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Medicare Part B Physicians Fee Schedule Effective March 1, 2003 Ohio Palmetto GBA Medicare Part B Operations P.O. Box 182947 Columbus, Ohio 43218-2947 A CMS Contracted Intermediary and Carrier

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Medicare Part B

Physicians Fee Schedule

Effective March 1, 2003

Ohio

Palmetto GBA Medicare Part B Operations

P.O. Box 182947 Columbus, Ohio 43218-2947 A CMS Contracted Intermediary and Carrier

CPT codes, descriptors and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

The 2003 Participation Enrollment Period is being extended an additional 45 days from March 1, 2003 to April 14, 2003 and CMS has implemented a positive 1.6 percent update to the current 2003 Physician Fee Schedule effective March 1, 2003. The 2003 Physician Fee Schedules printed prior to March 3, 2003 are no longer valid.

Announcement About Medicare Participation for March 1, 2003

“We have great news to share with physicians and other practitioners throughout the country. As you know, CMS was scheduled to implement a negative 4.4 percent update effective March 1, 2003. CMS has worked with Congress for many months in an effort to correct a defect in the formula generated in part by unanticipated changes in economic conditions. We are pleased to announce that Congress has acted – this flaw will be corrected and, instead of a negative 4.4 percent update, we are now preparing to implement a positive 1.6 percent update effective March 1, 2003. Medicare remains a lifeline to millions of seniors and disabled Americans, and your commitment and participation in the Medicare program make this lifeline possible. We hope that you will keep this in mind as you make your decision regarding your participation in 2003. All physicians and practitioners now have until April 14, 2003, to make their 2003 Medicare participation decisions. As stated above, the 2003 Participation Enrollment Period is being extended an additional 45 days from March 1, 2003 to April 14, 2003, in order to allow physicians/practitioners an opportunity to make changes to their participation status. The participation period is the period of time in which providers can elect to participate in Medicare or to change their enrollment status. Any change in the participation status made during this period will be effective March 1, 2003. Any change to the participation status made before March 1, is effective back to January 1, 2003.” FIs must prepare an article to be published on their Web site and in their next regularly scheduled bulletin announcing the new legislative change by Congress that increased the payment for services paid under the 2003 MPFS. The 2003 MPFS is effective for dates of service on or after March 1, 2003. The new participation enrollment effective date will be March 1, 2003. To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients.

There will be no special mailing of the new March 1, 2003 Participation Enrollment and Fee Schedule materials. Please refer to the Medicare Web site at http://www.PalmettoGBA.com for the new 2003 Physicians Fee Schedule. The new fee schedule will be available after March 1, 2003. Bek/3-1-2003

CPT codes, descriptors and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

WHY PARTICIPATE?

If you bill for physicians’ professional services, services and supplies (such as drugs and biologicals) provided incident to physicians’ professional services, outpatient physical and occupational therapy services, diagnostic tests, and radiology services, your Medicare fee schedule amounts are 5 percent higher if you participate. Also, regardless of the Medicare Part B services for which you are billing, participants have "one stop" billing for beneficiaries who have nonemployment-related Medigap coverage and who assign both their Medicare and Medigap payments to participants. After we have made payment, we automatically send the claim on to the Medigap insurer for payment of all coinsurance and deductible amounts due under the Medigap policy. The Medigap insurer must pay the participant directly. The number of physicians, practitioners and suppliers who choose to participate in Medicare continues to grow. During CY 2002, 89.3 percent of all physicians, practitioners and suppliers are billing under signed Medicare participation agreements - this was a 0.6 percent increase over the number of CY 2001 participants. To sign a participation agreement (CMS-460) is to agree to accept assignment for all covered services that you provide to Medicare patients in CY 2003. We hope you will decide to be a participating provider within the Medicare Program. Please call Brenda Knox at (614) 277-7169 if you have any questions or need further information on participation. The Medicare Participating Program address is listed below:

ATTN: BRENDA KNOX PALMETTO/GBA

MEDICARE OPERATIONS PARTICIPATING PROVIDER ROGRAM

PO BOX 182195 COLUMBUS, OH 43218-2195

http://www.PalmettoGBA.com

bek/3-1-2003

CPT codes, descriptors and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

2003 FACT SHEET

FOR PHYSICIANS AND OTHER PROVIDERS: KEY NEWS FROM MEDICARE FOR 2003

Billing and business staff: Please share this with physicians and other providers. 1. Good News: No Flu Vaccine Shortages

or Delays Anticipated

The Centers for Disease Control and Prevention (CDC) report that they do not anticipate influenza vaccine shortages or delays. Manufacturers of the vaccine are currently meeting their production goals. To date, 94.9 million doses have been produced, which exceeds the 87.7 million doses that were produced in the 2001-02 influenza season. The vaccine is expected to be available in October. Influenza vaccine for the 2002-03 influenza season is still available for purchase. Health care providers who have not ordered influenza vaccine should do so as soon as possible to ensure timely receipt of the vaccine. We also note that Medicare payment for administration of the flu vaccine will be increasing in 2003.

2. Immunization Administration

CPT code 90471 is used for immunization administration and CPT code 90472 is used for each additional vaccine. Payment under the physician fee schedule for CY 2003 will nearly double for CPT code 90471 and will be slightly reduced for CPT code 90472. Since CPT code 90472 must be billed in conjunction with CPT code 90471, the total payment for these procedures will increase when billed together.

3. Now Is The Time To Become

HIPAA-Compliant

Two major Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) go into effect in 2003. Compliance with the privacy regulations is required beginning April 14, 2003 and the last date for compliance with the standard transactions and code sets regulations is October 16, 2003. In addition, as part of the Administrative Simplification Compliance Act (ASCA), Medicare will not accept paper claims after October 16, 2003; however, there are a few exceptions

to this provision, including for small providers and for providers having no method available to submit claims electronically.

Now is the time to ensure you will be ready! The Department of Health and Human Services has resources available. Visit the Web site at www.cms.hhs.gov/hipaa. Your Medicare carrier or fiscal intermediary can also provide you with information about the transactions and code sets standards and can help you begin to test your HIPAA transactions early to ensure you are compliant.

4. Medicare and You 2003

The national edition of Medicare and You 2003 will be available for order after October 1, 2002. Call 1-800-MEDICARE (1-800-633-4227) to request up to 25 copies, or fax an order to 410-786-1905 for more than 25 copies.

5. Medicare Physician Web Site

A physician Web page is now available on the CMS Web site at http://cms.hhs.gov/physicians/. The page includes links to general information on enrollment, billing, conditions of participation, publications, education, training, data, and statistics. There are also links to specific information on the physician fee schedule, the Practicing Physicians Advisory Council (PPAC), the Physician Regulatory Issues Team (PRIT), Medicare payments, and the participating physician directory. We continue to work on improvements and will be soliciting feedback to make the page as comprehensive and as easy to navigate as possible.

6. Relevant Medicare Patient Brochures

That May Be Of Interest To Physicians There are a variety of brochures that physicians might find helpful to address frequently asked coverage-related

CPT codes, descriptors and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

questions. These include: Medicare and Your Mental Health Benefits (Publication #10184), Women with Medicare: Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam (Publication #02248), Medicare Preventive Services: To Help Keep You Healthy (Publication # 10110) and Choosing Long-Term Care: A Guide for People with Medicare (Publication #02223). Publications newly available this year includes: Medicare Coverage of Diabetes Supplies and Services (Publication# 11022) and Medicare Coverage of Ambulance Services (Publication # 11021-will be available late Fall). A complete listing of all publications for beneficiaries is available at www.medicare.gov. Many publications are available in different languages and formats including: Braille, Spanish, Chinese, Audiocassette, and Large Print. To order copies for your office, fax your request to (410) 786-1905, and include the name of a contact person, phone number, and mailing address (No P.O Boxes please).

7. Medicare Learning Network Website

The Medicare Learning Network Web site, which is located at http://cms.hhs.gov/medlearn, is the Internet gateway to all of the educational information, products and services that are created by CMS and its contractors. This Web site allows Medicare providers to quickly obtain information they need to successfully navigate the Medicare program. It provides: quick reference guides, Web-based training modules, videos, publications, training materials, provider education events with on-line registration, questions and answers, and links to Medicare contractors. Bookmark and visit the Medicare Learning Network Web site frequently as it is continually being updated to bring you the most accurate and up-to-date information possible.

8. Medicare Coverage Information

Medicare's coverage rules are written in many types of documents located across multiple Web sites. Currently, National Coverage Determinations (NCDs) are located on cms.hhs.gov; Local Medical Review Policies (LMRPs) are located on lmrp.net; and contractor articles and Frequently Asked Questions (FAQ's) are located on individual contractor Web

sites. The CMS has undertaken an effort to build a single access to Medicare coverage information. When finished, the cms.hhs.gov Web site will allow users to search across NCDs, LMRPs, and contractor articles/FAQs from a single point of entry. The Web site pages will be released in December 2002.

9. Advance Beneficiary Notices (ABNs)

The new ABN standard form, CMS-R-131, has been published and must be used on and after October 1, 2002. For replicable ABN forms and information on how to properly use an ABN, see our ABN Quick Reference Guide on our Medlearn Web site at http://cms.hhs.gov/medlearn/refabn.asp.

10. Drugs Furnished Incident to a Physician’s Professional Services

We allow payment for certain injectable drugs furnished incident to a physician’s service if the drug is not usually self-administered by Medicare beneficiaries. Contact your local carrier for more information.

11. Filing of Appeals on Initial Claim

Determinations

As mandated by section 521 of the Benefits Improvement and Protections Act of 2000, effective October 1, 2002, physicians and other suppliers that wish to appeal an initial claim determination must file their appeal within 120 days of the initial determination. This represents an increase of 60 days for an appeal of a Medicare Part A claim and a decrease of 60 days for an appeal of a Medicare Part B claim.

12. CMS Publishes Nursing Home Quality

Measures

In April 2002, CMS started publishing new nursing home quality measures on its consumer Web site at Nursing Home Compare on www.medicare.gov. The release was initially limited to six pilot states and starting in October will be expanded nationally. The quality data will enable beneficiaries, their caregivers, and families to choose nursing homes based, in part, on information relevant to both long (chronic) and short stays (typically Medicare-covered). The measures represent the best available science and

CPT codes, descriptors and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

include risk adjustment methodology. This quality data is one source of information for consumers to use in choosing a nursing home. We encourage consumers to review the other data on the nursing home site, and to visit nursing homes in person before selection. Additionally, quality improvement organizations in each State will be assisting nursing homes to use the data to implement quality improvement strategies. For more information about the pilot go to the www.cms.hhs.gov Web site, specifically the Nursing Home Quality Initiative.

13. Data Will Help Home Health Agencies

Improve Care

The CMS is implementing the Outcomes Based Quality Improvement (OBQI) System for Home Health Agencies (HHAs). The CMS contractors will offer HHAs OBQI training and technical assistance that will assist HHAs in interpreting outcome reports, target outcomes for improvement, and develop and implement plans to improve these outcomes. The CMS will maintain a Home Health OBQI Clearinghouse Web site at www.obqi.org which will contain continuously updated literature, and administrative and clinical enhancements to home health care.

Other Physician Fee Schedule Information Revisions to the 2003 Medicare Physician Fee Schedule affect the amount you will receive when providing services to a Medicare beneficiary. Below is a summary of the major changes effective January 1, 2003, as well as other useful information. Full physician fee schedule information is attached.

14. Medicare Qualifications For Clinical Nurse Specialists

The definition of a clinical nurse specialist (CNS) has been revised to include individuals certified as a clinical nurse specialist by a national certifying body that has established standards for clinical nurse specialists and that is approved by the Secretary. This revision is consistent with the certification criteria for nurse practitioners and will potentially enable CNSs who specialize in fields such as oncology, critical care, or rehabilitation to qualify as a CNS for Medicare purposes.

15. Telehealth Services

Effective October 1, 2001, Medicare Part B coverage was expanded to include office or other outpatient visits, professional consultation, individual psychotherapy, and pharmacologic management via telehealth in rural Health Professional Shortage Areas and non-Metropolitan Statistical Area Counties. A process has been established, as required by the law, to add or delete services to the list of Medicare telehealth services included in the physician fee schedule. In addition, a psychiatric diagnostic interview examination has been added to the list of Medicare telehealth services for CY 2003.

16. Enrollment of Physical and

Occupational Therapists as Therapists in Independent Practice

We have revised the regulations at §§410.59 and 410.60 to allow enrollment of therapists as physical or occupational therapists in private practice when they are employed by physician groups. We believe that this reflects actual practice patterns, will permit more flexible employment opportunities for therapists and also increases beneficiaries’ access to therapy services, particularly in rural areas.

CPT codes, descriptors and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

MEDICARE FEE SCHEDULE INFORMATION FOR FEE SCREEN YEAR 2003

CLINICAL PSYCHOLOGIST and CLINICAL SOCIAL WORKERS Reimbursements for ALL Clinical Psychologist (CP – specialty 68) services are based on the current year’s physician fee schedule payments. For the Clinical Social Worker (CSW – specialty 80) services reimbursement amounts remain, as set by law, at 75% of the Clinical Psychologist reimbursement level.

FACILITY SETTING PAYMENT DIFFERENTIAL As part of the resource-based practice expense initiative, the Center For Medicare and Medicaid Services (CMS) is replacing the previous policy that systematically reduced the practice expense relative value units (RVUs) by 50 percent for certain procedures performed in facilities with a policy that would generally identify two different levels (facility and nonfacility) of practice expense RVUs for each procedure code depending on the location of the service. Some services, by the nature of their codes, are performed only in certain settings and will have only one level of practice expense RVU per code. Many of these are evaluation and management codes with code descriptions specific as to the location of the service. Other services, such as most major surgical services with a 90-day global period, are performed entirely or almost entirely in the hospital, and those services generally are provided with a practice expense RVU only for the out-of office or facility setting. The higher nonfacility practice expense RVUs are generally used to calculate payments for services performed in a physician’s office and for services furnished to a patient in the patient’s home, or facility or institution other than a hospital, skilled nursing facility (SNF), or ambulatory surgical center (ASC). For these services, the physician typically bears the cost of resources, such as labor, medical supplies and medical equipment associated with the physician’s service. The lower facility practice expense RVUs generally are used to calculate payments for physicians’ services furnished to hospital, SNF and ASF patients. The cost for nonphysicians’ services and other items, including medical equipment and supplies, are typically borne by the hospital, SNF, or the ASC. The facility-based fees are linked to their own separate RVUs independent of the nonfacility fee RVUs. This differs from the former site-of service fee reductions, which were based simply on a percentage reduction of the full fee rather than a separate RVU.

CPT codes, descriptors and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

2003 NON-PHYSICIAN PRACTITIONER FEE SCHEDULE

Sections 4511 and 4512 of the Balanced Budget Act of 1997 (BBA) provide that payment for the professional services of these non-physician practitioners will be linked to the physician fee schedule. Payment may be made for services furnished by nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNs) in all settings permitted by State law, but only if no facility or other provider charges are paid in connection with the service. Payment would be equal to 80 percent of the lesser of the actual charge or 85 percent of the physician fee schedule. Payment for a PA’s services may only be made to the PA’s employer. Under certain circumstances, a PA as an independent contractor qualifies as an employment relationship where payment is made to the employer.

2003 NURSE MIDWIVES FEE SCHEDULE

65% of the Medicare Physician Fee Schedule The non-participating fee schedule amounts and limiting charges do not apply to services rendered by:

Physician Assistants

Nurse Practitioners

Clinical Nurse Specialists

Certified Registered Nurse Anesthetists

Certified Nurse Midwives

Clinical Social Workers

Clinical Psychologists

CPT codes, descriptors and other data only are copyright 2002 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

NEW 2003 MEDICARE PHYSICIANS FEE SCHEDULE FORMAT

Attached are the new Ohio and West Virginia 2003 MEDICARE PHYSICIAN FEE SCHEDULE (MPFS) amounts. The new 2003 MPFS amounts are effective for calendar year (CY) 2003 dates of service processed on and after March 1, 2003. These reports contains the following:

HEADING

DEFINITION

Codes with the “#” symbol. If these procedures are performed in the hospital in/outpatient, emergency department, skilled nursing, inpatient psychiatric, comprehensive in/outpatient rehabilitation facility or ambulatory surgical center, they are subject to ‘Facility Setting’ amounts.

PROCEDURE CODE/MOD

Procedure code and modifier: HCPCS procedure codes and HCPCS modifiers do NOT appear in bold type; CPT procedure codes and CPT modifiers appear in bold type.

PAR FEE Participating fee schedule amount.

NONPAR FEE

Nonparticipating fee schedule amount.

LIMITING CHARGE

Limiting charge for nonparticipating physicians. The limiting charge equals 115% of the nonparticipating fee schedule amount. The limiting charge applies to non-assigned claims.

If you elected to be a participant during 2003, the limiting charges indicated on the enclosed report will not pertain to your practice. The nonparticipating fee schedule amounts and limiting charges do not apply to services or supplies unless they are paid under the physician fee schedule. Limiting charge applies to unassigned claims by nonparticipating providers.

NEW 2003 ANESTHESIA CONVERSION FACTOR The new 2003 anesthesia conversion factors are effective for calendar year (CY) 2003 dates of service processed on and after March 1, 2003.

OHIO

PAR NON-PAR LIMITINGAMOUNT AMOUNT CHARGE

16.71 15.87 18.25

WEST VIRGINIA

PAR NON-PAR LIMITINGAMOUNT AMOUNT CHARGE

16.67 15.84 18.22

OHIO - MEDICARE CARRIER 00883 PAGE 1FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

G0030 26 73.98 70.28 80.82 G0141 49.99 47.49 54.61G0031 26 94.38 89.66 103.11 G0166 196.32 186.50 214.48G0032 26 74.33 70.61 81.20 # G0166 3.94 3.74 4.30G0033 26 94.38 89.66 103.11 G0168 94.49 89.77 103.24G0034 26 74.33 70.61 81.20 # G0168 22.96 21.81 25.08G0035 26 94.38 89.66 103.11 G0179 54.56 51.83 59.60G0036 26 73.98 70.28 80.82 G0180 70.55 67.02 77.07G0037 26 94.38 89.66 103.11 G0181 119.16 113.20 130.18G0038 26 73.98 70.28 80.82 G0182 125.76 119.47 137.39G0039 26 94.74 90.00 103.50 G0202 125.84 119.55 137.48G0040 26 73.98 70.28 80.82 G0202 TC 89.97 85.47 98.29G0041 26 94.03 89.33 102.73 G0202 26 35.87 34.08 39.19G0042 26 73.98 70.28 80.82 G0204 133.76 127.07 146.13G0043 26 94.38 89.66 103.11 G0204 TC 88.93 84.48 97.15G0044 26 73.98 70.28 80.82 G0204 26 44.83 42.59 48.98G0045 26 94.38 89.66 103.11 G0206 107.78 102.39 117.75G0046 26 73.98 70.28 80.82 G0206 TC 71.56 67.98 78.18G0047 26 94.38 89.66 103.11 G0206 26 36.22 34.41 39.57G0101 34.42 32.70 37.61 G0210 26 76.41 72.59 83.48

# G0101 22.61 21.48 24.70 G0211 26 76.41 72.59 83.48G0102 19.73 18.74 21.55 G0212 26 76.41 72.59 83.48

# G0102 8.61 8.18 9.41 G0213 26 76.41 72.59 83.48G0104 99.85 94.86 109.09 G0214 26 76.41 72.59 83.48

# G0104 54.71 51.97 59.77 G0215 26 76.41 72.59 83.48G0105 420.36 399.34 459.24 G0216 26 76.41 72.59 83.48

# G0105 201.24 191.18 219.86 G0217 26 76.41 72.59 83.48G0106 130.16 123.65 142.20 G0218 26 76.41 72.59 83.48G0106 TC 80.96 76.91 88.45 G0220 26 76.41 72.59 83.48G0106 26 49.20 46.74 53.75 G0221 26 76.41 72.59 83.48G0108 28.83 27.39 31.50 G0222 26 76.41 72.59 83.48G0109 17.02 16.17 18.60 G0223 26 76.41 72.59 83.48G0110 58.42 55.50 63.83 G0224 26 76.41 72.59 83.48

# G0110 44.18 41.97 48.27 G0225 26 76.41 72.59 83.48G0111 20.24 19.23 22.11 G0226 26 76.41 72.59 83.48

# G0111 15.03 14.28 16.42 G0227 26 76.41 72.59 83.48G0112 106.64 101.31 116.51 G0228 26 76.41 72.59 83.48

# G0112 87.54 83.16 95.63 G0229 26 76.41 72.59 83.48G0113 77.46 73.59 84.63 G0230 26 76.41 72.59 83.48

# G0113 62.88 59.74 68.70 G0231 26 76.41 72.59 83.48G0114 62.03 58.93 67.77 G0232 26 76.41 72.59 83.48

# G0114 57.86 54.97 63.22 G0233 26 76.41 72.59 83.48G0115 67.59 64.21 73.84 G0234 26 76.41 72.59 83.48

# G0115 58.22 55.31 63.61 G0236 18.16 17.25 19.84G0116 77.17 73.31 84.31 G0236 TC 14.94 14.19 16.32

# G0116 53.56 50.88 58.51 G0236 26 3.23 3.07 3.53G0117 49.70 47.22 54.30 G0237 17.03 16.18 18.61

# G0117 24.35 23.13 26.60 G0245 60.48 57.46 66.08G0118 34.66 32.93 37.87 # G0245 44.86 42.62 49.01

# G0118 9.31 8.84 10.17 G0246 35.12 33.36 38.36G0120 130.16 123.65 142.20 # G0246 22.62 21.49 24.71G0120 TC 80.96 76.91 88.45 G0247 37.99 36.09 41.50G0120 26 49.20 46.74 53.75 # G0247 27.22 25.86 29.74G0121 420.36 399.34 459.24 G0248 149.67 142.19 163.52

# G0121 201.24 191.18 219.86 G0249 116.68 110.85 127.48G0124 49.99 47.49 54.61 G0250 9.32 8.85 10.18G0125 26 74.33 70.61 81.20 G0253 26 95.78 90.99 104.64G0127 15.56 14.78 17.00 G0254 26 95.78 90.99 104.64

# G0127 8.96 8.51 9.79 G0262 728.19 691.78 795.55G0128 4.30 4.09 4.70 G0262 TC 621.62 590.54 679.12G0130 41.01 38.96 44.80 G0262 26 106.58 101.25 116.44G0130 TC 28.84 27.40 31.51 G0268 43.37 41.20 47.38G0130 26 12.17 11.56 13.29 # G0268 31.91 30.31 34.86

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 2FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

G0270 16.67 15.84 18.22 11040 37.99 36.09 41.50G0271 6.60 6.27 7.21 # 11040 27.22 25.86 29.74G0272 16.85 16.01 18.41 11041 54.83 52.09 59.90G0273 435.60 413.82 475.89 # 11041 43.37 41.20 47.38G0273 TC 391.48 371.91 427.70 11042 77.56 73.68 84.73G0273 26 44.12 41.91 48.20 # 11042 60.19 57.18 65.76G0274 201.03 190.98 219.63 11043 218.92 207.97 239.17G0274 TC 94.86 90.12 103.64 # 11043 186.62 177.29 203.88G0274 26 106.18 100.87 116.00 11044 287.43 273.06 314.02G0275 12.91 12.26 14.10 # 11044 258.96 246.01 282.91G0278 12.91 12.26 14.10 11055 34.04 32.34 37.19G0281 12.45 11.83 13.60 # 11055 22.58 21.45 24.67G0283 12.45 11.83 13.60 11056 43.37 41.20 47.38G0288 372.33 353.71 406.77 # 11056 32.25 30.64 35.24G0289 83.44 79.27 91.16 11057 52.69 50.06 57.57M0064 25.95 24.65 28.35 # 11057 41.58 39.50 45.43

# M0064 17.97 17.07 19.63 11100 73.91 70.21 80.74P3001 49.99 47.49 54.61 # 11100 44.04 41.84 48.12Q0035 23.21 22.05 25.36 11101 28.80 27.36 31.46Q0035 TC 14.25 13.54 15.57 # 11101 22.55 21.42 24.63Q0035 26 8.96 8.51 9.79 11200 72.11 68.50 78.78Q0091 37.41 35.54 40.87 # 11200 40.16 38.15 43.87

# Q0091 18.66 17.73 20.39 11201 30.69 29.16 33.53Q0092 11.46 10.89 12.52 # 11201 15.41 14.64 16.84R0070 97.79 92.90 106.84 11300 53.97 51.27 58.96W0002 1,249.39 1,186.92 1,364.96 # 11300 27.23 25.87 29.7510021 130.92 124.37 143.03 11301 70.50 66.98 77.03

# 10021 67.03 63.68 73.23 # 11301 45.84 43.55 50.0810022 140.29 133.28 153.27 11302 85.06 80.81 92.93

# 10022 63.20 60.04 69.05 # 11302 56.59 53.76 61.8210040 82.84 78.70 90.51 11303 102.39 97.27 111.86

# 10040 69.30 65.84 75.72 # 11303 65.93 62.63 72.0210060 97.08 92.23 106.06 11305 54.93 52.18 60.01

# 10060 68.61 65.18 74.96 # 11305 35.13 33.37 38.3810061 158.49 150.57 173.16 11306 75.94 72.14 82.96

# 10061 142.17 135.06 155.32 # 11306 52.67 50.04 57.5510080 119.66 113.68 130.73 11307 87.99 83.59 96.13

# 10080 71.04 67.49 77.61 # 11307 60.56 57.53 66.1610081 196.44 186.62 214.61 11308 104.06 98.86 113.69

# 10081 149.56 142.08 163.39 # 11308 74.89 71.15 81.8210120 101.34 96.27 110.71 11310 66.48 63.16 72.63

# 10120 60.36 57.34 65.94 # 11310 39.40 37.43 43.0410121 209.35 198.88 228.71 11311 82.63 78.50 90.28

# 10121 168.73 160.29 184.33 # 11311 57.28 54.42 62.5810140 112.63 107.00 123.05 11312 95.38 90.61 104.20

# 10140 91.10 86.55 99.53 # 11312 65.52 62.24 71.5810160 74.22 70.51 81.09 11313 124.90 118.66 136.46

# 10160 62.07 58.97 67.82 # 11313 87.74 83.35 95.8510180 141.97 134.87 155.10 11400 105.23 99.97 114.97

# 10180 134.68 127.95 147.14 # 11400 66.34 63.02 72.4711000 45.79 43.50 50.03 11401 121.49 115.42 132.73

# 11000 31.90 30.31 34.86 # 11401 85.38 81.11 93.2811001 24.80 23.56 27.09 11402 138.28 131.37 151.08

# 11001 15.43 14.66 16.86 # 11402 98.69 93.76 107.8211010 251.83 239.24 275.13 11403 157.50 149.63 172.07

# 11010 236.55 224.72 258.43 # 11403 117.57 111.69 128.4411011 331.56 314.98 362.23 11404 179.83 170.84 196.47

# 11011 288.85 274.41 315.57 # 11404 130.52 123.99 142.5911012 472.72 449.08 516.44 11406 221.62 210.54 242.12

# 11012 428.27 406.86 467.89 # 11406 167.45 159.08 182.9411420 101.29 96.23 110.66

# 11420 73.16 69.50 79.93

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 3FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

11421 129.10 122.65 141.05 11642 215.06 204.31 234.96# 11421 96.46 91.64 105.39 # 11642 161.93 153.83 176.90

11422 144.04 136.84 157.37 11643 249.60 237.12 272.69# 11422 112.09 106.49 122.46 # 11643 190.91 181.36 208.56

11423 171.41 162.84 187.27 11644 318.86 302.92 348.36# 11423 130.78 124.24 142.88 # 11644 246.98 234.63 269.82

11424 197.46 187.59 215.73 11646 431.42 409.85 471.33# 11424 152.66 145.03 166.78 # 11646 357.45 339.58 390.52

11426 279.57 265.59 305.43 11719 15.21 14.45 16.62# 11426 224.01 212.81 244.73 # 11719 8.96 8.51 9.79

11440 120.17 114.16 131.28 11720 24.14 22.93 26.37# 11440 90.30 85.79 98.66 # 11720 16.85 16.01 18.41

11441 141.00 133.95 154.04 11721 36.31 34.49 39.66# 11441 112.88 107.24 123.33 # 11721 28.33 26.91 30.95

11442 159.81 151.82 174.59 11730 72.37 68.75 79.06# 11442 125.09 118.84 136.67 # 11730 59.52 56.54 65.02

11443 195.13 185.37 213.18 11732 32.89 31.25 35.94# 11443 155.54 147.76 169.92 # 11732 30.46 28.94 33.28

11444 249.32 236.85 272.38 11740 42.98 40.83 46.95# 11444 202.10 192.00 220.80 # 11740 19.37 18.40 21.16

11446 321.68 305.60 351.44 11750 132.96 126.31 145.26# 11446 273.76 260.07 299.08 # 11750 99.97 94.97 109.22

11450 251.44 238.87 274.70 11752 181.93 172.83 198.75# 11450 142.40 135.28 155.57 # 11752 169.77 161.28 185.47

11451 330.22 313.71 360.77 11755 88.27 83.86 96.44# 11451 206.95 196.60 226.09 # 11755 69.17 65.71 75.57

11462 241.70 229.62 264.06 11760 125.91 119.61 137.55# 11462 132.31 125.69 144.54 # 11760 106.82 101.48 116.70

11463 352.10 334.50 384.68 11762 194.09 184.39 212.05# 11463 212.16 201.55 231.78 # 11762 181.58 172.50 198.38

11470 286.33 272.01 312.81 11765 66.08 62.78 72.20# 11470 171.39 162.82 187.24 # 11765 43.85 41.66 47.91

11471 371.95 353.35 406.35 11770 206.79 196.45 225.92# 11471 234.09 222.39 255.75 # 11770 146.02 138.72 159.53

11600 138.63 131.70 151.46 11771 419.32 398.35 458.10# 11600 85.16 80.90 93.04 # 11771 364.11 345.90 397.79

11601 159.93 151.93 174.72 11772 500.21 475.20 546.48# 11601 112.70 107.07 123.13 # 11772 429.02 407.57 468.71

11602 170.25 161.74 186.00 11900 45.65 43.37 49.88# 11602 120.24 114.23 131.36 # 11900 27.24 25.88 29.76

11603 188.01 178.61 205.40 11901 55.13 52.37 60.23# 11603 132.11 125.50 144.33 # 11901 42.63 40.50 46.58

11604 207.12 196.76 226.27 11920 139.51 132.53 152.41# 11604 142.53 135.40 155.71 # 11920 92.28 87.67 100.82

11606 272.03 258.43 297.19 11921 165.05 156.80 180.32# 11606 195.63 185.85 213.73 # 11921 112.26 106.65 122.65

11620 132.88 126.24 145.18 11922 32.76 31.12 35.79# 11620 80.10 76.10 87.52 # 11922 28.60 27.17 31.25

11621 158.48 150.56 173.14 11950 75.01 71.26 81.95# 11621 112.29 106.68 122.68 # 11950 47.23 44.87 51.60

11622 180.90 171.86 197.64 11951 102.68 97.55 112.18# 11622 130.55 124.02 142.62 # 11951 64.83 61.59 70.83

11623 213.72 203.03 233.48 11952 135.82 129.03 148.38# 11623 158.15 150.24 172.78 # 11952 91.71 87.12 100.19

11624 245.37 233.10 268.07 11954 163.86 155.67 179.02# 11624 182.87 173.73 199.79 # 11954 106.22 100.91 116.05

11626 326.95 310.60 357.19 11960 740.88 703.84 809.42# 11626 253.33 240.66 276.76 11970 456.63 433.80 498.87

11640 140.79 133.75 153.81 11971 304.62 289.39 332.80# 11640 92.17 87.56 100.69 # 11971 218.85 207.91 239.10

11641 185.18 175.92 202.31 11976 126.93 120.58 138.67# 11641 138.30 131.39 151.10 # 11976 94.99 90.24 103.78

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 4FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

11980 94.47 89.75 103.21 12052 215.00 204.25 234.89# 11980 76.76 72.92 83.86 # 12052 154.58 146.85 168.88

11981 113.93 108.23 124.46 12053 233.64 221.96 255.25# 11981 78.86 74.92 86.16 # 12053 173.91 165.21 189.99

11982 130.06 123.56 142.09 12054 259.56 246.58 283.57# 11982 94.99 90.24 103.78 # 12054 191.50 181.93 209.22

11983 210.72 200.18 230.21 12055 333.06 316.41 363.87# 11983 175.30 166.54 191.52 # 12055 249.38 236.91 272.45

12001 141.37 134.30 154.45 12056 435.46 413.69 475.74# 12001 81.64 77.56 89.19 # 12056 311.49 295.92 340.31

12002 150.32 142.80 164.22 12057 447.43 425.06 488.82# 12002 104.83 99.59 114.53 # 12057 363.74 345.55 397.38

12004 174.56 165.83 190.70 13100 242.33 230.21 264.74# 12004 123.16 117.00 134.55 # 13100 184.68 175.45 201.77

12005 218.65 207.72 238.88 13101 280.78 266.74 306.75# 12005 154.41 146.69 168.69 # 13101 229.74 218.25 250.99

12006 272.43 258.81 297.63 13102 74.98 71.23 81.91# 12006 197.43 187.56 215.69 # 13102 68.73 65.29 75.08

12007 307.22 291.86 335.64 13120 253.04 240.39 276.45# 12007 226.31 214.99 247.24 # 13120 193.32 183.65 211.20

12011 150.15 142.64 164.04 13121 304.73 289.49 332.91# 12011 84.17 79.96 91.95 # 13121 249.17 236.71 272.22

12013 164.42 156.20 179.63 13122 87.47 83.10 95.57# 12013 111.29 105.73 121.59 # 13122 79.13 75.17 86.45

12014 191.93 182.33 209.68 13131 281.28 267.22 307.30# 12014 133.25 126.59 145.58 # 13131 223.29 212.13 243.95

12015 241.76 229.67 264.12 13132 391.42 371.85 427.63# 12015 168.49 160.07 184.08 # 13132 340.37 323.35 371.85

12016 286.40 272.08 312.89 13133 127.94 121.54 139.77# 12016 207.92 197.52 227.15 # 13133 122.04 115.94 133.33

12017 250.89 238.35 274.10 13150 332.38 315.76 363.1212018 296.00 281.20 323.38 # 13150 240.36 228.34 262.5912020 192.22 182.61 210.00 13151 354.59 336.86 387.39

# 12020 152.98 145.33 167.13 # 13151 278.54 264.61 304.3012021 132.60 125.97 144.87 13152 452.14 429.53 493.96

# 12021 108.98 103.53 119.06 # 13152 381.64 362.56 416.9412031 162.94 154.79 178.01 13153 140.41 133.39 153.40

# 12031 110.16 104.65 120.35 # 13153 133.12 126.46 145.4312032 198.53 188.60 216.89 13160 642.59 610.46 702.03

# 12032 139.50 132.53 152.41 14000 494.18 469.47 539.8912034 224.99 213.74 245.80 # 14000 391.74 372.15 427.97

# 12034 163.52 155.34 178.64 14001 641.16 609.10 700.4712035 244.61 232.38 267.24 # 14001 537.68 510.80 587.42

# 12035 193.21 183.55 211.08 14020 538.39 511.47 588.1912036 344.28 327.07 376.13 # 14020 442.89 420.75 483.86

# 12036 247.05 234.70 269.91 14021 720.85 684.81 787.5312037 382.14 363.03 417.48 # 14021 637.16 605.30 696.10

# 12037 284.21 270.00 310.50 14040 609.93 579.43 666.3412041 178.24 169.33 194.73 # 14040 550.21 522.70 601.11

# 12041 120.94 114.89 132.12 14041 824.92 783.67 901.2212042 215.65 204.87 235.60 # 14041 751.99 714.39 821.55

# 12042 154.53 146.80 168.82 14060 658.89 625.95 719.8412044 235.78 223.99 257.59 # 14060 601.94 571.84 657.62

# 12044 178.13 169.22 194.60 14061 891.52 846.94 973.9812045 268.58 255.15 293.42 # 14061 812.34 771.72 887.48

# 12045 209.20 198.74 228.55 14300 855.65 812.87 934.8012046 360.58 342.55 393.93 # 14300 783.42 744.25 855.89

# 12046 257.09 244.24 280.88 14350 608.49 578.07 664.7812047 397.00 377.15 433.72 15000 285.50 271.23 311.91

# 12047 283.79 269.60 310.04 # 15000 235.49 223.72 257.2812051 205.14 194.88 224.11 15001 83.97 79.77 91.74

# 12051 144.37 137.15 157.72 # 15001 54.80 52.06 59.87

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 5FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

15050 350.27 332.76 382.67 15756 2,113.92 2,008.22 2,309.45# 15050 311.03 295.48 339.80 15757 2,161.62 2,053.54 2,361.57

15100 768.30 729.89 839.37 15758 2,163.56 2,055.38 2,363.69# 15100 642.94 610.79 702.41 15760 659.00 626.05 719.96

15101 182.40 173.28 199.27 # 15760 572.88 544.24 625.88# 15101 120.24 114.23 131.36 15770 511.90 486.31 559.26

15120 744.19 706.98 813.03 15775 258.72 245.78 282.65# 15120 667.79 634.40 729.56 # 15775 205.94 195.64 224.99

15121 252.04 239.44 275.36 15776 422.14 401.03 461.18# 15121 170.79 162.25 186.59 # 15776 322.83 306.69 352.69

15200 650.91 618.36 711.11 15780 508.92 483.47 555.99# 15200 509.92 484.42 557.08 # 15780 507.88 482.49 554.86

15201 89.36 84.89 97.62 15781 361.83 343.74 395.30# 15201 75.13 71.37 82.08 # 15781 352.46 334.84 385.07

15220 648.19 615.78 708.15 15782 313.72 298.03 342.73# 15220 524.57 498.34 573.09 # 15782 308.51 293.08 337.04

15221 79.77 75.78 87.15 15783 328.97 312.52 359.40# 15221 67.61 64.23 73.86 # 15783 289.04 274.59 315.78

15240 677.93 644.03 740.63 15786 139.12 132.16 151.98# 15240 600.14 570.13 655.65 # 15786 122.45 116.33 133.78

15241 124.63 118.40 136.16 15787 23.81 22.62 26.01# 15241 106.23 100.92 116.06 # 15787 18.25 17.34 19.94

15260 731.93 695.33 799.63 15788 188.87 179.43 206.34# 15260 696.86 662.02 761.32 # 15788 115.60 109.82 126.29

15261 188.08 178.68 205.48 15789 402.58 382.45 439.82# 15261 142.59 135.46 155.78 # 15789 310.21 294.70 338.91

15342 111.05 105.50 121.33 15792 173.91 165.21 189.99# 15342 65.56 62.28 71.62 # 15792 146.48 139.16 160.03

15343 18.82 17.88 20.56 15793 263.45 250.28 287.82# 15343 13.26 12.60 14.49 15810 316.58 300.75 345.86

15350 453.25 430.59 495.18 15811 425.68 404.40 465.06# 15350 310.87 295.33 339.63 # 15811 378.45 359.53 413.46

15351 73.21 69.55 79.98 15819 599.64 569.66 655.11# 15351 54.45 51.73 59.49 15820 444.98 422.73 486.14

15400 327.53 311.15 357.82 # 15820 380.04 361.04 415.2015401 83.62 79.44 91.36 15821 478.20 454.29 522.43

# 15401 56.19 53.38 61.39 # 15821 406.67 386.34 444.2915570 651.89 619.30 712.20 15822 379.91 360.91 415.05

# 15570 579.31 550.34 632.89 # 15822 316.37 300.55 345.6315572 638.77 606.83 697.85 15823 547.38 520.01 598.01

# 15572 571.06 542.51 623.89 # 15823 480.36 456.34 524.7915574 680.38 646.36 743.31 15831 763.47 725.30 834.10

# 15574 628.99 597.54 687.17 15832 730.52 693.99 798.0915576 650.58 618.05 710.76 15833 673.05 639.40 735.31

# 15576 559.60 531.62 611.36 15834 677.22 643.36 739.8615600 288.97 274.52 315.70 15835 704.57 669.34 769.74

# 15600 157.36 149.49 171.91 15836 587.50 558.13 641.8515610 214.47 203.75 234.31 15837 590.81 561.27 645.46

# 15610 187.73 178.34 205.09 # 15837 556.78 528.94 608.2815620 350.76 333.22 383.20 15838 476.79 452.95 520.89

# 15620 234.43 222.71 256.12 15839 622.26 591.15 679.8215630 343.65 326.47 375.44 # 15839 571.56 542.98 624.43

# 15630 255.80 243.01 279.46 15840 860.98 817.93 940.6215650 371.22 352.66 405.56 15841 1,442.52 1,370.39 1,575.95

# 15650 286.49 272.17 313.00 15842 2,311.14 2,195.58 2,524.9215732 1,142.20 1,085.09 1,247.85 15845 779.14 740.18 851.2115734 1,155.86 1,098.07 1,262.78 15851 89.97 85.47 98.2915736 1,064.09 1,010.89 1,162.52 # 15851 44.82 42.58 48.9715738 1,145.32 1,088.05 1,251.26 15852 94.49 89.77 103.2415740 706.88 671.54 772.27 # 15852 46.22 43.91 50.50

# 15740 639.17 607.21 698.29 15860 120.59 114.56 131.7415750 740.27 703.26 808.75 # 15860 103.58 98.40 113.16

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 6FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

15920 508.80 483.36 555.86 # 17266 122.25 116.14 133.5615922 650.97 618.42 711.18 17270 109.12 103.66 119.2115931 562.34 534.22 614.35 # 17270 70.92 67.37 77.4815933 711.58 676.00 777.40 17271 118.42 112.50 129.3815934 796.61 756.78 870.30 # 17271 80.92 76.87 88.4015935 930.32 883.80 1,016.37 17272 136.24 129.43 148.8415936 801.65 761.57 875.81 # 17272 96.31 91.49 105.2115937 925.55 879.27 1,011.16 17273 155.11 147.35 169.4515940 579.53 550.55 633.13 # 17273 111.01 105.46 121.2815941 799.03 759.08 872.94 17274 188.64 179.21 206.0915944 757.39 719.52 827.45 # 17274 138.98 132.03 151.8315945 840.03 798.03 917.73 17276 226.80 215.46 247.7815946 1,350.04 1,282.54 1,474.92 # 17276 170.89 162.35 186.7015950 481.03 456.98 525.53 17280 100.19 95.18 109.4615951 707.20 671.84 772.62 # 17280 62.69 59.56 68.4915952 712.47 676.85 778.38 17281 131.65 125.07 143.8315953 812.85 772.21 888.04 # 17281 93.45 88.78 102.1015956 982.94 933.79 1,073.86 17282 152.67 145.04 166.8015958 993.30 943.64 1,085.19 # 17282 111.34 105.77 121.6416000 71.61 68.03 78.23 17283 189.41 179.94 206.93

# 16000 43.83 41.64 47.89 # 17283 142.53 135.40 155.7116010 75.41 71.64 82.39 17284 225.42 214.15 246.27

# 16010 46.58 44.25 50.89 # 17284 173.33 164.66 189.3616015 158.79 150.85 173.48 17286 300.38 285.36 328.16

# 16015 125.80 119.51 137.44 # 17286 244.81 232.57 267.4616020 70.43 66.91 76.95 17304 568.06 539.66 620.61

# 16020 40.22 38.21 43.94 # 17304 414.22 393.51 452.5416025 138.15 131.24 150.93 17305 240.11 228.10 262.32

# 16025 96.14 91.33 105.03 # 17305 155.38 147.61 169.7516030 187.85 178.46 205.23 17306 240.11 228.10 262.32

# 16030 113.53 107.85 124.03 # 17306 155.73 147.94 170.1316035 201.05 191.00 219.65 17307 240.46 228.44 262.7116036 79.92 75.92 87.31 # 17307 156.42 148.60 170.8917000 58.98 56.03 64.43 17310 75.69 71.91 82.70

# 17000 32.24 30.63 35.22 # 17310 35.06 33.31 38.3117003 9.97 9.47 10.89 17340 42.23 40.12 46.14

# 17003 8.23 7.82 8.99 # 17340 38.06 36.16 41.5817004 190.70 181.17 208.35 17360 109.30 103.84 119.42

# 17004 149.73 142.24 163.58 # 17360 79.09 75.14 86.4117106 342.32 325.20 373.98 19000 74.66 70.93 81.57

# 17106 288.15 273.74 314.80 # 19000 43.06 40.91 47.0517107 605.07 574.82 661.04 19001 44.80 42.56 48.94

# 17107 538.05 511.15 587.82 # 19001 21.18 20.12 23.1417108 835.76 793.97 913.07 19020 378.55 359.62 413.56

# 17108 777.07 738.22 848.95 # 19020 259.79 246.80 283.8217110 84.41 80.19 92.22 19030 181.69 172.61 198.50

# 17110 40.66 38.63 44.42 # 19030 76.13 72.32 83.1717111 95.61 90.83 104.45 19100 99.34 94.37 108.53

# 17111 54.29 51.58 59.32 # 19100 64.96 61.71 70.9717250 62.29 59.18 68.06 19101 296.94 282.09 324.40

# 17250 31.39 29.82 34.29 # 19101 188.25 178.84 205.6717260 82.06 77.96 89.65 19102 246.03 233.73 268.79

# 17260 48.72 46.28 53.22 # 19102 100.88 95.84 110.2217261 100.54 95.51 109.84 19103 567.58 539.20 620.08

# 17261 63.38 60.21 69.24 # 19103 184.21 175.00 201.2517262 125.52 119.24 137.13 19110 471.10 447.55 514.68

# 17262 85.93 81.63 93.87 # 19110 325.60 309.32 355.7217263 139.75 132.76 152.67 19112 464.50 441.28 507.47

# 17263 96.35 91.53 105.26 # 19112 253.72 241.03 277.1817264 151.46 143.89 165.47 19120 392.64 373.01 428.96

# 17264 103.19 98.03 112.73 # 19120 329.09 312.64 359.5417266 178.16 169.25 194.64 19125 417.08 396.23 455.66

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 7FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 19125 354.93 337.18 387.76 20220 217.38 206.51 237.4919126 152.47 144.85 166.58 # 20220 150.02 142.52 163.9019140 529.80 503.31 578.81 20225 223.59 212.41 244.27

# 19140 331.86 315.27 362.56 # 20225 176.71 167.87 193.0519160 396.14 376.33 432.78 20240 275.55 261.77 301.0419162 813.96 773.26 889.25 20245 538.20 511.29 587.9819180 556.73 528.89 608.22 20250 352.16 334.55 384.7319182 481.68 457.60 526.24 20251 400.73 380.69 437.7919200 931.09 884.54 1,017.22 20500 252.76 240.12 276.1419220 942.95 895.80 1,030.17 # 20500 180.88 171.84 197.6219240 942.04 894.94 1,029.18 20501 137.72 130.83 150.4519260 935.93 889.13 1,022.50 # 20501 37.71 35.82 41.1919271 1,159.56 1,101.58 1,266.82 20520 267.68 254.30 292.4519272 1,297.68 1,232.80 1,417.72 # 20520 197.89 188.00 216.2019290 148.63 141.20 162.38 20525 378.81 359.87 413.85

# 19290 63.20 60.04 69.05 # 20525 293.38 278.71 320.5219291 82.64 78.51 90.29 20526 63.01 59.86 68.84

# 19291 31.25 29.69 34.14 # 20526 50.51 47.98 55.1819295 92.37 87.75 100.91 20550 55.76 52.97 60.9219316 691.88 657.29 755.88 # 20550 37.70 35.82 41.1919318 1,034.17 982.46 1,129.83 20551 53.68 51.00 58.6519324 382.38 363.26 417.75 # 20551 41.18 39.12 44.9919325 555.83 528.04 607.25 20552 49.02 46.57 53.5619328 385.56 366.28 421.22 # 20552 36.52 34.69 39.8919330 484.94 460.69 529.79 20553 55.41 52.64 60.5419340 364.77 346.53 398.51 # 20553 41.18 39.12 44.9919342 721.55 685.47 788.29 20600 49.02 46.57 53.5619350 824.69 783.46 900.98 # 20600 38.60 36.67 42.17

# 19350 593.77 564.08 648.69 20605 53.91 51.21 58.8919355 776.60 737.77 848.44 # 20605 39.67 37.69 43.34

# 19355 491.15 466.59 536.58 20610 65.21 61.95 71.2419357 1,070.02 1,016.52 1,169.00 # 20610 46.11 43.80 50.3719361 1,129.84 1,073.35 1,234.35 20612 54.29 51.58 59.3219364 2,503.54 2,378.36 2,735.11 # 20612 37.28 35.42 40.7319366 1,209.95 1,149.45 1,321.87 20615 258.67 245.74 282.6019367 1,639.66 1,557.68 1,791.33 # 20615 182.97 173.82 199.8919368 2,033.86 1,932.17 2,222.00 20650 267.31 253.94 292.0319369 1,914.93 1,819.18 2,092.06 # 20650 205.15 194.89 224.1219370 533.98 507.28 583.37 20660 187.30 177.94 204.6319371 623.66 592.48 681.35 20661 450.06 427.56 491.6919380 611.50 580.93 668.07 20662 466.85 443.51 510.0419396 304.00 288.80 332.12 20663 418.22 397.31 456.91

# 19396 122.38 116.26 133.70 20664 644.72 612.48 704.3520000 158.04 150.14 172.66 20665 127.91 121.51 139.74

# 20000 124.01 117.81 135.48 # 20665 98.74 93.80 107.8720005 241.48 229.41 263.82 20670 282.81 268.67 308.97

# 20005 213.01 202.36 232.71 # 20670 194.61 184.88 212.6120100 603.30 573.14 659.11 20680 324.42 308.20 354.43

# 20100 552.95 525.30 604.10 20690 207.68 197.30 226.9020101 226.18 214.87 247.10 20692 360.00 342.00 393.30

# 20101 177.57 168.69 193.99 20693 701.28 666.22 766.1520102 273.24 259.58 298.52 20694 499.41 474.44 545.61

# 20102 216.29 205.48 236.30 # 20694 399.06 379.11 435.9820103 360.62 342.59 393.98 20802 2,657.48 2,524.61 2,903.30

# 20103 317.56 301.68 346.93 20805 3,455.02 3,282.27 3,774.6120150 842.49 800.37 920.43 20808 4,191.48 3,981.91 4,579.2020200 118.08 112.18 129.01 20816 2,846.58 2,704.25 3,109.89

# 20200 80.23 76.22 87.65 20822 2,515.35 2,389.58 2,748.0220205 227.89 216.50 248.98 20824 2,823.89 2,682.70 3,085.11

# 20205 126.84 120.50 138.58 20827 2,638.28 2,506.37 2,882.3320206 147.48 140.11 161.13 20838 2,703.41 2,568.24 2,953.48

# 20206 50.25 47.74 54.90 20900 459.10 436.15 501.57

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 8FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 20900 451.80 429.21 493.59 21081 1,497.44 1,422.57 1,635.9620902 630.15 598.64 688.44 # 21081 1,338.75 1,271.81 1,462.5820910 519.00 493.05 567.01 21082 1,322.80 1,256.66 1,445.16

# 20910 443.99 421.79 485.06 # 21082 1,195.35 1,135.58 1,305.9220912 510.24 484.73 557.44 21083 1,276.74 1,212.90 1,394.8420920 405.42 385.15 442.92 # 21083 1,142.70 1,085.57 1,248.4120922 582.70 553.57 636.61 21084 1,464.06 1,390.86 1,599.49

# 20922 493.46 468.79 539.11 # 21084 1,307.79 1,242.40 1,428.7620924 513.01 487.36 560.46 21085 571.18 542.62 624.0120926 449.62 427.14 491.21 # 21085 516.32 490.50 564.0820931 111.09 105.54 121.37 21086 1,625.06 1,543.81 1,775.3820937 168.28 159.87 183.85 # 21086 1,451.78 1,379.19 1,586.0720938 183.28 174.12 200.24 21087 1,596.06 1,516.26 1,743.7020950 129.21 122.75 141.16 # 21087 1,443.62 1,371.44 1,577.1620955 2,611.63 2,481.05 2,853.21 21100 365.63 347.35 399.4520956 2,630.11 2,498.60 2,873.39 # 21100 300.35 285.33 328.1320957 2,415.30 2,294.54 2,638.72 21110 383.60 364.42 419.0820962 2,591.98 2,462.38 2,831.74 # 21110 349.22 331.76 381.5220969 2,865.10 2,721.85 3,130.13 21116 298.93 283.98 326.5820970 2,771.83 2,633.24 3,028.23 # 21116 41.27 39.21 45.0920972 2,414.73 2,293.99 2,638.09 21120 529.70 503.22 578.7020973 2,807.46 2,667.09 3,067.15 # 21120 400.52 380.49 437.5620974 40.29 38.28 44.02 21121 573.10 544.45 626.12

# 20974 37.16 35.30 40.60 # 21121 513.03 487.38 560.4920975 157.20 149.34 171.74 21122 595.38 565.61 650.4520979 49.29 46.83 53.85 21123 727.02 690.67 794.27

# 20979 36.10 34.30 39.45 21125 742.26 705.15 810.9221010 636.18 604.37 695.03 # 21125 691.56 656.98 755.5321015 456.77 433.93 499.02 21127 771.21 732.65 842.5521025 648.67 616.24 708.68 # 21127 691.34 656.77 755.29

# 21025 632.00 600.40 690.46 21137 654.40 621.68 714.9321026 377.52 358.64 412.44 21138 821.21 780.15 897.17

# 21026 366.76 348.42 400.68 21139 906.51 861.18 990.3621029 547.95 520.55 598.63 21141 1,089.90 1,035.41 1,190.72

# 21029 519.83 493.84 567.92 21142 1,146.73 1,089.39 1,252.8021030 313.90 298.21 342.94 21143 1,128.76 1,072.32 1,233.17

# 21030 288.90 274.46 315.63 21145 1,188.94 1,129.49 1,298.9121031 243.94 231.74 266.50 21146 1,241.60 1,179.52 1,356.45

# 21031 202.97 192.82 221.74 21147 1,266.64 1,203.31 1,383.8121032 242.55 230.42 264.98 21150 1,522.77 1,446.63 1,663.62

# 21032 206.78 196.44 225.91 21151 1,790.32 1,700.80 1,955.9221034 1,006.44 956.12 1,099.54 21154 1,969.27 1,870.81 2,151.43

# 21034 1,005.39 955.12 1,098.39 21155 2,165.53 2,057.25 2,365.8421040 278.64 264.71 304.42 21159 2,665.82 2,532.53 2,912.41

# 21040 237.66 225.78 259.65 21160 2,769.19 2,630.73 3,025.3421044 738.09 701.19 806.37 21172 1,626.97 1,545.62 1,777.4621045 987.26 937.90 1,078.59 21175 2,083.78 1,979.59 2,276.5321046 869.87 826.38 950.34 21179 1,515.47 1,439.70 1,655.6621047 1,078.06 1,024.16 1,177.78 21180 1,636.75 1,554.91 1,788.1521048 895.34 850.57 978.16 21181 683.57 649.39 746.8021049 1,021.38 970.31 1,115.86 21182 2,019.13 1,918.17 2,205.9021050 824.86 783.62 901.16 21183 2,209.02 2,098.57 2,413.3621060 763.02 724.87 833.60 21184 2,378.67 2,259.74 2,598.7021070 529.27 502.81 578.23 21188 1,423.83 1,352.64 1,555.5421076 865.16 821.90 945.19 21193 1,051.51 998.93 1,148.77

# 21076 783.21 744.05 855.66 21194 1,211.71 1,151.12 1,323.7921077 2,176.61 2,067.78 2,377.95 21195 1,097.68 1,042.80 1,199.22

# 21077 1,970.34 1,871.82 2,152.59 21196 1,192.61 1,132.98 1,302.9321079 1,454.07 1,381.37 1,588.58 21198 956.50 908.68 1,044.98

# 21079 1,298.85 1,233.91 1,419.00 21199 948.46 901.04 1,036.2021080 1,660.75 1,577.71 1,814.37 21206 885.54 841.26 967.45

# 21080 1,486.08 1,411.78 1,623.55 21208 740.68 703.65 809.20

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 9FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 21208 694.49 659.77 758.74 21360 448.59 426.16 490.0821209 542.12 515.01 592.26 21365 981.86 932.77 1,072.69

# 21209 466.42 443.10 509.57 21366 1,108.71 1,053.27 1,211.2621210 714.96 679.21 781.09 21385 616.93 586.08 673.99

# 21210 685.45 651.18 748.86 21386 636.43 604.61 695.3021215 737.10 700.25 805.29 21387 665.44 632.17 727.00

# 21215 673.90 640.21 736.24 21390 686.94 652.59 750.4821230 774.56 735.83 846.20 21395 839.18 797.22 916.8021235 686.54 652.21 750.04 21400 163.45 155.28 178.57

# 21235 541.39 514.32 591.47 # 21400 91.57 86.99 100.0421240 943.52 896.34 1,030.79 21401 298.18 283.27 325.7621242 904.35 859.13 988.00 # 21401 238.45 226.53 260.5121243 1,298.55 1,233.62 1,418.66 21406 509.94 484.44 557.1121244 782.92 743.77 855.34 21407 605.63 575.35 661.6521245 884.98 840.73 966.84 21408 841.20 799.14 919.01

# 21245 815.53 774.75 890.96 21421 459.95 436.95 502.4921246 854.52 811.79 933.56 # 21421 413.07 392.42 451.2821247 1,469.42 1,395.95 1,605.34 21422 586.77 557.43 641.0421248 764.97 726.72 835.73 21423 689.92 655.42 753.73

# 21248 722.26 686.15 789.07 21431 508.61 483.18 555.6621249 1,085.37 1,031.10 1,185.77 21432 601.06 571.01 656.66

# 21249 1,039.88 987.89 1,136.07 21433 1,601.73 1,521.64 1,749.8921255 1,044.72 992.48 1,141.35 21435 1,121.53 1,065.45 1,225.2721256 1,085.83 1,031.54 1,186.27 21436 1,696.65 1,611.82 1,853.5921260 1,016.32 965.50 1,110.33 21440 303.12 287.96 331.1521261 1,936.93 1,840.08 2,116.09 # 21440 232.28 220.67 253.7721263 1,559.68 1,481.70 1,703.96 21445 459.36 436.39 501.8521267 1,237.26 1,175.40 1,351.71 # 21445 394.43 374.71 430.9221268 1,477.29 1,403.43 1,613.94 21450 354.60 336.87 387.4021270 728.78 692.34 796.19 # 21450 211.19 200.63 230.7221275 819.11 778.15 894.87 21451 420.96 399.91 459.9021280 439.44 417.47 480.09 # 21451 386.93 367.58 422.7221282 313.07 297.42 342.03 21452 402.96 382.81 440.2321295 211.24 200.68 230.78 # 21452 222.74 211.60 243.3421296 323.03 306.88 352.91 21453 479.73 455.74 524.1021300 124.14 117.93 135.62 # 21453 440.84 418.80 481.62

# 21300 38.36 36.44 41.91 21454 454.86 432.12 496.9421310 115.90 110.11 126.63 21461 641.28 609.22 700.60

# 21310 28.05 26.65 30.65 # 21461 595.44 565.67 650.5221315 178.21 169.30 194.70 21462 750.67 713.14 820.11

# 21315 103.21 98.05 112.76 # 21462 664.56 631.33 726.0321320 240.24 228.23 262.46 21465 735.72 698.93 803.77

# 21320 143.01 135.86 156.24 21470 950.22 902.71 1,038.1221325 275.37 261.60 300.84 21480 78.80 74.86 86.0921330 403.77 383.58 441.12 # 21480 30.18 28.67 32.9721335 584.09 554.89 638.12 21485 289.62 275.14 316.4121336 416.46 395.64 454.99 # 21485 273.65 259.97 298.9721337 287.49 273.12 314.09 21490 740.03 703.03 808.48

# 21337 218.73 207.79 238.96 21493 167.05 158.70 182.5121338 460.41 437.39 503.00 21494 419.44 398.47 458.2421339 553.44 525.77 604.64 21495 394.86 375.12 431.3921340 737.01 700.16 805.18 21497 316.15 300.34 345.3921343 847.24 804.88 925.61 # 21497 289.06 274.61 315.8021344 1,243.97 1,181.77 1,359.04 21501 303.59 288.41 331.6721345 655.57 622.79 716.21 # 21501 275.81 262.02 301.32

# 21345 592.37 562.75 647.16 21502 544.94 517.69 595.3421346 764.53 726.30 835.25 21510 480.84 456.80 525.3221347 831.23 789.67 908.12 21550 160.36 152.34 175.1921348 1,038.94 986.99 1,135.04 # 21550 121.81 115.72 133.0821355 300.02 285.02 327.77 21555 320.46 304.44 350.11

# 21355 226.40 215.08 247.34 # 21555 257.26 244.40 281.0621356 275.67 261.89 301.17 21556 331.86 315.27 362.56

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 10FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

21557 619.35 588.38 676.64 22522 228.34 216.92 249.4621600 541.80 514.71 591.92 22548 1,676.97 1,593.12 1,832.0921610 986.43 937.11 1,077.68 22554 1,238.88 1,176.94 1,353.4821615 681.20 647.14 744.21 22556 1,502.77 1,427.63 1,641.7721616 805.61 765.33 880.13 22558 1,387.02 1,317.67 1,515.3221620 553.08 525.43 604.24 22585 335.15 318.39 366.1521627 713.22 677.56 779.19 22590 1,352.51 1,284.88 1,477.6121630 1,169.80 1,111.31 1,278.01 22595 1,287.75 1,223.36 1,406.8621632 1,157.93 1,100.03 1,265.03 22600 1,084.21 1,030.00 1,184.5021700 556.05 528.25 607.49 22610 1,077.30 1,023.44 1,176.96

# 21700 487.64 463.26 532.75 22612 1,377.36 1,308.49 1,504.7621705 645.90 613.61 705.65 22614 390.12 370.61 426.2021720 510.67 485.14 557.91 22630 1,377.34 1,308.47 1,504.74

# 21720 478.02 454.12 522.24 22632 316.91 301.06 346.2221725 544.43 517.21 594.79 22800 1,210.81 1,150.27 1,322.8121740 1,104.52 1,049.29 1,206.68 22802 1,972.07 1,873.47 2,154.4921750 781.00 741.95 853.24 22804 2,306.22 2,190.91 2,519.5521800 120.71 114.67 131.87 22808 1,688.86 1,604.42 1,845.08

# 21800 75.56 71.78 82.55 22810 1,909.31 1,813.84 2,085.9221805 273.71 260.02 299.02 22812 2,056.74 1,953.90 2,246.9921810 515.61 489.83 563.30 22818 2,010.01 1,909.51 2,195.9421820 153.20 145.54 167.37 22819 2,222.09 2,110.99 2,427.64

# 21820 105.97 100.67 115.77 22830 744.15 706.94 812.9821825 655.17 622.41 715.77 22840 758.84 720.90 829.0421920 164.17 155.96 179.35 22842 761.34 723.27 831.76

# 21920 105.14 99.88 114.86 22843 798.56 758.63 872.4221925 592.95 563.30 647.80 22844 994.87 945.13 1,086.90

# 21925 341.19 324.13 372.75 22845 729.52 693.04 797.0021930 358.71 340.77 391.89 22846 757.02 719.17 827.05

# 21930 289.95 275.45 316.77 22847 835.00 793.25 912.2421935 1,170.35 1,111.83 1,278.60 22848 362.60 344.47 396.1422100 699.20 664.24 763.88 22849 1,251.24 1,188.68 1,366.9822101 707.29 671.93 772.72 22850 694.32 659.60 758.5422102 712.48 676.86 778.39 22851 402.75 382.61 440.0022103 141.13 134.07 154.18 22852 663.58 630.40 724.9622110 910.65 865.12 994.89 22855 1,036.66 984.83 1,132.5522112 900.58 855.55 983.88 22900 380.19 361.18 415.3622114 898.16 853.25 981.24 23000 487.55 463.17 532.6522116 139.72 132.73 152.64 # 23000 432.34 410.72 472.3322210 1,608.44 1,528.02 1,757.22 23020 748.10 710.70 817.3122212 1,311.01 1,245.46 1,432.28 23030 356.13 338.32 389.0722214 1,328.77 1,262.33 1,451.68 # 23030 297.10 282.25 324.5922216 365.49 347.22 399.30 23031 319.55 303.57 349.1122220 1,443.42 1,371.25 1,576.94 # 23031 261.91 248.81 286.1322222 1,344.77 1,277.53 1,469.16 23035 903.83 858.64 987.4422224 1,440.67 1,368.64 1,573.94 23040 801.34 761.27 875.4622226 365.15 346.89 398.92 23044 675.25 641.49 737.7122305 202.78 192.64 221.54 23065 181.54 172.46 198.33

# 22305 182.64 173.51 199.54 # 23065 133.61 126.93 145.9722310 282.90 268.76 309.07 23066 445.21 422.95 486.39

# 22310 262.07 248.97 286.32 # 23066 394.16 374.45 430.6222315 669.54 636.06 731.47 23075 281.79 267.70 307.8622318 1,439.40 1,367.43 1,572.54 # 23075 207.13 196.77 226.2922319 1,635.03 1,553.28 1,786.27 23076 600.32 570.30 655.8522325 1,238.97 1,177.02 1,353.57 23077 1,143.68 1,086.50 1,249.4822326 1,357.49 1,289.62 1,483.06 23100 564.72 536.48 616.9522327 1,289.11 1,224.65 1,408.35 23101 547.30 519.94 597.9322328 271.69 258.11 296.83 23105 705.25 669.99 770.4922505 244.15 231.94 266.73 23106 566.69 538.36 619.11

# 22505 188.24 178.83 205.65 23107 728.13 691.72 795.4822520 496.89 472.05 542.86 23120 639.47 607.50 698.6322521 468.15 444.74 511.45 23125 770.74 732.20 842.03

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 11FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

23130 665.92 632.62 727.51 23545 314.50 298.78 343.6023140 579.31 550.34 632.89 # 23545 259.99 246.99 284.0423145 792.46 752.84 865.77 23550 586.88 557.54 641.1723146 718.48 682.56 784.94 23552 662.22 629.11 723.4823150 708.44 673.02 773.97 23570 232.24 220.63 253.7223155 856.64 813.81 935.88 # 23570 187.45 178.08 204.7923156 729.96 693.46 797.48 23575 388.81 369.37 424.7823170 666.78 633.44 728.46 # 23575 317.97 302.07 347.3823172 655.78 622.99 716.44 23585 702.32 667.20 767.2823174 814.70 773.97 890.07 23600 325.45 309.18 355.5623180 935.64 888.86 1,022.19 # 23600 250.09 237.59 273.2323182 921.09 875.04 1,006.30 23605 505.82 480.53 552.6123184 977.67 928.79 1,068.11 # 23605 437.76 415.87 478.2523190 600.09 570.09 655.60 23615 749.51 712.03 818.8323195 790.92 751.37 864.08 23616 1,441.89 1,369.80 1,575.2723200 995.36 945.59 1,087.43 23620 293.65 278.97 320.8223210 1,013.10 962.45 1,106.82 # 23620 218.99 208.04 239.2523220 1,146.87 1,089.53 1,252.96 23625 430.61 409.08 470.4423221 1,327.96 1,261.56 1,450.79 # 23625 361.16 343.10 394.5723222 1,717.92 1,632.02 1,876.82 23630 596.47 566.65 651.6523330 273.25 259.59 298.53 23650 333.44 316.77 364.29

# 23330 204.49 194.27 223.41 # 23650 258.44 245.52 282.3523331 653.47 620.80 713.92 23655 336.50 319.68 367.6323332 909.95 864.45 994.12 23660 593.91 564.21 648.8423350 291.60 277.02 318.57 23665 458.95 436.00 501.40

# 23350 49.91 47.41 54.52 # 23665 391.59 372.01 427.8123395 1,188.55 1,129.12 1,298.49 23670 635.94 604.14 694.7623397 1,172.43 1,113.81 1,280.88 23675 549.83 522.34 600.6923400 1,065.64 1,012.36 1,164.21 # 23675 487.67 463.29 532.7823405 680.12 646.11 743.03 23680 763.90 725.71 834.5723406 857.14 814.28 936.42 23700 230.66 219.13 252.0023410 957.87 909.98 1,046.48 23800 1,093.06 1,038.41 1,194.1723412 1,011.77 961.18 1,105.36 23802 1,168.72 1,110.28 1,276.8223415 774.17 735.46 845.78 23900 1,348.51 1,281.08 1,473.2423420 1,045.78 993.49 1,142.51 23920 1,085.43 1,031.16 1,185.8323430 811.34 770.77 886.39 23921 466.60 443.27 509.7623440 843.09 800.94 921.08 23930 333.07 316.42 363.8823450 1,014.34 963.62 1,108.16 # 23930 258.76 245.82 282.6923455 1,075.02 1,021.27 1,174.46 23931 279.76 265.77 305.6423460 1,137.13 1,080.27 1,242.31 # 23931 207.18 196.82 226.3423462 1,122.78 1,066.64 1,226.64 23935 723.52 687.34 790.4423465 1,129.66 1,073.18 1,234.16 24000 452.89 430.25 494.7923466 1,067.82 1,014.43 1,166.59 24006 685.19 650.93 748.5723470 1,139.08 1,082.13 1,244.45 24065 284.36 270.14 310.6623472 1,358.68 1,290.75 1,484.36 # 24065 196.86 187.02 215.0723480 883.51 839.33 965.23 24066 521.27 495.21 569.4923485 1,016.46 965.64 1,110.49 # 24066 447.66 425.28 489.0723490 895.16 850.40 977.96 24075 442.36 420.24 483.2823491 1,064.68 1,011.45 1,163.17 # 24075 370.82 352.28 405.1223500 226.43 215.11 247.38 24076 508.50 483.08 555.54

# 23500 175.04 166.29 191.23 24077 952.40 904.78 1,040.5023505 367.01 348.66 400.96 24100 402.06 381.96 439.25

# 23505 294.78 280.04 322.05 24101 494.05 469.35 539.7523515 598.31 568.39 653.65 24102 606.28 575.97 662.3723520 230.73 219.19 252.07 24105 335.28 318.52 366.30

# 23520 180.72 171.68 197.43 24110 655.21 622.45 715.8223525 354.68 336.95 387.49 24115 755.79 718.00 825.70

# 23525 284.54 270.31 310.86 24116 924.16 877.95 1,009.6423530 580.35 551.33 634.03 24120 513.66 487.98 561.1823532 629.54 598.06 687.77 24125 570.54 542.01 623.3123540 252.01 239.41 275.32 24126 612.55 581.92 669.21

# 23540 178.74 169.80 195.27 24130 502.59 477.46 549.08

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 12FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

24134 971.33 922.76 1,061.17 24535 600.87 570.83 656.4524136 547.77 520.38 598.44 # 24535 522.74 496.60 571.0924138 610.85 580.31 667.36 24538 763.50 725.33 834.1324140 986.72 937.38 1,077.99 24545 792.01 752.41 865.2724145 715.25 679.49 781.41 24546 1,127.24 1,070.88 1,231.5124147 714.85 679.11 780.98 24560 291.19 276.63 318.1224149 971.55 922.97 1,061.42 # 24560 223.82 212.63 244.5224150 1,074.88 1,021.14 1,174.31 24565 514.26 488.55 561.8324151 1,232.28 1,170.67 1,346.27 # 24565 438.21 416.30 478.7524152 748.87 711.43 818.14 24566 680.91 646.86 743.8924153 687.10 652.75 750.66 24575 730.86 694.32 798.4724155 803.42 763.25 877.74 24576 285.74 271.45 312.1724160 563.59 535.41 615.72 # 24576 232.26 220.65 253.7524164 462.61 439.48 505.40 24577 533.07 506.42 582.3824200 268.22 254.81 293.03 # 24577 458.41 435.49 500.81

# 24200 185.58 176.30 202.75 24579 871.37 827.80 951.9724201 494.85 470.11 540.63 24582 726.98 690.63 794.22

# 24201 430.61 409.08 470.44 24586 1,011.14 960.58 1,104.6724220 432.75 411.11 472.78 24587 1,004.13 953.92 1,097.01

# 24220 66.05 62.75 72.16 24600 418.23 397.32 456.9224300 345.57 328.29 377.53 # 24600 348.43 331.01 380.6624301 736.65 699.82 804.79 24605 399.09 379.14 436.0124305 575.78 546.99 629.04 24615 665.24 631.98 726.7824310 539.60 512.62 589.51 24620 518.37 492.45 566.3224320 802.72 762.58 876.97 24635 1,121.99 1,065.89 1,225.7724330 699.52 664.54 764.22 24640 170.41 161.89 186.1724331 765.90 727.61 836.75 # 24640 111.38 105.81 121.6824332 478.79 454.85 523.08 24650 255.39 242.62 279.0124340 597.72 567.83 653.00 # 24650 189.76 180.27 207.3124341 598.08 568.18 653.41 24655 446.33 424.01 487.6124342 765.89 727.60 836.74 # 24655 368.20 349.79 402.2624343 628.14 596.73 686.24 24665 673.15 639.49 735.4124344 961.47 913.40 1,050.41 24666 755.30 717.54 825.1724345 628.14 596.73 686.24 24670 267.49 254.12 292.2424346 961.47 913.40 1,050.41 # 24670 212.62 201.99 232.2924350 439.79 417.80 480.47 24675 467.37 444.00 510.6024351 484.31 460.09 529.10 # 24675 391.67 372.09 427.9024352 515.05 489.30 562.70 24685 713.16 677.50 779.1324354 514.78 489.04 562.40 24800 801.86 761.77 876.0424356 529.00 502.55 577.93 24802 965.51 917.23 1,054.8124360 843.08 800.93 921.07 24900 779.72 740.73 851.8424361 949.85 902.36 1,037.71 24920 834.85 793.11 912.0824362 1,043.34 991.17 1,139.85 24925 626.54 595.21 684.4924363 1,161.10 1,103.05 1,268.51 24930 824.90 783.66 901.2124365 597.85 567.96 653.15 24931 837.73 795.84 915.2224366 643.92 611.72 703.48 24935 1,059.72 1,006.73 1,157.7424400 906.91 861.56 990.79 25000 402.25 382.14 439.4624410 1,095.13 1,040.37 1,196.43 25001 290.44 275.92 317.3124420 1,152.25 1,094.64 1,258.84 25020 637.09 605.24 696.0324430 986.62 937.29 1,077.88 25023 1,127.37 1,071.00 1,231.6524435 1,042.43 990.31 1,138.86 25024 669.51 636.03 731.4324470 656.12 623.31 716.81 25025 1,085.90 1,031.61 1,186.3524495 684.48 650.26 747.80 25028 565.44 537.17 617.7524498 932.33 885.71 1,018.57 25031 520.18 494.17 568.3024500 315.49 299.72 344.68 25035 887.81 843.42 969.93

# 24500 248.47 236.05 271.46 25040 623.95 592.75 681.6624505 536.54 509.71 586.17 25065 166.14 157.83 181.50

# 24505 459.80 436.81 502.33 25066 459.74 436.75 502.2624515 882.91 838.76 964.57 25075 406.63 386.30 444.2524516 902.36 857.24 985.83 25076 646.85 614.51 706.6924530 370.16 351.65 404.40 25077 932.04 885.44 1,018.26

# 24530 316.34 300.52 345.60 25085 616.94 586.09 674.00

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 13FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

25100 425.34 404.07 464.68 25400 1,082.38 1,028.26 1,182.5025101 470.08 446.58 513.57 25405 1,302.46 1,237.34 1,422.9425105 630.38 598.86 688.69 25415 1,224.36 1,163.14 1,337.6125107 666.07 632.77 727.69 25420 1,411.99 1,341.39 1,542.6025110 458.70 435.77 501.14 25425 1,467.43 1,394.06 1,603.1725111 369.61 351.13 403.80 25426 1,352.15 1,284.54 1,477.2225112 443.74 421.55 484.78 25430 638.46 606.54 697.5225115 962.47 914.35 1,051.50 25431 620.70 589.67 678.1225116 858.20 815.29 937.58 25440 819.73 778.74 895.5525118 459.12 436.16 501.58 25441 885.38 841.11 967.2825119 648.42 616.00 708.40 25442 750.52 712.99 819.9425120 781.86 742.77 854.19 25443 732.09 695.49 799.8125125 876.91 833.06 958.02 25444 774.01 735.31 845.6125126 862.78 819.64 942.59 25445 680.59 646.56 743.5425130 507.49 482.12 554.44 25446 1,101.56 1,046.48 1,203.4525135 603.65 573.47 659.49 25447 728.26 691.85 795.6325136 532.56 505.93 581.82 25449 967.10 918.75 1,056.5625145 806.61 766.28 881.22 25450 771.57 732.99 842.9425150 717.91 682.01 784.31 25455 878.46 834.54 959.7225151 866.66 823.33 946.83 25490 968.88 920.44 1,058.5125170 1,073.29 1,019.63 1,172.57 25491 1,022.10 971.00 1,116.6525210 548.92 521.47 599.69 25492 1,132.30 1,075.69 1,237.0425215 757.43 719.56 827.49 25500 250.65 238.12 273.8425230 503.27 478.11 549.83 # 25500 200.65 190.62 219.2125240 596.60 566.77 651.79 25505 492.84 468.20 538.4325246 411.80 391.21 449.89 # 25505 415.40 394.63 453.82

# 25246 72.53 68.90 79.24 25515 723.84 687.65 790.8025248 561.06 533.01 612.96 25520 543.23 516.07 593.4825250 484.39 460.17 529.20 # 25520 480.72 456.68 525.1825251 668.88 635.44 730.76 25525 917.92 872.02 1,002.8225259 343.49 326.32 375.27 25526 1,069.89 1,016.40 1,168.8625260 912.13 866.52 996.50 25530 238.95 227.00 261.0525263 907.29 861.93 991.22 # 25530 186.86 177.52 204.1525265 1,015.96 965.16 1,109.93 25535 481.95 457.85 526.5325270 806.33 766.01 880.91 # 25535 414.24 393.53 452.5625272 868.50 825.08 948.84 25545 718.88 682.94 785.3825274 954.38 906.66 1,042.66 25560 251.32 238.75 274.5625275 607.06 576.71 663.22 # 25560 198.89 188.95 217.2925280 860.12 817.11 939.68 25565 518.90 492.96 566.9025290 862.09 818.99 941.84 # 25565 440.42 418.40 481.1625295 821.51 780.43 897.49 25574 602.84 572.70 658.6125300 706.84 671.50 772.23 25575 812.48 771.86 887.6425301 689.87 655.38 753.69 25600 272.50 258.88 297.7125310 912.70 867.07 997.13 # 25600 215.55 204.77 235.4925312 998.11 948.20 1,090.43 25605 535.19 508.43 584.6925315 1,050.89 998.35 1,148.10 # 25605 457.40 434.53 499.7125316 1,193.82 1,134.13 1,304.25 25611 680.52 646.49 743.4625320 837.24 795.38 914.69 25620 696.06 661.26 760.4525332 790.42 750.90 863.54 25622 269.69 256.21 294.6425335 1,045.70 993.42 1,142.43 # 25622 213.43 202.76 233.1725337 896.69 851.86 979.64 25624 454.54 431.81 496.5825350 949.93 902.43 1,037.79 # 25624 376.76 357.92 411.6125355 1,031.48 979.91 1,126.90 25628 692.03 657.43 756.0425360 934.09 887.39 1,020.50 25630 286.46 272.14 312.9625365 1,152.23 1,094.62 1,258.81 # 25630 226.74 215.40 247.7125370 1,191.39 1,131.82 1,301.59 25635 439.97 417.97 480.6725375 1,213.07 1,152.42 1,325.28 # 25635 338.23 321.32 369.5225390 1,040.86 988.82 1,137.14 25645 625.09 593.84 682.9225391 1,229.64 1,168.16 1,343.38 25650 294.38 279.66 321.6125392 1,205.81 1,145.52 1,317.35 # 25650 235.34 223.57 257.1125393 1,359.00 1,291.05 1,484.71 25651 417.74 396.85 456.3825394 715.14 679.38 781.29 25652 549.99 522.49 600.86

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 14FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

25660 384.41 365.19 419.97 26180 387.89 368.50 423.7825670 663.39 630.22 724.75 26185 409.55 389.07 447.4325671 455.63 432.85 497.78 26200 403.74 383.55 441.0825675 450.93 428.38 492.64 26205 545.61 518.33 596.08

# 25675 378.35 359.43 413.34 26210 387.50 368.13 423.3525676 670.55 637.02 732.57 26215 495.93 471.13 541.8025680 464.20 440.99 507.14 26230 456.87 434.03 499.1325685 761.99 723.89 832.47 26235 447.59 425.21 488.9925690 477.72 453.83 521.90 26236 396.12 376.31 432.7625695 683.17 649.01 746.36 26250 523.13 496.97 571.5225800 779.69 740.71 851.82 26255 810.28 769.77 885.2425805 873.23 829.57 954.01 26260 492.38 467.76 537.9225810 826.18 784.87 902.60 26261 575.93 547.13 629.2025820 640.70 608.67 699.97 26262 410.59 390.06 448.5725825 749.33 711.86 818.64 26320 318.16 302.25 347.5925830 1,004.83 954.59 1,097.78 26340 262.55 249.42 286.8325900 868.31 824.89 948.62 26350 938.95 892.00 1,025.8025905 915.70 869.92 1,000.41 26352 1,023.74 972.55 1,118.4325907 846.52 804.19 924.82 26356 1,074.40 1,020.68 1,173.7825909 905.73 860.44 989.51 26357 1,083.58 1,029.40 1,183.8125915 1,509.15 1,433.69 1,648.74 26358 1,124.79 1,068.55 1,228.8325920 696.91 662.06 761.37 26370 1,007.87 957.48 1,101.1025922 617.03 586.18 674.11 26372 1,119.65 1,063.67 1,223.2225924 701.08 666.03 765.93 26373 1,079.75 1,025.76 1,179.6225927 848.15 805.74 926.60 26390 954.03 906.33 1,042.2825929 579.09 550.14 632.66 26392 1,200.31 1,140.29 1,311.3325931 838.84 796.90 916.44 26410 754.37 716.65 824.1526010 268.21 254.80 293.02 26412 861.37 818.30 941.05

# 26010 122.71 116.57 134.06 26415 882.35 838.23 963.9626011 521.77 495.68 570.03 26416 1,027.30 975.94 1,122.33

# 26011 174.51 165.78 190.65 26418 732.19 695.58 799.9226020 374.89 356.15 409.57 26420 889.57 845.09 971.8526025 376.18 357.37 410.98 26426 846.52 804.19 924.8226030 444.01 421.81 485.08 26428 925.01 878.76 1,010.5726034 463.98 440.78 506.90 26432 626.94 595.59 684.9326035 662.52 629.39 723.80 26433 680.98 646.93 743.9726037 519.14 493.18 567.16 26434 755.76 717.97 825.6726040 267.09 253.74 291.80 26437 737.62 700.74 805.8526045 412.17 391.56 450.29 26440 859.55 816.57 939.0626055 647.30 614.94 707.18 26442 1,034.94 983.19 1,130.67

# 26055 235.10 223.35 256.85 26445 825.37 784.10 901.7226060 228.35 216.93 249.47 26449 979.19 930.23 1,069.7626070 261.72 248.63 285.92 26450 447.18 424.82 488.5426075 279.27 265.31 305.11 26455 442.27 420.16 483.1826080 331.45 314.88 362.11 26460 425.99 404.69 465.3926100 284.65 270.42 310.98 26471 722.19 686.08 788.9926105 287.15 272.79 313.71 26474 714.57 678.84 780.6726110 275.74 261.95 301.24 26476 689.30 654.84 753.0726115 657.93 625.03 718.78 26477 694.80 660.06 759.07

# 26115 311.02 295.47 339.79 26478 746.63 709.30 815.7026116 421.82 400.73 460.84 26479 744.10 706.90 812.9426117 587.29 557.93 641.62 26480 965.14 916.88 1,054.4126121 540.48 513.46 590.48 26483 1,047.00 994.65 1,143.8526123 679.20 645.24 742.03 26485 1,019.26 968.30 1,113.5526125 274.77 261.03 300.18 26489 973.31 924.64 1,063.3426130 397.66 377.78 434.45 26490 882.25 838.14 963.8626135 498.88 473.94 545.03 26492 952.34 904.72 1,040.4326140 450.67 428.14 492.36 26494 908.09 862.69 992.0926145 457.52 434.64 499.84 26496 940.82 893.78 1,027.8526160 785.92 746.62 858.61 26497 955.72 907.93 1,044.12

# 26160 262.25 249.14 286.51 26498 1,219.79 1,158.80 1,332.6226170 358.39 340.47 391.54 26499 950.49 902.97 1,038.42

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 15FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

26500 760.04 722.04 830.35 # 26705 323.02 306.87 352.9026502 820.38 779.36 896.26 26706 416.27 395.46 454.7826504 824.72 783.48 901.00 26715 535.39 508.62 584.9126508 751.83 714.24 821.38 26720 179.19 170.23 195.7626510 718.92 682.97 785.42 # 26720 126.06 119.76 137.7226516 814.86 774.12 890.24 26725 326.11 309.80 356.2726517 924.56 878.33 1,010.08 # 26725 250.06 237.56 273.1926518 927.38 881.01 1,013.16 26727 533.15 506.49 582.4626520 870.08 826.58 950.57 26735 553.85 526.16 605.0826525 877.43 833.56 958.59 26740 218.21 207.30 238.4026530 483.16 459.00 527.85 # 26740 171.67 163.09 187.5526531 564.38 536.16 616.58 26742 414.49 393.77 452.8426535 341.82 324.73 373.44 # 26742 340.53 323.50 372.0326536 618.04 587.14 675.21 26746 549.05 521.60 599.8426540 779.27 740.31 851.36 26750 201.13 191.07 219.7326541 917.01 871.16 1,001.83 # 26750 152.16 144.55 166.2326542 790.29 750.78 863.40 26755 308.00 292.60 336.4926545 818.25 777.34 893.94 # 26755 233.34 221.67 254.9226546 925.14 878.88 1,010.71 26756 487.98 463.58 533.1226548 882.65 838.52 964.30 26765 446.27 423.96 487.5526550 1,650.33 1,567.81 1,802.98 26770 292.20 277.59 319.2326551 3,205.58 3,045.30 3,502.10 # 26770 213.37 202.70 233.1126553 2,729.57 2,593.09 2,982.05 26775 367.01 348.66 400.9626554 3,617.30 3,436.44 3,951.91 # 26775 290.96 276.41 317.8726555 1,461.06 1,388.01 1,596.21 26776 509.51 484.03 556.6326556 3,142.48 2,985.36 3,433.16 26785 447.74 425.35 489.1526560 667.74 634.35 729.50 26820 902.53 857.40 986.0126561 980.95 931.90 1,071.69 26841 830.14 788.63 906.9226562 1,252.30 1,189.69 1,368.14 26842 902.14 857.03 985.5826565 793.68 754.00 867.10 26843 829.88 788.39 906.6526567 794.16 754.45 867.62 26844 919.27 873.31 1,004.3126568 1,077.48 1,023.61 1,177.15 26850 801.71 761.62 875.8626580 1,263.23 1,200.07 1,380.08 26852 894.49 849.77 977.2426587 770.92 732.37 842.23 26860 669.05 635.60 730.94

# 26587 715.36 679.59 781.53 26861 104.32 99.10 113.9726590 1,305.52 1,240.24 1,426.28 26862 834.32 792.60 911.4926591 610.36 579.84 666.82 26863 235.05 223.30 256.8026593 694.04 659.34 758.24 26910 796.49 756.67 870.1726596 698.30 663.39 762.90 26951 640.05 608.05 699.2626600 231.44 219.87 252.85 26952 750.22 712.71 819.62

# 26600 178.31 169.39 194.80 26990 872.01 828.41 952.6726605 336.77 319.93 367.92 26991 687.33 652.96 750.90

# 26605 271.49 257.92 296.61 # 26991 615.44 584.67 672.3726607 513.23 487.57 560.71 26992 1,238.00 1,176.10 1,352.5226608 535.46 508.69 584.99 27000 501.17 476.11 547.5326615 513.18 487.52 560.65 27001 581.53 552.45 635.3226641 390.64 371.11 426.78 27003 630.09 598.59 688.38

# 26641 326.75 310.41 356.97 27005 775.39 736.62 847.1126645 440.08 418.08 480.79 27006 775.06 736.31 846.76

# 26645 365.07 346.82 398.84 27025 825.75 784.46 902.1326650 555.86 528.07 607.28 27030 977.22 928.36 1,067.6126665 640.95 608.90 700.24 27033 997.31 947.44 1,089.5626670 373.54 354.86 408.09 27035 1,274.48 1,210.76 1,392.37

# 26670 311.73 296.14 340.56 27036 1,026.32 975.00 1,121.2526675 419.62 398.64 458.44 27040 325.61 309.33 355.73

# 26675 347.05 329.70 379.16 # 27040 249.56 237.08 272.6426676 550.32 522.80 601.22 27041 693.64 658.96 757.8026685 604.52 574.29 660.43 27047 629.86 598.37 688.1326686 663.42 630.25 724.79 # 27047 546.86 519.52 597.4526700 324.57 308.34 354.59 27048 532.74 506.10 582.02

# 26700 249.22 236.76 272.27 27049 1,022.97 971.82 1,117.5926705 394.56 374.83 431.05 27050 434.78 413.04 475.00

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 16FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

27052 558.81 530.87 610.50 # 27200 138.17 131.26 150.9527054 735.29 698.53 803.31 27202 1,051.41 998.84 1,148.6727060 483.43 459.26 528.15 27215 781.23 742.17 853.5027062 484.79 460.55 529.63 27216 1,142.39 1,085.27 1,248.0627065 556.84 529.00 608.35 27217 1,035.33 983.56 1,131.0927066 872.69 829.06 953.42 27218 1,333.06 1,266.41 1,456.3727067 1,089.05 1,034.60 1,189.79 27220 522.96 496.81 571.3327070 1,075.05 1,021.30 1,174.50 # 27220 456.63 433.80 498.8727071 1,140.56 1,083.53 1,246.06 27222 886.42 842.10 968.4227075 2,246.81 2,134.47 2,454.64 27226 996.05 946.25 1,088.1927076 1,609.20 1,528.74 1,758.05 27227 1,570.56 1,492.03 1,715.8327077 2,577.62 2,448.74 2,816.05 27228 1,803.23 1,713.07 1,970.0327078 1,096.27 1,041.46 1,197.68 27230 503.74 478.55 550.3327079 1,097.90 1,043.01 1,199.46 # 27230 449.22 426.76 490.7727080 526.40 500.08 575.09 27232 768.40 729.98 839.4827086 252.09 239.49 275.41 27235 895.93 851.13 978.80

# 27086 211.81 201.22 231.40 27236 1,035.42 983.65 1,131.2027087 667.88 634.49 729.66 27238 454.83 432.09 496.9027090 770.60 732.07 841.88 27240 879.11 835.15 960.4227091 1,407.94 1,337.54 1,538.17 27244 1,117.60 1,061.72 1,220.9827093 484.49 460.27 529.31 27245 1,381.59 1,312.51 1,509.39

# 27093 67.78 64.39 74.05 27246 462.84 439.70 505.6627095 456.34 433.52 498.55 # 27246 409.37 388.90 447.24

# 27095 76.79 72.95 83.89 27248 786.78 747.44 859.5627096 410.68 390.15 448.67 27250 501.90 476.81 548.33

# 27096 65.50 62.23 71.56 27252 718.58 682.65 785.0527097 690.59 656.06 754.47 27253 920.13 874.12 1,005.2427098 707.66 672.28 773.12 27254 1,239.91 1,177.91 1,354.6027100 910.44 864.92 994.66 27256 321.52 305.44 351.2627105 927.92 881.52 1,013.75 27257 375.07 356.32 409.7727110 1,002.43 952.31 1,095.16 27258 1,128.50 1,072.08 1,232.8927111 925.32 879.05 1,010.91 27259 1,496.52 1,421.69 1,634.9427120 1,159.25 1,101.29 1,266.48 27265 423.46 402.29 462.6327122 1,006.24 955.93 1,099.32 27266 575.87 547.08 629.1427125 979.36 930.39 1,069.95 27275 223.64 212.46 244.3327130 1,302.09 1,236.99 1,422.54 27280 1,063.35 1,010.18 1,161.7127132 1,512.68 1,437.05 1,652.61 27282 887.73 843.34 969.8427134 1,808.30 1,717.89 1,975.57 27284 1,588.19 1,508.78 1,735.1027137 1,368.45 1,300.03 1,495.03 27286 1,606.95 1,526.60 1,755.5927138 1,426.40 1,355.08 1,558.34 27290 1,540.97 1,463.92 1,683.5127140 929.73 883.24 1,015.73 27295 1,262.68 1,199.55 1,379.4827146 1,286.71 1,222.37 1,405.73 27301 834.58 792.85 911.7827147 1,454.84 1,382.10 1,589.42 # 27301 767.21 728.85 838.1827151 1,373.47 1,304.80 1,500.52 27303 881.74 837.65 963.3027156 1,725.03 1,638.78 1,884.60 27305 572.16 543.55 625.0827158 1,364.57 1,296.34 1,490.79 27306 465.11 441.85 508.1327161 1,194.94 1,135.19 1,305.47 27307 534.46 507.74 583.9027165 1,263.99 1,200.79 1,380.91 27310 743.47 706.30 812.2527170 1,158.08 1,100.18 1,265.21 27315 435.66 413.88 475.9627175 605.99 575.69 662.04 27320 418.94 397.99 457.6927176 851.29 808.73 930.04 27323 297.55 282.67 325.0727177 1,034.89 983.15 1,130.62 # 27323 212.82 202.18 232.5127178 829.32 787.85 906.03 27324 446.80 424.46 488.1327179 918.85 872.91 1,003.85 27327 478.35 454.43 522.5927181 982.67 933.54 1,073.57 # 27327 406.12 385.81 443.6827185 744.02 706.82 812.84 27328 478.47 454.55 522.7327187 1,038.20 986.29 1,134.23 27329 1,084.90 1,030.66 1,185.2627193 485.80 461.51 530.74 27330 433.40 411.73 473.49

# 27193 419.13 398.17 457.90 27331 514.12 488.41 561.6727194 723.61 687.43 790.54 27332 655.66 622.88 716.31

# 27194 664.92 631.67 726.42 27333 599.87 569.88 655.3627200 187.48 178.11 204.83 27334 705.01 669.76 770.22

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 17FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

27335 789.16 749.70 862.16 27477 754.14 716.43 823.8927340 389.72 370.23 425.76 27479 957.79 909.90 1,046.3927345 511.06 485.51 558.34 27485 704.90 669.66 770.1127347 495.53 470.75 541.36 27486 1,270.10 1,206.60 1,387.5927350 655.85 623.06 716.52 27487 1,627.47 1,546.10 1,778.0227355 688.65 654.22 752.35 27488 1,060.66 1,007.63 1,158.7727356 797.63 757.75 871.41 27495 1,204.10 1,143.90 1,315.4927357 859.85 816.86 939.39 27496 535.66 508.88 585.2127358 285.80 271.51 312.24 27497 577.69 548.81 631.1327360 1,090.35 1,035.83 1,191.20 27498 625.61 594.33 683.4827365 1,180.65 1,121.62 1,289.86 27499 690.89 656.35 754.8027370 453.02 430.37 494.93 27500 604.47 574.25 660.39

# 27370 48.46 46.04 52.95 # 27500 515.57 489.79 563.2627372 506.12 480.81 552.93 27501 648.93 616.48 708.95

# 27372 438.41 416.49 478.96 # 27501 560.03 532.03 611.8327380 596.50 566.68 651.68 27502 839.79 797.80 917.4727381 786.60 747.27 859.36 27503 841.18 799.12 918.9927385 633.63 601.95 692.24 27506 1,222.18 1,161.07 1,335.2327386 824.13 782.92 900.36 27507 1,019.51 968.53 1,113.8127390 502.76 477.62 549.26 27508 497.71 472.82 543.7427391 620.52 589.49 677.91 # 27508 431.73 410.14 471.6627392 774.58 735.85 846.23 27509 648.13 615.72 708.0827393 567.42 539.05 619.91 27510 632.80 601.16 691.3327394 736.61 699.78 804.75 27511 1,026.21 974.90 1,121.1427395 970.55 922.02 1,060.32 27513 1,283.45 1,219.28 1,402.1727396 707.42 672.05 772.86 27514 1,226.84 1,165.50 1,340.3327397 898.96 854.01 982.11 27516 505.97 480.67 552.7727400 758.29 720.38 828.44 # 27516 429.57 408.09 469.3027403 662.71 629.57 724.01 27517 704.44 669.22 769.6027405 705.62 670.34 770.89 # 27517 638.81 606.87 697.9027407 795.15 755.39 868.70 27519 1,099.72 1,044.73 1,201.4427409 957.22 909.36 1,045.76 27520 318.38 302.46 347.8327418 839.20 797.24 916.83 # 27520 252.75 240.11 276.1327420 753.80 716.11 823.53 27524 726.99 690.64 794.2427422 752.32 714.70 821.91 27530 374.45 355.73 409.0927424 752.37 714.75 821.96 # 27530 309.86 294.37 338.5327425 478.64 454.71 522.92 27532 571.73 543.14 624.6127427 720.35 684.33 786.98 # 27532 505.06 479.81 551.7827428 1,024.04 972.84 1,118.77 27535 899.33 854.36 982.5127429 1,115.85 1,060.06 1,219.07 27536 1,065.72 1,012.43 1,164.2927430 749.01 711.56 818.29 27538 477.35 453.48 521.5027435 735.86 699.07 803.93 # 27538 399.56 379.58 436.5227437 602.86 572.72 658.63 27540 905.83 860.54 989.6227438 765.52 727.24 836.33 27550 496.15 471.34 542.0427440 645.40 613.13 705.10 # 27550 435.73 413.94 476.0327441 685.30 651.04 748.70 27552 611.63 581.05 668.2127442 806.93 766.58 881.57 27556 1,104.60 1,049.37 1,206.7827443 758.07 720.17 828.20 27557 1,246.10 1,183.80 1,361.3727445 1,164.99 1,106.74 1,272.75 27558 1,292.50 1,227.88 1,412.0627446 1,053.19 1,000.53 1,150.61 27560 368.22 349.81 402.2827447 1,400.92 1,330.87 1,530.50 # 27560 291.47 276.90 318.4427448 886.07 841.77 968.04 27562 437.87 415.98 478.3827450 1,070.19 1,016.68 1,169.18 27566 859.59 816.61 939.1027454 1,281.11 1,217.05 1,399.61 27570 191.49 181.92 209.2127455 969.61 921.13 1,059.30 27580 1,374.44 1,305.72 1,501.5827457 967.21 918.85 1,056.68 27590 921.94 875.84 1,007.2227465 1,057.81 1,004.92 1,155.66 27591 1,026.26 974.95 1,121.1927466 1,230.24 1,168.73 1,344.04 27592 828.31 786.89 904.9227468 1,358.85 1,290.91 1,484.55 27594 596.37 566.55 651.5327470 1,234.14 1,172.43 1,348.29 27596 868.18 824.77 948.4927472 1,333.47 1,266.80 1,456.82 27598 829.52 788.04 906.2527475 687.85 653.46 751.48 27600 501.88 476.79 548.31

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 18FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

27601 499.78 474.79 546.01 27695 602.69 572.56 658.4427602 579.37 550.40 632.96 27696 687.62 653.24 751.2327603 755.91 718.11 825.83 27698 723.83 687.64 790.79

# 27603 571.17 542.61 624.00 27700 583.05 553.90 636.9927604 589.15 559.69 643.64 27702 931.47 884.90 1,017.64

# 27604 483.23 459.07 527.93 27703 1,050.12 997.61 1,147.2527605 495.50 470.73 541.34 27704 498.09 473.19 544.17

# 27605 256.93 244.08 280.69 27705 842.57 800.44 920.5127606 627.87 596.48 685.95 27707 486.57 462.24 531.58

# 27606 352.49 334.87 385.10 27709 824.83 783.59 901.1327607 843.36 801.19 921.37 27712 1,077.94 1,024.04 1,177.6527610 722.10 686.00 788.90 27715 1,131.65 1,075.07 1,236.3327612 600.95 570.90 656.54 27720 977.26 928.40 1,067.6627613 290.42 275.90 317.29 27722 969.67 921.19 1,059.37

# 27613 194.23 184.52 212.20 27724 1,346.91 1,279.56 1,471.4927614 628.62 597.19 686.77 27725 1,201.75 1,141.66 1,312.91

# 27614 484.16 459.95 528.94 27727 1,093.45 1,038.78 1,194.6027615 1,090.54 1,036.01 1,191.41 27730 1,032.59 980.96 1,128.1027618 615.85 585.06 672.82 # 27730 648.87 616.43 708.89

# 27618 442.22 420.11 483.13 27732 708.98 673.53 774.5627619 804.78 764.54 879.22 # 27732 517.99 492.09 565.90

# 27619 669.35 635.88 731.26 27734 682.25 648.14 745.3627620 541.03 513.98 591.08 27740 1,214.06 1,153.36 1,326.3627625 693.22 658.56 757.34 # 27740 792.49 752.87 865.8027626 741.82 704.73 810.44 27742 1,008.48 958.06 1,101.7727630 595.61 565.83 650.70 # 27742 809.85 769.36 884.76

# 27630 446.99 424.64 488.34 27745 833.01 791.36 910.0627635 722.20 686.09 789.00 27750 337.00 320.15 368.1727637 854.88 812.14 933.96 # 27750 273.45 259.78 298.7527638 895.67 850.89 978.52 27752 537.33 510.46 587.0327640 1,125.15 1,068.89 1,229.22 # 27752 461.28 438.22 503.9527641 965.28 917.02 1,054.57 27756 674.68 640.95 737.0927645 1,234.07 1,172.37 1,348.23 27758 908.94 863.49 993.0127646 1,127.24 1,070.88 1,231.51 27759 1,045.17 992.91 1,141.8527647 902.63 857.50 986.13 27760 320.71 304.67 350.3727648 375.23 356.47 409.94 # 27760 258.90 245.96 282.85

# 27648 48.46 46.04 52.95 27762 493.26 468.60 538.8927650 739.66 702.68 808.08 # 27762 419.64 398.66 458.4627652 774.43 735.71 846.07 27766 646.44 614.12 706.2427654 778.77 739.83 850.80 27780 302.74 287.60 330.7427656 628.87 597.43 687.04 # 27780 236.76 224.92 258.66

# 27656 417.74 396.85 456.38 27781 417.50 396.63 456.1227658 663.31 630.14 724.66 # 27781 342.84 325.70 374.56

# 27658 535.52 508.74 585.05 27784 602.66 572.53 658.4127659 798.36 758.44 872.21 27786 312.79 297.15 341.72

# 27659 637.93 606.03 696.93 # 27786 249.24 236.78 272.3027664 709.88 674.39 775.55 27788 423.51 402.33 462.68

# 27664 524.45 498.23 572.96 # 27788 348.15 330.74 380.3527665 730.70 694.17 798.30 27792 607.76 577.37 663.98

# 27665 562.63 534.50 614.68 27808 352.71 335.07 385.3327675 596.19 566.38 651.34 # 27808 276.66 262.83 302.2527676 682.65 648.52 745.80 27810 492.02 467.42 537.5327680 531.25 504.69 580.39 # 27810 415.63 394.85 454.0827681 592.09 562.49 646.86 27814 829.54 788.06 906.2727685 632.89 601.25 691.44 27816 335.79 319.00 366.85

# 27685 571.77 543.18 624.66 # 27816 278.84 264.90 304.6427686 832.80 791.16 909.83 27818 511.39 485.82 558.69

# 27686 668.89 635.45 730.77 # 27818 434.99 413.24 475.2327687 566.82 538.48 619.25 27822 913.99 868.29 998.5327690 698.08 663.18 762.66 27823 1,036.17 984.36 1,132.0127691 806.10 765.80 880.67 27824 352.47 334.85 385.0827692 110.11 104.60 120.29 # 27824 279.54 265.56 305.39

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 19FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

27825 557.01 529.16 608.53 # 28060 444.60 422.37 485.73# 27825 480.61 456.58 525.07 28062 600.95 570.90 656.54

27826 774.88 736.14 846.56 # 28062 493.30 468.64 538.9427827 1,108.87 1,053.43 1,211.44 28070 485.36 461.09 530.2527828 1,222.96 1,161.81 1,336.08 # 28070 421.81 400.72 460.8327829 537.08 510.23 586.76 28072 484.15 459.94 528.9327830 353.60 335.92 386.31 # 28072 434.50 412.78 474.70

# 27830 302.90 287.76 330.92 28080 421.70 400.62 460.7127831 379.24 360.28 414.32 # 28080 344.96 327.71 376.8727832 566.90 538.56 619.34 28086 593.53 563.85 648.4327840 395.18 375.42 431.73 # 28086 462.26 439.15 505.0227842 434.76 413.02 474.97 28088 487.79 463.40 532.9127846 771.08 732.53 842.41 # 28088 399.94 379.94 436.9327848 875.55 831.77 956.54 28090 459.89 436.90 502.4427860 226.53 215.20 247.48 # 28090 379.32 360.35 414.4027870 1,063.13 1,009.97 1,161.47 28092 442.96 420.81 483.9327871 773.17 734.51 844.69 # 28092 362.74 344.60 396.2927880 891.80 847.21 974.29 28100 645.70 613.42 705.4327881 974.99 926.24 1,065.18 # 28100 507.14 481.78 554.0527882 811.57 770.99 886.64 28102 636.99 605.14 695.9127884 707.91 672.51 773.39 28103 617.26 586.40 674.3627886 773.34 734.67 844.87 # 28103 526.62 500.29 575.3327888 785.77 746.48 858.45 28104 515.61 489.83 563.3027889 772.00 733.40 843.41 # 28104 453.10 430.45 495.0227892 585.69 556.41 639.87 28106 533.30 506.64 582.6427893 580.44 551.42 634.13 28107 575.73 546.94 628.9827894 757.23 719.37 827.28 # 28107 474.33 450.61 518.2028001 305.64 290.36 333.91 28108 427.16 405.80 466.67

# 28001 222.30 211.19 242.87 # 28108 358.41 340.49 391.5628002 428.27 406.86 467.89 28110 476.33 452.51 520.39

# 28002 337.99 321.09 369.25 # 28110 411.39 390.82 449.4428003 733.97 697.27 801.86 28111 574.09 545.39 627.20

# 28003 717.30 681.44 783.66 # 28111 477.21 453.35 521.3528005 726.47 690.15 793.67 28112 519.76 493.77 567.8428008 463.07 439.92 505.91 # 28112 450.31 427.79 491.96

# 28008 401.26 381.20 438.38 28113 517.13 491.27 564.9628010 379.47 360.50 414.58 # 28113 450.46 427.94 492.13

# 28010 300.65 285.62 328.46 28114 892.28 847.67 974.8228011 496.26 471.45 542.17 # 28114 789.84 750.35 862.90

# 28011 416.39 395.57 454.91 28116 626.29 594.98 684.2328020 528.26 501.85 577.13 # 28116 555.10 527.35 606.45

# 28020 438.67 416.74 479.25 28118 575.01 546.26 628.2028022 473.87 450.18 517.71 # 28118 496.53 471.70 542.46

# 28022 411.37 390.80 449.42 28119 518.50 492.58 566.4728024 465.01 441.76 508.02 # 28119 438.29 416.38 478.84

# 28024 404.59 384.36 442.01 28120 662.26 629.15 723.5228030 373.59 354.91 408.15 # 28120 568.50 540.08 621.0928035 533.63 506.95 582.99 28122 690.45 655.93 754.32

# 28035 400.98 380.93 438.07 # 28122 634.89 603.15 693.6228043 405.98 385.68 443.53 28124 528.29 501.88 577.16

# 28043 325.42 309.15 355.52 # 28124 470.99 447.44 514.5628045 476.04 452.24 520.08 28126 432.36 410.74 472.35

# 28045 398.60 378.67 435.47 # 28126 392.08 372.48 428.3528046 838.63 796.70 916.21 28130 647.40 615.03 707.28

# 28046 790.01 750.51 863.09 28140 655.75 622.96 716.4028050 443.99 421.79 485.06 # 28140 558.17 530.26 609.80

# 28050 383.22 364.06 418.67 28150 477.40 453.53 521.5628052 442.43 420.31 483.36 # 28150 421.49 400.42 460.48

# 28052 374.37 355.65 409.00 28153 437.45 415.58 477.9228054 419.38 398.41 458.17 # 28153 357.23 339.37 390.28

# 28054 348.19 330.78 380.40 28160 451.83 429.24 493.6328060 518.57 492.64 566.54 # 28160 414.32 393.60 452.64

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 20FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

28171 683.16 649.00 746.35 28292 632.76 601.12 691.2928173 742.94 705.79 811.66 # 28292 560.18 532.17 612.00

# 28173 664.46 631.24 725.93 28293 665.14 631.88 726.6628175 578.96 550.01 632.51 # 28293 585.62 556.34 639.79

# 28175 485.89 461.60 530.84 28294 715.52 679.74 781.7028190 299.46 284.49 327.16 # 28294 628.36 596.94 686.48

# 28190 195.63 185.85 213.73 28296 758.60 720.67 828.7728192 471.69 448.11 515.33 # 28296 682.20 648.09 745.30

# 28192 381.06 362.01 416.31 28297 795.07 755.32 868.6228193 534.97 508.22 584.45 # 28297 744.72 707.48 813.60

# 28193 463.09 439.94 505.93 28298 677.69 643.81 740.3828200 480.00 456.00 524.40 # 28298 619.70 588.72 677.03

# 28200 414.71 393.97 453.07 28299 822.66 781.53 898.7628202 679.95 645.95 742.84 # 28299 744.52 707.29 813.38

# 28202 525.77 499.48 574.40 28300 915.11 869.35 999.7528208 462.61 439.48 505.40 # 28300 725.86 689.57 793.01

# 28208 391.42 371.85 427.63 28302 900.12 855.11 983.3828210 591.26 561.70 645.96 # 28302 718.51 682.58 784.97

# 28210 485.69 461.41 530.62 28304 726.14 689.83 793.3028220 462.54 439.41 505.32 # 28304 642.10 610.00 701.50

# 28220 405.24 384.98 442.73 28305 913.53 867.85 998.0328222 520.97 494.92 569.16 # 28305 738.86 701.92 807.21

# 28222 478.61 454.68 522.88 28306 561.31 533.24 613.2328225 418.70 397.77 457.44 # 28306 466.51 443.18 509.66

# 28225 353.07 335.42 385.73 28307 718.99 683.04 785.5028226 463.92 440.72 506.83 # 28307 539.80 512.81 589.73

# 28226 422.60 401.47 461.69 28308 491.95 467.35 537.4528230 456.15 433.34 498.34 # 28308 407.57 387.19 445.27

# 28230 421.07 400.02 460.02 28309 892.39 847.77 974.9428232 422.77 401.63 461.87 28310 541.50 514.43 591.59

# 28232 375.54 356.76 410.27 # 28310 466.84 443.50 510.0328234 424.12 402.91 463.35 28312 495.21 470.45 541.02

# 28234 355.71 337.92 388.61 # 28312 454.58 431.85 496.6328238 676.98 643.13 739.60 28313 531.05 504.50 580.18

# 28238 583.22 554.06 637.17 28315 474.55 450.82 518.4428240 459.48 436.51 501.99 # 28315 399.54 379.56 436.49

# 28240 411.55 390.97 449.62 28320 695.74 660.95 760.0928250 556.20 528.39 607.65 28322 757.88 719.99 827.99

# 28250 489.53 465.05 534.81 # 28322 645.37 613.10 705.0728260 656.17 623.36 716.86 28340 614.60 583.87 671.45

# 28260 595.75 565.96 650.85 # 28340 526.40 500.08 575.0928261 867.43 824.06 947.67 28341 677.09 643.24 739.73

# 28261 820.20 779.19 896.07 # 28341 595.14 565.38 650.1928262 1,254.58 1,191.85 1,370.63 28344 482.23 458.12 526.84

# 28262 1,189.64 1,130.16 1,299.68 # 28344 383.95 364.75 419.4628264 819.26 778.30 895.05 28345 568.72 540.28 621.3228270 498.70 473.77 544.84 # 28345 512.12 486.51 559.49

# 28270 455.64 432.86 497.79 28360 1,035.78 983.99 1,131.5928272 419.98 398.98 458.83 28400 302.62 287.49 330.61

# 28272 351.92 334.32 384.47 # 28400 258.87 245.93 282.8228280 535.18 508.42 584.68 28405 433.43 411.76 473.52

# 28280 462.61 439.48 505.40 # 28405 399.75 379.76 436.7228285 493.55 468.87 539.20 28406 577.00 548.15 630.37

# 28285 427.22 405.86 466.74 28415 1,203.77 1,143.58 1,315.1228286 487.59 463.21 532.69 28420 1,242.04 1,179.94 1,356.93

# 28286 424.39 403.17 463.65 28430 279.23 265.27 305.0628288 512.55 486.92 559.96 # 28430 233.74 222.05 255.36

# 28288 490.32 465.80 535.67 28435 342.22 325.11 373.8828289 692.82 658.18 756.91 # 28435 309.92 294.42 338.58

# 28289 624.07 592.87 681.80 28436 478.12 454.21 522.3428290 576.96 548.11 630.33 28445 1,102.05 1,046.95 1,203.99

# 28290 554.73 526.99 606.04 28450 269.89 256.40 294.86

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 21FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 28450 222.31 211.19 242.87 # 28675 298.70 283.77 326.3428455 317.04 301.19 346.37 28705 1,293.72 1,229.03 1,413.38

# 28455 303.85 288.66 331.96 28715 987.11 937.75 1,078.4128456 335.79 319.00 366.85 28725 884.59 840.36 966.4128465 579.87 550.88 633.51 28730 827.24 785.88 903.7628470 247.12 234.76 269.97 28735 822.88 781.74 899.00

# 28470 200.93 190.88 219.51 28737 726.39 690.07 793.5828475 308.85 293.41 337.42 28740 808.04 767.64 882.79

# 28475 281.77 267.68 307.83 # 28740 650.39 617.87 710.5528476 382.46 363.34 417.84 28750 822.11 781.00 898.1528485 519.74 493.75 567.81 # 28750 634.59 602.86 693.2928490 143.51 136.33 156.78 28755 516.37 490.55 564.13

# 28490 119.89 113.90 130.99 # 28755 430.25 408.74 470.0528495 166.90 158.56 182.34 28760 672.49 638.87 734.70

# 28495 144.33 137.11 157.68 # 28760 593.32 563.65 648.2028496 475.85 452.06 519.87 28800 649.24 616.78 709.30

# 28496 278.60 264.67 304.37 28805 653.34 620.67 713.7728505 555.07 527.32 606.42 28810 526.76 500.42 575.48

# 28505 398.81 378.87 435.70 28820 566.81 538.47 619.2428510 132.74 126.10 145.02 # 28820 430.34 408.82 470.14

# 28510 119.55 113.57 130.61 28825 513.01 487.36 560.4628515 156.28 148.47 170.74 # 28825 392.51 372.88 428.81

# 28515 137.53 130.65 150.25 29000 199.29 189.33 217.7328525 523.00 496.85 571.38 # 29000 152.76 145.12 166.89

# 28525 366.04 347.74 399.90 29010 190.98 181.43 208.6428530 149.71 142.22 163.55 # 29010 144.10 136.90 157.44

# 28530 140.68 133.65 153.70 29015 198.12 188.21 216.4428531 484.91 460.66 529.76 # 29015 150.54 143.01 164.46

# 28531 242.87 230.73 265.34 29020 195.87 186.08 213.9928540 215.24 204.48 235.15 # 29020 132.32 125.70 144.5628545 243.38 231.21 265.89 29025 206.11 195.80 225.1728546 450.93 428.38 492.64 # 29025 160.97 152.92 175.86

# 28546 349.53 332.05 381.86 29035 180.43 171.41 197.1228555 724.58 688.35 791.60 # 29035 125.91 119.61 137.55

# 28555 561.02 532.97 612.92 29040 179.12 170.16 195.6828570 214.97 204.22 234.85 # 29040 146.48 139.16 160.03

# 28570 206.98 196.63 226.12 29044 206.02 195.72 225.0828575 345.19 327.93 377.12 # 29044 150.81 143.27 164.76

# 28575 333.73 317.04 364.60 29046 207.90 197.51 227.1428576 584.16 554.95 638.19 # 29046 169.36 160.89 185.02

# 28576 410.18 389.67 448.12 29049 74.77 71.03 81.6828585 667.01 633.66 728.71 # 29049 56.36 53.54 61.57

# 28585 623.95 592.75 681.66 29055 161.34 153.27 176.2628600 236.18 224.37 258.03 # 29055 123.15 116.99 134.54

# 28600 221.25 210.19 241.72 29058 99.77 94.78 109.0028605 292.78 278.14 319.86 # 29058 78.93 74.98 86.23

# 28605 291.39 276.82 318.34 29065 75.78 71.99 82.7928606 776.04 737.24 847.83 # 29065 60.15 57.14 65.71

# 28606 459.34 436.37 501.83 29075 69.71 66.22 76.1528615 657.95 625.05 718.81 # 29075 54.08 51.38 59.0928630 150.76 143.22 164.70 29085 74.73 70.99 81.6428635 168.15 159.74 183.70 # 29085 57.02 54.17 62.3028636 362.69 344.56 396.24 29086 49.65 47.17 54.25

# 28636 225.87 214.58 246.77 # 29086 43.74 41.55 47.7828645 407.15 386.79 444.81 29105 73.00 69.35 79.75

# 28645 327.28 310.92 357.56 # 29105 53.20 50.54 58.1228660 157.96 150.06 172.57 29125 55.16 52.40 60.26

# 28660 134.35 127.63 146.77 # 29125 37.45 35.58 40.9228665 169.56 161.08 185.24 29126 69.34 65.87 75.7528666 380.22 361.21 415.39 # 29126 46.42 44.10 50.72

# 28666 212.15 201.54 231.77 29130 35.21 33.45 38.4728675 455.31 432.54 497.42 # 29130 25.84 24.55 28.23

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 22FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

29131 45.70 43.42 49.93 29730 56.13 53.32 61.32# 29131 29.38 27.91 32.10 # 29730 42.93 40.78 46.90

29200 52.81 50.17 57.70 29740 82.10 78.00 89.70# 29200 37.53 35.65 41.00 # 29740 63.35 60.18 69.21

29220 51.77 49.18 56.56 29750 86.15 81.84 94.12# 29220 39.61 37.63 43.27 # 29750 71.91 68.31 78.56

29240 58.12 55.21 63.49 29800 577.88 548.99 631.34# 29240 41.11 39.05 44.91 29804 615.29 584.53 672.21

29260 48.14 45.73 52.59 29805 516.23 490.42 563.98# 29260 33.20 31.54 36.27 29806 980.56 931.53 1,071.26

29280 48.07 45.67 52.52 29807 953.03 905.38 1,041.19# 29280 31.75 30.16 34.68 29819 553.18 525.52 604.35

29305 185.04 175.79 202.16 29820 513.70 488.02 561.22# 29305 141.29 134.23 154.36 29821 557.86 529.97 609.47

29325 202.53 192.40 221.26 29822 541.74 514.65 591.85# 29325 158.78 150.84 173.47 29823 591.61 562.03 646.33

29345 111.40 105.83 121.70 29824 599.38 569.41 654.82# 29345 92.99 88.34 101.59 29825 552.48 524.86 603.59

29355 115.78 109.99 126.49 29826 636.05 604.25 694.89# 29355 99.80 94.81 109.03 29827 1,024.81 973.57 1,119.61

29358 121.17 115.11 132.38 29830 427.10 405.75 466.61# 29358 94.78 90.04 103.55 29834 465.48 442.21 508.54

29365 98.88 93.94 108.03 29835 475.54 451.76 519.52# 29365 80.12 76.11 87.53 29836 548.89 521.45 599.67

29405 72.64 69.01 79.36 29837 501.21 476.15 547.57# 29405 58.75 55.81 64.18 29838 560.27 532.26 612.10

29425 79.14 75.18 86.46 29840 416.28 395.47 454.79# 29425 65.94 62.64 72.04 29843 446.62 424.29 487.93

29435 96.44 91.62 105.36 29844 468.75 445.31 512.11# 29435 79.78 75.79 87.16 29845 532.42 505.80 581.67

29440 45.06 42.81 49.23 29846 491.61 467.03 537.08# 29440 32.56 30.93 35.57 29847 509.17 483.71 556.27

29445 130.09 123.59 142.13 29848 420.65 399.62 459.56# 29445 106.13 100.82 115.94 29850 506.71 481.37 553.58

29450 128.44 122.02 140.32 29851 885.00 840.75 966.86# 29450 117.68 111.80 128.57 29855 744.02 706.82 812.84

29505 64.00 60.80 69.92 29856 957.27 909.41 1,045.82# 29505 43.51 41.33 47.53 29860 577.87 548.98 631.33

29515 56.78 53.94 62.03 29861 637.71 605.82 696.69# 29515 45.32 43.05 49.51 29862 706.69 671.36 772.06

29520 50.89 48.35 55.60 29863 705.30 670.04 770.55# 29520 35.61 33.83 38.90 29870 381.48 362.41 416.77

29530 50.60 48.07 55.28 29871 476.69 452.86 520.79# 29530 34.28 32.57 37.46 29873 471.56 447.98 515.18

29540 33.49 31.82 36.59 29874 504.58 479.35 551.25# 29540 31.06 29.51 33.94 29875 467.97 444.57 511.26

29550 32.73 31.09 35.75 29876 574.17 545.46 627.28# 29550 28.22 26.81 30.83 29877 539.87 512.88 589.81

29580 43.31 41.14 47.31 29879 582.36 553.24 636.23# 29580 34.63 32.90 37.84 29880 609.87 579.38 666.29

29590 46.75 44.41 51.07 29881 564.87 536.63 617.12# 29590 40.15 38.14 43.86 29882 607.64 577.26 663.85

29700 51.31 48.74 56.05 29883 766.51 728.18 837.41# 29700 33.25 31.59 36.33 29884 537.41 510.54 587.12

29705 56.84 54.00 62.10 29885 652.19 619.58 712.52# 29705 44.68 42.45 48.82 29886 552.35 524.73 603.44

29710 103.65 98.47 113.24 29887 649.33 616.86 709.39# 29710 79.34 75.37 86.68 29888 935.67 888.89 1,022.22

29715 74.48 70.76 81.37 29889 1,089.16 1,034.70 1,189.91# 29715 51.22 48.66 55.96 29891 606.92 576.57 663.06

29720 62.96 59.81 68.78 29892 641.27 609.21 700.59# 29720 41.78 39.69 45.64 29893 350.50 332.98 382.93

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 23FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

29894 492.41 467.79 537.96 # 30903 77.90 74.01 85.1129895 482.66 458.53 527.31 30905 208.49 198.07 227.7829897 506.25 480.94 553.08 # 30905 103.96 98.76 113.5729898 560.59 532.56 612.44 30906 240.53 228.50 262.7829899 941.59 894.51 1,028.69 # 30906 137.74 130.85 150.4829900 428.96 407.51 468.64 30915 523.40 497.23 571.8129901 471.48 447.91 515.10 30920 676.03 642.23 738.5629902 505.78 480.49 552.56 30930 123.97 117.77 135.4430000 143.00 135.85 156.23 31000 129.00 122.55 140.93

# 30000 106.54 101.21 116.39 # 31000 66.84 63.50 73.0330020 148.89 141.45 162.67 31002 144.84 137.60 158.24

# 30020 108.96 103.51 119.04 31020 263.21 250.05 287.5630100 82.46 78.34 90.09 # 31020 240.29 228.28 262.52

# 30100 54.33 51.61 59.35 31030 395.58 375.80 432.1730110 160.70 152.67 175.57 # 31030 389.68 370.20 425.73

# 30110 93.68 89.00 102.35 31032 465.76 442.47 508.8430115 324.93 308.68 354.98 31040 609.39 578.92 665.7630117 295.18 280.42 322.48 31050 380.64 361.61 415.85

# 30117 231.98 220.38 253.44 31051 503.83 478.64 550.4430118 659.12 626.16 720.08 31070 339.74 322.75 371.1630120 413.28 392.62 451.51 31075 638.80 606.86 697.8930124 234.65 222.92 256.36 31080 747.40 710.03 816.5330125 502.17 477.06 548.62 31081 866.04 822.74 946.1530130 267.41 254.04 292.15 31084 889.08 844.63 971.3230140 292.15 277.54 319.17 31085 930.23 883.72 1,016.2830150 656.19 623.38 716.89 31086 860.91 817.86 940.5430160 669.76 636.27 731.71 31087 878.78 834.84 960.0730200 72.48 68.86 79.19 31090 678.31 644.39 741.05

# 30200 45.74 43.45 49.97 31200 387.37 368.00 423.2030210 116.73 110.89 127.52 31201 594.09 564.39 649.05

# 30210 62.56 59.43 68.34 31205 683.93 649.73 747.1930220 147.00 139.65 160.60 31225 1,268.71 1,205.27 1,386.06

# 30220 89.01 84.56 97.24 31230 1,431.19 1,359.63 1,563.5730300 130.55 124.02 142.62 31231 111.90 106.31 122.26

# 30300 53.46 50.79 58.41 # 31231 63.28 60.12 69.1430310 141.45 134.38 154.54 31233 176.19 167.38 192.4930320 358.91 340.96 392.10 # 31233 126.19 119.88 137.8630400 691.36 656.79 755.31 31235 202.99 192.84 221.7730410 874.39 830.67 955.27 # 31235 152.64 145.01 166.7630420 1,044.45 992.23 1,141.06 31237 225.78 214.49 246.6630430 531.81 505.22 581.00 # 31237 171.61 163.03 187.4830435 819.21 778.25 894.99 31238 255.41 242.64 279.0430450 1,211.59 1,151.01 1,323.66 # 31238 189.78 180.29 207.3330460 708.61 673.18 774.16 31239 558.45 530.53 610.1130462 1,278.90 1,214.96 1,397.20 31240 155.02 147.27 169.3630465 757.22 719.36 827.26 31254 274.37 260.65 299.7530520 424.74 403.50 464.03 31255 409.45 388.98 447.3330540 523.61 497.43 572.04 31256 195.38 185.61 213.4530545 774.43 735.71 846.07 31267 321.55 305.47 351.2930560 129.87 123.38 141.89 31276 518.84 492.90 566.84

# 30560 101.05 96.00 110.40 31287 231.84 220.25 253.2930580 433.33 411.66 473.41 31288 270.44 256.92 295.4630600 414.63 393.90 452.99 31290 1,070.25 1,016.74 1,169.2530620 459.92 436.92 502.46 31291 1,134.20 1,077.49 1,239.1130630 522.58 496.45 570.92 31292 920.28 874.27 1,005.4130801 130.98 124.43 143.09 31293 996.93 947.08 1,089.14

# 30801 122.30 116.19 133.62 31294 1,157.15 1,099.29 1,264.1830802 186.71 177.37 203.98 31300 1,153.57 1,095.89 1,260.27

# 30802 177.68 168.80 194.12 31320 655.99 623.19 716.6730901 95.76 90.97 104.62 31360 1,323.83 1,257.64 1,446.29

# 30901 58.60 55.67 64.02 31365 1,728.98 1,642.53 1,888.9130903 169.23 160.77 184.89 31367 1,670.32 1,586.80 1,824.82

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 24FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

31368 2,032.45 1,930.83 2,220.45 31603 223.92 212.72 244.6331370 1,638.61 1,556.68 1,790.18 31605 183.75 174.56 200.7431375 1,509.23 1,433.77 1,648.84 31610 717.35 681.48 783.7031380 1,508.87 1,433.43 1,648.44 31611 572.92 544.27 625.9131382 1,590.30 1,510.79 1,737.41 31612 86.93 82.58 94.9731390 2,056.10 1,953.30 2,246.30 # 31612 49.77 47.28 54.3731395 2,399.90 2,279.91 2,621.90 31613 488.21 463.80 533.3731400 943.86 896.67 1,031.17 31614 701.77 666.68 766.6831420 929.47 883.00 1,015.45 31615 210.76 200.22 230.2531500 113.23 107.57 123.71 # 31615 121.52 115.44 132.7631502 93.79 89.10 102.47 31622 225.42 214.15 246.27

# 31502 34.06 32.36 37.21 # 31622 145.90 138.61 159.4031505 46.84 44.50 51.18 31623 220.03 209.03 240.38

# 31505 31.56 29.98 34.48 # 31623 149.19 141.73 162.9931510 173.33 164.66 189.36 31624 209.60 199.12 228.99

# 31510 109.09 103.64 119.19 # 31624 148.83 141.39 162.6031511 192.48 182.86 210.29 31625 173.26 164.60 189.29

# 31511 110.18 104.67 120.37 31628 260.08 247.08 284.1431512 187.47 178.10 204.82 # 31628 192.02 182.42 209.78

# 31512 118.02 112.12 128.94 31629 171.16 162.60 186.9931513 126.05 119.75 137.71 31630 217.81 206.92 237.9631515 152.64 145.01 166.76 31631 239.54 227.56 261.69

# 31515 99.16 94.20 108.33 31635 199.13 189.17 217.5531520 146.95 139.60 160.54 31640 273.82 260.13 299.1531525 202.97 192.82 221.74 31641 267.34 253.97 292.07

# 31525 153.32 145.65 167.50 31643 178.32 169.40 194.8131526 153.22 145.56 167.39 31645 161.79 153.70 176.7631527 185.62 176.34 202.79 31646 140.93 133.88 153.9631528 135.52 128.74 148.05 31656 114.68 108.95 125.2931529 157.56 149.68 172.13 31700 132.42 125.80 144.6731530 192.43 182.81 210.23 # 31700 75.13 71.37 82.0831531 212.89 202.25 232.59 31708 74.19 70.48 81.0531535 185.79 176.50 202.98 31710 74.01 70.31 80.8631536 210.76 200.22 230.25 31715 63.64 60.46 69.5331540 243.65 231.47 266.19 31717 198.29 188.38 216.6431541 267.58 254.20 292.33 # 31717 110.78 105.24 121.0331560 317.73 301.84 347.12 31720 105.23 99.97 114.9731561 346.06 328.76 378.07 # 31720 52.10 49.50 56.9331570 293.56 278.88 320.71 31725 95.59 90.81 104.43

# 31570 226.54 215.21 247.49 31730 192.90 183.26 210.7531571 250.83 238.29 274.03 # 31730 147.06 139.71 160.6731575 114.68 108.95 125.29 31750 1,064.72 1,011.48 1,163.20

# 31575 62.59 59.46 68.38 31755 1,283.05 1,218.90 1,401.7431576 161.25 153.19 176.17 31760 1,292.91 1,228.26 1,412.50

# 31576 111.59 106.01 121.91 31766 1,776.63 1,687.80 1,940.9731577 197.50 187.63 215.77 31770 1,392.86 1,323.22 1,521.70

# 31577 139.16 132.20 152.03 31775 1,491.02 1,416.47 1,628.9431578 221.03 209.98 241.48 31780 1,144.81 1,087.57 1,250.71

# 31578 153.32 145.65 167.50 31781 1,438.85 1,366.91 1,571.9531579 189.86 180.37 207.43 31785 1,114.41 1,058.69 1,217.49

# 31579 129.44 122.97 141.42 31786 1,491.40 1,416.83 1,629.3531580 1,042.43 990.31 1,138.86 31800 529.41 502.94 578.3831582 1,592.47 1,512.85 1,739.78 31805 900.16 855.15 983.4231584 1,411.07 1,340.52 1,541.60 31820 456.09 433.29 498.2831585 489.65 465.17 534.95 # 31820 451.92 429.32 493.7231586 755.00 717.25 824.84 31825 652.64 620.01 713.0131587 960.89 912.85 1,049.78 31830 452.99 430.34 494.8931588 1,103.01 1,047.86 1,205.04 32000 166.43 158.11 181.8331590 705.69 670.41 770.97 # 32000 75.80 72.01 82.8131595 718.03 682.13 784.45 32002 112.98 107.33 123.4331600 378.83 359.89 413.87 32005 115.79 110.00 126.5031601 250.12 237.61 273.25 32020 207.33 196.96 226.50

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 25FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

32035 627.77 596.38 685.84 32800 891.71 847.12 974.1932036 695.82 661.03 760.18 32810 878.89 834.95 960.1932095 621.01 589.96 678.45 32815 1,412.23 1,341.62 1,542.8632100 965.73 917.44 1,055.06 32820 1,347.46 1,280.09 1,472.1032110 1,340.91 1,273.86 1,464.94 32851 2,277.58 2,163.70 2,488.2632120 798.95 759.00 872.85 32852 2,454.74 2,332.00 2,681.8032124 842.57 800.44 920.51 32853 2,772.94 2,634.29 3,029.4332140 911.63 866.05 995.96 32854 2,920.58 2,774.55 3,190.7332141 912.11 866.50 996.48 32900 1,245.54 1,183.26 1,360.7532150 912.30 866.69 996.69 32905 1,280.06 1,216.06 1,398.4732151 933.52 886.84 1,019.87 32906 1,596.45 1,516.63 1,744.1232160 592.68 563.05 647.51 32940 1,204.62 1,144.39 1,316.0532200 955.75 907.96 1,044.15 32960 145.76 138.47 159.2432201 344.09 326.89 375.92 # 32960 90.89 86.35 99.3032215 786.76 747.42 859.53 32997 304.45 289.23 332.6132220 1,423.46 1,352.29 1,555.13 33010 120.02 114.02 131.1232225 918.29 872.38 1,003.24 33011 121.41 115.34 132.6432310 885.13 840.87 967.00 33015 426.63 405.30 466.1032320 1,417.95 1,347.05 1,549.11 33020 789.26 749.80 862.2732400 131.02 124.47 143.14 33025 765.84 727.55 836.68

# 32400 86.22 81.91 94.20 33030 1,191.61 1,132.03 1,301.8332402 586.69 557.36 640.96 33031 1,361.03 1,292.98 1,486.9332405 155.96 148.16 170.38 33050 940.83 893.79 1,027.86

# 32405 95.88 91.09 104.75 33120 1,557.68 1,479.80 1,701.7732420 112.62 106.99 123.04 33130 1,308.17 1,242.76 1,429.1732440 1,430.37 1,358.85 1,562.68 33140 1,177.32 1,118.45 1,286.2232442 1,551.05 1,473.50 1,694.53 33141 249.79 237.30 272.9032445 1,489.46 1,414.99 1,627.24 33200 832.30 790.69 909.2932480 1,375.06 1,306.31 1,502.26 33201 749.77 712.28 819.1232482 1,425.40 1,354.13 1,557.25 33206 457.61 434.73 499.9432484 1,220.93 1,159.88 1,333.86 33207 528.61 502.18 577.5132486 1,413.55 1,342.87 1,544.30 33208 537.77 510.88 587.5132488 1,504.73 1,429.49 1,643.91 33210 170.37 161.85 186.1332491 1,281.62 1,217.54 1,400.17 33211 176.09 167.29 192.3832500 1,271.30 1,207.74 1,388.90 33212 376.54 357.71 411.3732501 243.65 231.47 266.19 33213 423.42 402.25 462.5932520 1,260.81 1,197.77 1,377.44 33214 514.92 489.17 562.5532522 1,386.14 1,316.83 1,514.35 33215 295.06 280.31 322.3632525 1,508.83 1,433.39 1,648.40 33216 407.48 387.11 445.1832540 913.55 867.87 998.05 33217 415.42 394.65 453.8532601 345.98 328.68 377.98 33218 374.31 355.59 408.9332602 371.82 353.23 406.21 33220 377.21 358.35 412.1032603 456.10 433.30 498.30 33222 335.68 318.90 366.7432604 517.85 491.96 565.75 33223 438.14 416.23 478.6632605 430.07 408.57 469.86 33224 477.71 453.82 521.8932606 498.84 473.90 544.99 33225 423.78 402.59 462.9832650 660.42 627.40 721.51 33226 460.11 437.10 502.6732651 766.82 728.48 837.75 33233 270.39 256.87 295.4032652 1,097.38 1,042.51 1,198.89 33234 500.47 475.45 546.7732653 757.76 719.87 827.85 33235 591.29 561.73 645.9932654 755.30 717.54 825.17 33236 836.12 794.31 913.4632655 775.48 736.71 847.22 33237 893.17 848.51 975.7932656 787.37 748.00 860.20 33238 929.98 883.48 1,016.0032657 811.50 770.93 886.57 33240 495.24 470.48 541.0532658 717.86 681.97 784.27 33241 253.98 241.28 277.4732659 717.41 681.54 783.77 33243 1,290.41 1,225.89 1,409.7732660 1,021.32 970.25 1,115.79 33244 829.80 788.31 906.5632661 799.40 759.43 873.34 33245 947.46 900.09 1,035.1032662 963.77 915.58 1,052.92 33246 1,329.50 1,263.03 1,452.4832663 1,106.44 1,051.12 1,208.79 33249 867.25 823.89 947.4732664 835.68 793.90 912.99 33250 1,330.42 1,263.90 1,453.4932665 906.30 860.99 990.14 33251 1,493.65 1,418.97 1,631.82

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 26FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

33253 1,841.44 1,749.37 2,011.78 33518 252.61 239.98 275.9833261 1,517.11 1,441.25 1,657.44 33519 370.32 351.80 404.5733282 335.79 319.00 366.85 33521 489.09 464.64 534.3433284 251.40 238.83 274.65 33522 607.85 577.46 664.0833300 1,138.01 1,081.11 1,243.28 33523 725.93 689.63 793.0733305 1,343.40 1,276.23 1,467.66 33530 304.65 289.42 332.8333310 1,183.93 1,124.73 1,293.44 33533 1,748.54 1,661.11 1,910.2833315 1,392.24 1,322.63 1,521.02 33534 1,881.81 1,787.72 2,055.8833320 1,065.92 1,012.62 1,164.51 33535 1,994.39 1,894.67 2,178.8733321 1,270.91 1,207.36 1,388.46 33536 2,090.94 1,986.39 2,284.3533322 1,300.32 1,235.30 1,420.60 33542 1,780.88 1,691.84 1,945.6233330 1,315.52 1,249.74 1,437.20 33545 2,186.49 2,077.17 2,388.7533332 1,414.74 1,344.00 1,545.60 33572 231.10 219.55 252.4833335 1,787.71 1,698.32 1,953.07 33600 1,740.00 1,653.00 1,900.9533400 1,665.47 1,582.20 1,819.53 33602 1,709.90 1,624.41 1,868.0733401 1,427.28 1,355.92 1,559.31 33606 1,876.65 1,782.82 2,050.2433403 1,468.00 1,394.60 1,603.79 33608 1,888.61 1,794.18 2,063.3133404 1,637.86 1,555.97 1,789.37 33610 1,901.99 1,806.89 2,077.9233405 2,016.33 1,915.51 2,202.84 33611 2,018.25 1,917.34 2,204.9433406 2,142.01 2,034.91 2,340.15 33612 2,121.82 2,015.73 2,318.0933410 1,880.03 1,786.03 2,053.93 33615 1,999.44 1,899.47 2,184.3933411 2,087.94 1,983.54 2,281.07 33617 2,249.56 2,137.08 2,457.6433412 2,377.03 2,258.18 2,596.91 33619 2,747.22 2,609.86 3,001.3433413 2,428.92 2,307.47 2,653.59 33641 1,286.37 1,222.05 1,405.3633414 1,860.83 1,767.79 2,032.96 33645 1,512.71 1,437.07 1,652.6333415 1,658.50 1,575.58 1,811.92 33647 1,775.71 1,686.92 1,939.9633416 1,808.43 1,718.01 1,975.71 33660 1,792.78 1,703.14 1,958.6133417 1,770.97 1,682.42 1,934.78 33665 1,787.17 1,697.81 1,952.4833420 1,228.54 1,167.11 1,342.18 33670 1,911.00 1,815.45 2,087.7733422 1,511.42 1,435.85 1,651.23 33681 1,864.26 1,771.05 2,036.7133425 1,523.75 1,447.56 1,664.69 33684 1,798.23 1,708.32 1,964.5733426 1,905.79 1,810.50 2,082.08 33688 1,749.85 1,662.36 1,911.7133427 2,250.69 2,138.16 2,458.88 33690 1,274.65 1,210.92 1,392.5633430 1,930.95 1,834.40 2,109.56 33692 1,856.96 1,764.11 2,028.7333460 1,454.71 1,381.97 1,589.27 33694 2,025.32 1,924.05 2,212.6633463 1,559.10 1,481.15 1,703.32 33697 2,149.18 2,041.72 2,347.9833464 1,652.65 1,570.02 1,805.52 33702 1,671.15 1,587.59 1,825.7333465 1,722.10 1,636.00 1,881.40 33710 1,848.37 1,755.95 2,019.3433468 1,933.49 1,836.82 2,112.34 33720 1,645.72 1,563.43 1,797.9433470 1,329.94 1,263.44 1,452.96 33722 1,788.25 1,698.84 1,953.6733471 1,355.98 1,288.18 1,481.41 33730 1,970.87 1,872.33 2,153.1833472 1,441.02 1,368.97 1,574.32 33732 1,718.60 1,632.67 1,877.5733474 1,403.37 1,333.20 1,533.18 33735 1,242.22 1,180.11 1,357.1333475 1,947.57 1,850.19 2,127.72 33736 1,490.20 1,415.69 1,628.0433476 1,509.67 1,434.19 1,649.32 33737 1,410.02 1,339.52 1,540.4533478 1,623.26 1,542.10 1,773.42 33750 1,304.01 1,238.81 1,424.6333496 1,708.07 1,622.67 1,866.07 33755 1,320.48 1,254.46 1,442.6333500 1,508.46 1,433.04 1,648.00 33762 1,313.24 1,247.58 1,434.7233501 1,084.72 1,030.48 1,185.05 33764 1,316.52 1,250.69 1,438.2933502 1,444.77 1,372.53 1,578.41 33766 1,466.56 1,393.23 1,602.2133503 1,329.46 1,262.99 1,452.44 33767 1,528.45 1,452.03 1,669.8333504 1,590.82 1,511.28 1,737.97 33770 2,126.82 2,020.48 2,323.5533505 1,666.55 1,583.22 1,820.70 33771 1,942.88 1,845.74 2,122.6033506 2,086.27 1,981.96 2,279.25 33774 1,848.84 1,756.40 2,019.8633508 16.14 15.33 17.63 33775 1,910.62 1,815.09 2,087.3533510 1,703.11 1,617.95 1,860.64 33776 2,037.69 1,935.81 2,226.1833511 1,770.81 1,682.27 1,934.61 33777 1,979.42 1,880.45 2,162.5233512 1,867.65 1,774.27 2,040.41 33778 2,343.32 2,226.15 2,560.0733513 1,890.69 1,796.16 2,065.58 33779 2,031.13 1,929.57 2,219.0133514 1,940.00 1,843.00 2,119.45 33780 2,478.63 2,354.70 2,707.9133516 2,056.62 1,953.79 2,246.86 33781 2,032.72 1,931.08 2,220.7433517 133.84 127.15 146.22 33786 2,282.94 2,168.79 2,494.11

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 27FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

33788 1,618.44 1,537.52 1,768.15 34530 980.79 931.75 1,071.5133800 1,061.64 1,008.56 1,159.84 34800 1,117.04 1,061.19 1,220.3733802 1,148.88 1,091.44 1,255.16 34802 1,230.49 1,168.97 1,344.3233803 1,274.07 1,210.37 1,391.93 34804 1,230.49 1,168.97 1,344.3233813 1,367.17 1,298.81 1,493.63 34808 208.93 198.48 228.2533814 1,597.23 1,517.37 1,744.98 34812 342.09 324.99 373.7433820 1,063.58 1,010.40 1,161.96 34813 241.98 229.88 264.3633822 1,192.11 1,132.50 1,302.38 34820 493.59 468.91 539.2533824 1,239.90 1,177.91 1,354.60 34825 673.02 639.37 735.2833840 1,317.28 1,251.42 1,439.13 34826 209.27 198.81 228.6333845 1,431.42 1,359.85 1,563.83 34830 1,729.03 1,642.58 1,888.9733851 1,387.66 1,318.28 1,516.02 34831 1,779.06 1,690.11 1,943.6333852 1,506.71 1,431.37 1,646.08 34832 1,872.82 1,779.18 2,046.0633853 1,958.06 1,860.16 2,139.18 34833 633.71 602.02 692.3233860 2,188.77 2,079.33 2,391.23 34834 297.81 282.92 325.3633861 2,376.48 2,257.66 2,596.31 34900 933.91 887.21 1,020.2933863 2,531.52 2,404.94 2,765.68 35001 1,091.04 1,036.49 1,191.9633870 2,501.67 2,376.59 2,733.08 35002 1,142.26 1,085.15 1,247.9233875 1,938.98 1,842.03 2,118.33 35005 976.59 927.76 1,066.9233877 2,482.03 2,357.93 2,711.62 35011 956.93 909.08 1,045.4433910 1,497.31 1,422.44 1,635.81 35013 1,170.31 1,111.79 1,278.5633915 1,235.75 1,173.96 1,350.05 35021 1,081.09 1,027.04 1,181.1033916 1,564.59 1,486.36 1,709.31 35022 1,239.98 1,177.98 1,354.6833917 1,555.55 1,477.77 1,699.44 35045 981.56 932.48 1,072.3533918 1,623.07 1,541.92 1,773.21 35081 1,535.21 1,458.45 1,677.2233919 2,329.13 2,212.67 2,544.57 35082 2,049.52 1,947.04 2,239.1033920 1,875.14 1,781.38 2,048.59 35091 1,913.60 1,817.92 2,090.6133922 1,435.14 1,363.38 1,567.89 35092 2,375.12 2,256.36 2,594.8133924 289.14 274.68 315.88 35102 1,667.21 1,583.85 1,821.4333935 3,470.95 3,297.40 3,792.01 35103 2,139.79 2,032.80 2,337.7233945 2,477.57 2,353.69 2,706.74 35111 1,325.83 1,259.54 1,448.4733960 951.20 903.64 1,039.19 35112 1,563.53 1,485.35 1,708.1533961 575.74 546.95 628.99 35121 1,612.61 1,531.98 1,761.7833967 252.10 239.50 275.43 35122 1,864.07 1,770.87 2,036.50

# 33967 251.06 238.51 274.29 35131 1,343.34 1,276.17 1,467.6033968 33.71 32.02 36.82 35132 1,588.09 1,508.69 1,734.9933970 349.49 332.02 381.82 35141 1,080.14 1,026.13 1,180.0533971 670.38 636.86 732.39 35142 1,240.40 1,178.38 1,355.1433973 505.22 479.96 551.95 35151 1,222.06 1,160.96 1,335.1033974 957.11 909.25 1,045.64 35152 1,360.92 1,292.87 1,486.8033975 1,041.86 989.77 1,138.24 35161 1,061.73 1,008.64 1,159.9433976 1,196.33 1,136.51 1,306.99 35162 1,104.36 1,049.14 1,206.5133977 1,151.60 1,094.02 1,258.12 35180 766.21 727.90 837.0933978 1,278.23 1,214.32 1,396.47 35182 1,583.63 1,504.45 1,730.1233979 2,432.84 2,311.20 2,657.88 35184 971.88 923.29 1,061.7833980 3,125.48 2,969.21 3,414.59 35188 801.35 761.28 875.4734001 723.75 687.56 790.69 35189 1,490.22 1,415.71 1,628.0734051 859.64 816.66 939.16 35190 714.40 678.68 780.4834101 566.08 537.78 618.45 35201 871.56 827.98 952.1834111 559.01 531.06 610.72 35206 778.96 740.01 851.0134151 1,328.97 1,262.52 1,451.90 35207 748.30 710.89 817.5234201 575.11 546.35 628.30 35211 1,381.73 1,312.64 1,509.5434203 906.96 861.61 990.85 35216 1,163.09 1,104.94 1,270.6834401 1,299.84 1,234.85 1,420.08 35221 1,299.83 1,234.84 1,420.0734421 673.76 640.07 736.08 35226 867.36 823.99 947.5934451 1,410.91 1,340.36 1,541.41 35231 1,094.22 1,039.51 1,195.4434471 572.86 544.22 625.85 35236 972.45 923.83 1,062.4034490 596.57 566.74 651.75 35241 1,443.11 1,370.95 1,576.5934501 950.95 903.40 1,038.91 35246 1,533.60 1,456.92 1,675.4634502 1,466.02 1,392.72 1,601.63 35251 1,581.17 1,502.11 1,727.4334510 1,101.68 1,046.60 1,203.59 35256 1,041.21 989.15 1,137.5234520 1,024.96 973.71 1,119.77 35261 952.11 904.50 1,040.18

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 28FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

35266 859.84 816.85 939.38 35548 1,184.81 1,125.57 1,294.4135271 1,372.67 1,304.04 1,499.65 35549 1,286.81 1,222.47 1,405.8435276 1,445.38 1,373.11 1,579.08 35551 1,459.76 1,386.77 1,594.7935281 1,477.93 1,404.03 1,614.63 35556 1,199.02 1,139.07 1,309.9335286 938.35 891.43 1,025.14 35558 1,138.30 1,081.39 1,243.6035301 1,044.97 992.72 1,141.63 35560 1,702.91 1,617.76 1,860.4235311 1,457.31 1,384.44 1,592.11 35563 1,289.05 1,224.60 1,408.2935321 862.74 819.60 942.54 35565 1,240.57 1,178.54 1,355.3235331 1,423.35 1,352.18 1,555.01 35566 1,489.95 1,415.45 1,627.7735341 1,375.13 1,306.37 1,502.33 35571 1,363.01 1,294.86 1,489.0935351 1,250.94 1,188.39 1,366.65 35572 359.29 341.33 392.5335355 1,017.71 966.82 1,111.84 35582 1,480.61 1,406.58 1,617.5735361 1,513.38 1,437.71 1,653.37 35583 1,262.88 1,199.74 1,379.7035363 1,615.98 1,535.18 1,765.46 35585 1,641.04 1,558.99 1,792.8435371 809.95 769.45 884.87 35587 1,412.76 1,342.12 1,543.4435372 976.49 927.67 1,066.82 35600 257.28 244.42 281.0835381 888.34 843.92 970.51 35601 963.79 915.60 1,052.9435390 166.47 158.15 181.87 35606 1,025.52 974.24 1,120.3835400 157.46 149.59 172.03 35612 866.69 823.36 946.8635450 535.15 508.39 584.65 35616 870.82 827.28 951.3735452 385.20 365.94 420.83 35621 1,087.10 1,032.75 1,187.6635454 339.30 322.34 370.69 35623 1,286.06 1,221.76 1,405.0235456 407.47 387.10 445.17 35626 1,489.84 1,415.35 1,627.6535458 519.40 493.43 567.44 35631 1,801.00 1,710.95 1,967.5935459 472.11 448.50 515.78 35636 1,576.11 1,497.30 1,721.9035460 334.08 317.38 364.99 35641 1,349.24 1,281.78 1,474.0535470 466.33 443.01 509.46 35642 991.19 941.63 1,082.8735471 540.89 513.85 590.93 35645 969.21 920.75 1,058.8635472 378.07 359.17 413.05 35646 1,705.89 1,620.60 1,863.6935473 333.93 317.23 364.81 35647 1,541.48 1,464.41 1,684.0735474 383.67 364.49 419.16 35650 1,018.09 967.19 1,112.2735475 504.52 479.29 551.18 35651 1,363.74 1,295.55 1,489.8835476 329.03 312.58 359.47 35654 1,341.60 1,274.52 1,465.7035480 598.74 568.80 654.12 35656 1,073.05 1,019.40 1,172.3135481 423.52 402.34 462.69 35661 1,024.28 973.07 1,119.0335482 373.66 354.98 408.23 35663 1,181.95 1,122.85 1,291.2835483 443.40 421.23 484.41 35665 1,137.02 1,080.17 1,242.2035484 564.71 536.47 616.94 35666 1,290.56 1,226.03 1,409.9335485 521.82 495.73 570.09 35671 1,122.47 1,066.35 1,226.3035490 588.74 559.30 643.20 35681 83.59 79.41 91.3235491 409.12 388.66 446.96 35682 375.63 356.85 410.3835492 367.95 349.55 401.98 35683 443.43 421.26 484.4535493 444.97 422.72 486.13 35685 208.78 198.34 228.0935494 551.21 523.65 602.20 35686 172.90 164.26 188.9035495 517.74 491.85 565.63 35691 990.36 940.84 1,081.9735500 328.48 312.06 358.87 35693 850.46 807.94 929.1335501 1,037.48 985.61 1,133.45 35694 1,043.24 991.08 1,139.7435506 1,079.23 1,025.27 1,179.06 35695 1,043.62 991.44 1,140.1635507 1,075.73 1,021.94 1,175.23 35700 160.38 152.36 175.2135508 1,032.79 981.15 1,128.32 35701 490.85 466.31 536.2635509 993.20 943.54 1,085.07 35721 459.86 436.87 502.4035511 1,133.52 1,076.84 1,238.37 35741 497.31 472.44 543.3135515 1,032.75 981.11 1,128.28 35761 369.78 351.29 403.9835516 860.73 817.69 940.34 35800 418.38 397.46 457.0835518 1,127.98 1,071.58 1,232.32 35820 670.29 636.78 732.3035521 1,194.90 1,135.16 1,305.43 35840 569.50 541.03 622.1835526 1,581.96 1,502.86 1,728.29 35860 346.82 329.48 378.9035531 1,908.77 1,813.33 2,085.33 35870 1,238.22 1,176.31 1,352.7635533 1,494.85 1,420.11 1,633.13 35875 621.09 590.04 678.5535536 1,681.19 1,597.13 1,836.70 35876 989.62 940.14 1,081.1635541 1,406.40 1,336.08 1,536.49 35879 893.29 848.63 975.9235546 1,392.13 1,322.52 1,520.90 35881 998.67 948.74 1,091.05

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 29FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

35901 531.45 504.88 580.61 36512 89.66 85.18 97.9635903 658.11 625.20 718.98 36513 89.66 85.18 97.9635905 1,736.49 1,649.67 1,897.12 36514 89.66 85.18 97.9635907 1,854.39 1,761.67 2,025.92 36515 89.66 85.18 97.9636000 29.81 28.32 32.57 36516 89.66 85.18 97.96

# 36000 8.63 8.20 9.43 36522 298.25 283.34 325.8436002 159.83 151.84 174.62 # 36522 103.09 97.94 112.63

# 36002 109.48 104.01 119.61 36530 373.53 354.85 408.0836005 331.45 314.88 362.11 36531 305.34 290.07 333.58

# 36005 47.05 44.70 51.41 36532 184.69 175.46 201.7836010 122.08 115.98 133.38 36533 681.13 647.07 744.1336011 156.57 148.74 171.05 # 36533 327.97 311.57 358.3136012 174.89 166.15 191.07 36534 159.15 151.19 173.8736013 120.84 114.80 132.02 36535 187.47 178.10 204.8236014 150.11 142.60 163.99 # 36535 153.09 145.44 167.2636015 174.54 165.81 190.68 36536 1,303.63 1,238.45 1,424.2236100 154.99 147.24 169.33 # 36536 189.98 180.48 207.5536120 100.19 95.18 109.46 36537 295.71 280.92 323.0636140 100.20 95.19 109.47 # 36537 45.68 43.40 49.9136145 100.19 95.18 109.46 36550 24.11 22.90 26.3436160 128.49 122.07 140.38 36600 26.57 25.24 29.0336200 151.15 143.59 165.13 # 36600 15.46 14.69 16.8936215 234.09 222.39 255.75 36620 52.24 49.63 57.0736216 263.20 250.04 287.55 36625 100.72 95.68 110.0336217 316.98 301.13 346.30 36640 107.66 102.28 117.6236218 50.62 48.09 55.30 36660 69.32 65.85 75.7336245 236.87 225.03 258.78 36680 67.96 64.56 74.2436246 264.60 251.37 289.08 36800 155.42 147.65 169.8036247 315.59 299.81 344.78 36810 236.15 224.34 257.9936248 51.32 48.75 56.06 36815 148.13 140.72 161.8336260 579.10 550.15 632.67 36819 786.33 747.01 859.0636261 331.31 314.74 361.95 36820 787.02 747.67 859.8236262 247.36 234.99 270.24 36821 530.25 503.74 579.3036400 45.07 42.82 49.24 36822 467.10 443.75 510.31

# 36400 17.64 16.76 19.27 36823 1,200.42 1,140.40 1,311.4636405 23.08 21.93 25.22 36825 586.30 556.99 640.54

# 36405 14.40 13.68 15.73 36830 692.34 657.72 756.3836406 19.74 18.75 21.56 36831 455.04 432.29 497.13

# 36406 8.63 8.20 9.43 36832 613.43 582.76 670.1736410 20.44 19.42 22.33 36833 688.08 653.68 751.73

# 36410 8.63 8.20 9.43 36834 529.82 503.33 578.8336420 50.64 48.11 55.33 36835 444.98 422.73 486.1436425 37.02 35.17 40.45 36860 167.55 159.17 183.0536430 36.83 34.99 40.24 # 36860 123.10 116.95 134.4936440 50.32 47.80 54.97 36861 147.22 139.86 160.8436450 111.68 106.10 122.02 36870 1,665.22 1,581.96 1,819.2536455 121.35 115.28 132.57 # 36870 278.63 264.70 304.4136460 338.05 321.15 369.32 37140 1,258.34 1,195.42 1,374.7336470 124.05 117.85 135.53 37145 1,361.29 1,293.23 1,487.21

# 36470 56.68 53.85 61.93 37160 1,178.47 1,119.55 1,287.4836471 155.41 147.64 169.79 37180 1,343.65 1,276.47 1,467.94

# 36471 81.44 77.37 88.98 37181 1,440.78 1,368.74 1,574.0536481 365.36 347.09 399.15 37182 891.51 846.93 973.9736488 77.93 74.03 85.13 37183 414.23 393.52 452.5536489 236.40 224.58 258.27 37195 291.88 277.29 318.88

# 36489 129.79 123.30 141.80 37200 226.24 214.93 247.1736490 95.50 90.73 104.34 37201 278.03 264.13 303.7536491 82.94 78.79 90.61 37202 327.46 311.09 357.7536493 75.95 72.15 82.97 37203 279.46 265.49 305.3136500 176.61 167.78 192.95 37204 903.49 858.32 987.0736510 66.73 63.39 72.90 37205 447.68 425.30 489.1036511 89.66 85.18 97.96 37206 209.24 198.78 228.60

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 30FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

37207 454.84 432.10 496.92 38542 440.75 418.71 481.5237208 214.55 203.82 234.39 38550 445.95 423.65 487.2037209 113.11 107.45 123.57 38555 922.28 876.17 1,007.6037250 109.05 103.60 119.14 38562 642.16 610.05 701.5637251 82.87 78.73 90.54 38564 648.65 616.22 708.6537500 715.98 680.18 782.21 38570 522.74 496.60 571.0937565 587.67 558.29 642.03 38571 773.52 734.84 845.0737600 641.72 609.63 701.07 38572 906.39 861.07 990.2337605 728.60 692.17 796.00 38700 786.96 747.61 859.7537606 394.26 374.55 430.73 38720 1,084.78 1,030.54 1,185.1237607 374.22 355.51 408.84 38724 1,140.49 1,083.47 1,245.9937609 360.20 342.19 393.52 38740 589.88 560.39 644.45

# 37609 203.93 193.73 222.79 38745 794.28 754.57 867.7637615 354.72 336.98 387.53 38746 252.65 240.02 276.0237616 1,034.66 982.93 1,130.37 38747 254.36 241.64 277.8937617 1,188.36 1,128.94 1,298.28 38760 749.58 712.10 818.9237618 316.11 300.30 345.35 38765 1,168.58 1,110.15 1,276.6737620 597.72 567.83 653.00 38770 751.47 713.90 820.9937650 464.67 441.44 507.66 38780 981.53 932.45 1,072.3237660 1,128.06 1,071.66 1,232.41 38790 1,147.03 1,089.68 1,253.1337700 258.68 245.75 282.61 # 38790 65.68 62.40 71.7637720 353.24 335.58 385.92 38792 26.56 25.23 29.0137730 450.12 427.61 491.75 38794 221.19 210.13 241.6537735 624.26 593.05 682.01 39000 510.62 485.09 557.8537760 615.10 584.35 672.00 39010 729.57 693.09 797.0537780 256.78 243.94 280.53 39200 806.59 766.26 881.2037785 396.38 376.56 433.04 39220 1,021.31 970.24 1,115.78

# 37785 252.96 240.31 276.36 39400 387.57 368.19 423.4237788 1,246.80 1,184.46 1,362.13 39501 796.39 756.57 870.0637790 537.46 510.59 587.18 39502 938.09 891.19 1,024.8738100 800.56 760.53 874.61 39503 4,772.91 4,534.26 5,214.4038101 846.01 803.71 924.27 39520 985.71 936.42 1,076.8838102 250.04 237.54 273.17 39530 915.75 869.96 1,000.4538115 868.72 825.28 949.07 39531 965.04 916.79 1,054.3138120 934.68 887.95 1,021.14 39540 802.50 762.38 876.7438200 132.12 125.51 144.34 39541 850.17 807.66 928.8138205 77.46 73.59 84.63 39545 863.09 819.94 942.9338206 77.46 73.59 84.63 39560 745.14 707.88 814.0638220 201.43 191.36 220.06 39561 1,044.30 992.09 1,140.90

# 38220 55.24 52.48 60.35 40490 106.53 101.20 116.3838221 217.54 206.66 237.66 # 40490 67.98 64.58 74.27

# 38221 69.95 66.45 76.42 40500 371.00 352.45 405.3238230 257.84 244.95 281.69 # 40500 364.05 345.85 397.7338240 113.40 107.73 123.89 40510 418.94 397.99 457.6938241 113.40 107.73 123.89 # 40510 410.26 389.75 448.2138242 88.22 83.81 96.38 40520 454.33 431.61 496.3538300 234.22 222.51 255.89 # 40520 423.08 401.93 462.22

# 38300 167.54 159.16 183.03 40525 588.64 559.21 643.0938305 533.55 506.87 582.90 40527 681.55 647.47 744.59

# 38305 449.16 426.70 490.71 40530 441.99 419.89 482.8738308 450.31 427.79 491.96 # 40530 429.49 408.02 469.2238380 557.24 529.38 608.79 40650 332.11 315.50 362.8338381 865.09 821.84 945.12 # 40650 310.24 294.73 338.9438382 723.15 686.99 790.04 40652 405.73 385.44 443.2638500 251.71 239.12 274.99 # 40652 404.69 384.46 442.13

# 38500 235.05 223.30 256.80 40654 477.62 453.74 521.8038505 153.29 145.63 167.47 # 40654 470.33 446.81 513.83

# 38505 82.45 78.33 90.08 40700 855.95 813.15 935.1238510 434.94 413.19 475.17 40701 1,064.95 1,011.70 1,163.4638520 453.45 430.78 495.40 40702 840.77 798.73 918.5438525 390.30 370.79 426.41 40720 952.86 905.22 1,041.0038530 515.00 489.25 562.64 40761 1,014.87 964.13 1,108.75

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 31FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

40800 108.89 103.45 118.97 # 41110 104.24 99.03 113.88# 40800 75.90 72.11 82.93 41112 223.63 212.45 244.32

40801 182.32 173.20 199.18 # 41112 200.37 190.35 218.90# 40801 152.11 144.50 166.18 41113 242.10 230.00 264.50

40804 128.45 122.03 140.33 # 41113 226.13 214.82 247.04# 40804 84.00 79.80 91.77 41114 519.27 493.31 567.31

40805 199.25 189.29 217.68 41115 158.45 150.53 173.11# 40805 164.52 156.29 179.73 # 41115 156.02 148.22 170.45

40806 45.31 43.04 49.50 41116 212.73 202.09 232.40# 40806 41.83 39.74 45.70 41120 688.09 653.69 751.74

40808 104.72 99.48 114.40 41130 769.20 730.74 840.35# 40808 72.77 69.13 79.50 41135 1,452.89 1,380.25 1,587.29

40810 122.66 116.53 134.01 41140 1,593.35 1,513.68 1,740.73# 40810 91.06 86.51 99.49 41145 1,906.44 1,811.12 2,082.79

40812 174.32 165.60 190.44 41150 1,492.05 1,417.45 1,630.07# 40812 149.67 142.19 163.52 41153 1,541.17 1,464.11 1,683.73

40814 249.43 236.96 272.50 41155 1,772.04 1,683.44 1,935.96# 40814 236.93 225.08 258.84 41250 174.71 165.97 190.87

40816 263.04 249.89 287.37 # 41250 134.08 127.38 146.49# 40816 252.97 240.32 276.37 41251 183.29 174.13 200.25

40818 235.24 223.48 257.00 # 41251 158.29 150.38 172.9440819 217.54 206.66 237.66 41252 237.58 225.70 259.56

# 40819 216.85 206.01 236.91 # 41252 197.30 187.44 215.5640820 135.11 128.35 147.60 41500 294.35 279.63 321.57

# 40820 129.21 122.75 141.16 41510 299.43 284.46 327.1340830 156.75 148.91 171.25 41520 211.13 200.57 230.66

# 40830 155.71 147.92 170.11 41800 114.10 108.40 124.6640831 193.34 183.67 211.22 # 41800 93.27 88.61 101.9040840 558.31 530.39 609.95 41805 115.95 110.15 126.6740842 548.52 521.09 599.25 41806 194.76 185.02 212.7740843 723.18 687.02 790.07 # 41806 190.59 181.06 208.2240844 951.09 903.54 1,039.07 41822 190.68 181.15 208.32

# 40844 950.05 902.55 1,037.93 # 41822 125.74 119.45 137.3740845 1,106.92 1,051.57 1,209.31 41823 254.46 241.74 278.0041000 133.06 126.41 145.37 # 41823 234.32 222.60 255.99

# 41000 102.50 97.38 111.99 41825 134.47 127.75 146.9141005 127.44 121.07 139.23 # 41825 133.08 126.43 145.39

# 41005 100.01 95.01 109.26 41826 181.62 172.54 198.4241006 256.78 243.94 280.53 41827 257.42 244.55 281.23

# 41006 244.62 232.39 267.25 41828 224.57 213.34 245.3441007 254.80 242.06 278.37 # 41828 203.39 193.22 222.20

# 41007 231.19 219.63 252.57 41830 244.44 232.22 267.0541008 255.94 243.14 279.61 # 41830 231.94 220.34 253.39

# 41008 244.83 232.59 267.48 41872 200.48 190.46 219.0341009 266.72 253.38 291.39 41874 220.41 209.39 240.80

# 41009 252.83 240.19 276.22 # 41874 203.74 193.55 222.5841010 153.84 146.15 168.07 42000 136.08 129.28 148.6741015 300.67 285.64 328.49 # 42000 101.35 96.28 110.72

# 41015 266.30 252.99 290.94 42100 138.29 131.38 151.0941016 301.89 286.80 329.82 # 42100 137.95 131.05 150.71

# 41016 275.15 261.39 300.60 42104 153.07 145.42 167.2341017 303.64 288.46 331.73 42106 173.63 164.95 189.69

# 41017 274.48 260.76 299.87 42107 315.36 299.59 344.5341018 355.68 337.90 388.59 42120 451.91 429.31 493.71

# 41018 329.29 312.83 359.75 42140 198.88 188.94 217.2841100 145.42 138.15 158.87 # 42140 180.13 171.12 196.79

# 41100 112.08 106.48 122.45 42145 572.73 544.09 625.7041105 130.83 124.29 142.93 42160 183.90 174.71 200.92

# 41105 100.97 95.92 110.31 # 42160 163.76 155.57 178.9141108 111.82 106.23 122.16 42180 201.38 191.31 220.01

# 41108 79.18 75.22 86.50 # 42180 170.82 162.28 186.6241110 143.48 136.31 156.76 42182 269.20 255.74 294.10

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 32FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 42182 254.96 242.21 278.54 42800 161.34 153.27 176.2642200 822.40 781.28 898.47 # 42800 145.02 137.77 158.4442205 832.40 790.78 909.40 42802 170.27 161.76 186.0242210 900.88 855.84 984.22 # 42802 153.60 145.92 167.8142215 656.12 623.31 716.81 42804 154.15 146.44 168.4142220 503.27 478.11 549.83 # 42804 137.48 130.61 150.2042225 690.87 656.33 754.78 42806 183.88 174.69 200.8942226 720.09 684.09 786.70 # 42806 157.49 149.62 172.0642227 651.57 618.99 711.84 42808 265.29 252.03 289.8342235 517.88 491.99 565.79 # 42808 198.96 189.01 217.3642260 628.83 597.39 687.00 42809 191.90 182.31 209.6642280 109.85 104.36 120.01 # 42809 130.78 124.24 142.88

# 42280 86.24 81.93 94.22 42810 318.60 302.67 348.0742281 137.93 131.03 150.68 # 42810 283.18 269.02 309.37

# 42281 108.76 103.32 118.82 42815 504.11 478.90 550.7442300 167.45 159.08 182.94 42820 299.55 284.57 327.26

# 42300 141.06 134.01 154.11 42821 313.37 297.70 342.3642305 420.50 399.48 459.40 42825 260.88 247.84 285.0242310 141.13 134.07 154.18 42826 261.16 248.10 285.32

# 42310 117.87 111.98 128.78 42830 183.78 174.59 200.7842320 187.58 178.20 204.93 42831 193.73 184.04 211.65

# 42320 165.36 157.09 180.65 42835 198.96 189.01 217.3642325 222.61 211.48 243.20 42836 251.11 238.55 274.33

# 42325 145.87 138.58 159.37 42842 611.40 580.83 667.9542326 265.33 252.06 289.87 42844 951.18 903.62 1,039.16

# 42326 210.47 199.95 229.94 42845 1,550.37 1,472.85 1,693.7842330 182.49 173.37 199.38 42860 193.27 183.61 211.15

# 42330 122.42 116.30 133.75 42870 421.46 400.39 460.4542335 255.49 242.72 279.13 42890 878.06 834.16 959.2842340 345.84 328.55 377.83 42892 1,043.97 991.77 1,140.5442400 116.93 111.08 127.74 42894 1,478.58 1,404.65 1,615.35

# 42400 44.00 41.80 48.07 42900 335.10 318.35 366.1042405 246.09 233.79 268.86 42950 575.94 547.14 629.21

# 42405 244.00 231.80 266.57 42953 663.53 630.35 724.9042408 334.63 317.90 365.59 42955 517.52 491.64 565.3942409 226.89 215.55 247.88 42960 163.94 155.74 179.1042410 639.85 607.86 699.04 42961 400.25 380.24 437.2842415 1,091.24 1,036.68 1,192.18 42962 492.06 467.46 537.5842420 1,250.23 1,187.72 1,365.88 42970 341.29 324.23 372.8642425 870.93 827.38 951.49 42971 443.29 421.13 484.3042426 1,342.93 1,275.78 1,467.15 42972 473.07 449.42 516.8342440 478.93 454.98 523.23 43020 542.99 515.84 593.2242450 345.87 328.58 377.87 43030 541.26 514.20 591.3342500 334.91 318.16 365.88 43045 1,191.69 1,132.11 1,301.9342505 429.70 408.22 469.45 43100 611.84 581.25 668.4442507 452.96 430.31 494.86 43101 953.28 905.62 1,041.4642508 635.23 603.47 693.99 43107 2,195.34 2,085.57 2,398.4142509 798.17 758.26 872.00 43108 1,926.08 1,829.78 2,104.2542510 562.48 534.36 614.51 43112 2,386.97 2,267.62 2,607.7642550 489.95 465.45 535.27 43113 2,006.57 1,906.24 2,192.18

# 42550 62.47 59.35 68.25 43116 1,880.43 1,786.41 2,054.3742600 405.92 385.62 443.46 43117 2,170.79 2,062.25 2,371.59

# 42600 384.04 364.84 419.57 43118 1,866.73 1,773.39 2,039.4042650 67.95 64.55 74.23 43121 1,645.92 1,563.62 1,798.16

# 42650 43.99 41.79 48.06 43122 2,169.29 2,060.83 2,369.9542660 84.51 80.28 92.32 43123 1,895.39 1,800.62 2,070.7142665 219.82 208.83 240.15 43124 1,615.57 1,534.79 1,765.0142700 176.65 167.82 192.99 43130 772.03 733.43 843.44

# 42700 128.39 121.97 140.27 43135 994.40 944.68 1,086.3842720 380.18 361.17 415.35 43200 338.42 321.50 369.73

# 42720 376.01 357.21 410.79 # 43200 102.64 97.51 112.1442725 713.63 677.95 779.64 43201 234.37 222.65 256.05

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 33FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 43201 124.29 118.08 135.79 43330 1,104.01 1,048.81 1,206.1343202 289.95 275.45 316.77 43331 1,186.05 1,126.75 1,295.76

# 43202 112.15 106.54 122.52 43340 1,135.01 1,078.26 1,240.0043204 201.35 191.28 219.97 43341 1,252.60 1,189.97 1,368.4743205 202.07 191.97 220.77 43350 967.15 918.79 1,056.6143215 143.19 136.03 156.43 43351 1,088.51 1,034.08 1,189.1943216 133.48 126.81 145.83 43352 937.21 890.35 1,023.9043217 157.57 149.69 172.14 43360 1,977.46 1,878.59 2,160.3843219 156.01 148.21 170.44 43361 2,234.11 2,122.40 2,440.7643220 118.75 112.81 129.73 43400 1,164.41 1,106.19 1,272.1243226 129.90 123.41 141.92 43401 1,223.16 1,162.00 1,336.3043227 192.74 183.10 210.57 43405 1,114.87 1,059.13 1,218.0043228 205.55 195.27 224.56 43410 840.14 798.13 917.8543231 177.50 168.63 193.92 43415 1,401.93 1,331.83 1,531.6043232 244.90 232.66 267.56 43420 861.57 818.49 941.2643234 226.25 214.94 247.18 43425 1,225.40 1,164.13 1,338.75

# 43234 113.74 108.05 124.26 43450 100.54 95.51 109.8443235 294.58 279.85 321.83 # 43450 74.15 70.44 81.01

# 43235 128.25 121.84 140.12 43453 80.96 76.91 88.4543236 274.26 260.55 299.63 43456 134.45 127.73 146.89

# 43236 154.81 147.07 169.13 43458 159.91 151.91 174.7043239 323.49 307.32 353.42 43460 197.59 187.71 215.87

# 43239 151.95 144.35 166.00 43500 607.58 577.20 663.7843240 355.75 337.96 388.65 43501 1,081.54 1,027.46 1,181.5843241 138.65 131.72 151.48 43502 1,244.33 1,182.11 1,359.4343242 374.16 355.45 408.77 43510 768.55 730.12 839.6443243 238.08 226.18 260.11 43520 594.41 564.69 649.3943244 261.42 248.35 285.60 43600 108.71 103.27 118.7643245 603.56 573.38 659.39 43605 655.31 622.54 715.92

# 43245 168.44 160.02 184.02 43610 803.07 762.92 877.3643246 226.59 215.26 247.55 43611 972.34 923.72 1,062.2843247 178.50 169.58 195.02 43620 1,613.06 1,532.41 1,762.2743248 166.64 158.31 182.06 43621 1,647.20 1,564.84 1,799.5743249 154.43 146.71 168.72 43622 1,737.68 1,650.80 1,898.4243250 169.17 160.71 184.82 43631 1,219.23 1,158.27 1,332.0143251 194.29 184.58 212.27 43632 1,219.93 1,158.93 1,332.7743255 249.93 237.43 273.04 43633 1,246.47 1,184.15 1,361.7743256 227.66 216.28 248.72 43634 1,351.20 1,283.64 1,476.1943258 237.35 225.48 259.30 43635 107.26 101.90 117.1943259 253.18 240.52 276.60 43638 1,541.56 1,464.48 1,684.1543260 310.85 295.31 339.61 43639 1,575.98 1,497.18 1,721.7643261 326.64 310.31 356.86 43640 932.87 886.23 1,019.1643262 383.34 364.17 418.80 43641 946.48 899.16 1,034.0343263 376.55 357.72 411.38 43651 564.54 536.31 616.7643264 459.09 436.14 501.56 43652 672.06 638.46 734.2343265 514.04 488.34 561.59 43653 455.29 432.53 497.4143267 383.34 364.17 418.80 43750 265.78 252.49 290.3643268 383.34 364.17 418.80 43760 91.75 87.16 100.2343269 420.75 399.71 459.67 # 43760 58.42 55.50 63.8343271 382.99 363.84 418.42 43761 104.35 99.13 114.0043272 383.34 364.17 418.80 43800 758.85 720.91 829.0543280 973.65 924.97 1,063.72 43810 805.22 764.96 879.7043300 613.87 583.18 670.66 43820 841.84 799.75 919.7143305 1,120.92 1,064.87 1,224.60 43825 1,039.56 987.58 1,135.7243310 1,543.80 1,466.61 1,686.60 43830 541.15 514.09 591.2043312 1,783.90 1,694.71 1,948.92 43831 462.08 438.98 504.8343313 2,588.98 2,459.53 2,828.46 43832 865.80 822.51 945.8943314 2,844.00 2,701.80 3,107.07 43840 851.53 808.95 930.2943320 1,143.20 1,086.04 1,248.95 43842 1,113.71 1,058.02 1,216.7243324 1,137.35 1,080.48 1,242.55 43843 1,107.06 1,051.71 1,209.4743325 1,129.20 1,072.74 1,233.65 43846 1,402.50 1,332.38 1,532.2443326 1,146.48 1,089.16 1,252.53 43847 1,569.74 1,491.25 1,714.94

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 34FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

43848 1,704.78 1,619.54 1,862.47 44360 146.29 138.98 159.8343850 1,319.90 1,253.91 1,442.00 44361 159.94 151.94 174.7343855 1,394.13 1,324.42 1,523.08 44363 190.84 181.30 208.5043860 1,337.74 1,270.85 1,461.48 44364 204.44 194.22 223.3543865 1,416.31 1,345.49 1,547.31 44365 183.24 174.08 200.1943870 552.53 524.90 603.64 44366 237.82 225.93 259.8243880 1,334.70 1,267.97 1,458.17 44369 242.17 230.06 264.5744005 888.82 844.38 971.04 44370 256.50 243.68 280.2344010 711.46 675.89 777.27 44372 239.23 227.27 261.3644015 135.62 128.84 148.17 44373 193.62 183.94 211.5344020 772.94 734.29 844.43 44376 281.25 267.19 307.2744021 790.79 751.25 863.94 44377 295.22 280.46 322.5344025 786.96 747.61 859.75 44378 375.99 357.19 410.7744050 773.33 734.66 844.86 44379 392.87 373.23 429.2144055 1,165.52 1,107.24 1,273.33 44380 68.06 64.66 74.3644100 114.09 108.39 124.65 44382 79.54 75.56 86.8944110 662.02 628.92 723.26 44383 160.74 152.70 175.6144111 807.12 766.76 881.77 44385 227.68 216.30 248.7544120 927.95 881.55 1,013.78 # 44385 103.71 98.52 113.3044121 232.10 220.50 253.58 44386 290.34 275.82 317.1944125 955.23 907.47 1,043.59 # 44386 120.18 114.17 131.3044126 1,920.66 1,824.63 2,098.32 44388 334.20 317.49 365.1144127 2,208.78 2,098.34 2,413.09 # 44388 156.75 148.91 171.2544128 237.65 225.77 259.64 44389 371.51 352.93 405.8744130 798.07 758.17 871.90 # 44389 172.53 163.90 188.4944139 115.53 109.75 126.21 44390 388.63 369.20 424.5844140 1,146.23 1,088.92 1,252.26 # 44390 207.02 196.67 226.1744141 1,131.92 1,075.32 1,236.62 44391 373.80 355.11 408.3844143 1,284.83 1,220.59 1,403.68 # 44391 225.18 213.92 246.0144144 1,185.86 1,126.57 1,295.56 44392 405.29 385.03 442.7844145 1,421.74 1,350.65 1,553.25 # 44392 207.35 196.98 226.5344146 1,533.97 1,457.27 1,675.86 44393 454.88 432.14 496.9644147 1,121.26 1,065.20 1,224.98 # 44393 259.03 246.08 282.9944150 1,366.26 1,297.95 1,492.64 44394 446.57 424.24 487.8844151 1,516.81 1,440.97 1,657.12 # 44394 238.91 226.96 261.0044152 1,509.16 1,433.70 1,648.76 44397 252.57 239.94 275.9344153 1,705.65 1,620.37 1,863.43 44500 31.01 29.46 33.8844155 1,562.99 1,484.84 1,707.57 44602 850.50 807.98 929.1844156 1,723.62 1,637.44 1,883.06 44603 988.25 938.84 1,079.6744160 1,017.58 966.70 1,111.71 44604 864.90 821.66 944.9144200 797.76 757.87 871.55 44605 1,064.74 1,011.50 1,163.2344201 550.37 522.85 601.28 44615 867.16 823.80 947.3744202 1,194.46 1,134.74 1,304.95 44620 670.66 637.13 732.7044203 232.10 220.50 253.58 44625 818.11 777.20 893.7844204 1,355.83 1,288.04 1,481.25 44626 1,361.14 1,293.08 1,487.0444205 1,201.40 1,141.33 1,312.53 44640 1,144.53 1,087.30 1,250.4044206 1,442.03 1,369.93 1,575.42 44650 1,189.79 1,130.30 1,299.8544207 1,578.93 1,499.98 1,724.98 44660 1,113.70 1,058.02 1,216.7244208 1,706.48 1,621.16 1,864.33 44661 1,295.87 1,231.08 1,415.7444210 1,510.33 1,434.81 1,650.03 44680 838.51 796.58 916.0744211 1,875.65 1,781.87 2,049.15 44700 867.01 823.66 947.2144212 1,752.46 1,664.84 1,914.57 44701 157.22 149.36 171.7644300 666.61 633.28 728.27 44800 638.21 606.30 697.2544310 858.38 815.46 937.78 44820 671.17 637.61 733.2544312 452.52 429.89 494.37 44850 603.33 573.16 659.1344314 814.84 774.10 890.22 44900 567.21 538.85 619.6844316 1,118.60 1,062.67 1,222.07 44901 285.44 271.17 311.8544320 958.07 910.17 1,046.70 44950 550.69 523.16 601.6344322 780.79 741.75 853.01 44955 80.34 76.32 87.7744340 451.35 428.78 493.10 44960 678.54 644.61 741.3044345 843.99 801.79 922.06 44970 493.72 469.03 539.3844346 921.56 875.48 1,006.80 45000 284.26 270.05 310.56

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 35FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

45005 235.27 223.51 257.04 45342 218.51 207.58 238.72# 45005 133.18 126.52 145.50 45345 160.02 152.02 174.82

45020 303.35 288.18 331.41 45355 180.14 171.13 196.8045100 231.83 220.24 253.28 45378 420.36 399.34 459.2445108 294.06 279.36 321.26 # 45378 201.24 191.18 219.8645110 1,531.61 1,455.03 1,673.28 45378 53 99.85 94.86 109.0945111 910.51 864.98 994.73 # 45378 53 54.71 51.97 59.7745112 1,611.82 1,531.23 1,760.91 45379 468.87 445.43 512.2445113 1,637.13 1,555.27 1,788.56 # 45379 251.48 238.91 274.7545114 1,461.77 1,388.68 1,596.98 45380 462.54 439.41 505.3245116 1,318.64 1,252.71 1,440.62 # 45380 238.21 226.30 260.2545119 1,642.06 1,559.96 1,793.95 45381 373.60 354.92 408.1645120 1,332.35 1,265.73 1,455.59 # 45381 219.07 208.12 239.3445121 1,470.18 1,396.67 1,606.17 45382 554.18 526.47 605.4445123 887.70 843.32 969.82 # 45382 293.74 279.05 320.9145126 2,429.04 2,307.59 2,653.73 45383 548.94 521.49 599.7145130 877.57 833.69 958.74 # 45383 311.42 295.85 340.2345135 1,050.78 998.24 1,147.98 45384 494.23 469.52 539.9545136 1,515.42 1,439.65 1,655.60 # 45384 251.84 239.25 275.1445150 329.22 312.76 359.67 45385 523.71 497.52 572.1545160 829.90 788.41 906.67 # 45385 283.06 268.91 309.2545170 636.10 604.30 694.95 45386 704.80 669.56 769.9945190 558.54 530.61 610.20 # 45386 237.74 225.85 259.7345300 61.76 58.67 67.47 45387 313.92 298.22 342.95

# 45300 23.56 22.38 25.74 45500 428.43 407.01 468.0645303 72.97 69.32 79.72 45505 421.58 400.50 460.58

# 45303 27.13 25.77 29.64 45520 48.14 45.73 52.5945305 94.74 90.00 103.50 # 45520 28.00 26.60 30.59

# 45305 55.50 52.73 60.64 45540 906.84 861.50 990.7345307 126.95 120.60 138.69 45541 753.43 715.76 823.12

# 45307 54.03 51.33 59.03 45550 1,244.00 1,181.80 1,359.0745308 87.53 83.15 95.62 45560 614.75 584.01 671.61

# 45308 48.29 45.88 52.76 45562 852.95 810.30 931.8545309 162.03 153.93 177.02 45563 1,296.28 1,231.47 1,416.19

# 45309 106.47 101.15 116.32 45800 960.65 912.62 1,049.5145315 146.47 139.15 160.02 45805 1,151.11 1,093.55 1,257.58

# 45315 78.41 74.49 85.66 45820 995.84 946.05 1,087.9645317 125.45 119.18 137.06 45825 1,158.23 1,100.32 1,265.37

# 45317 83.09 78.94 90.78 45900 136.26 129.45 148.8745320 126.97 120.62 138.71 45905 486.48 462.16 531.48

# 45320 87.38 83.01 95.46 # 45905 121.16 115.10 132.3745321 66.22 62.91 72.35 45910 657.79 624.90 718.6445327 93.35 88.68 101.98 # 45910 145.58 138.30 159.0545330 99.85 94.86 109.09 45915 281.58 267.50 307.63

# 45330 54.71 51.97 59.77 # 45915 158.30 150.39 172.9545331 122.05 115.95 133.34 46020 221.49 210.42 241.98

# 45331 62.66 59.53 68.46 # 46020 195.79 186.00 213.9045332 206.44 196.12 225.54 46030 152.75 145.11 166.88

# 45332 94.97 90.22 103.75 # 46030 89.90 85.41 98.2245333 193.25 183.59 211.13 46040 382.60 363.47 417.99

# 45333 95.32 90.55 104.13 # 46040 303.08 287.93 331.1245334 142.36 135.24 155.53 46045 267.28 253.92 292.0145335 138.01 131.11 150.78 46050 169.36 160.89 185.02

# 45335 74.46 70.74 81.35 # 46050 92.96 88.31 101.5645337 124.04 117.84 135.52 46060 353.94 336.24 386.6845338 239.30 227.34 261.44 46070 191.34 181.77 209.04

# 45338 123.32 117.15 134.72 46080 223.95 212.75 244.6645339 233.31 221.64 254.89 # 46080 154.15 146.44 168.41

# 45339 162.82 154.68 177.88 46083 216.93 206.08 236.9945340 312.47 296.85 341.38 # 46083 108.24 102.83 118.25

# 45340 89.19 84.73 97.44 46200 268.20 254.79 293.0145341 149.11 141.65 162.90 # 46200 216.46 205.64 236.49

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 36FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

46210 282.60 268.47 308.74 46751 567.75 539.36 620.26# 46210 181.55 172.47 198.34 46753 460.96 437.91 503.60

46211 348.06 330.66 380.26 46754 273.09 259.44 298.36# 46211 267.50 254.13 292.25 # 46754 131.41 124.84 143.57

46220 105.38 100.11 115.13 46760 800.23 760.22 874.25# 46220 80.72 76.68 88.18 46761 760.72 722.68 831.08

46221 137.75 130.86 150.49 46762 685.56 651.28 748.97# 46221 115.52 109.74 126.20 46900 193.45 183.78 211.35

46230 249.08 236.63 272.12 # 46900 100.04 95.04 109.30# 46230 158.45 150.53 173.11 46910 202.40 192.28 221.12

46250 341.26 324.20 372.83 # 46910 123.23 117.07 134.63# 46250 248.54 236.11 271.53 46916 187.45 178.08 204.79

46255 393.49 373.82 429.89 # 46916 128.76 122.32 140.67# 46255 284.80 270.56 311.14 46917 237.14 225.28 259.07

46257 322.94 306.79 352.81 # 46917 126.02 119.72 137.6846258 341.56 324.48 373.15 46922 207.63 197.25 226.8446260 391.58 372.00 427.80 # 46922 123.24 117.08 134.6446261 422.25 401.14 461.31 46924 284.10 269.90 310.3946262 447.27 424.91 488.65 # 46924 166.04 157.74 181.4046270 321.85 305.76 351.62 46934 353.06 335.41 385.72

# 46270 236.77 224.93 258.67 # 46934 261.04 247.99 285.1946275 341.63 324.55 373.23 46935 241.19 229.13 263.50

# 46275 275.65 261.87 301.15 # 46935 124.17 117.96 135.6546280 363.08 344.93 396.67 46936 349.90 332.41 382.2746285 301.95 286.85 329.88 # 46936 263.78 250.59 288.18

# 46285 250.90 238.36 274.11 46937 255.13 242.37 278.7346288 425.76 404.47 465.14 # 46937 163.45 155.28 178.5746320 197.48 187.61 215.75 46938 358.12 340.21 391.24

# 46320 116.92 111.07 127.73 # 46938 296.30 281.49 323.7146500 156.84 149.00 171.35 46940 199.34 189.37 217.78

# 46500 82.53 78.40 90.16 # 46940 118.43 112.51 129.3946600 47.36 44.99 51.74 46942 178.39 169.47 194.89

# 46600 24.79 23.55 27.08 # 46942 103.03 97.88 112.5646604 84.12 79.91 91.90 46945 209.33 198.86 228.69

# 46604 66.75 63.41 72.92 # 46945 147.52 140.14 161.1646606 62.11 59.00 67.85 46946 274.79 261.05 300.21

# 46606 41.63 39.55 45.48 # 46946 186.59 177.26 203.8546608 123.00 116.85 134.38 47000 358.36 340.44 391.51

# 46608 75.78 71.99 82.79 # 47000 94.79 90.05 103.5646610 101.51 96.43 110.89 47001 98.66 93.73 107.79

# 46610 68.52 65.09 74.85 47010 940.20 893.19 1,027.1746611 140.51 133.48 153.50 47011 292.56 277.93 319.62

# 46611 93.29 88.63 101.92 47015 851.68 809.10 930.4746612 176.46 167.64 192.79 47100 669.31 635.84 731.22

# 46612 120.55 114.52 131.70 47120 1,945.54 1,848.26 2,125.5046614 140.14 133.13 153.10 47122 2,944.01 2,796.81 3,216.33

# 46614 101.94 96.84 111.37 47125 2,643.54 2,511.36 2,888.0646615 165.57 157.29 180.88 47130 2,855.64 2,712.86 3,119.79

# 46615 138.14 131.23 150.91 47134 2,033.86 1,932.17 2,222.0046700 512.66 487.03 560.08 47135 4,725.52 4,489.24 5,162.6346705 417.46 396.59 456.08 47136 4,189.74 3,980.25 4,577.2946706 135.91 129.11 148.48 47300 843.70 801.52 921.7546715 435.32 413.55 475.58 47350 1,074.72 1,020.98 1,174.1346716 849.75 807.26 928.35 47360 1,473.00 1,399.35 1,609.2546730 1,468.36 1,394.94 1,604.18 47361 2,501.60 2,376.52 2,733.0046735 1,751.07 1,663.52 1,913.05 47362 1,046.96 994.61 1,143.8046740 1,595.84 1,516.05 1,743.46 47370 1,083.07 1,028.92 1,183.2646742 2,018.77 1,917.83 2,205.50 47371 1,083.07 1,028.92 1,183.2646744 2,736.88 2,600.04 2,990.05 47380 1,248.17 1,185.76 1,363.6246746 3,103.71 2,948.52 3,390.80 47381 1,261.80 1,198.71 1,378.5246748 3,325.36 3,159.09 3,632.95 47382 809.24 768.78 884.1046750 592.32 562.70 647.11 47400 1,746.33 1,659.01 1,907.86

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 37FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

47420 1,100.11 1,045.10 1,201.87 48153 2,644.80 2,512.56 2,889.4447425 1,097.20 1,042.34 1,198.69 48154 2,446.14 2,323.83 2,672.4047460 1,010.44 959.92 1,103.91 48155 1,444.59 1,372.36 1,578.2147480 651.66 619.08 711.94 48180 1,354.06 1,286.36 1,479.3147490 534.48 507.76 583.92 48400 97.66 92.78 106.7047500 97.32 92.45 106.32 48500 854.28 811.57 933.3147505 120.70 114.67 131.87 48510 817.85 776.96 893.50

# 47505 37.71 35.82 41.19 48511 280.54 266.51 306.4947510 460.11 437.10 502.67 48520 866.61 823.28 946.7747511 758.26 720.35 828.40 48540 1,080.11 1,026.10 1,180.0247525 323.02 306.87 352.90 48545 1,018.83 967.89 1,113.0747530 394.02 374.32 430.47 48547 1,394.43 1,324.71 1,523.4247550 156.44 148.62 170.91 48554 1,772.68 1,684.05 1,936.6647552 319.03 303.08 348.54 48556 918.26 872.35 1,003.2047553 333.02 316.37 363.83 49000 676.13 642.32 738.6747554 474.79 451.05 518.71 49002 625.53 594.25 683.3947555 393.00 373.35 429.35 49010 729.90 693.41 797.4247556 442.20 420.09 483.10 49020 1,272.44 1,208.82 1,390.1447560 258.87 245.93 282.82 49021 311.83 296.24 340.6847561 279.48 265.51 305.34 49040 805.35 765.08 879.8447562 616.81 585.97 673.87 49041 346.52 329.19 378.5747563 659.55 626.57 720.56 49060 936.20 889.39 1,022.8047564 779.00 740.05 851.06 49061 335.62 318.84 366.6747570 693.26 658.60 757.39 49062 696.40 661.58 760.8247600 766.01 727.71 836.87 49080 203.97 193.77 222.8447605 822.02 780.92 898.06 # 49080 67.85 64.46 74.1347610 1,038.97 987.02 1,135.07 49081 154.51 146.78 168.8047612 1,032.30 980.69 1,127.79 # 49081 68.05 64.65 74.3547620 1,129.15 1,072.69 1,233.59 49085 700.00 665.00 764.7547630 454.24 431.53 496.26 49180 351.14 333.58 383.6247700 912.50 866.88 996.91 # 49180 86.18 81.87 94.1547701 1,569.86 1,491.37 1,715.08 49200 622.64 591.51 680.2447711 1,289.39 1,224.92 1,408.66 49201 888.35 843.93 970.5247712 1,666.35 1,583.03 1,820.48 49215 1,816.69 1,725.86 1,984.7447715 1,043.09 990.94 1,139.58 49220 858.92 815.97 938.3747716 931.89 885.30 1,018.10 49250 509.45 483.98 556.5847720 920.94 874.89 1,006.12 49255 669.67 636.19 731.6247721 1,085.65 1,031.37 1,186.08 49320 307.48 292.11 335.9347740 1,054.04 1,001.34 1,151.54 49321 318.75 302.81 348.2347741 1,198.37 1,138.45 1,309.22 49322 345.99 328.69 377.9947760 1,431.57 1,359.99 1,563.99 49323 515.47 489.70 563.1647765 1,410.54 1,340.01 1,541.01 49400 99.98 94.98 109.2347780 1,465.64 1,392.36 1,601.21 49419 393.36 373.69 429.7447785 1,731.08 1,644.53 1,891.21 49420 118.94 112.99 129.9447800 1,302.66 1,237.53 1,423.16 49421 361.69 343.61 395.1547801 923.93 877.73 1,009.39 49422 351.08 333.53 383.5647802 1,234.49 1,172.77 1,348.69 49423 79.14 75.18 86.4647900 1,125.47 1,069.20 1,229.58 49424 43.96 41.76 48.0248000 1,497.25 1,422.39 1,635.75 49425 688.14 653.73 751.7948001 1,865.75 1,772.46 2,038.33 49426 593.52 563.84 648.4248005 2,202.18 2,092.07 2,405.88 49427 50.77 48.23 55.4648020 874.76 831.02 955.67 49428 340.89 323.85 372.4348100 719.69 683.71 786.27 49429 416.92 396.07 455.4848102 484.11 459.90 528.89 49491 634.57 602.84 693.27

# 48102 259.78 246.79 283.81 49492 779.74 740.75 851.8648120 879.16 835.20 960.48 49495 355.33 337.56 388.1948140 1,273.33 1,209.66 1,391.11 49496 564.03 535.83 616.2048145 1,340.43 1,273.41 1,464.42 49500 331.34 314.77 361.9948146 1,506.53 1,431.20 1,645.88 49501 503.33 478.16 549.8848148 998.72 948.78 1,091.10 49505 454.67 431.94 496.7348150 2,642.91 2,510.76 2,887.37 # 49505 438.35 416.43 478.8948152 2,436.53 2,314.70 2,661.91 49507 585.73 556.44 639.91

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 38FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

49520 565.00 536.75 617.26 50390 97.32 92.45 106.3249521 668.89 635.45 730.77 50392 167.36 158.99 182.8449525 505.25 479.99 551.99 50393 205.80 195.51 224.8449540 600.64 570.61 656.20 50394 113.76 108.07 124.2849550 493.54 468.86 539.19 # 50394 38.06 36.16 41.5849553 540.38 513.36 590.36 50395 167.72 159.33 183.2349555 535.53 508.75 585.06 50396 109.69 104.21 119.8449557 627.60 596.22 685.65 50398 96.85 92.01 105.8149560 662.32 629.20 723.58 # 50398 72.54 68.91 79.2549561 787.96 748.56 860.84 50400 1,070.44 1,016.92 1,169.4649565 667.88 634.49 729.66 50405 1,318.02 1,252.12 1,439.9449566 796.20 756.39 869.85 50500 1,130.05 1,073.55 1,234.5849568 254.71 241.97 278.27 50520 1,019.21 968.25 1,113.4949570 343.51 326.33 375.28 50525 1,278.90 1,214.96 1,397.2049572 400.79 380.75 437.86 50526 1,396.38 1,326.56 1,525.5449580 262.74 249.60 287.04 50540 1,115.61 1,059.83 1,218.8049582 430.52 408.99 470.34 50541 837.56 795.68 915.0349585 385.37 366.10 421.02 50542 1,064.37 1,011.15 1,162.8249587 441.76 419.67 482.62 50543 1,338.58 1,271.65 1,462.4049590 504.85 479.61 551.55 50544 1,161.00 1,102.95 1,268.3949600 648.90 616.46 708.93 50545 1,243.51 1,181.33 1,358.5349605 3,890.58 3,696.05 4,250.46 50546 1,068.63 1,015.20 1,167.4849606 1,068.77 1,015.33 1,167.63 50547 1,373.28 1,304.62 1,500.3149610 643.81 611.62 703.36 50548 1,258.03 1,195.13 1,374.4049611 681.83 647.74 744.90 50551 356.13 338.32 389.0749650 362.57 344.44 396.11 # 50551 279.04 265.09 304.8549651 477.67 453.79 521.86 50553 716.88 681.04 783.2049900 720.53 684.50 787.18 # 50553 299.47 284.50 327.1849904 1,349.04 1,281.59 1,473.83 50555 806.66 766.33 881.2849905 340.79 323.75 372.31 # 50555 326.06 309.76 356.2250010 651.89 619.30 712.20 50557 768.27 729.86 839.3450020 1,038.10 986.20 1,134.13 # 50557 330.03 313.53 360.5650021 474.69 450.96 518.60 50559 336.13 319.32 367.2250040 947.93 900.53 1,035.61 50561 780.63 741.60 852.8450045 872.83 829.19 953.57 # 50561 378.50 359.58 413.5250060 1,058.62 1,005.69 1,156.54 50562 566.05 537.75 618.4150065 1,073.53 1,019.85 1,172.83 50570 475.13 451.37 519.0850070 1,111.69 1,056.11 1,214.53 50572 517.11 491.25 564.9450075 1,377.28 1,308.42 1,504.68 50574 549.80 522.31 600.6650080 917.71 871.82 1,002.59 50575 697.40 662.53 761.9150081 1,262.76 1,199.62 1,379.56 50576 547.67 520.29 598.3350100 977.96 929.06 1,068.42 50578 565.62 537.34 617.9450120 895.43 850.66 978.26 50580 591.11 561.55 645.7850125 928.38 881.96 1,014.25 50590 721.98 685.88 788.7650130 957.05 909.20 1,045.58 # 50590 520.92 494.87 569.1050135 1,052.89 1,000.25 1,150.29 50600 892.17 847.56 974.6950200 132.10 125.50 144.33 50605 888.49 844.07 970.6850205 659.44 626.47 720.44 50610 909.70 864.22 993.8550220 961.74 913.65 1,050.70 50620 848.32 805.90 926.7950225 1,108.10 1,052.70 1,210.61 50630 838.58 796.65 916.1550230 1,198.29 1,138.38 1,309.14 50650 977.05 928.20 1,067.4350234 1,214.46 1,153.74 1,326.80 50660 1,084.75 1,030.51 1,185.0950236 1,415.05 1,344.30 1,545.95 50684 466.92 443.57 510.1150240 1,275.62 1,211.84 1,393.62 # 50684 37.71 35.82 41.1950280 880.43 836.41 961.87 50686 143.13 135.97 156.3750290 845.29 803.03 923.48 # 50686 81.31 77.24 88.8350320 1,225.46 1,164.19 1,338.82 50688 103.32 98.15 112.8750340 797.03 757.18 870.76 50690 487.72 463.33 532.8350360 1,855.75 1,762.96 2,027.40 # 50690 57.81 54.92 63.1650365 2,193.06 2,083.41 2,395.92 50700 886.92 842.57 968.9650370 871.85 828.26 952.50 50715 1,152.68 1,095.05 1,259.3150380 1,286.32 1,222.00 1,405.30 50722 975.84 927.05 1,066.11

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 39FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

50725 1,065.09 1,011.84 1,163.62 51535 753.49 715.82 823.1950727 516.31 490.49 564.06 51550 882.88 838.74 964.5550728 730.01 693.51 797.54 51555 1,173.67 1,114.99 1,282.2450740 1,037.57 985.69 1,133.54 51565 1,205.22 1,144.96 1,316.7050750 1,087.14 1,032.78 1,187.70 51570 1,343.59 1,276.41 1,467.8750760 1,038.84 986.90 1,134.94 51575 1,670.48 1,586.96 1,825.0050770 1,084.71 1,030.47 1,185.04 51580 1,717.71 1,631.82 1,876.5950780 1,029.69 978.21 1,124.94 51585 1,915.19 1,819.43 2,092.3450782 1,134.01 1,077.31 1,238.91 51590 1,775.17 1,686.41 1,939.3750783 1,147.90 1,090.51 1,254.09 51595 1,995.40 1,895.63 2,179.9750785 1,137.41 1,080.54 1,242.62 51596 2,131.63 2,025.05 2,328.8150800 872.29 828.68 952.98 51597 2,081.52 1,977.44 2,274.0650810 1,217.79 1,156.90 1,330.44 51600 198.68 188.75 217.0650815 1,151.74 1,094.15 1,258.27 # 51600 43.81 41.62 47.8650820 1,237.60 1,175.72 1,352.08 51605 497.98 473.08 544.0450825 1,578.22 1,499.31 1,724.21 # 51605 32.31 30.69 35.2950830 1,728.23 1,641.82 1,888.09 51610 505.59 480.31 552.3650840 1,150.44 1,092.92 1,256.86 # 51610 52.08 49.48 56.9050845 1,137.65 1,080.77 1,242.89 51700 74.02 70.32 80.8750860 879.59 835.61 960.95 # 51700 43.81 41.62 47.8650900 786.48 747.16 859.23 51701 56.04 53.24 61.2350920 826.45 785.13 902.90 # 51701 26.17 24.86 28.5950930 1,064.83 1,011.59 1,163.33 51702 87.64 83.26 95.7550940 829.62 788.14 906.36 # 51702 28.60 27.17 31.2550945 901.07 856.02 984.42 51703 122.92 116.77 134.2950947 1,304.27 1,239.06 1,424.92 # 51703 77.08 73.23 84.2150948 1,189.49 1,130.02 1,299.52 51705 87.80 83.41 95.9250951 380.84 361.80 416.07 # 51705 57.94 55.04 63.30

# 50951 291.24 276.68 318.18 51710 192.75 183.11 210.5850953 724.24 688.03 791.23 # 51710 102.46 97.34 111.94

# 50953 311.35 295.78 340.15 51715 270.78 257.24 295.8350955 883.07 838.92 964.76 # 51715 187.44 178.07 204.78

# 50955 337.18 320.32 368.37 51720 124.42 118.20 135.9350957 739.72 702.73 808.14 # 51720 100.81 95.77 110.14

# 50957 338.64 321.71 369.97 51725 312.61 296.98 341.5350959 216.60 205.77 236.64 51725 TC 236.50 224.68 258.3850961 843.72 801.53 921.76 51725 26 76.11 72.30 83.15

# 50961 301.31 286.24 329.18 51726 309.47 294.00 338.1050970 356.59 338.76 389.57 51726 TC 223.30 212.14 243.9650972 344.70 327.47 376.59 51726 26 86.16 81.85 94.1350974 456.46 433.64 498.69 51736 43.03 40.88 47.0150976 451.04 428.49 492.76 51736 TC 12.16 11.55 13.2850978 256.34 243.52 280.05 51736 26 30.87 29.33 33.7350980 341.87 324.78 373.50 51741 72.03 68.43 78.6951000 95.05 90.30 103.85 51741 TC 14.94 14.19 16.32

# 51000 38.79 36.85 42.38 51741 26 57.09 54.24 62.3851005 145.80 138.51 159.29 51772 283.61 269.43 309.84

# 51005 52.04 49.44 56.86 51772 TC 201.08 191.03 219.6851010 334.68 317.95 365.64 51772 26 82.53 78.40 90.16

# 51010 208.62 198.19 227.92 51784 242.49 230.37 264.9351020 435.06 413.31 475.31 51784 TC 165.31 157.04 180.6051030 446.96 424.61 488.30 51784 26 77.18 73.32 84.3251040 301.38 286.31 329.26 51785 242.83 230.69 265.2951045 452.20 429.59 494.03 51785 TC 166.00 157.70 181.3651050 423.59 402.41 462.77 51785 26 76.83 72.99 83.9451060 536.86 510.02 586.52 51792 235.93 224.13 257.7551065 531.29 504.73 580.44 51792 TC 177.85 168.96 194.3051080 407.42 387.05 445.11 51792 26 58.08 55.18 63.4651500 602.65 572.52 658.40 51795 294.60 279.87 321.8551520 561.89 533.80 613.87 51795 TC 217.42 206.55 237.5351525 790.45 750.93 863.57 51795 26 77.18 73.32 84.3251530 724.67 688.44 791.71 51797 212.75 202.11 232.43

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 40FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

51797 TC 132.32 125.70 144.56 52315 399.94 379.94 436.9351797 26 80.42 76.40 87.86 # 52315 265.55 252.27 290.1151798 19.13 18.17 20.90 52317 529.87 503.38 578.8951800 979.54 930.56 1,070.14 # 52317 339.57 322.59 370.9851820 1,067.95 1,014.55 1,166.73 52318 463.09 439.94 505.9351840 638.99 607.04 698.10 52320 239.01 227.06 261.1251841 787.29 747.93 860.12 52325 312.26 296.65 341.1551845 588.32 558.90 642.74 52327 264.83 251.59 289.3351860 723.07 686.92 789.96 52330 797.96 758.06 871.7751865 866.23 822.92 946.36 # 52330 256.24 243.43 279.9451880 481.45 457.38 525.99 52332 678.34 644.42 741.0851900 766.62 728.29 837.53 # 52332 146.00 138.70 159.5151920 696.33 661.51 760.74 52334 247.91 235.51 270.8451925 941.64 894.56 1,028.74 52341 309.57 294.09 338.2051940 1,638.43 1,556.51 1,789.99 52342 334.01 317.31 364.9151960 1,309.22 1,243.76 1,430.32 52343 370.58 352.05 404.8651980 666.72 633.38 728.39 52344 396.06 376.26 432.7051990 716.97 681.12 783.29 52345 420.84 399.80 459.7751992 765.55 727.27 836.36 52346 472.90 449.26 516.6552000 235.97 224.17 257.80 52347 276.09 262.29 301.63

# 52000 104.36 99.14 114.01 52351 301.70 286.62 329.6152001 483.33 459.16 528.03 52352 354.08 336.38 386.84

# 52001 290.25 275.74 317.10 52353 408.66 388.23 446.4652005 312.97 297.32 341.92 52354 377.76 358.87 412.70

# 52005 123.36 117.19 134.77 52355 451.73 429.14 493.5152007 156.73 148.89 171.22 52400 522.60 496.47 570.9452010 385.91 366.61 421.60 52450 420.61 399.58 459.52

# 52010 156.03 148.23 170.46 52500 461.21 438.15 503.8752204 280.32 266.30 306.25 52510 370.83 352.29 405.13

# 52204 123.71 117.52 135.15 52601 657.24 624.38 718.0452214 394.00 374.30 430.45 52606 436.35 414.53 476.71

# 52214 189.81 180.32 207.37 52612 439.92 417.92 480.6152224 332.98 316.33 363.78 52614 381.79 362.70 417.11

# 52224 161.43 153.36 176.36 52620 360.92 342.87 394.3052234 235.77 223.98 257.58 52630 390.12 370.61 426.2052235 277.06 263.21 302.69 52640 361.98 343.88 395.4652240 490.71 466.17 536.10 52647 1,886.69 1,792.36 2,061.2152250 232.09 220.49 253.56 # 52647 556.70 528.87 608.2052260 201.27 191.21 219.89 52648 596.64 566.81 651.8352265 310.08 294.58 338.77 52700 374.08 355.38 408.69

# 52265 152.78 145.14 166.91 53000 341.29 324.23 372.8652270 352.11 334.50 384.68 # 53000 164.88 156.64 180.14

# 52270 176.05 167.25 192.34 53010 281.01 266.96 307.0052275 427.57 406.19 467.12 53020 174.11 165.40 190.21

# 52275 242.49 230.37 264.93 # 53020 91.12 86.56 99.5452276 470.43 446.91 513.95 53025 171.67 163.09 187.55

# 52276 258.26 245.35 282.15 # 53025 59.16 56.20 64.6352277 317.84 301.95 347.24 53040 658.88 625.94 719.8352281 387.29 367.93 423.12 # 53040 496.02 471.22 541.90

# 52281 145.95 138.65 159.45 53060 308.91 293.46 337.4852282 700.19 665.18 764.96 # 53060 196.40 186.58 214.57

# 52282 325.50 309.23 355.61 53080 494.11 469.40 539.8152283 347.16 329.80 379.27 53085 696.52 661.69 760.94

# 52283 192.64 183.01 210.46 53200 265.41 252.14 289.9652285 358.07 340.17 391.20 # 53200 133.11 126.45 145.42

# 52285 186.52 177.19 203.77 53210 745.46 708.19 814.4252290 235.01 223.26 256.75 53215 879.56 835.58 960.9252300 271.97 258.37 297.13 53220 446.30 423.99 487.5952301 284.83 270.59 311.18 53230 570.71 542.17 623.5052305 269.88 256.39 294.85 53235 598.01 568.11 653.3352310 272.36 258.74 297.55 53240 417.62 396.74 456.25

# 52310 144.57 137.34 157.94 53250 373.63 354.95 408.19

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 41FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

53260 300.45 285.43 328.24 54057 155.19 147.43 169.54# 53260 194.19 184.48 212.15 # 54057 90.94 86.39 99.35

53265 320.80 304.76 350.47 54060 244.18 231.97 266.77# 53265 199.61 189.63 218.07 # 54060 128.54 122.11 140.43

53270 313.47 297.80 342.47 54065 274.49 260.77 299.89# 53270 207.20 196.84 226.37 # 54065 162.68 154.55 177.73

53275 280.06 266.06 305.97 54100 187.86 178.47 205.2453400 751.70 714.12 821.24 # 54100 98.97 94.02 108.1253405 825.69 784.41 902.07 54105 327.32 310.95 357.5953410 925.09 878.84 1,010.67 # 54105 206.48 196.16 225.5853415 1,058.46 1,005.54 1,156.37 54110 627.51 596.13 685.5553420 839.62 797.64 917.29 54111 812.00 771.40 887.1153425 909.75 864.26 993.90 54112 917.18 871.32 1,002.0253430 928.75 882.31 1,014.66 54115 568.18 539.77 620.7453431 1,082.57 1,028.44 1,182.71 # 54115 447.68 425.30 489.1053440 740.52 703.49 809.01 54120 634.54 602.81 693.2353442 645.79 613.50 705.53 54125 812.99 772.34 888.1953444 731.21 694.65 798.85 54130 1,153.76 1,096.07 1,260.4853445 810.04 769.54 884.97 54135 1,465.09 1,391.84 1,600.6253446 597.49 567.62 652.76 54150 261.02 247.97 285.1753447 745.55 708.27 814.51 # 54150 137.05 130.20 149.7353448 1,159.66 1,101.68 1,266.93 54152 146.88 139.54 160.4753449 577.49 548.62 630.91 54160 268.35 254.93 293.1753450 393.49 373.82 429.89 # 54160 156.54 148.71 171.0253460 444.06 421.86 485.14 54161 192.56 182.93 210.3753502 479.65 455.67 524.02 54162 195.94 186.14 214.0653505 468.52 445.09 511.85 54163 187.96 178.56 205.3453510 611.85 581.26 668.45 54164 162.47 154.35 177.5053515 757.78 719.89 827.87 54200 123.98 117.78 135.4553520 525.12 498.86 573.69 # 54200 53.49 50.82 58.4453600 76.65 72.82 83.74 54205 529.43 502.96 578.40

# 53600 62.07 58.97 67.82 54220 158.86 150.92 173.5653601 70.72 67.18 77.26 # 54220 128.65 122.22 140.55

# 53601 51.27 48.71 56.02 54230 66.80 63.46 72.9853605 63.92 60.72 69.83 54231 153.38 145.71 167.5753620 107.54 102.16 117.48 # 54231 107.20 101.84 117.12

# 53620 83.93 79.73 91.69 54235 84.61 80.38 92.4453621 98.07 93.17 107.15 # 54235 59.60 56.62 65.11

# 53621 69.59 66.11 76.03 54240 116.43 110.61 127.2053660 62.29 59.18 68.06 54240 TC 50.72 48.18 55.41

# 53660 38.67 36.74 42.25 54240 26 65.71 62.42 71.7853661 61.26 58.20 66.93 54250 185.28 176.02 202.42

# 53661 38.34 36.42 41.88 54250 TC 74.32 70.60 81.1953665 38.41 36.49 41.96 54250 26 110.96 105.41 121.2253850 2,561.30 2,433.24 2,798.23 54300 680.07 646.07 742.98

# 53850 510.75 485.21 557.99 54304 801.20 761.14 875.3153852 2,199.81 2,089.82 2,403.29 54308 760.87 722.83 831.25

# 53852 533.33 506.66 582.66 54312 864.45 821.23 944.4153853 1,539.66 1,462.68 1,682.08 54316 1,022.59 971.46 1,117.18

# 53853 314.54 298.81 343.63 54318 749.39 711.92 818.7154000 225.13 213.87 245.95 54322 797.20 757.34 870.94

# 54000 108.11 102.70 118.11 54324 1,013.10 962.45 1,106.8254001 270.65 257.12 295.69 54326 956.53 908.70 1,045.01

# 54001 154.32 146.60 168.59 54328 951.56 903.98 1,039.5854015 431.03 409.48 470.90 54332 1,023.02 971.87 1,117.65

# 54015 310.88 295.34 339.64 54336 1,285.55 1,221.27 1,404.4654050 144.07 136.87 157.40 54340 604.06 573.86 659.94

# 54050 64.89 61.65 70.90 54344 977.11 928.25 1,067.4954055 240.92 228.87 263.20 54348 1,049.87 997.38 1,146.99

# 54055 95.07 90.32 103.87 54352 1,460.75 1,387.71 1,595.8754056 155.52 147.74 169.90 54360 731.53 694.95 799.19

# 54056 65.93 62.63 72.02 54380 849.75 807.26 928.35

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 42FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

54385 1,007.64 957.26 1,100.85 55300 188.09 178.69 205.4954390 1,282.59 1,218.46 1,401.23 55400 492.85 468.21 538.4454400 542.63 515.50 592.83 55450 365.85 347.56 399.6954401 619.42 588.45 676.72 # 55450 242.57 230.44 265.0154405 777.75 738.86 849.69 55500 337.76 320.87 369.0054406 657.16 624.30 717.95 55520 365.27 347.01 399.0654408 694.69 659.96 758.95 55530 337.49 320.62 368.7154410 832.22 790.61 909.20 55535 382.04 362.94 417.3854411 918.73 872.79 1,003.71 55540 450.66 428.13 492.3554415 477.12 453.26 521.25 55550 376.87 358.03 411.7354416 654.38 621.66 714.91 55600 377.91 359.01 412.8654417 806.29 765.98 880.88 55605 478.47 454.55 522.7354420 699.80 664.81 764.53 55650 655.96 623.16 716.6354430 642.47 610.35 701.90 55680 320.38 304.36 350.0154435 409.08 388.63 446.92 55700 182.12 173.01 198.9654450 77.90 74.01 85.11 # 55700 85.93 81.63 93.87

# 54450 59.84 56.85 65.38 55705 289.84 275.35 316.6554500 240.03 228.03 262.23 55720 477.20 453.34 521.34

# 54500 65.71 62.42 71.78 55725 536.57 509.74 586.2054505 212.32 201.70 231.96 55801 991.23 941.67 1,082.9254512 487.81 463.42 532.93 55810 1,242.87 1,180.73 1,357.8454520 314.21 298.50 343.28 55812 1,509.71 1,434.22 1,649.3554522 544.89 517.65 595.30 55815 1,652.77 1,570.13 1,805.6554530 499.26 474.30 545.45 55821 802.37 762.25 876.5954535 704.52 669.29 769.68 55831 871.99 828.39 952.6554550 452.11 429.50 493.93 55840 1,264.24 1,201.03 1,381.1854560 652.48 619.86 712.84 55842 1,349.67 1,282.19 1,474.5254600 405.35 385.08 442.84 55845 1,554.12 1,476.41 1,697.8754620 285.19 270.93 311.57 55859 719.30 683.34 785.8454640 404.84 384.60 442.29 55860 817.26 776.40 892.8654650 673.50 639.83 735.80 55862 1,027.63 976.25 1,122.6954660 306.04 290.74 334.35 55865 1,244.04 1,181.84 1,359.1254670 380.40 361.38 415.59 55866 1,574.86 1,496.12 1,720.5454680 738.01 701.11 806.28 55870 166.06 157.76 181.4254690 652.65 620.02 713.02 # 55870 134.81 128.07 147.2854692 688.69 654.26 752.40 55873 1,072.03 1,018.43 1,171.1954700 376.53 357.70 411.36 56405 136.79 129.95 149.44

# 54700 239.02 227.07 261.13 # 56405 99.98 94.98 109.2354800 262.54 249.41 286.82 56420 134.62 127.89 147.07

# 54800 117.04 111.19 127.87 # 56420 98.15 93.24 107.2354820 311.63 296.05 340.46 56440 232.88 221.24 254.4354830 323.14 306.98 353.03 # 56440 190.17 180.66 207.7654840 312.41 296.79 341.31 56441 158.49 150.57 173.1654860 375.03 356.28 409.72 # 56441 140.44 133.42 153.4354861 502.90 477.76 549.42 56501 138.67 131.74 151.5054900 742.91 705.76 811.62 # 56501 105.68 100.40 115.4654901 1,011.26 960.70 1,104.81 56515 211.17 200.61 230.7055000 130.85 124.31 142.96 # 56515 184.43 175.21 201.49

# 55000 72.16 68.55 78.83 56605 81.70 77.62 89.2655040 314.78 299.04 343.90 # 56605 60.17 57.16 65.7355041 441.63 419.55 482.48 56606 39.81 37.82 43.4955060 324.42 308.20 354.43 # 56606 29.74 28.25 32.4955100 355.98 338.18 388.91 56620 466.67 443.34 509.84

# 55100 194.51 184.78 212.50 56625 535.58 508.80 585.1255110 331.65 315.07 362.33 56630 756.43 718.61 826.4055120 302.52 287.39 330.50 56631 1,002.79 952.65 1,095.5555150 425.49 404.22 464.85 56632 1,164.13 1,105.92 1,271.8155175 317.00 301.15 346.32 56633 978.93 929.98 1,069.4855180 622.96 591.81 680.58 56634 1,092.74 1,038.10 1,193.8255200 259.78 246.79 283.81 56637 1,314.16 1,248.45 1,435.7255250 394.35 374.63 430.82 56640 1,310.35 1,244.83 1,431.55

# 55250 228.36 216.94 249.48 56700 159.07 151.12 173.79

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 43FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

56720 41.42 39.35 45.25 57307 897.12 852.26 980.1056740 268.71 255.27 293.56 57308 597.83 567.94 653.1356800 245.04 232.79 267.71 57310 411.23 390.67 449.2756805 1,066.22 1,012.91 1,164.85 57311 476.40 452.58 520.4756810 258.99 246.04 282.95 57320 484.13 459.92 528.9156820 114.99 109.24 125.63 57330 697.55 662.67 762.07

# 56820 80.61 76.58 88.07 57335 1,050.65 998.12 1,147.8456821 149.23 141.77 163.04 57400 129.83 123.34 141.84

# 56821 111.03 105.48 121.30 57410 157.08 149.23 171.6157000 193.85 184.16 211.78 # 57410 104.30 99.09 113.9557010 370.83 352.29 405.13 57415 197.02 187.17 215.2557020 113.97 108.27 124.51 # 57415 150.49 142.97 164.42

# 57020 81.67 77.59 89.23 57420 120.01 114.01 131.1157022 171.98 163.38 187.89 # 57420 85.63 81.35 93.5557023 281.44 267.37 307.48 57421 156.76 148.92 171.2657061 125.01 118.76 136.57 # 57421 118.56 112.63 129.52

# 57061 90.29 85.78 98.65 57452 117.07 111.22 127.9057065 204.02 193.82 222.89 # 57452 80.61 76.58 88.07

# 57065 181.45 172.38 198.24 57454 160.45 152.43 175.2957100 85.68 81.40 93.61 # 57454 124.68 118.45 136.22

# 57100 64.50 61.28 70.47 57455 144.27 137.06 157.6257105 136.86 130.02 149.52 # 57455 107.81 102.42 117.78

# 57105 112.90 107.26 123.35 57456 136.40 129.58 149.0257106 385.96 366.66 421.66 # 57456 100.98 95.93 110.3257107 1,269.29 1,205.83 1,386.70 57460 286.69 272.36 313.2157109 1,451.03 1,378.48 1,585.25 # 57460 156.12 148.31 170.5657110 820.07 779.07 895.93 57461 319.62 303.64 349.1957111 1,503.82 1,428.63 1,642.92 # 57461 186.97 177.62 204.2657112 1,561.33 1,483.26 1,705.75 57500 108.92 103.47 118.9957120 455.10 432.35 497.20 # 57500 55.79 53.00 60.9557130 166.91 158.56 182.34 57505 111.64 106.06 121.9757135 205.85 195.56 224.89 # 57505 87.67 83.29 95.78

# 57135 180.16 171.15 196.82 57510 179.91 170.91 196.5557150 56.48 53.66 61.71 # 57510 127.83 121.44 139.66

# 57150 29.74 28.25 32.49 57511 157.34 149.47 171.8957155 376.44 357.62 411.26 # 57511 101.43 96.36 110.8157160 73.71 70.02 80.52 57513 164.99 156.74 180.25

# 57160 49.40 46.93 53.97 # 57513 127.83 121.44 139.6657170 84.16 79.95 91.94 57520 304.68 289.45 332.87

# 57170 48.05 45.65 52.50 # 57520 257.11 244.25 280.8957180 140.15 133.14 153.11 57522 261.18 248.12 285.34

# 57180 112.02 106.42 122.38 # 57522 220.55 209.52 240.9557200 264.57 251.34 289.04 57530 313.57 297.89 342.5757210 332.94 316.29 363.73 57531 1,574.08 1,495.38 1,719.6957220 287.41 273.04 314.00 57540 699.94 664.94 764.6857230 345.51 328.23 377.46 57545 748.17 710.76 817.3757240 374.70 355.97 409.37 57550 351.61 334.03 384.1357250 352.30 334.69 384.89 57555 551.08 523.53 602.0657260 508.28 482.87 555.30 57556 500.09 475.09 546.3557265 673.82 640.13 736.15 57700 225.37 214.10 246.2257268 424.49 403.27 463.76 57720 275.66 261.88 301.1657270 710.51 674.98 776.23 57800 57.54 54.66 62.8657280 865.74 822.45 945.82 # 57800 47.47 45.10 51.8757282 546.05 518.75 596.56 57820 119.12 113.16 130.1357284 750.01 712.51 819.39 # 57820 105.22 99.96 114.9557287 609.76 579.27 666.16 58100 108.42 103.00 118.4557288 713.57 677.89 779.57 # 58100 84.12 79.91 91.9057289 671.69 638.11 733.83 58120 212.07 201.47 231.6957291 500.09 475.09 546.35 # 58120 198.87 188.93 217.2757292 777.43 738.56 849.34 58140 825.45 784.18 901.8157300 469.64 446.16 513.08 58145 488.44 464.02 533.6257305 772.65 734.02 844.12 58146 1,059.68 1,006.70 1,157.71

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 44FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

58150 883.14 838.98 964.83 58673 786.87 747.53 859.6658152 1,159.18 1,101.22 1,266.40 58700 661.89 628.80 723.1258180 882.51 838.38 964.14 58720 652.67 620.04 713.0558200 1,228.45 1,167.03 1,342.08 58740 772.32 733.70 843.7658210 1,635.74 1,553.95 1,787.04 58750 848.79 806.35 927.3058240 2,169.35 2,060.88 2,370.01 58752 837.67 795.79 915.1658260 747.02 709.67 816.12 58760 755.99 718.19 825.9258262 844.80 802.56 922.94 58770 799.75 759.76 873.7258263 914.32 868.60 998.89 58800 315.58 299.80 344.7758267 968.32 919.90 1,057.89 # 58800 314.54 298.81 343.6358270 816.17 775.36 891.66 58805 353.92 336.22 386.6558275 894.02 849.32 976.72 58820 279.57 265.59 305.4358280 957.53 909.65 1,046.10 58822 575.57 546.79 628.8158285 1,251.98 1,189.38 1,367.79 58823 209.74 199.25 229.1458290 1,059.22 1,006.26 1,157.20 58825 620.21 589.20 677.5858291 1,164.65 1,106.42 1,272.38 58900 360.00 342.00 393.3058292 1,233.82 1,172.13 1,347.95 58920 630.58 599.05 688.9158293 1,281.92 1,217.82 1,400.49 58925 645.38 613.11 705.0858294 1,136.02 1,079.22 1,241.10 58940 427.47 406.10 467.0258301 104.21 99.00 113.85 58943 1,063.11 1,009.95 1,161.44

# 58301 68.10 64.70 74.41 58950 982.40 933.28 1,073.2758321 69.60 66.12 76.04 58951 1,283.92 1,219.72 1,402.68

# 58321 50.15 47.64 54.79 58952 1,430.39 1,358.87 1,562.7058322 78.58 74.65 85.85 58953 1,802.85 1,712.71 1,969.62

# 58322 58.78 55.84 64.22 58954 1,958.19 1,860.28 2,139.3258323 27.82 26.43 30.39 58960 866.16 822.85 946.28

# 58323 12.54 11.91 13.70 58970 431.27 409.71 471.1758340 477.20 453.34 521.34 # 58970 198.96 189.01 217.36

# 58340 45.91 43.61 50.15 58976 232.45 220.83 253.9558345 242.11 230.00 264.50 # 58976 208.14 197.73 227.3958346 402.24 382.13 439.45 59000 120.63 114.60 131.7958350 107.25 101.89 117.17 # 59000 80.00 76.00 87.40

# 58350 76.69 72.86 83.79 59001 164.01 155.81 179.1858353 219.85 208.86 240.19 59012 202.77 192.63 221.5258400 389.45 369.98 425.48 59015 149.25 141.79 163.0658410 728.49 692.07 795.88 # 59015 131.54 124.96 143.7058520 680.33 646.31 743.26 59020 58.46 55.54 63.8758540 816.75 775.91 892.30 59020 TC 20.87 19.83 22.8058545 851.14 808.58 929.87 59020 26 37.59 35.71 41.0758546 1,073.21 1,019.55 1,172.48 59025 39.11 37.15 42.7258550 816.79 775.95 892.34 59025 TC 8.69 8.26 9.5058552 828.94 787.49 905.61 59025 26 30.42 28.90 33.2458553 1,066.16 1,012.85 1,164.78 59030 121.81 115.72 133.0858554 1,055.40 1,002.63 1,153.02 59050 50.48 47.96 55.1558555 205.92 195.62 224.96 59051 42.24 40.13 46.15

# 58555 184.74 175.50 201.83 59100 745.08 707.83 814.0058558 263.50 250.33 287.88 59120 700.55 665.52 765.3558559 339.48 322.51 370.89 59121 712.66 677.03 778.5858560 385.32 366.05 420.96 59130 807.99 767.59 882.7358561 547.98 520.58 598.67 59135 836.58 794.75 913.9658562 286.49 272.17 313.00 59136 791.63 752.05 864.8658563 340.18 323.17 371.65 59140 349.62 332.14 381.9658600 331.16 314.60 361.79 59150 689.68 655.20 753.4858605 301.68 286.60 329.59 59151 670.03 636.53 732.0158611 75.65 71.87 82.65 59160 236.59 224.76 258.4758615 263.82 250.63 288.22 # 59160 190.40 180.88 208.0158660 644.92 612.67 704.57 59200 79.83 75.84 87.2258661 624.04 592.84 681.77 # 59200 44.76 42.52 48.9058662 662.42 629.30 723.70 59300 174.96 166.21 191.1458670 348.60 331.17 380.85 # 59300 137.11 130.25 149.7958671 349.30 331.84 381.62 59320 150.77 143.23 164.7158672 737.47 700.60 805.69 59325 241.68 229.60 264.04

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 45FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

59350 280.33 266.31 306.26 60502 1,143.03 1,085.88 1,248.7659400 1,542.58 1,465.45 1,685.27 60505 1,252.94 1,190.29 1,368.8359409 764.75 726.51 835.49 60512 234.87 223.13 256.6059410 855.48 812.71 934.62 60520 1,017.42 966.55 1,111.5359412 102.23 97.12 111.69 60521 1,176.91 1,118.06 1,285.7759414 91.29 86.73 99.74 60522 1,390.59 1,321.06 1,519.2259425 359.97 341.97 393.27 60540 934.23 887.52 1,020.65

# 59425 271.07 257.52 296.15 60545 1,108.12 1,052.71 1,210.6259426 632.58 600.95 691.09 60600 1,177.25 1,118.39 1,286.15

# 59426 467.98 444.58 511.27 60605 1,444.75 1,372.51 1,578.3959430 124.82 118.58 136.37 60650 1,076.48 1,022.66 1,176.0659510 1,750.76 1,663.22 1,912.70 61000 96.03 91.23 104.9159514 902.65 857.52 986.15 61001 96.94 92.09 105.9059515 1,020.68 969.65 1,115.10 61020 111.95 106.35 122.3059525 481.96 457.86 526.54 61026 119.17 113.21 130.1959610 1,628.57 1,547.14 1,779.21 61050 103.56 98.38 113.1459612 858.04 815.14 937.41 61055 130.21 123.70 142.2659614 944.26 897.05 1,031.61 61070 71.63 68.05 78.2659618 1,862.80 1,769.66 2,035.11 61105 364.06 345.86 397.7459620 989.00 939.55 1,080.48 61107 335.00 318.25 365.9959622 1,115.35 1,059.58 1,218.52 61108 695.31 660.54 759.6259812 291.17 276.61 318.10 61120 594.61 564.88 649.61

# 59812 254.01 241.31 277.51 61140 1,039.84 987.85 1,136.0359820 296.79 281.95 324.24 61150 1,132.66 1,076.03 1,237.43

# 59820 263.46 250.29 287.83 61151 815.80 775.01 891.2659821 322.23 306.12 352.04 61154 989.01 939.56 1,080.49

# 59821 289.59 275.11 316.38 61156 1,063.22 1,010.06 1,161.5759830 397.61 377.73 434.39 61210 384.35 365.13 419.9059840 266.61 253.28 291.27 61215 354.60 336.87 387.40

# 59840 206.19 195.88 225.26 61250 693.24 658.58 757.3759841 418.00 397.10 456.67 61253 802.07 761.97 876.27

# 59841 346.81 329.47 378.89 61304 1,408.23 1,337.82 1,538.4959850 346.91 329.56 378.99 61305 1,697.13 1,612.27 1,854.1159851 361.53 343.45 394.97 61312 1,604.11 1,523.90 1,752.4959852 510.27 484.76 557.47 61313 1,612.37 1,531.75 1,761.5159855 373.66 354.98 408.23 61314 1,484.67 1,410.44 1,622.0159856 452.03 429.43 493.84 61315 1,774.05 1,685.35 1,938.1559857 548.52 521.09 599.25 61316 85.45 81.18 93.3659866 224.55 213.32 245.32 61320 1,640.64 1,558.61 1,792.4059870 376.80 357.96 411.65 61321 1,798.86 1,708.92 1,965.2659871 160.24 152.23 175.06 61322 1,729.81 1,643.32 1,889.82

# 59871 122.04 115.94 133.33 61323 1,791.27 1,701.71 1,956.9760000 150.85 143.31 164.81 61330 1,428.00 1,356.60 1,560.09

# 60000 143.55 136.37 156.83 61332 1,692.13 1,607.52 1,848.6560001 94.32 89.60 103.04 61333 1,650.98 1,568.43 1,803.69

# 60001 49.52 47.04 54.10 61334 1,149.87 1,092.38 1,256.2460100 123.05 116.90 134.44 61340 1,203.25 1,143.09 1,314.55

# 60100 77.56 73.68 84.73 61343 1,918.62 1,822.69 2,096.0960200 604.81 574.57 660.76 61345 1,746.00 1,658.70 1,907.5160210 654.96 622.21 715.54 61440 1,695.23 1,610.47 1,852.0460212 921.55 875.47 1,006.79 61450 1,662.31 1,579.19 1,816.0760220 709.38 673.91 775.00 61458 1,753.81 1,666.12 1,916.0460225 833.40 791.73 910.49 61460 1,821.15 1,730.09 1,989.6060240 950.76 903.22 1,038.70 61470 1,633.79 1,552.10 1,784.9260252 1,200.51 1,140.48 1,311.55 61480 1,713.05 1,627.40 1,871.5160254 1,598.25 1,518.34 1,746.09 61490 1,661.97 1,578.87 1,815.7060260 1,041.54 989.46 1,137.88 61500 1,174.43 1,115.71 1,283.0760270 1,198.70 1,138.77 1,309.59 61501 978.15 929.24 1,068.6360271 1,000.20 950.19 1,092.72 61510 1,835.09 1,743.34 2,004.8460280 408.37 387.95 446.14 61512 2,246.19 2,133.88 2,453.9660281 554.11 526.40 605.36 61514 1,635.50 1,553.73 1,786.7960500 915.67 869.89 1,000.37 61516 1,586.44 1,507.12 1,733.19

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 46FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

61517 72.42 68.80 79.12 61618 1,117.89 1,062.00 1,221.3061518 2,393.05 2,273.40 2,614.41 61619 1,337.71 1,270.82 1,461.4461519 2,631.90 2,500.31 2,875.36 61623 526.48 500.16 575.1861520 3,450.52 3,277.99 3,769.69 61624 1,020.41 969.39 1,114.8061521 2,822.67 2,681.54 3,083.77 61626 831.55 789.97 908.4761522 1,866.70 1,773.37 2,039.38 61680 1,969.10 1,870.65 2,151.2561524 1,771.96 1,683.36 1,935.86 61682 3,865.47 3,672.20 4,223.0361526 3,199.07 3,039.12 3,494.99 61684 2,526.77 2,400.43 2,760.4961530 2,746.77 2,609.43 3,000.84 61686 4,059.34 3,856.37 4,434.8361531 967.14 918.78 1,056.60 61690 1,875.95 1,782.15 2,049.4761533 1,277.94 1,214.04 1,396.15 61692 3,244.68 3,082.45 3,544.8261534 1,364.18 1,295.97 1,490.37 61697 3,196.73 3,036.89 3,492.4261535 784.58 745.35 857.15 61698 3,061.20 2,908.14 3,344.3661536 2,256.04 2,143.24 2,464.73 61700 3,190.41 3,030.89 3,485.5261538 1,730.51 1,643.98 1,890.58 61702 3,063.17 2,910.01 3,346.5161539 2,057.72 1,954.83 2,248.05 61703 1,152.69 1,095.06 1,259.3261541 1,829.36 1,737.89 1,998.57 61705 2,246.72 2,134.38 2,454.5461542 2,018.09 1,917.19 2,204.77 61708 1,910.79 1,815.25 2,087.5461543 1,885.46 1,791.19 2,059.87 61710 1,668.09 1,584.69 1,822.3961544 1,603.84 1,523.65 1,752.20 61711 2,296.93 2,182.08 2,509.3961545 2,773.32 2,634.65 3,029.85 61720 1,106.01 1,050.71 1,208.3261546 1,999.58 1,899.60 2,184.54 61735 1,332.06 1,265.46 1,455.2861548 1,383.94 1,314.74 1,511.95 61750 1,172.66 1,114.03 1,281.1361550 827.46 786.09 904.00 61751 1,140.06 1,083.06 1,245.5261552 1,083.57 1,029.39 1,183.80 61760 1,277.60 1,213.72 1,395.7861556 1,351.75 1,284.16 1,476.78 61770 1,376.37 1,307.55 1,503.6861557 1,459.43 1,386.46 1,594.43 61790 667.82 634.43 729.5961558 1,546.96 1,469.61 1,690.05 61791 959.22 911.26 1,047.9561559 2,116.28 2,010.47 2,312.04 61793 1,129.69 1,073.21 1,234.1961563 1,690.16 1,605.65 1,846.50 61795 247.92 235.52 270.8561564 2,128.83 2,022.39 2,325.75 61850 809.39 768.92 884.2661570 1,555.01 1,477.26 1,698.85 61860 1,347.99 1,280.59 1,472.6861571 1,688.43 1,604.01 1,844.61 61862 1,262.14 1,199.03 1,378.8861575 2,161.69 2,053.61 2,361.65 61870 979.60 930.62 1,070.2161576 3,139.83 2,982.84 3,430.27 61875 954.79 907.05 1,043.1161580 1,864.85 1,771.61 2,037.35 61880 460.16 437.15 502.7261581 1,910.57 1,815.04 2,087.30 61885 432.32 410.70 472.3161582 2,041.26 1,939.20 2,230.08 61886 562.05 533.95 614.0461583 2,345.83 2,228.54 2,562.82 61888 356.31 338.49 389.2661584 2,215.67 2,104.89 2,420.62 62000 682.22 648.11 745.3361585 2,405.26 2,285.00 2,627.75 62005 998.21 948.30 1,090.5561586 1,599.41 1,519.44 1,747.36 62010 1,288.98 1,224.53 1,408.2161590 2,555.68 2,427.90 2,792.09 62100 1,424.89 1,353.65 1,556.7061591 2,687.36 2,552.99 2,935.94 62115 1,352.63 1,285.00 1,477.7561592 2,526.34 2,400.02 2,760.02 62116 1,506.96 1,431.61 1,646.3561595 1,852.97 1,760.32 2,024.37 62117 1,713.58 1,627.90 1,872.0961596 2,208.87 2,098.43 2,413.19 62120 1,456.07 1,383.27 1,590.7661597 2,349.91 2,232.41 2,567.27 62121 1,341.79 1,274.70 1,465.9161598 2,093.28 1,988.62 2,286.91 62140 881.53 837.45 963.0761600 1,603.55 1,523.37 1,751.88 62141 981.84 932.75 1,072.6661601 1,801.31 1,711.24 1,967.93 62142 717.50 681.63 783.8761605 1,796.76 1,706.92 1,962.96 62143 867.91 824.51 948.1961606 2,462.52 2,339.39 2,690.30 62145 1,224.07 1,162.87 1,337.3061607 2,284.21 2,170.00 2,495.50 62146 1,050.51 997.98 1,147.6861608 2,682.79 2,548.65 2,930.95 62147 1,252.61 1,189.98 1,368.4861609 602.82 572.68 658.58 62148 116.30 110.49 127.0661610 1,670.35 1,586.83 1,824.85 62160 167.62 159.24 183.1361611 442.31 420.19 483.22 62161 1,194.32 1,134.60 1,304.7961612 1,612.95 1,532.30 1,762.15 62162 1,533.70 1,457.02 1,675.5761613 2,609.60 2,479.12 2,850.99 62163 970.35 921.83 1,060.1061615 2,043.56 1,941.38 2,232.59 62164 1,658.19 1,575.28 1,811.5761616 2,755.00 2,617.25 3,009.84 62165 1,298.23 1,233.32 1,418.32

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 47FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

62180 1,365.45 1,297.18 1,491.76 62368 26 35.62 33.84 38.9262190 747.50 710.13 816.65 63001 1,026.46 975.14 1,121.4162192 819.00 778.05 894.76 63003 1,041.58 989.50 1,137.9362194 296.60 281.77 324.04 63005 992.51 942.88 1,084.3162200 1,198.55 1,138.62 1,309.41 63011 876.70 832.87 957.8062201 968.06 919.66 1,057.61 63012 1,017.99 967.09 1,112.1562220 861.92 818.82 941.64 63015 1,267.65 1,204.27 1,384.9162223 854.09 811.39 933.10 63016 1,249.59 1,187.11 1,365.1862225 402.02 381.92 439.21 63017 1,055.76 1,002.97 1,153.4262230 708.06 672.66 773.56 63020 990.03 940.53 1,081.6162252 84.28 80.07 92.08 63030 817.78 776.89 893.4262252 TC 38.55 36.62 42.11 63035 191.15 181.59 208.8362252 26 45.72 43.43 49.94 63040 1,215.50 1,154.73 1,327.9462256 476.30 452.49 520.36 63042 1,151.05 1,093.50 1,257.5362258 955.22 907.46 1,043.58 63045 1,085.63 1,031.35 1,186.0562263 705.00 669.75 770.21 63046 1,041.98 989.88 1,138.36

# 62263 322.32 306.20 352.13 63047 978.11 929.20 1,068.5862264 566.74 538.40 619.16 63048 198.28 188.37 216.63

# 62264 217.40 206.53 237.51 63055 1,415.46 1,344.69 1,546.3962268 276.59 262.76 302.17 63056 1,308.29 1,242.88 1,429.3162269 274.96 261.21 300.39 63057 313.79 298.10 342.8262270 174.44 165.72 190.58 63064 1,579.05 1,500.10 1,725.12

# 62270 60.54 57.51 66.14 63066 200.04 190.04 218.5562272 222.06 210.96 242.60 63075 1,271.86 1,208.27 1,389.51

# 62272 76.21 72.40 83.26 63076 247.92 235.52 270.8562273 179.95 170.95 196.59 63077 1,354.53 1,286.80 1,479.82

# 62273 103.21 98.05 112.76 63078 194.80 185.06 212.8262280 425.91 404.61 465.30 63081 1,533.40 1,456.73 1,675.24

# 62280 130.04 123.54 142.07 63082 267.21 253.85 291.9362281 377.33 358.46 412.23 63085 1,693.55 1,608.87 1,850.20

# 62281 127.31 120.94 139.08 63086 191.90 182.31 209.6662282 486.52 462.19 531.52 63087 2,191.49 2,081.92 2,394.21

# 62282 114.96 109.21 125.59 63088 261.92 248.82 286.1462284 235.55 223.77 257.34 63090 1,743.27 1,656.11 1,904.53

# 62284 80.67 76.64 88.14 63091 177.71 168.82 194.1462287 491.91 467.31 537.41 63170 1,333.04 1,266.39 1,456.3562290 412.63 392.00 450.80 63172 1,222.37 1,161.25 1,335.44

# 62290 160.87 152.83 175.75 63173 1,473.48 1,399.81 1,609.7862291 364.55 346.32 398.27 63180 1,259.65 1,196.67 1,376.17

# 62291 151.68 144.10 165.72 63182 1,316.57 1,250.74 1,438.3562292 483.56 459.38 528.29 63185 960.85 912.81 1,049.7362294 691.84 657.25 755.84 63190 1,149.52 1,092.04 1,255.8562310 243.79 231.60 266.34 63191 1,188.16 1,128.75 1,298.06

# 62310 91.00 86.45 99.42 63194 1,302.20 1,237.09 1,422.6562311 233.46 221.79 255.06 63195 1,256.22 1,193.41 1,372.42

# 62311 74.76 71.02 81.67 63196 1,448.53 1,376.10 1,582.5262318 270.40 256.88 295.41 63197 1,403.78 1,333.59 1,533.63

# 62318 96.42 91.60 105.34 63198 1,484.38 1,410.16 1,621.6862319 241.99 229.89 264.37 63199 1,740.82 1,653.78 1,901.85

# 62319 88.50 84.08 96.69 63200 1,279.07 1,215.12 1,397.3962350 398.62 378.69 435.49 63250 2,469.17 2,345.71 2,697.5762351 659.81 626.82 720.84 63251 2,586.02 2,456.72 2,825.2362355 312.55 296.92 341.46 63252 2,565.06 2,436.81 2,802.3362360 181.79 172.70 198.61 63265 1,396.46 1,326.64 1,525.6462361 336.13 319.32 367.22 63266 1,444.62 1,372.39 1,578.2562362 427.12 405.76 466.62 63267 1,175.98 1,117.18 1,284.7662365 359.43 341.46 392.68 63268 1,162.16 1,104.05 1,269.6662367 45.43 43.16 49.63 63270 1,723.56 1,637.38 1,882.9962367 TC 13.15 12.49 14.36 63271 1,736.67 1,649.84 1,897.3262367 26 23.02 21.87 25.15 63272 1,628.98 1,547.53 1,779.6662368 67.40 64.03 73.63 63273 1,578.70 1,499.77 1,724.7462368 TC 16.81 15.97 18.37 63275 1,523.70 1,447.52 1,664.65

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 48FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

63276 1,509.41 1,433.94 1,649.03 64421 248.62 236.19 271.6263277 1,350.70 1,283.17 1,475.65 # 64421 80.55 76.52 88.0063278 1,334.63 1,267.90 1,458.09 64425 123.04 116.89 134.4263280 1,817.93 1,727.03 1,986.08 # 64425 84.14 79.93 91.9263281 1,796.89 1,707.05 1,963.11 64430 129.51 123.03 141.4863282 1,694.38 1,609.66 1,851.11 # 64430 74.30 70.59 81.1863283 1,612.86 1,532.22 1,762.05 64435 135.76 128.97 148.3263285 2,278.65 2,164.72 2,489.43 # 64435 80.55 76.52 88.0063286 2,254.67 2,141.94 2,463.23 64445 153.14 145.48 167.3063287 2,327.78 2,211.39 2,543.10 # 64445 69.80 66.31 76.2663290 2,363.34 2,245.17 2,581.95 64446 160.87 152.83 175.7563300 1,571.49 1,492.92 1,716.86 64447 75.39 71.62 82.3663301 1,730.23 1,643.72 1,890.28 64448 147.96 140.56 161.6463302 1,756.72 1,668.88 1,919.21 64450 94.12 89.41 102.8263303 1,895.79 1,801.00 2,071.15 # 64450 63.56 60.38 69.4463304 1,885.55 1,791.27 2,059.96 64470 244.74 232.50 267.3863305 1,989.33 1,889.86 2,173.34 # 64470 91.25 86.69 99.6963306 1,881.60 1,787.52 2,055.65 64472 119.16 113.20 130.1863307 1,900.27 1,805.26 2,076.05 # 64472 61.16 58.10 66.8263308 319.08 303.13 348.60 64475 215.89 205.10 235.8763600 761.89 723.80 832.37 # 64475 71.08 67.53 77.6663610 464.03 440.83 506.95 64476 102.32 97.20 111.7863615 1,038.92 986.97 1,135.02 # 64476 46.41 44.09 50.7063650 364.65 346.42 398.38 64479 339.08 322.13 370.4563655 690.17 655.66 754.01 # 64479 110.24 104.73 120.4463660 376.64 357.81 411.48 64480 141.09 134.04 154.1563685 438.28 416.37 478.83 # 64480 75.81 72.02 82.8263688 348.33 330.91 380.55 64483 342.40 325.28 374.0763700 1,058.35 1,005.43 1,156.24 # 64483 96.54 91.71 105.4763702 1,091.43 1,036.86 1,192.39 64484 144.91 137.66 158.3163704 1,342.84 1,275.70 1,467.06 # 64484 64.35 61.13 70.3063706 1,512.26 1,436.65 1,652.15 64505 117.88 111.99 128.7963707 756.39 718.57 826.36 # 64505 69.26 65.80 75.6763709 944.94 897.69 1,032.34 64508 209.15 198.69 228.4963710 930.71 884.17 1,016.80 # 64508 60.88 57.84 66.5263740 758.03 720.13 828.15 64510 157.58 149.70 172.1663741 505.57 480.29 552.33 # 64510 60.00 57.00 65.5563744 541.31 514.24 591.38 64520 209.54 199.06 228.9263746 414.47 393.75 452.81 # 64520 66.47 63.15 72.6264400 110.52 104.99 120.74 64530 263.04 249.89 287.37

# 64400 54.96 52.21 60.04 # 64530 77.26 73.40 84.4164402 102.41 97.29 111.88 64550 26.34 25.02 28.77

# 64402 66.65 63.32 72.82 # 64550 8.63 8.20 9.4364405 109.82 104.33 119.98 64553 155.57 147.79 169.96

# 64405 64.68 61.45 70.67 # 64553 134.04 127.34 146.4464408 144.70 137.47 158.09 64555 172.15 163.54 188.07

# 64408 77.68 73.80 84.87 # 64555 108.60 103.17 118.6564410 140.91 133.86 153.94 64560 176.14 167.33 192.43

# 64410 68.68 65.25 75.04 # 64560 116.41 110.59 127.1864412 136.68 129.85 149.33 64561 778.05 739.15 850.02

# 64412 58.55 55.62 63.96 # 64561 380.09 361.09 415.2564413 123.15 116.99 134.54 64565 179.99 170.99 196.64

# 64413 69.33 65.86 75.74 # 64565 89.70 85.22 98.0064415 162.52 154.39 177.55 64573 512.20 486.59 559.58

# 64415 70.15 66.64 76.64 64575 275.65 261.87 301.1564416 156.07 148.27 170.51 64577 311.57 295.99 340.3964417 168.36 159.94 183.93 64580 296.38 281.56 323.79

# 64417 70.44 66.92 76.96 64581 733.21 696.55 801.0364418 143.16 136.00 156.40 64585 202.45 192.33 221.18

# 64418 63.29 60.13 69.15 # 64585 157.65 149.77 172.2464420 168.97 160.52 184.60 64590 179.09 170.14 195.66

# 64420 57.50 54.63 62.82 64595 136.95 130.10 149.62

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 49FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

64600 454.37 431.65 496.40 64784 630.06 598.56 688.34# 64600 187.33 177.96 204.65 64786 991.80 942.21 1,083.54

64605 590.64 561.11 645.28 64787 251.70 239.12 274.99# 64605 292.35 277.73 319.39 64788 307.40 292.03 335.83

64610 423.97 402.77 463.19 64790 723.34 687.17 790.2564612 153.92 146.22 168.15 64792 915.76 869.97 1,000.47

# 64612 110.17 104.66 120.36 64795 185.98 176.68 203.1864613 177.54 168.66 193.96 64802 551.74 524.15 602.77

# 64613 108.09 102.69 118.09 64804 852.76 810.12 931.6464614 235.92 224.12 257.74 64809 749.74 712.25 819.09

# 64614 119.24 113.28 130.27 64818 612.73 582.09 669.4064620 322.07 305.97 351.87 64820 676.44 642.62 739.01

# 64620 147.40 140.03 161.03 64821 673.38 639.71 735.6764622 411.23 390.67 449.27 64822 673.38 639.71 735.67

# 64622 155.65 147.87 170.05 64823 766.38 728.06 837.2764623 124.56 118.33 136.08 64831 634.63 602.90 693.34

# 64623 46.08 43.78 50.35 64832 334.52 317.79 365.4664626 420.73 399.69 459.64 64834 662.98 629.83 724.30

# 64626 190.85 181.31 208.51 64835 718.43 682.51 784.8964627 138.73 131.79 151.56 64836 715.98 680.18 782.21

# 64627 54.35 51.63 59.37 64837 370.62 352.09 404.9064630 269.54 256.06 294.47 64840 793.09 753.44 866.46

# 64630 157.03 149.18 171.56 64856 888.17 843.76 970.3264640 337.54 320.66 368.76 64857 931.33 884.76 1,017.47

# 64640 163.22 155.06 178.32 64858 1,072.91 1,019.26 1,172.1564680 353.30 335.64 385.99 64859 250.56 238.03 273.73

# 64680 142.52 135.39 155.70 64861 1,224.44 1,163.22 1,337.7064702 310.24 294.73 338.94 64862 1,219.22 1,158.26 1,332.0064704 298.68 283.75 326.31 64864 791.76 752.17 865.0064708 429.09 407.64 468.79 64865 952.50 904.88 1,040.6164712 483.68 459.50 528.43 64866 956.28 908.47 1,044.7464713 636.75 604.91 695.65 64868 883.20 839.04 964.9064714 544.51 517.28 594.87 64870 934.82 888.08 1,021.2964716 422.69 401.56 461.79 64872 118.28 112.37 129.2364718 432.37 410.75 472.36 64874 173.75 165.06 189.8264719 364.09 345.89 397.77 64876 182.06 172.96 198.9064721 384.00 364.80 419.52 64885 1,077.81 1,023.92 1,177.51

# 64721 372.54 353.91 407.00 64886 1,268.91 1,205.46 1,386.2864722 297.72 282.83 325.25 64890 967.81 919.42 1,057.3364726 279.29 265.33 305.13 64891 904.30 859.09 987.9564727 180.23 171.22 196.90 64892 906.53 861.20 990.3864732 313.79 298.10 342.82 64893 978.27 929.36 1,068.7664734 334.78 318.04 365.75 64895 1,112.45 1,056.83 1,215.3564736 294.62 279.89 321.87 64896 1,195.62 1,135.84 1,306.2264738 364.57 346.34 398.29 64897 1,134.71 1,077.97 1,239.6764740 350.95 333.40 383.41 64898 1,216.65 1,155.82 1,329.1964742 413.91 393.21 452.19 64901 594.15 564.44 649.1164744 363.85 345.66 397.51 64902 681.54 647.46 744.5864746 397.84 377.95 434.64 64905 873.50 829.83 954.3064752 449.02 426.57 490.56 64907 1,177.28 1,118.42 1,286.1864755 746.47 709.15 815.52 65091 635.64 603.86 694.4464760 410.51 389.98 448.48 65093 658.89 625.95 719.8464761 368.17 349.76 402.22 65101 667.83 634.44 729.6164763 489.76 465.27 535.06 65103 693.37 658.70 757.5164766 547.20 519.84 597.82 65105 745.57 708.29 814.5364771 508.76 483.32 555.82 65110 1,061.89 1,008.80 1,160.1264772 474.09 450.39 517.95 65112 1,238.20 1,176.29 1,352.7364774 340.28 323.27 371.76 65114 1,277.90 1,214.01 1,396.1164776 341.61 324.53 373.21 65125 325.64 309.36 355.7664778 179.89 170.90 196.54 # 65125 169.03 160.58 184.6764782 383.41 364.24 418.88 65130 659.34 626.37 720.3364783 217.73 206.84 237.87 65135 673.53 639.85 735.83

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 50FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

65140 709.03 673.58 774.62 65855 319.89 303.90 349.4965150 609.62 579.14 666.01 # 65855 269.53 256.05 294.4665155 764.28 726.07 834.98 65860 273.20 259.54 298.4765175 613.13 582.47 669.84 # 65860 240.56 228.53 262.8165205 48.39 45.97 52.87 65865 443.59 421.41 484.62

# 65205 33.46 31.79 36.56 65870 480.10 456.10 524.5265210 58.32 55.40 63.71 65875 493.74 469.05 539.41

# 65210 42.00 39.90 45.89 65880 523.81 497.62 572.2665220 307.45 292.08 335.89 65900 846.81 804.47 925.14

# 65220 33.82 32.13 36.95 65920 594.37 564.65 649.3565222 62.29 59.18 68.06 65930 577.86 548.97 631.32

# 65222 44.93 42.68 49.08 66020 142.20 135.09 155.3565235 523.21 497.05 571.61 # 66020 113.03 107.38 123.4965260 843.37 801.20 921.38 66030 123.59 117.41 135.0265265 957.17 909.31 1,045.71 # 66030 94.07 89.37 102.7865270 209.73 199.24 229.13 66130 547.02 519.67 597.62

# 65270 152.09 144.49 166.16 # 66130 515.42 489.65 563.1065272 338.58 321.65 369.90 66150 681.71 647.62 744.76

# 65272 305.59 290.31 333.86 66155 679.96 645.96 742.8565273 337.38 320.51 368.59 66160 781.31 742.24 853.5865275 396.66 376.83 433.35 66165 664.57 631.34 726.04

# 65275 379.99 360.99 415.14 66170 1,032.51 980.88 1,128.0165280 554.26 526.55 605.53 66172 1,092.44 1,037.82 1,193.4965285 954.20 906.49 1,042.46 66180 966.97 918.62 1,056.4165286 513.93 488.23 561.46 66185 592.90 563.26 647.75

# 65286 471.91 448.31 515.56 66220 638.48 606.56 697.5465290 423.50 402.33 462.68 66225 740.39 703.37 808.8865400 519.70 493.72 567.78 66250 495.95 471.15 541.82

# 65400 468.65 445.22 512.00 # 66250 445.25 422.99 486.4465410 114.92 109.17 125.55 66500 301.59 286.51 329.49

# 65410 78.80 74.86 86.09 66505 320.95 304.90 350.6465420 438.12 416.21 478.64 66600 626.77 595.43 684.74

# 65420 399.58 379.60 436.54 66605 907.89 862.50 991.8865426 468.71 445.27 512.06 66625 458.10 435.20 500.48

# 65426 424.95 403.70 464.26 # 66625 422.33 401.21 461.3965430 345.15 327.89 377.07 66630 492.77 468.13 538.35

# 65430 79.15 75.19 86.47 66635 459.93 436.93 502.4765435 81.03 76.98 88.53 66680 415.54 394.76 453.97

# 65435 48.74 46.30 53.25 66682 494.94 470.19 540.7265436 360.02 342.02 393.32 66700 369.32 350.85 403.48

# 65436 327.03 310.68 357.28 # 66700 328.69 312.26 359.1065450 392.89 373.25 429.24 66710 358.55 340.62 391.71

# 65450 351.57 333.99 384.09 # 66710 312.37 296.75 341.2665600 315.67 299.89 344.87 66720 369.67 351.19 403.87

# 65600 178.16 169.25 194.64 # 66720 336.33 319.51 367.4465710 907.81 862.42 991.78 66740 348.13 330.72 380.3365730 946.34 899.02 1,033.87 66761 335.86 319.07 366.9365750 1,056.61 1,003.78 1,154.35 # 66761 291.76 277.17 318.7565755 1,049.13 996.67 1,146.17 66762 357.88 339.99 390.9965770 1,185.46 1,126.19 1,295.12 # 66762 310.65 295.12 339.3965772 413.31 392.64 451.54 66770 395.32 375.55 431.88

# 65772 378.59 359.66 413.61 # 66770 350.87 333.33 383.3365775 509.18 483.72 556.28 66820 431.41 409.84 471.3265800 150.71 143.17 164.65 66821 220.19 209.18 240.56

# 65800 120.85 114.81 132.03 # 66821 204.91 194.66 223.8665805 150.71 143.17 164.65 66825 664.23 631.02 725.67

# 65805 121.20 115.14 132.41 66830 546.46 519.14 597.0165810 484.06 459.86 528.84 66840 532.45 505.83 581.7065815 505.89 480.60 552.69 66850 595.88 566.09 651.00

# 65815 464.22 441.01 507.16 66852 644.16 611.95 703.7465820 676.22 642.41 738.77 66920 584.01 554.81 638.0365850 743.68 706.50 812.48 66930 685.84 651.55 749.28

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 51FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

66940 618.85 587.91 676.10 67320 233.15 221.49 254.7166982 826.02 784.72 902.43 67331 220.91 209.86 241.3466983 543.95 516.75 594.26 67332 241.75 229.66 264.1166984 649.80 617.31 709.91 67334 214.18 203.47 233.9966985 553.37 525.70 604.56 67335 133.95 127.25 146.3466986 761.15 723.09 831.55 67340 265.04 251.79 289.5666990 81.30 77.24 88.83 67343 520.77 494.73 568.9467005 306.93 291.58 335.32 67345 262.52 249.39 286.8067010 370.31 351.79 404.56 # 67345 158.69 150.76 173.3767015 542.98 515.83 593.20 67350 175.90 167.11 192.1867025 840.10 798.10 917.82 67400 834.83 793.09 912.05

# 67025 518.89 492.95 566.89 67405 728.01 691.61 795.3567027 900.16 855.15 983.42 67412 896.21 851.40 979.11

# 67027 712.99 677.34 778.94 67413 842.17 800.06 920.0767028 457.65 434.77 499.99 67414 989.87 940.38 1,081.44

# 67028 135.74 128.95 148.29 67415 94.57 89.84 103.3267030 415.95 395.15 454.42 67420 1,456.62 1,383.79 1,591.3667031 280.34 266.32 306.27 67430 1,115.30 1,059.54 1,218.47

# 67031 247.35 234.98 270.23 67440 1,070.18 1,016.67 1,169.1767036 760.86 722.82 831.24 67445 1,159.17 1,101.21 1,266.3967038 1,338.03 1,271.13 1,461.80 67450 1,089.95 1,035.45 1,190.7767039 975.95 927.15 1,066.22 67500 59.29 56.33 64.7867040 1,122.07 1,065.97 1,225.87 # 67500 36.72 34.88 40.1167101 663.78 630.59 725.18 67505 63.51 60.33 69.38

# 67101 591.90 562.31 646.66 # 67505 38.50 36.58 42.0767105 542.05 514.95 592.19 67515 52.04 49.44 56.86

# 67105 471.90 448.31 515.56 # 67515 32.60 30.97 35.6267107 1,017.45 966.58 1,111.57 67550 845.98 803.68 924.2367108 1,399.85 1,329.86 1,529.34 67560 854.96 812.21 934.0467110 1,033.28 981.62 1,128.86 67570 1,112.69 1,057.06 1,215.62

# 67110 689.84 655.35 753.65 67700 310.23 294.72 338.9367112 1,180.84 1,121.80 1,290.07 # 67700 71.32 67.75 77.9167115 424.53 403.30 463.80 67710 302.74 287.60 330.7467120 783.48 744.31 855.96 # 67710 55.15 52.39 60.25

# 67120 472.68 449.05 516.41 67715 65.89 62.60 71.9967121 822.76 781.62 898.86 67800 141.86 134.77 154.9967141 474.88 451.14 518.81 # 67800 74.49 70.77 81.39

# 67141 437.37 415.50 477.83 67801 345.82 328.53 377.8167145 385.56 366.28 421.22 # 67801 101.70 96.62 111.11

# 67145 347.02 329.67 379.12 67805 364.44 346.22 398.1567208 542.97 515.82 593.19 # 67805 119.62 113.64 130.69

# 67208 500.25 475.24 546.53 67808 288.55 274.12 315.2467210 584.98 555.73 639.09 67810 247.59 235.21 270.49

# 67210 532.20 505.59 581.43 # 67810 80.21 76.20 87.6367218 1,240.43 1,178.41 1,355.17 67820 101.82 96.73 111.2467220 870.54 827.01 951.06 # 67820 46.95 44.60 51.29

# 67220 829.21 787.75 905.91 67825 242.91 230.76 265.3767221 312.15 296.54 341.02 # 67825 88.03 83.63 96.17

# 67221 216.66 205.83 236.70 67830 448.31 425.89 489.7767225 27.16 25.80 29.67 # 67830 137.52 130.64 150.24

# 67225 24.73 23.49 27.01 67835 371.29 352.73 405.6467227 564.30 536.09 616.50 67840 350.25 332.74 382.65

# 67227 496.59 471.76 542.52 # 67840 110.30 104.79 120.5167228 822.33 781.21 898.39 67850 377.81 358.92 412.76

# 67228 731.00 694.45 798.62 # 67850 135.42 128.65 147.9567250 732.66 696.03 800.43 67875 440.10 418.10 480.8267255 746.94 709.59 816.03 # 67875 123.41 117.24 134.8367311 464.76 441.52 507.75 67880 569.48 541.01 622.1667312 572.72 544.08 625.69 # 67880 252.43 239.81 275.7867314 517.23 491.37 565.08 67882 680.59 646.56 743.5467316 632.55 600.92 691.06 # 67882 352.09 334.49 384.6667318 543.11 515.95 593.34 67900 614.31 583.59 671.13

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 52FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 67900 458.04 435.14 500.41 # 68320 381.05 362.00 416.3067901 500.72 475.68 547.03 68325 491.96 467.36 537.4667902 506.38 481.06 553.22 68326 479.82 455.83 524.2067903 665.77 632.48 727.35 68328 547.16 519.80 597.77

# 67903 494.57 469.84 540.32 68330 426.70 405.37 466.1867904 736.02 699.22 804.10 # 68330 374.26 355.55 408.88

# 67904 517.94 492.04 565.85 68335 461.82 438.73 504.5467906 593.89 564.20 648.83 68340 660.71 627.67 721.82

# 67906 482.76 458.62 527.41 # 68340 302.35 287.23 330.3167908 517.13 491.27 564.96 68360 393.30 373.64 429.69

# 67908 405.31 385.04 442.80 # 68360 346.42 329.10 378.4767909 550.23 522.72 601.13 68362 548.53 521.10 599.27

# 67909 433.55 411.87 473.65 68400 451.77 429.18 493.5667911 431.60 410.02 471.52 # 68400 137.85 130.96 150.6067914 580.74 551.70 634.46 68420 486.46 462.14 531.46

# 67914 263.00 249.85 287.33 # 68420 171.84 163.25 187.7467915 511.16 485.60 558.44 68440 296.71 281.87 324.15

# 67915 171.54 162.96 187.40 # 68440 50.85 48.31 55.5667916 749.40 711.93 818.72 68500 754.65 716.92 824.46

# 67916 385.82 366.53 421.51 68505 788.89 749.45 861.8767917 583.88 554.69 637.89 68510 601.71 571.62 657.36

# 67917 456.78 433.94 499.03 # 68510 248.90 236.46 271.9367921 560.49 532.47 612.34 68520 533.54 506.86 582.89

# 67921 244.83 232.59 267.48 68525 239.22 227.26 261.3567922 505.76 480.47 552.54 68530 618.21 587.30 675.40

# 67922 225.52 214.24 246.38 # 68530 242.83 230.69 265.2967923 740.26 703.25 808.74 68540 719.88 683.89 786.47

# 67923 410.37 389.85 448.33 68550 893.74 849.05 976.4167924 551.90 524.31 602.96 68700 479.95 455.95 524.34

# 67924 425.49 404.22 464.85 68705 357.92 340.02 391.0267930 563.62 535.44 615.76 # 68705 111.37 105.80 121.67

# 67930 243.10 230.95 265.59 68720 609.19 578.73 665.5467935 757.85 719.96 827.95 68745 593.03 563.38 647.89

# 67935 423.79 402.60 462.99 68750 611.47 580.90 668.0467938 376.87 358.03 411.73 68760 290.71 276.17 317.60

# 67938 68.16 64.75 74.46 # 68760 106.66 101.33 116.5367950 525.93 499.63 574.57 68761 155.72 147.93 170.12

# 67950 474.54 450.81 518.43 # 68761 84.53 80.30 92.3567961 532.65 506.02 581.92 68770 828.94 787.49 905.61

# 67961 415.62 394.84 454.07 # 68770 472.65 449.02 516.3767966 555.98 528.18 607.41 68801 65.09 61.84 71.12

# 67966 454.93 432.18 497.01 # 68801 55.02 52.27 60.1167971 632.08 600.48 690.55 68810 155.21 147.45 169.5767973 819.80 778.81 895.63 # 68810 102.43 97.31 111.9167974 813.83 773.14 889.11 68811 171.92 163.32 187.8267975 595.22 565.46 650.28 68815 546.62 519.29 597.1868020 313.04 297.39 342.00 # 68815 219.50 208.53 239.81

# 68020 73.78 70.09 80.60 68840 101.36 96.29 110.7368040 288.22 273.81 314.88 # 68840 79.49 75.52 86.85

# 68040 45.49 43.22 49.70 68850 548.93 521.48 599.7068100 314.74 299.00 343.85 # 68850 40.90 38.86 44.69

# 68100 72.71 69.07 79.43 69000 129.14 122.68 141.0868110 366.82 348.48 400.75 # 69000 75.32 71.55 82.28

# 68110 113.67 107.99 124.19 69005 170.17 161.66 185.9168115 371.96 353.36 406.36 # 69005 152.12 144.51 166.19

# 68115 127.14 120.78 138.90 69020 134.75 128.01 147.2168130 265.73 252.44 290.31 # 69020 82.32 78.20 89.9368135 343.32 326.15 375.07 69100 86.06 81.76 94.02

# 68135 99.20 94.24 108.38 # 69100 45.08 42.83 49.2568200 44.21 42.00 48.30 69105 85.44 81.17 93.35

# 68200 26.50 25.18 28.96 # 69105 68.42 65.00 74.7568320 395.64 375.86 432.24 69110 256.05 243.25 279.74

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 53FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 69110 230.01 218.51 251.29 69636 1,042.61 990.48 1,139.0569120 312.64 297.01 341.56 69637 1,035.13 983.37 1,130.8869140 589.61 560.13 644.15 69641 870.73 827.19 951.2769145 218.58 207.65 238.80 69642 1,134.87 1,078.13 1,239.85

# 69145 189.07 179.62 206.56 69643 1,046.59 994.26 1,143.4069150 913.66 867.98 998.18 69644 1,142.73 1,085.59 1,248.4369155 1,339.03 1,272.08 1,462.89 69645 1,107.38 1,052.01 1,209.8169200 79.75 75.76 87.12 69646 1,202.75 1,142.61 1,314.00

# 69200 56.14 53.33 61.33 69650 667.76 634.37 729.5369205 100.95 95.90 110.29 69660 797.17 757.31 870.9169210 43.72 41.53 47.76 69661 1,042.77 990.63 1,139.22

# 69210 31.91 30.31 34.86 69662 1,026.65 975.32 1,121.6269220 85.06 80.81 92.93 69666 673.81 640.12 736.14

# 69220 47.21 44.85 51.58 69667 674.89 641.15 737.3269222 131.84 125.25 144.04 69670 796.86 757.02 870.57

# 69222 113.44 107.77 123.94 69676 683.86 649.67 747.1269300 398.04 378.14 434.86 69700 510.51 484.98 557.7369310 756.45 718.63 826.42 69711 725.94 689.64 793.0969320 1,136.45 1,079.63 1,241.57 69714 932.26 885.65 1,018.5069400 84.71 80.47 92.54 69715 1,186.53 1,127.20 1,296.28

# 69400 46.17 43.86 50.44 69717 948.81 901.37 1,036.5869401 73.27 69.61 80.05 69718 1,192.16 1,132.55 1,302.43

# 69401 36.46 34.64 39.84 69720 991.92 942.32 1,083.6769405 209.22 198.76 228.57 69725 1,611.53 1,530.95 1,760.59

# 69405 152.62 144.99 166.74 69740 1,011.19 960.63 1,104.7269410 62.01 58.91 67.75 69745 1,085.23 1,030.97 1,185.62

# 69410 18.25 17.34 19.94 69801 604.48 574.26 660.4069420 133.81 127.12 146.19 69802 894.64 849.91 977.40

# 69420 76.51 72.68 83.58 69805 911.46 865.89 995.7769421 157.04 149.19 171.57 69806 850.00 807.50 928.63

# 69421 133.43 126.76 145.77 69820 710.52 674.99 776.2469424 91.69 87.11 100.18 69840 660.73 627.69 721.84

# 69424 64.26 61.05 70.21 69905 768.41 729.99 839.4969433 139.33 132.36 152.21 69910 917.04 871.19 1,001.87

# 69433 88.63 84.20 96.83 69915 1,369.26 1,300.80 1,495.9269436 147.00 139.65 160.60 69930 1,093.85 1,039.16 1,195.0369440 547.28 519.92 597.91 69950 1,605.54 1,525.26 1,754.0569450 428.34 406.92 467.96 69955 1,696.57 1,611.74 1,853.5069501 632.76 601.12 691.29 69960 1,697.87 1,612.98 1,854.9369502 849.70 807.22 928.30 69970 1,830.82 1,739.28 2,000.1769505 882.66 838.53 964.31 69990 209.72 199.23 229.1169511 915.14 869.38 999.79 70010 215.60 204.82 235.5469530 1,256.12 1,193.31 1,372.31 70010 TC 156.00 148.20 170.4369535 2,243.97 2,131.77 2,451.54 70010 26 59.60 56.62 65.1169540 125.61 119.33 137.23 70015 108.24 102.83 118.25

# 69540 102.00 96.90 111.44 70015 TC 49.00 46.55 53.5369550 766.16 727.85 837.03 70015 26 59.25 56.29 64.7369552 1,252.41 1,189.79 1,368.26 70030 23.90 22.71 26.1269554 2,044.56 1,942.33 2,233.68 70030 TC 15.29 14.53 16.7169601 924.04 877.84 1,009.52 70030 26 8.61 8.18 9.4169602 921.13 875.07 1,006.33 70100 27.74 26.35 30.3069603 945.83 898.54 1,033.32 70100 TC 18.76 17.82 20.4969604 942.70 895.57 1,029.91 70100 26 8.98 8.53 9.8169605 1,220.24 1,159.23 1,333.11 70110 34.80 33.06 38.0269610 318.46 302.54 347.92 70110 TC 22.59 21.46 24.68

# 69610 289.98 275.48 316.80 70110 26 12.22 11.61 13.3569620 466.71 443.37 509.88 70120 31.56 29.98 34.48

# 69620 338.92 321.97 370.27 70120 TC 22.59 21.46 24.6869631 701.77 666.68 766.68 70120 26 8.98 8.53 9.8169632 895.45 850.68 978.28 70130 45.37 43.10 49.5769633 857.92 815.02 937.27 70130 TC 28.49 27.07 31.1369635 888.05 843.65 970.20 70130 26 16.88 16.04 18.45

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 54FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

70134 43.98 41.78 48.05 70355 26 10.05 9.55 10.9870134 TC 27.11 25.75 29.61 70360 23.90 22.71 26.1270134 26 16.88 16.04 18.45 70360 TC 15.29 14.53 16.7170140 31.93 30.33 34.88 70360 26 8.61 8.18 9.4170140 TC 22.59 21.46 24.68 70370 63.06 59.91 68.9070140 26 9.34 8.87 10.20 70370 TC 47.26 44.90 51.6470150 41.42 39.35 45.25 70370 26 15.80 15.01 17.2670150 TC 28.49 27.07 31.13 70371 118.10 112.20 129.0370150 26 12.93 12.28 14.12 70371 TC 76.10 72.30 83.1570160 27.38 26.01 29.91 70371 26 42.01 39.91 45.9070160 TC 18.76 17.82 20.49 70373 86.54 82.21 94.5470160 26 8.61 8.18 9.41 70373 TC 64.63 61.40 70.6170170 49.48 47.01 54.06 70373 26 21.90 20.81 23.9370170 TC 34.75 33.01 37.96 70380 32.94 31.29 35.9870170 26 14.73 13.99 16.09 70380 TC 24.32 23.10 26.5770190 33.00 31.35 36.05 70380 26 8.61 8.18 9.4170190 TC 22.59 21.46 24.68 70390 83.66 79.48 91.4070190 26 10.42 9.90 11.39 70390 TC 64.63 61.40 70.6170200 42.50 40.38 46.44 70390 26 19.03 18.08 20.7970200 TC 28.49 27.07 31.13 70450 212.97 202.32 232.6770200 26 14.00 13.30 15.30 70450 TC 170.60 162.07 186.3870210 31.20 29.64 34.09 70450 26 42.37 40.25 46.2970210 TC 22.59 21.46 24.68 70460 260.68 247.65 284.8070210 26 8.61 8.18 9.41 70460 TC 204.31 194.09 223.2070220 41.06 39.01 44.86 70460 26 56.37 53.55 61.5870220 TC 28.49 27.07 31.13 70470 318.58 302.65 348.0570220 26 12.56 11.93 13.72 70470 TC 255.38 242.61 279.0070240 24.63 23.40 26.91 70470 26 63.20 60.04 69.0570240 TC 15.29 14.53 16.71 70480 234.52 222.79 256.2170240 26 9.34 8.87 10.20 70480 TC 170.60 162.07 186.3870250 34.44 32.72 37.63 70480 26 63.91 60.71 69.8270250 TC 22.59 21.46 24.68 70481 272.89 259.25 298.1470250 26 11.85 11.26 12.95 70481 TC 204.31 194.09 223.2070260 49.54 47.06 54.12 70481 26 68.59 65.16 74.9370260 TC 32.67 31.04 35.70 70482 327.21 310.85 357.4870260 26 16.88 16.04 18.45 70482 TC 255.38 242.61 279.0070300 15.11 14.35 16.50 70482 26 71.83 68.24 78.4870300 TC 9.73 9.24 10.63 70486 227.34 215.97 248.3770300 26 5.38 5.11 5.88 70486 TC 170.60 162.07 186.3870310 23.54 22.36 25.71 70486 26 56.74 53.90 61.9970310 TC 15.29 14.53 16.71 70487 268.95 255.50 293.8370310 26 8.25 7.84 9.02 70487 TC 204.31 194.09 223.2070320 39.62 37.64 43.29 70487 26 64.64 61.41 70.6270320 TC 28.49 27.07 31.13 70488 325.77 309.48 355.9070320 26 11.13 10.57 12.16 70488 TC 255.38 242.61 279.0070328 26.70 25.37 29.18 70488 26 70.39 66.87 76.9070328 TC 17.72 16.83 19.35 70490 234.17 222.46 255.8370328 26 8.98 8.53 9.81 70490 TC 170.60 162.07 186.3870330 42.43 40.31 46.36 70490 26 63.56 60.38 69.4470330 TC 30.58 29.05 33.41 70491 272.89 259.25 298.1470330 26 11.85 11.26 12.95 70491 TC 204.31 194.09 223.2070332 103.02 97.87 112.55 70491 26 68.59 65.16 74.9370332 TC 76.10 72.30 83.15 70492 327.21 310.85 357.4870332 26 26.93 25.58 29.42 70492 TC 255.38 242.61 279.0070336 478.75 454.81 523.03 70492 26 71.83 68.24 78.4870336 TC 404.79 384.55 442.23 70496 470.51 446.98 514.0370336 26 73.96 70.26 80.80 70496 TC 383.60 364.42 419.0870350 22.51 21.38 24.59 70496 26 86.91 82.56 94.9470350 TC 13.90 13.21 15.19 70498 470.85 447.31 514.4170350 26 8.61 8.18 9.41 70498 TC 383.60 364.42 419.0870355 30.90 29.36 33.76 70498 26 87.25 82.89 95.3270355 TC 20.85 19.81 22.78 70540 465.25 441.99 508.29

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 55FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

70540 TC 398.80 378.86 435.69 71040 81.90 77.81 89.4870540 26 66.45 63.13 72.60 71040 TC 52.82 50.18 57.7170542 558.44 530.52 610.10 71040 26 29.08 27.63 31.7770542 TC 478.36 454.44 522.61 71060 116.90 111.06 127.7270542 26 80.08 76.08 87.49 71060 TC 80.27 76.26 87.7070543 991.10 941.55 1,082.78 71060 26 36.63 34.80 40.0270543 TC 885.14 840.88 967.01 71090 88.78 84.34 96.9970543 26 105.95 100.65 115.75 71090 TC 61.16 58.10 66.8270544 464.40 441.18 507.36 71090 26 27.62 26.24 30.1870544 TC 404.79 384.55 442.23 71100 31.63 30.05 34.5670544 26 59.61 56.63 65.12 71100 TC 20.85 19.81 22.7870545 464.40 441.18 507.36 71100 26 10.78 10.24 11.7870545 TC 404.79 384.55 442.23 71101 37.61 35.73 41.0970545 26 59.61 56.63 65.12 71101 TC 24.32 23.10 26.5770546 881.74 837.65 963.30 71101 26 13.29 12.63 14.5270546 TC 791.98 752.38 865.24 71110 41.78 39.69 45.6470546 26 89.77 85.28 98.07 71110 TC 28.49 27.07 31.1370547 464.40 441.18 507.36 71110 26 13.29 12.63 14.5270547 TC 404.79 384.55 442.23 71111 48.47 46.05 52.9670547 26 59.61 56.63 65.12 71111 TC 32.67 31.04 35.7070548 464.40 441.18 507.36 71111 26 15.80 15.01 17.2670548 TC 404.79 384.55 442.23 71120 33.68 32.00 36.8070548 26 59.61 56.63 65.12 71120 TC 23.63 22.45 25.8270549 881.74 837.65 963.30 71120 26 10.05 9.55 10.9870549 TC 791.98 752.38 865.24 71130 36.49 34.67 39.8770549 26 89.77 85.28 98.07 71130 TC 25.71 24.42 28.0870551 478.75 454.81 523.03 71130 26 10.78 10.24 11.7870551 TC 404.79 384.55 442.23 71250 270.80 257.26 295.8570551 26 73.96 70.26 80.80 71250 TC 213.34 202.67 233.0770552 574.09 545.39 627.20 71250 26 57.46 54.59 62.7870552 TC 485.05 460.80 529.92 71260 316.79 300.95 346.0970552 26 89.04 84.59 97.28 71260 TC 255.38 242.61 279.0070553 1,016.29 965.48 1,110.30 71260 26 61.41 58.34 67.0970553 TC 898.87 853.93 982.02 71270 387.90 368.51 423.7970553 26 117.42 111.55 128.28 71270 TC 319.31 303.34 348.8471010 26.00 24.70 28.41 71270 26 68.59 65.16 74.9371010 TC 17.03 16.18 18.61 71275 533.90 507.21 583.2971010 26 8.98 8.53 9.81 71275 TC 439.43 417.46 480.0871015 29.18 27.72 31.88 71275 26 94.46 89.74 103.2071015 TC 18.76 17.82 20.49 71550 472.40 448.78 516.1071015 26 10.42 9.90 11.39 71550 TC 400.56 380.53 437.6171020 33.36 31.69 36.44 71550 26 71.83 68.24 78.4871020 TC 22.59 21.46 24.68 71551 565.24 536.98 617.5371020 26 10.78 10.24 11.78 71551 TC 479.77 455.78 524.1571021 40.40 38.38 44.14 71551 26 85.48 81.21 93.3971021 TC 27.11 25.75 29.61 71552 991.91 942.31 1,083.6671021 26 13.29 12.63 14.52 71552 TC 880.21 836.20 961.6371022 42.90 40.76 46.87 71552 26 111.69 106.11 122.0371022 TC 27.11 25.75 29.61 71555 494.92 470.17 540.7071022 26 15.79 15.00 17.25 71555 TC 404.79 384.55 442.2371023 47.87 45.48 52.30 71555 26 90.13 85.62 98.4671023 TC 28.49 27.07 31.13 72010 59.80 56.81 65.3371023 26 19.38 18.41 21.17 72010 TC 37.18 35.32 40.6271030 43.59 41.41 47.62 72010 26 22.62 21.49 24.7171030 TC 28.49 27.07 31.13 72020 22.83 21.69 24.9471030 26 15.09 14.34 16.49 72020 TC 15.29 14.53 16.7171034 75.45 71.68 82.43 72020 26 7.54 7.16 8.2371034 TC 52.12 49.51 56.94 72040 32.67 31.04 35.7071034 26 23.33 22.16 25.48 72040 TC 21.89 20.80 23.9271035 27.74 26.35 30.30 72040 26 10.78 10.24 11.7871035 TC 18.76 17.82 20.49 72050 48.46 46.04 52.9571035 26 8.98 8.53 9.81 72050 TC 32.67 31.04 35.70

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 56FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

72050 26 15.79 15.00 17.25 72141 TC 404.79 384.55 442.2372052 58.61 55.68 64.03 72141 26 79.71 75.72 87.0872052 TC 40.65 38.62 44.41 72142 581.26 552.20 635.0372052 26 17.96 17.06 19.62 72142 TC 485.05 460.80 529.9272069 29.20 27.74 31.90 72142 26 96.22 91.41 105.1272069 TC 17.72 16.83 19.35 72146 528.62 502.19 577.5272069 26 11.48 10.91 12.55 72146 TC 448.91 426.46 490.4372070 34.41 32.69 37.59 72146 26 79.71 75.72 87.0872070 TC 23.63 22.45 25.82 72147 580.91 551.86 634.6472070 26 10.78 10.24 11.78 72147 TC 485.05 460.80 529.9272072 37.88 35.99 41.39 72147 26 95.87 91.08 104.7472072 TC 27.11 25.75 29.61 72148 522.87 496.73 571.2472072 26 10.78 10.24 11.78 72148 TC 448.91 426.46 490.4372074 44.14 41.93 48.22 72148 26 73.96 70.26 80.8072074 TC 33.36 31.69 36.44 72149 574.44 545.72 627.5872074 26 10.78 10.24 11.78 72149 TC 485.05 460.80 529.9272080 35.80 34.01 39.11 72149 26 89.39 84.92 97.6672080 TC 24.32 23.10 26.57 72156 1,026.71 975.37 1,121.6872080 26 11.48 10.91 12.55 72156 TC 898.87 853.93 982.0272090 38.68 36.75 42.26 72156 26 127.84 121.45 139.6772090 TC 24.32 23.10 26.57 72157 1,026.71 975.37 1,121.6872090 26 14.35 13.63 15.67 72157 TC 898.87 853.93 982.0272100 35.80 34.01 39.11 72157 26 127.84 121.45 139.6772100 TC 24.32 23.10 26.57 72158 1,016.65 965.82 1,110.6972100 26 11.48 10.91 12.55 72158 TC 898.87 853.93 982.0272110 49.15 46.69 53.69 72158 26 117.77 111.88 128.6672110 TC 33.36 31.69 36.44 72170 27.38 26.01 29.9172110 26 15.79 15.00 17.25 72170 TC 18.76 17.82 20.4972114 61.04 57.99 66.69 72170 26 8.61 8.18 9.4172114 TC 42.74 40.60 46.69 72190 34.74 33.00 37.9572114 26 18.31 17.39 20.00 72190 TC 24.32 23.10 26.5772120 44.14 41.93 48.22 72190 26 10.42 9.90 11.3972120 TC 32.67 31.04 35.70 72191 516.36 490.54 564.1272120 26 11.48 10.91 12.55 72191 TC 426.93 405.58 466.4272125 270.80 257.26 295.85 72191 26 89.43 84.96 97.7072125 TC 213.34 202.67 233.07 72192 267.56 254.18 292.3172125 26 57.46 54.59 62.78 72192 TC 213.34 202.67 233.0772126 315.72 299.93 344.92 72192 26 54.22 51.51 59.2472126 TC 255.38 242.61 279.00 72193 304.85 289.61 333.0572126 26 60.34 57.32 65.92 72193 TC 247.39 235.02 270.2772127 382.51 363.38 417.89 72193 26 57.46 54.59 62.7872127 TC 319.31 303.34 348.84 72194 366.44 348.12 400.3472127 26 63.20 60.04 69.05 72194 TC 306.10 290.80 334.4272128 270.80 257.26 295.85 72194 26 60.34 57.32 65.9272128 TC 213.34 202.67 233.07 72195 472.75 449.11 516.4872128 26 57.46 54.59 62.78 72195 TC 400.56 380.53 437.6172129 315.72 299.93 344.92 72195 26 72.19 68.58 78.8772129 TC 255.38 242.61 279.00 72196 564.89 536.65 617.1572129 26 60.34 57.32 65.92 72196 TC 479.77 455.78 524.1572130 382.51 363.38 417.89 72196 26 85.12 80.86 92.9972130 TC 319.31 303.34 348.84 72197 998.95 949.00 1,091.3572130 26 63.20 60.04 69.05 72197 TC 887.26 842.90 969.3472131 271.15 257.59 296.23 72197 26 111.69 106.11 122.0372131 TC 213.34 202.67 233.07 72200 27.38 26.01 29.9172131 26 57.81 54.92 63.16 72200 TC 18.76 17.82 20.4972132 316.07 300.27 345.31 72200 26 8.61 8.18 9.4172132 TC 255.38 242.61 279.00 72202 31.93 30.33 34.8872132 26 60.69 57.66 66.31 72202 TC 22.59 21.46 24.6872133 382.86 363.72 418.28 72202 26 9.34 8.87 10.2072133 TC 319.31 303.34 348.84 72220 29.46 27.99 32.1972133 26 63.55 60.37 69.43 72220 TC 20.85 19.81 22.7872141 484.50 460.28 529.32 72220 26 8.61 8.18 9.41

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 57FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

72240 216.54 205.71 236.57 73110 26 8.61 8.18 9.4172240 TC 171.64 163.06 187.52 73115 84.62 80.39 92.4572240 26 44.90 42.66 49.06 73115 TC 57.34 54.47 62.6472255 200.21 190.20 218.73 73115 26 27.28 25.92 29.8172255 TC 156.00 148.20 170.43 73120 25.97 24.67 28.3772255 26 44.20 41.99 48.29 73120 TC 17.72 16.83 19.3572265 187.58 178.20 204.93 73120 26 8.25 7.84 9.0272265 TC 146.98 139.63 160.57 73130 27.72 26.33 30.2872265 26 40.60 38.57 44.36 73130 TC 19.11 18.15 20.8772270 286.02 271.72 312.48 73130 26 8.61 8.18 9.4172270 TC 220.29 209.28 240.67 73140 21.75 20.66 23.7672270 26 65.73 62.44 71.81 73140 TC 15.29 14.53 16.7172275 114.54 108.81 125.13 73140 26 6.47 6.15 7.0772275 TC 78.91 74.96 86.20 73200 233.16 221.50 254.7372275 26 35.62 33.84 38.92 73200 TC 178.94 169.99 195.4972285 359.75 341.76 393.02 73200 26 54.22 51.51 59.2472285 TC 302.63 287.50 330.63 73201 271.15 257.59 296.2372285 26 57.12 54.26 62.40 73201 TC 213.34 202.67 233.0772295 324.47 308.25 354.49 73201 26 57.81 54.92 63.1672295 TC 283.17 269.01 309.36 73202 328.92 312.47 359.3472295 26 41.30 39.24 45.13 73202 TC 267.89 254.50 292.6873000 26.66 25.33 29.13 73202 26 61.04 57.99 66.6973000 TC 18.76 17.82 20.49 73206 479.89 455.90 524.2973000 26 7.90 7.51 8.64 73206 TC 390.47 370.95 426.5973010 27.38 26.01 29.91 73206 26 89.43 84.96 97.7073010 TC 18.76 17.82 20.49 73218 465.25 441.99 508.2973010 26 8.61 8.18 9.41 73218 TC 398.80 378.86 435.6973020 24.57 23.34 26.84 73218 26 66.45 63.13 72.6073020 TC 17.03 16.18 18.61 73219 558.44 530.52 610.1073020 26 7.54 7.16 8.23 73219 TC 478.36 454.44 522.6173030 29.83 28.34 32.59 73219 26 80.08 76.08 87.4973030 TC 20.85 19.81 22.78 73220 991.80 942.21 1,083.5473030 26 8.98 8.53 9.81 73220 TC 885.14 840.88 967.0173040 103.03 97.88 112.56 73220 26 106.65 101.32 116.5273040 TC 76.10 72.30 83.15 73221 465.25 441.99 508.2973040 26 26.93 25.58 29.42 73221 TC 398.80 378.86 435.6973050 34.73 32.99 37.94 73221 26 66.45 63.13 72.6073050 TC 24.32 23.10 26.57 73222 558.09 530.19 609.7273050 26 10.40 9.88 11.36 73222 TC 478.36 454.44 522.6173060 29.46 27.99 32.19 73222 26 79.74 75.75 87.1173060 TC 20.85 19.81 22.78 73223 991.44 941.87 1,083.1573060 26 8.61 8.18 9.41 73223 TC 885.14 840.88 967.0173070 26.30 24.99 28.74 73223 26 106.30 100.99 116.1473070 TC 18.76 17.82 20.49 73500 25.64 24.36 28.0173070 26 7.54 7.16 8.23 73500 TC 17.03 16.18 18.6173080 29.46 27.99 32.19 73500 26 8.61 8.18 9.4173080 TC 20.85 19.81 22.78 73510 31.62 30.04 34.5573080 26 8.61 8.18 9.41 73510 TC 20.85 19.81 22.7873085 103.38 98.21 112.94 73510 26 10.77 10.23 11.7673085 TC 76.10 72.30 83.15 73520 37.60 35.72 41.0873085 26 27.28 25.92 29.81 73520 TC 24.32 23.10 26.5773090 26.66 25.33 29.13 73520 26 13.28 12.62 14.5173090 TC 18.76 17.82 20.49 73525 103.03 97.88 112.5673090 26 7.90 7.51 8.64 73525 TC 76.10 72.30 83.1573092 25.62 24.34 27.99 73525 26 26.93 25.58 29.4273092 TC 17.72 16.83 19.35 73530 33.13 31.47 36.1973092 26 7.90 7.51 8.64 73530 TC 18.76 17.82 20.4973100 26.32 25.00 28.75 73530 26 14.36 13.64 15.6973100 TC 17.72 16.83 19.35 73540 31.25 29.69 34.1473100 26 8.60 8.17 9.40 73540 TC 20.85 19.81 22.7873110 27.72 26.33 30.28 73540 26 10.40 9.88 11.3673110 TC 19.11 18.15 20.87 73542 104.50 99.28 114.17

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 58FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

73542 TC 76.10 72.30 83.15 73719 558.09 530.19 609.7273542 26 28.40 26.98 31.03 73719 TC 478.36 454.44 522.6173550 29.46 27.99 32.19 73719 26 79.74 75.75 87.1173550 TC 20.85 19.81 22.78 73720 991.45 941.88 1,083.1673550 26 8.61 8.18 9.41 73720 TC 885.14 840.88 967.0173560 27.73 26.34 30.29 73720 26 106.31 100.99 116.1473560 TC 18.76 17.82 20.49 73721 465.25 441.99 508.2973560 26 8.97 8.52 9.80 73721 TC 398.80 378.86 435.6973562 30.18 28.67 32.97 73721 26 66.45 63.13 72.6073562 TC 20.85 19.81 22.78 73722 558.79 530.85 610.4873562 26 9.33 8.86 10.19 73722 TC 478.36 454.44 522.6173564 34.06 32.36 37.21 73722 26 80.44 76.42 87.8873564 TC 22.59 21.46 24.68 73723 991.44 941.87 1,083.1573564 26 11.48 10.91 12.55 73723 TC 885.14 840.88 967.0173565 26.69 25.36 29.16 73723 26 106.30 100.99 116.1473565 TC 17.72 16.83 19.35 73725 495.28 470.52 541.1073565 26 8.97 8.52 9.80 73725 TC 404.79 384.55 442.2373580 121.79 115.70 133.06 73725 26 90.49 85.97 98.8773580 TC 94.86 90.12 103.64 74000 27.74 26.35 30.3073580 26 26.93 25.58 29.42 74000 TC 18.76 17.82 20.4973590 27.38 26.01 29.91 74000 26 8.98 8.53 9.8173590 TC 18.76 17.82 20.49 74010 32.34 30.72 35.3373590 26 8.61 8.18 9.41 74010 TC 20.85 19.81 22.7873592 25.97 24.67 28.37 74010 26 11.49 10.92 12.5673592 TC 17.72 16.83 19.35 74020 35.88 34.09 39.2073592 26 8.25 7.84 9.02 74020 TC 22.59 21.46 24.6873600 25.97 24.67 28.37 74020 26 13.29 12.63 14.5273600 TC 17.72 16.83 19.35 74022 42.91 40.76 46.8773600 26 8.25 7.84 9.02 74022 TC 27.11 25.75 29.6173610 27.72 26.33 30.28 74022 26 15.80 15.01 17.2673610 TC 19.11 18.15 20.87 74150 263.21 250.05 287.5673610 26 8.61 8.18 9.41 74150 TC 204.31 194.09 223.2073615 103.38 98.21 112.94 74150 26 58.90 55.96 64.3573615 TC 76.10 72.30 83.15 74160 310.59 295.06 339.3273615 26 27.28 25.92 29.81 74160 TC 247.39 235.02 270.2773620 25.97 24.67 28.37 74160 26 63.20 60.04 69.0573620 TC 17.72 16.83 19.35 74170 375.77 356.98 410.5373620 26 8.25 7.84 9.02 74170 TC 306.10 290.80 334.4273630 27.72 26.33 30.28 74170 26 69.66 66.18 76.1173630 TC 19.11 18.15 20.87 74175 520.67 494.64 568.8473630 26 8.61 8.18 9.41 74175 TC 426.93 405.58 466.4273650 25.28 24.02 27.62 74175 26 93.74 89.05 102.4173650 TC 17.03 16.18 18.61 74181 473.10 449.45 516.8773650 26 8.25 7.84 9.02 74181 TC 400.56 380.53 437.6173660 21.75 20.66 23.76 74181 26 72.54 68.91 79.2573660 TC 15.29 14.53 16.71 74182 565.24 536.98 617.5373660 26 6.47 6.15 7.07 74182 TC 479.77 455.78 524.1573700 233.16 221.50 254.73 74182 26 85.48 81.21 93.3973700 TC 178.94 169.99 195.49 74183 998.95 949.00 1,091.3573700 26 54.22 51.51 59.24 74183 TC 887.26 842.90 969.3473701 270.80 257.26 295.85 74183 26 111.69 106.11 122.0373701 TC 213.34 202.67 233.07 74185 494.21 469.50 539.9373701 26 57.46 54.59 62.78 74185 TC 404.79 384.55 442.2373702 328.23 311.82 358.59 74185 26 89.42 84.95 97.6973702 TC 267.89 254.50 292.68 74190 70.96 67.41 77.5273702 26 60.34 57.32 65.92 74190 TC 47.26 44.90 51.6473706 484.21 460.00 529.00 74190 26 23.71 22.52 25.9073706 TC 390.47 370.95 426.59 74210 60.69 57.66 66.3173706 26 93.74 89.05 102.41 74210 TC 42.74 40.60 46.6973718 465.25 441.99 508.29 74210 26 17.96 17.06 19.6273718 TC 398.80 378.86 435.69 74220 65.71 62.42 71.7873718 26 66.45 63.13 72.60 74220 TC 42.74 40.60 46.69

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 59FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

74220 26 22.98 21.83 25.10 74328 26 34.83 33.09 38.0574230 73.47 69.80 80.27 74329 148.45 141.03 162.1874230 TC 47.26 44.90 51.64 74329 TC 113.62 107.94 124.1374230 26 26.22 24.91 28.65 74329 26 34.83 33.09 38.0574235 154.11 146.40 168.36 74330 158.50 150.58 173.1774235 TC 94.86 90.12 103.64 74330 TC 113.62 107.94 124.1374235 26 59.25 56.29 64.73 74330 26 44.88 42.64 49.0474240 86.94 82.59 94.98 74340 121.44 115.37 132.6874240 TC 52.82 50.18 57.71 74340 TC 94.86 90.12 103.6474240 26 34.12 32.41 37.27 74340 26 26.58 25.25 29.0474241 87.98 83.58 96.12 74350 151.33 143.76 165.3274241 TC 53.86 51.17 58.85 74350 TC 113.62 107.94 124.1374241 26 34.12 32.41 37.27 74350 26 37.71 35.82 41.1974245 131.42 124.85 143.58 74355 132.56 125.93 144.8274245 TC 86.17 81.86 94.14 74355 TC 94.86 90.12 103.6474245 26 45.25 42.99 49.44 74355 26 37.71 35.82 41.1974246 93.54 88.86 102.19 74360 140.55 133.52 153.5574246 TC 59.42 56.45 64.92 74360 TC 113.62 107.94 124.1374246 26 34.12 32.41 37.27 74360 26 26.93 25.58 29.4274247 95.28 90.52 104.10 74363 264.10 250.90 288.5474247 TC 61.16 58.10 66.82 74363 TC 220.29 209.28 240.6774247 26 34.12 32.41 37.27 74363 26 43.81 41.62 47.8674249 138.37 131.45 151.17 74400 85.58 81.30 93.5074249 TC 93.12 88.46 101.73 74400 TC 61.16 58.10 66.8274249 26 45.25 42.99 49.44 74400 26 24.42 23.20 26.6874250 70.60 67.07 77.13 74410 94.95 90.20 103.7374250 TC 47.26 44.90 51.64 74410 TC 70.54 67.01 77.0674250 26 23.34 22.17 25.50 74410 26 24.42 23.20 26.6874251 81.38 77.31 88.91 74415 101.21 96.15 110.5774251 TC 47.26 44.90 51.64 74415 TC 76.79 72.95 83.8974251 26 34.12 32.41 37.27 74415 26 24.42 23.20 26.6874260 78.64 74.71 85.92 74420 112.81 107.17 123.2574260 TC 53.86 51.17 58.85 74420 TC 94.86 90.12 103.6474260 26 24.78 23.54 27.07 74420 26 17.96 17.06 19.6274270 95.98 91.18 104.86 74425 65.21 61.95 71.2474270 TC 61.85 58.76 67.57 74425 TC 47.26 44.90 51.6474270 26 34.12 32.41 37.27 74425 26 17.96 17.06 19.6274280 130.16 123.65 142.20 74430 54.03 51.33 59.0374280 TC 80.96 76.91 88.45 74430 TC 37.87 35.98 41.3874280 26 49.20 46.74 53.75 74430 26 16.15 15.34 17.6474283 193.32 183.65 211.20 74440 59.68 56.70 65.2174283 TC 92.77 88.13 101.35 74440 TC 40.65 38.62 44.4174283 26 100.54 95.51 109.84 74440 26 19.03 18.08 20.7974290 42.91 40.76 46.87 74445 97.04 92.19 106.0274290 TC 27.11 25.75 29.61 74445 TC 40.65 38.62 44.4174290 26 15.80 15.01 17.26 74445 26 56.39 53.57 61.6174291 25.34 24.07 27.68 74450 69.33 65.86 75.7474291 TC 15.29 14.53 16.71 74450 TC 52.82 50.18 57.7174291 26 10.05 9.55 10.98 74450 26 16.52 15.69 18.0474300 26 17.96 17.06 19.62 74455 73.85 70.16 80.6874301 26 10.42 9.90 11.39 74455 TC 57.34 54.47 62.6474305 49.32 46.85 53.88 74455 26 16.52 15.69 18.0474305 TC 28.49 27.07 31.13 74470 71.75 68.16 78.3874305 26 20.83 19.79 22.76 74470 TC 45.17 42.91 49.3574320 140.20 133.19 153.17 74470 26 26.58 25.25 29.0474320 TC 113.62 107.94 124.13 74475 173.56 164.88 189.6174320 26 26.58 25.25 29.04 74475 TC 146.98 139.63 160.5774327 98.77 93.83 107.90 74475 26 26.58 25.25 29.0474327 TC 63.94 60.74 69.85 74480 173.56 164.88 189.6174327 26 34.83 33.09 38.05 74480 TC 146.98 139.63 160.5774328 148.45 141.03 162.18 74480 26 26.58 25.25 29.0474328 TC 113.62 107.94 124.13 74485 140.55 133.52 153.55

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 60FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

74485 TC 113.62 107.94 124.13 75680 537.76 510.87 587.5074485 26 26.93 25.58 29.42 75680 TC 454.82 432.08 496.8974710 55.10 52.35 60.20 75680 26 82.94 78.79 90.6174710 TC 37.87 35.98 41.38 75685 520.17 494.16 568.2874710 26 17.23 16.37 18.83 75685 TC 454.82 432.08 496.8974740 66.28 62.97 72.42 75685 26 65.35 62.08 71.3974740 TC 47.26 44.90 51.64 75705 564.31 536.09 616.5074740 26 19.03 18.08 20.79 75705 TC 454.82 432.08 496.8974742 143.79 136.60 157.09 75705 26 109.49 104.02 119.6274742 TC 113.62 107.94 124.13 75710 512.25 486.64 559.6474742 26 30.17 28.66 32.96 75710 TC 454.82 432.08 496.8974775 84.05 79.85 91.83 75710 26 57.43 54.56 62.7474775 TC 52.82 50.18 57.71 75716 520.17 494.16 568.2874775 26 31.23 29.67 34.12 75716 TC 454.82 432.08 496.8975552 484.50 460.28 529.32 75716 26 65.35 62.08 71.3975552 TC 404.79 384.55 442.23 75722 512.25 486.64 559.6475552 26 79.71 75.72 87.08 75722 TC 454.82 432.08 496.8975553 504.26 479.05 550.91 75722 26 57.43 54.56 62.7475553 TC 404.79 384.55 442.23 75724 530.87 504.33 579.9875553 26 99.47 94.50 108.68 75724 TC 454.82 432.08 496.8975554 497.03 472.18 543.01 75724 26 76.05 72.25 83.0975554 TC 404.79 384.55 442.23 75726 511.55 485.97 558.8775554 26 92.24 87.63 100.77 75726 TC 454.82 432.08 496.8975555 493.41 468.74 539.05 75726 26 56.74 53.90 61.9975555 TC 404.79 384.55 442.23 75731 511.55 485.97 558.8775555 26 88.62 84.19 96.82 75731 TC 454.82 432.08 496.8975600 479.93 455.93 524.32 75731 26 56.74 53.90 61.9975600 TC 454.82 432.08 496.89 75733 520.17 494.16 568.2875600 26 25.11 23.85 27.43 75733 TC 454.82 432.08 496.8975605 512.25 486.64 559.64 75733 26 65.35 62.08 71.3975605 TC 454.82 432.08 496.89 75736 511.55 485.97 558.8775605 26 57.43 54.56 62.74 75736 TC 454.82 432.08 496.8975625 511.55 485.97 558.87 75736 26 56.74 53.90 61.9975625 TC 454.82 432.08 496.89 75741 520.17 494.16 568.2875625 26 56.74 53.90 61.99 75741 TC 454.82 432.08 496.8975630 564.37 536.15 616.57 75741 26 65.35 62.08 71.3975630 TC 474.28 450.57 518.16 75743 537.06 510.21 586.7475630 26 90.10 85.60 98.44 75743 TC 454.82 432.08 496.8975635 680.19 646.18 743.11 75743 26 82.24 78.13 89.8575635 TC 561.32 533.25 613.24 75746 511.55 485.97 558.8775635 26 118.87 112.93 129.87 75746 TC 454.82 432.08 496.8975650 529.14 502.68 578.08 75746 26 56.74 53.90 61.9975650 TC 454.82 432.08 496.89 75756 513.63 487.95 561.1475650 26 74.33 70.61 81.20 75756 TC 454.82 432.08 496.8975658 521.56 495.48 569.80 75756 26 58.81 55.87 64.2575658 TC 454.82 432.08 496.89 75774 473.12 449.46 516.8875658 26 66.74 63.40 72.91 75774 TC 454.82 432.08 496.8975660 520.51 494.48 568.65 75774 26 18.30 17.39 20.0075660 TC 454.82 432.08 496.89 75790 140.57 133.54 153.5775660 26 65.70 62.42 71.78 75790 TC 49.00 46.55 53.5375662 539.15 512.19 589.02 75790 26 91.57 86.99 100.0475662 TC 454.82 432.08 496.89 75801 236.54 224.71 258.4275662 26 84.33 80.11 92.13 75801 TC 195.62 185.84 213.7275665 520.52 494.49 568.66 75801 26 40.92 38.87 44.7075665 TC 454.82 432.08 496.89 75803 253.79 241.10 277.2775665 26 65.70 62.42 71.78 75803 TC 195.62 185.84 213.7275671 537.76 510.87 587.50 75803 26 58.17 55.26 63.5575671 TC 454.82 432.08 496.89 75805 260.86 247.82 284.9975671 26 82.94 78.79 90.61 75805 TC 220.29 209.28 240.6775676 520.87 494.83 569.05 75805 26 40.57 38.54 44.3275676 TC 454.82 432.08 496.89 75807 278.46 264.54 304.2275676 26 66.05 62.75 72.16 75807 TC 220.29 209.28 240.67

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 61FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

75807 26 58.17 55.26 63.55 75896 TC 757.80 719.91 827.9075809 51.84 49.25 56.64 75896 26 66.04 62.74 72.1575809 TC 28.49 27.07 31.13 75898 120.10 114.10 131.2275809 26 23.34 22.17 25.50 75898 TC 37.87 35.98 41.3875810 511.90 486.31 559.26 75898 26 82.23 78.12 89.8475810 TC 454.82 432.08 496.89 75900 781.87 742.78 854.2075810 26 57.09 54.24 62.38 75900 TC 757.46 719.59 827.5375820 69.58 66.10 76.02 75900 26 24.42 23.20 26.6875820 TC 34.75 33.01 37.96 75901 93.85 89.16 102.5375820 26 34.83 33.09 38.05 75901 TC 69.43 65.96 75.8575822 106.30 100.99 116.14 75901 26 24.42 23.20 26.6875822 TC 53.51 50.83 58.45 75902 88.83 84.39 97.0575822 26 52.79 50.15 57.67 75902 TC 69.43 65.96 75.8575825 511.90 486.31 559.26 75902 26 19.39 18.42 21.1875825 TC 454.82 432.08 496.89 75940 481.75 457.66 526.3175825 26 57.09 54.24 62.38 75940 TC 454.82 432.08 496.8975827 511.20 485.64 558.49 75940 26 26.93 25.58 29.4275827 TC 454.82 432.08 496.89 75945 185.84 176.55 203.0375827 26 56.39 53.57 61.61 75945 TC 165.04 156.79 180.3175831 511.20 485.64 558.49 75945 26 20.80 19.76 22.7275831 TC 454.82 432.08 496.89 75946 103.50 98.33 113.0875831 26 56.39 53.57 61.61 75946 TC 83.05 78.90 90.7475833 529.14 502.68 578.08 75946 26 20.46 19.44 22.3675833 TC 454.82 432.08 496.89 75952 26 248.26 235.85 271.2375833 26 74.33 70.61 81.20 75953 26 91.77 87.18 100.2675840 512.26 486.65 559.65 75954 26 90.03 85.53 98.3675840 TC 454.82 432.08 496.89 75960 579.14 550.18 632.7175840 26 57.44 54.57 62.76 75960 TC 537.86 510.97 587.6275842 528.80 502.36 577.71 75960 26 41.28 39.22 45.1075842 TC 454.82 432.08 496.89 75961 590.23 560.72 644.8375842 26 73.98 70.28 80.82 75961 TC 379.42 360.45 414.5275860 512.25 486.64 559.64 75961 26 210.80 200.26 230.3075860 TC 454.82 432.08 496.89 75962 595.72 565.93 650.8275860 26 57.43 54.56 62.74 75962 TC 568.44 540.02 621.0275870 512.25 486.64 559.64 75962 26 27.28 25.92 29.8175870 TC 454.82 432.08 496.89 75964 321.28 305.22 351.0075870 26 57.43 54.56 62.74 75964 TC 302.98 287.83 331.0075872 511.55 485.97 558.87 75964 26 18.30 17.39 20.0075872 TC 454.82 432.08 496.89 75966 634.83 603.09 693.5575872 26 56.74 53.90 61.99 75966 TC 568.44 540.02 621.0275880 69.58 66.10 76.02 75966 26 66.39 63.07 72.5375880 TC 34.75 33.01 37.96 75968 320.93 304.88 350.6175880 26 34.83 33.09 38.05 75968 TC 302.98 287.83 331.0075885 526.28 499.97 574.97 75968 26 17.95 17.05 19.6175885 TC 454.82 432.08 496.89 75970 458.24 435.33 500.6375885 26 71.46 67.89 78.07 75970 TC 416.60 395.77 455.1475887 526.28 499.97 574.97 75970 26 41.64 39.56 45.4975887 TC 454.82 432.08 496.89 75978 595.02 565.27 650.0675887 26 71.46 67.89 78.07 75978 TC 568.44 540.02 621.0275889 511.20 485.64 558.49 75978 26 26.58 25.25 29.0475889 TC 454.82 432.08 496.89 75980 267.08 253.73 291.7975889 26 56.39 53.57 61.61 75980 TC 195.62 185.84 213.7275891 511.20 485.64 558.49 75980 26 71.46 67.89 78.0775891 TC 454.82 432.08 496.89 75982 291.41 276.84 318.3775891 26 56.39 53.57 61.61 75982 TC 220.29 209.28 240.6775893 481.74 457.65 526.30 75982 26 71.12 67.56 77.6975893 TC 454.82 432.08 496.89 75984 106.09 100.79 115.9175893 26 26.93 25.58 29.42 75984 TC 70.54 67.01 77.0675894 937.12 890.26 1,023.80 75984 26 35.56 33.78 38.8575894 TC 871.42 827.85 952.03 75989 172.52 163.89 188.4775894 26 65.70 62.42 71.78 75989 TC 113.62 107.94 124.1375896 823.84 782.65 900.05 75989 26 58.90 55.96 64.35

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 62FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

75992 595.72 565.93 650.82 76076 26 11.13 10.57 12.1675992 TC 568.44 540.02 621.02 76078 37.50 35.63 40.9775992 26 27.28 25.92 29.81 76078 TC 27.45 26.08 29.9975993 321.28 305.22 351.00 76078 26 10.05 9.55 10.9875993 TC 302.98 287.83 331.00 76080 64.46 61.24 70.4375993 26 18.30 17.39 20.00 76080 TC 37.87 35.98 41.3875994 634.83 603.09 693.55 76080 26 26.58 25.25 29.0475994 TC 568.44 540.02 621.02 76085 18.16 17.25 19.8475994 26 66.39 63.07 72.53 76085 TC 14.94 14.19 16.3275995 635.18 603.42 693.93 76085 26 3.23 3.07 3.5375995 TC 568.44 540.02 621.02 76086 112.81 107.17 123.2575995 26 66.74 63.40 72.91 76086 TC 94.86 90.12 103.6475996 320.58 304.55 350.23 76086 26 17.96 17.06 19.6275996 TC 302.98 287.83 331.00 76088 154.65 146.92 168.9675996 26 17.60 16.72 19.23 76088 TC 132.38 125.76 144.6276000 55.52 52.74 60.65 76088 26 22.27 21.16 24.3376000 TC 47.26 44.90 51.64 76090 72.71 69.07 79.4376000 26 8.27 7.86 9.04 76090 TC 37.87 35.98 41.3876001 128.25 121.84 140.12 76090 26 34.83 33.09 38.0576001 TC 94.86 90.12 103.64 76091 90.35 85.83 98.7076001 26 33.39 31.72 36.48 76091 TC 47.26 44.90 51.6476003 74.19 70.48 81.05 76091 26 43.09 40.94 47.0876003 TC 47.26 44.90 51.64 76092 79.31 75.34 86.6476003 26 26.93 25.58 29.42 76092 TC 44.13 41.92 48.2176005 75.67 71.89 82.67 76092 26 35.18 33.42 38.4376005 TC 47.26 44.90 51.64 76093 717.34 681.47 783.6976005 26 28.42 27.00 31.05 76093 TC 636.19 604.38 695.0476006 22.91 21.76 25.02 76093 26 81.15 77.09 88.6576010 27.74 26.35 30.30 76094 943.53 896.35 1,030.8076010 TC 18.76 17.82 20.49 76094 TC 862.73 819.59 942.5376010 26 8.98 8.53 9.81 76094 26 80.80 76.76 88.2776012 26 73.42 69.75 80.21 76095 338.21 321.30 369.5076013 26 85.80 81.51 93.74 76095 TC 258.51 245.58 282.4276020 28.10 26.70 30.71 76095 26 79.71 75.72 87.0876020 TC 18.76 17.82 20.49 76096 75.26 71.50 82.2376020 26 9.34 8.87 10.20 76096 TC 47.26 44.90 51.6476040 42.49 40.37 46.43 76096 26 28.01 26.61 30.6076040 TC 28.49 27.07 31.13 76098 23.54 22.36 25.7176040 26 13.99 13.29 15.28 76098 TC 15.29 14.53 16.7176061 58.75 55.81 64.18 76098 26 8.25 7.84 9.0276061 TC 36.49 34.67 39.87 76100 74.25 70.54 81.1276061 26 22.27 21.16 24.33 76100 TC 45.17 42.91 49.3576062 78.70 74.77 85.99 76100 26 29.08 27.63 31.7776062 TC 52.12 49.51 56.94 76101 80.51 76.48 87.9576062 26 26.58 25.25 29.04 76101 TC 51.43 48.86 56.1976065 61.23 58.17 66.90 76101 26 29.08 27.63 31.7776065 TC 27.11 25.75 29.61 76102 91.98 87.38 100.4976065 26 34.13 32.42 37.28 76102 TC 62.90 59.76 68.7276066 55.75 52.96 60.90 76102 26 29.08 27.63 31.7776066 TC 39.96 37.96 43.65 76120 56.90 54.06 62.1776066 26 15.79 15.00 17.25 76120 TC 37.87 35.98 41.3876070 118.89 112.95 129.89 76120 26 19.03 18.08 20.7976070 TC 106.67 101.34 116.54 76125 42.13 40.02 46.0276070 26 12.22 11.61 13.35 76125 TC 28.49 27.07 31.1376071 114.28 108.57 124.86 76125 26 13.64 12.96 14.9076071 TC 103.50 98.33 113.08 76150 15.29 14.53 16.7176071 26 10.78 10.24 11.78 76355 358.44 340.52 391.6076075 126.96 120.61 138.70 76355 TC 297.77 282.88 325.3176075 TC 111.88 106.29 122.23 76355 26 60.67 57.64 66.2976075 26 15.08 14.33 16.48 76360 355.23 337.47 388.0976076 38.58 36.65 42.15 76360 TC 297.77 282.88 325.3176076 TC 27.45 26.08 29.99 76360 26 57.46 54.59 62.78

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 63FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

76362 526.63 500.30 575.35 76770 26 36.63 34.80 40.0276362 TC 328.04 311.64 358.39 76775 80.51 76.48 87.9576362 26 198.59 188.66 216.96 76775 TC 51.43 48.86 56.1976370 149.04 141.59 162.83 76775 26 29.08 27.63 31.7776370 TC 106.67 101.34 116.54 76778 107.86 102.47 117.8476370 26 42.37 40.25 46.29 76778 TC 71.23 67.67 77.8276375 135.42 128.65 147.95 76778 26 36.63 34.80 40.0276375 TC 127.51 121.13 139.30 76800 106.06 100.76 115.8776375 26 7.90 7.51 8.64 76800 TC 51.43 48.86 56.1976380 174.61 165.88 190.76 76800 26 54.63 51.90 59.6976380 TC 126.13 119.82 137.79 76801 89.53 85.05 97.8176380 26 48.48 46.06 52.97 76801 TC 39.64 37.66 43.3176393 478.77 454.83 523.05 76801 26 49.89 47.40 54.5176393 TC 403.73 383.54 441.07 76802 70.17 66.66 76.6676393 26 75.04 71.29 81.98 76802 TC 28.18 26.77 30.7976394 644.11 611.90 703.69 76802 26 41.99 39.89 45.8776394 TC 432.95 411.30 473.00 76805 125.64 119.36 137.2676394 26 211.16 200.60 230.69 76805 TC 76.10 72.30 83.1576400 484.15 459.94 528.93 76805 26 49.54 47.06 54.1276400 TC 404.79 384.55 442.23 76810 93.03 88.38 101.6476400 26 79.37 75.40 86.71 76810 TC 42.45 40.33 46.3876490 256.67 243.84 280.42 76810 26 50.58 48.05 55.2676490 TC 60.88 57.84 66.52 76811 232.51 220.88 254.0176490 26 195.78 185.99 213.89 76811 TC 134.56 127.83 147.0076506 84.06 79.86 91.84 76811 26 97.95 93.05 107.0176506 TC 51.43 48.86 56.19 76812 139.57 132.59 152.4876506 26 32.63 31.00 35.65 76812 TC 48.08 45.68 52.5376511 126.92 120.57 138.66 76812 26 91.49 86.92 99.9676511 TC 77.81 73.92 85.01 76815 84.09 79.89 91.8776511 26 49.11 46.65 53.65 76815 TC 51.43 48.86 56.1976512 115.36 109.59 126.03 76815 26 32.66 31.03 35.6876512 TC 80.60 76.57 88.06 76816 83.01 78.86 90.6976512 26 34.76 33.02 37.97 76816 TC 39.96 37.96 43.6576513 124.39 118.17 135.90 76816 26 43.06 40.91 47.0576513 TC 89.63 85.15 97.92 76817 91.88 87.29 100.3876513 26 34.76 33.02 37.97 76817 TC 54.20 51.49 59.2176516 96.06 91.26 104.95 76817 26 37.69 35.81 41.1876516 TC 67.40 64.03 73.63 76818 112.18 106.57 122.5676516 26 28.66 27.23 31.31 76818 TC 58.72 55.78 64.1576519 86.68 82.35 94.70 76818 26 53.46 50.79 58.4176519 TC 58.02 55.12 63.39 76819 97.48 92.61 106.5076519 26 28.66 27.23 31.31 76819 TC 58.72 55.78 64.1576529 107.57 102.19 117.52 76819 26 38.76 36.82 42.3476529 TC 77.82 73.93 85.02 76825 155.57 147.79 169.9676529 26 29.75 28.26 32.50 76825 TC 71.23 67.67 77.8276536 79.08 75.13 86.40 76825 26 84.34 80.12 92.1476536 TC 51.43 48.86 56.19 76826 67.70 64.32 73.9776536 26 27.65 26.27 30.21 76826 TC 26.06 24.76 28.4776604 74.55 70.82 81.44 76826 26 41.64 39.56 45.4976604 TC 47.26 44.90 51.64 76827 92.32 87.70 100.8676604 26 27.29 25.93 29.82 76827 TC 62.90 59.76 68.7276645 64.81 61.57 70.81 76827 26 29.42 27.95 32.1476645 TC 37.87 35.98 41.38 76828 69.36 65.89 75.7776645 26 26.93 25.58 29.42 76828 TC 40.66 38.63 44.4276700 111.80 106.21 122.14 76828 26 28.70 27.27 31.3676700 TC 71.23 67.67 77.82 76830 89.72 85.23 98.0176700 26 40.57 38.54 44.32 76830 TC 55.25 52.49 60.3676705 80.87 76.83 88.35 76830 26 34.47 32.75 37.6676705 TC 51.43 48.86 56.19 76831 91.15 86.59 99.5876705 26 29.44 27.97 32.17 76831 TC 55.25 52.49 60.3676770 107.86 102.47 117.84 76831 26 35.90 34.11 39.2376770 TC 71.23 67.67 77.82 76856 89.72 85.23 98.01

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 64FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

76856 TC 55.25 52.49 60.36 76986 155.17 147.41 169.5276856 26 34.47 32.75 37.66 76986 TC 94.86 90.12 103.6476857 88.85 84.41 97.07 76986 26 60.31 57.29 65.8876857 TC 69.82 66.33 76.28 77261 71.38 67.81 77.9876857 26 19.03 18.08 20.79 77262 107.64 102.26 117.6076870 87.21 82.85 95.28 77263 159.33 151.36 174.0676870 TC 55.25 52.49 60.36 77280 159.92 151.92 174.7176870 26 31.96 30.36 34.91 77280 TC 125.08 118.83 136.6576872 92.16 87.55 100.68 77280 26 34.83 33.09 38.0576872 TC 57.68 54.80 63.02 77285 253.25 240.59 276.6876872 26 34.47 32.75 37.66 77285 TC 201.18 191.12 219.7976873 154.36 146.64 168.64 77285 26 52.07 49.47 56.8976873 TC 77.15 73.29 84.28 77290 312.44 296.82 341.3476873 26 77.21 73.35 84.35 77290 TC 235.23 223.47 256.9976880 80.87 76.83 88.35 77290 26 77.21 73.35 84.3576880 TC 51.43 48.86 56.19 77295 1,234.93 1,173.18 1,349.1676880 26 29.44 27.97 32.17 77295 TC 1,009.02 958.57 1,102.3676885 91.88 87.29 100.38 77295 26 225.91 214.61 246.8076885 TC 55.25 52.49 60.36 77300 79.18 75.22 86.5076885 26 36.63 34.80 40.02 77300 TC 48.30 45.89 52.7776886 82.31 78.19 89.92 77300 26 30.88 29.34 33.7476886 TC 51.43 48.86 56.19 77301 1,414.11 1,343.40 1,544.9176886 26 30.88 29.34 33.74 77301 TC 1,009.02 958.57 1,102.3676930 89.34 84.87 97.60 77301 26 405.09 384.84 442.5776930 TC 55.25 52.49 60.36 77305 102.24 97.13 111.7076930 26 34.08 32.38 37.24 77305 TC 67.41 64.04 73.6576932 89.34 84.87 97.60 77305 26 34.83 33.09 38.0576932 TC 55.25 52.49 60.36 77310 136.51 129.68 149.1376932 26 34.08 32.38 37.24 77310 TC 84.44 80.22 92.2576936 327.40 311.03 357.68 77310 26 52.07 49.47 56.8976936 TC 227.59 216.21 248.64 77315 173.46 164.79 189.5176936 26 99.81 94.82 109.04 77315 TC 96.25 91.44 105.1676941 123.08 116.93 134.47 77315 26 77.21 73.35 84.3576941 TC 55.25 52.49 60.36 77321 192.63 183.00 210.4576941 26 67.83 64.44 74.11 77321 TC 145.58 138.30 159.0576942 139.00 132.05 151.86 77321 26 47.05 44.70 51.4176942 TC 105.26 100.00 115.00 77326 131.45 124.88 143.6176942 26 33.75 32.06 36.87 77326 TC 85.48 81.21 93.3976945 88.64 84.21 96.84 77326 26 45.97 43.67 50.2276945 TC 55.25 52.49 60.36 77327 194.04 184.34 211.9976945 26 33.39 31.72 36.48 77327 TC 125.08 118.83 136.6576946 74.28 70.57 81.16 77327 26 68.95 65.50 75.3376946 TC 55.25 52.49 60.36 77328 282.72 268.58 308.8776946 26 19.02 18.07 20.78 77328 TC 178.94 169.99 195.4976948 74.28 70.57 81.16 77328 26 103.78 98.59 113.3876948 TC 55.25 52.49 60.36 77331 61.51 58.43 67.1976948 26 19.03 18.08 20.79 77331 TC 18.07 17.17 19.7576950 76.34 72.52 83.40 77331 26 43.45 41.28 47.4776950 TC 47.26 44.90 51.64 77332 74.88 71.14 81.8176950 26 29.08 27.63 31.77 77332 TC 48.30 45.89 52.7776965 267.62 254.24 292.38 77332 26 26.58 25.25 29.0476965 TC 200.83 190.79 219.41 77333 110.81 105.27 121.0676965 26 66.79 63.45 72.97 77333 TC 68.80 65.36 75.1676970 57.98 55.08 63.34 77333 26 42.01 39.91 45.9076970 TC 37.87 35.98 41.38 77334 178.50 169.58 195.0276970 26 20.10 19.10 21.97 77334 TC 117.09 111.24 127.9376975 95.82 91.03 104.68 77334 26 61.41 58.34 67.0976975 TC 55.25 52.49 60.36 77336 107.71 102.32 117.6776975 26 40.57 38.54 44.32 77370 125.78 119.49 137.4176977 32.75 31.11 35.78 77401 64.29 61.08 70.2476977 TC 29.88 28.39 32.65 77402 64.29 61.08 70.2476977 26 2.86 2.72 3.13 77403 64.29 61.08 70.24

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 65FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

77404 64.29 61.08 70.24 77783 26 184.60 175.37 201.6877406 64.29 61.08 70.24 77784 1,010.40 959.88 1,103.8677407 75.75 71.96 82.75 77784 TC 733.13 696.47 800.9477408 75.75 71.96 82.75 77784 26 277.27 263.41 302.9277409 75.75 71.96 82.75 77789 71.64 68.06 78.2777411 75.75 71.96 82.75 77789 TC 16.33 15.51 17.8477412 84.44 80.22 92.25 77789 26 55.30 52.54 60.4277413 84.44 80.22 92.25 77790 70.14 66.63 76.6277414 84.44 80.22 92.25 77790 TC 18.07 17.17 19.7577416 84.44 80.22 92.25 77790 26 52.07 49.47 56.8977417 21.54 20.46 23.53 78000 45.13 42.87 49.3077418 627.89 596.50 685.98 78000 TC 35.44 33.67 38.7277427 164.12 155.91 179.30 78000 26 9.69 9.21 10.5977431 92.90 88.26 101.50 78001 60.18 57.17 65.7577432 406.09 385.79 443.66 78001 TC 47.26 44.90 51.6477470 506.49 481.17 553.35 78001 26 12.93 12.28 14.1277470 TC 402.70 382.57 439.96 78003 51.61 49.03 56.3877470 26 103.78 98.59 113.38 78003 TC 35.44 33.67 38.7277600 188.06 178.66 205.46 78003 26 16.17 15.36 17.6677600 TC 110.14 104.63 120.32 78006 110.59 105.06 120.8277600 26 77.92 74.02 85.12 78006 TC 86.17 81.86 94.1477605 251.82 239.23 275.11 78006 26 24.42 23.20 26.6877605 TC 146.63 139.30 160.20 78007 117.90 112.01 128.8177605 26 105.19 99.93 114.92 78007 TC 93.12 88.46 101.7377610 187.71 178.32 205.07 78007 26 24.78 23.54 27.0777610 TC 110.14 104.63 120.32 78010 85.76 81.47 93.6977610 26 77.57 73.69 84.74 78010 TC 66.02 62.72 72.1377615 250.41 237.89 273.57 78010 26 19.74 18.75 21.5677615 TC 146.63 139.30 160.20 78011 109.83 104.34 119.9977615 26 103.78 98.59 113.38 78011 TC 87.21 82.85 95.2877620 187.70 178.32 205.07 78011 26 22.62 21.49 24.7177620 TC 110.14 104.63 120.32 78015 126.52 120.19 138.2277620 26 77.56 73.68 84.73 78015 TC 93.12 88.46 101.7377750 290.72 276.18 317.61 78015 26 33.39 31.72 36.4877750 TC 48.30 45.89 52.77 78016 166.71 158.37 182.1377750 26 242.43 230.31 264.86 78016 TC 125.43 119.16 137.0377761 274.73 260.99 300.14 78016 26 41.28 39.22 45.1077761 TC 91.04 86.49 99.46 78018 239.04 227.09 261.1577761 26 183.69 174.51 200.69 78018 TC 195.97 186.17 214.1077762 412.60 391.97 450.77 78018 26 43.08 40.93 47.0777762 TC 130.30 123.79 142.36 78020 79.52 75.54 86.8777762 26 282.31 268.19 308.42 78020 TC 49.37 46.90 53.9477763 585.36 556.09 639.50 78020 26 30.15 28.64 32.9477763 TC 161.91 153.81 176.88 78070 106.95 101.60 116.8477763 26 423.45 402.28 462.62 78070 TC 66.02 62.72 72.1377776 291.07 276.52 318.00 78070 26 40.93 38.88 44.7177776 TC 79.23 75.27 86.56 78075 233.29 221.63 254.8777776 26 211.84 201.25 231.44 78075 TC 195.97 186.17 214.1077777 522.12 496.01 570.41 78075 26 37.33 35.46 40.7877777 TC 152.88 145.24 167.03 78102 101.65 96.57 111.0677777 26 369.24 350.78 403.40 78102 TC 74.01 70.31 80.8677778 739.35 702.38 807.74 78102 26 27.64 26.26 30.2077778 TC 185.19 175.93 202.32 78103 152.00 144.40 166.0677778 26 554.15 526.44 605.41 78103 TC 114.31 108.59 124.8877781 815.72 774.93 891.17 78103 26 37.69 35.81 41.1877781 TC 733.13 696.47 800.94 78104 186.83 177.49 204.1177781 26 82.59 78.46 90.23 78104 TC 146.98 139.63 160.5777782 856.67 813.84 935.92 78104 26 39.85 37.86 43.5477782 TC 733.13 696.47 800.94 78110 44.44 42.22 48.5577782 26 123.53 117.35 134.95 78110 TC 34.75 33.01 37.9677783 917.73 871.84 1,002.62 78110 26 9.69 9.21 10.5977783 TC 733.13 696.47 800.94 78111 104.25 99.04 113.90

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 66FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

78111 TC 93.12 88.46 101.73 78220 26 24.42 23.20 26.6878111 26 11.13 10.57 12.16 78223 174.39 165.67 190.5278120 74.39 70.67 81.27 78223 TC 132.38 125.76 144.6278120 TC 62.90 59.76 68.72 78223 26 42.01 39.91 45.9078120 26 11.49 10.92 12.56 78230 101.49 96.42 110.8878121 121.08 115.03 132.28 78230 TC 79.23 75.27 86.5678121 TC 104.93 99.68 114.63 78230 26 22.27 21.16 24.3378121 26 16.15 15.34 17.64 78231 140.52 133.49 153.5178122 188.70 179.27 206.16 78231 TC 114.31 108.59 124.8878122 TC 166.08 157.78 181.45 78231 26 26.20 24.89 28.6278122 26 22.62 21.49 24.71 78232 150.85 143.31 164.8178130 133.71 127.02 146.07 78232 TC 127.51 121.13 139.3078130 TC 102.85 97.71 112.37 78232 26 23.34 22.17 25.5078130 26 30.87 29.33 33.73 78258 140.87 133.83 153.9078135 208.46 198.04 227.75 78258 TC 103.89 98.70 113.5178135 TC 176.16 167.35 192.45 78258 26 36.98 35.13 40.4078135 26 32.30 30.69 35.29 78261 182.83 173.69 199.7478140 172.63 164.00 188.60 78261 TC 148.02 140.62 161.7178140 TC 142.11 135.00 155.25 78261 26 34.81 33.07 38.0378140 26 30.52 28.99 33.34 78262 187.68 178.30 205.0578160 149.60 142.12 163.44 78262 TC 153.57 145.89 167.7778160 TC 132.38 125.76 144.62 78262 26 34.10 32.40 37.2678160 26 17.22 16.36 18.81 78264 187.84 178.45 205.2278162 138.66 131.73 151.49 78264 TC 149.06 141.61 162.8578162 TC 115.36 109.59 126.03 78264 26 38.78 36.84 42.3778162 26 23.30 22.14 25.46 78270 66.35 63.03 72.4878170 212.62 201.99 232.29 78270 TC 56.29 53.48 61.5078170 TC 191.45 181.88 209.16 78270 26 10.05 9.55 10.9878170 26 21.17 20.11 23.13 78271 69.47 66.00 75.9078172 26 26.22 24.91 28.65 78271 TC 59.42 56.45 64.9278185 105.58 100.30 115.35 78271 26 10.05 9.55 10.9878185 TC 85.48 81.21 93.39 78272 97.73 92.84 106.7778185 26 20.10 19.10 21.97 78272 TC 84.09 79.89 91.8778190 262.01 248.91 286.25 78272 26 13.64 12.96 14.9078190 TC 206.39 196.07 225.48 78278 225.35 214.08 246.1978190 26 55.62 52.84 60.77 78278 TC 176.16 167.35 192.4578191 294.93 280.18 322.21 78278 26 49.20 46.74 53.7578191 TC 264.41 251.19 288.87 78282 26 19.38 18.41 21.1778191 26 30.52 28.99 33.34 78290 144.25 137.04 157.6078195 207.28 196.92 226.46 78290 TC 110.14 104.63 120.3278195 TC 146.98 139.63 160.57 78290 26 34.10 32.40 37.2678195 26 60.31 57.29 65.88 78291 154.65 146.92 168.9678201 107.38 102.01 117.31 78291 TC 110.49 104.97 120.7278201 TC 85.48 81.21 93.39 78291 26 44.16 41.95 48.2478201 26 21.90 20.81 23.93 78300 121.23 115.17 132.4578202 129.38 122.91 141.35 78300 TC 90.34 85.82 98.6978202 TC 103.89 98.70 113.51 78300 26 30.88 29.34 33.7478202 26 25.49 24.22 27.85 78305 173.67 164.99 189.7478205 248.88 236.44 271.91 78305 TC 132.38 125.76 144.6278205 TC 213.34 202.67 233.07 78305 26 41.29 39.23 45.1178205 26 35.54 33.76 38.82 78306 197.35 187.48 215.6078206 255.46 242.69 279.09 78306 TC 154.27 146.56 168.5478206 TC 207.35 196.98 226.53 78306 26 43.08 40.93 47.0778206 26 48.11 45.70 52.56 78315 223.67 212.49 244.3678215 130.39 123.87 142.45 78315 TC 172.69 164.06 188.6778215 TC 105.97 100.67 115.77 78315 26 50.98 48.43 55.6978215 26 24.42 23.20 26.68 78320 265.39 252.12 289.9478216 153.80 146.11 168.03 78320 TC 213.34 202.67 233.0778216 TC 125.43 119.16 137.03 78320 26 52.05 49.45 56.8778216 26 28.37 26.95 30.99 78350 38.58 36.65 42.1578220 158.53 150.60 173.19 78350 TC 27.45 26.08 29.9978220 TC 134.12 127.41 146.52 78350 26 11.13 10.57 12.16

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 67FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

78414 26 22.62 21.49 24.71 78496 278.74 264.80 304.5278428 121.48 115.41 132.72 78496 TC 253.27 240.61 276.7078428 TC 81.66 77.58 89.22 78496 26 25.47 24.20 27.8378428 26 39.82 37.83 43.50 78580 160.67 152.64 175.5478445 92.17 87.56 100.69 78580 TC 123.69 117.51 135.1478445 TC 67.41 64.04 73.65 78580 26 36.98 35.13 40.4078445 26 24.76 23.52 27.05 78584 164.55 156.32 179.7778455 180.46 171.44 197.16 78584 TC 115.36 109.59 126.0378455 TC 143.85 136.66 157.16 78584 26 49.20 46.74 53.7578455 26 36.62 34.79 40.01 78585 258.18 245.27 282.0678456 196.56 186.73 214.74 78585 TC 203.61 193.43 222.4478456 TC 146.31 138.99 159.84 78585 26 54.57 51.84 59.6278456 26 50.25 47.74 54.90 78586 113.92 108.22 124.4578457 134.66 127.93 147.12 78586 TC 93.82 89.13 102.5078457 TC 96.25 91.44 105.16 78586 26 20.10 19.10 21.9778457 26 38.42 36.50 41.98 78587 125.87 119.58 137.5278458 190.11 180.60 207.69 78587 TC 101.46 96.39 110.8578458 TC 144.89 137.65 158.30 78587 26 24.42 23.20 26.6878458 26 45.23 42.97 49.42 78588 170.28 161.77 186.0478459 26 76.41 72.59 83.48 78588 TC 115.71 109.92 126.4178460 128.21 121.80 140.07 78588 26 54.57 51.84 59.6278460 TC 85.48 81.21 93.39 78591 122.95 116.80 134.3278460 26 42.73 40.59 46.68 78591 TC 102.85 97.71 112.3778461 232.69 221.06 254.22 78591 26 20.10 19.10 21.9778461 TC 170.60 162.07 186.38 78593 148.81 141.37 162.5878461 26 62.09 58.99 67.84 78593 TC 124.39 118.17 135.9078464 309.95 294.45 338.62 78593 26 24.42 23.20 26.6878464 TC 255.38 242.61 279.00 78594 206.20 195.89 225.2778464 26 54.57 51.84 59.62 78594 TC 179.63 170.65 196.2578465 499.21 474.25 545.39 78594 26 26.56 25.23 29.0178465 TC 425.63 404.35 465.00 78596 318.58 302.65 348.0578465 26 73.57 69.89 80.37 78596 TC 255.38 242.61 279.0078466 129.67 123.19 141.67 78596 26 63.20 60.04 69.0578466 TC 94.86 90.12 103.64 78600 126.14 119.83 137.8078466 26 34.81 33.07 38.03 78600 TC 103.89 98.70 113.5178468 172.24 163.63 188.17 78600 26 22.25 21.14 24.3178468 TC 132.38 125.76 144.62 78601 148.49 141.07 162.2378468 26 39.85 37.86 43.54 78601 TC 123.00 116.85 134.3878469 233.93 222.23 255.56 78601 26 25.49 24.22 27.8578469 TC 188.32 178.90 205.74 78605 149.56 142.08 163.3978469 26 45.60 43.32 49.82 78605 TC 123.00 116.85 134.3878472 248.28 235.87 271.25 78605 26 26.56 25.23 29.0178472 TC 199.10 189.15 217.52 78606 171.63 163.05 187.5178472 26 49.18 46.72 53.73 78606 TC 139.68 132.70 152.6178473 371.36 352.79 405.71 78606 26 31.96 30.36 34.9178473 TC 297.77 282.88 325.31 78607 299.06 284.11 326.7378473 26 73.59 69.91 80.40 78607 TC 236.97 225.12 258.8978478 87.87 83.48 96.00 78607 26 62.09 58.99 67.8478478 TC 56.64 53.81 61.88 78610 72.41 68.79 79.1178478 26 31.22 29.66 34.11 78610 TC 57.34 54.47 62.6478480 87.87 83.48 96.00 78610 26 15.08 14.33 16.4878480 TC 56.64 53.81 61.88 78615 160.51 152.48 175.3578480 26 31.22 29.66 34.11 78615 TC 138.98 132.03 151.8378481 237.84 225.95 259.84 78615 26 21.52 20.44 23.5178481 TC 188.32 178.90 205.74 78630 216.17 205.36 236.1678481 26 49.52 47.04 54.10 78630 TC 182.07 172.97 198.9278483 358.50 340.58 391.67 78630 26 34.10 32.40 37.2678483 TC 283.87 269.68 310.13 78635 123.29 117.13 134.7078483 26 74.63 70.90 81.54 78635 TC 92.08 87.48 100.6078494 312.86 297.22 341.80 78635 26 31.21 29.65 34.1078494 TC 253.27 240.61 276.70 78645 152.06 144.46 166.1378494 26 59.59 56.61 65.10 78645 TC 123.69 117.51 135.14

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 68FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

78645 26 28.37 26.95 30.99 78805 TC 123.00 116.85 134.3878647 258.56 245.63 282.47 78805 26 36.62 34.79 40.0178647 TC 213.34 202.67 233.07 78806 275.53 261.75 301.0178647 26 45.23 42.97 49.42 78806 TC 232.45 220.83 253.9578650 197.99 188.09 216.30 78806 26 43.08 40.93 47.0778650 TC 167.47 159.10 182.97 78807 292.23 277.62 319.2678650 26 30.51 28.98 33.33 78807 TC 236.97 225.12 258.8978660 103.36 98.19 112.92 78807 26 55.26 52.50 60.3878660 TC 76.79 72.95 83.89 79000 184.62 175.39 201.7078660 26 26.56 25.23 29.01 79000 TC 94.86 90.12 103.6478700 132.76 126.12 145.04 79000 26 89.76 85.27 98.0678700 TC 110.14 104.63 120.32 79001 99.67 94.69 108.8978700 26 22.62 21.49 24.71 79001 TC 47.26 44.90 51.6478701 152.63 145.00 166.75 79001 26 52.42 49.80 57.2778701 TC 128.21 121.80 140.07 79020 184.64 175.41 201.7278701 26 24.42 23.20 26.68 79020 TC 94.86 90.12 103.6478704 179.78 170.79 196.41 79020 26 89.78 85.29 98.0878704 TC 142.80 135.66 156.01 79030 199.69 189.71 218.1778704 26 36.98 35.13 40.40 79030 TC 94.86 90.12 103.6478707 209.32 198.85 228.68 79030 26 104.84 99.60 114.5478707 TC 161.22 153.16 176.13 79035 221.21 210.15 241.6778707 26 48.11 45.70 52.56 79035 TC 94.86 90.12 103.6478708 221.89 210.80 242.42 79035 26 126.36 120.04 138.0578708 TC 161.22 153.16 176.13 79100 161.26 153.20 176.1878708 26 60.67 57.64 66.29 79100 TC 94.86 90.12 103.6478709 231.59 220.01 253.01 79100 26 66.40 63.08 72.5478709 TC 161.22 153.16 176.13 79200 194.65 184.92 212.6678709 26 70.37 66.85 76.88 79200 TC 94.86 90.12 103.6478710 246.37 234.05 269.16 79200 26 99.79 94.80 109.0278710 TC 213.34 202.67 233.07 79300 26 81.10 77.05 88.6178710 26 33.03 31.38 36.09 79400 193.22 183.56 211.0978715 72.41 68.79 79.11 79400 TC 94.86 90.12 103.6478715 TC 57.34 54.47 62.64 79400 26 98.36 93.44 107.4678715 26 15.08 14.33 16.48 79420 26 75.05 71.30 82.0078725 83.31 79.14 91.01 79440 196.04 186.24 214.1878725 TC 64.63 61.40 70.61 79440 TC 94.86 90.12 103.6478725 26 18.68 17.75 20.41 79440 26 101.19 96.13 110.5578730 71.12 67.56 77.69 80500 21.44 20.37 23.4378730 TC 52.82 50.18 57.71 # 80500 19.70 18.72 21.5378730 26 18.30 17.39 20.00 80502 72.67 69.04 79.4078740 104.81 99.57 114.51 # 80502 70.93 67.38 77.4978740 TC 76.79 72.95 83.89 83020 26 19.36 18.39 21.1578740 26 28.02 26.62 30.61 83912 26 19.01 18.06 20.7778760 129.97 123.47 141.99 84165 26 19.36 18.39 21.1578760 TC 96.94 92.09 105.90 84181 26 18.66 17.73 20.3978760 26 33.03 31.38 36.09 84182 26 19.70 18.72 21.5378761 150.90 143.36 164.86 85060 23.66 22.48 25.8578761 TC 115.36 109.59 126.03 85097 98.07 93.17 107.1578761 26 35.54 33.76 38.82 # 85097 49.46 46.99 54.0478800 156.03 148.23 170.46 85390 26 18.31 17.39 20.0078800 TC 123.00 116.85 134.38 85576 26 19.36 18.39 21.1578800 26 33.03 31.38 36.09 86077 51.54 48.96 56.3078801 192.02 182.42 209.78 # 86077 49.80 47.31 54.4178801 TC 152.53 144.90 166.64 86078 52.93 50.28 57.8278801 26 39.49 37.52 43.15 # 86078 49.80 47.31 54.4178802 242.87 230.73 265.34 86079 52.58 49.95 57.4478802 TC 199.79 189.80 218.27 # 86079 49.80 47.31 54.4178802 26 43.08 40.93 47.07 86255 26 19.70 18.72 21.5378803 291.88 277.29 318.88 86256 26 19.36 18.39 21.1578803 TC 236.97 225.12 258.89 86320 26 19.70 18.72 21.5378803 26 54.91 52.16 59.98 # 86320 26 19.36 18.39 21.1578805 159.62 151.64 174.39 86325 26 19.36 18.39 21.15

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 69FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

86327 26 22.21 21.10 24.27 88309 TC 81.98 77.88 89.5686334 26 19.36 18.39 21.15 88309 26 121.10 115.05 132.3186490 10.77 10.23 11.76 88311 16.37 15.55 17.8886510 11.82 11.23 12.91 88311 TC 3.48 3.31 3.8186580 9.39 8.92 10.26 88311 26 12.89 12.25 14.0986585 7.30 6.94 7.98 88312 76.59 72.76 83.6787164 26 17.97 17.07 19.63 88312 TC 47.93 45.53 52.3687207 26 19.70 18.72 21.53 88312 26 28.66 27.23 31.3188104 49.19 46.73 53.74 88313 50.75 48.21 55.4488104 TC 19.46 18.49 21.26 88313 TC 37.86 35.97 41.3788104 26 29.74 28.25 32.49 88313 26 12.89 12.25 14.0988106 43.29 41.13 47.30 88314 46.93 44.58 51.2788106 TC 13.55 12.87 14.80 88314 TC 22.93 21.78 25.0588106 26 29.74 28.25 32.49 88314 26 24.00 22.80 26.2288107 64.11 60.90 70.04 88318 41.67 39.59 45.5388107 TC 23.62 22.44 25.81 88318 TC 19.45 18.48 21.2588107 26 40.48 38.46 44.23 88318 26 22.21 21.10 24.2788108 50.58 48.05 55.26 88319 96.37 91.55 105.2888108 TC 20.84 19.80 22.77 88319 TC 68.07 64.67 74.3788108 26 29.74 28.25 32.49 88319 26 28.30 26.89 30.9288125 20.57 19.54 22.47 88321 77.48 73.61 84.6588125 TC 6.60 6.27 7.21 # 88321 68.80 65.36 75.1688125 26 13.97 13.27 15.26 88323 100.84 95.80 110.1788141 22.21 21.10 24.27 88323 TC 28.83 27.39 31.5088160 53.61 50.93 58.57 88323 26 72.01 68.41 78.6788160 TC 27.10 25.75 29.61 88325 185.25 175.99 202.3988160 26 26.52 25.19 28.97 # 88325 117.88 111.99 128.7988161 51.88 49.29 56.68 88329 47.97 45.57 52.4188161 TC 25.36 24.09 27.70 # 88329 35.47 33.70 38.7688161 26 26.52 25.19 28.97 88331 81.48 77.41 89.0288162 54.04 51.34 59.04 88331 TC 18.07 17.17 19.7588162 TC 13.55 12.87 14.80 88331 26 63.41 60.24 69.2888162 26 40.48 38.46 44.23 88332 40.91 38.86 44.6988172 47.18 44.82 51.54 88332 TC 9.39 8.92 10.2688172 TC 15.29 14.53 16.71 88332 26 31.52 29.94 34.4388172 26 31.89 30.30 34.85 88342 78.14 74.23 85.3688173 116.53 110.70 127.31 88342 TC 33.00 31.35 36.0588173 TC 42.72 40.58 46.67 88342 26 45.14 42.88 49.3188173 26 73.81 70.12 80.64 88346 83.72 79.53 91.4688180 55.81 53.02 60.97 88346 TC 38.21 36.30 41.7588180 TC 36.82 34.98 40.23 88346 26 45.51 43.23 49.7188180 26 18.99 18.04 20.75 88347 97.61 92.73 106.6488182 84.27 80.06 92.07 88347 TC 52.79 50.15 57.6788182 TC 43.07 40.92 47.06 88347 26 44.81 42.57 48.9688182 26 41.20 39.14 45.01 88348 339.68 322.70 371.1188291 30.02 28.52 32.80 88348 TC 259.78 246.79 283.8188300 14.03 13.33 15.33 88348 26 79.91 75.91 87.3088300 TC 9.38 8.91 10.25 88349 356.16 338.35 389.1088300 26 4.65 4.42 5.08 88349 TC 315.68 299.90 344.8988302 31.13 29.57 34.01 88349 26 40.48 38.46 44.2388302 TC 23.97 22.77 26.19 88355 160.01 152.01 174.8188302 26 7.16 6.80 7.82 88355 TC 61.49 58.42 67.1888304 40.30 38.29 44.03 88355 26 98.52 93.59 107.6388304 TC 28.48 27.06 31.12 88356 213.67 202.99 233.4488304 26 11.82 11.23 12.91 88356 TC 55.24 52.48 60.3588305 90.48 85.96 98.85 88356 26 158.42 150.50 173.0888305 TC 50.71 48.17 55.40 88358 167.85 159.46 183.3888305 26 39.77 37.78 43.45 88358 TC 18.43 17.51 20.1488307 156.11 148.30 170.55 88358 26 149.42 141.95 163.2488307 TC 71.56 67.98 78.18 88362 240.75 228.71 263.0288307 26 84.55 80.32 92.37 88362 TC 126.43 120.11 138.1388309 203.08 192.93 221.87 88362 26 114.32 108.60 124.89

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 70FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

88365 106.05 100.75 115.86 90818 94.75 90.01 103.5188365 TC 56.96 54.11 62.23 90819 99.53 94.55 108.7388365 26 49.09 46.64 53.64 90821 140.73 133.69 153.7488371 26 18.31 17.39 20.00 90822 144.82 137.58 158.2288372 26 19.70 18.72 21.53 90823 67.50 64.13 73.7589060 26 19.70 18.72 21.53 90824 74.01 70.31 80.8689100 82.24 78.13 89.85 90826 100.50 95.48 109.80

# 89100 30.15 28.64 32.94 90827 104.92 99.67 114.6289105 98.05 93.15 107.12 90828 147.17 139.81 160.78

# 89105 25.13 23.87 27.45 90829 150.20 142.69 164.0989130 85.47 81.20 93.38 90845 87.30 82.94 95.38

# 89130 21.57 20.49 23.56 # 90845 86.26 81.95 94.2489132 68.37 64.95 74.69 90846 91.18 86.62 99.61

# 89132 9.69 9.21 10.59 # 90846 90.84 86.30 99.2589135 90.54 86.01 98.91 90847 111.25 105.69 121.54

# 89135 38.80 36.86 42.39 # 90847 109.17 103.71 119.2789136 69.45 65.98 75.88 90849 31.52 29.94 34.43

# 89136 10.76 10.22 11.75 # 90849 30.48 28.96 33.3089140 112.31 106.69 122.69 90853 30.82 29.28 33.67

# 89140 44.94 42.69 49.09 # 90853 30.13 28.62 32.9189141 129.18 122.72 141.13 90857 34.37 32.65 37.55

# 89141 44.10 41.90 48.19 # 90857 32.63 31.00 35.6589350 14.94 14.19 16.32 90862 49.47 47.00 54.0589360 16.33 15.51 17.84 # 90862 46.69 44.36 51.0190471 7.30 6.94 7.98 90865 161.94 153.84 176.9290472 5.21 4.95 5.69 # 90865 137.28 130.42 149.9890780 40.31 38.29 44.03 90870 97.86 92.97 106.9290781 20.50 19.48 22.40 90871 138.47 131.55 151.2890782 4.17 3.96 4.55 90880 118.16 112.25 129.0990783 14.94 14.19 16.32 # 90880 106.01 100.71 115.8290784 17.38 16.51 18.99 90901 45.47 43.20 49.6890788 4.52 4.29 4.93 # 90901 22.20 21.09 24.2590801 145.20 137.94 158.63 90911 64.31 61.09 70.25

# 90801 137.21 130.35 149.90 # 90911 46.26 43.95 50.5490802 154.57 146.84 168.87 90918 679.41 645.44 742.26

# 90802 146.93 139.58 160.52 90919 463.98 440.78 506.9090804 62.74 59.60 68.54 90920 407.04 386.69 444.69

# 90804 58.58 55.65 64.00 90921 254.89 242.15 278.4790805 68.90 65.46 75.28 90922 21.44 20.37 23.43

# 90805 66.13 62.82 72.24 90923 15.04 14.29 16.4390806 94.01 89.31 102.71 90924 13.24 12.58 14.47

# 90806 90.54 86.01 98.91 90925 8.58 8.15 9.3790807 100.18 95.17 109.45 90935 69.36 65.89 75.77

# 90807 97.75 92.86 106.79 90937 113.52 107.84 124.0290808 140.33 133.31 153.31 90945 72.93 69.28 79.67

# 90808 136.16 129.35 148.75 90947 116.04 110.24 126.7890809 145.10 137.85 158.53 90997 118.29 112.38 129.24

# 90809 142.67 135.54 155.87 91000 39.40 37.43 43.0490810 67.43 64.06 73.67 91000 TC 3.13 2.97 3.42

# 90810 63.96 60.76 69.87 91000 26 36.27 34.46 39.6390811 75.33 71.56 82.29 91010 144.45 137.23 157.81

# 90811 71.51 67.93 78.12 91010 TC 81.63 77.55 89.1890812 101.83 96.74 111.25 91010 26 62.82 59.68 68.63

# 90812 96.28 91.47 105.19 91011 168.46 160.04 184.0590813 106.61 101.28 116.47 91011 TC 93.44 88.77 102.09

# 90813 103.13 97.97 112.67 91011 26 75.03 71.28 81.9790814 147.10 139.75 160.71 91012 172.23 163.62 188.16

# 90814 142.94 135.79 156.16 91012 TC 98.65 93.72 107.7890815 151.18 143.62 165.16 91012 26 73.58 69.90 80.39

# 90815 147.71 140.32 161.37 91020 162.12 154.01 177.1190816 63.15 59.99 68.99 91020 TC 90.31 85.79 98.6690817 68.62 65.19 74.97 91020 26 71.81 68.22 78.45

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 71FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

91030 124.08 117.88 135.56 # 92130 43.34 41.17 47.3591030 TC 78.49 74.57 85.76 92135 66.90 63.56 73.0991030 26 45.59 43.31 49.81 92135 TC 48.27 45.86 52.7491032 131.88 125.29 144.08 92135 26 18.63 17.70 20.3691032 TC 71.21 67.65 77.80 92136 87.37 83.00 95.4591032 26 60.67 57.64 66.29 92136 TC 58.71 55.77 64.1491033 143.85 136.66 157.16 92136 26 28.66 27.23 31.3191033 TC 78.52 74.59 85.78 92140 52.90 50.26 57.8091033 26 65.33 62.06 71.37 # 92140 26.16 24.85 28.5891052 113.12 107.46 123.58 92225 21.80 20.71 23.8291052 TC 73.63 69.95 80.44 # 92225 19.72 18.73 21.5491052 26 39.49 37.52 43.15 92226 19.64 18.66 21.4691055 111.63 106.05 121.96 # 92226 17.55 16.67 19.1791055 TC 66.68 63.35 72.85 92230 81.20 77.14 88.7191055 26 44.95 42.70 49.11 # 92230 29.46 27.99 32.1991060 28.18 26.77 30.79 92235 122.54 116.41 133.8791060 TC 6.26 5.95 6.84 92235 TC 79.20 75.24 86.5391060 26 21.92 20.82 23.94 92235 26 43.34 41.17 47.3591065 143.06 135.91 156.30 92240 219.20 208.24 239.4891065 TC 133.01 126.36 145.31 92240 TC 160.80 152.76 175.6791065 26 10.05 9.55 10.98 92240 26 58.39 55.47 63.7991100 51.43 48.86 56.19 92250 68.44 65.02 74.7791105 17.62 16.74 19.25 92250 TC 45.15 42.89 49.3291122 228.32 216.90 249.44 92250 26 23.29 22.13 25.4591122 TC 138.94 131.99 151.79 92260 15.96 15.16 17.4391122 26 89.38 84.91 97.65 # 92260 10.75 10.21 11.7491132 26 26.55 25.22 29.00 92265 96.48 91.66 105.4191133 26 33.38 31.71 36.47 92265 TC 56.27 53.46 61.4892002 65.33 62.06 71.37 92265 26 40.21 38.20 43.93

# 92002 44.84 42.60 48.99 92270 92.32 87.70 100.8692004 119.40 113.43 130.44 92270 TC 49.67 47.19 54.27

# 92004 86.06 81.76 94.02 92270 26 42.65 40.52 46.6092012 59.08 56.13 64.55 92275 106.87 101.53 116.76

# 92012 35.12 33.36 38.36 92275 TC 54.18 51.47 59.1992014 87.56 83.18 95.66 92275 26 52.69 50.06 57.57

# 92014 57.35 54.48 62.65 92283 36.75 34.91 40.1592018 130.11 123.60 142.14 92283 TC 27.79 26.40 30.3692019 68.81 65.37 75.18 92283 26 8.96 8.51 9.7992020 45.75 43.46 49.98 92284 88.60 84.17 96.80

# 92020 19.36 18.39 21.15 92284 TC 76.40 72.58 83.4792060 51.48 48.91 56.25 92284 26 12.20 11.59 13.3392060 TC 15.63 14.85 17.08 92285 37.49 35.62 40.9692060 26 35.85 34.06 39.17 92285 TC 26.74 25.40 29.2192065 33.60 31.92 36.71 92285 26 10.75 10.21 11.7492065 TC 14.24 13.53 15.56 92286 124.36 118.14 135.8692065 26 19.36 18.39 21.15 92286 TC 89.60 85.12 97.8992070 61.91 58.81 67.63 92286 26 34.76 33.02 37.97

# 92070 37.25 35.39 40.70 92287 123.90 117.71 135.3792081 84.63 80.40 92.46 # 92287 41.26 39.20 45.0892081 TC 65.64 62.36 71.71 92311 79.90 75.91 87.3092081 26 18.99 18.04 20.75 # 92311 52.81 50.17 57.7092082 53.50 50.83 58.45 92312 86.09 81.79 94.0692082 TC 30.56 29.03 33.38 # 92312 64.56 61.33 70.5392082 26 22.94 21.79 25.06 92313 72.69 69.06 79.4292083 74.09 70.39 80.95 # 92313 44.21 42.00 48.3092083 TC 47.58 45.20 51.98 92315 47.96 45.56 52.3992083 26 26.51 25.18 28.96 # 92315 22.61 21.48 24.7092100 59.49 56.52 65.00 92316 58.40 55.48 63.80

# 92100 47.34 44.97 51.72 # 92316 35.48 33.71 38.7792120 57.92 55.02 63.27 92317 51.09 48.54 55.82

# 92120 41.60 39.52 45.45 # 92317 21.57 20.49 23.5692130 61.74 58.65 67.45 92325 14.24 13.53 15.56

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 72FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

92326 58.02 55.12 63.39 92575 11.12 10.56 12.1492330 76.43 72.61 83.50 92576 17.03 16.18 18.61

# 92330 52.12 49.51 56.94 92577 27.11 25.75 29.6192335 50.04 47.54 54.67 92579 27.11 25.75 29.61

# 92335 22.61 21.48 24.70 92582 27.11 25.75 29.6192502 100.05 95.05 109.31 92583 33.37 31.70 36.4692504 24.60 23.37 26.88 92584 91.76 87.17 100.25

# 92504 10.02 9.52 10.95 92585 94.64 89.91 103.4092506 89.27 84.81 97.53 92585 TC 68.12 64.71 74.42

# 92506 46.90 44.56 51.24 92585 26 26.52 25.19 28.9792507 73.77 70.08 80.59 92586 68.12 64.71 74.42

# 92507 27.94 26.54 30.52 92587 55.82 53.03 60.9892508 60.15 57.14 65.71 92587 TC 48.31 45.89 52.77

# 92508 13.97 13.27 15.26 92587 26 7.51 7.13 8.2092511 79.51 75.53 86.86 92588 73.91 70.21 80.74

# 92511 46.17 43.86 50.44 92588 TC 54.57 51.84 59.6292512 58.89 55.95 64.34 92588 26 19.34 18.37 21.13

# 92512 26.94 25.59 29.43 92589 20.16 19.15 22.0292516 50.02 47.52 54.65 92596 22.25 21.14 24.31

# 92516 23.97 22.77 26.19 92597 89.27 84.81 97.5392520 47.78 45.39 52.20 # 92597 46.90 44.56 51.24

# 92520 42.57 40.44 46.51 92601 123.65 117.47 135.0992526 76.95 73.10 84.07 92602 86.84 82.50 94.88

# 92526 27.99 26.59 30.58 92603 83.37 79.20 91.0892541 54.49 51.77 59.54 92604 56.98 54.13 62.2592541 TC 32.30 30.69 35.29 92607 103.15 97.99 112.6992541 26 22.19 21.08 24.24 92608 20.51 19.48 22.4092542 54.72 51.98 59.78 92609 55.92 53.12 61.0992542 TC 36.82 34.98 40.23 92610 39.97 37.97 43.6792542 26 17.90 17.01 19.56 92611 43.44 41.27 47.4692543 26.22 24.91 28.65 92612 165.30 157.04 180.6092543 TC 20.49 19.47 22.39 # 92612 65.98 62.68 72.0892543 26 5.72 5.43 6.24 92614 128.14 121.73 139.9992544 44.19 41.98 48.28 # 92614 65.98 62.68 72.0892544 TC 29.87 28.38 32.64 92616 175.66 166.88 191.9192544 26 14.32 13.60 15.64 # 92616 96.14 91.33 105.0392545 40.67 38.64 44.44 92950 180.57 171.54 197.2792545 TC 28.14 26.73 30.74 92953 16.70 15.87 18.2592545 26 12.53 11.90 13.69 92960 163.77 155.58 178.9292546 89.73 85.24 98.03 # 92960 114.45 108.73 125.0492546 TC 73.98 70.28 80.82 92961 234.63 222.90 256.3492546 26 15.75 14.96 17.20 92970 171.42 162.85 187.2892547 48.29 45.88 52.76 92971 97.00 92.15 105.9792548 160.96 152.91 175.85 92973 169.27 160.81 184.9392548 TC 132.70 126.07 144.98 92974 155.63 147.85 170.0392548 26 28.25 26.84 30.87 92975 371.25 352.69 405.5992552 16.68 15.85 18.23 92977 291.88 277.29 318.8892553 24.68 23.45 26.97 92978 257.92 245.02 281.7792555 14.25 13.54 15.57 92978 TC 165.04 156.79 180.3192556 21.55 20.47 23.54 92978 26 92.88 88.24 101.4892557 44.50 42.28 48.62 92979 156.93 149.08 171.4492561 26.76 25.42 29.23 92979 TC 83.05 78.90 90.7492562 15.29 14.53 16.71 92979 26 73.88 70.19 80.7292563 14.25 13.54 15.57 92980 779.99 740.99 852.1492564 17.73 16.84 19.37 92981 216.93 206.08 236.9992565 14.95 14.20 16.33 92982 579.19 550.23 632.7692567 19.82 18.83 21.65 92984 154.19 146.48 168.4592568 14.25 13.54 15.57 92986 1,189.07 1,129.62 1,299.0692569 15.29 14.53 16.71 92987 1,236.73 1,174.89 1,351.1292571 14.60 13.87 15.95 92990 948.03 900.63 1,035.7292572 3.48 3.31 3.81 92995 636.92 605.07 695.8392573 13.21 12.55 14.43 92996 169.26 160.80 184.92

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 73FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

92997 630.55 599.02 688.87 93318 26 99.08 94.13 108.2592998 307.46 292.09 335.90 93320 81.93 77.83 89.5093000 24.94 23.69 27.24 93320 TC 62.55 59.42 68.3393005 16.33 15.51 17.84 93320 26 19.37 18.40 21.1693010 8.61 8.18 9.41 93321 48.55 46.12 53.0493012 213.29 202.63 233.02 93321 TC 40.66 38.63 44.42

# 93012 86.89 82.55 94.93 93321 26 7.89 7.50 8.6393014 26.20 24.89 28.62 93325 110.28 104.77 120.4993015 99.54 94.56 108.74 93325 TC 106.34 101.02 116.1793016 22.96 21.81 25.08 93325 26 3.94 3.74 4.3093017 61.16 58.10 66.82 93350 139.28 132.32 152.1793018 15.42 14.65 16.85 93350 TC 64.64 61.41 70.6293024 100.91 95.86 110.24 93350 26 74.63 70.90 81.5493024 TC 41.01 38.96 44.80 93501 771.43 732.86 842.7993024 26 59.90 56.91 65.45 93501 TC 615.06 584.31 671.9693025 403.74 383.55 441.08 93501 26 156.37 148.55 170.8393025 TC 365.01 346.76 398.77 93503 135.35 128.58 147.8793025 26 38.73 36.79 42.31 93505 300.00 285.00 327.7593040 13.46 12.79 14.71 93505 TC 72.99 69.34 79.7493041 5.56 5.28 6.07 93505 26 227.01 215.66 248.0193042 7.90 7.51 8.64 93508 668.17 634.76 729.9793224 151.65 144.07 165.68 93508 TC 454.82 432.08 496.8993225 45.18 42.92 49.36 93508 26 213.35 202.68 233.0893226 79.93 75.93 87.32 93510 1,570.33 1,491.81 1,715.5893227 26.55 25.22 29.00 93510 TC 1,344.79 1,277.55 1,469.1893230 161.38 153.31 176.31 93510 26 225.54 214.26 246.4093231 55.60 52.82 60.74 93511 1,571.11 1,492.55 1,716.4393232 79.23 75.27 86.56 93511 TC 1,309.00 1,243.55 1,430.0893233 26.55 25.22 29.00 93511 26 262.11 249.00 286.3593235 117.47 111.60 128.34 93514 1,674.09 1,590.39 1,828.9593236 94.86 90.12 103.64 93514 TC 1,309.00 1,243.55 1,430.0893237 22.61 21.48 24.70 93514 26 365.09 346.84 398.8793268 284.66 270.43 310.99 93524 2,072.16 1,968.55 2,263.8393270 45.18 42.92 49.36 93524 TC 1,710.70 1,625.17 1,868.9593271 213.29 202.63 233.02 93524 26 361.46 343.39 394.9093272 26.20 24.89 28.62 93526 2,069.57 1,966.09 2,261.0093278 55.67 52.89 60.82 93526 TC 1,757.62 1,669.74 1,920.2093278 TC 42.76 40.62 46.71 93526 26 311.96 296.36 340.8193278 26 12.91 12.26 14.10 93527 2,090.07 1,985.57 2,283.4193303 205.71 195.42 224.73 93527 TC 1,710.70 1,625.17 1,868.9593303 TC 140.04 133.04 153.00 93527 26 379.36 360.39 414.4593303 26 65.67 62.39 71.75 93528 2,180.75 2,071.71 2,382.4793304 108.93 103.48 119.00 93528 TC 1,710.70 1,625.17 1,868.9593304 TC 70.89 67.35 77.45 93528 26 470.04 446.54 513.5293304 26 38.03 36.13 41.55 93529 1,958.89 1,860.95 2,140.0993307 187.03 177.68 204.33 93529 TC 1,710.70 1,625.17 1,868.9593307 TC 140.04 133.04 153.00 93529 26 248.19 235.78 271.1593307 26 46.99 44.64 51.34 93530 830.72 789.18 907.5693308 98.15 93.24 107.23 93530 TC 615.06 584.31 671.9693308 TC 70.89 67.35 77.45 93530 26 215.66 204.88 235.6193308 26 27.26 25.90 29.79 93531 2,189.10 2,079.65 2,391.6093312 249.92 237.42 273.03 93531 TC 1,757.62 1,669.74 1,920.2093312 TC 139.02 132.07 151.88 93531 26 431.48 409.91 471.4093312 26 110.90 105.36 121.16 93532 2,227.88 2,116.49 2,433.9693313 43.93 41.73 47.99 93532 TC 1,710.70 1,625.17 1,868.95

# 93313 43.58 41.40 47.61 93532 26 517.18 491.32 565.0293314 202.52 192.39 221.25 93533 2,054.08 1,951.38 2,244.0993314 TC 139.02 132.07 151.88 93533 TC 1,710.70 1,625.17 1,868.9593314 26 63.51 60.33 69.38 93533 26 343.37 326.20 375.1393315 26 140.32 133.30 153.30 93539 20.45 19.43 22.3493316 44.62 42.39 48.75 93540 21.88 20.79 23.9193317 26 92.58 87.95 101.14 93541 15.06 14.31 16.46

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 74FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

93542 15.06 14.31 16.46 93631 627.50 596.13 685.5593543 15.06 14.31 16.46 93631 TC 230.47 218.95 251.7993544 12.91 12.26 14.10 93631 26 397.03 377.18 433.7693545 20.45 19.43 22.34 93640 442.80 420.66 483.7693555 268.85 255.41 293.72 93640 TC 260.26 247.25 284.3493555 TC 226.89 215.55 247.88 93640 26 182.54 173.41 199.4293555 26 41.95 39.85 45.83 93641 569.00 540.55 621.6393556 399.51 379.53 436.46 93641 TC 260.26 247.25 284.3493556 TC 356.83 338.99 389.84 93641 26 308.73 293.29 337.2893556 26 42.68 40.55 46.63 93642 510.64 485.11 557.8893561 44.25 42.04 48.35 93642 TC 260.26 247.25 284.3493561 TC 19.82 18.83 21.65 93642 26 250.38 237.86 273.5493561 26 24.43 23.21 26.69 93650 546.84 519.50 597.4393562 20.07 19.07 21.93 93651 845.89 803.60 924.1493562 TC 12.17 11.56 13.29 93652 920.46 874.44 1,005.6193562 26 7.90 7.51 8.64 93660 155.89 148.10 170.3293571 258.64 245.71 282.57 93660 TC 58.70 55.77 64.1493571 TC 165.04 156.79 180.31 93660 26 97.19 92.33 106.1893571 26 93.60 88.92 102.26 93662 26 153.70 146.02 167.9293572 158.73 150.79 173.41 93701 46.47 44.15 50.7793572 TC 83.05 78.90 90.74 93701 TC 37.51 35.63 40.9793572 26 75.68 71.90 82.69 93701 26 8.96 8.51 9.7993580 949.21 901.75 1,037.01 93720 34.68 32.95 37.8993581 1,269.72 1,206.23 1,387.16 93721 26.42 25.10 28.8793600 181.68 172.60 198.49 93722 8.27 7.86 9.0493600 TC 71.24 67.68 77.83 93724 396.33 376.51 432.9993600 26 110.44 104.92 120.66 93724 TC 144.21 137.00 157.5593602 150.75 143.21 164.69 93724 26 252.12 239.51 275.4493602 TC 40.31 38.29 44.03 93727 27.60 26.22 30.1593602 26 110.44 104.92 120.66 93731 41.38 39.31 45.2193603 171.25 162.69 187.09 93731 TC 18.07 17.17 19.7593603 TC 61.16 58.10 66.82 93731 26 23.31 22.14 25.4693603 26 110.09 104.59 120.28 93732 65.76 62.47 71.8493609 368.51 350.08 402.59 93732 TC 18.77 17.83 20.5093609 TC 99.03 94.08 108.19 93732 26 46.99 44.64 51.3493609 26 269.48 256.01 294.41 93733 36.07 34.27 39.4193610 206.07 195.77 225.14 93733 TC 27.11 25.75 29.6193610 TC 49.35 46.88 53.91 93733 26 8.96 8.51 9.7993610 26 156.72 148.88 171.21 93734 32.23 30.62 35.2193612 215.80 205.01 235.76 93734 TC 12.86 12.22 14.0593612 TC 59.08 56.13 64.55 93734 26 19.37 18.40 21.1693612 26 156.72 148.88 171.21 93735 54.70 51.97 59.7793613 367.17 348.81 401.13 93735 TC 16.68 15.85 18.2393615 58.23 55.32 63.62 93735 26 38.02 36.12 41.5493615 TC 11.82 11.23 12.91 93736 31.52 29.94 34.4393615 26 46.41 44.09 50.70 93736 TC 23.64 22.46 25.8393616 83.36 79.19 91.07 93736 26 7.89 7.50 8.6393616 TC 11.82 11.23 12.91 93741 65.21 61.95 71.2493616 26 71.54 67.96 78.15 93741 TC 24.32 23.10 26.5793618 366.16 347.85 400.03 93741 26 40.89 38.85 44.6893618 TC 144.21 137.00 157.55 93742 70.95 67.40 77.5193618 26 221.95 210.85 242.48 93742 TC 24.32 23.10 26.5793619 660.89 627.85 722.03 93742 26 46.63 44.30 50.9593619 TC 280.07 266.07 305.98 93743 79.48 75.51 86.8493619 26 380.82 361.78 416.05 93743 TC 26.75 25.41 29.2293620 26 602.78 572.64 658.54 93743 26 52.73 50.09 57.6093621 26 110.77 105.23 121.01 93744 84.59 80.36 92.4193622 26 178.97 170.02 195.52 93744 TC 24.32 23.10 26.5793623 26 148.10 140.70 161.81 93744 26 60.26 57.25 65.8493624 322.22 306.11 352.03 93784 40.91 38.86 44.6993624 TC 72.28 68.67 78.97 93786 31.95 30.35 34.9093624 26 249.94 237.44 273.06 93790 8.96 8.51 9.79

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 75FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

93797 20.44 19.42 22.33 93980 TC 151.54 143.96 165.55# 93797 9.32 8.85 10.18 93980 26 62.48 59.36 68.26

93798 27.89 26.50 30.48 93981 193.23 183.57 211.11# 93798 14.35 13.63 15.67 93981 TC 171.32 162.75 187.16

93875 68.81 65.37 75.18 93981 26 21.90 20.81 23.9393875 TC 57.69 54.81 63.03 93990 132.81 126.17 145.1093875 26 11.13 10.57 12.16 93990 TC 119.89 113.90 130.9993880 182.74 173.60 199.64 93990 26 12.92 12.27 14.1193880 TC 152.24 144.63 166.32 94010 37.79 35.90 41.2993880 26 30.51 28.98 33.33 94010 TC 29.53 28.05 32.2693882 124.72 118.48 136.25 94010 26 8.27 7.86 9.0493882 TC 103.92 98.72 113.53 94014 35.93 34.13 39.2593882 26 20.81 19.77 22.74 94015 10.42 9.90 11.3993886 211.44 200.87 231.00 94016 25.51 24.23 27.8693886 TC 162.32 154.20 177.33 94060 66.16 62.85 72.2893886 26 49.12 46.66 53.66 94060 TC 51.07 48.52 55.8093888 140.72 133.68 153.73 94060 26 15.09 14.34 16.4993888 TC 108.80 103.36 118.86 94070 176.04 167.24 192.3393888 26 31.93 30.33 34.88 94070 TC 146.93 139.58 160.5293922 78.95 75.00 86.25 94070 26 29.11 27.65 31.8093922 TC 66.03 62.73 72.14 94200 26.93 25.58 29.4293922 26 12.92 12.27 14.11 94200 TC 21.54 20.46 23.5393923 126.54 120.21 138.24 94200 26 5.39 5.12 5.8993923 TC 103.22 98.06 112.77 94240 76.84 73.00 83.9593923 26 23.32 22.15 25.47 94240 TC 64.26 61.05 70.2193924 154.77 147.03 169.08 94240 26 12.58 11.95 13.7493924 TC 128.93 122.48 140.85 94250 29.01 27.56 31.6993924 26 25.84 24.55 28.23 94250 TC 23.62 22.44 25.8193925 204.59 194.36 223.51 94250 26 5.39 5.12 5.8993925 TC 175.16 166.40 191.36 94260 25.23 23.97 27.5793925 26 29.43 27.96 32.15 94260 TC 18.77 17.83 20.5093926 139.64 132.66 152.56 94260 26 6.47 6.15 7.0793926 TC 119.89 113.90 130.99 94350 78.92 74.97 86.2293926 26 19.74 18.75 21.56 94350 TC 66.34 63.02 72.4793930 165.51 157.23 180.81 94350 26 12.58 11.95 13.7493930 TC 142.18 135.07 155.33 94360 31.36 29.79 34.2693930 26 23.33 22.16 25.48 94360 TC 18.78 17.84 20.5293931 117.28 111.42 128.13 94360 26 12.58 11.95 13.7493931 TC 101.49 96.42 110.88 94370 78.57 74.64 85.8493931 26 15.79 15.00 17.25 94370 TC 65.99 62.69 72.0993965 81.19 77.13 88.70 94370 26 12.58 11.95 13.7493965 TC 63.60 60.42 69.48 94375 35.59 33.81 38.8893965 26 17.59 16.71 19.22 94375 TC 20.50 19.48 22.4093970 178.73 169.79 195.26 94375 26 15.09 14.34 16.4993970 TC 143.92 136.72 157.23 94400 47.56 45.18 51.9693970 26 34.81 33.07 38.03 94400 TC 28.15 26.74 30.7593971 124.82 118.58 136.37 94400 26 19.40 18.43 21.1993971 TC 102.20 97.09 111.65 94450 39.56 37.58 43.2293971 26 22.62 21.49 24.71 94450 TC 20.15 19.14 22.0193975 287.54 273.16 314.13 94450 26 19.41 18.44 21.2193975 TC 196.72 186.88 214.91 94620 112.55 106.92 122.9693975 26 90.82 86.28 99.22 94620 TC 81.64 77.56 89.1993976 176.08 167.28 192.37 94620 26 30.91 29.36 33.7693976 TC 115.76 109.97 126.47 94621 129.80 123.31 141.8193976 26 60.33 57.31 65.91 94621 TC 60.81 57.77 66.4493978 162.35 154.23 177.36 94621 26 69.00 65.55 75.3893978 TC 128.98 122.53 140.91 94640 25.01 23.76 27.3293978 26 33.37 31.70 36.46 94656 57.56 54.68 62.8893979 115.77 109.98 126.48 94657 40.25 38.24 43.9893979 TC 92.81 88.17 101.40 94660 52.29 49.68 57.1393979 26 22.96 21.81 25.08 # 94660 37.01 35.16 40.4393980 214.02 203.32 233.82 94662 36.66 34.83 40.05

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 76FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

94664 19.11 18.15 20.87 # 95170 3.23 3.07 3.5394667 29.54 28.06 32.27 95180 130.02 123.52 142.0594668 25.36 24.09 27.70 # 95180 103.63 98.45 113.2294680 77.89 74.00 85.10 95250 112.17 106.56 122.5494680 TC 64.96 61.71 70.97 95805 674.45 640.73 736.8494680 26 12.93 12.28 14.12 95805 TC 580.40 551.38 634.0994681 108.37 102.95 118.39 95805 26 94.05 89.35 102.7594681 TC 98.32 93.40 107.41 95806 213.97 203.27 233.7694681 26 10.05 9.55 10.98 95806 TC 132.43 125.81 144.6894690 77.92 74.02 85.12 95806 26 81.54 77.46 89.0894690 TC 74.33 70.61 81.20 95807 491.12 466.56 536.5494690 26 3.59 3.41 3.92 95807 TC 410.28 389.77 448.2494720 65.39 62.12 71.44 95807 26 80.84 76.80 88.3294720 TC 52.81 50.17 57.70 95808 566.71 538.37 619.1394720 26 12.58 11.95 13.74 95808 TC 434.24 412.53 474.4194725 102.22 97.11 111.68 95808 26 132.47 125.85 144.7394725 TC 89.64 85.16 97.93 95810 745.25 707.99 814.1994725 26 12.58 11.95 13.74 95810 TC 570.71 542.17 623.5094750 81.65 77.57 89.21 95810 26 174.54 165.81 190.6894750 TC 70.51 66.98 77.03 95811 768.96 730.51 840.0994750 26 11.14 10.58 12.17 95811 TC 581.13 552.07 634.8894760 3.83 3.64 4.19 95811 26 187.83 178.44 205.2194761 7.66 7.28 8.37 95812 207.73 197.34 226.9494762 28.51 27.08 31.14 95812 TC 151.10 143.55 165.0894770 66.25 62.94 72.38 95812 26 56.63 53.80 61.8794770 TC 59.06 56.11 64.53 95813 269.56 256.08 294.4994770 26 7.19 6.83 7.85 95813 TC 179.57 170.59 196.1895004 3.82 3.63 4.17 95813 26 89.99 85.49 98.3195010 21.08 20.03 23.03 95816 170.92 162.37 186.73

# 95010 7.89 7.50 8.63 95816 TC 113.94 108.24 124.4895015 19.00 18.05 20.76 95816 26 56.98 54.13 62.25

# 95015 7.89 7.50 8.63 95819 193.14 183.48 211.0095024 5.56 5.28 6.07 95819 TC 136.16 129.35 148.7595027 5.56 5.28 6.07 95819 26 56.98 54.13 62.2595028 8.34 7.92 9.11 95822 221.98 210.88 242.5195044 7.30 6.94 7.98 95822 TC 165.00 156.75 180.2695052 9.03 8.58 9.87 95822 26 56.98 54.13 62.2595056 6.26 5.95 6.84 95824 26 39.77 37.78 43.4595060 12.86 12.22 14.05 95827 138.29 131.38 151.0995065 7.30 6.94 7.98 95827 TC 83.40 79.23 91.1195070 79.53 75.55 86.88 95827 26 54.89 52.15 59.9795071 101.76 96.67 111.17 95829 1,630.51 1,548.98 1,781.3395075 64.75 61.51 70.74 95829 TC 1,311.25 1,245.69 1,432.54

# 95075 49.47 47.00 54.05 95829 26 319.26 303.30 348.8095078 9.39 8.92 10.26 95830 187.53 178.15 204.8795115 14.25 13.54 15.57 # 95830 90.29 85.78 98.6595117 18.07 17.17 19.75 95831 28.93 27.48 31.6095144 11.21 10.65 12.25 # 95831 15.04 14.29 16.43

# 95144 3.23 3.07 3.53 95832 26.52 25.19 28.9795145 19.55 18.57 21.36 # 95832 15.06 14.31 16.46

# 95145 3.23 3.07 3.53 95833 38.62 36.69 42.1995146 23.72 22.53 25.91 # 95833 25.42 24.15 27.77

# 95146 3.57 3.39 3.90 95834 42.65 40.52 46.6095147 31.35 29.78 34.25 # 95834 32.23 30.62 35.21

# 95147 3.23 3.07 3.53 95851 25.96 24.66 28.3695148 30.66 29.13 33.50 # 95851 8.95 8.50 9.78

# 95148 3.57 3.39 3.90 95852 20.67 19.64 22.5995149 37.95 36.05 41.46 # 95852 6.09 5.79 6.66

# 95149 3.57 3.39 3.90 95857 42.54 40.41 46.4795165 9.48 9.01 10.36 # 95857 27.95 26.55 30.53

# 95165 3.23 3.07 3.53 95858 97.01 92.16 105.9895170 11.56 10.98 12.63 95858 TC 14.95 14.20 16.33

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 77FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

95858 26 82.07 77.97 89.67 95930 TC 36.12 34.31 39.4695860 92.91 88.26 101.50 95930 26 18.28 17.37 19.9895860 TC 42.03 39.93 45.92 95933 59.67 56.69 65.1995860 26 50.88 48.34 55.59 95933 TC 28.85 27.41 31.5295861 109.50 104.03 119.63 95933 26 30.83 29.29 33.6895861 TC 27.46 26.09 30.00 95934 35.22 33.46 38.4895861 26 82.04 77.94 89.63 95934 TC 8.00 7.60 8.7495863 133.30 126.64 145.64 95934 26 27.23 25.87 29.7595863 TC 34.40 32.68 37.58 95936 37.37 35.50 40.8395863 26 98.90 93.96 108.05 95936 TC 8.00 7.60 8.7495864 170.33 161.81 186.08 95936 26 29.37 27.90 32.0995864 TC 64.98 61.73 70.99 95937 46.21 43.90 50.4995864 26 105.34 100.07 115.08 95937 TC 12.51 11.88 13.6695867 63.47 60.30 69.35 95937 26 33.70 32.02 36.8295867 TC 21.20 20.14 23.16 95950 306.16 290.85 334.4895867 26 42.27 40.16 46.18 95950 TC 225.89 214.60 246.7995868 88.41 83.99 96.59 95950 26 80.27 76.26 87.7095868 TC 25.72 24.43 28.09 95951 26 316.09 300.29 345.3395868 26 62.70 59.57 68.51 95953 393.09 373.44 429.4695869 27.70 26.32 30.27 95953 TC 231.79 220.20 253.2395869 TC 8.00 7.60 8.74 95953 26 161.30 153.24 176.2395869 26 19.70 18.72 21.53 95954 269.34 255.87 294.2595870 27.35 25.98 29.88 95954 TC 139.97 132.97 152.9295870 TC 8.00 7.60 8.74 95954 26 129.37 122.90 141.3495870 26 19.36 18.39 21.15 95955 123.96 117.76 135.4295872 100.74 95.70 110.06 95955 TC 72.64 69.01 79.3695872 TC 22.24 21.13 24.30 95955 26 51.32 48.75 56.0695872 26 78.50 74.58 85.77 95956 673.33 639.66 735.6195875 102.87 97.73 112.39 95956 TC 511.33 485.76 558.6295875 TC 44.82 42.58 48.97 95956 26 162.00 153.90 176.9995875 26 58.06 55.16 63.43 95957 166.84 158.50 182.2895900 55.21 52.45 60.32 95957 TC 62.21 59.10 67.9795900 TC 33.00 31.35 36.05 95957 26 104.64 99.41 114.3295900 26 22.21 21.10 24.27 95958 286.56 272.23 313.0695903 60.37 57.35 65.95 95958 TC 63.95 60.75 69.8695903 TC 28.48 27.06 31.12 95958 26 222.61 211.48 243.2095903 26 31.89 30.30 34.85 95961 208.41 197.99 227.6995904 46.40 44.08 50.69 95961 TC 47.26 44.90 51.6495904 TC 28.48 27.06 31.12 95961 26 161.16 153.10 176.0795904 26 17.92 17.02 19.57 95962 219.22 208.26 239.5095920 162.21 154.10 177.22 95962 TC 47.26 44.90 51.6495920 TC 47.26 44.90 51.64 95962 26 171.96 163.36 187.8695920 26 114.95 109.20 125.58 95965 26 409.66 389.18 447.5695921 59.47 56.50 64.98 95966 26 204.48 194.26 223.4095921 TC 13.90 13.21 15.19 95967 26 179.01 170.06 195.5795921 26 45.57 43.29 49.78 95970 23.31 22.14 25.4695922 64.08 60.88 70.01 # 95970 22.62 21.49 24.7195922 TC 13.90 13.21 15.19 95971 40.18 38.17 43.9095922 26 50.18 47.67 54.82 # 95971 38.45 36.53 42.0195923 135.87 129.08 148.44 95972 81.68 77.60 89.2495923 TC 88.56 84.13 96.75 # 95972 78.21 74.30 85.4595923 26 47.31 44.94 51.68 95973 50.14 47.63 54.7795925 61.68 58.60 67.39 # 95973 48.05 45.65 52.5095925 TC 33.36 31.69 36.44 95974 160.15 152.14 174.9695925 26 28.32 26.90 30.94 95975 90.29 85.78 98.6595926 62.02 58.92 67.76 95990 53.50 50.83 58.4595926 TC 33.36 31.69 36.44 96000 90.43 85.91 98.8095926 26 28.66 27.23 31.31 96001 108.01 102.61 118.0095927 63.07 59.92 68.91 96002 21.16 20.10 23.1295927 TC 33.36 31.69 36.44 96003 19.37 18.40 21.1695927 26 29.71 28.22 32.45 96004 109.76 104.27 119.9195930 54.40 51.68 59.43 96100 66.05 62.75 72.16

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 78FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

96105 66.05 62.75 72.16 97012 14.30 13.59 15.6396110 37.02 35.17 40.45 97016 13.49 12.82 14.7496111 66.05 62.75 72.16 97018 6.35 6.03 6.9396115 66.05 62.75 72.16 97020 4.62 4.39 5.0596117 66.05 62.75 72.16 97022 14.17 13.46 15.4896150 26.17 24.86 28.59 97024 4.62 4.39 5.05

# 96150 25.82 24.53 28.21 97026 4.62 4.39 5.0596151 25.09 23.84 27.42 97028 5.69 5.41 6.22

# 96151 24.75 23.51 27.04 97032 15.69 14.91 17.1596152 24.02 22.82 26.24 97033 19.53 18.55 21.33

# 96152 23.67 22.49 25.86 97034 13.54 12.86 14.7996153 5.38 5.11 5.88 97035 11.80 11.21 12.8996154 23.66 22.48 25.85 97036 21.99 20.89 24.02

# 96154 23.31 22.14 25.46 97039 11.44 10.87 12.5096155 22.95 21.80 25.07 97110 27.13 25.77 29.64

# 96155 22.60 21.47 24.69 97112 27.82 26.43 30.3996400 35.42 33.65 38.70 97113 28.85 27.41 31.5296405 77.94 74.04 85.15 97116 23.92 22.72 26.13

# 96405 27.59 26.21 30.14 97124 21.41 20.34 23.3996406 117.98 112.08 128.89 97139 15.28 14.52 16.70

# 96406 40.20 38.19 43.92 97140 25.71 24.42 28.0896408 35.44 33.67 38.72 97150 17.81 16.92 19.4696410 55.94 53.14 61.11 97504 27.48 26.11 30.0396412 41.70 39.62 45.56 97520 26.78 25.44 29.2696414 48.65 46.22 53.15 97530 27.46 26.09 30.0096420 45.52 43.24 49.73 97532 23.29 22.13 25.4596422 44.83 42.59 48.98 97533 24.68 23.45 26.9796423 17.37 16.50 18.98 97535 29.56 28.08 32.2996425 51.77 49.18 56.56 97537 26.08 24.78 28.5096440 365.39 347.12 399.19 97542 26.78 25.44 29.26

# 96440 126.47 120.15 138.17 97601 37.98 36.08 41.4996445 359.18 341.22 392.40 97703 21.25 20.19 23.22

# 96445 117.84 111.95 128.74 97750 27.82 26.43 30.3996450 289.57 275.09 316.35 97802 16.67 15.84 18.22

# 96450 103.10 97.95 112.64 97803 16.67 15.84 18.2296520 32.67 31.04 35.70 97804 6.60 6.27 7.2196530 38.22 36.31 41.76 98925 29.56 28.08 32.2996542 191.92 182.32 209.67 # 98925 21.92 20.82 23.94

# 96542 72.47 68.85 79.18 98926 39.61 37.63 43.2796567 178.16 169.25 194.64 # 98926 33.36 31.69 36.4496570 54.58 51.85 59.63 98927 50.39 47.87 55.05

# 96570 54.24 51.53 59.26 # 98927 43.09 40.94 47.0896571 27.99 26.59 30.58 98928 58.98 56.03 64.43

# 96571 27.64 26.26 30.20 # 98928 50.64 48.11 55.3396900 17.72 16.83 19.35 98929 67.23 63.87 73.4596910 55.58 52.80 60.72 # 98929 57.85 54.96 63.2096912 63.91 60.71 69.82 98940 25.04 23.79 27.3696913 96.92 92.07 105.88 # 98940 21.22 20.16 23.1896920 144.97 137.72 158.38 98941 34.75 33.01 37.96

# 96920 60.59 57.56 66.19 # 98941 30.58 29.05 33.4196921 148.48 141.06 162.22 98942 45.52 43.24 49.73

# 96921 61.66 58.58 67.37 # 98942 41.01 38.96 44.8096922 205.58 195.30 224.60 99170 137.95 131.05 150.71

# 96922 110.43 104.91 120.65 # 99170 84.47 80.25 92.2997001 71.07 67.52 77.65 99175 50.74 48.20 55.43

# 97001 61.35 58.28 67.02 99183 115.31 109.54 125.9797002 38.14 36.23 41.66 99185 23.28 22.12 25.44

# 97002 30.84 29.30 33.70 99186 74.49 70.77 81.3997003 75.58 71.80 82.57 99195 16.33 15.51 17.84

# 97003 59.61 56.63 65.12 99201 33.73 32.04 36.8597004 46.12 43.81 50.38 # 99201 22.62 21.49 24.71

# 97004 29.46 27.99 32.19 99202 60.48 57.46 66.08

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.

OHIO - MEDICARE CARRIER 00883 PAGE 79FSY 2003 LOCALITY FEE SCHEDULE EFFECTIVE DATE 3/1/2003

PAR NON-PAR LIMITING PAR NON-PAR LIMITINGNOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE NOTE PROCEDURE MOD AMOUNT AMOUNT CHARGE---- --------- ------------------------------ ---- --------- ------------------------------

# 99202 44.86 42.62 49.01 99283 59.00 56.05 64.4699203 89.72 85.23 98.01 99284 92.11 87.50 100.63

# 99203 68.53 65.10 74.87 99285 143.60 136.42 156.8899204 127.95 121.55 139.78 99289 244.32 232.10 266.92

# 99204 101.21 96.15 110.57 99290 122.33 116.21 133.6499205 163.42 155.25 178.54 99291 204.82 194.58 223.77

# 99205 134.25 127.54 146.67 # 99291 195.45 185.68 213.5399211 19.73 18.74 21.55 99292 105.02 99.77 114.74

# 99211 8.61 8.18 9.41 # 99292 97.72 92.83 106.7599212 35.12 33.36 38.36 99293 784.29 745.08 856.84

# 99212 22.62 21.49 24.71 99294 388.10 368.70 424.0199213 49.37 46.90 53.94 99295 886.94 842.59 968.98

# 99213 33.74 32.05 36.86 99296 389.48 370.01 425.5199214 77.15 73.29 84.28 99298 136.80 129.96 149.45

# 99214 55.28 52.52 60.40 99299 128.41 121.99 140.2999215 113.33 107.66 123.81 99301 68.98 65.53 75.36

# 99215 89.02 84.57 97.26 # 99301 59.61 56.63 65.1299217 63.56 60.38 69.44 99302 93.96 89.26 102.6599218 63.56 60.38 69.44 # 99302 79.37 75.40 86.7199219 105.94 100.64 115.74 99303 116.49 110.67 127.2799220 148.31 140.89 162.02 # 99303 98.78 93.84 107.9299221 64.25 61.04 70.20 99311 39.53 37.55 43.1899222 106.64 101.31 116.51 # 99311 29.80 28.31 32.5699223 148.30 140.89 162.02 99312 60.67 57.64 66.2999231 31.95 30.35 34.90 # 99312 49.21 46.75 53.7699232 52.78 50.14 57.66 99313 83.23 79.07 90.9399233 75.04 71.29 81.98 # 99313 70.03 66.53 76.5199234 127.82 121.43 139.64 99315 67.83 64.44 74.1199235 169.16 160.70 184.81 # 99315 55.67 52.89 60.8299236 211.53 200.95 231.09 99316 88.57 84.14 96.7699238 67.38 64.01 73.61 # 99316 74.33 70.61 81.2099239 91.41 86.84 99.87 99321 42.13 40.02 46.0299241 45.85 43.56 50.09 99322 62.07 58.97 67.82

# 99241 32.31 30.69 35.29 99323 79.88 75.89 87.2799242 85.47 81.20 93.38 99331 38.83 36.89 42.42

# 99242 66.37 63.05 72.51 99332 50.27 47.76 54.9299243 112.91 107.26 123.35 99333 62.06 58.96 67.80

# 99243 88.26 83.85 96.43 99341 57.57 54.69 62.8999244 160.85 152.81 175.73 99342 86.52 82.19 94.52

# 99244 130.99 124.44 143.11 99343 128.72 122.28 140.6299245 208.77 198.33 228.08 99344 167.47 159.10 182.97

# 99245 173.35 164.68 189.38 99345 204.82 194.58 223.7799251 34.08 32.38 37.24 99347 45.35 43.08 49.5499252 68.50 65.08 74.84 99348 72.20 68.59 78.8899253 93.62 88.94 102.28 99349 111.99 106.39 122.3599254 134.55 127.82 146.99 99350 163.30 155.14 178.4199255 185.16 175.90 202.29 99354 117.14 111.28 127.9799261 21.52 20.44 23.51 # 99354 87.62 83.24 95.7399262 42.71 40.57 46.66 99355 109.50 104.03 119.6399263 63.54 60.36 69.41 # 99355 86.93 82.58 94.9799271 40.33 38.31 44.06 99356 85.10 80.85 92.98

# 99271 22.97 21.82 25.09 99357 85.44 81.17 93.3599272 63.55 60.37 69.43 99431 57.47 54.60 62.79

# 99272 43.75 41.56 47.79 99432 77.08 73.23 84.2199273 83.56 79.38 91.29 # 99432 62.14 59.03 67.88

# 99273 61.34 58.27 67.01 99433 30.18 28.67 32.9799274 114.31 108.59 124.88 99435 73.99 70.29 80.83

# 99274 88.62 84.19 96.82 99436 73.29 69.63 80.0799275 144.43 137.21 157.79 # 99436 72.94 69.29 79.68

# 99275 116.64 110.81 127.43 99440 143.35 136.18 156.6199281 15.82 15.03 17.2899282 26.25 24.94 28.68 ** END OF REPORT **

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

CPT CODES/MODIFIERS ARE BOLDED. CPT CODES, DESCRIPTORS AND OTHER DATA ONLY ARE COPYRIGHT 2002 AMERICAN MEDICAL ASSOCIATION (OR SUCH DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED. APPLICABLE FARS/DFARS CLAUSES APPLY.