1,544.81 $1,831.59 $2,118.3627259 $1,854.12 90 $2,218.94 $2,583.77 $2,948.5927265 $409.83 90 $486.82 $563.82 $640.8127266 $543.98 90 $633.13 $722.29 $811.4427275 $118.37 0 $212.05 $305.73 $399.4127280 $1,045.55 90 $1,330.94 $1,616.33 $1,901.7327282 $1,097.10 90 $1,264.28 $1,431.45 $1,598.6327284 $1,795.66 90 $2,173.53 $2,551.40 $2,929.2727286 $1,966.79 90 $2,329.60 $2,692.40 $3,055.2127290 $2,195.70 90 $2,653.41 $3,111.11 $3,568.8227295 $1,849.24 90 $2,156.81 $2,464.38 $2,771.9527301 $375.52 30 $529.98 $684.44 $838.8927303 $503.74 30 $715.33 $926.92 $1,138.5127305 $456.47 45 $585.84 $715.20 $844.5727306 $234.63 30 $352.73 $470.84 $588.9427307 $356.64 30 $485.64 $614.65 $743.6527310 $843.81 90 $929.24 $1,014.67 $1,100.1027315 $831.16 30 $864.91 $898.67 $932.4227320 $835.28 30 $858.63 $881.98 $905.3227323 $148.63 0 $214.08 $279.54 $344.9927324 $363.64 0 $456.15 $548.67 $641.1827327 $345.49 15 $420.56 $495.64 $570.7127328 $500.18 15 $602.88 $705.57 $808.2727329 $1,022.70 90 $1,386.79 $1,750.89 $2,114.9827330 $954.50 90 $1,007.64 $1,060.79 $1,113.93

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 21 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

27331 $1,145.88 90 $1,172.95 $1,200.02 $1,227.0927332 $1,236.47 90 $1,327.03 $1,417.59 $1,508.1627333 $1,167.25 90 $1,200.78 $1,234.30 $1,267.8327334 $1,252.99 90 $1,330.95 $1,408.90 $1,486.8627335 $1,511.54 90 $1,532.26 $1,552.98 $1,573.7027340 $378.53 60 $476.33 $574.14 $671.9427345 $617.81 60 $714.92 $812.03 $909.1427350 $906.06 60 $1,018.74 $1,131.42 $1,244.1027355 $841.45 60 $963.67 $1,085.89 $1,208.1227356 $1,016.60 90 $1,105.77 $1,194.94 $1,284.1027357 $1,113.39 90 $1,267.48 $1,421.57 $1,575.6627358 $422.75 90 $506.14 $589.53 $672.9127360 $773.57 90 $986.14 $1,198.72 $1,411.2927365 $1,281.10 90 $1,647.04 $2,012.97 $2,378.9127370 $75.07 0 $221.67 $368.27 $514.8827372 $366.41 30 $483.02 $599.64 $716.2527380 $821.13 90 $949.03 $1,076.93 $1,204.8327381 $1,004.03 90 $1,182.55 $1,361.07 $1,539.5927385 $979.90 90 $1,045.02 $1,110.15 $1,175.2727386 $1,246.28 90 $1,372.17 $1,498.06 $1,623.9527390 $576.77 30 $669.24 $761.71 $854.1927391 $617.81 45 $735.25 $852.68 $970.1227392 $931.47 45 $1,046.23 $1,160.99 $1,275.7427393 $655.50 30 $705.63 $755.77 $805.9027394 $764.73 30 $887.42 $1,010.12 $1,132.8127395 $1,192.60 30 $1,296.66 $1,400.73 $1,504.7927396 $1,200.27 90 $1,207.83 $1,215.40 $1,222.9627397 $1,338.99 90 $1,382.73 $1,426.47 $1,470.2127400 $1,303.86 90 $1,291.13 $1,278.39 $1,265.6627403 $1,376.78 90 $1,494.69 $1,612.59 $1,730.5027405 $1,078.14 90 $1,212.82 $1,347.49 $1,482.1727407 $1,257.47 90 $1,393.76 $1,530.04 $1,666.3327409 $1,373.00 90 $1,565.87 $1,758.75 $1,951.6227418 $1,346.09 90 $1,504.58 $1,663.07 $1,821.5727420 $1,210.03 90 $1,304.27 $1,398.50 $1,492.7427422 $1,175.20 90 $1,304.99 $1,434.78 $1,564.5727424 $1,211.00 90 $1,340.53 $1,470.05 $1,599.5827425 $1,254.53 90 $1,288.37 $1,322.22 $1,356.0627427 $1,535.98 90 $1,599.77 $1,663.57 $1,727.3627428 $1,880.69 90 $2,061.01 $2,241.33 $2,421.6627429 $1,947.13 90 $2,153.24 $2,359.36 $2,565.4727430 $1,175.95 90 $1,252.25 $1,328.54 $1,404.8427435 $1,124.64 90 $1,256.46 $1,388.28 $1,520.1027437 $1,377.14 90 $1,384.73 $1,392.32 $1,399.9127438 $1,836.03 90 $1,773.32 $1,710.62 $1,647.9127440 $1,548.40 90 $1,535.92 $1,523.43 $1,510.9527441 $1,474.30 90 $1,462.14 $1,449.97 $1,437.8127442 $1,849.24 90 $1,843.72 $1,838.19 $1,832.6727443 $1,842.36 90 $1,824.60 $1,806.84 $1,789.0827445 $2,282.44 90 $2,396.19 $2,509.94 $2,623.6927446 $2,413.36 90 $2,459.40 $2,505.45 $2,551.4927447 $3,533.56 90 $3,669.69 $3,805.82 $3,941.9527448 $1,429.31 90 $1,530.74 $1,632.16 $1,733.5927450 $1,658.45 90 $1,756.70 $1,854.94 $1,953.1927454 $1,510.50 90 $1,780.33 $2,050.17 $2,320.0027455 $1,219.56 90 $1,381.30 $1,543.05 $1,704.7927457 $1,169.53 90 $1,382.85 $1,596.17 $1,809.4927465 $1,529.12 90 $1,662.76 $1,796.39 $1,930.0327466 $1,890.15 90 $2,081.17 $2,272.18 $2,463.2027468 $2,499.79 90 $2,566.23 $2,632.67 $2,699.11

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 22 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

27470 $1,499.16 90 $1,752.12 $2,005.08 $2,258.0427472 $1,781.53 90 $1,983.85 $2,186.17 $2,388.4927475 $1,059.68 90 $1,214.74 $1,369.80 $1,524.8527477 $1,233.47 90 $1,389.33 $1,545.19 $1,701.0627479 $1,527.93 90 $1,728.56 $1,929.18 $2,129.8127485 $831.60 90 $952.45 $1,073.31 $1,194.1627486 $2,409.38 90 $2,548.15 $2,686.92 $2,825.7027487 $3,489.69 90 $3,420.39 $3,351.08 $3,281.7827488 $1,267.27 90 $1,525.10 $1,782.93 $2,040.7727495 $1,391.09 90 $1,563.82 $1,736.55 $1,909.2927496 $567.40 90 $661.28 $755.17 $849.0527497 $813.62 90 $884.12 $954.62 $1,025.1127498 $928.09 90 $1,016.01 $1,103.92 $1,191.8427499 $1,168.25 90 $1,244.61 $1,320.98 $1,397.3427500 $326.95 90 $478.30 $629.65 $781.0027501 $461.15 90 $632.10 $803.04 $973.9927502 $665.41 90 $932.16 $1,198.92 $1,465.6727503 $837.79 90 $1,038.48 $1,239.17 $1,439.8527506 $1,700.26 90 $1,972.57 $2,244.87 $2,517.1827507 $1,666.35 90 $1,778.41 $1,890.46 $2,002.5227508 $290.30 90 $438.05 $585.80 $733.5527509 $693.24 90 $806.81 $920.39 $1,033.9627510 $632.70 90 $763.01 $893.32 $1,023.6227511 $1,415.04 90 $1,555.84 $1,696.63 $1,837.4327513 $1,662.10 90 $1,836.45 $2,010.80 $2,185.1427514 $1,418.76 90 $1,651.41 $1,884.05 $2,116.7027516 $301.91 90 $451.81 $601.70 $751.6027517 $655.16 90 $808.34 $961.53 $1,114.7127519 $1,275.38 90 $1,570.97 $1,866.56 $2,162.1627520 $175.89 60 $269.26 $362.62 $455.9927524 $1,056.81 90 $1,141.15 $1,225.49 $1,309.8327530 $202.80 90 $333.14 $463.48 $593.8227532 $482.78 90 $651.19 $819.60 $988.0127535 $923.45 90 $1,130.33 $1,337.21 $1,544.0927536 $1,048.98 90 $1,368.15 $1,687.32 $2,006.4927538 $238.80 90 $378.63 $518.46 $658.2927540 $1,023.77 90 $1,232.96 $1,442.15 $1,651.3427550 $345.11 45 $444.98 $544.85 $644.7127552 $481.87 45 $609.59 $737.30 $865.0227556 $1,139.95 90 $1,404.49 $1,669.02 $1,933.5627557 $1,393.37 90 $1,726.82 $2,060.27 $2,393.7227558 $1,352.40 90 $1,738.23 $2,124.06 $2,509.8927560 $189.46 45 $274.31 $359.15 $444.0027562 $397.98 45 $486.18 $574.39 $662.5927566 $948.06 90 $1,141.66 $1,335.27 $1,528.8727570 $131.92 0 $166.89 $201.85 $236.8227580 $1,524.00 90 $1,795.01 $2,066.01 $2,337.0227590 $1,054.31 90 $1,136.30 $1,218.30 $1,300.2927591 $1,206.35 90 $1,371.72 $1,537.10 $1,702.4727592 $1,004.73 90 $1,170.93 $1,337.12 $1,503.3227594 $432.11 90 $556.58 $681.04 $805.5127596 $854.45 90 $1,048.03 $1,241.61 $1,435.2027598 $1,054.44 90 $1,205.60 $1,356.76 $1,507.9227600 $379.47 30 $509.21 $638.96 $768.7027601 $369.72 30 $493.32 $616.92 $740.5227602 $490.40 30 $619.41 $748.41 $877.4227603 $489.96 60 $645.72 $801.47 $957.2327604 $255.21 30 $422.54 $589.87 $757.2127605 $108.40 0 $270.34 $432.27 $594.2127606 $241.42 30 $431.81 $622.21 $812.60

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 23 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

27607 $358.97 30 $614.12 $869.26 $1,124.4127610 $824.14 60 $925.02 $1,025.90 $1,126.7827612 $825.10 60 $905.45 $985.80 $1,066.1527613 $210.13 0 $389.35 $568.58 $747.8027614 $364.31 0 $540.13 $715.96 $891.7827615 $917.24 90 $1,229.92 $1,542.60 $1,855.2827618 $261.35 21 $411.77 $562.20 $712.6227619 $404.06 30 $630.18 $856.30 $1,082.4127620 $770.68 60 $815.85 $861.02 $906.1927625 $914.75 90 $997.66 $1,080.57 $1,163.4927626 $970.80 90 $1,072.53 $1,174.27 $1,276.0027630 $320.46 45 $495.55 $670.64 $845.7327635 $758.58 60 $889.23 $1,019.87 $1,150.5227637 $986.36 90 $1,142.56 $1,298.76 $1,454.9527638 $980.17 90 $1,138.02 $1,295.86 $1,453.7127640 $881.38 90 $1,025.07 $1,168.76 $1,312.4527641 $806.29 90 $1,033.19 $1,260.09 $1,486.9927645 $1,556.39 90 $1,754.66 $1,952.94 $2,151.2127646 $1,253.39 90 $1,469.87 $1,686.36 $1,902.8427647 $1,452.14 90 $1,482.13 $1,512.12 $1,542.1027648 $110.51 0 $225.51 $340.50 $455.5027650 $964.45 90 $1,086.15 $1,207.85 $1,329.5427652 $1,104.77 90 $1,205.92 $1,307.07 $1,408.2227654 $1,165.61 90 $1,242.03 $1,318.45 $1,394.8727656 $482.72 45 $606.13 $729.54 $852.9627658 $493.54 90 $646.54 $799.54 $952.5527659 $619.58 90 $745.44 $871.29 $997.1527664 $345.53 90 $555.02 $764.50 $973.9927665 $451.38 90 $606.35 $761.32 $916.3027675 $565.11 30 $673.03 $780.95 $888.8727676 $710.74 60 $842.30 $973.87 $1,105.4327680 $391.33 60 $487.02 $582.72 $678.4127681 $380.68 60 $542.17 $703.66 $865.1627685 $594.31 90 $713.80 $833.29 $952.7927686 $516.56 90 $687.01 $857.46 $1,027.9227687 $600.04 90 $687.70 $775.35 $863.0127690 $706.15 90 $801.50 $896.86 $992.2127691 $840.30 90 $1,034.86 $1,229.43 $1,423.9927692 $215.00 90 $220.18 $225.35 $230.5327695 $834.32 90 $891.60 $948.87 $1,006.1527696 $1,037.77 90 $1,156.23 $1,274.69 $1,393.1427698 $1,000.02 90 $1,133.32 $1,266.62 $1,399.9227700 $1,642.69 90 $1,575.24 $1,507.79 $1,440.3427702 $2,448.34 90 $2,361.30 $2,274.26 $2,187.2227703 $2,840.30 90 $2,700.35 $2,560.40 $2,420.4527704 $975.21 30 $1,030.09 $1,084.97 $1,139.8627705 $911.18 90 $1,126.62 $1,342.06 $1,557.4927707 $530.41 90 $602.21 $674.01 $745.8127709 $1,058.27 90 $1,177.35 $1,296.42 $1,415.5027712 $1,385.75 90 $1,565.85 $1,745.95 $1,926.0427715 $1,817.61 90 $1,913.09 $2,008.57 $2,104.0527720 $1,294.96 90 $1,409.65 $1,524.34 $1,639.0327722 $1,527.93 90 $1,632.38 $1,736.82 $1,841.2727724 $1,725.99 90 $1,848.88 $1,971.76 $2,094.6527725 $1,746.28 90 $1,932.46 $2,118.64 $2,304.8127727 $1,742.95 90 $1,843.62 $1,944.29 $2,044.9727730 $777.68 90 $985.08 $1,192.47 $1,399.8727732 $449.72 90 $615.48 $781.25 $947.0127734 $1,071.39 90 $1,151.59 $1,231.79 $1,311.9927740 $1,393.66 90 $1,508.84 $1,624.01 $1,739.19

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 24 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

27742 $1,736.14 90 $1,775.05 $1,813.96 $1,852.8727745 $1,504.20 90 $1,510.84 $1,517.48 $1,524.1227750 $195.58 90 $301.80 $408.02 $514.2527752 $431.33 90 $532.90 $634.48 $736.0527756 $891.77 90 $998.84 $1,105.91 $1,212.9827758 $1,087.36 90 $1,339.94 $1,592.53 $1,845.1127759 $1,354.95 90 $1,523.65 $1,692.34 $1,861.0427760 $207.72 90 $294.25 $380.78 $467.3027762 $379.24 90 $467.00 $554.76 $642.5127766 $683.16 90 $815.34 $947.52 $1,079.6927780 $134.77 90 $211.16 $287.54 $363.9327781 $270.78 90 $380.33 $489.88 $599.4327784 $549.45 90 $694.91 $840.36 $985.8227786 $160.80 90 $252.97 $345.13 $437.3027788 $300.92 90 $398.85 $496.79 $594.7227792 $645.31 90 $777.25 $909.20 $1,041.1427808 $168.30 90 $269.61 $370.91 $472.2227810 $412.28 90 $522.32 $632.35 $742.3927814 $1,060.56 90 $1,141.90 $1,223.24 $1,304.5827816 $201.30 90 $284.61 $367.92 $451.2427818 $505.15 90 $603.00 $700.85 $798.7027822 $1,171.53 90 $1,354.43 $1,537.33 $1,720.2327823 $1,402.68 90 $1,537.72 $1,672.75 $1,807.7927824 $348.84 90 $402.33 $455.81 $509.3027825 $665.42 90 $742.28 $819.14 $896.0027826 $993.07 90 $1,173.10 $1,353.13 $1,533.1727827 $1,136.84 90 $1,391.16 $1,645.48 $1,899.8127828 $1,322.44 90 $1,657.42 $1,992.39 $2,327.3727829 $684.35 90 $812.78 $941.21 $1,069.6327830 $275.99 90 $347.13 $418.27 $489.4027831 $455.40 30 $489.87 $524.35 $558.8227832 $582.08 90 $687.66 $793.24 $898.8227840 $212.99 45 $303.34 $393.69 $484.0527842 $295.19 45 $398.46 $501.73 $605.0127846 $825.81 90 $964.16 $1,102.50 $1,240.8527848 $781.27 90 $1,034.38 $1,287.49 $1,540.5927860 $133.97 0 $182.31 $230.64 $278.9827870 $1,336.74 90 $1,536.98 $1,737.23 $1,937.4727871 $1,107.53 90 $1,207.47 $1,307.41 $1,407.3627880 $1,146.84 90 $1,197.88 $1,248.92 $1,299.9627881 $1,246.11 90 $1,389.08 $1,532.05 $1,675.0327882 $942.28 90 $1,018.47 $1,094.66 $1,170.8527884 $532.52 45 $649.75 $766.98 $884.2127886 $868.25 45 $1,024.62 $1,181.00 $1,337.3727888 $960.27 90 $1,112.97 $1,265.67 $1,418.3727889 $889.78 90 $995.07 $1,100.36 $1,205.6627892 $648.89 90 $775.22 $901.55 $1,027.8927893 $737.87 90 $836.33 $934.78 $1,033.2427894 $993.50 90 $1,132.86 $1,272.22 $1,411.5928001 $249.77 0 $309.34 $368.91 $428.4828002 $382.95 0 $464.02 $545.09 $626.1628003 $491.26 21 $666.06 $840.85 $1,015.6528005 $499.80 45 $673.97 $848.15 $1,022.3228008 $250.71 60 $364.58 $478.45 $592.3328010 $79.17 30 $214.53 $349.89 $485.2528011 $107.91 30 $276.38 $444.85 $613.3228020 $475.69 60 $582.84 $689.98 $797.1328022 $291.37 60 $406.89 $522.40 $637.9228024 $311.41 60 $424.03 $536.65 $649.2728030 $487.60 60 $565.38 $643.16 $720.95

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 25 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

28035 $637.20 30 $730.44 $823.69 $916.9328043 $256.52 21 $341.90 $427.28 $512.6628045 $393.37 21 $495.89 $598.40 $700.9228046 $622.15 90 $991.03 $1,359.91 $1,728.8028050 $476.34 60 $545.56 $614.78 $684.0028052 $307.35 60 $395.42 $483.49 $571.5628054 $215.19 60 $312.52 $409.86 $507.1928060 $477.51 60 $580.12 $682.73 $785.3328062 $711.85 90 $835.36 $958.88 $1,082.3928070 $458.13 90 $532.69 $607.25 $681.8128072 $302.93 90 $412.26 $521.58 $630.9128080 $396.36 30 $462.68 $528.99 $595.3128086 $618.91 60 $679.26 $739.61 $799.9628088 $485.53 60 $567.51 $649.48 $731.4628090 $312.42 45 $400.15 $487.87 $575.6028092 $221.19 30 $307.09 $392.99 $478.9028100 $528.47 60 $664.66 $800.86 $937.0528102 $710.90 90 $842.78 $974.67 $1,106.5528103 $657.80 90 $770.16 $882.51 $994.8728104 $371.70 60 $467.02 $562.34 $657.6628106 $426.13 90 $577.28 $728.44 $879.5928107 $378.83 90 $549.43 $720.03 $890.6428108 $323.73 60 $416.76 $509.78 $602.8128110 $332.19 60 $417.69 $503.19 $588.6828111 $419.66 30 $528.89 $638.12 $747.3628112 $370.17 60 $486.41 $602.65 $718.8928113 $392.23 30 $490.12 $588.01 $685.9028114 $970.66 60 $1,124.29 $1,277.92 $1,431.5528116 $577.40 60 $770.94 $964.48 $1,158.0128118 $603.65 60 $691.69 $779.72 $867.7628119 $530.72 60 $631.19 $731.67 $832.1428120 $484.97 60 $609.38 $733.78 $858.1928122 $436.95 60 $555.36 $673.77 $792.1928124 $402.48 60 $464.63 $526.79 $588.9428126 $218.93 60 $332.75 $446.57 $560.3928130 $767.94 90 $904.78 $1,041.63 $1,178.4728140 $482.72 60 $611.49 $740.26 $869.0228150 $286.23 30 $404.46 $522.70 $640.9328153 $320.45 30 $399.70 $478.94 $558.1928160 $293.23 30 $387.64 $482.05 $576.4628171 $946.45 90 $967.15 $987.84 $1,008.5428173 $776.25 90 $882.98 $989.71 $1,096.4428175 $611.80 90 $662.93 $714.07 $765.2028190 $166.04 0 $233.14 $300.24 $367.3428192 $325.00 30 $406.46 $487.91 $569.3728193 $455.40 30 $557.12 $658.83 $760.5528200 $517.23 90 $599.47 $681.71 $763.9528202 $619.58 90 $740.74 $861.90 $983.0628208 $285.69 90 $359.27 $432.85 $506.4328210 $438.47 90 $550.98 $663.49 $776.0028220 $383.18 60 $477.34 $571.50 $665.6628222 $482.72 60 $582.52 $682.32 $782.1228225 $375.35 60 $461.99 $548.63 $635.2728226 $310.35 60 $417.30 $524.25 $631.2028230 $288.44 30 $381.28 $474.11 $566.9528232 $135.72 30 $264.11 $392.50 $520.9028234 $104.99 30 $232.37 $359.75 $487.1328238 $833.59 60 $907.24 $980.88 $1,054.5328240 $264.92 60 $365.99 $467.07 $568.1428250 $506.41 60 $596.21 $686.02 $775.82

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 26 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

28260 $751.15 60 $843.25 $935.35 $1,027.4528261 $799.03 60 $991.80 $1,184.57 $1,377.3428262 $1,343.80 90 $1,608.10 $1,872.40 $2,136.7128264 $987.36 90 $1,121.36 $1,255.36 $1,389.3628270 $265.12 60 $380.21 $495.31 $610.4028272 $135.72 60 $257.57 $379.43 $501.2828280 $289.43 45 $428.23 $567.03 $705.8328285 $476.64 60 $522.25 $567.86 $613.4728286 $390.03 60 $487.40 $584.78 $682.1528288 $294.63 60 $432.48 $570.34 $708.1928290 $515.69 90 $602.10 $688.51 $774.9228292 $810.90 90 $859.57 $908.24 $956.9128293 $897.78 90 $999.72 $1,101.66 $1,203.5928294 $881.72 90 $984.58 $1,087.44 $1,190.3028296 $1,140.77 90 $1,203.86 $1,266.95 $1,330.0428297 $1,067.64 90 $1,155.71 $1,243.78 $1,331.8528298 $777.70 90 $887.56 $997.41 $1,107.2728299 $1,026.95 90 $1,107.28 $1,187.60 $1,267.9328300 $876.16 90 $1,010.70 $1,145.23 $1,279.7728302 $682.06 90 $865.74 $1,049.41 $1,233.0928304 $606.89 90 $761.40 $915.92 $1,070.4328305 $831.35 90 $963.65 $1,095.94 $1,228.2428306 $552.16 90 $649.11 $746.05 $843.0028307 $644.16 90 $816.29 $988.41 $1,160.5428308 $539.06 90 $617.41 $695.76 $774.1128309 $789.29 60 $1,024.61 $1,259.92 $1,495.2428310 $323.47 90 $433.37 $543.27 $653.1728312 $183.42 90 $329.34 $475.27 $621.1928313 $278.63 90 $416.36 $554.09 $691.8128315 $474.10 90 $537.18 $600.26 $663.3428320 $609.50 90 $750.72 $891.94 $1,033.1628322 $457.20 90 $653.27 $849.35 $1,045.4228340 $460.45 90 $624.87 $789.30 $953.7228341 $568.01 90 $745.16 $922.30 $1,099.4528344 $446.51 90 $553.12 $659.72 $766.3328345 $899.73 90 $953.79 $1,007.84 $1,061.9028360 $899.73 90 $1,150.50 $1,401.26 $1,652.0328400 $149.64 90 $231.16 $312.67 $394.1928405 $350.75 90 $429.11 $507.47 $585.8328406 $489.94 90 $604.30 $718.67 $833.0328415 $1,097.94 90 $1,389.60 $1,681.26 $1,972.9128420 $1,389.86 90 $1,628.84 $1,867.82 $2,106.8128430 $139.42 90 $216.92 $294.42 $371.9228435 $265.80 90 $337.20 $408.60 $480.0028436 $362.34 90 $483.09 $603.84 $724.5928445 $788.21 90 $1,080.97 $1,373.74 $1,666.5028450 $115.89 90 $192.27 $268.65 $345.0328455 $206.49 90 $292.45 $378.42 $464.3828456 $259.78 90 $344.09 $428.40 $512.7128465 $543.66 90 $704.12 $864.57 $1,025.0328470 $112.09 60 $189.20 $266.32 $343.4328475 $199.46 60 $265.38 $331.30 $397.2228476 $262.92 60 $348.13 $433.34 $518.5528485 $433.72 90 $585.39 $737.06 $888.7328490 $64.46 30 $101.52 $138.58 $175.6428495 $102.92 30 $149.46 $196.00 $242.5428496 $179.75 30 $317.41 $455.07 $592.7428505 $279.37 60 $449.71 $620.04 $790.3828510 $63.71 30 $95.60 $127.50 $159.3928515 $95.95 30 $127.65 $159.34 $191.04

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 27 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

28525 $259.45 60 $412.19 $564.93 $717.6728530 $66.97 60 $111.23 $155.49 $199.7528531 $174.80 60 $333.13 $491.46 $649.7928540 $100.78 45 $161.10 $221.41 $281.7328545 $149.49 45 $213.55 $277.61 $341.6728546 $242.19 45 $399.53 $556.86 $714.2028555 $483.63 90 $659.72 $835.81 $1,011.9028570 $134.24 45 $192.01 $249.79 $307.5628575 $221.98 45 $300.38 $378.77 $457.1728576 $326.60 45 $543.54 $760.48 $977.4228585 $632.54 90 $770.52 $908.50 $1,046.4828600 $100.03 45 $165.06 $230.08 $295.1128605 $187.17 45 $248.14 $309.11 $370.0728606 $305.94 45 $502.17 $698.40 $894.6328615 $444.20 90 $705.74 $967.28 $1,228.8228630 $124.15 7 $149.84 $175.53 $201.2128635 $153.46 7 $185.87 $218.29 $250.7028636 $266.80 2 $330.44 $394.07 $457.7128645 $304.25 90 $399.29 $494.33 $589.3728660 $83.61 7 $120.07 $156.53 $192.9928665 $128.97 7 $154.12 $179.27 $204.4328666 $254.15 45 $432.31 $610.48 $788.6428675 $231.75 60 $355.40 $479.04 $602.6928705 $1,342.40 90 $1,628.20 $1,913.99 $2,199.7928715 $1,251.40 90 $1,460.71 $1,670.02 $1,879.3228725 $995.79 90 $1,103.39 $1,210.99 $1,318.6028730 $869.31 90 $1,045.40 $1,221.49 $1,397.5928735 $1,103.73 90 $1,229.51 $1,355.30 $1,481.0828737 $995.78 90 $1,086.99 $1,178.19 $1,269.4028740 $705.18 90 $865.13 $1,025.07 $1,185.0228750 $575.55 90 $749.60 $923.65 $1,097.6928755 $353.91 90 $461.30 $568.69 $676.0828760 $547.44 90 $693.61 $839.79 $985.9628800 $780.41 90 $885.65 $990.88 $1,096.1228805 $757.56 90 $822.08 $886.59 $951.1128810 $507.26 90 $562.09 $616.93 $671.7628820 $241.48 45 $392.22 $542.97 $693.7128825 $175.42 45 $316.88 $458.34 $599.8029000 $413.16 2 $436.19 $459.23 $482.2629010 $249.92 2 $308.97 $368.01 $427.0629015 $307.37 2 $359.78 $412.18 $464.5929020 $286.49 2 $312.72 $338.96 $365.1929025 $349.35 2 $370.23 $391.12 $412.0029035 $182.65 2 $227.72 $272.80 $317.8729040 $216.53 2 $253.11 $289.70 $326.2829044 $207.30 2 $259.17 $311.03 $362.9029046 $229.90 2 $270.55 $311.21 $351.8629049 $71.30 2 $99.45 $127.59 $155.7429055 $164.57 2 $209.08 $253.58 $298.0929058 $106.95 2 $139.88 $172.80 $205.7329065 $100.15 2 $117.56 $134.97 $152.3829075 $78.79 2 $94.25 $109.71 $125.1629085 $77.50 2 $93.13 $108.75 $124.3829105 $55.05 2 $73.40 $91.75 $110.1029125 $46.61 2 $59.67 $72.74 $85.8029126 $108.54 2 $112.33 $116.11 $119.9029130 $28.35 2 $37.65 $46.94 $56.2429131 $108.54 2 $107.19 $105.84 $104.4829200 $31.06 0 $43.68 $56.30 $68.9229220 $39.41 0 $50.63 $61.86 $73.08

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 28 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

29240 $50.37 0 $58.92 $67.47 $76.0229260 $26.83 0 $39.87 $52.92 $65.9629280 $31.05 0 $41.65 $52.26 $62.8629305 $188.49 2 $264.06 $339.64 $415.2129325 $224.02 2 $287.17 $350.32 $413.4729345 $108.06 2 $135.54 $163.03 $190.5129355 $116.61 2 $143.34 $170.06 $196.7929358 $258.73 2 $265.22 $271.72 $278.2129365 $97.11 2 $126.57 $156.03 $185.4929405 $94.37 2 $112.17 $129.98 $147.7829425 $96.30 2 $114.57 $132.84 $151.1129435 $150.55 2 $169.95 $189.36 $208.7629440 $30.68 1 $44.75 $58.83 $72.9029445 $174.60 S $208.23 $241.85 $275.4829450 $52.75 2 $101.53 $150.31 $199.0929505 $75.79 2 $87.55 $99.30 $111.0629515 $51.49 2 $64.19 $76.89 $89.5929520 $39.45 0 $49.54 $59.64 $69.7329530 $31.06 0 $42.00 $52.94 $63.8829540 $29.20 0 $35.96 $42.72 $49.4829550 $20.70 0 $27.90 $35.10 $42.3029580 $63.49 0 $65.03 $66.57 $68.1129590 $81.65 0 $84.37 $87.10 $89.8229700 $48.34 0 $55.52 $62.71 $69.8929705 $44.64 0 $60.52 $76.41 $92.2929710 $48.25 0 $84.94 $121.63 $158.3229715 $58.55 0 $81.67 $104.79 $127.9129720 $27.80 0 $51.01 $74.22 $97.4329730 $18.80 0 $43.68 $68.56 $93.4529740 $32.12 0 $58.61 $85.11 $111.6029750 $46.00 0 $74.19 $102.38 $130.5729800 $460.00 0 $642.96 $825.92 $1,008.8829804 $1,745.70 60 $1,704.44 $1,663.17 $1,621.9129819 $1,094.95 60 $1,188.24 $1,281.53 $1,374.8229820 $1,083.34 60 $1,146.11 $1,208.88 $1,271.6529821 $1,280.21 60 $1,318.20 $1,356.18 $1,394.1729822 $1,257.40 60 $1,307.50 $1,357.60 $1,407.6929823 $1,377.48 60 $1,454.15 $1,530.81 $1,607.4829825 $1,163.88 60 $1,243.74 $1,323.59 $1,403.4529826 $1,555.54 60 $1,688.76 $1,821.97 $1,955.1929830 $790.36 0 $865.14 $939.92 $1,014.6929834 $890.99 60 $946.99 $1,002.99 $1,058.9929835 $917.63 60 $1,002.25 $1,086.87 $1,171.4929836 $1,112.18 60 $1,159.94 $1,207.70 $1,255.4629837 $840.02 60 $950.19 $1,060.37 $1,170.5429838 $856.07 60 $975.42 $1,094.77 $1,214.1329840 $671.32 0 $762.77 $854.21 $945.6629843 $777.50 60 $878.50 $979.50 $1,080.4929844 $798.31 60 $887.55 $976.80 $1,066.0429845 $951.95 60 $1,051.89 $1,151.82 $1,251.7629846 $957.83 60 $1,083.79 $1,209.76 $1,335.7229847 $840.27 60 $1,051.97 $1,263.66 $1,475.3629848 $756.72 90 $849.10 $941.47 $1,033.8529850 $1,067.21 90 $1,109.66 $1,152.11 $1,194.5629851 $1,416.43 90 $1,535.29 $1,654.14 $1,773.0029855 $1,187.12 90 $1,247.97 $1,308.82 $1,369.6729856 $1,349.15 90 $1,455.04 $1,560.92 $1,666.8129860 $721.71 $850.10 $978.48 $1,106.8729861 $1,038.02 $1,133.37 $1,228.72 $1,324.0829862 $1,189.62 $1,357.88 $1,526.15 $1,694.41

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 29 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

29863 $1,113.73 $1,274.34 $1,434.95 $1,595.5729870 $660.26 0 $704.44 $748.62 $792.7929871 $821.97 60 $867.15 $912.34 $957.5229874 $1,081.22 60 $1,155.70 $1,230.18 $1,304.6729875 $1,615.47 60 $1,603.27 $1,591.08 $1,578.8829876 $1,316.33 60 $1,384.08 $1,451.84 $1,519.5929877 $1,187.62 60 $1,282.38 $1,377.14 $1,471.9129879 $1,303.90 60 $1,396.21 $1,488.51 $1,580.8229880 $1,520.06 60 $1,634.10 $1,748.13 $1,862.1729881 $1,360.49 60 $1,479.01 $1,597.53 $1,716.0429882 $1,387.56 60 $1,518.51 $1,649.45 $1,780.4029883 $1,992.41 60 $1,922.50 $1,852.59 $1,782.6829884 $1,172.85 60 $1,186.24 $1,199.63 $1,213.0329885 $1,254.31 60 $1,334.66 $1,415.00 $1,495.3529886 $1,106.53 60 $1,196.81 $1,287.09 $1,377.3729887 $1,508.45 60 $1,568.10 $1,627.75 $1,687.3929888 $2,777.05 60 $2,891.14 $3,005.24 $3,119.3329889 $1,791.70 60 $2,152.47 $2,513.25 $2,874.0229891 $952.36 $1,080.13 $1,207.90 $1,335.6729892 $966.33 $1,139.38 $1,312.42 $1,485.4729893 $533.66 $554.33 $575.00 $595.6629894 $837.27 60 $942.99 $1,048.71 $1,154.4329895 $977.65 60 $1,097.63 $1,217.60 $1,337.5829897 $822.82 60 $868.71 $914.60 $960.4929898 $1,052.32 60 $1,141.01 $1,229.69 $1,318.3830000 $104.20 0 $164.24 $224.28 $284.3230020 $120.93 0 $163.33 $205.72 $248.1230100 $98.42 0 $121.62 $144.81 $168.0130110 $135.31 7 $172.13 $208.95 $245.7730115 $315.57 15 $377.25 $438.93 $500.6030117 $257.19 7 $428.89 $600.59 $772.2930118 $861.31 30 $995.23 $1,129.14 $1,263.0630120 $855.56 60 $898.51 $941.46 $984.4130124 $286.99 30 $350.89 $414.80 $478.7030125 $803.82 30 $948.88 $1,093.95 $1,239.0130130 $229.59 30 $329.81 $430.03 $530.2530140 $501.12 90 $550.03 $598.93 $647.8430150 $658.45 90 $868.44 $1,078.44 $1,288.4330160 $1,092.22 90 $1,210.97 $1,329.72 $1,448.4730200 $46.25 0 $67.26 $88.27 $109.2730210 $73.92 0 $107.89 $141.87 $175.8430220 $87.20 30 $169.87 $252.55 $335.2230300 $77.12 0 $124.00 $170.87 $217.7530310 $210.17 7 $246.45 $282.73 $319.0230320 $469.20 30 $559.80 $650.41 $741.0130400 $1,056.66 90 $1,263.57 $1,470.49 $1,677.4030410 $1,538.66 90 $1,773.34 $2,008.02 $2,242.7130420 $1,752.62 90 $2,001.05 $2,249.47 $2,497.9030430 $531.82 45 $788.23 $1,044.64 $1,301.0630435 $823.75 45 $1,140.34 $1,456.93 $1,773.5330450 $1,176.65 45 $1,602.64 $2,028.63 $2,454.6230460 $1,081.84 45 $1,183.38 $1,284.92 $1,386.4630462 $2,410.04 45 $2,536.20 $2,662.36 $2,788.5230520 $1,084.66 90 $1,140.71 $1,196.77 $1,252.8230540 $843.27 60 $975.26 $1,107.25 $1,239.2530545 $1,562.58 60 $1,681.39 $1,800.20 $1,919.0130560 $39.01 7 $118.31 $197.62 $276.9230580 $804.00 90 $907.31 $1,010.62 $1,113.9430600 $433.96 90 $599.73 $765.49 $931.2630620 $1,005.56 90 $1,031.96 $1,058.36 $1,084.75

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 30 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

30630 $797.47 90 $865.59 $933.71 $1,001.8330801 $84.16 0 $123.66 $163.17 $202.6730802 $159.85 15 $210.04 $260.23 $310.4230901 $66.62 0 $91.41 $116.19 $140.9830903 $140.39 0 $164.21 $188.03 $211.8530905 $215.18 0 $260.08 $304.98 $349.8730906 $168.75 0 $229.42 $290.08 $350.7530915 $728.05 30 $808.74 $889.43 $970.1230920 $1,164.06 30 $1,266.85 $1,369.64 $1,472.4330930 $102.29 30 $137.37 $172.44 $207.5231000 $69.85 0 $118.02 $166.18 $214.3531002 $167.98 0 $206.06 $244.15 $282.2331020 $314.72 90 $431.27 $547.82 $664.3731030 $942.72 90 $1,050.03 $1,157.34 $1,264.6531032 $1,151.42 90 $1,190.37 $1,229.33 $1,268.2831040 $1,419.04 90 $1,519.74 $1,620.45 $1,721.1531050 $882.81 90 $936.46 $990.11 $1,043.7631051 $1,088.31 90 $1,198.70 $1,309.09 $1,419.4731070 $771.63 90 $799.82 $828.01 $856.2031075 $1,248.87 90 $1,341.39 $1,433.92 $1,526.4431080 $1,371.70 90 $1,531.91 $1,692.13 $1,852.3431081 $1,463.03 90 $1,582.70 $1,702.38 $1,822.0531084 $1,790.66 90 $1,900.79 $2,010.92 $2,121.0631085 $1,909.09 90 $2,036.52 $2,163.95 $2,291.3831086 $1,580.73 90 $1,679.17 $1,777.61 $1,876.0631087 $1,611.86 90 $1,721.84 $1,831.83 $1,941.8131090 $2,034.18 90 $2,015.01 $1,995.84 $1,976.6631200 $570.23 90 $695.50 $820.78 $946.0531201 $840.42 90 $973.46 $1,106.50 $1,239.5431205 $1,205.34 90 $1,368.02 $1,530.70 $1,693.3931225 $1,818.37 90 $2,136.73 $2,455.09 $2,773.4631230 $2,169.50 90 $2,521.53 $2,873.57 $3,225.6031231 $110.21 $142.05 $173.88 $205.7231233 $199.41 $283.57 $367.72 $451.8831235 $357.34 $423.56 $489.78 $556.0031237 $251.00 $322.01 $393.02 $464.0331238 $426.46 $451.39 $476.31 $501.2431239 $1,127.56 $1,210.72 $1,293.87 $1,377.0331240 $340.72 $366.55 $392.39 $418.2231254 $795.21 S $817.17 $839.13 $861.0931255 $1,273.94 S $1,294.46 $1,314.97 $1,335.4931256 $455.58 S $496.11 $536.64 $577.1731267 $659.57 S $715.60 $771.63 $827.6631276 $963.05 S $1,017.42 $1,071.79 $1,126.1631287 $532.93 $582.18 $631.43 $680.6731288 $625.42 $677.04 $728.66 $780.2831290 $1,698.77 $1,855.69 $2,012.61 $2,169.5331291 $1,709.87 $1,894.22 $2,078.56 $2,262.9131292 $1,624.40 $1,732.31 $1,840.21 $1,948.1231293 $1,893.14 $2,032.63 $2,172.13 $2,311.6231294 $1,899.69 $2,144.67 $2,389.65 $2,634.6331300 $1,248.87 90 $1,557.75 $1,866.64 $2,175.5231320 $688.66 60 $820.41 $952.17 $1,083.9231360 $1,948.57 90 $2,209.77 $2,470.98 $2,732.1831365 $2,790.72 90 $3,048.81 $3,306.89 $3,564.9831367 $2,033.36 90 $2,418.49 $2,803.63 $3,188.7631368 $2,802.37 90 $3,293.56 $3,784.76 $4,275.9531370 $2,443.19 90 $2,741.35 $3,039.51 $3,337.6731375 $1,570.15 90 $1,932.43 $2,294.72 $2,657.0031380 $1,699.64 90 $2,074.29 $2,448.94 $2,823.59

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 31 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

31382 $1,796.62 90 $2,157.79 $2,518.95 $2,880.1231390 $2,640.85 90 $3,117.12 $3,593.39 $4,069.6631395 $3,348.80 90 $3,853.61 $4,358.42 $4,863.2331400 $1,598.45 90 $1,699.84 $1,801.23 $1,902.6231420 $1,267.40 90 $1,388.97 $1,510.54 $1,632.1131500 $158.70 0 $171.00 $183.31 $195.6131505 $63.64 0 $83.67 $103.71 $123.7431510 $196.28 14 $260.74 $325.20 $389.6631511 $214.59 14 $274.07 $333.55 $393.0431512 $287.99 14 $328.77 $369.55 $410.3331513 $420.07 14 $391.22 $362.37 $333.5231515 $151.59 14 $192.17 $232.75 $273.3231520 $214.59 0 $247.85 $281.11 $314.3731525 $357.62 0 $404.93 $452.23 $499.5431526 $493.47 0 $496.87 $500.26 $503.6631527 $503.32 30 $476.60 $449.89 $423.1731528 $378.19 14 $369.72 $361.25 $352.7731529 $372.78 14 $373.32 $373.86 $374.4131530 $429.23 30 $466.80 $504.37 $541.9431531 $559.03 30 $530.64 $502.26 $473.8731535 $453.57 30 $471.89 $490.21 $508.5231536 $615.56 30 $629.94 $644.32 $658.6931540 $530.23 30 $562.86 $595.48 $628.1131541 $643.09 30 $713.12 $783.14 $853.1731560 $1,216.50 60 $1,176.87 $1,137.25 $1,097.6231561 $1,444.63 60 $1,351.70 $1,258.77 $1,165.8431570 $495.82 30 $576.98 $658.15 $739.3131571 $681.11 60 $694.75 $708.39 $722.0231575 $133.76 0 $159.28 $184.81 $210.3331576 $270.19 14 $313.83 $357.48 $401.1231577 $307.05 30 $361.44 $415.83 $470.2331578 $348.76 30 $429.85 $510.95 $592.0431579 $172.50 14 $258.29 $344.09 $429.8831580 $1,294.40 90 $1,533.24 $1,772.08 $2,010.9331582 $1,488.14 90 $1,939.93 $2,391.73 $2,843.5231584 $1,795.92 90 $2,074.73 $2,353.54 $2,632.3531587 $1,203.48 90 $1,336.16 $1,468.83 $1,601.5131588 $1,610.00 90 $1,642.06 $1,674.13 $1,706.1931590 $1,549.23 90 $1,586.12 $1,623.00 $1,659.8931595 $1,140.97 90 $1,217.32 $1,293.67 $1,370.0231600 $546.77 14 $591.19 $635.62 $680.0431601 $604.77 14 $637.53 $670.29 $703.0431603 $592.08 14 $593.52 $594.96 $596.4031605 $526.34 14 $515.36 $504.39 $493.4131610 $658.23 14 $779.93 $901.63 $1,023.3431611 $455.77 14 $679.01 $902.24 $1,125.4831612 $91.27 0 $102.22 $113.17 $124.1231613 $299.66 60 $407.65 $515.65 $623.6431614 $556.51 60 $676.28 $796.05 $915.8331615 $205.53 0 $235.73 $265.94 $296.1431622 $367.44 0 $402.41 $437.38 $472.3531625 $419.90 14 $458.54 $497.19 $535.8331628 $482.38 14 $525.02 $567.66 $610.2931629 $431.16 14 $525.16 $619.17 $713.1731630 $511.93 14 $516.47 $521.00 $525.5431631 $453.10 14 $443.70 $434.30 $424.9031635 $492.38 14 $494.03 $495.68 $497.3431640 $542.07 14 $541.03 $539.98 $538.9431641 $792.19 30 $695.28 $598.37 $501.4631645 $384.99 0 $416.15 $447.30 $478.46

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 32 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

31646 $370.35 0 $384.29 $398.24 $412.1831656 $343.59 0 $391.79 $440.00 $488.2031700 $233.16 0 $249.29 $265.42 $281.5631708 $98.42 0 $135.18 $171.95 $208.7131710 $117.70 0 $131.95 $146.20 $160.4631715 $171.79 0 $166.30 $160.81 $155.3231717 $110.56 0 $257.40 $404.25 $551.0931720 $113.71 0 $140.02 $166.34 $192.6531725 $160.96 0 $180.58 $200.20 $219.8331730 $314.12 0 $330.53 $346.94 $363.3531750 $1,412.30 90 $1,640.80 $1,869.30 $2,097.8031755 $1,199.53 90 $1,608.51 $2,017.50 $2,426.4831760 $1,437.50 90 $1,644.56 $1,851.63 $2,058.6931770 $1,169.55 90 $1,544.56 $1,919.58 $2,294.5931775 $1,169.55 90 $1,581.74 $1,993.93 $2,406.1231780 $1,872.18 90 $2,025.29 $2,178.41 $2,331.5231781 $1,958.89 90 $2,201.45 $2,444.00 $2,686.5631785 $2,046.55 90 $2,094.32 $2,142.08 $2,189.8531786 $1,932.00 90 $2,208.90 $2,485.79 $2,762.6931800 $637.10 30 $802.34 $967.59 $1,132.8331805 $1,178.75 30 $1,343.70 $1,508.65 $1,673.6031820 $357.90 0 $448.23 $538.56 $628.8931825 $575.96 0 $687.99 $800.02 $912.0531830 $306.93 0 $417.48 $528.03 $638.5832000 $146.89 0 $178.38 $209.86 $241.3532002 $248.96 0 $270.56 $292.16 $313.7632005 $186.24 0 $244.86 $303.47 $362.0932020 $282.66 0 $315.70 $348.74 $381.7932035 $824.11 90 $974.88 $1,125.66 $1,276.4332036 $851.13 90 $1,005.52 $1,159.91 $1,314.3032095 $801.79 90 $945.30 $1,088.81 $1,232.3232100 $1,159.72 90 $1,406.81 $1,653.90 $1,900.9932110 $1,315.74 90 $1,613.81 $1,911.89 $2,209.9632120 $1,220.15 90 $1,316.38 $1,412.60 $1,508.8332124 $1,255.99 90 $1,366.80 $1,477.60 $1,588.4132140 $1,360.64 90 $1,512.93 $1,665.23 $1,817.5232141 $1,402.13 90 $1,613.63 $1,825.13 $2,036.6232150 $1,244.46 90 $1,401.57 $1,558.68 $1,715.8032151 $1,182.96 90 $1,398.42 $1,613.88 $1,829.3432160 $976.35 90 $1,051.39 $1,126.44 $1,201.4832200 $1,101.21 90 $1,276.26 $1,451.31 $1,626.3632201 $378.88 $656.07 $933.26 $1,210.4532215 $1,458.65 90 $1,542.15 $1,625.64 $1,709.1432220 $1,793.58 90 $2,054.21 $2,314.83 $2,575.4632225 $1,278.33 90 $1,374.74 $1,471.15 $1,567.5632310 $1,293.22 90 $1,495.11 $1,697.01 $1,898.9032320 $1,956.40 90 $2,189.73 $2,423.06 $2,656.3932400 $130.19 0 $159.38 $188.57 $217.7632402 $756.34 0 $822.78 $889.21 $955.6532405 $229.50 0 $260.32 $291.14 $321.9632420 $117.94 0 $147.71 $177.48 $207.2532440 $2,296.03 90 $2,503.93 $2,711.83 $2,919.7332442 $2,512.93 90 $2,784.93 $3,056.92 $3,328.9232445 $2,563.61 90 $2,758.78 $2,953.95 $3,149.1132480 $1,986.74 90 $2,219.64 $2,452.55 $2,685.4532482 $2,127.26 $2,469.16 $2,811.06 $3,152.9732484 $2,178.86 $2,374.97 $2,571.09 $2,767.2032486 $2,322.42 $2,561.39 $2,800.35 $3,039.3232488 $2,482.48 $2,704.81 $2,927.14 $3,149.4832491 $2,148.71 $2,276.07 $2,403.44 $2,530.80

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 33 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

32500 $1,682.51 90 $1,855.12 $2,027.73 $2,200.3332501 $538.00 $552.95 $567.90 $582.8532540 $1,570.15 90 $1,642.46 $1,714.78 $1,787.0932601 $530.87 $572.64 $614.41 $656.1932602 $580.61 $640.72 $700.83 $760.9532603 $742.96 $830.78 $918.60 $1,006.4232604 $829.45 $931.12 $1,032.79 $1,134.4632605 $626.49 $698.80 $771.11 $843.4132606 $800.24 $897.74 $995.24 $1,092.7432650 $1,033.36 $1,146.92 $1,260.48 $1,374.0432651 $1,351.25 $1,491.19 $1,631.13 $1,771.0732652 $1,879.10 $2,028.45 $2,177.81 $2,327.1632653 $1,276.50 $1,371.76 $1,467.02 $1,562.2832654 $1,302.95 $1,343.56 $1,384.17 $1,424.7932655 $1,546.49 $1,673.23 $1,799.97 $1,926.7132656 $1,516.02 $1,638.77 $1,761.53 $1,884.2832657 $1,587.80 $1,686.13 $1,784.45 $1,882.7832658 $1,384.60 $1,429.57 $1,474.55 $1,519.5232659 $1,497.89 $1,598.37 $1,698.85 $1,799.3432660 $2,185.80 $2,242.13 $2,298.46 $2,354.7832661 $1,276.37 $1,475.92 $1,675.47 $1,875.0332662 $1,801.65 $1,932.10 $2,062.55 $2,193.0032663 $2,060.74 $2,141.12 $2,221.49 $2,301.8732664 $1,429.84 $1,601.47 $1,773.11 $1,944.7432665 $1,727.63 $1,866.00 $2,004.37 $2,142.7332800 $881.32 30 $1,089.56 $1,297.80 $1,506.0532810 $1,291.17 60 $1,393.04 $1,494.92 $1,596.7932815 $2,584.27 60 $2,672.93 $2,761.59 $2,850.2432820 $2,892.25 60 $2,793.48 $2,694.71 $2,595.9432851 $4,140.00 $4,277.78 $4,415.55 $4,553.3332852 $4,600.00 $4,753.04 $4,906.08 $5,059.1232853 $5,175.00 $5,283.64 $5,392.28 $5,500.9232854 $5,635.00 $5,713.99 $5,792.98 $5,871.9632900 $1,086.33 90 $1,362.90 $1,639.46 $1,916.0332905 $1,475.80 90 $1,740.55 $2,005.30 $2,270.0532906 $1,981.27 90 $2,336.65 $2,692.02 $3,047.4032940 $1,086.33 90 $1,349.22 $1,612.11 $1,874.9932960 $133.57 0 $161.52 $189.47 $217.4233010 $225.36 0 $230.12 $234.88 $239.6433011 $156.08 0 $174.48 $192.88 $211.2833015 $209.24 10 $363.29 $517.34 $671.3833020 $1,550.27 90 $1,643.03 $1,735.80 $1,828.5633025 $1,565.37 90 $1,723.60 $1,881.82 $2,040.0533030 $2,268.18 90 $2,292.29 $2,316.40 $2,340.5133031 $3,062.77 90 $3,125.86 $3,188.95 $3,252.0533050 $1,982.57 90 $1,988.32 $1,994.08 $1,999.8333120 $3,834.09 90 $3,842.38 $3,850.67 $3,858.9633130 $3,121.10 90 $3,100.84 $3,080.58 $3,060.3233200 $2,075.40 90 $2,150.26 $2,225.13 $2,299.9933201 $1,591.41 90 $1,680.83 $1,770.24 $1,859.6633206 $1,448.06 90 $1,433.93 $1,419.80 $1,405.6833207 $1,312.97 90 $1,309.30 $1,305.62 $1,301.9533208 $1,384.95 90 $1,291.67 $1,198.39 $1,105.1233210 $479.29 7 $453.32 $427.36 $401.3933211 $446.17 $478.39 $510.61 $542.8333212 $629.46 7 $667.00 $704.53 $742.0733213 $714.64 $711.48 $708.33 $705.1733214 $1,005.87 $1,078.18 $1,150.48 $1,222.7933216 $889.12 15 $876.72 $864.32 $851.9133217 $869.00 $898.07 $927.14 $956.21

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 34 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

33218 $572.20 15 $628.35 $684.50 $740.6433220 $596.58 $676.60 $756.61 $836.6333222 $610.97 15 $645.92 $680.86 $715.8133223 $654.39 $702.79 $751.19 $799.5933233 $420.89 $438.66 $456.43 $474.2133234 $538.53 $646.08 $753.62 $861.1733235 $671.58 $827.94 $984.31 $1,140.6733236 $1,105.67 $1,255.26 $1,404.84 $1,554.4333237 $1,508.65 $1,579.05 $1,649.46 $1,719.8633238 $1,611.40 $1,650.30 $1,689.19 $1,728.0933240 $856.36 $855.97 $855.58 $855.1933241 $421.49 $432.69 $443.90 $455.1033243 $1,863.00 $2,062.01 $2,261.02 $2,460.0333244 $996.04 $1,132.02 $1,268.01 $1,403.9933245 $2,617.62 90 $2,606.01 $2,594.40 $2,582.7933246 $2,554.80 90 $2,823.51 $3,092.21 $3,360.9233249 $1,967.33 90 $1,953.08 $1,938.84 $1,924.5933253 $3,188.26 30 $3,351.10 $3,513.94 $3,676.7833300 $1,874.62 90 $1,994.85 $2,115.08 $2,235.3133305 $2,642.70 90 $2,812.72 $2,982.74 $3,152.7533310 $1,834.87 90 $1,997.19 $2,159.50 $2,321.8233315 $3,119.82 90 $3,264.44 $3,409.06 $3,553.6833320 $2,490.52 90 $2,383.01 $2,275.50 $2,167.9833321 $2,789.90 $2,769.53 $2,749.17 $2,728.8033322 $3,709.72 90 $3,692.45 $3,675.18 $3,657.9233330 $3,481.91 90 $3,422.62 $3,363.33 $3,304.0433332 $3,344.20 $3,299.61 $3,255.03 $3,210.4433335 $3,969.73 90 $3,878.69 $3,787.64 $3,696.6033400 $3,894.64 90 $4,076.82 $4,259.01 $4,441.1933401 $3,102.83 $3,097.28 $3,091.73 $3,086.1933403 $3,280.32 $3,255.24 $3,230.16 $3,205.0833405 $3,919.51 90 $3,988.95 $4,058.40 $4,127.8433406 $3,988.06 $4,353.26 $4,718.46 $5,083.6633411 $4,102.03 90 $4,136.58 $4,171.14 $4,205.6933412 $4,188.73 90 $4,345.67 $4,502.61 $4,659.5533413 $4,540.43 $4,711.43 $4,882.44 $5,053.4433414 $2,980.83 $3,271.37 $3,561.91 $3,852.4533415 $3,677.89 90 $3,767.58 $3,857.27 $3,946.9633416 $3,853.59 90 $4,030.08 $4,206.56 $4,383.0533417 $3,952.95 90 $4,070.51 $4,188.06 $4,305.6233420 $2,484.91 90 $2,612.21 $2,739.51 $2,866.8133422 $3,102.89 90 $3,341.36 $3,579.83 $3,818.3033425 $3,915.58 90 $4,035.22 $4,154.86 $4,274.5033426 $4,312.49 90 $4,235.24 $4,157.98 $4,080.7333427 $4,312.49 90 $4,460.07 $4,607.65 $4,755.2333430 $3,982.18 90 $4,002.77 $4,023.37 $4,043.9633460 $3,904.68 90 $3,939.68 $3,974.67 $4,009.6733463 $2,706.26 $2,991.75 $3,277.23 $3,562.7233464 $2,886.49 $3,151.00 $3,415.51 $3,680.0133465 $4,061.96 90 $4,181.29 $4,300.62 $4,419.9533468 $4,211.70 90 $4,197.13 $4,182.55 $4,167.9833470 $3,013.66 90 $3,083.65 $3,153.65 $3,223.6433472 $3,192.12 90 $3,132.97 $3,073.83 $3,014.6833474 $3,894.64 90 $3,877.94 $3,861.24 $3,844.5533475 $3,769.10 $3,972.03 $4,174.95 $4,377.8833476 $4,076.61 90 $4,152.44 $4,228.27 $4,304.1033478 $4,443.45 90 $3,968.04 $3,492.63 $3,017.2233496 $3,214.33 $3,423.35 $3,632.37 $3,841.3933500 $2,548.63 90 $2,716.03 $2,883.42 $3,050.8233501 $1,915.83 90 $1,970.19 $2,024.54 $2,078.90

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 35 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

33502 $2,117.37 90 $2,229.29 $2,341.22 $2,453.1433503 $2,499.87 90 $2,493.70 $2,487.53 $2,481.3533504 $3,894.64 90 $4,035.69 $4,176.74 $4,317.7933505 $3,952.55 $3,903.19 $3,853.84 $3,804.4833506 $3,952.55 $3,983.46 $4,014.37 $4,045.2933510 $3,986.52 90 $3,796.21 $3,605.91 $3,415.6033511 $4,378.67 90 $4,385.42 $4,392.17 $4,398.9233512 $4,749.33 90 $4,631.69 $4,514.06 $4,396.4233513 $5,503.92 90 $5,358.37 $5,212.83 $5,067.2833514 $5,642.34 90 $5,712.94 $5,783.55 $5,854.1533516 $5,802.32 90 $6,003.66 $6,205.00 $6,406.3433517 $281.54 0 $372.05 $462.57 $553.0833518 $572.48 0 $704.68 $836.88 $969.0833519 $737.38 0 $920.29 $1,103.20 $1,286.1133521 $910.52 0 $1,107.19 $1,303.87 $1,500.5433522 $1,150.52 0 $1,266.25 $1,381.98 $1,497.7133523 $1,456.70 0 $1,529.01 $1,601.33 $1,673.6433530 $1,274.46 0 $1,154.20 $1,033.95 $913.6933533 $3,356.08 90 $3,544.57 $3,733.05 $3,921.5433534 $3,858.94 90 $4,230.07 $4,601.21 $4,972.3433535 $4,180.16 90 $4,425.69 $4,671.22 $4,916.7433536 $4,527.66 90 $4,854.99 $5,182.32 $5,509.6633542 $4,379.86 90 $4,541.32 $4,702.77 $4,864.2333545 $4,643.19 90 $4,790.53 $4,937.86 $5,085.2033572 $502.45 30 $572.47 $642.48 $712.5033600 $4,242.35 $4,111.93 $3,981.52 $3,851.1033602 $4,145.75 $4,018.13 $3,890.51 $3,762.8933606 $4,338.95 $4,227.90 $4,116.85 $4,005.8133608 $4,435.55 $4,311.02 $4,186.48 $4,061.9533610 $4,338.95 $4,067.82 $3,796.70 $3,525.5733611 $4,627.60 $4,515.96 $4,404.32 $4,292.6833612 $4,724.20 $4,622.92 $4,521.64 $4,420.3533615 $4,431.03 $4,425.96 $4,420.89 $4,415.8233617 $4,772.50 $4,732.96 $4,693.43 $4,653.8933619 $5,206.05 $5,245.24 $5,284.43 $5,323.6133641 $3,680.01 90 $3,449.50 $3,218.98 $2,988.4733645 $3,611.01 90 $3,685.81 $3,760.61 $3,835.4133660 $4,160.43 90 $4,302.56 $4,444.69 $4,586.8233665 $4,428.45 90 $4,371.99 $4,315.52 $4,259.0633670 $4,052.70 90 $4,070.56 $4,088.41 $4,106.2733681 $3,404.14 90 $3,642.00 $3,879.86 $4,117.7233684 $4,048.03 90 $4,229.13 $4,410.23 $4,591.3433688 $4,052.70 90 $4,030.38 $4,008.05 $3,985.7333690 $2,056.41 90 $2,072.44 $2,088.46 $2,104.4933692 $4,181.36 90 $4,338.84 $4,496.31 $4,653.7933694 $4,303.20 90 $4,257.27 $4,211.35 $4,165.4233697 $4,772.50 $4,671.20 $4,569.90 $4,468.6133702 $3,894.64 90 $4,056.83 $4,219.03 $4,381.2233710 $4,173.45 90 $4,322.78 $4,472.11 $4,621.4533720 $3,952.95 90 $3,880.55 $3,808.15 $3,735.7533722 $4,145.75 $4,112.84 $4,079.94 $4,047.0333730 $4,087.20 90 $4,071.51 $4,055.82 $4,040.1333732 $3,855.95 $3,798.47 $3,740.98 $3,683.5033735 $2,514.16 90 $2,619.53 $2,724.91 $2,830.2833736 $2,988.85 $2,993.79 $2,998.74 $3,003.6833737 $2,880.54 90 $2,876.24 $2,871.93 $2,867.6333750 $2,796.34 90 $2,756.36 $2,716.39 $2,676.4133755 $2,796.34 90 $2,775.23 $2,754.13 $2,733.0233762 $2,874.36 90 $2,838.29 $2,802.22 $2,766.1533764 $2,541.34 90 $2,521.89 $2,502.44 $2,482.99

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 36 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

33766 $2,769.16 90 $2,861.76 $2,954.35 $3,046.9533767 $3,142.95 $3,110.18 $3,077.42 $3,044.6533770 $4,531.00 $4,486.81 $4,442.61 $4,398.4233771 $4,724.20 $4,569.40 $4,414.61 $4,259.8133774 $3,542.47 90 $3,614.67 $3,686.88 $3,759.0833775 $3,992.98 90 $4,008.58 $4,024.18 $4,039.7833776 $4,162.18 90 $4,199.93 $4,237.68 $4,275.4333777 $3,632.24 90 $3,747.55 $3,862.85 $3,978.1633778 $4,504.62 90 $4,599.04 $4,693.47 $4,787.8933779 $4,007.24 90 $4,103.84 $4,200.45 $4,297.0533780 $4,035.73 90 $4,289.72 $4,543.71 $4,797.6933781 $4,082.24 90 $4,194.18 $4,306.12 $4,418.0633786 $4,660.95 90 $4,664.83 $4,668.70 $4,672.5833788 $3,385.95 90 $3,347.23 $3,308.50 $3,269.7833800 $1,504.20 90 $1,722.52 $1,940.85 $2,159.1733802 $1,899.66 90 $2,023.65 $2,147.65 $2,271.6433803 $2,140.46 90 $2,226.67 $2,312.88 $2,399.0933813 $2,522.38 90 $2,592.21 $2,662.05 $2,731.8833814 $3,347.74 90 $3,393.56 $3,439.39 $3,485.2133820 $2,046.47 90 $2,070.10 $2,093.73 $2,117.3733822 $1,941.37 90 $2,041.98 $2,142.60 $2,243.2133824 $2,590.64 90 $2,748.65 $2,906.66 $3,064.6633840 $2,538.28 90 $2,649.60 $2,760.91 $2,872.2333845 $2,801.81 90 $2,898.81 $2,995.81 $3,092.8133851 $2,834.71 90 $2,820.58 $2,806.45 $2,792.3233852 $3,362.68 90 $3,427.99 $3,493.30 $3,558.6133853 $3,857.10 $3,860.78 $3,864.45 $3,868.1333860 $4,833.78 90 $4,895.64 $4,957.51 $5,019.3733861 $4,827.72 $5,001.72 $5,175.72 $5,349.7333863 $5,047.86 $5,131.85 $5,215.85 $5,299.8433870 $5,754.56 90 $5,821.72 $5,888.88 $5,956.0433875 $3,891.85 90 $4,121.35 $4,350.85 $4,580.3533877 $4,677.60 90 $4,775.19 $4,872.78 $4,970.3733910 $2,047.90 90 $2,457.08 $2,866.27 $3,275.4533915 $1,680.77 90 $1,915.91 $2,151.06 $2,386.2033917 $3,663.90 $3,561.80 $3,459.70 $3,357.6033920 $4,338.95 $4,226.64 $4,114.33 $4,002.0233922 $3,567.30 $3,448.48 $3,329.66 $3,210.8333924 $588.28 $592.47 $596.65 $600.8433960 $1,070.99 90 $1,225.07 $1,379.14 $1,533.2233961 $972.90 $915.63 $858.36 $801.1033970 $931.98 15 $935.22 $938.46 $941.6933971 $589.30 15 $850.38 $1,111.45 $1,372.5333973 $997.10 $1,064.91 $1,132.73 $1,200.5433974 $1,044.21 $1,316.80 $1,589.38 $1,861.9733975 $1,988.02 $2,147.33 $2,306.64 $2,465.9533976 $2,709.02 $2,800.42 $2,891.82 $2,983.2233977 $1,739.78 $2,022.86 $2,305.94 $2,589.0233978 $1,988.02 $2,290.79 $2,593.57 $2,896.3434001 $1,140.46 60 $1,259.55 $1,378.65 $1,497.7434051 $1,222.76 60 $1,445.17 $1,667.58 $1,889.9834101 $1,086.03 60 $1,164.31 $1,242.60 $1,320.8834111 $658.70 60 $931.09 $1,203.48 $1,475.8734151 $1,580.41 60 $1,911.37 $2,242.33 $2,573.2934201 $1,125.64 60 $1,211.39 $1,297.14 $1,382.9034203 $1,068.25 60 $1,246.99 $1,425.72 $1,604.4634401 $1,295.05 90 $1,645.01 $1,994.97 $2,344.9334421 $1,140.60 90 $1,268.99 $1,397.38 $1,525.7734451 $1,899.66 90 $2,118.87 $2,338.08 $2,557.3034471 $1,054.89 90 $1,173.09 $1,291.28 $1,409.48

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 37 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

34490 $983.37 90 $1,100.53 $1,217.68 $1,334.8434502 $2,455.56 $2,747.15 $3,038.74 $3,330.3334510 $1,489.88 90 $1,597.27 $1,704.65 $1,812.0434520 $2,364.19 90 $2,235.24 $2,106.30 $1,977.3534530 $1,615.13 90 $1,682.81 $1,750.49 $1,818.1735001 $2,179.06 90 $2,301.15 $2,423.24 $2,545.3335002 $2,216.15 90 $2,265.65 $2,315.14 $2,364.6435005 $2,216.15 90 $2,182.90 $2,149.65 $2,116.4035011 $2,241.65 90 $2,134.69 $2,027.74 $1,920.7835013 $2,290.40 90 $2,267.03 $2,243.67 $2,220.3035021 $2,329.03 90 $2,442.66 $2,556.29 $2,669.9335022 $2,440.11 90 $2,437.79 $2,435.48 $2,433.1635045 $1,140.00 90 $1,403.67 $1,667.34 $1,931.0135081 $2,755.67 90 $2,806.64 $2,857.62 $2,908.5935082 $3,339.98 90 $3,527.39 $3,714.80 $3,902.2135091 $2,979.43 90 $3,321.91 $3,664.39 $4,006.8635092 $3,643.66 90 $3,899.67 $4,155.68 $4,411.6935102 $3,007.55 90 $3,112.21 $3,216.87 $3,321.5235103 $3,579.22 90 $3,846.59 $4,113.96 $4,381.3435111 $1,956.37 90 $2,179.97 $2,403.56 $2,627.1635112 $1,981.41 90 $2,310.85 $2,640.29 $2,969.7335121 $2,726.07 90 $2,913.49 $3,100.91 $3,288.3335122 $3,090.56 90 $3,415.14 $3,739.72 $4,064.3035131 $2,443.28 90 $2,621.69 $2,800.11 $2,978.5235132 $2,788.92 90 $2,948.08 $3,107.23 $3,266.3935141 $2,168.80 90 $2,212.97 $2,257.14 $2,301.3235142 $2,180.90 90 $2,319.03 $2,457.15 $2,595.2835151 $2,176.80 90 $2,346.83 $2,516.86 $2,686.8935152 $2,153.17 90 $2,254.57 $2,355.98 $2,457.3835180 $2,216.15 90 $2,125.35 $2,034.56 $1,943.7635182 $2,495.15 90 $2,611.34 $2,727.53 $2,843.7235184 $2,216.15 90 $2,207.08 $2,198.00 $2,188.9335188 $2,216.15 90 $2,166.96 $2,117.77 $2,068.5735189 $2,516.36 90 $2,574.49 $2,632.62 $2,690.7535190 $2,216.15 90 $2,131.66 $2,047.17 $1,962.6835201 $1,899.52 60 $1,926.53 $1,953.55 $1,980.5635206 $1,825.98 60 $1,830.10 $1,834.21 $1,838.3335207 $1,723.54 60 $1,723.39 $1,723.25 $1,723.1035211 $3,441.36 90 $3,430.32 $3,419.29 $3,408.2535216 $2,802.93 90 $2,821.78 $2,840.62 $2,859.4735221 $2,158.90 90 $2,279.35 $2,399.80 $2,520.2535226 $1,815.50 90 $1,844.99 $1,874.48 $1,903.9635231 $2,216.15 90 $2,344.56 $2,472.97 $2,601.3835236 $2,161.12 90 $2,318.74 $2,476.36 $2,633.9835241 $3,994.82 90 $3,805.71 $3,616.60 $3,427.4835246 $3,084.29 90 $2,905.18 $2,726.06 $2,546.9535251 $3,073.07 90 $3,010.05 $2,947.04 $2,884.0235256 $2,108.65 90 $2,188.39 $2,268.14 $2,347.8835261 $2,073.60 90 $2,141.16 $2,208.72 $2,276.2835266 $2,086.26 90 $2,144.55 $2,202.85 $2,261.1435271 $3,676.07 90 $3,414.77 $3,153.47 $2,892.1635276 $3,084.29 90 $2,913.76 $2,743.23 $2,572.7135281 $2,529.25 90 $2,685.88 $2,842.51 $2,999.1435286 $2,086.26 90 $2,202.67 $2,319.07 $2,435.4835301 $2,240.74 60 $2,245.52 $2,250.30 $2,255.0835311 $2,658.29 90 $2,862.14 $3,065.99 $3,269.8435321 $1,965.57 60 $2,043.39 $2,121.22 $2,199.0435331 $2,533.78 90 $2,722.62 $2,911.46 $3,100.3035341 $2,613.39 90 $2,749.80 $2,886.20 $3,022.6135351 $2,254.15 90 $2,420.37 $2,586.59 $2,752.81

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 38 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

35355 $2,111.90 90 $2,182.54 $2,253.19 $2,323.8335361 $2,875.32 90 $3,118.30 $3,361.28 $3,604.2535363 $3,111.56 90 $3,157.39 $3,203.21 $3,249.0435371 $1,872.49 90 $1,882.38 $1,892.28 $1,902.1735372 $1,912.40 90 $1,959.56 $2,006.73 $2,053.8935381 $2,026.39 90 $2,120.77 $2,215.16 $2,309.5435390 $299.03 90 $317.91 $336.80 $355.6835450 $1,187.84 S $1,261.60 $1,335.36 $1,409.1135452 $983.84 S $991.47 $999.09 $1,006.7235454 $911.09 S $929.93 $948.78 $967.6235456 $956.27 S $989.85 $1,023.44 $1,057.0235458 $1,069.34 S $1,123.72 $1,178.10 $1,232.4835459 $784.77 S $856.41 $928.04 $999.6835460 $549.41 S $587.36 $625.32 $663.2735470 $1,079.57 S $2,132.61 $3,185.64 $4,238.6835471 $1,173.58 S $2,090.02 $3,006.46 $3,922.9135472 $856.91 S $1,667.72 $2,478.53 $3,289.3435473 $737.55 S $1,511.54 $2,285.52 $3,059.5135474 $942.56 S $2,078.39 $3,214.21 $4,350.0435475 $1,064.41 S $1,751.69 $2,438.96 $3,126.2435476 $549.41 S $955.57 $1,361.74 $1,767.9035480 $1,392.29 S $1,378.54 $1,364.79 $1,351.0535481 $776.69 S $817.12 $857.56 $897.9935482 $902.72 S $895.99 $889.26 $882.5335483 $1,061.56 S $1,091.20 $1,120.84 $1,150.4935484 $1,242.83 S $1,240.14 $1,237.46 $1,234.7735485 $946.84 S $989.98 $1,033.13 $1,076.2735490 $1,355.95 S $1,410.38 $1,464.81 $1,519.2435491 $719.72 S $788.81 $857.91 $927.0035492 $886.63 90 $924.19 $961.75 $999.3135493 $1,044.23 S $1,086.83 $1,129.43 $1,172.0235494 $1,197.30 S $1,254.81 $1,312.32 $1,369.8335495 $872.17 S $969.07 $1,065.96 $1,162.8635501 $2,267.44 90 $2,401.34 $2,535.24 $2,669.1435506 $2,275.84 90 $2,284.84 $2,293.83 $2,302.8335507 $2,221.90 90 $2,358.39 $2,494.88 $2,631.3735508 $2,275.84 90 $2,261.70 $2,247.57 $2,233.4335509 $2,225.52 90 $2,328.83 $2,432.14 $2,535.4535511 $2,275.84 90 $2,417.37 $2,558.89 $2,700.4235515 $2,216.15 90 $2,222.39 $2,228.63 $2,234.8735516 $2,158.84 90 $2,172.54 $2,186.25 $2,199.9535518 $2,099.15 90 $2,200.64 $2,302.13 $2,403.6335521 $2,216.15 90 $2,251.63 $2,287.11 $2,322.5935526 $2,604.30 90 $2,829.65 $3,055.00 $3,280.3635531 $2,745.87 90 $3,082.12 $3,418.36 $3,754.6135533 $2,587.84 90 $2,751.12 $2,914.39 $3,077.6735536 $2,978.06 90 $3,095.90 $3,213.75 $3,331.5935541 $2,639.37 90 $2,685.83 $2,732.29 $2,778.7535546 $2,560.98 90 $2,742.55 $2,924.13 $3,105.7035548 $2,537.21 90 $2,546.06 $2,554.92 $2,563.7735549 $2,873.98 90 $3,016.07 $3,158.16 $3,300.2535551 $2,903.35 90 $2,938.83 $2,974.32 $3,009.8035556 $2,542.56 90 $2,541.81 $2,541.06 $2,540.3135558 $2,213.89 90 $2,338.80 $2,463.71 $2,588.6235560 $2,607.47 90 $2,914.17 $3,220.86 $3,527.5635563 $2,216.15 90 $2,304.64 $2,393.14 $2,481.6335565 $2,213.89 90 $2,363.48 $2,513.07 $2,662.6635566 $2,573.04 90 $2,717.38 $2,861.72 $3,006.0635571 $2,386.05 90 $2,541.63 $2,697.21 $2,852.7935583 $2,292.57 90 $2,456.92 $2,621.27 $2,785.62

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 39 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

35585 $2,356.32 90 $2,707.93 $3,059.54 $3,411.1535587 $2,292.57 90 $2,447.13 $2,601.70 $2,756.2635601 $2,216.15 $2,259.76 $2,303.36 $2,346.9735606 $2,167.16 $2,254.75 $2,342.35 $2,429.9435612 $2,167.16 $2,182.69 $2,198.22 $2,213.7535616 $2,216.15 $2,188.35 $2,160.55 $2,132.7535621 $2,186.74 $2,278.11 $2,369.48 $2,460.8535623 $1,688.19 $2,091.29 $2,494.39 $2,897.4835626 $2,604.98 $2,801.09 $2,997.20 $3,193.3135631 $2,657.98 90 $2,884.98 $3,111.99 $3,338.9935636 $2,057.16 $2,359.00 $2,660.84 $2,962.6935641 $2,981.16 $3,064.79 $3,148.42 $3,232.0535642 $1,887.65 $1,963.94 $2,040.23 $2,116.5335645 $1,893.65 $1,950.83 $2,008.01 $2,065.1935646 $2,963.11 $3,094.37 $3,225.63 $3,356.8935650 $2,037.65 $2,076.94 $2,116.23 $2,155.5235651 $3,090.56 $3,009.22 $2,927.87 $2,846.5335654 $2,666.17 $2,681.69 $2,697.21 $2,712.7335656 $2,413.13 $2,439.60 $2,466.08 $2,492.5535661 $2,167.25 $2,143.23 $2,119.21 $2,095.1935663 $2,185.53 $2,354.38 $2,523.22 $2,692.0735665 $2,207.95 $2,280.25 $2,352.55 $2,424.8435666 $2,250.52 $2,383.17 $2,515.82 $2,648.4635671 $2,101.40 $2,275.28 $2,449.16 $2,623.0435681 $1,724.16 0 $1,281.78 $839.40 $397.0235691 $2,265.87 $2,368.26 $2,470.66 $2,573.0535693 $2,067.08 $2,112.43 $2,157.79 $2,203.1435694 $2,317.59 $2,408.58 $2,499.57 $2,590.5635695 $2,317.59 $2,406.19 $2,494.79 $2,583.3935700 $263.26 $285.71 $308.16 $330.6135701 $847.49 90 $923.33 $999.18 $1,075.0235721 $626.41 90 $712.36 $798.31 $884.2635741 $626.41 90 $729.78 $833.16 $936.5335761 $460.00 90 $564.40 $668.81 $773.2135800 $688.78 90 $701.71 $714.65 $727.5835820 $1,727.01 90 $1,615.21 $1,503.42 $1,391.6235840 $1,270.75 90 $1,307.56 $1,344.36 $1,381.1735860 $631.39 90 $666.38 $701.37 $736.3635870 $3,663.29 90 $3,488.47 $3,313.65 $3,138.8235875 $1,079.63 90 $1,120.31 $1,160.99 $1,201.6735876 $1,275.21 $1,488.25 $1,701.29 $1,914.3335901 $961.27 $1,026.11 $1,090.96 $1,155.8035903 $1,060.33 $1,081.94 $1,103.56 $1,125.1735905 $1,733.29 $2,183.30 $2,633.30 $3,083.3135907 $1,787.38 $2,133.58 $2,479.77 $2,825.9736000 $62.67 0 $61.18 $59.70 $58.2136005 $105.32 0 $210.69 $316.06 $421.4336010 $290.96 0 $520.37 $749.77 $979.1836011 $216.63 0 $616.59 $1,016.54 $1,416.5036012 $293.88 0 $565.59 $837.30 $1,109.0036013 $216.63 0 $486.98 $757.32 $1,027.6736014 $285.33 0 $545.14 $804.96 $1,064.7736015 $288.96 0 $613.84 $938.71 $1,263.5936100 $383.04 0 $506.63 $630.22 $753.8136120 $422.13 0 $494.80 $567.46 $640.1336140 $207.13 0 $297.83 $388.54 $479.2436145 $195.94 0 $371.99 $548.04 $724.0836160 $259.94 0 $426.63 $593.32 $760.0136200 $305.90 0 $417.96 $530.02 $642.0836215 $314.11 0 $585.66 $857.21 $1,128.76

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 40 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

36216 $399.93 0 $812.76 $1,225.60 $1,638.4336217 $472.57 0 $1,254.39 $2,036.21 $2,818.0336218 $105.05 0 $178.06 $251.06 $324.0736245 $307.04 0 $635.70 $964.36 $1,293.0236246 $415.54 0 $826.60 $1,237.65 $1,648.7136247 $514.53 0 $1,195.47 $1,876.42 $2,557.3636248 $82.80 0 $127.82 $172.85 $217.8736400 $32.57 0 $41.34 $50.11 $58.8836405 $50.86 0 $53.13 $55.41 $57.6836406 $34.33 0 $41.11 $47.90 $54.6836410 $25.29 0 $32.90 $40.52 $48.1336420 $86.89 0 $178.87 $270.85 $362.8336425 $65.43 0 $108.22 $151.00 $193.7936430 $46.82 0 $49.14 $51.46 $53.7936440 $95.51 0 $99.78 $104.04 $108.3136450 $477.48 0 $434.06 $390.64 $347.2236455 $254.15 0 $261.74 $269.34 $276.9336460 $883.29 0 $887.72 $892.14 $896.5736468 $57.77 0 $68.68 $79.59 $90.4936469 $61.53 0 $73.40 $85.27 $97.1536470 $56.00 0 $91.31 $126.61 $161.9236471 $83.52 0 $135.95 $188.38 $240.8136481 $700.98 0 $775.72 $850.46 $925.1936500 $207.37 0 $245.88 $284.40 $322.9136510 $61.52 0 $107.08 $152.64 $198.2036522 $318.55 0 $676.16 $1,033.77 $1,391.3836600 $25.60 0 $31.04 $36.48 $41.9236620 $90.37 0 $101.63 $112.88 $124.1436625 $139.72 0 $167.67 $195.63 $223.5836640 $196.61 0 $207.51 $218.41 $229.3136660 $102.56 0 $120.36 $138.17 $155.9736680 $162.59 7 $165.17 $167.75 $170.3436800 $246.84 S $262.60 $278.35 $294.1136810 $469.57 S $556.87 $644.18 $731.4836815 $469.57 S $468.26 $466.96 $465.6536821 $980.85 $963.81 $946.77 $929.7336822 $491.14 30 $628.77 $766.40 $904.0436825 $1,389.05 30 $1,441.59 $1,494.13 $1,546.6736830 $1,328.89 30 $1,302.44 $1,276.00 $1,249.5536832 $1,388.79 30 $1,333.83 $1,278.88 $1,223.9236834 $1,030.85 $1,108.43 $1,186.00 $1,263.5836835 $1,189.10 30 $1,139.88 $1,090.67 $1,041.4536860 $281.13 S $261.78 $242.44 $223.0936861 $422.05 S $388.38 $354.72 $321.0537140 $2,450.98 90 $2,623.94 $2,796.90 $2,969.8737145 $2,389.05 90 $2,610.80 $2,832.56 $3,054.3137160 $2,417.23 90 $2,570.74 $2,724.25 $2,877.7637180 $2,777.37 90 $2,780.19 $2,783.01 $2,785.8337181 $2,581.84 90 $2,742.78 $2,903.72 $3,064.6637195 $447.65 $496.15 $544.65 $593.1537200 $504.31 0 $518.06 $531.81 $545.5737201 $707.04 0 $712.12 $717.19 $722.2737202 $566.69 0 $622.44 $678.19 $733.9437203 $632.24 0 $1,001.44 $1,370.64 $1,739.8437204 $1,121.49 0 $1,388.90 $1,656.30 $1,923.7137205 $636.39 0 $651.37 $666.36 $681.3437206 $317.81 0 $347.80 $377.78 $407.7737207 $699.03 0 $807.79 $916.56 $1,025.3237208 $348.94 0 $397.57 $446.20 $494.8337209 $217.80 S $230.75 $243.70 $256.65

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 41 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

37565 $692.43 30 $828.47 $964.52 $1,100.5637600 $713.03 30 $871.23 $1,029.43 $1,187.6337605 $769.30 30 $938.94 $1,108.58 $1,278.2337606 $933.43 60 $971.22 $1,009.00 $1,046.7937607 $568.69 $577.74 $586.78 $595.8337609 $242.81 0 $301.28 $359.75 $418.2237615 $837.43 30 $817.48 $797.53 $777.5937616 $1,016.68 60 $1,260.26 $1,503.84 $1,747.4237617 $1,080.40 60 $1,350.19 $1,619.97 $1,889.7637618 $657.78 30 $675.19 $692.60 $710.0137620 $1,261.09 90 $1,351.95 $1,442.82 $1,533.6837660 $950.68 90 $1,209.04 $1,467.40 $1,725.7637700 $400.85 30 $442.76 $484.67 $526.5837735 $1,331.70 60 $1,334.80 $1,337.89 $1,340.9937760 $803.05 90 $941.17 $1,079.29 $1,217.4137780 $211.42 30 $280.31 $349.20 $418.0937785 $170.18 30 $291.42 $412.66 $533.9137788 $2,134.40 90 $2,264.84 $2,395.28 $2,525.7237790 $678.50 $809.78 $941.06 $1,072.3438100 $1,212.88 45 $1,315.46 $1,418.03 $1,520.6138101 $1,342.36 45 $1,508.33 $1,674.30 $1,840.2738102 $407.44 $452.05 $496.66 $541.2738115 $1,344.28 45 $1,445.73 $1,547.17 $1,648.6238200 $175.75 0 $212.74 $249.73 $286.7238240 $274.90 30 $280.54 $286.18 $291.8238241 $334.58 30 $331.78 $328.99 $326.1938300 $80.16 0 $158.62 $237.08 $315.5438305 $262.20 30 $368.28 $474.36 $580.4438308 $407.10 30 $486.21 $565.32 $644.4438380 $792.18 45 $854.99 $917.80 $980.6138381 $1,570.15 60 $1,634.50 $1,698.85 $1,763.2038382 $813.05 60 $901.59 $990.13 $1,078.6738500 $127.20 0 $207.40 $287.61 $367.8138505 $139.14 0 $169.13 $199.13 $229.1238510 $315.53 0 $453.11 $590.68 $728.2638520 $411.63 0 $504.26 $596.90 $689.5338525 $349.22 0 $460.59 $571.96 $683.3238530 $499.86 0 $611.04 $722.23 $833.4138542 $308.89 60 $469.61 $630.32 $791.0438550 $517.84 60 $615.01 $712.18 $809.3538555 $1,437.14 60 $1,490.44 $1,543.74 $1,597.0338562 $1,132.30 60 $1,240.53 $1,348.76 $1,456.9938564 $1,126.27 60 $1,227.84 $1,329.41 $1,430.9738700 $984.96 60 $1,109.75 $1,234.54 $1,359.3338720 $1,640.64 60 $1,769.52 $1,898.39 $2,027.2738724 $1,296.18 60 $1,483.01 $1,669.84 $1,856.6838740 $702.16 60 $798.34 $894.52 $990.7038745 $1,104.84 60 $1,235.17 $1,365.50 $1,495.8338746 $372.60 $414.54 $456.48 $498.4238747 $414.17 $454.49 $494.82 $535.1438760 $651.15 60 $871.86 $1,092.57 $1,313.2938765 $1,543.52 60 $1,828.75 $2,113.98 $2,399.2138770 $1,639.89 60 $1,682.32 $1,724.75 $1,767.1738780 $2,214.23 60 $2,251.68 $2,289.13 $2,326.5938790 $254.20 0 $598.32 $942.43 $1,286.5538794 $289.80 0 $349.90 $410.00 $470.1139000 $550.80 0 $638.89 $726.98 $815.0739010 $957.58 90 $1,247.09 $1,536.60 $1,826.1139200 $1,385.57 90 $1,526.22 $1,666.86 $1,807.5139220 $1,651.07 90 $1,801.69 $1,952.31 $2,102.93

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 42 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

39400 $551.01 0 $624.08 $697.15 $770.2339501 $1,244.44 90 $1,344.51 $1,444.57 $1,544.6439502 $1,349.46 90 $1,578.62 $1,807.79 $2,036.9539503 $1,944.78 90 $3,588.61 $5,232.45 $6,876.2839520 $1,339.18 90 $1,518.92 $1,698.67 $1,878.4139530 $1,502.45 90 $1,623.45 $1,744.45 $1,865.4439531 $1,500.55 90 $1,668.46 $1,836.37 $2,004.2839540 $1,148.85 90 $1,366.78 $1,584.71 $1,802.6339541 $1,251.70 90 $1,399.60 $1,547.49 $1,695.3939545 $1,029.37 90 $1,271.66 $1,513.95 $1,756.2540490 $77.98 0 $112.36 $146.74 $181.1140510 $818.38 30 $819.25 $820.12 $820.9840520 $462.21 30 $573.28 $684.35 $795.4240525 $779.66 30 $919.34 $1,059.02 $1,198.7040527 $1,275.93 90 $1,331.43 $1,386.93 $1,442.4340530 $475.46 30 $576.38 $677.30 $778.2240650 $223.74 30 $351.10 $478.45 $605.8140652 $321.53 30 $457.33 $593.13 $728.9240654 $503.32 30 $637.67 $772.03 $906.3840700 $1,363.56 90 $1,470.98 $1,578.40 $1,685.8240701 $1,748.40 90 $1,824.72 $1,901.03 $1,977.3540702 $1,117.68 90 $1,303.15 $1,488.62 $1,674.0840720 $1,413.12 90 $1,530.76 $1,648.40 $1,766.0440761 $1,420.16 90 $1,569.44 $1,718.71 $1,867.9940800 $62.67 0 $110.54 $158.41 $206.2740801 $153.89 0 $238.71 $323.53 $408.3540804 $87.28 0 $137.74 $188.20 $238.6540805 $228.94 0 $300.07 $371.21 $442.3440806 $52.57 0 $85.40 $118.23 $151.0640808 $64.34 0 $109.58 $154.82 $200.0640810 $88.09 0 $143.49 $198.89 $254.2940812 $133.15 30 $199.15 $265.16 $331.1640814 $289.14 30 $368.20 $447.26 $526.3340816 $350.13 60 $441.39 $532.64 $623.9040818 $184.94 60 $258.81 $332.69 $406.5640819 $164.45 0 $238.13 $311.82 $385.5040820 $169.01 0 $227.25 $285.48 $343.7240830 $90.34 7 $151.26 $212.19 $273.1140831 $168.76 30 $248.01 $327.27 $406.5241000 $72.37 0 $115.93 $159.49 $203.0441005 $69.60 0 $122.26 $174.92 $227.5741006 $111.84 0 $215.59 $319.34 $423.0941007 $117.04 0 $248.06 $379.09 $510.1141008 $100.03 0 $230.51 $360.98 $491.4641009 $117.04 0 $245.51 $373.99 $502.4641010 $84.06 0 $146.99 $209.93 $272.8641015 $227.51 0 $325.02 $422.54 $520.0541016 $356.44 0 $418.89 $481.33 $543.7841017 $247.76 0 $356.80 $465.83 $574.8741018 $399.94 0 $488.33 $576.72 $665.1141100 $74.26 0 $133.58 $192.90 $252.2241105 $113.90 0 $158.66 $203.42 $248.1841108 $90.02 0 $119.63 $149.25 $178.8641110 $122.98 7 $167.76 $212.55 $257.3341112 $246.51 7 $313.65 $380.80 $447.9441113 $331.38 7 $380.60 $429.81 $479.0341114 $703.03 7 $811.46 $919.89 $1,028.3241115 $123.87 7 $181.74 $239.60 $297.4741116 $166.32 7 $275.11 $383.89 $492.6841120 $702.02 90 $965.13 $1,228.23 $1,491.34

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 43 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

41130 $972.96 90 $1,245.53 $1,518.10 $1,790.6741135 $2,056.53 90 $2,420.73 $2,784.93 $3,149.1341140 $1,707.81 90 $2,131.38 $2,554.96 $2,978.5341145 $2,483.02 90 $3,000.49 $3,517.96 $4,035.4441150 $1,587.79 90 $2,126.38 $2,664.97 $3,203.5641153 $1,969.14 90 $2,386.16 $2,803.19 $3,220.2141155 $2,291.95 90 $2,837.35 $3,382.74 $3,928.1441250 $97.75 0 $146.25 $194.76 $243.2641251 $179.40 0 $238.67 $297.95 $357.2241252 $214.41 0 $298.70 $382.98 $467.2741500 $412.38 30 $491.46 $570.55 $649.6341510 $792.18 30 $779.49 $766.80 $754.1141520 $328.28 30 $383.18 $438.09 $492.9941800 $70.12 0 $120.08 $170.03 $219.9941805 $83.95 0 $130.07 $176.20 $222.3241806 $177.10 0 $229.00 $280.90 $332.8041820 $342.61 0 $366.55 $390.48 $414.4241823 $195.50 0 $308.45 $421.41 $534.3641825 $107.99 0 $148.62 $189.26 $229.8941826 $174.68 0 $226.32 $277.95 $329.5941827 $304.75 7 $392.18 $479.60 $567.0341828 $199.54 0 $266.45 $333.37 $400.2841830 $150.65 0 $272.58 $394.51 $516.4441850 $58.65 0 $60.61 $62.56 $64.5242000 $68.64 0 $112.64 $156.64 $200.6342100 $82.52 0 $125.21 $167.90 $210.5942104 $120.65 0 $165.19 $209.72 $254.2642106 $138.59 0 $215.45 $292.31 $369.1842107 $386.78 90 $472.66 $558.54 $644.4242120 $1,987.10 90 $1,843.18 $1,699.26 $1,555.3442140 $109.78 15 $187.69 $265.59 $343.5042145 $1,400.80 90 $1,515.21 $1,629.62 $1,744.0342160 $126.01 0 $200.47 $274.93 $349.3942180 $169.34 15 $220.30 $271.26 $322.2242182 $238.00 15 $307.91 $377.82 $447.7242200 $1,568.32 90 $1,638.96 $1,709.60 $1,780.2442205 $1,862.46 90 $1,963.83 $2,065.19 $2,166.5642210 $2,061.84 90 $2,188.74 $2,315.65 $2,442.5542215 $1,487.39 90 $1,614.93 $1,742.47 $1,870.0242220 $1,562.15 90 $1,532.00 $1,501.86 $1,471.7142225 $1,556.49 90 $1,679.53 $1,802.57 $1,925.6142226 $1,512.18 90 $1,627.13 $1,742.08 $1,857.0342227 $1,547.32 90 $1,591.70 $1,636.07 $1,680.4542235 $1,267.40 90 $1,319.73 $1,372.06 $1,424.3942260 $507.74 90 $737.87 $968.00 $1,198.1342281 $160.66 90 $215.56 $270.47 $325.3742300 $119.80 0 $166.46 $213.12 $259.7942305 $293.25 0 $395.28 $497.32 $599.3542310 $98.58 0 $136.96 $175.34 $213.7242320 $244.44 0 $281.74 $319.05 $356.3542330 $209.67 15 $258.10 $306.53 $354.9542335 $295.28 30 $392.78 $490.29 $587.7942340 $475.46 30 $576.39 $677.31 $778.2442400 $72.55 0 $96.87 $121.19 $145.5142405 $187.93 0 $260.30 $332.66 $405.0342408 $473.25 15 $526.02 $578.80 $631.5742409 $310.38 15 $369.24 $428.10 $486.9642410 $581.32 60 $727.44 $873.56 $1,019.6842415 $1,448.73 60 $1,701.49 $1,954.26 $2,207.0242420 $1,450.14 60 $1,688.46 $1,926.79 $2,165.11

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 44 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

42425 $1,001.99 60 $1,165.47 $1,328.94 $1,492.4242426 $2,122.60 60 $2,314.69 $2,506.78 $2,698.8642440 $834.27 60 $948.74 $1,063.21 $1,177.6742450 $606.09 60 $664.50 $722.90 $781.3142500 $550.86 60 $609.76 $668.65 $727.5542505 $720.82 60 $799.50 $878.18 $956.8642507 $726.28 60 $813.12 $899.96 $986.8042508 $1,026.79 60 $1,130.54 $1,234.30 $1,338.0542509 $2,034.55 60 $1,976.12 $1,917.70 $1,859.2742510 $814.64 60 $943.63 $1,072.61 $1,201.6042550 $61.10 0 $240.34 $419.57 $598.8142600 $762.45 60 $766.61 $770.77 $774.9342650 $56.14 0 $73.42 $90.70 $107.9942660 $61.57 0 $85.55 $109.53 $133.5142665 $166.48 0 $232.27 $298.05 $363.8442700 $99.33 0 $156.35 $213.37 $270.3942720 $194.47 0 $331.53 $468.59 $605.6442725 $407.10 15 $664.34 $921.57 $1,178.8142800 $92.05 7 $127.67 $163.28 $198.9042802 $109.94 7 $175.05 $240.17 $305.2842804 $101.93 7 $153.85 $205.78 $257.7042806 $119.18 7 $186.32 $253.46 $320.6042808 $229.34 30 $283.76 $338.19 $392.6142809 $112.48 0 $152.41 $192.34 $232.2742810 $312.15 30 $391.75 $471.34 $550.9442815 $942.55 30 $1,007.06 $1,071.57 $1,136.0942820 $460.23 30 $507.26 $554.29 $601.3242821 $471.48 30 $520.64 $569.79 $618.9542825 $401.89 30 $443.52 $485.15 $526.7842826 $443.14 30 $481.36 $519.57 $557.7942830 $274.73 30 $317.06 $359.39 $401.7242831 $294.38 30 $336.38 $378.39 $420.3942835 $255.38 30 $289.10 $322.83 $356.5542836 $266.99 30 $322.24 $377.50 $432.7542842 $734.21 30 $984.70 $1,235.19 $1,485.6842844 $1,099.86 30 $1,461.70 $1,823.55 $2,185.3942845 $1,522.11 30 $2,119.48 $2,716.85 $3,314.2242860 $264.35 30 $302.94 $341.53 $380.1242870 $445.96 30 $560.69 $675.42 $790.1542890 $1,158.63 60 $1,332.12 $1,505.62 $1,679.1142892 $1,428.04 60 $1,672.23 $1,916.43 $2,160.6242900 $389.85 30 $454.08 $518.31 $582.5442950 $746.35 60 $962.93 $1,179.50 $1,396.0842953 $1,263.04 60 $1,400.22 $1,537.41 $1,674.5942955 $835.56 0 $976.91 $1,118.27 $1,259.6242960 $142.05 0 $184.43 $226.81 $269.1942961 $250.10 0 $372.66 $495.22 $617.7842962 $319.28 0 $470.60 $621.92 $773.2342970 $284.88 0 $384.86 $484.83 $584.8142971 $338.78 0 $440.26 $541.75 $643.2342972 $439.38 0 $529.93 $620.49 $711.0443020 $1,101.21 90 $1,108.77 $1,116.34 $1,123.9043030 $1,296.91 90 $1,274.95 $1,252.99 $1,231.0343045 $1,770.55 90 $1,855.40 $1,940.24 $2,025.0943100 $1,467.10 90 $1,488.70 $1,510.30 $1,531.9043101 $1,961.80 90 $1,997.47 $2,033.15 $2,068.8243107 $3,047.19 $3,505.76 $3,964.34 $4,422.9143112 $3,141.83 $3,578.31 $4,014.80 $4,451.2843113 $3,600.95 $3,826.96 $4,052.98 $4,278.9943116 $3,311.26 $3,599.27 $3,887.28 $4,175.30

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 45 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

43117 $3,244.21 $3,712.54 $4,180.86 $4,649.1943118 $3,428.78 $3,649.58 $3,870.38 $4,091.1843121 $3,020.77 $3,202.41 $3,384.06 $3,565.7043122 $3,020.77 $3,393.52 $3,766.27 $4,139.0143123 $3,428.78 $3,442.97 $3,457.15 $3,471.3443124 $2,873.37 $3,031.72 $3,190.07 $3,348.4343130 $1,086.33 90 $1,173.89 $1,261.46 $1,349.0243135 $1,694.27 90 $1,785.67 $1,877.07 $1,968.4743200 $321.36 0 $380.67 $439.98 $499.2943202 $369.77 0 $438.53 $507.30 $576.0643204 $610.88 0 $575.64 $540.40 $505.1643205 $429.41 $455.10 $480.78 $506.4743215 $478.71 0 $479.41 $480.12 $480.8243216 $457.40 $432.95 $408.51 $384.0643217 $494.56 0 $516.21 $537.86 $559.5243219 $499.48 0 $462.52 $425.55 $388.5943220 $364.32 0 $364.17 $364.01 $363.8643226 $376.43 0 $361.97 $347.50 $333.0443227 $530.97 0 $512.19 $493.41 $474.6343228 $529.00 0 $509.10 $489.19 $469.2943234 $338.68 0 $397.19 $455.70 $514.2243235 $390.10 0 $447.35 $504.60 $561.8543239 $453.65 0 $514.58 $575.50 $636.4343241 $516.31 0 $474.92 $433.54 $392.1543243 $611.44 0 $607.93 $604.42 $600.9143244 $555.21 $578.75 $602.29 $625.8343245 $512.16 0 $610.97 $709.78 $808.6043246 $629.02 0 $599.75 $570.48 $541.2043247 $505.13 0 $510.81 $516.49 $522.1843248 $393.42 $397.80 $402.18 $406.5743249 $355.81 S $388.90 $421.99 $455.0943250 $538.62 $512.44 $486.27 $460.0943251 $562.09 0 $566.72 $571.35 $575.9843255 $643.39 S $601.19 $558.99 $516.7843258 $584.31 0 $607.32 $630.33 $653.3443259 $439.30 $497.90 $556.50 $615.1043260 $761.31 0 $792.54 $823.76 $854.9943261 $794.21 $824.50 $854.78 $885.0743262 $1,056.24 0 $1,090.73 $1,125.21 $1,159.7043263 $834.67 0 $840.72 $846.76 $852.8143264 $1,119.25 0 $1,145.43 $1,171.61 $1,197.7943265 $999.86 0 $999.85 $999.84 $999.8343267 $885.17 0 $882.29 $879.41 $876.5343268 $1,026.11 0 $986.62 $947.12 $907.6343269 $862.09 0 $840.89 $819.68 $798.4843271 $928.11 0 $969.22 $1,010.34 $1,051.4543272 $1,005.40 0 $1,010.55 $1,015.71 $1,020.8643300 $1,423.70 90 $1,417.14 $1,410.58 $1,404.0243305 $2,044.95 90 $2,124.61 $2,204.26 $2,283.9243310 $1,867.60 90 $2,114.14 $2,360.67 $2,607.2143312 $2,130.39 90 $2,484.04 $2,837.68 $3,191.3343320 $1,696.01 90 $1,847.49 $1,998.96 $2,150.4443324 $1,687.59 90 $1,828.17 $1,968.75 $2,109.3443325 $1,728.45 90 $1,889.47 $2,050.48 $2,211.5043326 $1,624.07 90 $1,856.81 $2,089.56 $2,322.3043330 $1,666.30 90 $1,800.84 $1,935.39 $2,069.9343331 $1,774.86 90 $1,843.73 $1,912.59 $1,981.4643340 $1,874.62 90 $2,028.21 $2,181.81 $2,335.4043341 $1,829.65 90 $1,944.08 $2,058.52 $2,172.9543350 $1,198.83 90 $1,348.51 $1,498.20 $1,647.88

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 46 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

43351 $1,368.50 90 $1,538.68 $1,708.85 $1,879.0343352 $1,257.83 90 $1,364.87 $1,471.91 $1,578.9543360 $2,834.64 $3,193.74 $3,552.84 $3,911.9443361 $3,255.85 $3,670.19 $4,084.52 $4,498.8643400 $1,593.51 90 $1,786.49 $1,979.47 $2,172.4543401 $2,267.48 90 $2,283.91 $2,300.33 $2,316.7643405 $1,673.20 $1,722.94 $1,772.67 $1,822.4143410 $1,184.04 90 $1,340.98 $1,497.91 $1,654.8543415 $1,762.60 90 $1,959.71 $2,156.81 $2,353.9243420 $1,086.33 90 $1,230.82 $1,375.31 $1,519.8043425 $2,091.63 90 $2,132.25 $2,172.87 $2,213.4943450 $109.51 0 $146.81 $184.11 $221.4043453 $181.52 0 $244.86 $308.20 $371.5543456 $286.08 0 $445.88 $605.69 $765.4943458 $285.67 $383.35 $481.02 $578.7043460 $390.22 0 $408.72 $427.23 $445.7343500 $939.00 45 $1,038.50 $1,138.00 $1,237.5143501 $1,297.38 45 $1,511.97 $1,726.56 $1,941.1643502 $1,416.23 $1,668.41 $1,920.59 $2,172.7743510 $1,147.71 45 $1,202.04 $1,256.37 $1,310.7043520 $788.24 45 $907.59 $1,026.94 $1,146.2943600 $248.30 0 $238.56 $228.82 $219.0843605 $939.00 45 $1,070.02 $1,201.03 $1,332.0543610 $1,206.11 45 $1,301.24 $1,396.37 $1,491.5143611 $1,294.51 $1,489.92 $1,685.33 $1,880.7543620 $2,265.90 90 $2,562.93 $2,859.97 $3,157.0043621 $2,351.15 $2,649.21 $2,947.28 $3,245.3443622 $2,416.33 $2,779.62 $3,142.90 $3,506.1943631 $1,796.90 $1,982.11 $2,167.32 $2,352.5243632 $1,796.90 $1,959.16 $2,121.41 $2,283.6743633 $1,833.63 $2,033.20 $2,232.76 $2,432.3343634 $2,393.63 $2,470.05 $2,546.48 $2,622.9043635 $814.66 60 $633.60 $452.53 $271.4743640 $1,298.94 60 $1,512.27 $1,725.60 $1,938.9443641 $1,388.86 60 $1,584.09 $1,779.31 $1,974.5443750 $497.14 0 $512.17 $527.21 $542.2443760 $83.35 0 $110.97 $138.59 $166.2143761 $77.94 0 $118.41 $158.88 $199.3543800 $1,011.99 45 $1,125.25 $1,238.51 $1,351.7643810 $1,085.09 45 $1,226.83 $1,368.57 $1,510.3143820 $1,220.37 45 $1,334.38 $1,448.39 $1,562.4043825 $1,406.57 45 $1,588.52 $1,770.47 $1,952.4243830 $1,005.17 45 $1,084.33 $1,163.50 $1,242.6643831 $724.66 30 $798.83 $872.99 $947.1643832 $1,240.46 45 $1,384.96 $1,529.46 $1,673.9643840 $1,240.57 45 $1,292.54 $1,344.51 $1,396.4943842 $1,469.17 0 $1,736.31 $2,003.44 $2,270.5843843 $1,663.30 0 $1,881.40 $2,099.50 $2,317.6043846 $1,972.90 45 $2,318.22 $2,663.55 $3,008.8743847 $1,652.06 $2,103.06 $2,554.06 $3,005.0543848 $2,057.17 $2,459.37 $2,861.57 $3,263.7743850 $1,707.33 60 $1,915.39 $2,123.44 $2,331.5043855 $1,831.56 60 $2,005.78 $2,180.01 $2,354.2343860 $1,708.52 60 $1,934.22 $2,159.93 $2,385.6343865 $1,914.13 60 $2,135.27 $2,356.40 $2,577.5443870 $939.00 45 $1,002.98 $1,066.95 $1,130.9343880 $1,293.49 45 $1,560.94 $1,828.40 $2,095.8544005 $1,178.80 90 $1,396.17 $1,613.55 $1,830.9244010 $1,134.06 60 $1,229.56 $1,325.06 $1,420.5744015 $420.55 30 $438.84 $457.12 $475.41

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 47 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

44020 $1,146.16 60 $1,250.66 $1,355.15 $1,459.6544021 $796.30 60 $1,002.00 $1,207.69 $1,413.3944025 $1,116.29 60 $1,270.25 $1,424.22 $1,578.1844050 $1,066.64 90 $1,234.32 $1,402.00 $1,569.6844055 $1,146.83 60 $1,412.50 $1,678.17 $1,943.8444100 $239.51 0 $249.66 $259.80 $269.9544110 $1,236.89 60 $1,282.57 $1,328.25 $1,373.9344111 $1,380.29 60 $1,520.63 $1,660.98 $1,801.3244120 $1,506.14 60 $1,682.21 $1,858.27 $2,034.3444121 $416.93 30 $493.53 $570.13 $646.7344125 $1,432.08 60 $1,687.16 $1,942.25 $2,197.3344130 $1,283.79 60 $1,384.69 $1,485.58 $1,586.4844139 $208.34 30 $212.25 $216.16 $220.0844140 $1,586.84 90 $1,771.04 $1,955.24 $2,139.4444141 $1,615.62 90 $1,892.22 $2,168.82 $2,445.4144143 $1,630.61 90 $1,840.39 $2,050.16 $2,259.9444144 $1,604.09 90 $1,797.60 $1,991.12 $2,184.6344145 $1,911.88 90 $2,267.52 $2,623.15 $2,978.7944146 $1,998.39 90 $2,296.29 $2,594.19 $2,892.0944147 $1,956.01 90 $2,116.59 $2,277.17 $2,437.7444150 $2,225.17 90 $2,500.68 $2,776.19 $3,051.7144151 $2,176.84 90 $2,524.60 $2,872.37 $3,220.1344152 $2,656.25 90 $2,845.36 $3,034.47 $3,223.5844153 $2,985.30 90 $3,317.09 $3,648.88 $3,980.6844155 $2,492.77 90 $2,758.21 $3,023.64 $3,289.0844156 $2,890.25 90 $3,069.97 $3,249.70 $3,429.4244160 $1,849.85 60 $2,031.53 $2,213.20 $2,394.8844300 $866.18 60 $974.82 $1,083.45 $1,192.0944310 $1,212.86 60 $1,398.17 $1,583.49 $1,768.8044312 $624.42 60 $739.91 $855.39 $970.8844314 $1,206.20 60 $1,395.13 $1,584.06 $1,772.9944316 $1,796.50 60 $1,864.38 $1,932.27 $2,000.1544320 $1,043.65 60 $1,259.65 $1,475.64 $1,691.6444322 $1,121.32 60 $1,251.46 $1,381.59 $1,511.7344340 $411.07 60 $524.39 $637.71 $751.0344345 $903.43 60 $1,055.57 $1,207.71 $1,359.8544346 $982.62 60 $1,177.96 $1,373.31 $1,568.6544360 $434.86 0 $414.42 $393.98 $373.5344361 $491.07 0 $471.99 $452.92 $433.8444363 $485.30 0 $473.80 $462.30 $450.8044364 $608.35 0 $565.17 $521.99 $478.8244365 $608.35 $551.56 $494.78 $437.9944366 $709.55 0 $664.40 $619.25 $574.1044369 $791.20 0 $693.14 $595.07 $497.0144372 $735.93 0 $684.13 $632.33 $580.5344373 $606.04 0 $533.97 $461.91 $389.8444376 $372.60 $442.07 $511.54 $581.0044377 $632.50 $627.11 $621.72 $616.3344378 $829.15 $826.41 $823.67 $820.9344380 $216.46 0 $217.60 $218.74 $219.8844382 $256.34 0 $265.41 $274.49 $283.5644385 $228.61 0 $295.11 $361.61 $428.1244386 $226.38 0 $337.38 $448.37 $559.3744388 $398.88 0 $450.69 $502.50 $554.3144389 $466.42 0 $527.84 $589.25 $650.6744390 $444.03 0 $533.88 $623.73 $713.5844391 $620.76 0 $713.00 $805.24 $897.4844392 $737.43 0 $798.30 $859.16 $920.0344393 $807.77 0 $844.88 $881.99 $919.1044394 $580.75 $643.91 $707.08 $770.24

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 48 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

44500 $71.73 $73.84 $75.95 $78.0644602 $1,054.23 $1,274.53 $1,494.84 $1,715.1444603 $1,338.97 $1,523.07 $1,707.18 $1,891.2844604 $1,275.99 $1,410.84 $1,545.69 $1,680.5544605 $1,304.39 60 $1,542.99 $1,781.59 $2,020.1944615 $1,122.90 $1,296.46 $1,470.02 $1,643.5944620 $901.90 60 $1,022.45 $1,143.00 $1,263.5444625 $1,240.08 60 $1,414.09 $1,588.10 $1,762.1144626 $1,891.82 $2,128.68 $2,365.54 $2,602.4044640 $1,054.86 60 $1,371.91 $1,688.95 $2,006.0044650 $1,198.83 60 $1,434.97 $1,671.11 $1,907.2544660 $1,212.84 60 $1,439.14 $1,665.45 $1,891.7544661 $1,851.88 60 $2,040.77 $2,229.67 $2,418.5644680 $1,549.08 60 $1,650.48 $1,751.89 $1,853.2944700 $1,479.53 $1,602.77 $1,726.00 $1,849.2444800 $878.34 45 $1,016.55 $1,154.76 $1,292.9744820 $917.83 45 $1,064.34 $1,210.84 $1,357.3544850 $958.13 45 $1,009.09 $1,060.04 $1,111.0044900 $610.98 45 $727.67 $844.36 $961.0544901 $334.69 $683.87 $1,033.06 $1,382.2444950 $721.05 45 $849.98 $978.90 $1,107.8344955 $514.59 45 $443.69 $372.78 $301.8844960 $941.12 45 $1,084.47 $1,227.82 $1,371.1745000 $244.44 0 $319.44 $394.44 $469.4445005 $201.16 15 $250.89 $300.61 $350.3445020 $406.17 30 $452.65 $499.12 $545.6045100 $334.43 15 $377.83 $421.24 $464.6445108 $523.72 90 $603.84 $683.97 $764.0945110 $2,199.23 90 $2,502.88 $2,806.54 $3,110.1945111 $1,578.95 90 $1,760.32 $1,941.68 $2,123.0545112 $2,293.82 90 $2,490.37 $2,686.93 $2,883.4845113 $2,418.87 $2,759.74 $3,100.60 $3,441.4745114 $2,145.88 90 $2,375.31 $2,604.75 $2,834.1845116 $1,686.44 90 $1,880.90 $2,075.36 $2,269.8245119 $2,399.00 $2,672.23 $2,945.46 $3,218.6945120 $2,224.38 90 $2,393.69 $2,563.00 $2,732.3145121 $2,324.94 90 $2,487.04 $2,649.13 $2,811.2345123 $1,487.01 $1,648.48 $1,809.95 $1,971.4245130 $1,269.81 90 $1,321.01 $1,372.22 $1,423.4245135 $2,058.63 90 $2,069.71 $2,080.78 $2,091.8645150 $711.85 90 $724.40 $736.95 $749.5045160 $1,270.31 90 $1,416.86 $1,563.42 $1,709.9745170 $535.19 30 $702.11 $869.04 $1,035.9645190 $792.37 $894.36 $996.36 $1,098.3545300 $71.43 0 $89.79 $108.14 $126.5045303 $103.61 0 $334.92 $566.22 $797.5345305 $105.53 0 $140.69 $175.85 $211.0145307 $158.16 0 $192.65 $227.14 $261.6245308 $173.57 $188.68 $203.78 $218.8945309 $183.02 $222.16 $261.30 $300.4445315 $174.98 0 $220.58 $266.18 $311.7845317 $192.49 0 $226.54 $260.60 $294.6545320 $230.71 0 $262.46 $294.20 $325.9545321 $171.11 0 $172.18 $173.25 $174.3345330 $135.65 0 $161.12 $186.59 $212.0645331 $174.96 0 $207.24 $239.52 $271.8045332 $210.22 0 $265.97 $321.73 $377.4845333 $250.58 0 $290.52 $330.47 $370.4145334 $299.26 0 $308.83 $318.39 $327.9645337 $350.90 0 $331.69 $312.48 $293.27

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 49 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

45338 $261.84 $316.29 $370.74 $425.1945339 $371.09 $396.86 $422.62 $448.3945355 $189.38 0 $229.46 $269.54 $309.6145378 $640.07 0 $673.65 $707.24 $740.8245379 $678.94 0 $732.45 $785.96 $839.4745380 $658.85 0 $731.94 $805.03 $878.1245382 $745.87 0 $827.35 $908.82 $990.3045383 $780.05 0 $832.24 $884.42 $936.6145384 $869.92 $889.51 $909.10 $928.7045385 $929.67 0 $963.94 $998.21 $1,032.4845500 $838.68 90 $857.53 $876.39 $895.2445505 $843.27 90 $890.69 $938.11 $985.5345520 $82.41 0 $98.75 $115.09 $131.4345540 $1,359.31 90 $1,534.69 $1,710.06 $1,885.4445541 $1,344.85 90 $1,425.56 $1,506.26 $1,586.9745550 $1,688.31 90 $1,965.54 $2,242.77 $2,520.0045560 $540.54 90 $684.11 $827.69 $971.2645562 $1,214.85 $1,385.73 $1,556.61 $1,727.5045563 $1,812.20 $2,085.39 $2,358.58 $2,631.7745800 $1,570.15 90 $1,720.71 $1,871.28 $2,021.8445805 $1,728.41 90 $1,839.82 $1,951.23 $2,062.6445820 $1,570.15 90 $1,724.51 $1,878.88 $2,033.2445825 $1,728.41 90 $1,852.11 $1,975.80 $2,099.5045900 $81.41 0 $125.08 $168.76 $212.4345905 $107.98 0 $255.05 $402.13 $549.2045910 $140.98 0 $356.45 $571.92 $787.3945915 $145.06 0 $233.72 $322.39 $411.0546030 $61.36 0 $103.88 $146.40 $188.9246040 $185.47 15 $339.92 $494.37 $648.8246045 $216.99 15 $300.97 $384.95 $468.9346050 $69.30 0 $116.15 $163.00 $209.8546060 $735.78 60 $779.48 $823.18 $866.8846070 $148.97 0 $192.92 $236.88 $280.8346080 $124.11 0 $189.14 $254.17 $319.2046083 $72.15 0 $124.10 $176.05 $227.9946200 $396.24 60 $452.98 $509.73 $566.4746210 $114.11 30 $214.01 $313.92 $413.8246211 $362.72 90 $463.74 $564.76 $665.7846220 $58.81 15 $105.95 $153.09 $200.2346221 $143.87 30 $186.85 $229.83 $272.8146230 $110.91 15 $178.00 $245.10 $312.1946250 $435.42 90 $517.13 $598.85 $680.5646255 $680.06 90 $736.09 $792.13 $848.1646257 $661.66 90 $709.64 $757.62 $805.6146258 $745.80 90 $788.03 $830.26 $872.4946260 $733.61 90 $787.61 $841.60 $895.6046261 $833.41 90 $834.57 $835.74 $836.9046262 $902.67 90 $921.15 $939.64 $958.1246270 $269.43 30 $386.67 $503.91 $621.1546275 $710.02 90 $763.94 $817.87 $871.7946280 $806.46 90 $865.79 $925.12 $984.4546285 $291.75 30 $344.28 $396.80 $449.3346288 $650.16 $732.83 $815.49 $898.1646320 $74.50 0 $127.83 $181.15 $234.4846500 $36.27 0 $91.41 $146.56 $201.7046600 $43.16 0 $64.33 $85.50 $106.6646604 $80.01 0 $199.94 $319.87 $439.8046606 $76.79 0 $128.85 $180.91 $232.9746608 $111.71 0 $172.64 $233.57 $294.5046610 $126.37 0 $185.64 $244.92 $304.19

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 50 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

46611 $156.91 $209.57 $262.23 $314.8946612 $145.41 0 $230.74 $316.06 $401.3946614 $182.16 0 $206.23 $230.30 $254.3746615 $231.15 $269.66 $308.16 $346.6746700 $754.60 90 $845.92 $937.24 $1,028.5646705 $802.60 90 $847.42 $892.23 $937.0546715 $941.43 90 $973.94 $1,006.45 $1,038.9646716 $751.37 90 $959.36 $1,167.36 $1,375.3546730 $1,593.35 90 $1,888.16 $2,182.96 $2,477.7746735 $1,966.90 90 $2,301.97 $2,637.04 $2,972.1146740 $1,871.30 90 $2,252.19 $2,633.08 $3,013.9746742 $2,556.06 $2,989.64 $3,423.21 $3,856.7946744 $2,869.44 $3,536.84 $4,204.24 $4,871.6546746 $3,139.25 $4,047.26 $4,955.28 $5,863.2946748 $3,491.40 $4,309.07 $5,126.73 $5,944.4046750 $815.80 90 $966.47 $1,117.14 $1,267.8146751 $950.68 90 $998.33 $1,045.98 $1,093.6346753 $990.24 90 $995.01 $999.77 $1,004.5446754 $203.55 90 $285.57 $367.60 $449.6246760 $780.00 90 $995.70 $1,211.41 $1,427.1146761 $1,250.15 90 $1,379.53 $1,508.92 $1,638.3046762 $1,146.74 90 $1,222.28 $1,297.83 $1,373.3746900 $71.20 0 $122.15 $173.09 $224.0446910 $90.00 0 $146.79 $203.59 $260.3846916 $112.43 7 $165.26 $218.09 $270.9246917 $174.80 7 $286.73 $398.66 $510.6046922 $155.77 7 $205.51 $255.25 $304.9946924 $324.64 7 $463.93 $603.22 $742.5146934 $167.46 15 $273.30 $379.13 $484.9746935 $131.67 15 $208.31 $284.94 $361.5846936 $344.23 15 $445.96 $547.69 $649.4246937 $307.57 15 $368.33 $429.08 $489.8446938 $412.57 15 $480.56 $548.56 $616.5546940 $71.96 15 $128.89 $185.83 $242.7646942 $57.50 15 $118.56 $179.63 $240.6946945 $167.67 15 $211.33 $254.99 $298.6546946 $389.23 15 $435.93 $482.63 $529.3247000 $231.92 0 $308.17 $384.42 $460.6747010 $1,105.07 60 $1,279.47 $1,453.87 $1,628.2747011 $393.74 $426.06 $458.38 $490.7047015 $849.85 $1,047.66 $1,245.47 $1,443.2847100 $806.68 45 $923.78 $1,040.87 $1,157.9747120 $1,754.60 45 $2,311.97 $2,869.35 $3,426.7247122 $2,328.31 45 $3,130.97 $3,933.63 $4,736.2947125 $2,081.15 45 $2,837.28 $3,593.40 $4,349.5347130 $2,294.15 45 $3,019.90 $3,745.66 $4,471.4147135 $4,485.00 0 $5,667.15 $6,849.31 $8,031.4647136 $4,485.00 $5,302.17 $6,119.34 $6,936.5247300 $1,142.31 60 $1,288.77 $1,435.23 $1,581.6947350 $1,116.33 45 $1,357.97 $1,599.61 $1,841.2547360 $2,012.57 45 $2,272.21 $2,531.84 $2,791.4847361 $2,854.40 30 $3,326.99 $3,799.59 $4,272.1847362 $1,026.13 30 $1,281.99 $1,537.85 $1,793.7247400 $1,612.15 45 $1,962.92 $2,313.68 $2,664.4547420 $1,361.45 45 $1,548.82 $1,736.19 $1,923.5647425 $1,567.60 45 $1,756.20 $1,944.80 $2,133.4047460 $1,654.68 45 $1,748.65 $1,842.62 $1,936.5847480 $939.00 45 $1,054.92 $1,170.84 $1,286.7647490 $443.63 0 $539.63 $635.64 $731.6447500 $166.16 0 $170.78 $175.40 $180.01

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 51 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

47505 $143.27 0 $193.85 $244.42 $295.0047510 $387.65 45 $501.57 $615.49 $729.4147511 $494.96 0 $645.18 $795.39 $945.6147525 $326.87 0 $526.49 $726.10 $925.7247530 $241.45 $745.07 $1,248.68 $1,752.3047550 $294.37 45 $316.59 $338.82 $361.0447552 $367.60 0 $424.14 $480.69 $537.2347553 $504.11 14 $524.13 $544.16 $564.1847554 $629.12 14 $697.29 $765.46 $833.6347555 $540.80 14 $560.52 $580.25 $599.9747556 $685.30 14 $695.61 $705.92 $716.2347600 $1,204.40 45 $1,349.33 $1,494.26 $1,639.2047605 $1,219.98 45 $1,391.48 $1,562.98 $1,734.4847610 $1,441.62 45 $1,626.91 $1,812.19 $1,997.4847612 $1,913.70 45 $1,994.91 $2,076.12 $2,157.3447620 $1,681.83 45 $1,826.82 $1,971.81 $2,116.8047630 $631.55 45 $716.94 $802.33 $887.7347700 $1,243.28 45 $1,379.01 $1,514.74 $1,650.4847701 $1,778.10 45 $2,206.42 $2,634.74 $3,063.0647711 $1,856.38 $1,999.70 $2,143.02 $2,286.3447712 $2,349.48 $2,589.91 $2,830.35 $3,070.7847715 $1,550.26 60 $1,730.54 $1,910.81 $2,091.0947716 $1,406.99 60 $1,582.72 $1,758.44 $1,934.1747720 $1,298.78 60 $1,420.54 $1,542.29 $1,664.0547721 $1,485.21 60 $1,659.98 $1,834.75 $2,009.5147740 $1,413.14 60 $1,559.00 $1,704.86 $1,850.7147741 $1,886.38 $2,027.11 $2,167.85 $2,308.5847760 $1,619.05 60 $1,892.99 $2,166.93 $2,440.8747765 $1,463.95 60 $1,796.52 $2,129.09 $2,461.6547780 $1,847.54 60 $2,177.96 $2,508.37 $2,838.7947785 $2,445.51 $2,653.39 $2,861.26 $3,069.1447800 $1,755.77 60 $1,929.33 $2,102.90 $2,276.4647801 $1,072.11 60 $1,173.92 $1,275.73 $1,377.5447802 $1,451.41 60 $1,669.21 $1,887.01 $2,104.8247900 $1,748.31 $1,860.56 $1,972.81 $2,085.0648000 $1,102.56 60 $1,447.47 $1,792.38 $2,137.2948001 $1,285.68 $1,906.03 $2,526.38 $3,146.7348005 $1,453.99 $2,043.59 $2,633.18 $3,222.7848020 $1,570.15 60 $1,601.76 $1,633.37 $1,664.9948100 $910.69 60 $1,056.34 $1,201.99 $1,347.6548102 $218.64 0 $369.17 $519.70 $670.2448120 $1,415.45 60 $1,532.55 $1,649.65 $1,766.7548140 $1,678.85 60 $1,947.92 $2,216.99 $2,486.0648145 $1,923.41 60 $2,149.86 $2,376.31 $2,602.7648146 $2,172.87 $2,402.62 $2,632.38 $2,862.1348148 $1,317.82 60 $1,550.73 $1,783.65 $2,016.5648150 $3,063.43 60 $3,521.36 $3,979.29 $4,437.2248152 $2,890.61 $3,294.10 $3,697.58 $4,101.0748153 $3,048.84 $3,525.37 $4,001.90 $4,478.4348154 $2,890.61 $3,333.79 $3,776.97 $4,220.1548155 $2,713.39 60 $2,837.72 $2,962.04 $3,086.3748160 $3,724.89 0 $3,789.75 $3,854.62 $3,919.4848180 $2,039.48 60 $2,215.88 $2,392.29 $2,568.6948400 $165.60 $178.61 $191.62 $204.6348500 $1,203.19 60 $1,337.54 $1,471.89 $1,606.2448510 $1,209.87 60 $1,419.70 $1,629.54 $1,839.3748511 $432.95 $678.61 $924.27 $1,169.9248520 $1,432.70 60 $1,517.79 $1,602.88 $1,687.9748540 $1,644.10 60 $1,747.55 $1,850.99 $1,954.4448545 $1,195.26 $1,417.74 $1,640.22 $1,862.69

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 52 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

48547 $1,796.30 $2,030.69 $2,265.08 $2,499.4749000 $924.62 45 $1,133.31 $1,342.00 $1,550.6949002 $819.85 45 $967.73 $1,115.60 $1,263.4849010 $965.81 45 $1,050.22 $1,134.62 $1,219.0349020 $879.29 45 $1,299.64 $1,719.99 $2,140.3449021 $840.96 $973.19 $1,105.41 $1,237.6449040 $924.24 45 $1,066.67 $1,209.11 $1,351.5449041 $396.86 $632.41 $867.96 $1,103.5149060 $922.14 45 $1,117.06 $1,311.98 $1,506.9149061 $366.71 $608.20 $849.70 $1,091.1949062 $1,007.41 $1,104.61 $1,201.82 $1,299.0249080 $127.63 0 $186.84 $246.05 $305.2749081 $105.81 0 $142.34 $178.87 $215.4049085 $852.44 45 $918.92 $985.41 $1,051.8949180 $199.80 0 $276.08 $352.35 $428.6349200 $1,123.94 60 $1,266.52 $1,409.10 $1,551.6749201 $1,542.38 60 $1,717.20 $1,892.02 $2,066.8349215 $1,253.28 60 $1,764.54 $2,275.80 $2,787.0549220 $1,525.65 60 $1,615.35 $1,705.05 $1,794.7449250 $667.45 60 $765.72 $863.98 $962.2549255 $914.02 60 $1,005.60 $1,097.18 $1,188.7649400 $137.05 0 $171.10 $205.14 $239.1949420 $175.79 0 $202.03 $228.26 $254.5049421 $520.87 0 $555.15 $589.43 $623.7049422 $512.61 $534.88 $557.16 $579.4349423 $168.18 $343.88 $519.59 $695.2949424 $90.81 $135.41 $180.01 $224.6149425 $1,284.84 $1,363.07 $1,441.29 $1,519.5249427 $69.29 0 $80.20 $91.11 $102.0249428 $243.57 $362.35 $481.13 $599.9049429 $599.62 $683.41 $767.21 $851.0049495 $801.32 $820.47 $839.61 $858.7649496 $1,034.81 $1,066.55 $1,098.28 $1,130.0249500 $693.78 45 $722.85 $751.91 $780.9849501 $914.41 $968.97 $1,023.53 $1,078.1049505 $790.38 45 $848.90 $907.42 $965.9449507 $945.33 $1,013.09 $1,080.85 $1,148.6249520 $895.53 45 $980.21 $1,064.89 $1,149.5749521 $1,036.89 $1,105.77 $1,174.65 $1,243.5449525 $867.65 45 $918.17 $968.70 $1,019.2249540 $857.43 45 $937.84 $1,018.25 $1,098.6649550 $799.36 45 $902.92 $1,006.48 $1,110.0449553 $855.64 $921.66 $987.69 $1,053.7149555 $894.50 45 $986.93 $1,079.36 $1,171.7949557 $1,074.48 $1,141.81 $1,209.13 $1,276.4649560 $943.20 $1,115.64 $1,288.09 $1,460.5349561 $1,074.11 $1,299.63 $1,525.15 $1,750.6749565 $1,043.92 $1,151.26 $1,258.59 $1,365.9349566 $1,202.06 S $1,319.33 $1,436.60 $1,553.8849568 $400.10 $445.04 $489.98 $534.9149570 $520.82 45 $611.58 $702.33 $793.0949572 $680.78 $763.10 $845.42 $927.7349580 $593.69 45 $579.87 $566.04 $552.2249582 $711.39 $744.90 $778.41 $811.9349585 $654.51 $717.61 $780.72 $843.8249587 $755.78 $833.01 $910.24 $987.4749590 $785.75 45 $861.93 $938.11 $1,014.2849600 $798.96 45 $915.60 $1,032.23 $1,148.8749605 $1,477.84 60 $2,941.21 $4,404.58 $5,867.9649606 $1,267.33 0 $1,372.03 $1,476.73 $1,581.43

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 53 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

49610 $1,044.90 60 $1,116.21 $1,187.53 $1,258.8449611 $1,023.96 60 $1,074.51 $1,125.07 $1,175.6249900 $538.89 30 $712.83 $886.76 $1,060.7049905 $764.03 30 $758.50 $752.97 $747.4450010 $844.20 90 $1,007.90 $1,171.60 $1,335.3150020 $1,189.08 90 $1,315.01 $1,440.94 $1,566.8750021 $334.69 $606.08 $877.48 $1,148.8750040 $1,550.27 90 $1,639.06 $1,727.85 $1,816.6550045 $1,533.95 90 $1,557.04 $1,580.13 $1,603.2250060 $1,812.77 90 $1,890.21 $1,967.66 $2,045.1050065 $2,116.00 90 $2,032.63 $1,949.27 $1,865.9050070 $1,907.28 90 $1,971.21 $2,035.13 $2,099.0650075 $2,415.00 90 $2,371.57 $2,328.13 $2,284.7050080 $1,698.10 90 $1,818.20 $1,938.31 $2,058.4150081 $2,005.85 90 $2,148.22 $2,290.58 $2,432.9550100 $1,559.32 90 $1,581.92 $1,604.51 $1,627.1150120 $1,368.02 90 $1,529.54 $1,691.07 $1,852.5950125 $1,444.15 90 $1,512.20 $1,580.26 $1,648.3150130 $1,526.27 90 $1,655.97 $1,785.67 $1,915.3750135 $1,881.40 90 $1,836.64 $1,791.87 $1,747.1150200 $259.99 0 $279.64 $299.29 $318.9450205 $768.77 30 $897.90 $1,027.03 $1,156.1750220 $1,777.99 90 $1,914.72 $2,051.44 $2,188.1750225 $1,905.98 90 $2,009.68 $2,113.38 $2,217.0850230 $2,351.05 90 $2,477.78 $2,604.50 $2,731.2350234 $2,228.90 90 $2,291.56 $2,354.23 $2,416.8950236 $2,335.28 90 $2,454.87 $2,574.46 $2,694.0550240 $2,101.16 90 $2,317.81 $2,534.47 $2,751.1250280 $1,372.07 90 $1,519.24 $1,666.42 $1,813.5950320 $2,140.53 90 $2,347.61 $2,554.68 $2,761.7650340 $1,848.86 90 $1,801.83 $1,754.79 $1,707.7650360 $3,336.74 90 $3,418.71 $3,500.67 $3,582.6450365 $4,034.70 90 $4,216.42 $4,398.14 $4,579.8650370 $1,381.54 90 $1,477.92 $1,574.31 $1,670.6950380 $2,408.59 90 $2,494.51 $2,580.43 $2,666.3650390 $215.93 0 $223.18 $230.44 $237.6950392 $298.11 0 $316.80 $335.48 $354.1750393 $343.45 0 $367.71 $391.97 $416.2350394 $158.94 0 $206.35 $253.77 $301.1850395 $529.86 0 $526.92 $523.98 $521.0450396 $39.10 0 $105.08 $171.05 $237.0350398 $71.56 0 $271.28 $471.00 $670.7250400 $2,152.43 90 $2,139.21 $2,126.00 $2,112.7850405 $2,302.88 90 $2,458.18 $2,613.47 $2,768.7750500 $1,698.20 90 $1,798.80 $1,899.39 $1,999.9950520 $1,576.90 90 $1,616.92 $1,656.95 $1,696.9750525 $1,958.16 90 $2,012.54 $2,066.91 $2,121.2950526 $1,779.05 90 $1,934.12 $2,089.20 $2,244.2750540 $2,150.15 90 $2,171.31 $2,192.47 $2,213.6350551 $196.65 0 $340.48 $484.31 $628.1350553 $196.65 0 $497.92 $799.20 $1,100.4750555 $282.90 0 $669.59 $1,056.29 $1,442.9850557 $282.90 0 $672.19 $1,061.48 $1,450.7750561 $432.08 0 $714.82 $997.56 $1,280.3150570 $589.95 0 $675.76 $761.57 $847.3750572 $972.90 0 $967.87 $962.85 $957.8250574 $993.60 0 $976.14 $958.67 $941.2150575 $1,282.25 $1,305.32 $1,328.39 $1,351.4550576 $1,084.45 0 $1,040.76 $997.08 $953.3950580 $837.20 0 $899.25 $961.31 $1,023.36

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 54 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

50590 $1,678.08 90 $1,778.52 $1,878.96 $1,979.4050600 $1,310.17 90 $1,461.32 $1,612.47 $1,763.6150605 $1,239.70 90 $1,337.74 $1,435.78 $1,533.8350610 $1,550.27 90 $1,661.10 $1,771.93 $1,882.7750620 $1,342.42 90 $1,470.17 $1,597.92 $1,725.6750630 $1,556.11 90 $1,647.66 $1,739.21 $1,830.7650650 $1,623.77 90 $1,715.16 $1,806.54 $1,897.9350684 $66.02 0 $254.41 $442.79 $631.1850686 $75.90 0 $141.87 $207.83 $273.8050690 $54.75 0 $249.50 $444.26 $639.0150700 $1,693.90 90 $1,748.62 $1,803.34 $1,858.0750715 $1,236.83 90 $1,500.00 $1,763.16 $2,026.3350722 $1,368.50 90 $1,444.46 $1,520.43 $1,596.3950725 $2,058.63 90 $2,079.34 $2,100.05 $2,120.7650727 $713.00 90 $830.74 $948.47 $1,066.2150728 $1,049.95 90 $1,190.76 $1,331.57 $1,472.3950740 $1,799.51 90 $1,891.69 $1,983.86 $2,076.0450750 $2,026.30 90 $2,017.97 $2,009.64 $2,001.3150760 $1,943.51 90 $1,984.65 $2,025.80 $2,066.9450770 $2,060.62 90 $2,167.85 $2,275.08 $2,382.3250780 $1,900.76 90 $1,982.62 $2,064.49 $2,146.3550782 $1,971.10 90 $2,123.35 $2,275.59 $2,427.8450783 $2,027.45 90 $2,183.26 $2,339.06 $2,494.8750785 $2,111.78 90 $2,228.37 $2,344.96 $2,461.5650800 $1,779.26 90 $1,889.49 $1,999.72 $2,109.9550810 $2,369.40 90 $2,520.13 $2,670.86 $2,821.5950815 $2,463.30 90 $2,444.73 $2,426.16 $2,407.5950820 $2,495.53 90 $2,606.46 $2,717.39 $2,828.3250825 $2,523.01 90 $2,796.91 $3,070.81 $3,344.7150830 $2,637.19 90 $2,985.07 $3,332.94 $3,680.8250840 $2,349.28 90 $2,454.96 $2,560.64 $2,666.3250845 $1,768.80 $1,910.05 $2,051.31 $2,192.5650860 $1,399.87 90 $1,437.88 $1,475.88 $1,513.8950900 $1,567.36 90 $1,650.16 $1,732.96 $1,815.7750920 $1,570.15 90 $1,580.37 $1,590.59 $1,600.8150930 $1,899.80 90 $1,932.54 $1,965.29 $1,998.0350940 $971.75 0 $1,234.60 $1,497.46 $1,760.3150951 $215.05 0 $363.12 $511.20 $659.2750953 $237.63 0 $555.21 $872.79 $1,190.3650955 $244.95 0 $608.23 $971.50 $1,334.7850957 $254.15 0 $565.43 $876.71 $1,187.9950961 $254.15 0 $662.01 $1,069.88 $1,477.7450970 $115.00 0 $290.62 $466.24 $641.8650972 $143.75 0 $293.84 $443.93 $594.0250974 $253.00 0 $429.21 $605.42 $781.6250976 $253.00 0 $425.88 $598.75 $771.6350980 $253.00 0 $364.26 $475.51 $586.7751000 $49.66 0 $82.97 $116.28 $149.5951005 $84.78 0 $147.78 $210.78 $273.7851010 $195.42 0 $285.78 $376.15 $466.5151020 $1,112.17 90 $1,133.69 $1,155.21 $1,176.7351030 $1,098.25 90 $1,090.88 $1,083.50 $1,076.1351040 $939.00 90 $939.49 $939.98 $940.4751045 $970.75 90 $1,026.46 $1,082.17 $1,137.8851050 $1,129.69 90 $1,151.12 $1,172.55 $1,193.9751060 $1,829.65 90 $1,749.62 $1,669.60 $1,589.5751065 $960.25 90 $997.54 $1,034.82 $1,072.1151080 $678.16 90 $698.96 $719.76 $740.5651500 $1,099.02 90 $1,145.77 $1,192.51 $1,239.2651520 $1,267.40 90 $1,296.01 $1,324.61 $1,353.22

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 55 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

51525 $1,550.27 90 $1,615.94 $1,681.61 $1,747.2751530 $1,307.39 90 $1,385.16 $1,462.93 $1,540.7151535 $1,277.15 90 $1,387.53 $1,497.91 $1,608.2951550 $1,556.08 90 $1,649.02 $1,741.96 $1,834.9151555 $1,821.10 90 $1,920.11 $2,019.12 $2,118.1351565 $2,170.83 90 $2,274.75 $2,378.66 $2,482.5851570 $2,293.68 90 $2,426.67 $2,559.66 $2,692.6551575 $2,850.83 90 $3,122.67 $3,394.52 $3,666.3651580 $2,786.57 70 $2,975.46 $3,164.35 $3,353.2351585 $3,303.56 90 $3,597.16 $3,890.76 $4,184.3651590 $3,755.28 90 $3,799.73 $3,844.18 $3,888.6351595 $4,237.83 90 $4,192.57 $4,147.31 $4,102.0551596 $3,934.10 90 $4,148.69 $4,363.28 $4,577.8751597 $3,825.64 90 $4,211.31 $4,596.97 $4,982.6451600 $37.39 0 $151.85 $266.30 $380.7651605 $57.50 0 $295.65 $533.80 $771.9551610 $59.11 0 $223.63 $388.16 $552.6851700 $40.52 0 $69.38 $98.24 $127.1051705 $46.00 0 $85.71 $125.42 $165.1351710 $83.95 0 $151.84 $219.72 $287.6151715 $353.72 $414.19 $474.66 $535.1351720 $90.00 0 $123.77 $157.53 $191.3051725 $106.93 0 $199.46 $291.99 $384.5251726 $150.80 0 $267.01 $383.21 $499.4251736 $55.20 0 $67.42 $79.63 $91.8551741 $81.04 0 $103.81 $126.57 $149.3451772 $109.34 0 $208.16 $306.98 $405.8151784 $153.88 S $213.99 $274.10 $334.2151785 $147.48 0 $216.40 $285.32 $354.2451792 $142.60 0 $220.12 $297.64 $375.1751795 $99.75 0 $226.84 $353.94 $481.0351797 $139.95 0 $233.20 $326.45 $419.6951800 $1,792.45 90 $1,889.15 $1,985.85 $2,082.5551820 $2,449.08 90 $2,489.38 $2,529.67 $2,569.9751840 $1,411.19 90 $1,496.55 $1,581.91 $1,667.2751841 $1,683.73 90 $1,772.03 $1,860.33 $1,948.6351845 $1,521.32 90 $1,515.29 $1,509.25 $1,503.2251860 $1,204.27 90 $1,279.69 $1,355.10 $1,430.5251865 $1,589.30 90 $1,626.60 $1,663.89 $1,701.1951880 $643.66 90 $732.92 $822.17 $911.4351900 $1,716.26 90 $1,814.75 $1,913.23 $2,011.7251920 $1,504.20 90 $1,432.20 $1,360.20 $1,288.1951925 $1,636.90 90 $1,692.13 $1,747.35 $1,802.5851940 $1,667.50 90 $2,049.19 $2,430.87 $2,812.5651960 $2,474.16 90 $2,597.57 $2,720.97 $2,844.3851980 $1,318.82 90 $1,398.07 $1,477.32 $1,556.5752000 $217.43 0 $260.39 $303.36 $346.3252005 $294.11 0 $403.69 $513.26 $622.8452007 $371.27 0 $553.41 $735.56 $917.7052010 $298.80 0 $431.40 $563.99 $696.5952204 $276.21 7 $447.02 $617.83 $788.6452214 $339.96 7 $835.63 $1,331.30 $1,826.9852224 $320.35 7 $794.71 $1,269.08 $1,743.4452234 $544.97 15 $531.64 $518.32 $504.9952235 $979.50 30 $932.94 $886.38 $839.8252240 $1,576.73 30 $1,548.99 $1,521.25 $1,493.5152250 $494.96 7 $488.75 $482.54 $476.3352260 $325.44 7 $347.46 $369.47 $391.4952265 $244.66 30 $429.36 $614.06 $798.7652270 $414.64 15 $527.96 $641.27 $754.59

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 56 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

52275 $449.40 15 $630.86 $812.32 $993.7852276 $546.53 30 $583.19 $619.84 $656.5052277 $693.45 30 $714.92 $736.38 $757.8552281 $280.44 0 $405.10 $529.75 $654.4152282 $600.79 $706.87 $812.95 $919.0452283 $273.70 0 $387.39 $501.07 $614.7652285 $293.25 15 $403.89 $514.53 $625.1752290 $381.79 15 $405.69 $429.60 $453.5052300 $524.49 15 $549.92 $575.34 $600.7752301 $501.20 $531.50 $561.80 $592.1052305 $555.45 15 $537.36 $519.27 $501.1952310 $354.15 15 $424.27 $494.39 $564.5152315 $731.40 15 $814.12 $896.84 $979.5652317 $828.00 S $1,180.40 $1,532.81 $1,885.2152318 $1,091.10 S $1,105.61 $1,120.13 $1,134.6452320 $630.61 S $648.34 $666.08 $683.8152325 $1,151.35 S $1,148.47 $1,145.59 $1,142.7152327 $486.32 S $901.81 $1,317.30 $1,732.7852330 $483.79 S $960.34 $1,436.90 $1,913.4552332 $455.32 15 $611.76 $768.20 $924.6452334 $520.57 15 $543.25 $565.92 $588.6052450 $602.88 90 $688.54 $774.20 $859.8752500 $938.25 90 $978.19 $1,018.12 $1,058.0652601 $1,817.82 90 $1,749.49 $1,681.16 $1,612.8452606 $446.20 0 $551.79 $657.39 $762.9852612 $1,059.57 90 $1,112.60 $1,165.64 $1,218.6752614 $2,058.63 90 $1,848.34 $1,638.04 $1,427.7552620 $759.33 90 $770.17 $781.01 $791.8552630 $1,499.07 90 $1,507.73 $1,516.39 $1,525.0452640 $793.50 90 $865.63 $937.76 $1,009.8952700 $633.91 60 $659.04 $684.18 $709.3153000 $221.47 15 $294.46 $367.45 $440.4553010 $489.07 30 $512.18 $535.30 $558.4153020 $109.23 15 $172.96 $236.70 $300.4353025 $80.50 15 $145.24 $209.99 $274.7353040 $276.58 30 $481.05 $685.52 $889.9953060 $117.47 15 $205.28 $293.10 $380.9153080 $372.97 0 $486.73 $600.48 $714.2453085 $1,403.00 0 $1,375.91 $1,348.82 $1,321.7353200 $186.11 7 $246.74 $307.37 $368.0053210 $1,163.46 60 $1,211.05 $1,258.65 $1,306.2453215 $1,519.82 60 $1,594.08 $1,668.33 $1,742.5953220 $772.80 60 $790.89 $808.99 $827.0853230 $985.28 60 $1,020.58 $1,055.88 $1,091.1853235 $916.28 60 $993.77 $1,071.25 $1,148.7453240 $372.97 15 $448.80 $524.63 $600.4753250 $241.50 15 $249.55 $257.60 $265.6553260 $200.10 15 $257.60 $315.10 $372.5953265 $239.85 15 $302.46 $365.08 $427.6953270 $192.60 15 $274.81 $357.02 $439.2353275 $353.94 15 $391.56 $429.19 $466.8153400 $814.30 60 $969.80 $1,125.29 $1,280.7953405 $1,101.21 60 $1,208.14 $1,315.07 $1,422.0053410 $1,414.64 60 $1,503.82 $1,593.00 $1,682.1853415 $1,551.35 60 $1,747.65 $1,943.95 $2,140.2653420 $1,524.02 60 $1,611.67 $1,699.33 $1,786.9853425 $1,543.90 90 $1,574.64 $1,605.37 $1,636.1153430 $1,160.82 90 $1,329.45 $1,498.09 $1,666.7253440 $1,598.27 90 $1,680.39 $1,762.51 $1,844.6453442 $303.60 60 $566.42 $829.25 $1,092.07

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 57 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

53445 $1,877.40 90 $1,861.61 $1,845.81 $1,830.0253447 $586.50 60 $851.19 $1,115.88 $1,380.5653449 $698.54 90 $794.51 $890.48 $986.4453450 $341.40 30 $424.93 $508.45 $591.9853460 $374.90 30 $488.06 $601.22 $714.3853502 $693.47 30 $738.64 $783.80 $828.9753505 $802.70 30 $801.90 $801.09 $800.2953510 $1,098.25 90 $1,130.63 $1,163.02 $1,195.4053515 $1,436.76 90 $1,447.68 $1,458.59 $1,469.5153520 $553.57 90 $658.81 $764.05 $869.2853600 $57.55 0 $84.75 $111.95 $139.1553601 $41.56 0 $75.52 $109.48 $143.4453605 $101.20 0 $111.03 $120.86 $130.6853620 $80.25 0 $120.20 $160.16 $200.1153621 $70.15 0 $114.17 $158.20 $202.2253660 $54.55 0 $79.30 $104.06 $128.8153661 $40.06 0 $63.91 $87.76 $111.6153665 $134.63 0 $130.85 $127.08 $123.3053850 $856.83 $2,136.28 $3,415.73 $4,695.1854000 $111.53 0 $190.65 $269.77 $348.8954001 $131.80 0 $210.68 $289.56 $368.4554015 $121.94 0 $304.17 $486.40 $668.6254050 $52.06 0 $92.65 $133.24 $173.8254055 $77.25 0 $151.61 $225.98 $300.3454056 $93.12 7 $120.41 $147.70 $175.0054057 $179.22 7 $215.87 $252.52 $289.1754060 $157.57 7 $215.15 $272.72 $330.3054065 $180.55 7 $273.07 $365.59 $458.1154100 $85.71 7 $137.14 $188.57 $240.0054105 $129.97 7 $230.58 $331.20 $431.8154110 $811.90 30 $848.53 $885.16 $921.7954111 $1,262.70 30 $1,340.35 $1,417.99 $1,495.6454112 $1,478.90 30 $1,544.47 $1,610.04 $1,675.6254120 $875.43 30 $906.25 $937.06 $967.8854125 $1,537.15 90 $1,574.30 $1,611.46 $1,648.6154130 $2,058.63 90 $2,052.90 $2,047.17 $2,041.4354135 $2,467.09 90 $2,510.72 $2,554.36 $2,597.9954150 $124.20 15 $198.59 $272.99 $347.3854152 $201.25 15 $208.36 $215.47 $222.5754160 $170.93 30 $235.46 $299.99 $364.5254161 $306.13 30 $340.17 $374.21 $408.2554200 $43.02 0 $87.81 $132.60 $177.3954205 $488.75 0 $600.91 $713.08 $825.2454220 $196.65 0 $254.36 $312.07 $369.7854230 $192.07 7 $183.16 $174.24 $165.3354231 $227.70 $243.39 $259.09 $274.7854235 $107.43 7 $131.43 $155.43 $179.4454240 $124.86 7 $136.74 $148.61 $160.4954250 $125.35 0 $175.99 $226.63 $277.2754300 $713.54 30 $844.09 $974.64 $1,105.1954304 $1,210.34 90 $1,291.86 $1,373.38 $1,454.9054308 $1,056.85 90 $1,156.03 $1,255.21 $1,354.3954312 $1,220.93 90 $1,337.29 $1,453.65 $1,570.0154316 $1,550.20 90 $1,591.58 $1,632.97 $1,674.3554318 $763.60 90 $869.90 $976.20 $1,082.5054322 $1,494.20 90 $1,482.69 $1,471.18 $1,459.6754324 $1,692.95 90 $1,703.77 $1,714.59 $1,725.4154326 $1,768.70 90 $1,786.54 $1,804.38 $1,822.2254328 $1,992.95 90 $2,016.95 $2,040.95 $2,064.9554332 $1,509.52 90 $1,734.39 $1,959.26 $2,184.13

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 58 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

54336 $1,418.15 90 $1,739.67 $2,061.18 $2,382.7054340 $897.00 90 $998.61 $1,100.22 $1,201.8354344 $1,919.95 90 $1,902.19 $1,884.43 $1,866.6854348 $1,734.20 90 $1,800.67 $1,867.14 $1,933.6054352 $2,446.05 90 $2,603.95 $2,761.85 $2,919.7554360 $916.55 90 $1,043.68 $1,170.80 $1,297.9354380 $1,080.53 30 $1,202.70 $1,324.88 $1,447.0554385 $1,493.85 30 $1,565.93 $1,638.00 $1,710.0854390 $1,493.85 30 $1,784.53 $2,075.22 $2,365.9054400 $1,356.93 30 $1,350.19 $1,343.45 $1,336.7054401 $1,930.20 30 $1,887.14 $1,844.09 $1,801.0354405 $2,392.00 90 $2,233.66 $2,075.31 $1,916.9754420 $1,055.70 30 $1,093.37 $1,131.03 $1,168.7054430 $940.70 30 $1,075.92 $1,211.15 $1,346.3754435 $609.50 30 $657.12 $704.74 $752.3654450 $67.08 0 $88.87 $110.67 $132.4654500 $58.01 0 $141.22 $224.43 $307.6454505 $288.69 0 $325.78 $362.87 $399.9754520 $622.97 30 $654.92 $686.86 $718.8154530 $849.91 30 $923.34 $996.77 $1,070.2054535 $1,143.82 45 $1,184.10 $1,224.39 $1,264.6754550 $721.90 30 $763.08 $804.26 $845.4354560 $1,003.30 30 $1,055.70 $1,108.10 $1,160.5054600 $689.03 30 $770.03 $851.03 $932.0354620 $335.47 30 $396.45 $457.44 $518.4254640 $973.11 30 $1,042.18 $1,111.24 $1,180.3154650 $1,214.31 $1,289.23 $1,364.14 $1,439.0654660 $439.39 45 $512.35 $585.31 $658.2754670 $693.91 45 $728.10 $762.28 $796.4754680 $1,504.20 45 $1,436.82 $1,369.44 $1,302.0654700 $156.01 7 $252.56 $349.12 $445.6754800 $64.77 7 $173.88 $282.99 $392.1054820 $494.96 30 $527.98 $560.99 $594.0154830 $489.07 30 $541.24 $593.41 $645.5854840 $626.41 45 $677.25 $728.09 $778.9454860 $678.16 45 $711.83 $745.50 $779.1654861 $930.93 45 $990.23 $1,049.53 $1,108.8354900 $797.88 90 $938.66 $1,079.44 $1,220.2254901 $1,230.96 90 $1,382.20 $1,533.45 $1,684.6955000 $55.01 0 $96.82 $138.64 $180.4555040 $629.17 45 $670.95 $712.73 $754.5155041 $933.84 45 $967.85 $1,001.86 $1,035.8755060 $549.82 45 $600.40 $650.98 $701.5655100 $51.16 0 $195.22 $339.28 $483.3455110 $391.56 0 $459.01 $526.46 $593.9055120 $244.95 0 $336.26 $427.57 $518.8855150 $261.01 30 $464.53 $668.06 $871.5855175 $395.60 30 $477.57 $559.53 $641.5055180 $813.05 30 $1,024.09 $1,235.13 $1,446.1655200 $312.82 30 $470.72 $628.61 $786.5155250 $408.72 30 $527.34 $645.95 $764.5755300 $312.82 30 $336.86 $360.90 $384.9455400 $795.80 90 $903.99 $1,012.18 $1,120.3755450 $119.68 30 $278.76 $437.85 $596.9355500 $559.57 45 $592.73 $625.90 $659.0655520 $503.32 30 $545.46 $587.60 $629.7355530 $753.91 45 $791.70 $829.48 $867.2755535 $786.21 45 $803.31 $820.40 $837.5055540 $713.51 45 $789.04 $864.57 $940.1055600 $627.54 60 $646.33 $665.11 $683.90

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 59 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

55605 $750.95 60 $761.05 $771.15 $781.2555650 $1,583.65 45 $1,537.91 $1,492.17 $1,446.4455680 $1,583.65 45 $1,389.80 $1,195.95 $1,002.1155700 $184.80 15 $242.18 $299.56 $356.9455705 $633.91 30 $640.36 $646.82 $653.2755720 $642.16 30 $685.10 $728.04 $770.9855725 $1,037.30 60 $994.48 $951.67 $908.8555801 $1,672.15 90 $1,696.16 $1,720.17 $1,744.1855810 $2,349.18 90 $2,378.57 $2,407.95 $2,437.3455812 $2,668.00 90 $2,642.74 $2,617.47 $2,592.2155815 $3,305.10 90 $3,271.58 $3,238.06 $3,204.5455821 $1,549.81 90 $1,630.90 $1,711.99 $1,793.0855831 $1,632.31 90 $1,680.92 $1,729.53 $1,778.1455840 $2,303.16 90 $2,301.64 $2,300.12 $2,298.6055842 $2,513.57 90 $2,604.23 $2,694.88 $2,785.5455845 $3,020.98 90 $3,243.91 $3,466.84 $3,689.7755859 $1,106.20 30 $1,185.92 $1,265.64 $1,345.3755865 $1,897.50 90 $1,945.39 $1,993.29 $2,041.1856405 $109.34 0 $138.34 $167.33 $196.3356420 $86.11 0 $129.65 $173.20 $216.7456440 $321.65 0 $364.84 $408.04 $451.2356441 $168.31 0 $190.55 $212.79 $235.0256501 $99.45 0 $141.73 $184.01 $226.2856515 $304.14 0 $354.29 $404.44 $454.5856605 $78.93 0 $102.96 $126.98 $151.0156606 $42.10 0 $58.79 $75.47 $92.1656620 $908.74 60 $1,013.22 $1,117.69 $1,222.1756625 $1,229.18 60 $1,280.56 $1,331.94 $1,383.3256630 $1,558.36 90 $1,609.09 $1,659.81 $1,710.5456631 $2,071.73 90 $2,205.40 $2,339.08 $2,472.7556632 $2,366.18 $2,513.58 $2,660.98 $2,808.3856633 $1,695.76 90 $1,883.94 $2,072.12 $2,260.3156634 $2,180.45 90 $2,228.33 $2,276.22 $2,324.1056637 $2,250.26 90 $2,393.51 $2,536.76 $2,680.0156640 $2,183.20 90 $2,399.38 $2,615.56 $2,831.7356700 $203.07 30 $242.21 $281.35 $320.4956720 $111.47 0 $120.10 $128.73 $137.3656740 $423.92 30 $463.73 $503.54 $543.3656800 $394.41 30 $432.54 $470.66 $508.7956810 $371.23 30 $417.75 $464.28 $510.8057000 $326.75 30 $361.83 $396.91 $431.9957010 $460.12 30 $510.64 $561.16 $611.6857020 $89.19 0 $121.96 $154.73 $187.5057061 $115.67 15 $160.80 $205.94 $251.0757065 $236.58 15 $311.49 $386.40 $461.3157100 $77.06 0 $102.54 $128.03 $153.5157105 $156.03 0 $188.21 $220.38 $252.5657110 $1,106.95 60 $1,255.74 $1,404.52 $1,553.3157120 $953.67 60 $989.17 $1,024.67 $1,060.1857130 $313.17 7 $340.61 $368.04 $395.4857135 $299.07 30 $343.45 $387.84 $432.2257150 $49.86 0 $62.84 $75.81 $88.7957160 $58.04 0 $73.25 $88.46 $103.6757170 $67.56 0 $84.44 $101.32 $118.1957180 $79.88 0 $121.54 $163.21 $204.8757200 $508.30 7 $532.26 $556.21 $580.1757210 $570.29 7 $604.37 $638.45 $672.5457220 $561.67 7 $583.85 $606.04 $628.2257230 $540.67 7 $603.92 $667.17 $730.4357240 $750.66 60 $777.07 $803.47 $829.88

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 60 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

57250 $643.70 60 $723.84 $803.97 $884.1157260 $1,194.40 60 $1,264.30 $1,334.20 $1,404.1057265 $1,261.33 60 $1,400.15 $1,538.97 $1,677.7957268 $852.34 60 $919.83 $987.31 $1,054.8057270 $1,081.93 60 $1,220.64 $1,359.35 $1,498.0657280 $1,099.13 60 $1,362.45 $1,625.76 $1,889.0857282 $1,201.39 60 $1,134.54 $1,067.70 $1,000.8557284 $1,434.99 30 $1,493.47 $1,551.96 $1,610.4457288 $1,196.30 60 $1,376.67 $1,557.04 $1,737.4157289 $926.62 60 $1,078.20 $1,229.79 $1,381.3757291 $560.05 90 $808.74 $1,057.43 $1,306.1357292 $955.65 90 $1,190.91 $1,426.18 $1,661.4457300 $1,087.14 90 $1,156.83 $1,226.52 $1,296.2157305 $1,304.39 90 $1,436.17 $1,567.96 $1,699.7457307 $1,529.71 90 $1,653.53 $1,777.35 $1,901.1757308 $1,153.10 $1,236.07 $1,319.04 $1,402.0157310 $1,089.54 60 $1,119.27 $1,149.00 $1,178.7457311 $1,222.00 0 $1,199.59 $1,177.18 $1,154.7857320 $1,115.79 60 $1,180.27 $1,244.75 $1,309.2457330 $1,258.10 60 $1,352.03 $1,445.96 $1,539.8857335 $325.45 90 $886.80 $1,448.15 $2,009.5057400 $97.96 0 $133.51 $169.06 $204.6157410 $120.80 0 $164.57 $208.35 $252.1257415 $83.31 0 $157.61 $231.90 $306.2057452 $146.76 S $164.17 $181.57 $198.9857454 $194.35 S $225.11 $255.86 $286.6257460 $366.51 0 $466.22 $565.94 $665.6557500 $82.97 0 $119.25 $155.52 $191.8057505 $104.31 0 $125.20 $146.08 $166.9757510 $110.11 7 $147.86 $185.62 $223.3757511 $141.90 0 $169.96 $198.03 $226.0957513 $384.20 45 $373.77 $363.35 $352.9257520 $542.82 45 $592.21 $641.60 $691.0057522 $385.44 S $463.60 $541.75 $619.9157530 $455.23 45 $507.04 $558.86 $610.6757531 $2,141.70 $2,474.60 $2,807.50 $3,140.3957540 $937.52 45 $1,056.77 $1,176.01 $1,295.2657545 $1,077.55 45 $1,174.30 $1,271.04 $1,367.7957550 $927.42 45 $955.30 $983.19 $1,011.0757555 $1,219.44 45 $1,274.76 $1,330.08 $1,385.4057556 $1,143.38 45 $1,148.63 $1,153.89 $1,159.1457700 $461.81 45 $495.36 $528.91 $562.4757720 $458.57 45 $513.74 $568.91 $624.0857800 $60.16 0 $75.01 $89.87 $104.7257820 $518.82 15 $474.00 $429.17 $384.3558100 $86.67 0 $127.45 $168.23 $209.0258120 $426.22 0 $451.01 $475.80 $500.5958140 $1,175.43 45 $1,342.38 $1,509.33 $1,676.2958145 $827.08 45 $903.57 $980.07 $1,056.5658150 $1,704.81 45 $1,844.93 $1,985.06 $2,125.1858152 $2,059.37 45 $2,286.18 $2,513.00 $2,739.8158180 $1,380.91 45 $1,573.91 $1,766.92 $1,959.9258200 $1,968.78 90 $2,273.29 $2,577.80 $2,882.3158210 $2,924.37 90 $3,204.04 $3,483.70 $3,763.3758240 $3,565.45 90 $3,893.18 $4,220.90 $4,548.6358260 $1,748.06 45 $1,828.99 $1,909.92 $1,990.8558262 $1,815.50 45 $1,934.38 $2,053.26 $2,172.1358263 $1,988.48 45 $2,034.31 $2,080.14 $2,125.9758267 $2,034.59 45 $2,004.97 $1,975.36 $1,945.7458270 $1,849.36 45 $1,881.09 $1,912.82 $1,944.55

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 61 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

58275 $1,539.53 45 $1,715.99 $1,892.44 $2,068.9058280 $1,539.53 45 $1,674.29 $1,809.06 $1,943.8258285 $1,932.00 90 $2,060.81 $2,189.62 $2,318.4358300 $91.16 0 $114.11 $137.06 $160.0158301 $55.96 0 $81.41 $106.86 $132.3158340 $110.28 0 $235.16 $360.04 $484.9258345 $466.88 45 $495.95 $525.02 $554.0958350 $130.64 0 $151.45 $172.25 $193.0658520 $954.75 45 $1,055.32 $1,155.88 $1,256.4558540 $1,120.00 45 $1,267.18 $1,414.36 $1,561.5458600 $952.65 45 $943.33 $934.02 $924.7058605 $604.46 45 $622.11 $639.76 $657.4158611 $233.02 45 $257.29 $281.56 $305.8458615 $726.71 45 $722.10 $717.49 $712.8858700 $981.57 45 $1,055.05 $1,128.54 $1,202.0258720 $1,022.04 45 $1,189.64 $1,357.24 $1,524.8458740 $1,364.35 45 $1,423.62 $1,482.90 $1,542.1758750 $1,608.74 45 $1,796.33 $1,983.92 $2,171.5158752 $1,156.24 45 $1,396.79 $1,637.34 $1,877.8958760 $1,397.45 45 $1,463.46 $1,529.47 $1,595.4858770 $1,300.42 45 $1,440.82 $1,581.22 $1,721.6258800 $381.59 15 $472.85 $564.12 $655.3858805 $979.58 45 $1,015.98 $1,052.38 $1,088.7958820 $354.75 15 $433.49 $512.22 $590.9658822 $896.77 45 $970.37 $1,043.97 $1,117.5758823 $316.57 $572.54 $828.51 $1,084.4858825 $974.68 45 $1,023.85 $1,073.02 $1,122.1958900 $953.67 45 $991.24 $1,028.81 $1,066.3858920 $949.30 45 $1,082.94 $1,216.58 $1,350.2158925 $989.05 45 $1,141.73 $1,294.40 $1,447.0858940 $989.05 45 $1,065.15 $1,141.25 $1,217.3558943 $1,946.07 45 $1,994.46 $2,042.84 $2,091.2358950 $1,659.39 60 $1,784.24 $1,909.10 $2,033.9558951 $2,467.00 60 $2,619.29 $2,771.58 $2,923.8758952 $3,498.22 60 $3,557.12 $3,616.01 $3,674.9158960 $1,868.06 60 $1,921.02 $1,973.97 $2,026.9359000 $103.55 0 $145.90 $188.26 $230.6159012 $332.81 0 $361.33 $389.85 $418.3859015 $200.43 0 $227.69 $254.95 $282.2159020 $95.58 0 $103.42 $111.27 $119.1159020 $90.89 0 $100.30 $109.70 $119.1159025 $62.00 0 $73.89 $85.77 $97.6659025 $52.56 0 $67.59 $82.62 $97.6659030 $97.97 0 $126.26 $154.56 $182.8559050 $141.14 30 $147.06 $152.98 $158.8959051 $118.01 30 $108.75 $99.50 $90.2459100 $1,164.70 45 $1,200.21 $1,235.72 $1,271.2459120 $1,027.60 45 $1,170.18 $1,312.76 $1,455.3459121 $1,181.93 45 $1,274.13 $1,366.32 $1,458.5259130 $1,220.15 45 $1,253.19 $1,286.22 $1,319.2659135 $1,289.36 45 $1,415.04 $1,540.72 $1,666.4059140 $1,220.15 45 $1,157.00 $1,093.86 $1,030.7159150 $1,107.92 45 $1,174.02 $1,240.11 $1,306.2159151 $1,567.21 45 $1,541.01 $1,514.82 $1,488.6259160 $359.40 45 $403.03 $446.66 $490.3059200 $59.62 0 $81.10 $102.58 $124.0559300 $178.47 0 $222.57 $266.67 $310.7759320 $454.21 0 $460.01 $465.81 $471.6059350 $1,109.70 45 $1,042.01 $974.31 $906.6259400 $1,689.30 45 $1,973.64 $2,257.98 $2,542.33

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 62 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

59409 $1,020.16 $1,159.61 $1,299.05 $1,438.5059410 $1,080.74 45 $1,248.51 $1,416.28 $1,584.0559425 $382.00 $417.42 $452.84 $488.2559426 $752.46 $841.79 $931.13 $1,020.4659430 $46.23 45 $95.05 $143.87 $192.6959510 $2,049.43 45 $2,342.57 $2,635.72 $2,928.8659514 $1,410.84 $1,508.40 $1,605.96 $1,703.5259515 $1,485.32 45 $1,555.66 $1,625.99 $1,696.3359610 $1,900.50 $2,166.81 $2,433.11 $2,699.4259612 $1,207.25 $1,278.92 $1,350.58 $1,422.2559614 $1,283.00 $1,337.48 $1,391.96 $1,446.4359618 $2,271.00 $2,551.11 $2,831.21 $3,111.3259620 $1,567.00 $1,643.19 $1,719.38 $1,795.5759622 $1,667.50 $1,708.98 $1,750.47 $1,791.9559812 $417.89 30 $459.65 $501.41 $543.1759820 $470.21 30 $511.71 $553.21 $594.7159821 $530.40 30 $564.86 $599.31 $633.7759830 $396.75 30 $496.21 $595.67 $695.1259840 $368.96 30 $421.81 $474.66 $527.5159841 $375.62 30 $462.61 $549.60 $636.6059850 $514.77 30 $606.07 $697.37 $788.6859851 $655.70 30 $733.70 $811.71 $889.7159852 $630.20 45 $793.20 $956.21 $1,119.2159855 $555.24 $624.21 $693.19 $762.1659856 $794.01 $843.75 $893.50 $943.2459857 $1,023.62 $1,032.76 $1,041.91 $1,051.0559866 $415.92 $438.80 $461.68 $484.5659870 $496.34 30 $556.36 $616.38 $676.3959871 $223.57 $233.26 $242.95 $252.6460000 $59.98 0 $110.72 $161.45 $212.1960001 $117.55 S $129.05 $140.56 $152.0660100 $123.54 0 $149.43 $175.31 $201.2060200 $836.55 30 $908.97 $981.38 $1,053.8060210 $1,165.82 $1,252.12 $1,338.41 $1,424.7160212 $1,501.31 $1,617.85 $1,734.39 $1,850.9360220 $1,208.62 45 $1,306.13 $1,403.63 $1,501.1460225 $1,395.15 30 $1,526.32 $1,657.49 $1,788.6660240 $1,402.64 30 $1,589.70 $1,776.76 $1,963.8360252 $1,822.45 30 $2,048.09 $2,273.73 $2,499.3760254 $2,186.74 30 $2,527.43 $2,868.12 $3,208.8160260 $1,190.82 30 $1,421.82 $1,652.81 $1,883.8160270 $1,756.10 30 $1,942.79 $2,129.47 $2,316.1660271 $1,489.00 $1,701.84 $1,914.67 $2,127.5160280 $906.36 30 $978.82 $1,051.28 $1,123.7460281 $793.50 30 $941.46 $1,089.43 $1,237.3960500 $1,565.01 45 $1,675.43 $1,785.86 $1,896.2860502 $1,701.39 45 $1,864.83 $2,028.27 $2,191.7160505 $1,948.87 30 $2,134.98 $2,321.10 $2,507.2160512 $443.22 30 $437.58 $431.95 $426.3160520 $1,600.12 30 $1,735.51 $1,870.90 $2,006.2960521 $1,959.54 $2,079.40 $2,199.26 $2,319.1260522 $2,229.54 $2,378.40 $2,527.26 $2,676.1260540 $1,623.86 30 $1,773.78 $1,923.70 $2,073.6260545 $1,875.40 30 $2,092.62 $2,309.83 $2,527.0561000 $157.16 0 $173.52 $189.88 $206.2461001 $113.47 0 $136.12 $158.78 $181.4361020 $177.43 0 $194.73 $212.02 $229.3261026 $434.13 0 $402.53 $370.93 $339.3361050 $155.64 0 $181.53 $207.42 $233.3161055 $229.34 0 $241.30 $253.26 $265.22

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 63 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

61070 $63.92 0 $163.83 $263.74 $363.6561105 $591.68 0 $682.90 $774.11 $865.3361107 $662.81 0 $785.91 $909.02 $1,032.1261108 $1,127.91 7 $1,245.67 $1,363.43 $1,481.1961120 $866.05 30 $964.99 $1,063.93 $1,162.8861140 $1,884.73 30 $2,040.70 $2,196.67 $2,352.6561150 $1,918.87 30 $2,046.35 $2,173.83 $2,301.3161151 $217.93 0 $573.23 $928.52 $1,283.8261154 $2,184.00 90 $2,307.11 $2,430.22 $2,553.3361156 $2,079.01 90 $2,186.16 $2,293.31 $2,400.4561210 $829.54 0 $885.60 $941.65 $997.7161215 $1,001.34 0 $1,065.73 $1,130.13 $1,194.5261250 $1,099.32 90 $1,185.09 $1,270.86 $1,356.6361253 $1,425.85 90 $1,480.76 $1,535.66 $1,590.5761304 $2,793.83 90 $3,018.08 $3,242.32 $3,466.5761305 $3,228.69 90 $3,389.73 $3,550.77 $3,711.8261312 $2,903.33 90 $3,232.25 $3,561.17 $3,890.0961313 $2,902.35 90 $3,316.51 $3,730.66 $4,144.8261314 $2,930.58 90 $3,062.00 $3,193.42 $3,324.8461315 $3,024.63 90 $3,271.47 $3,518.32 $3,765.1661320 $2,834.74 90 $3,059.63 $3,284.53 $3,509.4261321 $3,127.86 90 $3,249.91 $3,371.97 $3,494.0261330 $2,097.30 90 $2,325.57 $2,553.85 $2,782.1261332 $2,203.93 90 $2,454.91 $2,705.89 $2,956.8761333 $2,611.45 90 $2,862.69 $3,113.93 $3,365.1661334 $2,587.93 90 $2,560.10 $2,532.28 $2,504.4561340 $2,320.18 90 $2,440.70 $2,561.22 $2,681.7361343 $3,468.89 90 $3,799.80 $4,130.70 $4,461.6161345 $2,617.40 90 $2,766.67 $2,915.95 $3,065.2261440 $2,541.50 90 $2,635.68 $2,729.87 $2,824.0561450 $2,506.99 90 $2,700.07 $2,893.15 $3,086.2261458 $3,441.52 90 $3,556.57 $3,671.61 $3,786.6661460 $2,958.06 90 $3,313.48 $3,668.91 $4,024.3361470 $3,335.82 90 $3,295.58 $3,255.34 $3,215.1061480 $3,383.06 90 $3,223.11 $3,063.17 $2,903.2261490 $2,027.50 90 $2,281.22 $2,534.94 $2,788.6761500 $2,436.55 90 $2,481.59 $2,526.63 $2,571.6761501 $2,402.87 90 $2,424.54 $2,446.21 $2,467.8861510 $3,582.51 90 $3,951.36 $4,320.21 $4,689.0661512 $3,993.29 90 $4,371.35 $4,749.41 $5,127.4661514 $3,360.32 90 $3,524.42 $3,688.51 $3,852.6161516 $3,421.64 90 $3,548.58 $3,675.51 $3,802.4561518 $3,798.69 90 $4,174.44 $4,550.18 $4,925.9361519 $4,108.77 90 $4,425.01 $4,741.25 $5,057.4961520 $4,242.55 90 $5,038.37 $5,834.19 $6,630.0161521 $4,402.67 90 $4,737.49 $5,072.32 $5,407.1461522 $3,353.32 90 $3,581.13 $3,808.94 $4,036.7661524 $3,378.13 90 $3,575.30 $3,772.46 $3,969.6361526 $3,119.82 90 $4,057.39 $4,994.96 $5,932.5261530 $3,848.72 90 $4,529.73 $5,210.73 $5,891.7461531 $1,973.40 90 $2,034.40 $2,095.40 $2,156.3961534 $1,869.50 90 $2,263.62 $2,657.73 $3,051.8561538 $3,702.44 90 $3,840.75 $3,979.07 $4,117.3861539 $3,490.19 90 $3,690.37 $3,890.55 $4,090.7361541 $3,304.73 90 $3,605.24 $3,905.76 $4,206.2761542 $3,576.29 90 $3,857.54 $4,138.79 $4,420.0461543 $2,884.45 90 $3,333.34 $3,782.23 $4,231.1161544 $3,162.34 90 $3,192.74 $3,223.14 $3,253.5461545 $3,860.00 90 $4,348.43 $4,836.86 $5,325.3061546 $2,705.41 90 $3,236.51 $3,767.61 $4,298.70

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 64 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

61548 $2,628.25 90 $2,902.40 $3,176.55 $3,450.7061550 $1,886.57 90 $1,984.81 $2,083.05 $2,181.2861552 $2,379.67 90 $2,521.78 $2,663.89 $2,806.0061556 $1,782.50 90 $2,134.27 $2,486.03 $2,837.8061557 $2,012.50 90 $2,396.90 $2,781.31 $3,165.7161558 $2,242.50 90 $2,588.44 $2,934.38 $3,280.3261559 $2,415.00 90 $3,080.26 $3,745.51 $4,410.7761563 $2,258.40 90 $2,679.52 $3,100.64 $3,521.7761564 $2,760.00 90 $3,211.30 $3,662.60 $4,113.9061570 $2,861.71 90 $3,124.53 $3,387.35 $3,650.1761571 $2,698.82 90 $3,009.82 $3,320.82 $3,631.8261575 $4,827.49 90 $4,775.18 $4,722.88 $4,670.5761576 $4,987.03 90 $5,441.65 $5,896.26 $6,350.8861580 $2,784.15 $3,292.80 $3,801.44 $4,310.0961581 $3,160.20 $3,613.30 $4,066.41 $4,519.5161582 $2,868.10 $3,463.25 $4,058.40 $4,653.5561583 $3,272.90 $3,770.94 $4,268.98 $4,767.0261584 $3,169.40 $3,720.05 $4,270.69 $4,821.3461585 $3,545.45 $4,045.69 $4,545.94 $5,046.1861586 $2,567.32 $2,822.26 $3,077.20 $3,332.1461590 $3,855.95 $4,190.66 $4,525.37 $4,860.0861591 $4,044.55 $4,618.04 $5,191.52 $5,765.0161592 $3,668.50 $4,155.62 $4,642.73 $5,129.8561595 $2,756.47 $3,190.39 $3,624.31 $4,058.2361596 $3,349.72 $3,898.97 $4,448.22 $4,997.4761597 $3,479.90 $4,070.91 $4,661.92 $5,252.9461598 $3,065.90 $3,524.32 $3,982.74 $4,441.1661600 $2,351.75 $2,722.80 $3,093.85 $3,464.9161601 $2,520.80 $2,979.44 $3,438.07 $3,896.7161605 $2,661.10 $3,041.61 $3,422.12 $3,802.6361606 $3,565.00 $4,021.39 $4,477.78 $4,934.1761607 $3,329.25 $3,774.43 $4,219.61 $4,664.7861608 $3,874.35 $4,377.46 $4,880.57 $5,383.6861609 $753.25 $904.92 $1,056.58 $1,208.2561610 $2,257.45 $2,663.21 $3,068.96 $3,474.7261611 $563.50 $676.94 $790.39 $903.8361612 $1,693.95 $2,330.54 $2,967.14 $3,603.7361613 $3,799.60 $4,471.28 $5,142.95 $5,814.6361615 $2,925.60 $3,393.71 $3,861.82 $4,329.9361616 $3,979.00 $4,588.93 $5,198.86 $5,808.7861618 $1,504.20 $1,789.05 $2,073.90 $2,358.7561619 $1,880.25 $2,212.80 $2,545.35 $2,877.8961624 $1,290.17 90 $1,704.99 $2,119.80 $2,534.6261626 $1,102.93 90 $1,440.50 $1,778.07 $2,115.6461680 $4,309.24 90 $4,436.40 $4,563.56 $4,690.7261682 $5,973.51 90 $6,317.49 $6,661.48 $7,005.4661684 $4,423.78 90 $4,690.53 $4,957.28 $5,224.0261686 $5,891.53 90 $6,408.15 $6,924.76 $7,441.3861690 $3,945.07 90 $4,046.44 $4,147.81 $4,249.1861692 $4,379.07 90 $5,043.56 $5,708.05 $6,372.5461700 $3,324.95 90 $4,480.45 $5,635.95 $6,791.4561702 $3,892.17 90 $4,629.83 $5,367.50 $6,105.1661703 $2,602.45 90 $2,536.76 $2,471.07 $2,405.3861705 $3,049.78 90 $3,596.25 $4,142.72 $4,689.1961708 $2,602.45 90 $2,898.51 $3,194.58 $3,490.6461710 $2,622.16 90 $2,708.16 $2,794.16 $2,880.1661711 $3,049.80 90 $3,422.98 $3,796.15 $4,169.3361720 $2,980.94 90 $2,921.91 $2,862.88 $2,803.8561735 $2,963.42 90 $3,026.54 $3,089.66 $3,152.7861750 $3,010.29 90 $2,976.96 $2,943.62 $2,910.29

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 65 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

61751 $3,103.75 90 $2,996.86 $2,889.96 $2,783.0761760 $2,037.80 90 $2,358.82 $2,679.83 $3,000.8561770 $2,707.48 90 $2,872.49 $3,037.50 $3,202.5061790 $2,304.76 90 $2,270.62 $2,236.48 $2,202.3461791 $1,876.65 90 $1,904.58 $1,932.50 $1,960.4361793 $2,220.41 90 $2,510.75 $2,801.09 $3,091.4461795 $597.60 0 $625.77 $653.93 $682.1061850 $2,178.55 90 $2,111.58 $2,044.61 $1,977.6361860 $2,495.63 90 $2,679.51 $2,863.38 $3,047.2661880 $270.19 90 $439.00 $607.81 $776.6361885 $331.12 90 $486.42 $641.72 $797.0362000 $1,734.50 90 $1,808.37 $1,882.24 $1,956.1162005 $2,323.12 90 $2,394.50 $2,465.89 $2,537.2762010 $2,443.55 90 $2,633.53 $2,823.51 $3,013.4962100 $2,408.33 90 $2,675.00 $2,941.67 $3,208.3362120 $2,235.83 90 $2,620.76 $3,005.68 $3,390.6162121 $3,107.84 90 $3,163.51 $3,219.18 $3,274.8562140 $1,711.58 90 $1,899.44 $2,087.30 $2,275.1662141 $2,003.62 90 $2,131.41 $2,259.21 $2,387.0062142 $834.13 90 $1,014.73 $1,195.34 $1,375.9462143 $1,687.74 90 $1,871.98 $2,056.21 $2,240.4562145 $2,226.40 90 $2,429.76 $2,633.12 $2,836.4962146 $1,696.25 90 $1,831.02 $1,965.79 $2,100.5662147 $2,012.50 90 $2,311.86 $2,611.21 $2,910.5762180 $2,512.60 7 $2,696.47 $2,880.34 $3,064.2062190 $2,022.37 7 $2,058.51 $2,094.65 $2,130.7962192 $2,023.07 7 $2,124.27 $2,225.47 $2,326.6862194 $367.20 7 $450.61 $534.01 $617.4262200 $2,512.60 7 $2,680.43 $2,848.27 $3,016.1062220 $2,245.63 7 $2,279.45 $2,313.28 $2,347.1062223 $2,310.88 7 $2,448.53 $2,586.19 $2,723.8462225 $764.46 7 $842.34 $920.23 $998.1162230 $1,067.24 7 $1,357.04 $1,646.83 $1,936.6362256 $770.30 7 $842.92 $915.54 $988.1662258 $1,835.69 7 $1,951.40 $2,067.10 $2,182.8162268 $420.36 0 $608.29 $796.22 $984.1462269 $626.70 0 $781.67 $936.64 $1,091.6162270 $98.06 0 $139.86 $181.67 $223.4762272 $88.41 0 $157.46 $226.50 $295.5562273 $131.93 0 $185.97 $240.01 $294.0562280 $181.70 0 $368.50 $555.30 $742.1062281 $198.95 0 $294.74 $390.53 $486.3362282 $232.30 0 $389.98 $547.65 $705.3362284 $291.76 0 $320.83 $349.89 $378.9662287 $862.50 0 $940.04 $1,017.58 $1,095.1262290 $287.03 0 $365.74 $444.44 $523.1562291 $266.78 0 $348.84 $430.91 $512.9762292 $1,066.59 0 $1,181.81 $1,297.04 $1,412.2662294 $203.55 0 $514.25 $824.95 $1,135.6462350 $724.82 30 $897.41 $1,070.00 $1,242.5962351 $1,068.57 30 $1,236.75 $1,404.94 $1,573.1262355 $589.00 30 $631.55 $674.10 $716.6562360 $235.61 30 $294.14 $352.67 $411.2162361 $559.00 30 $609.99 $660.98 $711.9762362 $727.07 30 $778.69 $830.32 $881.9462365 $586.75 30 $618.85 $650.95 $683.0562367 $62.13 $64.84 $67.56 $70.2762368 $95.44 $96.39 $97.33 $98.2863001 $2,473.26 90 $2,511.51 $2,549.76 $2,588.0263003 $2,438.44 90 $2,543.24 $2,648.04 $2,752.84

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 66 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

63005 $2,026.46 90 $2,098.00 $2,169.54 $2,241.0863011 $2,106.35 90 $2,172.24 $2,238.14 $2,304.0363012 $2,380.78 90 $2,526.70 $2,672.63 $2,818.5563015 $2,758.18 90 $2,853.64 $2,949.11 $3,044.5763016 $2,634.81 90 $2,699.60 $2,764.40 $2,829.1963017 $2,535.45 90 $2,602.26 $2,669.07 $2,735.8863020 $2,805.14 90 $2,705.68 $2,606.21 $2,506.7563030 $2,631.11 90 $2,751.44 $2,871.78 $2,992.1163035 $636.87 90 $598.81 $560.75 $522.6963040 $3,318.13 90 $3,191.31 $3,064.48 $2,937.6663042 $3,192.10 90 $3,202.83 $3,213.55 $3,224.2863045 $3,143.44 90 $3,122.42 $3,101.40 $3,080.3863046 $3,233.82 90 $3,362.83 $3,491.83 $3,620.8463047 $3,233.26 90 $3,654.84 $4,076.42 $4,498.0163048 $740.85 90 $802.23 $863.61 $924.9963055 $2,305.04 90 $2,559.59 $2,814.14 $3,068.7063056 $2,116.63 90 $2,321.46 $2,526.29 $2,731.1263057 $734.07 90 $750.50 $766.93 $783.3663064 $2,134.41 90 $2,497.21 $2,860.01 $3,222.8163066 $734.07 90 $719.51 $704.95 $690.3963075 $2,643.42 90 $3,032.44 $3,421.45 $3,810.4763076 $607.47 90 $749.36 $891.25 $1,033.1463077 $2,608.32 90 $2,824.26 $3,040.20 $3,256.1463078 $636.42 90 $618.78 $601.14 $583.5063081 $3,011.08 90 $3,264.38 $3,517.68 $3,770.9863082 $485.34 90 $622.70 $760.06 $897.4263085 $3,155.70 90 $3,307.07 $3,458.45 $3,609.8263086 $546.40 90 $573.69 $600.98 $628.2863087 $2,601.78 90 $3,033.97 $3,466.16 $3,898.3463088 $546.40 90 $585.88 $625.35 $664.8363090 $2,885.71 90 $3,134.18 $3,382.66 $3,631.1363091 $546.40 90 $565.72 $585.04 $604.3763170 $2,696.82 90 $2,877.65 $3,058.49 $3,239.3263172 $2,084.03 90 $2,247.22 $2,410.42 $2,573.6163173 $2,163.56 90 $2,465.59 $2,767.62 $3,069.6463180 $2,951.75 90 $3,076.30 $3,200.85 $3,325.4063182 $3,386.86 90 $3,482.61 $3,578.36 $3,674.1063185 $2,152.42 90 $2,259.27 $2,366.12 $2,472.9763190 $3,038.38 90 $3,030.66 $3,022.93 $3,015.2163191 $1,797.08 90 $1,922.36 $2,047.63 $2,172.9163194 $2,489.76 90 $2,611.13 $2,732.49 $2,853.8663195 $2,539.62 90 $2,686.22 $2,832.81 $2,979.4163196 $2,691.13 90 $2,751.87 $2,812.61 $2,873.3563197 $2,650.73 90 $2,844.90 $3,039.07 $3,233.2563198 $3,261.13 90 $3,248.77 $3,236.41 $3,224.0563199 $3,261.13 90 $3,251.77 $3,242.42 $3,233.0663200 $2,285.31 90 $2,469.13 $2,652.95 $2,836.7763250 $4,179.10 90 $4,314.74 $4,450.37 $4,586.0163251 $3,831.80 90 $4,126.60 $4,421.40 $4,716.2063252 $3,963.56 90 $4,382.41 $4,801.26 $5,220.1163265 $2,566.78 90 $2,622.39 $2,678.00 $2,733.6263266 $2,764.40 90 $2,874.57 $2,984.75 $3,094.9263267 $2,448.20 90 $2,498.05 $2,547.90 $2,597.7663268 $2,231.26 90 $2,310.58 $2,389.90 $2,469.2263270 $3,039.23 90 $3,136.92 $3,234.61 $3,332.3063271 $3,502.68 90 $3,521.01 $3,539.34 $3,557.6863272 $3,360.06 90 $3,488.23 $3,616.40 $3,744.5763273 $2,699.25 90 $2,806.58 $2,913.90 $3,021.2363275 $2,921.16 90 $3,066.35 $3,211.53 $3,356.7263276 $2,836.00 90 $3,048.70 $3,261.40 $3,474.10

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 67 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

63277 $2,579.05 90 $2,774.49 $2,969.93 $3,165.3663278 $2,555.80 90 $2,642.83 $2,729.86 $2,816.8963280 $3,202.86 90 $3,434.76 $3,666.67 $3,898.5763281 $3,175.11 90 $3,328.01 $3,480.90 $3,633.8063282 $2,925.77 90 $3,169.45 $3,413.13 $3,656.8263283 $2,632.52 90 $2,800.91 $2,969.29 $3,137.6863285 $3,628.71 90 $3,890.59 $4,152.48 $4,414.3663286 $3,657.78 90 $3,813.63 $3,969.47 $4,125.3263287 $3,487.09 90 $3,754.35 $4,021.61 $4,288.8763290 $3,628.53 90 $3,805.95 $3,983.36 $4,160.7863300 $3,076.34 90 $3,143.68 $3,211.03 $3,278.3763301 $3,142.84 90 $3,367.50 $3,592.15 $3,816.8163302 $3,220.50 90 $3,400.17 $3,579.84 $3,759.5163303 $3,303.83 90 $3,411.31 $3,518.79 $3,626.2763304 $3,478.41 90 $3,731.03 $3,983.66 $4,236.2863305 $3,733.86 90 $3,982.09 $4,230.32 $4,478.5563306 $3,526.71 90 $3,748.85 $3,970.98 $4,193.1263307 $3,838.64 90 $4,042.12 $4,245.61 $4,449.0963308 $778.88 90 $752.74 $726.60 $700.4663600 $1,856.29 90 $1,930.16 $2,004.03 $2,077.9163650 $1,072.68 90 $1,097.05 $1,121.43 $1,145.8063660 $639.53 90 $685.00 $730.47 $775.9563685 $649.31 90 $850.87 $1,052.42 $1,253.9863688 $506.78 90 $558.29 $609.79 $661.3063700 $1,721.51 90 $1,847.43 $1,973.35 $2,099.2763702 $1,902.45 90 $2,017.28 $2,132.10 $2,246.9363704 $2,055.79 90 $2,256.92 $2,458.05 $2,659.1963706 $2,306.81 90 $2,506.23 $2,705.65 $2,905.0763707 $2,224.76 90 $2,215.66 $2,206.56 $2,197.4663709 $2,622.92 90 $2,687.18 $2,751.44 $2,815.6963710 $2,205.23 90 $2,274.75 $2,344.26 $2,413.7863740 $2,015.88 7 $2,098.21 $2,180.55 $2,262.8863741 $879.60 7 $998.71 $1,117.83 $1,236.9463744 $897.45 7 $1,012.32 $1,127.20 $1,242.0763746 $854.29 7 $871.91 $889.52 $907.1464400 $91.12 0 $121.89 $152.67 $183.4464402 $113.85 0 $169.87 $225.88 $281.9064405 $101.15 0 $122.16 $143.17 $164.1864408 $152.95 0 $158.05 $163.15 $168.2564410 $115.43 0 $174.20 $232.96 $291.7364412 $111.00 0 $139.29 $167.58 $195.8764413 $140.27 0 $171.54 $202.81 $234.0864415 $100.30 0 $163.45 $226.59 $289.7464417 $115.30 0 $182.54 $249.78 $317.0264418 $147.74 0 $177.39 $207.04 $236.6964420 $104.15 0 $144.84 $185.53 $226.2164421 $161.27 0 $246.60 $331.92 $417.2564425 $113.15 0 $151.01 $188.88 $226.7464430 $124.98 0 $156.64 $188.30 $219.9664435 $114.85 0 $146.50 $178.15 $209.8064445 $100.36 0 $160.48 $220.61 $280.7364450 $102.37 0 $131.89 $161.42 $190.9464505 $114.10 0 $135.14 $156.18 $177.2264508 $132.25 0 $136.66 $141.07 $145.4864510 $117.75 0 $166.16 $214.57 $262.9964520 $116.95 0 $184.46 $251.96 $319.4764530 $226.20 0 $304.64 $383.07 $461.5164550 $35.65 0 $40.43 $45.20 $49.9864553 $182.85 0 $247.23 $311.61 $375.9964555 $144.90 0 $229.57 $314.23 $398.90

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 68 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

64560 $212.75 0 $267.68 $322.61 $377.5364565 $134.55 0 $217.56 $300.57 $383.5864590 $233.45 0 $354.99 $476.53 $598.0764595 $155.25 0 $309.16 $463.07 $616.9864600 $163.93 7 $338.86 $513.80 $688.7364605 $242.60 7 $431.44 $620.28 $809.1264610 $312.15 7 $552.71 $793.27 $1,033.8364612 $176.81 7 $219.41 $262.01 $304.6164613 $213.56 7 $249.35 $285.14 $320.9364620 $121.38 7 $218.09 $314.80 $411.5264622 $183.43 7 $312.41 $441.39 $570.3764623 $92.02 7 $138.50 $184.99 $231.4764630 $81.65 7 $188.55 $295.45 $402.3564640 $99.26 7 $208.62 $317.99 $427.3564680 $338.83 7 $461.40 $583.97 $706.5364702 $398.72 90 $470.63 $542.54 $614.4464704 $600.61 90 $629.98 $659.35 $688.7264708 $901.72 90 $957.37 $1,013.02 $1,068.6764712 $1,034.24 90 $1,127.49 $1,220.74 $1,313.9864713 $1,155.87 90 $1,239.72 $1,323.58 $1,407.4364714 $1,293.39 90 $1,270.46 $1,247.54 $1,224.6164716 $1,322.50 90 $1,353.52 $1,384.54 $1,415.5664718 $1,040.15 90 $1,104.69 $1,169.23 $1,233.7764719 $774.65 90 $775.11 $775.57 $776.0364721 $768.07 90 $909.65 $1,051.24 $1,192.8264722 $564.50 90 $631.94 $699.38 $766.8264726 $325.45 90 $383.30 $441.15 $499.0164727 $386.40 0 $409.85 $433.29 $456.7464732 $550.86 30 $565.52 $580.18 $594.8364734 $535.52 30 $588.64 $641.77 $694.8964736 $550.86 30 $584.45 $618.03 $651.6264738 $792.18 30 $793.60 $795.01 $796.4364740 $667.68 30 $713.80 $759.92 $806.0464742 $789.55 30 $856.05 $922.55 $989.0464744 $545.42 30 $608.19 $670.96 $733.7264746 $488.13 30 $552.07 $616.01 $679.9464752 $1,086.33 45 $1,098.55 $1,110.78 $1,123.0064755 $1,415.86 60 $1,465.74 $1,515.62 $1,565.5064760 $1,086.33 45 $1,043.96 $1,001.58 $959.2164761 $584.61 45 $611.67 $638.73 $665.7964763 $489.07 45 $597.34 $705.62 $813.8964766 $792.18 45 $843.81 $895.45 $947.0864771 $927.88 30 $975.02 $1,022.15 $1,069.2964772 $487.60 30 $623.93 $760.26 $896.5964774 $295.44 30 $368.44 $441.44 $514.4464776 $292.62 30 $379.16 $465.69 $552.2364778 $219.02 30 $249.53 $280.05 $310.5664782 $465.43 30 $542.90 $620.37 $697.8464783 $326.13 30 $346.87 $367.62 $388.3664784 $773.07 30 $893.60 $1,014.13 $1,134.6664786 $1,133.39 30 $1,321.71 $1,510.03 $1,698.3564787 $687.78 30 $648.28 $608.78 $569.2864788 $489.07 30 $550.52 $611.97 $673.4164790 $1,361.69 60 $1,411.46 $1,461.22 $1,510.9964792 $1,481.98 60 $1,656.02 $1,830.06 $2,004.1064795 $282.10 0 $299.55 $317.00 $334.4564802 $1,129.69 60 $1,191.96 $1,254.22 $1,316.4964804 $1,663.52 60 $1,752.86 $1,842.20 $1,931.5464820 $879.38 $1,012.47 $1,145.55 $1,278.6464831 $524.33 90 $642.50 $760.67 $878.84

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 69 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

64832 $241.74 90 $341.73 $441.72 $541.7164834 $794.47 90 $927.51 $1,060.55 $1,193.5964835 $958.52 90 $1,086.01 $1,213.50 $1,340.9964836 $1,090.83 90 $1,189.48 $1,288.12 $1,386.7764837 $411.19 90 $515.35 $619.52 $723.6864840 $781.60 90 $990.26 $1,198.92 $1,407.5864856 $1,031.61 90 $1,214.19 $1,396.77 $1,579.3564857 $976.90 90 $1,223.69 $1,470.47 $1,717.2664858 $1,063.06 90 $1,279.93 $1,496.80 $1,713.6764859 $347.18 90 $414.40 $481.62 $548.8464861 $1,392.65 90 $1,557.68 $1,722.72 $1,887.7564862 $1,311.00 90 $1,612.60 $1,914.20 $2,215.8164864 $2,114.85 90 $1,969.82 $1,824.80 $1,679.7764865 $2,045.13 90 $2,070.05 $2,094.97 $2,119.8964866 $2,060.43 90 $2,185.28 $2,310.13 $2,434.9964868 $2,042.69 90 $2,123.36 $2,204.04 $2,284.7164870 $2,091.63 90 $2,084.55 $2,077.47 $2,070.3964885 $1,516.90 90 $1,725.43 $1,933.95 $2,142.4864886 $1,688.55 90 $1,970.55 $2,252.56 $2,534.5664890 $1,233.96 90 $1,395.62 $1,557.29 $1,718.9564891 $1,379.29 90 $1,465.00 $1,550.71 $1,636.4364892 $1,303.56 90 $1,420.37 $1,537.18 $1,653.9864893 $1,447.88 90 $1,623.73 $1,799.58 $1,975.4464895 $1,461.79 90 $1,626.06 $1,790.33 $1,954.6064896 $1,767.26 90 $1,975.43 $2,183.61 $2,391.7864897 $1,618.89 90 $1,783.14 $1,947.39 $2,111.6464898 $1,906.43 90 $2,067.07 $2,227.71 $2,388.3564901 $315.84 90 $653.89 $991.95 $1,330.0064902 $631.90 90 $928.90 $1,225.90 $1,522.8964905 $884.35 90 $1,208.74 $1,533.13 $1,857.5264907 $884.35 90 $1,410.27 $1,936.18 $2,462.1065091 $781.28 30 $892.80 $1,004.32 $1,115.8365093 $938.69 30 $981.78 $1,024.87 $1,067.9665101 $802.81 30 $928.57 $1,054.34 $1,180.1065103 $814.49 30 $945.42 $1,076.35 $1,207.2865105 $984.64 30 $1,226.00 $1,467.37 $1,708.7365110 $1,562.58 30 $1,702.16 $1,841.73 $1,981.3165112 $1,699.70 30 $1,918.80 $2,137.90 $2,356.9965114 $1,832.43 60 $1,978.92 $2,125.41 $2,271.8965130 $847.64 30 $929.55 $1,011.47 $1,093.3865135 $1,002.21 30 $1,079.13 $1,156.04 $1,232.9665140 $1,101.21 30 $1,179.12 $1,257.04 $1,334.9565150 $836.08 30 $929.97 $1,023.87 $1,117.7665155 $937.38 30 $1,132.93 $1,328.48 $1,524.0365175 $520.49 30 $657.55 $794.60 $931.6665205 $39.11 0 $77.51 $115.91 $154.3165210 $46.75 0 $91.29 $135.83 $180.3765220 $58.10 0 $141.56 $225.02 $308.4765222 $62.98 0 $109.95 $156.92 $203.8965235 $1,206.79 45 $1,213.33 $1,219.87 $1,226.4065260 $1,203.43 45 $1,319.17 $1,434.91 $1,550.6565265 $1,387.17 45 $1,508.02 $1,628.87 $1,749.7365270 $96.55 0 $176.77 $256.99 $337.2165272 $262.20 7 $366.53 $470.87 $575.2065273 $408.41 7 $462.85 $517.30 $571.7465275 $602.19 60 $676.14 $750.09 $824.0465280 $990.69 60 $1,049.26 $1,107.83 $1,166.4065285 $1,244.21 60 $1,398.78 $1,553.35 $1,707.9365286 $465.94 30 $632.63 $799.33 $966.0265290 $346.15 30 $471.61 $597.08 $722.54

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 70 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

65400 $632.90 30 $739.52 $846.15 $952.7765410 $180.43 0 $206.87 $233.31 $259.7565420 $499.63 30 $595.04 $690.45 $785.8765426 $737.65 30 $785.62 $833.59 $881.5765430 $39.61 0 $151.52 $263.43 $375.3465435 $92.84 0 $106.60 $120.35 $134.1165436 $250.96 0 $316.78 $382.61 $448.4365450 $125.47 0 $258.27 $391.06 $523.8665600 $598.87 30 $597.31 $595.76 $594.2065710 $1,958.99 90 $2,051.55 $2,144.11 $2,236.6765730 $2,325.16 90 $2,358.32 $2,391.48 $2,424.6465750 $2,363.46 90 $2,326.01 $2,288.55 $2,251.1065755 $2,034.35 90 $2,188.42 $2,342.48 $2,496.5565800 $97.93 0 $139.85 $181.77 $223.6965805 $163.93 0 $196.45 $228.97 $261.5065810 $664.07 90 $740.60 $817.13 $893.6765815 $412.38 90 $608.83 $805.27 $1,001.7265820 $807.78 30 $976.89 $1,146.00 $1,315.1065850 $1,185.24 45 $1,306.86 $1,428.48 $1,550.1065855 $1,064.20 45 $984.97 $905.74 $826.5065860 $493.35 30 $524.95 $556.55 $588.1565865 $717.60 30 $837.61 $957.61 $1,077.6265870 $692.50 30 $784.52 $876.55 $968.5765875 $680.80 30 $791.81 $902.83 $1,013.8465880 $736.84 30 $845.18 $953.53 $1,061.8765900 $1,830.07 30 $1,800.19 $1,770.32 $1,740.4465920 $1,078.42 30 $1,139.85 $1,201.29 $1,262.7265930 $1,274.56 30 $1,236.97 $1,199.39 $1,161.8066020 $190.26 0 $227.05 $263.84 $300.6366030 $144.97 0 $180.91 $216.85 $252.7966130 $304.75 45 $564.00 $823.25 $1,082.5066150 $1,029.65 45 $1,158.36 $1,287.07 $1,415.7866155 $945.49 45 $1,091.13 $1,236.76 $1,382.4066160 $1,074.96 45 $1,226.26 $1,377.56 $1,528.8666165 $955.18 45 $1,051.34 $1,147.49 $1,243.6566170 $1,516.69 45 $1,521.04 $1,525.39 $1,529.7366172 $1,667.56 $1,780.99 $1,894.43 $2,007.8666220 $1,583.65 90 $1,555.25 $1,526.85 $1,498.4566225 $1,926.66 90 $1,881.21 $1,835.76 $1,790.3166250 $1,427.68 90 $1,247.98 $1,068.28 $888.5866500 $446.93 30 $481.16 $515.38 $549.6166505 $407.10 30 $420.67 $434.24 $447.8166600 $1,101.21 45 $1,144.36 $1,187.51 $1,230.6566605 $1,583.65 45 $1,612.63 $1,641.61 $1,670.5966625 $900.77 45 $927.34 $953.90 $980.4766630 $792.18 45 $823.63 $855.09 $886.5466635 $792.18 45 $855.91 $919.64 $983.3766680 $801.73 45 $876.28 $950.83 $1,025.3866682 $970.62 45 $1,004.22 $1,037.83 $1,071.4366700 $454.64 45 $526.52 $598.39 $670.2766710 $717.58 45 $769.37 $821.17 $872.9666720 $548.17 45 $622.85 $697.53 $772.2266740 $709.17 45 $753.89 $798.62 $843.3466761 $844.64 45 $812.36 $780.08 $747.8066762 $704.73 30 $767.73 $830.72 $893.7266770 $886.45 30 $918.81 $951.18 $983.5466820 $412.38 45 $493.83 $575.29 $656.7466821 $773.24 45 $708.44 $643.63 $578.8366825 $885.80 45 $1,015.55 $1,145.31 $1,275.0666830 $652.48 90 $781.60 $910.72 $1,039.84

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 71 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

66840 $1,121.70 90 $1,152.01 $1,182.31 $1,212.6266850 $1,407.21 90 $1,422.90 $1,438.59 $1,454.2866852 $1,743.11 90 $1,744.23 $1,745.35 $1,746.4766920 $1,407.73 90 $1,473.64 $1,539.55 $1,605.4666930 $1,839.92 90 $1,762.37 $1,684.82 $1,607.2766940 $1,432.48 90 $1,450.69 $1,468.90 $1,487.1166983 $2,103.70 90 $1,978.35 $1,853.00 $1,727.6566984 $2,152.21 90 $1,903.70 $1,655.19 $1,406.6966985 $1,150.97 90 $1,147.86 $1,144.76 $1,141.6566986 $1,215.97 90 $1,328.53 $1,441.09 $1,553.6667005 $1,407.01 90 $1,340.39 $1,273.77 $1,207.1567010 $1,607.44 90 $1,606.19 $1,604.95 $1,603.7067015 $638.75 60 $731.75 $824.76 $917.7667025 $945.51 60 $997.77 $1,050.03 $1,102.2967027 $887.08 $1,055.16 $1,223.25 $1,391.3367028 $290.20 45 $396.50 $502.80 $609.1067030 $412.38 45 $563.95 $715.53 $867.1067031 $766.86 45 $771.78 $776.70 $781.6367036 $2,592.80 60 $2,382.94 $2,173.08 $1,963.2267038 $3,323.90 60 $3,481.91 $3,639.93 $3,797.9467039 $3,196.37 60 $3,122.11 $3,047.85 $2,973.6067040 $3,066.33 60 $3,037.02 $3,007.71 $2,978.4067101 $1,563.77 90 $1,587.10 $1,610.43 $1,633.7767105 $1,599.54 90 $1,646.10 $1,692.65 $1,739.2167107 $2,438.54 90 $2,532.83 $2,627.13 $2,721.4267108 $3,128.50 90 $3,197.06 $3,265.63 $3,334.1967110 $2,244.30 90 $2,257.17 $2,270.04 $2,282.9167112 $2,812.26 90 $2,752.95 $2,693.63 $2,634.3267115 $938.31 30 $903.22 $868.13 $833.0367120 $1,095.42 30 $1,177.70 $1,259.98 $1,342.2567121 $1,966.57 30 $1,827.23 $1,687.89 $1,548.5567141 $783.99 30 $850.71 $917.44 $984.1667145 $783.99 30 $864.04 $944.09 $1,024.1367208 $1,057.82 90 $1,128.15 $1,198.49 $1,268.8267210 $1,024.13 90 $1,043.38 $1,062.62 $1,081.8767218 $887.90 90 $1,298.26 $1,708.62 $2,118.9867227 $1,194.96 90 $1,177.07 $1,159.17 $1,141.2867228 $1,137.27 90 $1,248.59 $1,359.90 $1,471.2267250 $1,399.54 90 $1,415.78 $1,432.01 $1,448.2567255 $1,729.89 90 $1,735.26 $1,740.62 $1,745.9967311 $1,040.57 30 $1,070.72 $1,100.87 $1,131.0167312 $1,295.57 30 $1,306.09 $1,316.61 $1,327.1367314 $960.45 30 $1,019.99 $1,079.53 $1,139.0767316 $1,132.26 30 $1,248.02 $1,363.78 $1,479.5467318 $1,006.25 30 $1,106.58 $1,206.91 $1,307.2467320 $1,392.85 30 $1,240.76 $1,088.66 $936.5767331 $1,031.92 30 $978.40 $924.87 $871.3567332 $1,133.17 30 $1,049.30 $965.43 $881.5667334 $731.40 30 $697.88 $664.37 $630.8567335 $101.20 0 $157.38 $213.55 $269.7367340 $1,021.29 30 $1,007.97 $994.64 $981.3267343 $469.01 30 $659.66 $850.31 $1,040.9667345 $173.91 0 $261.94 $349.96 $437.9967350 $264.50 0 $297.93 $331.35 $364.7867400 $1,358.81 30 $1,388.08 $1,417.34 $1,446.6167405 $1,028.11 30 $1,132.04 $1,235.96 $1,339.8967412 $1,736.47 60 $1,676.11 $1,615.75 $1,555.3967413 $1,421.92 30 $1,437.14 $1,452.37 $1,467.5967414 $1,409.06 30 $1,497.09 $1,585.12 $1,673.1567415 $239.50 0 $241.18 $242.86 $244.54

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 72 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

67420 $2,528.69 30 $2,714.74 $2,900.79 $3,086.8567430 $2,285.23 30 $2,332.83 $2,380.43 $2,428.0267440 $1,772.67 30 $1,978.57 $2,184.47 $2,390.3667445 $2,089.21 30 $2,073.38 $2,057.55 $2,041.7167450 $2,175.72 30 $2,258.56 $2,341.40 $2,424.2467500 $53.56 0 $84.43 $115.30 $146.1767505 $162.85 7 $168.71 $174.58 $180.4467515 $63.67 0 $80.38 $97.08 $113.7967550 $945.30 30 $1,080.54 $1,215.78 $1,351.0267560 $922.00 60 $1,070.39 $1,218.79 $1,367.1867570 $851.67 30 $1,174.95 $1,498.23 $1,821.5167700 $48.25 0 $138.00 $227.74 $317.4967710 $195.63 0 $248.98 $302.33 $355.6867715 $191.86 0 $248.51 $305.15 $361.8067800 $110.83 15 $146.34 $181.85 $217.3667801 $151.98 15 $238.17 $324.36 $410.5667805 $159.74 15 $263.23 $366.72 $470.2167808 $266.28 15 $336.33 $406.39 $476.4467810 $98.65 0 $166.99 $235.33 $303.6767820 $54.19 0 $75.14 $96.09 $117.0467825 $108.03 0 $165.84 $223.65 $281.4667830 $701.50 7 $660.94 $620.37 $579.8167835 $1,077.55 30 $1,051.07 $1,024.58 $998.1067840 $155.44 0 $249.22 $342.99 $436.7767850 $121.10 0 $207.29 $293.48 $379.6767875 $117.95 30 $248.86 $379.76 $510.6767880 $400.95 30 $518.06 $635.17 $752.2867882 $487.39 30 $622.78 $758.18 $893.5767901 $1,247.95 60 $1,308.96 $1,369.97 $1,430.9867902 $1,083.00 60 $1,155.11 $1,227.22 $1,299.3367903 $1,346.89 60 $1,414.16 $1,481.43 $1,548.7067904 $1,291.30 60 $1,351.99 $1,412.67 $1,473.3667906 $1,499.59 60 $1,422.67 $1,345.75 $1,268.8367908 $886.02 30 $949.96 $1,013.91 $1,077.8567909 $1,143.61 30 $1,150.65 $1,157.70 $1,164.7467911 $1,441.30 30 $1,364.63 $1,287.95 $1,211.2867914 $182.24 15 $372.44 $562.64 $752.8467915 $116.91 15 $277.04 $437.18 $597.3167916 $690.65 30 $803.49 $916.34 $1,029.1867917 $829.91 30 $904.50 $979.10 $1,053.6967921 $309.36 15 $415.19 $521.01 $626.8467922 $174.95 15 $331.69 $488.43 $645.1767923 $693.74 30 $810.47 $927.19 $1,043.9267924 $824.39 30 $853.42 $882.44 $911.4767930 $124.57 30 $287.07 $449.57 $612.0667935 $235.39 30 $499.20 $763.02 $1,026.8367938 $73.60 0 $173.87 $274.14 $374.4167950 $846.18 45 $944.59 $1,043.00 $1,141.4167961 $782.80 60 $855.30 $927.80 $1,000.3167966 $951.75 60 $971.90 $992.05 $1,012.2067971 $959.21 60 $1,080.34 $1,201.47 $1,322.5967973 $1,183.50 60 $1,321.35 $1,459.20 $1,597.0567974 $1,407.77 60 $1,525.49 $1,643.22 $1,760.9467975 $1,126.08 60 $1,148.56 $1,171.04 $1,193.5268020 $38.78 0 $159.95 $281.11 $402.2868040 $52.74 0 $161.52 $270.31 $379.0968100 $82.61 0 $190.54 $298.47 $406.4068110 $103.50 15 $218.97 $334.44 $449.9168115 $180.78 15 $281.92 $383.05 $484.1968130 $529.37 15 $575.43 $621.50 $667.56

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 73 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

68135 $40.25 0 $201.91 $363.58 $525.2468200 $58.15 0 $91.37 $124.60 $157.8268320 $950.68 30 $966.96 $983.25 $999.5368325 $1,101.21 30 $1,108.77 $1,116.34 $1,123.9068326 $924.36 30 $990.79 $1,057.22 $1,123.6568328 $1,089.63 30 $1,117.62 $1,145.62 $1,173.6168330 $649.57 30 $716.61 $783.65 $850.6968335 $990.63 30 $987.22 $983.81 $980.4068340 $527.53 0 $699.36 $871.19 $1,043.0268360 $473.54 30 $574.93 $676.33 $777.7268362 $776.97 30 $871.59 $966.21 $1,060.8368400 $196.50 15 $326.14 $455.79 $585.4368420 $167.17 15 $305.46 $443.76 $582.0568440 $47.26 0 $136.78 $226.30 $315.8268500 $950.68 45 $1,072.02 $1,193.36 $1,314.7168505 $915.40 45 $1,057.59 $1,199.77 $1,341.9668510 $296.21 0 $465.74 $635.28 $804.8168520 $939.00 45 $1,006.15 $1,073.31 $1,140.4668525 $361.78 45 $411.18 $460.59 $509.9968530 $999.92 30 $1,015.01 $1,030.10 $1,045.2068540 $1,190.82 45 $1,277.89 $1,364.95 $1,452.0268550 $1,707.75 45 $1,719.29 $1,730.83 $1,742.3768700 $794.71 30 $869.19 $943.68 $1,018.1668705 $158.47 15 $259.69 $360.92 $462.1468720 $1,363.82 60 $1,432.75 $1,501.69 $1,570.6268745 $1,266.99 90 $1,333.04 $1,399.08 $1,465.1368750 $1,252.65 15 $1,378.71 $1,504.77 $1,630.8368760 $98.58 15 $173.98 $249.39 $324.7968761 $127.53 15 $172.84 $218.15 $263.4768770 $376.05 30 $628.47 $880.89 $1,133.3168801 $68.84 $106.87 $144.90 $182.9368810 $102.89 $160.65 $218.40 $276.1668811 $214.76 $240.73 $266.71 $292.6868815 $281.82 $446.92 $612.01 $777.1168840 $59.95 0 $109.81 $159.66 $209.5268850 $59.11 0 $271.90 $484.69 $697.4869000 $48.91 0 $100.29 $151.66 $203.0469005 $142.60 0 $203.82 $265.03 $326.2569020 $46.23 0 $106.86 $167.49 $228.1369100 $56.19 0 $79.70 $103.22 $126.7369105 $57.10 0 $94.10 $131.10 $168.1069110 $244.44 30 $351.00 $457.57 $564.1369120 $626.41 90 $694.06 $761.70 $829.3569140 $951.75 90 $1,155.44 $1,359.12 $1,562.8169145 $375.84 90 $396.92 $418.00 $439.0869150 $1,853.02 90 $1,932.56 $2,012.10 $2,091.6369155 $2,136.70 90 $2,294.95 $2,453.19 $2,611.4469200 $67.88 0 $98.98 $130.08 $161.1869205 $170.10 0 $199.13 $228.15 $257.1869210 $46.51 30 $55.13 $63.75 $72.3869220 $70.22 7 $93.89 $117.56 $141.2269222 $110.98 14 $170.09 $229.20 $288.3169300 $830.79 90 $860.19 $889.59 $919.0069310 $1,053.91 90 $1,360.95 $1,667.99 $1,975.0369320 $1,312.64 90 $1,620.29 $1,927.94 $2,235.5969400 $25.51 0 $77.56 $129.62 $181.6769401 $20.70 0 $53.97 $87.25 $120.5269405 $50.60 0 $172.85 $295.10 $417.3469420 $80.28 0 $128.04 $175.79 $223.5569421 $154.35 0 $205.26 $256.16 $307.07

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 74 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

69424 $89.12 0 $117.20 $145.29 $173.3769433 $168.13 0 $195.72 $223.32 $250.9169436 $251.70 30 $286.13 $320.56 $354.9969440 $880.40 30 $951.52 $1,022.64 $1,093.7669450 $233.45 30 $419.09 $604.73 $790.3769501 $949.49 90 $1,027.43 $1,105.37 $1,183.3169502 $1,484.28 90 $1,609.08 $1,733.87 $1,858.6769505 $1,595.48 90 $1,867.68 $2,139.87 $2,412.0769511 $1,626.22 90 $1,846.05 $2,065.88 $2,285.7269530 $2,349.28 90 $2,589.22 $2,829.16 $3,069.1069535 $2,516.16 90 $3,113.51 $3,710.86 $4,308.2269540 $113.85 15 $178.80 $243.75 $308.7069550 $1,320.04 90 $1,521.47 $1,722.90 $1,924.3369552 $2,059.98 90 $2,316.24 $2,572.50 $2,828.7569554 $2,503.13 90 $2,962.03 $3,420.93 $3,879.8369601 $1,395.26 90 $1,563.08 $1,730.89 $1,898.7169602 $1,607.07 90 $1,863.50 $2,119.93 $2,376.3669603 $1,426.50 90 $1,684.81 $1,943.12 $2,201.4369604 $1,982.33 90 $2,179.97 $2,377.60 $2,575.2469605 $2,136.52 90 $2,357.83 $2,579.15 $2,800.4669610 $111.55 7 $229.81 $348.06 $466.3269620 $1,120.93 90 $1,152.41 $1,183.89 $1,215.3769631 $1,982.68 90 $2,020.59 $2,058.49 $2,096.4069632 $1,869.13 90 $1,946.64 $2,024.15 $2,101.6669633 $2,037.99 90 $2,118.28 $2,198.56 $2,278.8569635 $1,815.96 90 $2,077.60 $2,339.25 $2,600.8969636 $1,833.39 90 $2,016.84 $2,200.28 $2,383.7369637 $1,819.65 90 $2,053.01 $2,286.37 $2,519.7369641 $2,355.34 90 $2,363.87 $2,372.40 $2,380.9369642 $2,603.32 90 $2,673.45 $2,743.58 $2,813.7169643 $2,657.26 90 $2,727.50 $2,797.74 $2,867.9869644 $2,617.14 90 $2,705.37 $2,793.60 $2,881.8369645 $2,492.70 90 $2,603.58 $2,714.45 $2,825.3369646 $2,702.45 90 $2,780.77 $2,859.09 $2,937.4169650 $939.00 90 $1,131.52 $1,324.04 $1,516.5769660 $1,728.45 90 $1,866.24 $2,004.02 $2,141.8169661 $1,698.59 90 $1,919.23 $2,139.88 $2,360.5269662 $2,039.08 90 $2,147.69 $2,256.30 $2,364.9169666 $1,406.06 90 $1,524.63 $1,643.19 $1,761.7669667 $1,406.06 90 $1,531.13 $1,656.19 $1,781.2669670 $1,077.55 90 $1,332.80 $1,588.05 $1,843.3169676 $1,267.13 90 $1,342.09 $1,417.06 $1,492.0269700 $545.42 90 $706.22 $867.02 $1,027.8269720 $1,874.62 90 $2,034.25 $2,193.89 $2,353.5269725 $2,949.92 90 $3,042.45 $3,134.97 $3,227.5069740 $2,256.14 90 $2,299.70 $2,343.26 $2,386.8369745 $3,081.52 90 $3,031.84 $2,982.17 $2,932.4969801 $1,645.05 90 $1,703.13 $1,761.21 $1,819.2969802 $2,035.14 90 $2,008.98 $1,982.82 $1,956.6669805 $1,756.35 90 $1,850.77 $1,945.19 $2,039.6169806 $2,189.36 90 $2,273.03 $2,356.70 $2,440.3769820 $1,741.91 90 $1,710.65 $1,679.38 $1,648.1269840 $907.80 90 $1,074.82 $1,241.84 $1,408.8569905 $1,606.13 90 $1,684.30 $1,762.48 $1,840.6569910 $2,099.68 90 $2,175.95 $2,252.22 $2,328.4969915 $2,523.55 90 $2,711.67 $2,899.78 $3,087.9069950 $2,966.01 90 $3,161.85 $3,357.69 $3,553.5369955 $2,701.72 90 $2,918.02 $3,134.33 $3,350.6369960 $3,345.19 90 $3,502.83 $3,660.47 $3,818.1169970 $3,812.25 90 $3,948.08 $4,083.91 $4,219.74

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 75 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

70010 $220.37 $227.72 $235.06 $242.4170010 26 $93.08 $105.82 $118.56 $131.2970015 $187.45 $193.70 $199.95 $206.2070015 26 $107.31 $110.85 $114.40 $117.9470030 $40.25 $39.91 $39.56 $39.2270030 26 $28.04 $27.42 $26.79 $26.1770100 $53.83 $55.92 $58.01 $60.0970100 26 $16.86 $18.07 $19.27 $20.4870110 $63.68 $69.24 $74.80 $80.3670110 26 $24.68 $27.45 $30.22 $32.9970120 $59.93 $62.07 $64.22 $66.3670120 26 $19.96 $21.21 $22.47 $23.7270130 $75.97 $82.34 $88.70 $95.0770130 26 $30.83 $33.25 $35.67 $38.0970134 $74.75 $77.24 $79.74 $82.2370134 26 $29.90 $30.05 $30.21 $30.3670140 $66.51 $66.89 $67.28 $67.6670140 26 $20.96 $22.37 $23.78 $25.1970150 $83.25 $86.13 $89.00 $91.8870150 26 $29.19 $30.97 $32.75 $34.5370160 $56.59 $57.53 $58.48 $59.4270160 26 $16.86 $18.19 $19.52 $20.8570170 $82.80 $85.56 $88.32 $91.0870170 26 $28.75 $29.01 $29.27 $29.5370190 $52.50 $58.14 $63.79 $69.4370190 26 $17.80 $19.64 $21.48 $23.3270200 $68.98 $75.97 $82.95 $89.9470200 26 $24.36 $26.12 $27.88 $29.6470210 $64.20 $65.12 $66.04 $66.9570210 26 $21.40 $21.40 $21.41 $21.4170220 $71.24 $76.63 $82.01 $87.4070220 26 $24.49 $27.20 $29.90 $32.6170240 $42.41 $43.54 $44.67 $45.8070240 26 $17.83 $19.10 $20.37 $21.6370250 $61.05 $62.95 $64.85 $66.7470250 26 $22.75 $24.09 $25.43 $26.7870260 $95.49 $96.71 $97.93 $99.1570260 26 $32.16 $33.29 $34.42 $35.5470300 $22.02 $22.99 $23.96 $24.9370300 26 $9.76 $9.39 $9.03 $8.6670310 $36.74 $36.49 $36.24 $35.9970310 26 $14.65 $14.70 $14.76 $14.8170320 $56.75 $58.64 $60.54 $62.4370320 26 $20.70 $21.39 $22.08 $22.7770328 $58.19 $57.61 $57.03 $56.4470328 26 $20.93 $20.94 $20.95 $20.9670330 $80.01 $85.56 $91.11 $96.6670330 26 $24.95 $29.88 $34.81 $39.7570332 $154.19 $156.97 $159.74 $162.5270332 26 $56.86 $55.58 $54.30 $53.0370336 $829.15 $878.97 $928.80 $978.6270336 26 $93.15 $116.32 $139.50 $162.6770350 $40.25 $43.74 $47.23 $50.7270350 26 $17.25 $17.32 $17.39 $17.4670355 $54.55 $56.21 $57.87 $59.5370355 26 $19.21 $20.46 $21.72 $22.9770360 $46.88 $47.66 $48.44 $49.2170360 26 $16.91 $18.38 $19.86 $21.3370370 $98.38 $100.19 $101.99 $103.8070370 26 $30.97 $32.61 $34.26 $35.90

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 76 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

70371 $201.25 $207.96 $214.67 $221.3870371 26 $75.90 $78.43 $80.96 $83.4970373 $108.03 $111.63 $115.23 $118.8370373 26 $35.69 $56.94 $78.18 $99.4370380 $52.22 $54.60 $56.98 $59.3770380 26 $14.66 $15.55 $16.45 $17.3470390 $119.75 $126.22 $132.70 $139.1770390 26 $31.15 $31.71 $32.27 $32.8470450 $285.16 $329.25 $373.33 $417.4270450 26 $103.21 $106.16 $109.11 $112.0670460 $344.20 $357.35 $370.49 $383.6470460 26 $127.45 $132.97 $138.49 $144.0170470 $588.80 $544.26 $499.73 $455.1970470 26 $137.95 $144.92 $151.89 $158.8670480 $435.85 $405.07 $374.28 $343.5070480 26 $126.42 $129.61 $132.81 $136.0070481 $507.15 $470.86 $434.57 $398.2870481 26 $142.45 $147.52 $152.60 $157.6770482 $606.05 $559.26 $512.46 $465.6770482 26 $156.56 $160.96 $165.36 $169.7570486 $394.50 $374.66 $354.82 $334.9870486 26 $118.61 $123.78 $128.96 $134.1370487 $456.43 $435.59 $414.75 $393.9170487 26 $134.89 $139.54 $144.19 $148.8470488 $603.75 $557.00 $510.25 $463.5070488 26 $143.80 $151.09 $158.38 $165.6770490 $435.85 $405.07 $374.28 $343.5070490 26 $124.79 $128.53 $132.26 $136.0070491 $474.87 $449.34 $423.81 $398.2870491 26 $138.13 $145.65 $153.18 $160.7070492 $606.05 $559.12 $512.18 $465.2570492 26 $146.43 $154.15 $161.86 $169.5870540 $880.90 $806.20 $731.51 $656.8170540 26 $150.66 $162.88 $175.09 $187.3170551 $880.90 $895.39 $909.88 $924.3870551 26 $151.41 $164.10 $176.78 $189.4770552 $908.54 $902.37 $896.19 $890.0270552 26 $179.16 $194.97 $210.78 $226.6070553 $1,184.50 $1,235.12 $1,285.74 $1,336.3570553 26 $225.63 $251.21 $276.78 $302.3671010 $43.55 $44.38 $45.20 $46.0371010 26 $16.87 $17.73 $18.59 $19.4571010 TC $28.75 $28.14 $27.53 $26.9371015 $53.29 $58.34 $63.39 $68.4471015 26 $20.11 $21.57 $23.04 $24.5071020 $58.44 $60.40 $62.35 $64.3171020 26 $21.83 $22.99 $24.16 $25.3271020 TC $40.48 $39.29 $38.11 $36.9271021 $70.88 $74.39 $77.90 $81.4171021 26 $24.96 $27.41 $29.86 $32.3171022 $80.56 $80.64 $80.71 $80.7971022 26 $29.99 $31.13 $32.28 $33.4271023 $81.65 $84.37 $87.10 $89.8271023 26 $43.79 $42.00 $40.22 $38.4371030 $83.30 $86.62 $89.95 $93.2771030 26 $31.97 $34.96 $37.96 $40.9571034 $141.30 $144.52 $147.74 $150.9771034 26 $51.20 $51.01 $50.82 $50.6371035 $63.18 $62.12 $61.07 $60.0171035 26 $21.15 $20.13 $19.11 $18.09

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 77 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

71040 $108.74 $112.36 $115.99 $119.6171040 26 $67.71 $65.19 $62.67 $60.1571060 $153.54 $158.66 $163.77 $168.8971060 26 $82.54 $83.94 $85.34 $86.7471090 $110.28 $113.96 $117.63 $121.3171090 26 $49.53 $50.23 $50.93 $51.6271100 $57.23 $60.07 $62.90 $65.7471100 26 $20.83 $22.15 $23.46 $24.7871101 $74.20 $74.96 $75.72 $76.4771101 26 $27.36 $28.69 $30.03 $31.3671110 $76.58 $78.07 $79.57 $81.0671110 26 $24.49 $25.67 $26.84 $28.0271111 $91.32 $94.03 $96.73 $99.4471111 26 $31.53 $32.85 $34.18 $35.5071120 $58.14 $60.00 $61.86 $63.7271120 26 $19.75 $20.56 $21.37 $22.1771130 $61.14 $62.68 $64.23 $65.7771130 26 $20.61 $22.40 $24.18 $25.9771250 $457.82 $434.79 $411.76 $388.7371250 26 $114.03 $120.54 $127.04 $133.5571260 $377.95 $402.81 $427.67 $452.5271260 26 $132.88 $137.87 $142.87 $147.8671270 $650.90 $658.93 $666.97 $675.0071270 26 $144.70 $151.28 $157.86 $164.4471550 $811.90 $786.09 $760.28 $734.4671550 26 $161.91 $169.00 $176.09 $183.1872010 $112.63 $116.71 $120.79 $124.8872010 26 $45.01 $48.06 $51.11 $54.1672020 $44.30 $46.10 $47.89 $49.6972020 26 $15.48 $17.10 $18.73 $20.3572040 $59.50 $62.13 $64.76 $67.3972040 26 $21.37 $23.56 $25.75 $27.9572050 $81.55 $87.36 $93.18 $98.9972050 26 $29.68 $32.38 $35.09 $37.7972052 $112.21 $115.72 $119.23 $122.7472052 26 $36.48 $39.33 $42.18 $45.0372069 $70.39 $69.08 $67.77 $66.4672069 26 $22.19 $24.14 $26.10 $28.0572070 $60.49 $64.45 $68.41 $72.3772070 26 $21.37 $23.40 $25.44 $27.4772072 $74.62 $76.60 $78.58 $80.5772072 26 $23.65 $23.97 $24.29 $24.6172074 $87.52 $87.51 $87.50 $87.5072074 26 $25.06 $41.43 $57.81 $74.1872080 $66.73 $68.42 $70.11 $71.7972080 26 $21.07 $22.99 $24.92 $26.8472090 $72.13 $72.98 $73.83 $74.6872090 26 $26.43 $28.63 $30.83 $33.0372100 $63.06 $66.39 $69.72 $73.0672100 26 $21.65 $23.75 $25.84 $27.9472110 $82.34 $87.20 $92.05 $96.9172110 26 $30.24 $32.94 $35.65 $38.3572114 $105.06 $108.17 $111.28 $114.3872114 26 $34.51 $37.94 $41.37 $44.7972120 $82.50 $85.34 $88.18 $91.0272120 26 $23.59 $24.22 $24.85 $25.4872125 $457.70 $437.43 $417.16 $396.8872125 26 $116.15 $123.93 $131.71 $139.4972126 $532.45 $505.30 $478.14 $450.9972126 26 $129.97 $134.37 $138.77 $143.16

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 78 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

72127 $640.55 $604.91 $569.28 $533.6472127 26 $144.32 $148.37 $152.42 $156.4772128 $457.70 $434.71 $411.72 $388.7372128 26 $116.15 $123.49 $130.83 $138.1772129 $532.45 $505.37 $478.29 $451.2172129 26 $128.85 $137.45 $146.05 $154.6572130 $640.55 $604.91 $569.28 $533.6472130 26 $142.16 $144.75 $147.35 $149.9472131 $457.70 $434.71 $411.72 $388.7372131 26 $116.15 $123.49 $130.83 $138.1772132 $532.45 $505.30 $478.14 $450.9972132 26 $129.97 $131.87 $133.77 $135.6772133 $640.55 $606.00 $571.44 $536.8972133 26 $144.04 $145.95 $147.85 $149.7672141 $811.90 $766.06 $720.22 $674.3772141 26 $161.91 $174.14 $186.38 $198.6172141 TC $649.75 $609.15 $568.55 $527.9572142 $1,006.25 $937.80 $869.34 $800.8972142 26 $181.43 $189.03 $196.63 $204.2472146 $885.50 $833.24 $780.99 $728.7372146 26 $157.62 $174.10 $190.58 $207.0672147 $1,006.25 $958.70 $911.15 $863.6172147 26 $195.68 $209.10 $222.52 $235.9472148 $808.40 $779.52 $750.63 $721.7572148 26 $155.91 $167.47 $179.04 $190.6072149 $1,006.25 $1,013.55 $1,020.84 $1,028.1472149 26 $179.16 $188.23 $197.30 $206.3772156 $1,714.65 $1,592.54 $1,470.42 $1,348.3172156 26 $212.13 $245.74 $279.35 $312.9772157 $1,714.65 $1,711.18 $1,707.70 $1,704.2372157 26 $212.13 $246.68 $281.24 $315.7972158 $1,866.45 $1,762.93 $1,659.41 $1,555.8972158 26 $222.63 $249.55 $276.47 $303.3972159 $944.15 $975.62 $1,007.10 $1,038.5772159 26 $158.28 $167.28 $176.29 $185.2972170 $45.58 $48.97 $52.36 $55.7572170 26 $16.98 $18.93 $20.89 $22.8472190 $65.28 $66.41 $67.54 $68.6872190 26 $21.93 $24.09 $26.25 $28.4072192 $449.65 $428.03 $406.41 $384.7972192 26 $108.78 $116.07 $123.35 $130.6472193 $512.90 $490.73 $468.57 $446.4072193 26 $126.22 $132.39 $138.55 $144.7272194 $615.25 $581.27 $547.29 $513.3072194 26 $144.32 $141.28 $138.24 $135.1972196 $811.90 $838.96 $866.03 $893.0972196 26 $161.91 $178.10 $194.29 $210.4872200 $49.32 $51.22 $53.12 $55.0272200 26 $18.82 $20.37 $21.92 $23.4772202 $62.75 $64.36 $65.96 $67.5772202 26 $19.82 $21.46 $23.10 $24.7472220 $59.98 $61.46 $62.95 $64.4372220 26 $17.50 $19.28 $21.06 $22.8472240 $265.94 $274.80 $283.67 $292.5372240 26 $81.59 $92.82 $104.05 $115.2872255 $249.44 $257.75 $266.07 $274.3872255 26 $81.59 $92.43 $103.28 $114.1272265 $252.40 $273.38 $294.37 $315.3572265 26 $73.98 $81.47 $88.95 $96.4472270 $348.32 $359.93 $371.54 $383.15

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 79 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

72270 26 $132.47 $137.96 $143.44 $148.9372285 $575.00 $603.48 $631.95 $660.4372285 26 $89.02 $97.88 $106.74 $115.5972295 $410.81 $433.45 $456.09 $478.7372295 26 $82.47 $86.89 $91.31 $95.7473000 $51.39 $52.98 $54.57 $56.1773000 26 $14.52 $16.45 $18.38 $20.3173010 $52.26 $53.72 $55.18 $56.6373010 26 $16.52 $18.15 $19.78 $21.4173020 $48.90 $48.72 $48.54 $48.3673020 26 $15.87 $17.13 $18.38 $19.6473030 $52.19 $55.70 $59.20 $62.7173030 26 $17.50 $19.45 $21.40 $23.3573040 $131.24 $135.61 $139.99 $144.3673040 26 $56.19 $58.62 $61.05 $63.4973050 $59.59 $62.26 $64.92 $67.5973050 26 $18.02 $19.83 $21.64 $23.4573060 $55.09 $57.17 $59.25 $61.3373060 26 $17.27 $18.65 $20.03 $21.4173070 $46.88 $49.33 $51.77 $54.2273070 26 $15.12 $16.71 $18.29 $19.8873070 TC $29.90 $30.05 $30.20 $30.3473080 $52.23 $53.64 $55.05 $56.4673080 26 $18.11 $19.29 $20.47 $21.6573085 $131.24 $135.61 $139.99 $144.3673085 26 $56.19 $58.64 $61.08 $63.5373090 $46.14 $48.32 $50.49 $52.6773090 26 $17.05 $17.95 $18.85 $19.7573092 $43.70 $46.22 $48.73 $51.2573092 26 $14.95 $16.42 $17.89 $19.3673100 $43.32 $46.62 $49.93 $53.2373100 26 $15.26 $16.73 $18.20 $19.6773100 TC $28.75 $28.54 $28.32 $28.1173110 $47.57 $51.73 $55.89 $60.0573110 26 $16.75 $18.20 $19.64 $21.0973110 TC $29.90 $30.14 $30.38 $30.6373115 $136.29 $136.66 $137.04 $137.4173115 26 $55.88 $57.33 $58.79 $60.2473120 $45.89 $47.91 $49.93 $51.9573120 26 $14.45 $16.11 $17.77 $19.4373130 $46.80 $50.59 $54.37 $58.1673130 26 $17.09 $18.58 $20.07 $21.5673140 $38.09 $39.93 $41.78 $43.6273140 26 $12.52 $13.93 $15.35 $16.7673200 $395.60 $377.95 $360.30 $342.6673200 26 $108.78 $113.46 $118.15 $122.8373201 $457.70 $437.25 $416.80 $396.3573201 26 $123.83 $129.68 $135.53 $141.3973202 $552.00 $523.87 $495.74 $467.6173202 26 $126.19 $129.91 $133.63 $137.3473220 $801.55 $971.75 $1,141.96 $1,312.1673220 26 $153.66 $179.35 $205.03 $230.7273221 $774.11 $735.01 $695.91 $656.8173221 26 $146.52 $156.77 $167.02 $177.2773221 TC $690.00 $634.48 $578.96 $523.4473500 $44.95 $46.31 $47.67 $49.0373500 26 $15.95 $16.15 $16.35 $16.5573510 $51.34 $55.12 $58.90 $62.6873510 26 $18.87 $20.31 $21.75 $23.1973510 TC $20.70 $25.00 $29.31 $33.61

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 80 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

73520 $71.56 $73.61 $75.66 $77.7173520 26 $26.52 $27.16 $27.81 $28.4573525 $146.98 $155.50 $164.02 $172.5473525 26 $55.77 $58.13 $60.50 $62.8673530 $57.50 $55.39 $53.28 $51.1873530 26 $27.89 $29.76 $31.63 $33.5073540 $57.50 $54.83 $52.16 $49.4973540 26 $20.51 $21.96 $23.42 $24.8773550 $57.91 $58.86 $59.82 $60.7773550 26 $18.92 $19.75 $20.58 $21.4173560 $47.25 $50.16 $53.08 $55.9973560 26 $17.00 $18.18 $19.35 $20.5373562 $51.36 $55.54 $59.72 $63.9073562 26 $17.83 $20.30 $22.78 $25.2573564 $56.40 $60.66 $64.93 $69.1973564 26 $23.88 $25.07 $26.27 $27.4673565 $60.59 $60.03 $59.47 $58.9273565 26 $16.52 $17.91 $19.30 $20.6873580 $205.85 $212.71 $219.58 $226.4473580 26 $56.96 $59.06 $61.15 $63.2573590 $47.70 $51.10 $54.50 $57.9073590 26 $16.52 $18.15 $19.78 $21.4173590 TC $28.75 $29.18 $29.61 $30.0473592 $43.70 $47.14 $50.58 $54.0373592 26 $14.95 $16.21 $17.46 $18.7273600 $47.71 $49.79 $51.87 $53.9473600 26 $16.01 $17.36 $18.72 $20.0773610 $51.28 $53.76 $56.23 $58.7173610 26 $17.83 $19.23 $20.64 $22.0473610 TC $32.20 $31.83 $31.45 $31.0873615 $131.24 $135.61 $139.99 $144.3673615 26 $55.77 $80.71 $105.66 $130.6073620 $47.46 $49.78 $52.10 $54.4273620 26 $15.59 $17.08 $18.58 $20.0773630 $49.92 $51.97 $54.03 $56.0873630 26 $18.69 $19.60 $20.50 $21.4173650 $46.41 $48.27 $50.13 $51.9973650 26 $16.13 $17.18 $18.23 $19.2873660 $39.98 $41.67 $43.37 $45.0673660 26 $11.88 $13.14 $14.39 $15.6573700 $395.60 $377.95 $360.30 $342.6673700 26 $108.78 $112.29 $115.81 $119.3273701 $457.70 $437.25 $416.80 $396.3573701 26 $123.83 $126.60 $129.37 $132.1473702 $552.00 $523.80 $495.59 $467.3973702 26 $130.07 $145.35 $160.63 $175.9173720 $801.55 $1,030.36 $1,259.17 $1,487.9773720 26 $153.66 $179.24 $204.81 $230.3973721 $808.30 $757.80 $707.31 $656.8173721 26 $154.54 $164.35 $174.16 $183.9674000 $46.53 $47.70 $48.88 $50.0574000 26 $17.51 $18.87 $20.23 $21.6074010 $64.67 $64.76 $64.85 $64.9474010 26 $23.24 $24.59 $25.94 $27.2974020 $63.82 $67.43 $71.05 $74.6674020 26 $25.66 $26.95 $28.23 $29.5274022 $89.55 $88.75 $87.96 $87.1674022 26 $32.49 $33.71 $34.92 $36.1474150 $446.20 $423.97 $401.74 $379.5274150 26 $115.53 $122.15 $128.77 $135.39

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 81 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

74160 $523.25 $499.91 $476.57 $453.2274160 26 $132.97 $139.99 $147.02 $154.0474170 $632.50 $596.20 $559.91 $523.6174170 26 $143.95 $151.15 $158.35 $165.5574181 $811.90 $762.84 $713.78 $664.7274181 26 $161.16 $172.59 $184.02 $195.4574190 $110.40 $114.08 $117.76 $121.4474190 26 $62.46 $61.27 $60.07 $58.8874210 $104.07 $106.75 $109.42 $112.1074210 26 $38.72 $42.61 $46.49 $50.3874220 $111.06 $112.62 $114.17 $115.7374220 26 $47.12 $49.42 $51.72 $54.0274230 $151.12 $152.52 $153.93 $155.3374230 26 $57.69 $53.42 $49.14 $44.8774235 $240.74 $242.40 $244.07 $245.7374235 26 $135.57 $133.89 $132.20 $130.5274240 $147.56 $150.07 $152.58 $155.0974240 26 $65.09 $73.02 $80.96 $88.8974241 $155.87 $157.69 $159.51 $161.3374241 26 $65.68 $68.40 $71.13 $73.8574245 $221.45 $224.12 $226.79 $229.4674245 26 $86.94 $94.23 $101.52 $108.8074246 $162.81 $165.58 $168.35 $171.1274246 26 $65.09 $73.40 $81.71 $90.0274247 $163.30 $168.74 $174.19 $179.6374247 26 $65.68 $69.57 $73.46 $77.3574249 $234.60 $242.92 $251.23 $259.5574249 26 $84.34 $92.10 $99.87 $107.6374250 $127.86 $128.25 $128.64 $129.0374250 26 $45.46 $48.67 $51.89 $55.1074251 $126.50 $130.72 $134.93 $139.1574251 26 $60.74 $61.96 $63.18 $64.4074260 $134.55 $139.04 $143.52 $148.0174260 26 $56.55 $62.13 $67.72 $73.3074270 $171.53 $171.54 $171.55 $171.5574270 26 $63.61 $68.83 $74.05 $79.2774280 $232.20 $232.15 $232.10 $232.0574280 26 $88.85 $96.22 $103.59 $110.9674283 $333.50 $344.62 $355.73 $366.8574283 26 $252.33 $228.97 $205.61 $182.2574290 $84.71 $86.08 $87.46 $88.8374290 26 $30.85 $32.77 $34.69 $36.6174291 $63.71 $60.28 $56.86 $53.4374291 26 $23.09 $22.94 $22.80 $22.6574300 $96.60 $92.27 $87.93 $83.6074300 26 $41.50 $42.38 $43.27 $44.1574301 $44.85 $46.35 $47.84 $49.3474301 26 $19.77 $21.01 $22.24 $23.4874305 $104.80 $104.49 $104.18 $103.8874305 26 $41.81 $40.40 $39.00 $37.5974320 $171.74 $177.46 $183.19 $188.9174320 26 $59.96 $57.12 $54.29 $51.4574327 $180.07 $186.07 $192.08 $198.0874327 26 $99.89 $94.19 $88.50 $82.8074328 $250.70 $259.06 $267.41 $275.7774328 26 $76.58 $78.50 $80.43 $82.3574329 $250.70 $259.06 $267.41 $275.7774329 26 $76.58 $74.30 $72.02 $69.7474330 $179.93 $185.93 $191.92 $197.9274330 26 $74.78 $83.73 $92.68 $101.63

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 82 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

74340 $186.64 $192.37 $198.10 $203.8474340 26 $89.29 $86.65 $84.00 $81.3674350 $255.30 $263.81 $272.32 $280.8374350 26 $78.08 $75.55 $73.02 $70.5074355 $167.89 $174.28 $180.67 $187.0674355 26 $81.98 $78.37 $74.77 $71.1674360 $236.90 $244.80 $252.69 $260.5974360 26 $57.71 $65.79 $73.86 $81.9474363 $469.20 $484.84 $500.48 $516.1274363 26 $223.19 $176.71 $130.22 $83.7474400 $149.95 $154.08 $158.21 $162.3474400 26 $51.90 $55.69 $59.48 $63.2774410 $173.11 $177.36 $181.61 $185.8674410 26 $52.23 $55.14 $58.04 $60.9574415 $180.80 $184.40 $188.00 $191.6074415 26 $52.45 $55.79 $59.12 $62.4674420 $188.60 $194.89 $201.17 $207.4674420 26 $32.35 $35.60 $38.84 $42.0974425 $82.20 $84.94 $87.68 $90.4274425 26 $37.03 $36.85 $36.68 $36.5074430 $91.46 $99.47 $107.47 $115.4874430 26 $30.47 $30.03 $29.59 $29.1574440 $101.20 $104.57 $107.95 $111.3274440 26 $36.80 $36.87 $36.94 $37.0174445 $173.65 $179.44 $185.23 $191.0274445 26 $108.14 $109.67 $111.20 $112.7374450 $83.66 $98.77 $113.88 $129.0074450 26 $32.34 $33.75 $35.15 $36.5674455 $109.81 $116.13 $122.46 $128.7874455 26 $34.77 $37.77 $40.78 $43.7874470 $124.20 $128.34 $132.48 $136.6274470 26 $50.85 $53.74 $56.64 $59.5374475 $292.10 $301.84 $311.57 $321.3174475 26 $115.45 $99.09 $82.73 $66.3674480 $292.10 $301.84 $311.57 $321.3174480 26 $118.84 $101.24 $83.65 $66.0574485 $236.90 $244.80 $252.69 $260.5974485 26 $57.95 $61.23 $64.51 $67.8074710 26 $33.59 $35.83 $38.07 $40.3174740 $103.86 $110.35 $116.83 $123.3274740 26 $37.77 $42.01 $46.25 $50.5074742 $241.35 $253.39 $265.42 $277.4674742 26 $52.41 $57.11 $61.82 $66.5274775 $144.90 $152.67 $160.43 $168.2074775 26 $57.50 $60.05 $62.60 $65.1475600 $163.30 $168.74 $174.19 $179.6375600 26 $49.55 $51.23 $52.92 $54.6075605 $191.24 $197.61 $203.99 $210.3675605 26 $79.72 $100.65 $121.58 $142.5275625 $370.30 $382.64 $394.99 $407.3375625 26 $97.47 $104.03 $110.58 $117.1475630 $463.45 $478.90 $494.35 $509.8075630 26 $194.62 $188.76 $182.90 $177.0475650 $600.30 $620.31 $640.32 $660.3375650 26 $136.01 $146.04 $156.07 $166.1075658 $370.30 $382.64 $394.99 $407.3375658 26 $97.60 $114.28 $130.95 $147.6375660 $370.30 $382.64 $394.99 $407.3375660 26 $111.47 $125.58 $139.69 $153.8075662 $592.25 $612.10 $631.96 $651.81

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 83 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

75662 26 $179.67 $183.66 $187.65 $191.6475665 $258.74 $464.54 $670.33 $876.1375665 26 $96.65 $115.76 $134.86 $153.9775671 $328.01 $338.94 $349.88 $360.8175671 26 $170.25 $178.90 $187.55 $196.1975676 $370.30 $382.64 $394.99 $407.3375676 26 $103.80 $116.27 $128.75 $141.2275680 $648.60 $670.22 $691.84 $713.4675680 26 $168.07 $176.60 $185.12 $193.6575685 $370.30 $382.64 $394.99 $407.3375685 26 $98.02 $116.44 $134.85 $153.2775705 $385.49 $398.34 $411.19 $424.0475705 26 $131.11 $176.94 $222.77 $268.6075710 $212.36 $391.47 $570.58 $749.6975710 26 $64.97 $84.23 $103.49 $122.7675716 $249.88 $258.21 $266.54 $274.8775716 26 $97.39 $109.11 $120.83 $132.5575722 $258.74 $267.36 $275.99 $284.6175722 26 $92.98 $102.75 $112.52 $122.2975724 $461.15 $476.53 $491.90 $507.2875724 26 $139.41 $150.42 $161.43 $172.4475726 $282.74 $292.16 $301.59 $311.0175726 26 $131.34 $129.73 $128.12 $126.5075731 $258.74 $267.36 $275.99 $284.6175731 26 $89.46 $123.22 $156.99 $190.7575733 $500.25 $516.93 $533.60 $550.2875733 26 $147.15 $166.56 $185.98 $205.3975736 $258.74 $267.36 $275.99 $284.6175736 26 $92.98 $106.98 $120.99 $134.9975741 $340.40 $351.75 $363.09 $374.4475741 26 $120.02 $131.04 $142.07 $153.0975743 $410.55 $424.24 $437.92 $451.6175743 26 $141.62 $153.04 $164.46 $175.8975746 $185.15 $191.32 $197.50 $203.6775746 26 $97.65 $107.38 $117.11 $126.8475756 $267.95 $453.08 $638.21 $823.3475756 26 $90.76 $103.58 $116.40 $129.2275774 $145.22 $150.06 $154.90 $159.7475774 26 $48.88 $47.39 $45.89 $44.4075790 $516.13 $442.08 $368.02 $293.9775790 26 $203.58 $186.12 $168.65 $151.1975801 $221.36 $228.74 $236.12 $243.5075801 26 $78.82 $82.75 $86.69 $90.6275803 $260.36 $269.04 $277.72 $286.4075803 26 $85.87 $97.62 $109.37 $121.1275805 $230.36 $238.04 $245.72 $253.4075805 26 $90.85 $91.56 $92.27 $92.9775807 $370.30 $382.64 $394.99 $407.3375807 26 $101.17 $109.92 $118.66 $127.4175809 $79.35 $79.72 $80.08 $80.4575809 26 $37.26 $41.96 $46.66 $51.3675810 $161.99 $167.39 $172.79 $178.1975810 26 $59.53 $77.91 $96.29 $114.6775820 $135.12 $138.82 $142.51 $146.2175820 26 $70.08 $77.03 $83.97 $90.9275822 $154.98 $160.15 $165.31 $170.4875822 26 $98.85 $102.76 $106.67 $110.5875825 $198.74 $205.36 $211.99 $218.6175825 26 $74.40 $102.14 $129.88 $157.6275827 $198.74 $205.36 $211.99 $218.61

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 84 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

75827 26 $81.73 $99.53 $117.33 $135.1275831 $198.74 $205.36 $211.99 $218.6175831 26 $81.73 $102.78 $123.83 $144.8775833 $231.26 $238.97 $246.68 $254.3975833 26 $116.89 $132.61 $148.33 $164.0575840 $198.74 $205.36 $211.99 $218.6175840 26 $81.73 $98.06 $114.39 $130.7175842 $315.10 $325.60 $336.11 $346.6175842 26 $129.15 $141.98 $154.81 $167.6475860 $370.30 $505.89 $641.48 $777.0775860 26 $92.00 $105.64 $119.28 $132.9375870 $198.74 $205.36 $211.99 $218.6175870 26 $81.73 $97.73 $113.74 $129.7475872 $198.74 $205.36 $211.99 $218.6175872 26 $74.26 $93.22 $112.18 $131.1475880 $185.99 $192.19 $198.39 $204.5975880 26 $53.24 $61.54 $69.85 $78.1575885 $315.10 $325.60 $336.11 $346.6175885 26 $126.57 $136.83 $147.09 $157.3575887 $315.10 $325.60 $336.11 $346.6175887 26 $124.45 $131.36 $138.27 $145.1875889 $278.30 $287.58 $296.85 $306.1375889 26 $79.54 $98.01 $116.48 $134.9575891 $198.74 $205.36 $211.99 $218.6175891 26 $74.12 $97.59 $121.05 $144.5275893 $463.45 $478.90 $494.35 $509.8075893 26 $238.73 $179.53 $120.32 $61.1275894 $370.30 $382.64 $394.99 $407.3375894 26 $111.47 $149.37 $187.27 $225.1875896 $292.81 $302.57 $312.33 $322.0975896 26 $110.27 $143.37 $176.48 $209.5875898 $311.69 $322.08 $332.47 $342.8675898 26 $231.15 $238.42 $245.69 $252.9675900 $1,355.85 30 $1,401.05 $1,446.24 $1,491.4475940 $185.15 $191.32 $197.50 $203.6775940 26 $48.90 $68.23 $87.56 $106.8975960 $864.80 $893.63 $922.45 $951.2875960 26 $82.76 $89.41 $96.06 $102.7175961 $1,005.10 $1,038.60 $1,072.11 $1,105.6175961 26 $464.63 $461.88 $459.14 $456.3975962 $671.60 $693.99 $716.37 $738.7675962 26 $40.72 $55.18 $69.64 $84.1075964 $362.25 $374.33 $386.40 $398.4875964 26 $28.75 $41.09 $53.43 $65.7775966 $717.60 $741.52 $765.44 $789.3675966 26 $96.98 $127.61 $158.25 $188.8875968 $362.25 $374.33 $386.40 $398.4875968 26 $27.13 $39.54 $51.95 $64.3575970 $763.60 $789.05 $814.51 $839.9675970 26 $68.68 $82.91 $97.14 $111.3775978 $341.52 $352.90 $364.29 $375.6775978 26 $102.97 $99.31 $95.66 $92.0075980 $451.95 $467.02 $482.08 $497.1575980 26 $152.97 $147.51 $142.06 $136.6075982 $492.20 $508.61 $525.01 $541.4275982 26 $184.60 $165.15 $145.69 $126.2475984 $192.05 $198.45 $204.86 $211.2675984 26 $78.62 $72.91 $67.19 $61.4875989 $216.80 $253.84 $290.87 $327.9175989 26 $100.79 $112.69 $124.60 $136.50

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 85 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

75992 $888.95 $918.58 $948.22 $977.8575992 26 $41.84 $58.59 $75.34 $92.0975993 $479.55 $495.54 $511.52 $527.5175993 26 $26.55 $31.93 $37.30 $42.6875994 $949.90 $981.56 $1,013.23 $1,044.8975994 26 $110.80 $122.18 $133.56 $144.9475995 $949.90 $981.56 $1,013.23 $1,044.8975995 26 $99.85 $115.30 $130.75 $146.2075996 $997.05 $1,030.29 $1,063.52 $1,096.7675996 26 $26.55 $36.28 $46.00 $55.7376000 $102.23 $115.09 $127.96 $140.8276000 26 $25.73 $33.29 $40.86 $48.4276001 $232.30 $228.07 $223.84 $219.6176001 26 $114.13 $104.81 $95.48 $86.1676003 $126.50 $139.16 $151.82 $164.4876003 26 $56.55 $59.37 $62.19 $65.0276010 $47.15 $45.92 $44.69 $43.4576010 26 $17.41 $17.25 $17.09 $16.9476020 $47.48 $52.36 $57.23 $62.1176020 26 $17.66 $19.65 $21.63 $23.6276040 $74.94 $77.66 $80.39 $83.1176040 26 $26.71 $29.61 $32.51 $35.4176061 $105.86 $108.61 $111.37 $114.1276061 26 $45.76 $45.80 $45.83 $45.8776062 $156.65 $158.64 $160.62 $162.6176062 26 $55.98 $59.12 $62.25 $65.3976065 $69.00 $75.60 $82.20 $88.8076065 26 $27.48 $35.85 $44.21 $52.5876066 $82.18 $85.95 $89.71 $93.4876066 26 $27.94 $28.84 $29.74 $30.6476076 $116.10 $102.34 $88.59 $74.8376076 26 $20.20 $23.33 $26.45 $29.5876080 $105.13 $111.23 $117.33 $123.4376080 26 $51.36 $53.97 $56.58 $59.1976086 $188.60 $195.31 $202.03 $208.7476086 26 $33.83 $34.83 $35.84 $36.8476088 $258.75 $267.38 $276.00 $284.6376088 26 $45.04 $45.96 $46.87 $47.7976090 $76.89 $91.23 $105.56 $119.9076090 26 $24.70 $35.64 $46.58 $57.5276091 $98.46 $120.79 $143.12 $165.4576091 26 $35.38 $47.69 $60.00 $72.3176092 $95.80 $104.27 $112.75 $121.2276092 26 $35.38 $42.12 $48.86 $55.6076095 $607.32 $604.29 $601.26 $598.2376095 26 $155.28 $159.87 $164.46 $169.0576096 $192.17 $181.19 $170.22 $159.2476096 26 $82.22 $76.28 $70.34 $64.4076098 $46.04 $46.90 $47.76 $48.6376098 26 $19.26 $19.85 $20.44 $21.0376100 $148.35 $151.08 $153.80 $156.5376100 26 $61.58 $61.88 $62.19 $62.4976100 TC $67.85 $70.11 $72.38 $74.6476101 $167.27 $168.11 $168.94 $169.7876101 26 $80.60 $76.69 $72.77 $68.8676102 $192.01 $192.70 $193.38 $194.0776102 26 $80.60 $76.69 $72.77 $68.8676120 $96.60 $100.61 $104.63 $108.6476120 26 $29.62 $33.80 $37.99 $42.1776125 $71.30 $74.59 $77.88 $81.17

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 86 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

76125 26 $24.15 $25.40 $26.66 $27.9176140 $38.92 $41.85 $44.79 $47.7276140 26 $38.92 $40.22 $41.51 $42.8176150 $50.60 $44.06 $37.51 $30.9776150 26 $21.76 $22.49 $23.21 $23.9476350 $33.35 $34.46 $35.58 $36.6976350 26 $35.38 $36.56 $37.74 $38.9276355 $662.69 $676.79 $690.89 $704.9876355 26 $114.10 $121.12 $128.14 $135.1676360 $419.53 $433.51 $447.50 $461.4876360 26 $108.89 $120.65 $132.41 $144.1776370 $244.58 $261.56 $278.55 $295.5376370 26 $82.21 $85.59 $88.98 $92.3676380 $296.70 $287.29 $277.88 $268.4676380 26 $87.37 $94.49 $101.60 $108.7276506 $153.59 $157.32 $161.05 $164.7876506 26 $68.88 $74.12 $79.35 $84.5976511 $122.32 $146.44 $170.56 $194.6776511 26 $72.45 $80.11 $87.77 $95.4376512 $139.32 $171.95 $204.58 $237.2176512 26 $66.70 $74.31 $81.91 $89.5276513 $150.65 $194.38 $238.11 $281.8476513 26 $66.70 $67.54 $68.37 $69.2176516 $143.14 $157.10 $171.05 $185.0176516 26 $55.20 $57.04 $58.88 $60.7276519 $112.61 $128.20 $143.78 $159.3776519 26 $50.60 $50.11 $49.61 $49.1276519 TC $75.90 $78.43 $80.96 $83.4976529 $133.40 $161.59 $189.77 $217.9676529 26 $51.75 $54.19 $56.62 $59.0676536 $147.02 $153.82 $160.63 $167.4376536 26 $62.30 $66.32 $70.35 $74.3776604 $127.65 $122.67 $117.69 $112.7176604 26 $55.31 $58.99 $62.67 $66.3576645 $127.98 $130.46 $132.94 $135.4176645 26 $58.74 $60.34 $61.93 $63.5376700 $205.34 $215.42 $225.50 $235.5876700 26 $95.56 $99.73 $103.90 $108.0776705 $153.16 $159.23 $165.30 $171.3776705 26 $65.21 $67.36 $69.51 $71.6676770 $186.79 $192.45 $198.12 $203.7876770 26 $81.58 $84.36 $87.14 $89.9376770 TC $112.15 $115.89 $119.63 $123.3776775 $149.41 $151.47 $153.54 $155.6076775 26 $62.10 $63.10 $64.10 $65.1076778 $176.26 $181.47 $186.67 $191.8876778 26 $86.92 $77.78 $68.64 $59.5076800 $186.30 $179.14 $171.98 $164.8276800 26 $89.46 $96.81 $104.16 $111.5176805 $212.39 $221.35 $230.32 $239.2876805 26 $96.61 $99.26 $101.91 $104.5676805 TC $113.85 $117.65 $121.44 $125.2476810 $425.50 $383.43 $341.36 $299.2976810 26 $171.89 $158.12 $144.34 $130.5776815 $145.98 $151.08 $156.18 $161.2876815 26 $64.95 $67.28 $69.61 $71.9476816 $119.04 $131.51 $143.99 $156.4676816 26 $55.02 $62.01 $68.99 $75.9876818 $166.44 $184.26 $202.07 $219.8976818 26 $87.17 $95.33 $103.49 $111.65

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 87 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

76825 $178.85 $219.75 $260.66 $301.5676825 26 $81.25 $106.88 $132.52 $158.1576826 $117.30 $129.67 $142.03 $154.4076826 26 $81.95 $80.94 $79.93 $78.9276827 $158.70 $165.71 $172.73 $179.7476827 26 $73.91 $75.62 $77.34 $79.0576828 $49.68 $74.85 $100.01 $125.1876828 26 $58.39 $58.16 $57.93 $57.7176830 $180.82 $186.87 $192.92 $198.9776830 26 $70.07 $77.78 $85.49 $93.2076830 TC $124.56 $128.71 $132.87 $137.0276831 $169.29 $180.55 $191.81 $203.0776831 26 $69.25 $76.30 $83.34 $90.3976831 TC $90.78 $93.81 $96.83 $99.8676856 $173.72 $181.97 $190.22 $198.4776856 26 $77.33 $79.66 $82.00 $84.3376857 $103.42 $119.88 $136.34 $152.7976857 26 $38.94 $42.17 $45.39 $48.6276870 $140.23 $145.81 $151.38 $156.9676870 26 $62.71 $68.04 $73.36 $78.6976870 TC $81.85 $84.58 $87.31 $90.0476872 $232.75 $220.46 $208.16 $195.8776872 26 $109.58 $102.65 $95.71 $88.7876872 TC $117.07 $120.97 $124.88 $128.7876880 $126.66 $133.14 $139.63 $146.1176880 26 $56.89 $62.44 $67.99 $73.5476885 $172.25 $177.46 $182.66 $187.8776885 26 $71.81 $76.90 $81.98 $87.0776885 TC $90.78 $93.80 $96.81 $99.8376886 $152.34 $155.19 $158.04 $160.8976886 26 $60.89 $64.10 $67.30 $70.5176886 TC $84.26 $87.07 $89.88 $92.6976930 $128.00 $132.27 $136.53 $140.8076930 26 $72.77 $77.81 $82.85 $87.9076932 $132.26 $136.67 $141.08 $145.4976932 26 $67.85 $75.32 $82.78 $90.2576936 $475.24 30 $476.39 $477.53 $478.6876941 $206.09 30 $206.60 $207.11 $207.6276942 $150.93 $194.94 $238.95 $282.9576942 26 $74.60 $80.40 $86.19 $91.9976942 TC $90.71 $93.73 $96.76 $99.7876945 $175.56 30 $182.28 $189.00 $195.7276946 $128.74 $147.56 $166.37 $185.1976946 26 $46.88 $50.13 $53.39 $56.6476950 $129.95 $134.28 $138.62 $142.9576950 26 $42.56 $51.73 $60.91 $70.0876965 $491.58 $479.68 $467.79 $455.8976970 $88.71 $91.48 $94.25 $97.0376970 26 $38.42 $39.20 $39.97 $40.7576975 $171.35 $175.77 $180.18 $184.6076975 26 $92.46 $97.48 $102.49 $107.5176986 $264.50 $290.40 $316.30 $342.2076986 26 $129.82 $140.62 $151.42 $162.2377261 $136.83 $143.09 $149.35 $155.6277261 26 $136.83 $141.39 $145.95 $150.5177262 $198.12 $207.07 $216.02 $224.9777262 26 $198.12 $204.72 $211.33 $217.9377263 $296.43 $312.14 $327.85 $343.5777263 26 $296.43 $306.31 $316.19 $326.0777280 $203.79 $243.33 $282.88 $322.42

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 88 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

77280 26 $63.54 $67.06 $70.58 $74.1077285 $322.12 $384.99 $447.87 $510.7477285 26 $96.37 $101.31 $106.26 $111.2077290 $408.91 $462.41 $515.92 $569.4277290 26 $147.91 $144.35 $140.80 $137.2477295 $2,190.75 $2,291.05 $2,391.35 $2,491.6577295 26 $426.65 $445.37 $464.10 $482.8277300 $97.69 $117.96 $138.23 $158.5177300 26 $50.44 $55.67 $60.91 $66.1477305 $131.10 $155.79 $180.49 $205.1877305 26 $63.60 $67.16 $70.72 $74.2877310 $181.24 $211.94 $242.64 $273.3377310 26 $97.99 $103.16 $108.33 $113.4977315 $242.86 $277.56 $312.26 $346.9677315 26 $150.61 $156.86 $163.12 $169.3777321 $241.99 $290.68 $339.36 $388.0577321 26 $91.99 $96.25 $100.51 $104.7777326 $182.48 $188.56 $194.65 $200.7377326 26 $96.98 $100.79 $104.60 $108.4177327 $276.57 $314.17 $351.77 $389.3777327 26 $152.07 $157.08 $162.09 $167.0977328 $422.68 $470.77 $518.86 $566.9677328 26 $244.93 $251.83 $258.73 $265.6377331 $81.94 $95.17 $108.40 $121.6377331 26 $66.94 $74.71 $82.48 $90.2677332 $108.61 $122.62 $136.64 $150.6577332 26 $60.61 $58.79 $56.97 $55.1577333 $147.61 $172.09 $196.56 $221.0477333 26 $79.36 $81.68 $84.00 $86.3277334 $222.61 $267.96 $313.31 $358.6677334 26 $105.61 $113.20 $120.80 $128.3977336 $122.47 $154.51 $186.55 $218.5877336 26 $64.36 $66.51 $68.65 $70.8077370 $160.63 $192.31 $223.98 $255.6677370 26 $105.52 $109.04 $112.55 $116.0777401 $105.80 $112.88 $119.96 $127.0377401 26 $105.80 $109.33 $112.85 $116.3877402 $105.80 $194.36 $282.93 $371.4977402 26 $105.80 $109.33 $112.85 $116.3877403 $105.80 $113.94 $122.09 $130.2377403 26 $105.80 $109.33 $112.85 $116.3877404 $105.80 $113.94 $122.09 $130.2377404 26 $105.80 $109.33 $112.85 $116.3877406 $105.80 $113.94 $122.09 $130.2377406 26 $105.80 $109.33 $112.85 $116.3877407 $125.35 $134.70 $144.05 $153.4177407 26 $125.35 $129.53 $133.71 $137.8977408 $125.35 $134.70 $144.05 $153.4177408 26 $125.35 $129.53 $133.71 $137.8977409 $125.35 $134.70 $144.05 $153.4177409 26 $125.35 $129.53 $133.71 $137.8977411 $125.35 $134.70 $144.05 $153.4177411 26 $125.35 $129.53 $133.71 $137.8977412 $139.15 $149.79 $160.43 $171.0777412 26 $139.15 $143.79 $148.43 $153.0777413 $139.15 $149.79 $160.43 $171.0777413 26 $139.15 $143.79 $148.43 $153.0777414 $139.15 $149.79 $160.43 $171.0777414 26 $139.15 $143.79 $148.43 $153.0777416 $139.15 $149.79 $160.43 $171.07

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 89 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

77416 26 $139.15 $143.79 $148.43 $153.0777417 $35.65 $38.28 $40.91 $43.5477417 26 $35.65 $36.84 $38.03 $39.2277431 $139.23 $155.39 $171.55 $187.7177431 26 $161.00 $166.37 $171.73 $177.1077432 $825.70 $836.37 $847.03 $857.7077470 $577.98 $725.62 $873.26 $1,020.9077470 26 $160.23 $178.60 $196.97 $215.3477600 $313.35 $334.18 $355.00 $375.8377600 26 $206.85 $210.31 $213.76 $217.2277605 $336.87 $392.11 $447.36 $502.6077605 26 $195.12 $239.87 $284.62 $329.3677610 $417.19 $403.48 $389.76 $376.0577610 26 $299.44 $294.10 $288.76 $283.4177615 $590.50 $560.67 $530.85 $501.0277615 26 $433.00 $431.82 $430.63 $429.4577620 $320.85 $340.27 $359.70 $379.1277620 26 $140.30 $145.40 $150.50 $155.6077750 $411.29 $425.00 $438.71 $452.4277750 26 $419.47 $451.37 $483.28 $515.1877761 $498.82 $520.13 $541.44 $562.7677761 26 $388.19 $384.82 $381.45 $378.0777762 $712.98 $743.09 $773.19 $803.3077762 26 $522.10 $519.57 $517.04 $514.5277763 $910.13 $941.92 $973.70 $1,005.4977763 26 $711.51 $710.84 $710.17 $709.4977776 $536.06 $553.49 $570.92 $588.3477776 26 $462.56 $447.60 $432.64 $417.6777777 $773.41 $847.32 $921.23 $995.1377777 26 $630.16 $627.06 $623.97 $620.8777778 $1,046.76 $1,164.60 $1,282.43 $1,400.2777778 26 $872.76 $883.13 $893.50 $903.8777781 $917.70 $1,161.60 $1,405.51 $1,649.4177781 26 $94.30 $117.85 $141.40 $164.9577782 $964.85 $1,220.10 $1,475.34 $1,730.5977782 26 $141.45 $176.66 $211.86 $247.0777783 $1,035.00 $1,306.70 $1,578.39 $1,850.0977783 26 $211.60 $264.04 $316.48 $368.9277784 $1,140.80 $1,438.12 $1,735.44 $2,032.7677784 26 $317.40 $396.53 $475.65 $554.7877789 $173.56 $163.18 $152.79 $142.4177789 26 $158.56 $161.95 $165.34 $168.7377790 $131.65 $134.07 $136.50 $138.9277790 26 $116.65 $120.12 $123.60 $127.0778000 $74.75 $77.24 $79.74 $82.2378000 26 $21.11 $22.66 $24.20 $25.7578001 $101.20 $107.97 $114.74 $121.5178001 26 $25.36 $26.50 $27.63 $28.7778003 $86.25 $92.07 $97.88 $103.7078003 26 $32.20 $32.15 $32.09 $32.0478006 $186.30 $192.51 $198.72 $204.9378006 26 $53.85 $57.25 $60.66 $64.0678007 $198.95 $211.86 $224.76 $237.6778007 26 $51.75 $50.81 $49.87 $48.9378010 $142.60 $147.35 $152.11 $156.8678010 26 $41.41 $45.16 $48.91 $52.6778011 $185.15 $197.06 $208.98 $220.8978011 26 $47.15 $46.20 $45.25 $44.3078011 TC $138.00 $142.60 $147.20 $151.8078015 $213.90 $227.45 $241.01 $254.56

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 90 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

78015 26 $60.95 $62.63 $64.31 $65.9978016 $281.75 $299.78 $317.82 $335.8578016 26 $82.80 $82.24 $81.69 $81.1378018 $408.25 $421.86 $435.47 $449.0878018 26 $99.27 $103.83 $108.38 $112.9478070 $154.10 $159.24 $164.37 $169.5178070 26 $75.77 $77.66 $79.54 $81.4378075 $389.85 $403.83 $417.82 $431.8078075 26 $73.23 $77.88 $82.53 $87.1878102 $171.35 $177.06 $182.78 $188.4978102 26 $55.57 $59.64 $63.72 $67.7978103 $255.30 $263.81 $272.32 $280.8378103 26 $66.70 $69.93 $73.17 $76.4078104 $313.95 $324.42 $334.88 $345.3578104 26 $75.70 $82.67 $89.63 $96.6078110 $73.60 $78.84 $84.08 $89.3278110 26 $17.25 $17.89 $18.54 $19.1878111 $173.65 $179.40 $185.16 $190.9178111 26 $20.51 $21.50 $22.50 $23.4978120 $124.20 $132.80 $141.41 $150.0178120 26 $20.70 $21.41 $22.11 $22.8278121 $201.25 $207.96 $214.67 $221.3878121 26 $29.33 $30.64 $31.94 $33.2578122 $315.10 $328.11 $341.12 $354.1378122 26 $38.42 $44.32 $50.22 $56.1278130 $225.40 $232.91 $240.43 $247.9478130 26 $54.80 $55.83 $56.86 $57.9078135 $347.30 $371.67 $396.05 $420.4278135 26 $57.50 $59.43 $61.36 $63.2978140 $289.80 $299.46 $309.12 $318.7878140 26 $63.34 $67.53 $71.72 $75.9278185 $141.66 $146.38 $151.11 $155.8378185 26 $42.32 $42.83 $43.34 $43.8678190 $438.15 $468.19 $498.24 $528.2878190 26 $96.60 $100.92 $105.24 $109.5678191 $492.20 $527.07 $561.94 $596.8178191 26 $55.20 $56.75 $58.30 $59.8578195 $304.75 $307.31 $309.87 $312.4378195 26 $67.29 $85.25 $103.22 $121.1878201 $181.70 $187.76 $193.81 $199.8778201 26 $49.89 $47.83 $45.77 $43.7278202 $218.50 $225.78 $233.07 $240.3578202 26 $68.34 $64.95 $61.55 $58.1678205 $416.30 $430.18 $444.05 $457.9378205 26 $77.79 $84.65 $91.51 $98.3778215 $218.50 $225.78 $233.07 $240.3578215 26 $58.89 $65.29 $71.69 $78.1078216 $258.75 $276.01 $293.26 $310.5278216 26 $66.70 $68.85 $71.00 $73.1578220 $265.65 $283.81 $301.98 $320.1478220 26 $50.60 $49.65 $48.71 $47.7678223 $293.25 $303.03 $312.80 $322.5878223 26 $83.15 $89.53 $95.91 $102.2978230 $171.35 $177.06 $182.78 $188.4978230 26 $46.25 $47.61 $48.97 $50.3378231 $235.75 $251.67 $267.58 $283.5078231 26 $52.90 $52.46 $52.02 $51.5878232 $253.00 $270.44 $287.87 $305.3178232 26 $55.84 $57.61 $59.38 $61.1578258 $238.05 $253.25 $268.46 $283.66

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 91 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

78258 26 $71.06 $74.83 $78.60 $82.3778261 $307.05 $327.64 $348.22 $368.8178261 26 $70.15 $69.53 $68.90 $68.2878262 $313.95 $324.42 $334.88 $345.3578262 26 $68.65 $70.81 $72.98 $75.1478264 $315.10 $325.60 $336.11 $346.6178264 26 $75.60 $80.45 $85.30 $90.1478270 $110.40 $112.24 $114.08 $115.9178270 26 $20.55 $22.27 $23.99 $25.7278271 $116.15 $118.17 $120.19 $122.2178271 26 $21.96 $22.07 $22.18 $22.2978272 $163.30 $169.41 $175.53 $181.6478272 26 $26.45 $26.94 $27.42 $27.9178278 $379.50 $392.15 $404.80 $417.4578278 26 $92.95 $91.14 $89.33 $87.5278282 $135.70 $140.22 $144.75 $149.2778282 26 $54.05 $55.85 $57.66 $59.4678290 $242.65 $250.74 $258.83 $266.9278290 26 $67.61 $73.83 $80.04 $86.2678290 TC $173.65 $140.56 $107.46 $74.3778291 $261.05 $277.70 $294.34 $310.9978291 26 $75.33 $80.31 $85.29 $90.2778300 $204.70 $211.52 $218.35 $225.1778300 26 $64.90 $66.59 $68.29 $69.9878305 $293.25 $303.03 $312.80 $322.5878305 26 $83.81 $86.49 $89.18 $91.8678306 $332.35 $343.43 $354.51 $365.5978306 26 $81.72 $88.93 $96.14 $103.3478306 TC $250.70 $259.06 $267.41 $275.7778315 $376.05 $388.59 $401.12 $413.6678315 26 $91.12 $98.37 $105.63 $112.8878320 $445.05 $459.89 $474.72 $489.5678320 26 $107.34 $107.42 $107.50 $107.5878414 $449.65 $464.64 $479.63 $494.6278414 26 $89.70 $92.69 $95.68 $98.6778428 $204.70 $211.52 $218.35 $225.1778428 26 $90.71 $93.25 $95.78 $98.3278445 $156.40 $161.61 $166.83 $172.0478445 26 $52.19 $59.27 $66.35 $73.4378445 TC $106.95 $110.52 $114.08 $117.6578457 $227.70 $235.29 $242.88 $250.4778457 26 $78.69 $80.49 $82.28 $84.0878458 $319.70 $330.36 $341.01 $351.6778458 26 $93.91 $97.31 $100.71 $104.1178460 $218.50 $225.78 $233.07 $240.3578460 26 $92.71 $93.59 $94.46 $95.3478461 $391.00 $404.03 $417.07 $430.1078461 26 $169.20 $163.13 $157.05 $150.9878464 $519.80 $537.13 $554.45 $571.7878464 26 $116.84 $113.52 $110.20 $106.8878465 $833.75 $861.54 $889.34 $917.1378465 26 $151.05 $163.21 $175.37 $187.5478465 TC $686.55 $709.44 $732.32 $755.2178466 $167.38 $172.96 $178.54 $184.1278466 26 $64.00 $70.91 $77.82 $84.7278468 $289.80 $308.81 $327.82 $346.8378468 26 $80.50 $79.82 $79.13 $78.4578469 $394.45 $420.44 $446.43 $472.4278469 26 $106.38 $109.78 $113.17 $116.5778472 $440.45 $455.13 $469.82 $484.50

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 92 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

78472 26 $95.05 $105.02 $115.00 $124.9778473 $660.10 $682.10 $704.11 $726.1178473 26 $137.28 $144.38 $151.47 $158.5778478 $163.30 $168.74 $174.19 $179.6378478 26 $73.74 $72.47 $71.20 $69.9478478 TC $80.50 $83.18 $85.87 $88.5578480 $148.35 $153.30 $158.24 $163.1978480 26 $55.74 $60.89 $66.04 $71.1878481 $297.35 $307.26 $317.18 $327.0978481 26 $93.75 $98.79 $103.83 $108.8878483 $634.80 $655.96 $677.12 $698.2878483 26 $133.33 $146.53 $159.73 $172.9278580 $271.40 $280.45 $289.49 $298.5478580 26 $77.22 $78.74 $80.26 $81.7878584 $279.45 $296.66 $313.86 $331.0778584 26 $100.05 $98.99 $97.93 $96.8778585 $432.40 $461.69 $490.98 $520.2678585 26 $100.45 $102.58 $104.71 $106.8478586 $190.90 $203.67 $216.44 $229.2178586 26 $40.25 $39.88 $39.50 $39.1378587 $193.70 $200.16 $206.61 $213.0778587 26 $56.12 $56.25 $56.39 $56.5278591 $205.85 $219.84 $233.83 $247.8278591 26 $40.25 $39.88 $39.50 $39.1378593 $249.55 $266.55 $283.56 $300.5678593 26 $49.83 $51.97 $54.11 $56.2578594 $345.00 $368.97 $392.93 $416.9078594 26 $55.20 $54.19 $53.18 $52.1778596 $535.90 $553.76 $571.63 $589.4978596 26 $144.15 $131.88 $119.61 $107.3478600 $211.60 $225.84 $240.07 $254.3178600 26 $51.75 $49.01 $46.27 $43.5478601 $249.55 $266.18 $282.81 $299.4378601 26 $52.90 $51.89 $50.88 $49.8778605 $250.70 $259.06 $267.41 $275.7778605 26 $60.67 $63.86 $67.04 $70.2378606 $287.50 $297.08 $306.67 $316.2578606 26 $76.57 $82.37 $88.17 $93.9778606 TC $223.10 $230.54 $237.97 $245.4178607 $500.25 $516.93 $533.60 $550.2878607 26 $129.54 $136.15 $142.76 $149.3678610 $120.75 $124.78 $128.80 $132.8378610 26 $31.96 $31.82 $31.68 $31.5478615 $266.80 $275.69 $284.59 $293.4878615 26 $45.85 $46.25 $46.65 $47.0578630 $361.10 $373.14 $385.17 $397.2178630 26 $76.62 $79.13 $81.63 $84.1478635 $207.00 $220.67 $234.34 $248.0278635 26 $64.02 $67.00 $69.97 $72.9578645 $256.45 $265.00 $273.55 $282.1078645 26 $57.24 $63.00 $68.75 $74.5178647 $453.10 $468.20 $483.31 $498.4178650 $331.20 $342.24 $353.28 $364.3278650 26 $65.70 $68.32 $70.95 $73.5778660 $174.80 $185.81 $196.83 $207.8478660 26 $55.20 $54.19 $53.18 $52.1778700 $220.80 $228.16 $235.52 $242.8878700 26 $43.22 $45.32 $47.42 $49.5278701 $256.45 $273.75 $291.05 $308.3578701 26 $50.58 $52.47 $54.36 $56.25

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 93 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

78701 TC $185.50 $191.68 $197.87 $204.0578704 $302.45 $312.53 $322.62 $332.7078704 26 $68.96 $69.18 $69.40 $69.6378707 $350.75 $362.44 $374.14 $385.8378707 26 $96.73 $101.00 $105.27 $109.5478708 $384.67 $395.10 $405.54 $415.9778708 26 $109.70 $116.68 $123.67 $130.6578708 TC $264.89 $273.72 $282.55 $291.3878709 $411.98 $430.87 $449.77 $468.6678709 26 $124.45 $134.99 $145.54 $156.0878709 TC $265.64 $274.49 $283.35 $292.2078710 $411.70 $425.42 $439.15 $452.8778710 26 $69.81 $73.67 $77.54 $81.4078715 $120.75 $124.78 $128.80 $132.8378715 26 $32.43 $32.13 $31.84 $31.5478725 $140.30 $144.98 $149.65 $154.3378725 26 $38.38 $40.83 $43.28 $45.7378730 $118.45 $122.99 $127.52 $132.0678730 26 $34.50 $36.26 $38.02 $39.7978740 $178.25 $184.19 $190.14 $196.0878740 26 $58.91 $61.48 $64.06 $66.6378760 $218.50 $225.78 $233.07 $240.3578760 26 $74.76 $72.59 $70.42 $68.2578761 $254.15 $262.62 $271.10 $279.5778761 26 $73.88 $75.38 $76.89 $78.3978800 $261.05 $269.75 $278.46 $287.1678800 26 $69.54 $69.18 $68.82 $68.4678801 $322.00 $332.73 $343.47 $354.2078801 26 $81.06 $83.13 $85.21 $87.2878802 $407.10 $420.67 $434.24 $447.8178802 26 $90.49 $94.40 $98.30 $102.2178805 $263.35 $272.13 $280.91 $289.6978805 26 $68.65 $70.63 $72.60 $74.5878806 $405.95 $419.48 $433.02 $446.5578806 26 $86.81 $92.62 $98.43 $104.2578807 $515.20 $539.87 $564.55 $589.2278807 26 $102.35 $104.47 $106.60 $108.7278890 $87.40 $90.31 $93.23 $96.1478890 26 $20.39 $24.43 $28.48 $32.5278891 $178.25 $184.19 $190.14 $196.0878891 26 $10.35 $26.68 $43.01 $59.3479200 $334.65 $345.81 $356.96 $368.1279200 26 $189.81 $194.85 $199.88 $204.9279300 $584.20 $603.67 $623.15 $642.6279300 26 $449.65 $464.64 $479.63 $494.6279440 $334.65 $353.51 $372.36 $391.2280050 $30.07 $38.17 $46.27 $54.3780051 $18.40 $19.39 $20.39 $21.3880055 $43.64 $45.47 $47.31 $49.1480061 $28.52 $31.29 $34.05 $36.8280100 $41.57 $41.12 $40.66 $40.2180101 $30.23 $32.91 $35.58 $38.2680102 $62.10 $52.19 $42.28 $32.3780150 $43.70 $41.58 $39.47 $37.3580152 $41.24 $40.92 $40.60 $40.2880154 $47.00 $49.75 $52.49 $55.2480156 $33.04 $35.72 $38.40 $41.0980160 $43.49 $42.37 $41.25 $40.1380162 $31.35 $33.37 $35.39 $37.4180164 $33.37 $35.68 $37.99 $40.30

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 94 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

80166 $35.24 $36.40 $37.57 $38.7380168 $47.15 $45.65 $44.15 $42.6580170 $49.45 $46.51 $43.57 $40.6380172 $49.45 $46.40 $43.36 $40.3180174 $39.74 $39.87 $40.00 $40.1380176 $32.04 $33.11 $34.17 $35.2480178 $15.90 $17.57 $19.25 $20.9280182 $35.24 $34.45 $33.66 $32.8780184 $40.25 $38.01 $35.76 $33.5280185 $36.87 $38.17 $39.47 $40.7880186 $34.50 $34.94 $35.39 $35.8380188 $35.39 $35.91 $36.42 $36.9480190 $44.85 $43.81 $42.77 $41.7380194 $29.62 $30.25 $30.88 $31.5180196 $20.79 $19.41 $18.02 $16.6480198 $25.80 $30.45 $35.10 $39.7680200 $46.00 $44.47 $42.94 $41.4080400 $87.40 $85.27 $83.14 $81.0180402 $157.55 $176.93 $196.31 $215.7080406 $157.55 $167.81 $178.07 $188.3380408 $193.20 $232.55 $271.91 $311.2680410 $79.35 $119.33 $159.30 $199.2880412 $354.20 $508.68 $663.16 $817.6380414 $189.75 $166.74 $143.73 $120.7280415 $156.40 $149.69 $142.98 $136.2880416 $251.48 $259.86 $268.25 $276.6380417 $168.98 $174.61 $180.25 $185.8880418 $808.45 $1,005.24 $1,202.04 $1,398.8380420 $120.67 $124.69 $128.72 $132.7480422 $72.45 $86.40 $100.35 $114.3080424 $106.95 $113.10 $119.25 $125.4180426 $166.75 $231.44 $296.12 $360.8180428 $105.80 $115.19 $124.58 $133.9880430 $113.85 $130.24 $146.63 $163.0280432 $278.30 $297.24 $316.18 $335.1280434 $129.96 $134.29 $138.63 $142.9680435 $134.14 $138.61 $143.08 $147.5580436 $138.00 $164.37 $190.74 $217.1080438 $50.70 $74.08 $97.46 $120.8580439 $72.21 $92.88 $113.55 $134.2280440 $92.00 $109.38 $126.76 $144.1380502 $98.05 $105.22 $112.40 $119.5781000 $11.87 $12.93 $13.99 $15.0581000 26 $2.30 $2.38 $2.45 $2.5381001 $10.13 $11.66 $13.20 $14.7381002 $5.24 $6.97 $8.69 $10.4281003 $4.49 $6.27 $8.05 $9.8381005 $5.00 $6.43 $7.87 $9.3081007 $10.47 $9.07 $7.68 $6.2881015 $7.04 $7.24 $7.43 $7.6381020 $6.90 $7.69 $8.47 $9.2681025 $13.69 $15.34 $16.99 $18.6581050 $1.00 $4.40 $7.81 $11.2182000 $28.75 $28.57 $28.40 $28.2282003 $46.00 $47.45 $48.89 $50.3482009 $11.96 $12.70 $13.45 $14.1982010 $21.20 $20.79 $20.38 $19.9782013 $28.75 $31.74 $34.74 $37.7382024 $61.28 $69.98 $78.68 $87.3882030 $46.00 $52.03 $58.05 $64.08

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 95 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

82040 $8.99 $10.51 $12.04 $13.5682042 $26.98 $22.88 $18.78 $14.6982043 $25.55 $23.62 $21.69 $19.7682044 $5.75 $7.82 $9.88 $11.9582055 $27.99 $28.96 $29.92 $30.8982075 $34.50 $33.05 $31.59 $30.1482085 $24.05 $24.24 $24.44 $24.6382088 $79.54 $85.15 $90.77 $96.3882101 $65.55 $67.74 $69.92 $72.1182103 $29.90 $32.21 $34.53 $36.8482105 $36.00 $38.49 $40.98 $43.4782106 $41.40 $41.51 $41.61 $41.7282108 $50.60 $55.04 $59.49 $63.9382128 $25.88 $28.79 $31.70 $34.6182131 $66.70 $58.15 $49.60 $41.0582135 $33.79 $34.77 $35.74 $36.7282140 $36.49 $34.85 $33.21 $31.5782143 $34.50 $31.82 $29.14 $26.4782145 $32.24 $33.31 $34.39 $35.4682150 $14.94 $23.51 $32.08 $40.6582157 $55.00 $62.64 $70.28 $77.9282160 $71.30 $67.17 $63.04 $58.9182163 $47.15 $46.78 $46.40 $46.0382164 $30.79 $32.55 $34.32 $36.0882172 $37.95 $39.24 $40.54 $41.8382175 $48.30 $47.89 $47.48 $47.0782180 $28.75 $28.14 $27.54 $26.9382205 $38.32 $39.60 $40.87 $42.1582232 $47.15 $44.87 $42.59 $40.3182240 $47.15 $53.43 $59.71 $65.9982252 $11.50 $11.43 $11.36 $11.2982270 $12.23 $11.76 $11.30 $10.8382300 $52.90 $55.27 $57.64 $60.0182306 $86.25 $84.09 $81.93 $79.7782307 $63.25 $73.37 $83.49 $93.6182308 $57.50 $61.98 $66.47 $70.9582310 $9.74 $11.75 $13.75 $15.7682330 $40.25 $37.15 $34.04 $30.9482331 $11.50 $11.93 $12.37 $12.8082340 $11.54 $12.99 $14.44 $15.8982355 $33.35 $34.44 $35.54 $36.6382360 $33.35 $33.44 $33.52 $33.6182365 $38.32 $38.06 $37.79 $37.5382370 $25.30 $27.24 $29.18 $31.1282374 $8.81 $10.90 $12.99 $15.0882375 $41.40 $36.95 $32.50 $28.0582376 $15.02 $15.52 $16.02 $16.5282378 $38.06 $39.21 $40.36 $41.5182380 $20.46 $20.76 $21.07 $21.3782382 $37.34 $37.65 $37.95 $38.2682383 $45.54 $47.06 $48.57 $50.0982384 $43.94 $48.24 $52.54 $56.8482390 $24.59 $24.58 $24.56 $24.5582415 $31.20 $32.24 $33.28 $34.3282435 $8.06 $10.19 $12.31 $14.4482436 $14.95 $15.16 $15.37 $15.5782438 $12.34 $12.15 $11.96 $11.7782441 $17.25 $16.49 $15.74 $14.9882465 $14.09 $14.21 $14.33 $14.4582480 $18.40 $18.63 $18.86 $19.08

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 96 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

82482 $42.55 $43.97 $45.39 $46.8182485 $58.65 $56.15 $53.64 $51.1482486 $38.17 $39.44 $40.72 $41.9982487 $47.15 $44.64 $42.13 $39.6282488 $58.65 $56.81 $54.98 $53.1482489 $51.75 $49.78 $47.82 $45.8582491 $39.45 $50.58 $61.70 $72.8382495 $52.90 $54.66 $56.43 $58.1982507 $80.50 $70.54 $60.58 $50.6282520 $29.90 $32.49 $35.07 $37.6682525 $36.80 $34.00 $31.20 $28.4082528 $43.70 $49.96 $56.23 $62.4982530 $20.70 $30.82 $40.93 $51.0582533 $31.10 $37.33 $43.57 $49.8082540 $11.50 $11.88 $12.27 $12.6582550 $14.94 $16.42 $17.90 $19.3982550 26 $9.20 $9.51 $9.81 $10.1282552 $20.36 $23.75 $27.15 $30.5482552 26 $9.20 $9.51 $9.81 $10.1282553 $21.02 $23.87 $26.71 $29.5682554 $21.85 $20.88 $19.90 $18.9382565 $14.09 $15.12 $16.16 $17.1982570 $13.49 $13.55 $13.61 $13.6782575 $23.29 $21.86 $20.44 $19.0182585 $20.00 $21.18 $22.35 $23.5382595 $16.37 $16.37 $16.38 $16.3882600 $36.49 $37.71 $38.92 $40.1482607 $34.28 $33.21 $32.14 $31.0882608 $43.70 $43.43 $43.16 $42.8982615 $20.70 $19.71 $18.73 $17.7482626 $57.96 $58.88 $59.81 $60.7382627 $24.24 $33.93 $43.63 $53.3282633 $67.15 $68.75 $70.34 $71.9482634 $88.55 $84.40 $80.26 $76.1182638 $47.15 $41.10 $35.04 $28.9982646 $63.25 $57.30 $51.35 $45.4082649 $47.15 $51.91 $56.67 $61.4282651 $78.20 $73.37 $68.54 $63.7182652 $115.00 $106.66 $98.33 $89.9982654 $43.70 $40.60 $37.50 $34.4082664 $41.40 $59.96 $78.53 $97.0982666 $63.25 $57.30 $51.35 $45.4082668 $50.60 $49.83 $49.06 $48.2982670 $65.00 $66.85 $68.69 $70.5482671 $100.05 $90.89 $81.73 $72.5782672 $81.65 $70.65 $59.66 $48.6682677 $57.50 $58.61 $59.71 $60.8282679 $74.75 $69.66 $64.58 $59.4982690 $58.65 $53.40 $48.16 $42.9182696 $63.25 $60.29 $57.33 $54.3882705 $17.18 $14.97 $12.76 $10.5482710 $42.46 $43.68 $44.89 $46.1182715 $86.25 $71.77 $57.29 $42.8182725 $29.90 $30.95 $31.99 $33.0482728 $24.35 $27.63 $30.92 $34.2082735 $39.10 $40.19 $41.29 $42.3882742 $72.45 $63.43 $54.42 $45.4082746 $29.31 $31.85 $34.40 $36.9482747 $33.35 $35.94 $38.53 $41.1282757 $30.24 $31.25 $32.25 $33.26

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 97 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

82760 $29.90 $29.20 $28.50 $27.8182784 $16.38 $18.86 $21.33 $23.8182785 $30.79 $32.43 $34.07 $35.7182787 $24.15 $20.45 $16.75 $13.0582800 $34.50 $35.65 $36.80 $37.9582800 26 $10.35 $10.70 $11.04 $11.3982803 $39.79 $43.21 $46.63 $50.0582805 $34.50 $46.46 $58.41 $70.3782810 $28.75 $26.39 $24.03 $21.6882926 $23.00 $19.80 $16.60 $13.4182928 $12.65 $13.82 $15.00 $16.1782938 $52.90 $49.90 $46.91 $43.9182941 $42.89 $42.21 $41.53 $40.8582943 $41.40 $42.67 $43.94 $45.2282946 $34.50 $35.65 $36.80 $37.9582947 $11.35 $10.25 $9.16 $8.0682948 $7.84 $7.81 $7.78 $7.7582950 $11.75 $12.10 $12.46 $12.8182951 $43.40 $38.46 $33.53 $28.5982952 $9.90 $9.42 $8.93 $8.4582953 $46.00 $43.22 $40.43 $37.6582955 $15.15 $17.42 $19.69 $21.9682960 $28.75 $29.71 $30.67 $31.6382962 $8.26 $8.85 $9.43 $10.0282965 $23.00 $21.69 $20.37 $19.0682975 $31.05 $32.09 $33.12 $34.1682977 $14.24 $16.09 $17.95 $19.8082978 $29.90 $31.67 $33.43 $35.2082979 $20.70 $19.48 $18.27 $17.0582980 $49.45 $47.08 $44.71 $42.3482985 $44.85 $42.60 $40.36 $38.1183001 $36.05 $40.25 $44.45 $48.6583002 $41.80 $43.72 $45.64 $47.5783003 $45.56 $44.69 $43.81 $42.9483008 $36.80 $38.46 $40.13 $41.7983010 $25.94 $26.99 $28.04 $29.0983012 $39.10 $40.32 $41.55 $42.7783015 $56.35 $58.21 $60.07 $61.9383018 $57.21 $54.04 $50.86 $47.6983020 $55.66 $46.81 $37.95 $29.1083026 $6.90 $6.53 $6.15 $5.7883030 $21.63 $22.35 $23.07 $23.7983033 $17.25 $16.47 $15.69 $14.9183036 $20.29 $23.28 $26.26 $29.2583045 $14.95 $14.06 $13.17 $12.2983050 $23.00 $21.99 $20.97 $19.9683051 $24.36 $21.02 $17.69 $14.3583055 $17.51 $18.09 $18.68 $19.2683060 $25.30 $23.74 $22.18 $20.6283065 $20.70 $19.48 $18.27 $17.0583068 $23.00 $22.37 $21.74 $21.1183069 $11.50 $10.04 $8.58 $7.1283070 $12.76 $13.19 $13.61 $14.0483071 $20.70 $19.48 $18.25 $17.0383088 $72.45 $72.03 $71.60 $71.1883150 $43.71 $43.42 $43.13 $42.8483491 $35.71 $38.60 $41.50 $44.3983497 $32.61 $31.65 $30.69 $29.7483498 $67.85 $69.45 $71.05 $72.6583499 $129.95 $107.45 $84.95 $62.45

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 98 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

83500 $72.45 $67.03 $61.62 $56.2083505 $83.95 $81.62 $79.30 $76.9783516 $46.00 $41.53 $37.06 $32.5983518 $36.80 $31.92 $27.05 $22.1783519 $40.25 $41.87 $43.49 $45.1183520 $41.03 $43.59 $46.14 $48.7083525 $31.79 $32.58 $33.38 $34.1783527 $40.25 $36.45 $32.64 $28.8483528 $47.15 $44.55 $41.95 $39.3583540 $15.14 $16.56 $17.98 $19.4083550 $18.15 $20.68 $23.21 $25.7483570 $26.45 $23.77 $21.09 $18.4283582 $36.80 $38.03 $39.25 $40.4883586 $34.01 $34.23 $34.44 $34.6683593 $65.55 $65.44 $65.32 $65.2183615 $14.24 $15.58 $16.93 $18.2783625 $24.50 $26.73 $28.97 $31.2083632 $46.00 $49.26 $52.52 $55.7983655 $27.89 $28.77 $29.65 $30.5283661 $35.78 $39.79 $43.81 $47.8283670 $20.70 $21.37 $22.03 $22.7083690 $15.74 $16.26 $16.77 $17.2983718 $20.63 $19.75 $18.86 $17.9883719 $34.50 $32.61 $30.73 $28.8483721 $23.00 $23.78 $24.56 $25.3483727 $46.00 $43.12 $40.23 $37.3583735 $13.42 $15.01 $16.60 $18.1983775 $19.55 $19.08 $18.62 $18.1583785 $64.40 $57.01 $49.62 $42.2283805 $49.45 $51.10 $52.75 $54.4083825 $36.80 $36.45 $36.10 $35.7683835 $38.81 $42.37 $45.94 $49.5083840 $4.60 $17.51 $30.42 $43.3383858 $40.25 $39.85 $39.44 $39.0483864 $34.50 $37.09 $39.67 $42.2683866 $29.90 $30.90 $31.89 $32.8983872 $14.95 $16.00 $17.06 $18.1183873 $59.80 $55.57 $51.35 $47.1283874 $28.75 $32.77 $36.78 $40.8083887 $69.00 $66.22 $63.44 $60.6683898 $103.50 $79.97 $56.43 $32.9083912 $95.91 $83.13 $70.35 $57.5783915 $18.11 $22.11 $26.11 $30.1283916 $59.80 $56.55 $53.30 $50.0583918 $44.85 $43.62 $42.39 $41.1683930 $17.25 $17.15 $17.05 $16.9583935 $13.75 $16.42 $19.09 $21.7583945 $27.77 $29.84 $31.91 $33.9883970 $84.24 $90.98 $97.73 $104.4783986 $8.05 $8.34 $8.64 $8.9383992 $51.75 $46.70 $41.65 $36.5984022 $44.85 $42.79 $40.74 $38.6884030 $20.40 $24.66 $28.93 $33.1984035 $12.72 $13.14 $13.57 $13.9984060 $25.30 $23.96 $22.62 $21.2884066 $17.87 $18.47 $19.06 $19.6684075 $10.49 $12.20 $13.91 $15.6284078 $21.85 $21.08 $20.31 $19.5484080 $33.58 $34.39 $35.20 $36.0084081 $50.60 $47.35 $44.10 $40.85

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 99 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

84085 $16.10 $16.06 $16.01 $15.9784087 $27.60 $26.98 $26.37 $25.7584100 $9.74 $11.40 $13.06 $14.7384105 $11.50 $12.39 $13.28 $14.1784106 $10.23 $11.47 $12.71 $13.9684110 $14.95 $14.68 $14.40 $14.1384119 $21.11 $21.81 $22.52 $23.2284120 $38.59 $36.80 $35.01 $33.2284126 $75.90 $72.30 $68.70 $65.1084132 $9.84 $11.30 $12.75 $14.2184133 $9.74 $11.28 $12.83 $14.3784135 $63.25 $58.02 $52.78 $47.5584138 $49.15 $50.79 $52.43 $54.0784140 $48.30 $49.26 $50.22 $51.1884143 $85.10 $74.94 $64.79 $54.6384144 $38.75 $43.29 $47.83 $52.3784146 $49.26 $49.67 $50.07 $50.4884150 $73.60 $70.18 $66.76 $63.3484153 $60.35 $55.94 $51.53 $47.1284155 $12.70 $13.13 $13.56 $14.0084160 $17.29 $15.41 $13.52 $11.6484165 $28.02 $26.68 $25.33 $23.9984165 26 $19.68 $23.67 $27.66 $31.6584181 $90.85 $76.17 $61.49 $46.8184181 26 $25.30 $26.14 $26.99 $27.8384182 $112.70 $93.62 $74.53 $55.4584182 26 $25.30 $26.14 $26.99 $27.8384202 $29.59 $31.82 $34.04 $36.2784203 $18.67 $20.13 $21.58 $23.0484206 $34.50 $39.77 $45.04 $50.3084207 $59.80 $63.70 $67.60 $71.5184210 $26.70 $26.02 $25.34 $24.6684220 $28.75 $28.85 $28.96 $29.0684228 $19.55 $22.65 $25.74 $28.8484233 $139.00 $129.97 $120.95 $111.9284234 $126.50 $121.90 $117.30 $112.6984235 $124.20 $126.92 $129.64 $132.3684238 $104.65 $103.06 $101.47 $99.8884244 $56.35 $55.28 $54.20 $53.1384252 $64.40 $60.86 $57.31 $53.7784255 $51.40 $52.52 $53.64 $54.7784260 $50.05 $61.24 $72.43 $83.6284275 $37.95 $36.43 $34.91 $33.3984285 $65.55 $63.19 $60.83 $58.4784295 $8.99 $10.74 $12.48 $14.2384300 $10.35 $12.15 $13.95 $15.7584375 $57.50 $54.54 $51.59 $48.6384402 $73.60 $71.64 $69.68 $67.7284403 $60.13 $59.78 $59.44 $59.0984425 $49.43 $48.34 $47.25 $46.1684430 $29.04 $30.01 $30.97 $31.9484432 $63.56 $56.72 $49.88 $43.0484436 $13.55 $16.47 $19.39 $22.3184437 $14.95 $13.43 $11.90 $10.3884439 $26.42 $28.27 $30.11 $31.9684442 $40.05 $40.06 $40.06 $40.0784443 $29.04 $34.00 $38.97 $43.9384445 $91.59 $106.63 $121.66 $136.7084446 $50.60 $45.43 $40.26 $35.0984450 $9.84 $11.65 $13.47 $15.28

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 100 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

84460 $11.54 $12.71 $13.88 $15.0484466 $27.23 $30.34 $33.45 $36.5684478 $10.89 $12.64 $14.39 $16.1484479 $15.87 $17.05 $18.22 $19.4084480 $27.25 $31.67 $36.08 $40.5084481 $47.56 $49.32 $51.09 $52.8584482 $103.50 $84.01 $64.52 $45.0384485 $13.84 $14.30 $14.76 $15.2284488 $17.25 $17.52 $17.78 $18.0584490 $14.54 $16.38 $18.21 $20.0584510 $28.75 $27.79 $26.83 $25.8784520 $10.59 $11.42 $12.25 $13.0784525 $8.05 $7.23 $6.41 $5.5984540 $14.95 $13.90 $12.84 $11.7984545 $28.75 $24.64 $20.54 $16.4384550 $11.34 $12.53 $13.72 $14.9184560 $13.80 $12.49 $11.18 $9.8784577 $49.45 $43.31 $37.17 $31.0384578 $37.95 $27.98 $18.01 $8.0484580 $19.55 $20.10 $20.66 $21.2184583 $19.55 $17.17 $14.78 $12.4084585 $41.33 $40.67 $40.00 $39.3484588 $63.25 $74.03 $84.81 $95.5984590 $35.65 $33.53 $31.41 $29.2984597 $20.70 $28.27 $35.83 $43.4084600 $47.15 $45.95 $44.75 $43.5584620 $25.30 $26.14 $26.99 $27.8384630 $26.51 $26.02 $25.53 $25.0484681 $47.70 $46.74 $45.77 $44.8184702 $42.73 $43.05 $43.38 $43.7084703 $34.01 $28.96 $23.91 $18.8685002 $10.00 $10.74 $11.48 $12.2285007 $7.22 $8.78 $10.34 $11.9085008 $8.45 $8.35 $8.25 $8.1585009 $9.20 $9.42 $9.63 $9.8585013 $5.10 $7.20 $9.30 $11.4085014 $4.28 $6.87 $9.46 $12.0585018 $6.30 $6.68 $7.05 $7.4385025 $20.00 $21.06 $22.13 $23.1985025 26 $11.50 $11.88 $12.27 $12.6585027 $15.55 $16.83 $18.12 $19.4085041 $5.75 $6.05 $6.34 $6.6485044 $10.49 $10.41 $10.33 $10.2585044 26 $5.75 $5.94 $6.14 $6.3385045 $10.49 $11.79 $13.09 $14.3885048 $8.28 $7.57 $6.86 $6.1685060 $33.55 $36.77 $40.00 $43.2285097 $64.22 $93.66 $123.09 $152.5385170 $10.35 $10.70 $11.04 $11.3985210 $35.44 $35.01 $34.59 $34.1685220 $39.19 $40.59 $41.99 $43.4085230 $41.07 $41.49 $41.91 $42.3285240 $40.36 $41.01 $41.67 $42.3285244 $57.50 $56.86 $56.23 $55.5985246 $57.50 $58.68 $59.85 $61.0385250 $39.19 $40.50 $41.80 $43.1185260 $34.50 $39.26 $44.02 $48.7785270 $41.07 $41.45 $41.84 $42.2285280 $42.24 $43.65 $45.05 $46.4685290 $25.79 $29.33 $32.87 $36.40

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 101 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

85291 $17.25 $18.87 $20.48 $22.1085292 $34.50 $38.63 $42.76 $46.8985293 $34.50 $38.63 $42.76 $46.8985300 $28.75 $29.79 $30.84 $31.8885301 $28.75 $34.06 $39.37 $44.6785302 $34.50 $34.52 $34.53 $34.5585345 $16.10 $14.31 $12.53 $10.7485347 $14.95 $14.42 $13.90 $13.3785348 $14.95 $13.07 $11.19 $9.3185360 $22.04 $22.77 $23.51 $24.2485362 $19.55 $19.57 $19.59 $19.6285384 $34.50 $31.37 $28.23 $25.1085385 $34.50 $30.05 $25.59 $21.1485390 $10.35 $10.70 $11.04 $11.3985400 $17.25 $18.84 $20.44 $22.0385410 $17.25 $17.85 $18.44 $19.0485420 $23.00 $22.16 $21.33 $20.4985421 $43.70 $37.58 $31.46 $25.3485441 $12.76 $13.19 $13.61 $14.0485445 $29.90 $25.58 $21.26 $16.9485460 $39.10 $35.27 $31.44 $27.6185520 $42.55 $41.45 $40.36 $39.2685530 $42.55 $40.06 $37.58 $35.0985540 $31.80 $28.20 $24.61 $21.0185547 $46.00 $37.77 $29.53 $21.3085549 $50.60 $49.47 $48.34 $47.2185555 $19.55 $20.08 $20.62 $21.1585557 $39.74 $40.22 $40.70 $41.1885610 $14.15 $14.24 $14.33 $14.4385610 26 $3.45 $3.57 $3.68 $3.8085611 $16.10 $14.01 $11.92 $9.8385612 $28.75 $27.06 $25.37 $23.6885613 $28.75 $27.87 $26.99 $26.1185635 $31.05 $29.53 $28.00 $26.4885651 $10.45 $11.06 $11.66 $12.2785652 $9.01 $8.62 $8.23 $7.8485660 $10.47 $12.58 $14.68 $16.7985670 $13.75 $13.09 $12.42 $11.7685675 $14.95 $15.63 $16.32 $17.0085705 $69.00 $55.48 $41.96 $28.4485730 $12.12 $14.18 $16.24 $18.3085730 26 $9.20 $9.51 $9.81 $10.1285732 $20.70 $18.50 $16.30 $14.0985810 $26.27 $26.26 $26.26 $26.2586000 $20.70 $17.14 $13.58 $10.0286003 $165.60 $116.02 $66.43 $16.8586021 $57.50 $56.98 $56.46 $55.9486022 $58.96 $55.19 $51.43 $47.6686023 $11.50 $14.09 $16.68 $19.2786038 $32.00 $31.47 $30.94 $30.4186039 $46.00 $39.95 $33.90 $27.8586060 $11.50 $13.67 $15.83 $18.0086063 $19.55 $17.85 $16.15 $14.4486077 $59.22 $66.58 $73.94 $81.3186078 $41.22 $55.02 $68.82 $82.6286079 $43.78 $56.58 $69.38 $82.1886140 $10.21 $11.88 $13.56 $15.2386156 $41.40 $32.41 $23.42 $14.4386157 $36.38 $30.55 $24.71 $18.8886160 $35.71 $37.51 $39.30 $41.10

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 102 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

86161 $40.25 $36.94 $33.63 $30.3186162 $49.20 $50.08 $50.96 $51.8586171 $20.43 $21.11 $21.79 $22.4786185 $21.85 $21.97 $22.08 $22.2086215 $37.95 $38.36 $38.76 $39.1786225 $32.42 $34.95 $37.48 $40.0086226 $34.50 $33.00 $31.51 $30.0186235 $34.33 $36.63 $38.94 $41.2486243 $55.20 $53.78 $52.36 $50.9486255 $23.35 $29.35 $35.36 $41.3686255 26 $12.65 $20.37 $28.09 $35.8186256 $34.37 $35.98 $37.58 $39.1986256 26 $12.65 $13.07 $13.50 $13.9286277 $44.85 $43.72 $42.59 $41.4686280 $16.10 $16.64 $17.17 $17.7186308 $13.28 $14.32 $15.36 $16.4086309 $12.44 $12.85 $13.27 $13.6886310 $20.70 $19.85 $19.00 $18.1586316 $59.68 $56.80 $53.92 $51.0486317 $34.94 $34.94 $34.93 $34.9386318 $40.71 $38.53 $36.35 $34.1786320 $54.41 $48.79 $43.17 $37.5486325 $54.05 $54.05 $54.05 $54.0586327 $67.85 $63.98 $60.11 $56.2486329 $44.40 $42.00 $39.61 $37.2186331 $35.65 $34.57 $33.49 $32.4186332 $59.80 $60.29 $60.77 $61.2686334 $103.50 $85.38 $67.26 $49.1486334 26 $34.50 $33.35 $32.20 $31.0686337 $59.80 $61.58 $63.36 $65.1386340 $43.70 $41.81 $39.92 $38.0386341 $4.60 $19.42 $34.24 $49.0686353 $110.40 $114.01 $117.62 $121.2386361 $46.00 $41.01 $36.01 $31.0286376 $41.82 $39.21 $36.59 $33.9886382 $60.69 $54.10 $47.51 $40.9286384 $80.50 $63.09 $45.69 $28.2886403 $19.30 $19.61 $19.91 $20.2286430 $12.46 $12.67 $12.89 $13.1086431 $16.96 $17.58 $18.20 $18.8186485 $17.04 $18.96 $20.87 $22.7986490 $19.55 $19.40 $19.24 $19.0986510 $14.50 $17.17 $19.84 $22.5186580 $12.37 $13.55 $14.73 $15.9186586 $17.25 $18.24 $19.23 $20.2286590 $57.50 $47.46 $37.41 $27.3786592 $9.77 $11.22 $12.67 $14.1286593 $12.07 $12.82 $13.58 $14.3386618 $47.81 $50.11 $52.41 $54.7286622 $11.50 $15.56 $19.62 $23.6886628 $24.15 $26.02 $27.90 $29.7786631 $40.25 $37.78 $35.31 $32.8586632 $40.25 $38.46 $36.66 $34.8786635 $14.95 $23.23 $31.51 $39.7986641 $24.15 $23.31 $22.47 $21.6286644 $53.50 $45.07 $36.64 $28.2186645 $52.29 $49.26 $46.23 $43.2186651 $17.25 $17.83 $18.40 $18.9886652 $17.25 $21.95 $26.64 $31.3486653 $17.25 $22.39 $27.53 $32.66

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 103 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

86654 $17.25 $22.39 $27.53 $32.6686658 $70.07 $61.42 $52.78 $44.1386663 $59.70 $50.18 $40.65 $31.1386664 $57.50 $51.94 $46.38 $40.8286665 $76.53 $64.92 $53.30 $41.6986674 $57.50 $51.93 $46.36 $40.7986677 $43.36 $43.40 $43.44 $43.4886687 $17.25 $18.43 $19.62 $20.8086688 $17.03 $21.08 $25.13 $29.1886689 $14.32 $26.24 $38.15 $50.0786692 $24.15 $31.01 $37.88 $44.7486694 $50.00 $46.37 $42.75 $39.1286695 $34.50 $34.79 $35.08 $35.3786698 $14.95 $23.64 $32.32 $41.0186701 $40.00 $34.03 $28.07 $22.1086702 $46.00 $39.43 $32.86 $26.2986703 $69.00 $55.73 $42.46 $29.1986704 $37.95 $37.78 $37.61 $37.4386705 $40.25 $38.10 $35.95 $33.8086706 $42.55 $38.76 $34.97 $31.1886707 $31.05 $31.48 $31.90 $32.3386708 $36.80 $36.08 $35.36 $34.6486709 $34.50 $35.04 $35.59 $36.1386713 $60.00 $53.07 $46.14 $39.2186720 $14.95 $17.70 $20.46 $23.2186727 $95.45 $72.27 $49.09 $25.9286732 $14.95 $17.67 $20.39 $23.1086735 $12.40 $19.24 $26.08 $32.9286738 $60.00 $49.83 $39.65 $29.4886744 $14.95 $17.67 $20.39 $23.1086747 $55.08 $48.24 $41.40 $34.5686762 $14.47 $21.86 $29.25 $36.6486765 $36.60 $33.97 $31.34 $28.7086768 $11.50 $16.65 $21.80 $26.9586771 $11.50 $15.37 $19.24 $23.1086774 $11.50 $19.68 $27.85 $36.0386777 $29.90 $31.10 $32.30 $33.5086778 $32.50 $32.57 $32.63 $32.7086781 $23.38 $25.09 $26.79 $28.5086784 $14.95 $26.08 $37.21 $48.3586787 $51.26 $47.39 $43.52 $39.6586800 $40.11 $38.02 $35.94 $33.8586803 $28.75 $32.47 $36.18 $39.9086804 $31.05 $35.33 $39.60 $43.8886805 $54.05 $77.93 $101.80 $125.6886812 $111.20 $93.42 $75.65 $57.8786813 $112.38 $120.06 $127.73 $135.4186816 $69.00 $69.07 $69.14 $69.2186817 $143.75 $156.95 $170.15 $183.3586821 $132.25 $134.81 $137.38 $139.9486822 $103.50 $99.22 $94.95 $90.6786850 $12.65 $18.26 $23.87 $29.4786860 $49.45 $51.10 $52.75 $54.4086870 $34.50 $34.18 $33.86 $33.5386880 $15.49 $14.45 $13.41 $12.3886886 $16.10 $15.46 $14.81 $14.1786891 $98.90 $102.20 $105.49 $108.7986900 $11.60 $12.28 $12.96 $13.6586901 $13.80 $13.39 $12.99 $12.5886903 $20.70 $21.57 $22.45 $23.32

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 104 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

86904 $23.00 $23.20 $23.40 $23.5986905 $9.20 $8.76 $8.32 $7.8886906 $20.70 $20.22 $19.74 $19.2786920 $23.00 $23.77 $24.53 $25.3086921 $26.45 $27.33 $28.22 $29.1086922 $26.45 $25.17 $23.89 $22.6286930 $166.75 $172.31 $177.87 $183.4386931 $166.75 $172.31 $177.87 $183.4386932 $172.50 $178.25 $184.00 $189.7586940 $20.70 $18.22 $15.74 $13.2686941 $33.35 $32.21 $31.06 $29.9286945 $37.95 $39.22 $40.48 $41.7586950 $108.10 $111.70 $115.31 $118.9186965 $28.75 $29.71 $30.67 $31.6386970 $44.85 $46.35 $47.84 $49.3486971 $23.00 $23.77 $24.53 $25.3086972 $23.00 $23.77 $24.53 $25.3086975 $58.65 $60.61 $62.56 $64.5286976 $58.65 $60.61 $62.56 $64.5286977 $58.65 $60.61 $62.56 $64.5286978 $53.65 $55.44 $57.23 $59.0287001 $34.50 $33.97 $33.43 $32.9087003 $57.50 $52.29 $47.07 $41.8687015 $24.15 $22.01 $19.88 $17.7487040 $30.67 $28.28 $25.90 $23.5187045 $18.87 $20.70 $22.53 $24.3687070 $21.34 $23.86 $26.38 $28.9087075 $34.50 $31.21 $27.91 $24.6287076 $70.64 $59.92 $49.20 $38.4987081 $13.29 $13.68 $14.06 $14.4587084 $25.11 $25.95 $26.78 $27.6287086 $14.82 $15.93 $17.03 $18.1487088 $21.86 $19.70 $17.55 $15.3987101 $19.51 $18.67 $17.82 $16.9887102 $23.70 $23.94 $24.17 $24.4187103 $38.17 $34.38 $30.59 $26.8087106 $45.43 $41.08 $36.74 $32.3987109 $59.80 $52.74 $45.67 $38.6187110 $29.51 $34.19 $38.88 $43.5687116 $49.03 $40.94 $32.85 $24.7687118 $33.76 $31.71 $29.66 $27.6187140 $14.95 $16.58 $18.21 $19.8587143 $36.80 $34.91 $33.01 $31.1287147 $14.95 $19.16 $23.38 $27.5987158 $37.95 $29.60 $21.25 $12.8987164 $70.15 $55.68 $41.21 $26.7487166 $37.39 $38.64 $39.88 $41.1387176 $13.80 $13.53 $13.26 $12.9987177 $21.06 $23.01 $24.96 $26.9187181 $18.40 $13.47 $8.55 $3.6287184 $18.40 $18.33 $18.27 $18.2087186 $42.78 $38.08 $33.39 $28.6987187 $11.50 $16.27 $21.04 $25.8187188 $17.25 $17.83 $18.40 $18.9887190 $17.25 $14.19 $11.12 $8.0687205 $13.05 $12.92 $12.79 $12.6687206 $16.60 $17.49 $18.38 $19.2887207 $20.41 $20.65 $20.90 $21.1487210 $12.61 $13.02 $13.44 $13.8587220 $12.43 $12.80 $13.17 $13.53

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 105 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

87230 $42.94 $44.80 $46.67 $48.5387250 $61.08 $63.12 $65.15 $67.1987252 $61.53 $64.09 $66.64 $69.2087253 $50.05 $48.57 $47.09 $45.6188104 $51.33 $57.70 $64.07 $70.4488104 26 $40.98 $42.90 $44.82 $46.7488106 $41.63 $43.02 $44.40 $45.7988106 26 $31.69 $36.07 $40.44 $44.8288107 $47.15 $73.71 $100.27 $126.8388107 26 $31.69 $42.06 $52.43 $62.8088108 $57.50 $69.16 $80.82 $92.4888108 26 $45.48 $48.89 $52.30 $55.7088130 $47.15 $43.04 $38.93 $34.8288130 26 $36.74 $37.96 $39.19 $40.4188140 $18.11 $16.13 $14.15 $12.1888140 26 $3.06 $3.16 $3.27 $3.3788141 $32.56 $33.69 $34.83 $35.9688150 $13.54 $17.61 $21.69 $25.7688155 $28.75 $25.46 $22.16 $18.8788155 26 $23.99 $24.79 $25.59 $26.3988160 $47.74 $57.06 $66.38 $75.7088160 26 $34.42 $39.11 $43.80 $48.4988161 $40.25 $55.69 $71.13 $86.5688161 26 $29.90 $37.31 $44.71 $52.1288162 $57.20 $72.10 $87.00 $101.9088162 26 $38.92 $45.85 $52.79 $59.7288172 $53.44 $62.85 $72.25 $81.6688172 26 $45.21 $51.74 $58.26 $64.7988173 $70.94 $103.93 $136.92 $169.9088173 26 $66.46 $84.04 $101.61 $119.1988182 $160.80 $166.16 $171.52 $176.8888182 26 $31.12 $43.43 $55.73 $68.0488230 $220.80 $196.08 $171.35 $146.6388230 26 $65.55 $67.74 $69.92 $72.1188235 $72.99 $119.35 $165.70 $212.0688237 $241.50 $193.76 $146.02 $98.2988237 26 $74.75 $77.24 $79.74 $82.2388239 $273.70 $296.91 $320.11 $343.3288239 26 $82.80 $85.56 $88.32 $91.0888261 $334.65 $345.81 $356.96 $368.1288261 26 $228.57 $236.19 $243.81 $251.4388262 $469.20 $417.68 $366.15 $314.6388262 26 $298.32 $308.26 $318.21 $328.1588267 $533.60 $470.89 $408.19 $345.4888267 26 $332.07 $343.14 $354.21 $365.2888269 $684.25 $588.20 $492.14 $396.0988269 26 $189.92 $196.25 $202.58 $208.9188280 $66.70 $64.52 $62.34 $60.1688280 26 $54.05 $55.85 $57.66 $59.4688283 $66.70 $97.71 $128.73 $159.7488285 $13.80 $23.89 $33.98 $44.0788285 26 $10.35 $10.70 $11.04 $11.3988300 $16.00 $21.05 $26.10 $31.1588300 26 $12.48 $14.36 $16.24 $18.1288302 $39.65 $45.97 $52.30 $58.6288302 26 $30.81 $30.45 $30.09 $29.7288304 $65.91 $70.83 $75.75 $80.6888304 26 $44.29 $43.96 $43.62 $43.2988305 $108.28 $118.77 $129.25 $139.7488305 26 $75.24 $80.51 $85.78 $91.05

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 106 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

88307 $190.90 $207.82 $224.74 $241.6588307 26 $131.72 $141.68 $151.65 $161.6188309 $254.15 $285.74 $317.32 $348.9188309 26 $183.07 $203.51 $223.96 $244.4088311 $18.40 $21.47 $24.54 $27.6088311 26 $20.88 $23.29 $25.69 $28.1088312 $37.95 $61.60 $85.24 $108.8988312 26 $33.07 $40.70 $48.34 $55.9788313 $22.41 $41.97 $61.52 $81.0888313 26 $14.26 $20.69 $27.12 $33.5688314 $38.34 $39.62 $40.89 $42.1788314 26 $29.83 $35.33 $40.83 $46.3388318 $52.10 $53.84 $55.57 $57.3188318 26 $17.62 $22.28 $26.93 $31.5988319 $166.75 $171.62 $176.49 $181.3688319 26 $117.55 $96.65 $75.74 $54.8488321 $53.67 $76.20 $98.72 $121.2588323 $91.39 $123.49 $155.59 $187.6988323 26 $62.97 $87.89 $112.80 $137.7288325 $94.14 $136.93 $179.72 $222.5088329 $57.11 $65.70 $74.30 $82.8988331 $98.50 $109.58 $120.66 $131.7588331 26 $84.47 $99.56 $114.65 $129.7388332 $51.75 $53.48 $55.20 $56.9388332 26 $34.43 $43.74 $53.04 $62.3588342 $38.57 $62.88 $87.18 $111.4988342 26 $38.60 $53.79 $68.98 $84.1688346 $127.56 $131.81 $136.07 $140.3288346 26 $79.43 $75.20 $70.97 $66.7488347 $87.40 $111.54 $135.68 $159.8288347 26 $69.00 $68.15 $67.30 $66.4588348 $257.41 $265.99 $274.57 $283.1588348 26 $221.95 $226.68 $231.42 $236.1588349 $264.50 $273.32 $282.13 $290.9588349 26 $236.73 $202.30 $167.88 $133.4588356 $130.52 $134.87 $139.22 $143.5788356 26 $144.13 $178.09 $212.06 $246.0288358 $130.52 $179.64 $228.77 $277.8988358 26 $130.52 $134.87 $139.22 $143.5788362 $218.50 $225.78 $233.07 $240.3588362 26 $119.46 $140.12 $160.79 $181.4589050 $13.80 $13.22 $12.65 $12.0789051 $16.12 $16.63 $17.13 $17.6489060 $25.95 $24.81 $23.66 $22.5289100 $92.00 $118.58 $145.16 $171.7489105 $132.25 $147.31 $162.36 $177.4289125 $14.95 $11.91 $8.87 $5.8289130 $10.35 $10.70 $11.04 $11.3989132 $20.70 $51.68 $82.66 $113.6389135 $31.05 $85.52 $140.00 $194.4789136 $46.00 $76.76 $107.53 $138.2989140 $40.25 $96.41 $152.58 $208.7489141 $50.60 $116.47 $182.33 $248.2089160 $12.65 $11.52 $10.39 $9.2689190 $9.20 $10.67 $12.13 $13.6089300 $48.80 $42.67 $36.54 $30.4189310 $13.80 $15.60 $17.40 $19.2089320 $52.62 $54.23 $55.85 $57.4689325 $54.94 $51.82 $48.69 $45.5789330 $54.78 $52.02 $49.26 $46.50

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 107 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

90700 $28.83 $29.23 $29.63 $30.0290701 $15.74 $16.50 $17.26 $18.0290702 $10.62 $11.18 $11.74 $12.3090703 $9.53 $12.67 $15.81 $18.9590704 $17.95 $20.96 $23.98 $26.9990705 $27.82 $27.17 $26.53 $25.8890706 $26.32 $25.19 $24.06 $22.9490707 $38.12 $43.79 $49.47 $55.1490708 $22.16 $23.65 $25.15 $26.6490712 $10.62 $15.49 $20.35 $25.2290713 $31.35 $32.56 $33.78 $34.9990714 $9.66 $9.98 $10.31 $10.6390717 $32.51 $44.70 $56.89 $69.0790718 $12.74 $15.14 $17.54 $19.9490719 $10.30 $15.40 $20.50 $25.6090720 $46.00 $47.53 $49.07 $50.6090721 $48.30 $49.91 $51.52 $53.1390725 $15.57 $16.90 $18.24 $19.5790727 $17.25 $17.83 $18.40 $18.9890732 $22.94 $24.95 $26.95 $28.9690733 $43.18 $58.96 $74.73 $90.5190743 $86.25 $89.13 $92.00 $94.8890744 $36.80 $46.05 $55.31 $64.5690746 $55.20 $61.54 $67.87 $74.2190747 $161.00 $166.37 $171.73 $177.1090801 $27.60 $62.75 $97.90 $133.0490802 $81.32 $92.79 $104.26 $115.7290804 $59.31 $59.51 $59.71 $59.9190805 $73.58 $73.07 $72.56 $72.0490806 $99.22 $98.64 $98.06 $97.4990807 $110.59 $107.86 $105.12 $102.3990808 $146.46 $141.51 $136.55 $131.6090809 $159.45 $154.16 $148.88 $143.5990810 $64.58 $63.15 $61.71 $60.2890811 $79.21 $78.14 $77.08 $76.0190812 $102.46 $100.94 $99.42 $97.8990813 $113.97 $113.53 $113.10 $112.6690814 $145.88 $144.87 $143.86 $142.8590815 $159.10 $158.73 $158.37 $158.0090816 $64.18 $65.49 $66.80 $68.1190817 $80.33 $78.33 $76.33 $74.3290818 $101.69 $99.40 $97.12 $94.8390819 $113.27 $110.54 $107.82 $105.0990821 $164.67 $158.67 $152.67 $146.6690822 $183.42 $177.40 $171.39 $165.3790823 $69.14 $67.59 $66.05 $64.5090824 $85.50 $84.12 $82.73 $81.3590826 $104.87 $103.45 $102.02 $100.6090827 $116.80 $116.02 $115.24 $114.4690828 $164.38 $163.70 $163.02 $162.3490829 $183.29 $182.24 $181.19 $180.1590846 $27.60 $53.13 $78.66 $104.1990847 $29.90 $56.16 $82.41 $108.6790849 $8.05 $20.80 $33.55 $46.3190853 $8.05 $21.33 $34.62 $47.9090857 $8.05 $19.12 $30.19 $41.2690862 $46.53 $52.10 $57.67 $63.2490865 $139.24 $138.86 $138.49 $138.1190870 $86.53 $100.22 $113.90 $127.5990887 $27.60 $31.47 $35.33 $39.20

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 108 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

90918 $444.75 $599.39 $754.02 $908.6690919 $406.96 $488.85 $570.75 $652.6490920 $369.17 $442.87 $516.58 $590.2890921 $308.83 $329.61 $350.39 $371.1790922 $12.08 $17.33 $22.58 $27.8390923 $23.10 $22.07 $21.03 $20.0090924 $19.53 $19.01 $18.49 $17.9890925 $14.46 $13.63 $12.79 $11.9690935 $181.56 $167.65 $153.73 $139.8290937 $257.25 $265.57 $273.88 $282.2090945 $151.55 $146.42 $141.30 $136.1790947 $168.95 $180.32 $191.69 $203.0791000 $86.25 $80.77 $75.29 $69.8091010 $337.35 $327.64 $317.92 $308.2191011 $327.97 $356.83 $385.68 $414.5491012 $338.37 $361.70 $385.04 $408.3791020 $137.67 $207.27 $276.87 $346.4691030 $110.65 $135.20 $159.76 $184.3191030 26 $81.65 $84.37 $87.10 $89.8291052 $306.19 $272.57 $238.94 $205.3291055 $85.10 $128.19 $171.29 $214.3891060 $109.95 $111.64 $113.32 $115.0191065 $78.21 $120.39 $162.57 $204.7691100 $102.37 $117.19 $132.00 $146.8291105 $79.44 $83.97 $88.50 $93.0291122 $176.29 $226.30 $276.30 $326.3192002 $55.27 $65.87 $76.47 $87.0792004 $74.33 $98.39 $122.44 $146.5092012 $47.53 $57.30 $67.08 $76.8592014 $57.38 $74.39 $91.40 $108.4192015 $21.85 $33.73 $45.61 $57.4992018 $97.69 $127.65 $157.61 $187.5792019 $92.00 $100.30 $108.61 $116.9192020 $31.09 $39.73 $48.38 $57.0292060 $50.09 $61.23 $72.36 $83.5092070 $104.71 $108.07 $111.43 $114.7992081 $33.57 $50.51 $67.45 $84.3992082 $58.16 $67.84 $77.52 $87.2092083 $105.64 $109.12 $112.60 $116.0792100 $30.52 $49.49 $68.46 $87.4392120 $42.28 $58.89 $75.51 $92.1292130 $34.50 $57.61 $80.72 $103.8392140 $29.23 $42.63 $56.04 $69.4492225 $61.97 $66.89 $71.81 $76.7392226 $45.54 $53.50 $61.47 $69.4392230 $85.80 $103.98 $122.15 $140.3392235 $234.46 $223.74 $213.03 $202.3192240 $127.10 $206.77 $286.44 $366.1192240 26 $83.73 $90.49 $97.25 $104.0192250 $65.73 $74.60 $83.47 $92.3492260 $91.08 $84.75 $78.41 $72.0892265 $46.00 $78.95 $111.91 $144.8692270 $80.50 $83.18 $85.87 $88.5592270 26 $66.02 $64.46 $62.91 $61.3592275 $129.26 $150.02 $170.78 $191.5392286 $99.92 $122.82 $145.72 $168.6392311 $105.80 $119.41 $133.02 $146.6392312 $129.95 $128.19 $126.44 $124.6892315 $60.95 $62.50 $64.06 $65.6192316 $88.55 $87.73 $86.92 $86.10

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 109 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

92502 $93.47 $115.69 $137.91 $160.1392504 $46.00 $46.97 $47.95 $48.9292506 $51.75 $86.03 $120.30 $154.5892511 $160.04 $161.68 $163.31 $164.9592526 $66.27 $80.65 $95.04 $109.4292541 $57.81 $65.92 $74.03 $82.1492541 26 $38.94 $39.16 $39.39 $39.6192542 $44.03 $55.34 $66.66 $77.9792542 26 $24.70 $26.52 $28.33 $30.1592543 $69.80 $62.38 $54.96 $47.5492544 $29.90 $40.70 $51.50 $62.3092545 $29.90 $40.86 $51.82 $62.7792546 $69.00 $95.39 $121.77 $148.1692547 $24.15 $40.15 $56.15 $72.1692551 $15.71 $15.71 $15.70 $15.7092551 26 $9.20 $9.51 $9.81 $10.1292552 $20.72 $24.16 $27.61 $31.0592553 $29.96 $34.70 $39.45 $44.1992555 $16.84 $18.65 $20.46 $22.2792556 $26.61 $31.39 $36.18 $40.9692557 $50.73 $59.35 $67.97 $76.5992560 $5.75 $5.94 $6.14 $6.3392561 $18.01 $26.71 $35.41 $44.1192562 $17.85 $21.19 $24.53 $27.8792563 $18.05 $20.84 $23.63 $26.4392564 $19.58 $22.88 $26.19 $29.4992565 $18.08 $22.35 $26.62 $30.8992567 $20.44 $23.31 $26.17 $29.0492568 $16.55 $18.13 $19.70 $21.2892568 26 $11.50 $11.88 $12.27 $12.6592569 $18.05 $21.05 $24.05 $27.0592571 $18.08 $21.64 $25.21 $28.7792572 $14.33 $14.89 $15.46 $16.0292573 $9.20 $15.15 $21.10 $27.0492575 $13.80 $15.49 $17.18 $18.8792576 $21.08 $24.61 $28.13 $31.6692577 $21.83 $28.61 $35.39 $42.1792579 $39.10 $45.19 $51.27 $57.3692582 $33.08 $37.77 $42.47 $47.1692583 $29.33 $35.64 $41.95 $48.2692584 $125.02 $147.76 $170.49 $193.2392585 $200.61 $213.36 $226.10 $238.8592585 26 $78.25 $86.68 $95.10 $103.5392587 $65.86 $70.25 $74.64 $79.0392588 $100.18 $109.02 $117.87 $126.7192597 $115.00 $127.90 $140.80 $153.6992950 $175.88 $242.47 $309.07 $375.6692953 $95.45 $79.40 $63.36 $47.3192960 $176.57 $242.91 $309.25 $375.5892970 $295.55 $302.85 $310.15 $317.4492971 $118.45 $136.79 $155.14 $173.4892975 $600.53 $659.79 $719.05 $778.3192977 $230.48 $327.27 $424.06 $520.8592980 $1,441.13 S $1,640.62 $1,840.11 $2,039.6092981 $525.31 30 $551.68 $578.06 $604.4392982 $1,624.95 $1,635.71 $1,646.48 $1,657.2492984 $640.95 $599.73 $558.52 $517.3092986 $1,535.40 $1,749.81 $1,964.22 $2,178.6392987 $1,934.50 30 $2,028.94 $2,123.39 $2,217.8392990 $1,369.55 $1,475.05 $1,580.55 $1,686.04

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 110 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

92992 $1,915.40 $2,221.04 $2,526.68 $2,832.3392993 $2,300.00 $2,376.67 $2,453.33 $2,530.0092995 $1,717.61 $1,727.78 $1,737.95 $1,748.1292996 $528.19 $532.18 $536.18 $540.1792997 $1,220.36 $1,283.04 $1,345.73 $1,408.4192998 $472.48 $532.56 $592.64 $652.7293000 $53.85 $56.62 $59.40 $62.1793005 $22.71 $26.32 $29.93 $33.5493010 $33.63 $31.82 $30.00 $28.1993012 $20.70 $121.97 $223.25 $324.5293014 $22.87 $29.70 $36.52 $43.3593015 $211.32 $208.51 $205.69 $202.8893016 $43.05 $49.70 $56.35 $63.0093017 $103.50 $103.47 $103.44 $103.4193018 $89.19 $81.89 $74.59 $67.2993024 $134.20 $138.67 $143.15 $147.6293024 26 $122.71 $130.09 $137.47 $144.8693040 $35.49 $35.02 $34.55 $34.0793041 $18.07 $17.16 $16.24 $15.3393042 $17.41 $16.68 $15.95 $15.2293224 $220.94 $228.21 $235.48 $242.7693225 $46.00 $51.02 $56.03 $61.0593226 $115.00 $110.34 $105.68 $101.0293227 $82.74 $77.45 $72.16 $66.8793230 $217.35 $215.94 $214.52 $213.1193231 $63.25 $71.38 $79.51 $87.6493232 $79.35 $86.46 $93.56 $100.6793233 $68.99 $67.20 $65.41 $63.6293235 $158.70 $158.34 $157.98 $157.6293236 $83.95 $98.57 $113.19 $127.8193237 $74.75 $65.42 $56.09 $46.7593268 $236.64 $272.61 $308.58 $344.5593268 26 $56.75 $58.64 $60.54 $62.4393270 $66.70 $67.90 $69.10 $70.3093271 $128.80 $196.57 $264.34 $332.1093272 $47.10 $48.52 $49.95 $51.3793303 $318.60 $340.72 $362.85 $384.9793303 26 $109.95 $125.44 $140.92 $156.4193303 TC $156.40 $161.61 $166.83 $172.0493304 $173.85 $186.08 $198.31 $210.5493304 26 $69.30 $74.21 $79.13 $84.0493304 TC $78.20 $80.81 $83.41 $86.0293307 $267.60 $301.50 $335.40 $369.3093307 26 $142.35 $142.95 $143.55 $144.1693307 TC $151.80 $156.86 $161.92 $166.9893308 $136.88 $138.95 $141.01 $143.0893308 26 $76.11 $76.93 $77.74 $78.5693312 $278.95 $315.38 $351.80 $388.2393312 26 $134.41 $169.19 $203.96 $238.7493313 $100.12 $156.75 $213.38 $270.0193314 $217.04 $274.33 $331.62 $388.9193314 $73.60 $178.70 $283.81 $388.9193315 $422.25 $444.21 $466.17 $488.1393315 26 $196.40 $233.26 $270.12 $306.9893315 TC $155.25 $160.43 $165.60 $170.7893316 $79.15 $151.46 $223.78 $296.0993317 $336.45 $358.22 $379.98 $401.7593317 26 $122.26 $148.20 $174.15 $200.0993317 TC $155.25 $160.43 $165.60 $170.7893320 $123.66 $129.96 $136.26 $142.56

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 111 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

93320 26 $53.09 $55.73 $58.38 $61.0293320 TC $56.35 $58.23 $60.11 $61.9993321 $53.63 $63.65 $73.68 $83.7093321 26 $27.16 $29.11 $31.06 $33.0293325 $129.96 $137.10 $144.25 $151.3993325 26 $63.94 $55.27 $46.59 $37.9293325 TC $69.00 $71.30 $73.60 $75.9093350 $251.58 $256.68 $261.78 $266.8893350 26 $162.43 $175.73 $189.03 $202.3393501 $1,109.13 $1,119.03 $1,128.93 $1,138.8393501 26 $404.80 $389.21 $373.62 $358.0393503 $300.62 $288.20 $275.79 $263.3793505 $425.20 $444.10 $463.01 $481.9193505 26 $313.95 $342.15 $370.35 $398.5593510 $1,930.50 $2,268.64 $2,606.77 $2,944.9193510 26 $442.75 $470.10 $497.45 $524.8093511 $1,897.25 $1,985.07 $2,072.89 $2,160.7193511 26 $456.55 $456.31 $456.07 $455.8493514 $2,839.35 $2,844.53 $2,849.71 $2,854.8993514 26 $696.90 $720.13 $743.36 $766.5993524 $2,622.84 $2,715.14 $2,807.45 $2,899.7593524 26 $694.60 $688.26 $681.91 $675.5793526 $2,598.99 $2,666.97 $2,734.95 $2,802.9393526 26 $687.70 $684.57 $681.44 $678.3193527 $2,719.17 $2,903.87 $3,088.57 $3,273.2793527 26 $868.25 $854.24 $840.23 $826.2293528 $2,567.46 $2,722.34 $2,877.22 $3,032.1193528 26 $800.40 $827.08 $853.76 $880.4493529 $2,466.34 $2,518.02 $2,569.71 $2,621.3993529 26 $462.30 $458.07 $453.84 $449.6193539 $271.30 $223.62 $175.94 $128.2693540 $274.68 $223.85 $173.03 $122.2093541 $210.50 $165.81 $121.13 $76.4493542 $246.22 $185.26 $124.31 $63.3593543 $283.26 $229.70 $176.15 $122.5993544 $221.06 $177.38 $133.69 $90.0193545 $323.95 $277.01 $230.08 $183.1493555 $469.20 $484.84 $500.48 $516.1293555 26 $78.44 $84.70 $90.95 $97.2193556 $713.00 $736.77 $760.53 $784.3093556 26 $93.47 $107.51 $121.54 $135.5893561 $151.74 $125.38 $99.02 $72.6793561 26 $103.50 $120.19 $136.87 $153.5693562 $67.17 $56.51 $45.85 $35.2093562 26 $51.75 $48.86 $45.97 $43.0793600 $306.32 $301.22 $296.11 $291.0193600 26 $212.75 $237.77 $262.78 $287.8093602 $286.00 $270.96 $255.93 $240.8993602 26 $234.60 $241.01 $247.41 $253.8293603 $314.35 $307.01 $299.68 $292.3493603 26 $233.45 $238.20 $242.96 $247.7193609 $754.49 $736.49 $718.48 $700.4893609 26 $741.75 $708.34 $674.93 $641.5393610 $424.87 $393.08 $361.30 $329.5193610 26 $355.35 $338.48 $321.61 $304.7593612 $379.87 $375.74 $371.61 $367.4893612 26 $288.90 $288.77 $288.65 $288.5293615 $156.30 $136.63 $116.95 $97.2893615 26 $140.30 $142.18 $144.07 $145.9593616 $260.51 $220.08 $179.65 $139.22

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 112 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

93616 26 $259.90 $241.61 $223.32 $205.0493618 $1,007.03 $878.57 $750.12 $621.6693618 26 $761.59 $782.89 $804.19 $825.4993619 $1,432.90 $1,480.66 $1,528.43 $1,576.1993619 26 $1,162.62 $1,174.95 $1,187.28 $1,199.6293620 $1,981.12 $2,047.16 $2,113.19 $2,179.2393620 26 $1,660.73 $1,654.47 $1,648.21 $1,641.9593621 $1,820.99 $1,881.69 $1,942.39 $2,003.0993622 $1,937.57 $2,002.16 $2,066.74 $2,131.3393623 $303.78 $313.91 $324.03 $334.1693623 26 $232.30 $277.63 $322.97 $368.3093624 $909.55 $815.95 $722.34 $628.7493624 26 $463.45 $498.33 $533.21 $568.0993631 $1,101.70 $1,082.50 $1,063.29 $1,044.0993631 26 $749.80 $858.80 $967.79 $1,076.7993640 $1,045.44 $967.52 $889.59 $811.6793640 26 $645.84 $682.62 $719.40 $756.1893641 $1,213.25 $1,253.69 $1,294.14 $1,334.5893641 26 $891.93 $898.01 $904.10 $910.1893642 $1,170.70 $1,209.72 $1,248.75 $1,287.7793642 26 $738.28 $759.88 $781.48 $803.0893650 $1,895.63 $1,769.65 $1,643.67 $1,517.6993651 $2,875.97 $2,715.85 $2,555.72 $2,395.6093652 $2,941.97 $2,894.84 $2,847.71 $2,800.5793660 $163.44 $206.20 $248.96 $291.7293660 26 $190.81 $194.07 $197.33 $200.6093720 $48.30 $50.44 $52.58 $54.7393721 $29.90 $34.74 $39.57 $44.4193722 $37.14 $31.79 $26.45 $21.1093724 $699.20 $691.98 $684.76 $677.5393724 26 $464.60 $461.37 $458.14 $454.9193731 $69.71 $72.06 $74.41 $76.7693731 26 $47.15 $46.53 $45.92 $45.3093732 $93.73 $96.45 $99.17 $101.8993732 26 $75.90 $74.78 $73.66 $72.5593733 $50.68 $56.76 $62.84 $68.9293733 26 $24.87 $24.86 $24.85 $24.8493734 $56.80 $59.70 $62.60 $65.5093734 26 $32.20 $34.13 $36.06 $37.9993735 $76.91 $80.11 $83.31 $86.5193735 26 $48.59 $52.22 $55.85 $59.4993736 $47.23 $49.38 $51.53 $53.6893736 26 $32.37 $29.94 $27.50 $25.0793875 $122.83 $126.92 $131.02 $135.1193875 26 $80.04 $66.81 $53.58 $40.3493880 $287.96 $301.79 $315.61 $329.4493880 26 $186.42 $150.53 $114.65 $78.7693882 $206.00 $200.05 $194.10 $188.1593882 26 $28.75 $32.15 $35.55 $38.9493886 $328.07 $341.53 $354.98 $368.4493886 26 $181.39 $170.12 $158.86 $147.5993888 $216.74 $237.07 $257.39 $277.7293888 26 $135.09 $116.07 $97.06 $78.0493922 $98.77 $108.27 $117.77 $127.2693922 26 $30.12 $28.38 $26.64 $24.9093923 $185.57 $207.82 $230.07 $252.3393923 26 $57.99 $54.23 $50.46 $46.7093924 $202.55 $243.61 $284.67 $325.7293924 26 $60.99 $62.59 $64.19 $65.7993925 $270.55 $288.85 $307.15 $325.45

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 113 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

93925 26 $132.00 $120.47 $108.95 $97.4293926 $227.07 $227.33 $227.59 $227.8593926 26 $98.90 $83.25 $67.59 $51.9493930 $264.54 $286.82 $309.09 $331.3793930 26 $88.22 $82.85 $77.47 $72.1093931 $224.63 $216.15 $207.66 $199.1893931 26 $66.70 $59.50 $52.29 $45.0993965 $114.55 $128.92 $143.30 $157.6793965 26 $49.61 $49.97 $50.32 $50.6893970 $204.54 $243.36 $282.18 $321.0093970 26 $85.28 $81.75 $78.22 $74.6993971 $166.88 $179.77 $192.65 $205.5493971 26 $49.45 $50.90 $52.35 $53.8093975 $265.06 $332.71 $400.36 $468.0093975 26 $159.75 $154.74 $149.73 $144.7293976 $189.69 $216.75 $243.81 $270.8793976 26 $95.57 $95.01 $94.45 $93.8993978 $211.01 $221.96 $232.91 $243.8593978 26 $110.87 $108.34 $105.81 $103.2893979 $170.94 $180.53 $190.11 $199.7093979 26 $57.60 $57.20 $56.81 $56.4193980 $279.45 $304.19 $328.94 $353.6893980 26 $131.10 $132.99 $134.88 $136.7893981 $201.25 $232.89 $264.53 $296.1793981 26 $64.40 $62.07 $59.75 $57.4293990 $145.89 $182.76 $219.63 $256.5094010 $54.07 $57.67 $61.27 $64.8794010 26 $29.77 $29.22 $28.67 $28.1194060 $71.57 $81.63 $91.69 $101.7594060 26 $34.45 $36.24 $38.02 $39.8194070 $83.50 $121.62 $159.74 $197.8694070 26 $58.21 $60.77 $63.32 $65.8894150 $9.87 $17.41 $24.94 $32.4894150 26 $10.70 $9.85 $8.99 $8.1494200 $17.49 $22.23 $26.96 $31.7094200 26 $32.65 $26.69 $20.73 $14.7794240 $36.37 $37.58 $38.80 $40.0194240 26 $21.10 $22.11 $23.11 $24.1294250 $21.78 $27.83 $33.88 $39.9294250 26 $10.35 $10.70 $11.04 $11.3994260 $54.05 $51.29 $48.52 $45.7694260 26 $21.85 $20.87 $19.89 $18.9194350 $60.95 $62.98 $65.02 $67.0594350 26 $24.35 $22.67 $20.99 $19.3094360 $67.85 $70.11 $72.38 $74.6494360 26 $20.60 $20.91 $21.23 $21.5494370 $21.52 $62.15 $102.79 $143.4294370 26 $11.85 $16.24 $20.63 $25.0294375 $71.30 $64.35 $57.40 $50.4694375 26 $43.74 $40.68 $37.63 $34.5794450 $41.40 $53.93 $66.47 $79.0094450 26 $26.45 $29.30 $32.16 $35.0194620 $146.48 $176.49 $206.50 $236.5194620 26 $124.22 $112.07 $99.93 $87.7894640 $17.89 $23.84 $29.79 $35.7394642 $45.75 $47.73 $49.72 $51.7094656 $234.75 $226.92 $219.09 $211.2794657 $114.92 $111.05 $107.17 $103.3094660 $83.82 $99.04 $114.25 $129.4794664 $22.36 $26.70 $31.04 $35.38

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 114 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

94667 $24.15 $32.68 $41.21 $49.7594668 $17.25 $24.26 $31.27 $38.2894680 $95.96 $102.67 $109.37 $116.0894680 26 $51.22 $44.58 $37.94 $31.3094681 $89.52 $92.50 $95.49 $98.4794681 26 $64.63 $68.10 $71.58 $75.0594690 $32.20 $69.21 $106.23 $143.2494690 26 $8.22 $10.00 $11.79 $13.5794720 $39.58 $40.90 $42.22 $43.5494720 26 $29.41 $30.14 $30.87 $31.6094750 $249.55 $257.87 $266.19 $274.5194750 26 $113.16 $84.43 $55.70 $26.9894760 $13.51 $13.27 $13.03 $12.8094761 $28.75 $26.91 $25.07 $23.2294762 $47.15 $47.84 $48.53 $49.2194770 $54.05 $77.11 $100.17 $123.2394770 26 $34.06 $30.28 $26.49 $22.7194772 $149.50 $154.48 $159.47 $164.4594772 26 $40.25 $42.67 $45.10 $47.5295004 $2.64 $3.67 $4.70 $5.7395010 $5.28 $13.51 $21.73 $29.9695015 $8.31 $14.64 $20.97 $27.3095024 $6.02 $6.79 $7.56 $8.3495028 $10.08 $10.77 $11.46 $12.1595044 $6.83 $7.97 $9.11 $10.2695052 $8.43 $10.54 $12.65 $14.7695060 $7.56 $12.81 $18.06 $23.3095070 $81.61 $99.19 $116.77 $134.3695071 $92.11 $116.89 $141.67 $166.4595075 $117.30 $115.61 $113.91 $112.2295115 $14.52 $16.67 $18.82 $20.9895117 $14.61 $18.75 $22.90 $27.0495120 $19.44 $20.22 $20.99 $21.7795125 $16.47 $21.94 $27.42 $32.8995130 $21.10 $21.77 $22.44 $23.1295131 $30.01 $31.36 $32.70 $34.0595132 $35.71 $35.34 $34.96 $34.5995133 $41.63 $42.92 $44.20 $45.4995134 $50.06 $51.40 $52.74 $54.0895144 $23.00 $21.36 $19.72 $18.0895145 $32.22 $31.72 $31.22 $30.7295146 $48.07 $44.40 $40.74 $37.0795147 $80.03 $70.05 $60.07 $50.0995148 $95.75 $80.66 $65.57 $50.4795149 $117.20 $98.63 $80.07 $61.5095165 $58.71 $44.03 $29.36 $14.6895170 $18.40 $18.53 $18.66 $18.7995180 $78.72 $115.66 $152.59 $189.5395805 $517.50 $758.87 $1,000.23 $1,241.6095805 26 $141.65 $153.36 $165.07 $176.7995807 $356.50 $528.97 $701.44 $873.9095807 26 $143.75 $143.42 $143.08 $142.7595808 $399.05 $412.35 $425.66 $438.9695808 26 $166.62 $187.03 $207.44 $227.8495810 $399.05 $719.30 $1,039.55 $1,359.8095810 26 $198.58 $234.42 $270.27 $306.1195811 $618.67 $811.29 $1,003.92 $1,196.5495811 26 $300.56 $318.28 $335.99 $353.7195811 TC $314.06 $324.53 $335.00 $345.4795812 $193.55 $238.63 $283.71 $328.79

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 115 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

95813 $230.74 $288.16 $345.57 $402.9995816 $165.97 $201.42 $236.87 $272.3295816 26 $71.72 $81.43 $91.15 $100.8695819 $182.58 $219.60 $256.62 $293.6495819 26 $86.79 $92.71 $98.62 $104.5495819 TC $83.95 $86.75 $89.55 $92.3595822 $178.25 $217.60 $256.95 $296.3095822 26 $97.75 $96.78 $95.82 $94.8595824 $82.80 $85.56 $88.32 $91.0895824 26 $64.28 $67.79 $71.29 $74.8095829 $272.55 $1,027.88 $1,783.20 $2,538.5395829 26 $266.80 $336.10 $405.39 $474.6995830 $88.92 $160.36 $231.80 $303.2595831 $24.15 $28.30 $32.46 $36.6195832 $21.85 $30.09 $38.32 $46.5695833 $36.80 $47.18 $57.55 $67.9395834 $51.75 $60.65 $69.55 $78.4595857 $72.31 $77.12 $81.92 $86.7395860 $138.57 $146.59 $154.60 $162.6295860 26 $116.46 $112.57 $108.69 $104.8095861 $192.20 $197.99 $203.77 $209.5695861 26 $159.40 $157.22 $155.04 $152.8695863 $232.50 $231.93 $231.36 $230.7995863 26 $192.58 $192.33 $192.07 $191.8295864 $299.09 $310.23 $321.36 $332.5095864 26 $226.00 $224.73 $223.45 $222.1895867 $96.60 $105.89 $115.18 $124.4795867 26 $65.55 $73.61 $81.67 $89.7395868 $162.60 $169.59 $176.59 $183.5895868 26 $149.50 $147.74 $145.97 $144.2195869 $62.57 $67.08 $71.59 $76.1095869 26 $37.95 $41.46 $44.98 $48.4995870 $51.71 $58.91 $66.10 $73.3095870 26 $39.18 $42.05 $44.91 $47.7895872 $195.73 $198.84 $201.96 $205.0795872 26 $150.29 $156.93 $163.58 $170.2295875 $105.80 $120.57 $135.35 $150.1295875 26 $82.80 $93.48 $104.17 $114.8595900 $75.97 $83.85 $91.73 $99.6195900 26 $53.96 $53.89 $53.81 $53.7495903 $80.07 $91.22 $102.37 $113.5295904 $72.51 $77.62 $82.73 $87.8495904 26 $52.46 $51.64 $50.82 $50.0095920 $274.89 $276.92 $278.95 $280.9895920 26 $212.75 $197.38 $182.01 $166.6495925 $219.49 $193.64 $167.79 $141.9495925 26 $89.27 $93.12 $96.98 $100.8395926 $152.13 $151.13 $150.12 $149.1295927 $152.13 $151.37 $150.61 $149.8695930 $70.98 $95.79 $120.59 $145.4095933 $81.46 $87.91 $94.35 $100.8095933 26 $51.39 $55.11 $58.84 $62.5695934 $63.75 $69.60 $75.45 $81.3095936 $67.32 $73.32 $79.33 $85.3395937 $74.42 $81.79 $89.16 $96.5395937 26 $72.26 $65.30 $58.33 $51.3795950 $507.73 $524.65 $541.58 $558.5095950 26 $186.04 $175.65 $165.25 $154.8695951 $660.72 $682.74 $704.77 $726.7995951 26 $247.14 $314.14 $381.14 $448.14

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 116 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

95953 $579.60 $625.95 $672.30 $718.6695953 26 $249.73 $253.32 $256.90 $260.4995955 $272.21 $253.80 $235.40 $216.9995955 26 $126.50 $123.00 $119.51 $116.0195956 $656.65 $817.59 $978.52 $1,139.4695956 26 $275.98 $272.51 $269.05 $265.5895957 $194.36 $236.81 $279.26 $321.7095958 $408.74 $415.83 $422.91 $430.0095958 26 $365.23 $355.58 $345.93 $336.2895961 $344.85 $358.03 $371.21 $384.4095961 26 $232.97 $259.24 $285.50 $311.7795962 $316.49 $321.59 $326.70 $331.8095962 26 $280.60 $278.31 $276.02 $273.7496105 $96.60 $99.27 $101.94 $104.6196110 $69.00 $71.30 $73.60 $75.9096111 $96.60 $124.54 $152.49 $180.4396405 $45.66 $78.16 $110.65 $143.1596406 $70.16 $106.30 $142.45 $178.5996420 $89.70 $115.95 $142.19 $168.4496422 $143.75 $196.06 $248.38 $300.6996423 $115.00 $116.46 $117.91 $119.3796425 $241.50 $252.67 $263.84 $275.0196440 $142.00 $260.86 $379.73 $498.5996445 $123.72 $254.48 $385.24 $516.0196450 $230.11 $299.14 $368.17 $437.2096542 $133.17 $189.08 $244.98 $300.8996900 $21.78 $26.30 $30.83 $35.3596902 $32.00 $34.04 $36.09 $38.1396910 $30.36 $40.28 $50.20 $60.1296912 $34.58 $45.01 $55.44 $65.8796913 $115.00 $122.78 $130.56 $138.3497001 $81.49 $90.22 $98.94 $107.6797002 $39.14 $47.39 $55.64 $63.8997003 $81.49 $90.85 $100.21 $109.5797004 $39.14 $50.07 $61.01 $71.9497010 $17.25 $14.17 $11.09 $8.0197012 $16.10 $18.76 $21.43 $24.0997014 $16.10 $19.47 $22.84 $26.2297016 $19.55 $21.83 $24.11 $26.3897018 $19.55 $17.46 $15.36 $13.2797022 $16.10 $18.16 $20.22 $22.2897024 $16.10 $14.23 $12.36 $10.4997026 $16.10 $13.84 $11.59 $9.3397028 $14.95 $14.01 $13.06 $12.1297032 $22.44 $22.35 $22.27 $22.1897033 $23.85 $25.61 $27.37 $29.1397034 $14.95 $18.41 $21.88 $25.3497035 $21.03 $21.54 $22.04 $22.5597036 $20.70 $25.52 $30.33 $35.1597110 $27.18 $33.52 $39.87 $46.2197112 $34.65 $34.99 $35.34 $35.6897113 $34.65 $39.54 $44.43 $49.3297116 $33.24 $35.95 $38.65 $41.3697124 $25.30 $28.68 $32.07 $35.4597530 $20.70 $26.04 $31.38 $36.7297535 $21.96 $26.84 $31.72 $36.6197537 $21.96 $27.09 $32.22 $37.3597542 $16.00 $22.42 $28.84 $35.2697545 $189.48 $195.80 $202.11 $208.4397546 $79.74 $82.40 $85.05 $87.71

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 117 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

97750 $36.06 $39.18 $42.31 $45.4398925 $33.35 $36.70 $40.04 $43.3998926 $42.55 $48.01 $53.47 $58.9398927 $52.90 $60.47 $68.04 $75.6198928 $60.95 $74.48 $88.01 $101.5498929 $65.55 $81.85 $98.16 $114.4698940 $42.87 $44.49 $46.11 $47.7398941 $52.82 $55.28 $57.74 $60.2098942 $63.03 $65.42 $67.82 $70.2198943 $35.65 $38.71 $41.76 $44.8299000 $9.53 $10.00 $10.48 $10.9599050 $13.32 $21.23 $29.13 $37.0499058 $17.36 $19.41 $21.45 $23.5099175 $47.48 $56.40 $65.31 $74.2399183 $154.25 $190.30 $226.35 $262.4099190 $138.00 $142.60 $147.20 $151.8099191 $103.50 $106.95 $110.40 $113.8599192 $69.00 $71.30 $73.60 $75.9099195 $39.80 $39.67 $39.53 $39.4099201 $30.09 $36.63 $43.17 $49.7199202 $47.24 $59.64 $72.04 $84.4499203 $65.48 $84.11 $102.74 $121.3899204 $100.47 $124.51 $148.55 $172.5899205 $125.35 $158.76 $192.17 $225.5799211 $18.39 $21.89 $25.38 $28.8899212 $29.12 $36.09 $43.06 $50.0299213 $42.46 $50.54 $58.62 $66.7099214 $67.67 $79.94 $92.20 $104.4799215 $98.92 $118.12 $137.33 $156.5399217 $60.76 $73.30 $85.85 $98.3999218 $68.64 $78.71 $88.77 $98.8499219 $114.92 $129.22 $143.52 $157.8299220 $138.96 $162.46 $185.97 $209.4799221 $67.98 $81.29 $94.60 $107.9099222 $114.18 $129.33 $144.48 $159.6499223 $143.76 $166.03 $188.30 $210.5899231 $36.06 $40.08 $44.11 $48.1399232 $57.08 $63.34 $69.60 $75.8699233 $84.89 $96.53 $108.17 $119.8199234 $123.88 $146.42 $168.96 $191.4999235 $174.43 $195.85 $217.27 $238.6999236 $209.62 $242.03 $274.44 $306.8699238 $58.94 $72.09 $85.23 $98.3899239 $87.50 $100.59 $113.68 $126.7799241 $53.51 $62.02 $70.53 $79.0499242 $79.45 $95.56 $111.67 $127.7899243 $103.68 $124.91 $146.13 $167.3699244 $143.42 $172.40 $201.38 $230.3799245 $193.60 $230.29 $266.98 $303.6799251 $58.85 $64.01 $69.18 $74.3499252 $79.54 $88.79 $98.05 $107.3099253 $105.28 $118.71 $132.13 $145.5699254 $142.26 $157.63 $173.00 $188.3799255 $192.29 $215.40 $238.51 $261.6299281 $24.88 $29.14 $33.40 $37.6699282 $37.89 $44.34 $50.78 $57.2399283 $64.15 $75.71 $87.28 $98.8499284 $97.02 $115.14 $133.26 $151.3999285 $147.85 $173.98 $200.12 $226.2599291 $205.50 $258.23 $310.97 $363.70

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component

Page 118 Medical Fee Schedule - Rule 40.000 Appendix I, Table B

CPT CODE MOD Initial Fee FUD Third - Eff. 1/1/07 Two-Thirds - Eff 10/1/2007 Whole - Eff. 1/1/08

99292 $100.12 $123.67 $147.21 $170.7699295 $766.51 $982.56 $1,198.61 $1,414.6699296 $392.51 $496.16 $599.81 $703.4699315 $71.08 $76.09 $81.10 $86.1099316 $86.14 $97.14 $108.15 $119.1599341 $59.90 $66.34 $72.77 $79.2199342 $76.73 $89.09 $101.45 $113.8199343 $100.51 $122.72 $144.94 $167.1599344 $158.64 $178.32 $197.99 $217.6799345 $191.41 $219.69 $247.96 $276.2499347 $50.66 $54.80 $58.95 $63.0999348 $74.06 $81.59 $89.11 $96.6499349 $107.37 $121.03 $134.69 $148.3599350 $157.46 $177.31 $197.15 $217.0099354 $79.72 $108.40 $137.08 $165.7699355 $37.23 $68.06 $98.89 $129.7299356 $81.55 $99.50 $117.45 $135.4099357 $38.22 $66.81 $95.39 $123.9899358 $84.44 $96.25 $108.05 $119.8699359 $39.97 $46.94 $53.91 $60.8899374 $65.77 $80.85 $95.94 $111.0299375 $70.14 $104.44 $138.73 $173.0399377 $65.77 $83.47 $101.16 $118.8699378 $94.62 $118.51 $142.40 $166.2899379 $65.77 $83.35 $100.93 $118.5299380 $94.62 $116.16 $137.70 $159.2499381 $48.24 $75.42 $102.61 $129.7999382 $50.15 $79.32 $108.49 $137.6799383 $54.39 $81.40 $108.41 $135.4299384 $59.44 $90.63 $121.83 $153.0299385 $67.59 $97.34 $127.08 $156.8399386 $73.03 $110.61 $148.20 $185.7899387 $104.97 $131.84 $158.70 $185.5799391 $44.60 $63.12 $81.63 $100.1599392 $46.37 $68.52 $90.67 $112.8299393 $50.61 $70.97 $91.33 $111.7099394 $55.65 $78.34 $101.03 $123.7399395 $64.51 $87.09 $109.67 $132.2599396 $69.81 $95.62 $121.43 $147.2399397 $102.32 $119.26 $136.20 $153.1499401 $26.61 $35.90 $45.19 $54.4899402 $49.33 $65.67 $82.01 $98.3599403 $70.60 $92.09 $113.57 $135.0699404 $91.47 $118.66 $145.85 $173.0399431 $93.18 $105.54 $117.90 $130.2699432 $64.98 $80.55 $96.12 $111.7099433 $43.56 $49.96 $56.36 $62.7699435 $118.99 $129.93 $140.88 $151.8299436 $132.51 $137.49 $142.47 $147.4499440 $113.30 $148.62 $183.94 $219.2599455 $34.00 $35.13 $36.27 $37.4099456 $40.00 $41.33 $42.67 $44.00

4/2006CPT® Codes/Desc only are copyright 2010 American Medical Assoc.

Mod 26 is professional component, TC is technical component