NEW MEXICO MEDICAID FEE FOR SERVICE CPT CODE FEE SCHEDULE: Some procedure codes may be on

other fee schedule tables. As explained in the CPT Disclaimer and Agreement, this table is not to be

used as a guide to coverage of services by the Medicaid Program. The reimbursement amount will be

$0.00 for vaccination antigen procedure codes for which "VFC Antigen' is listed and the recipient is 18

years old or younger because the antigen is distributed for free for children by the New Mexico

Department of Health Vaccines for Children (VFC) Program. Use modifier 26 for professional component

pricing and modifier TC for technical component pricing. The pricing notes “26 Fee Schedule (FS)” and

“26 by Report” are for the professional component rates when modifier 26 is used. The pricing notes “TC

Fee Schedule” and “TC by Report” are for the technical component rates when modifier TC is used. The

pricing notes “General Fee Schedule” and “General by Report” and “Manual Review Fee Schedule” are for

the global rates. Rates that are $0.00 are priced and/or reviewed by the State.

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

10021 $126.43 General Fee Schedule 12/1/2009

10022 $139.09 General Fee Schedule 12/1/2009

10030 $736.15 General Fee Schedule 1/1/2014

10040 $81.86 General Fee Schedule 12/1/2009

10060 $90.72 General Fee Schedule 12/1/2009

10061 $164.27 General Fee Schedule 12/1/2009

10080 $155.43 General Fee Schedule 12/1/2009

10081 $242.55 General Fee Schedule 12/1/2009

10120 $125.88 General Fee Schedule 12/1/2009

10121 $235.74 General Fee Schedule 12/1/2009

10140 $126.56 General Fee Schedule 12/1/2009

10160 $105.93 General Fee Schedule 12/1/2009

10180 $201.30 General Fee Schedule 12/1/2009

11000 $45.43 General Fee Schedule 12/1/2009

11001 $20.84 General Fee Schedule 12/1/2009

11004 $554.96 General Fee Schedule 12/1/2009

11005 $754.93 General Fee Schedule 12/1/2009

11006 $697.33 General Fee Schedule 12/1/2009

11008 $283.57 General Fee Schedule 12/1/2009

11010 $420.42 General Fee Schedule 12/1/2009

11011 $496.29 General Fee Schedule 12/1/2009

11012 $720.88 General Fee Schedule 12/1/2009

11042 $80.93 General Fee Schedule 12/1/2009

11043 $218.99 General Fee Schedule 12/1/2009

11044 $285.66 General Fee Schedule 12/1/2009

11045 $30.13 General Fee Schedule 1/1/2011

11046 $52.53 General Fee Schedule 1/1/2011

Tuesday, February 11, 2014 Page 1 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

11047 $86.62 General Fee Schedule 1/1/2011

11055 $37.50 General Fee Schedule 12/1/2009

11056 $47.88 General Fee Schedule 12/1/2009

11057 $59.29 General Fee Schedule 12/1/2009

11100 $75.10 General Fee Schedule 12/1/2009

11101 $27.82 General Fee Schedule 12/1/2009

11200 $66.72 General Fee Schedule 12/1/2009

11201 $17.36 General Fee Schedule 12/1/2009

11300 $54.61 General Fee Schedule 12/1/2009

11301 $72.19 General Fee Schedule 12/1/2009

11302 $86.77 General Fee Schedule 12/1/2009

11303 $104.37 General Fee Schedule 12/1/2009

11305 $57.39 General Fee Schedule 12/1/2009

11306 $78.29 General Fee Schedule 12/1/2009

11307 $90.59 General Fee Schedule 12/1/2009

11308 $108.56 General Fee Schedule 12/1/2009

11310 $67.56 General Fee Schedule 12/1/2009

11311 $84.36 General Fee Schedule 12/1/2009

11312 $97.01 General Fee Schedule 12/1/2009

11313 $127.95 General Fee Schedule 12/1/2009

11400 $103.35 General Fee Schedule 12/1/2009

11401 $121.45 General Fee Schedule 12/1/2009

11402 $139.13 General Fee Schedule 12/1/2009

11403 $157.13 General Fee Schedule 12/1/2009

11404 $179.55 General Fee Schedule 12/1/2009

11406 $222.69 General Fee Schedule 12/1/2009

11420 $101.53 General Fee Schedule 12/1/2009

11421 $130.17 General Fee Schedule 12/1/2009

11422 $145.82 General Fee Schedule 12/1/2009

11423 $173.16 General Fee Schedule 12/1/2009

11424 $198.64 General Fee Schedule 12/1/2009

11426 $280.20 General Fee Schedule 12/1/2009

11440 $119.34 General Fee Schedule 12/1/2009

11441 $141.74 General Fee Schedule 12/1/2009

11442 $159.23 General Fee Schedule 12/1/2009

11443 $195.96 General Fee Schedule 12/1/2009

11444 $250.71 General Fee Schedule 12/1/2009

11446 $326.44 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 2 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

11450 $289.67 General Fee Schedule 12/1/2009

11451 $397.03 General Fee Schedule 12/1/2009

11462 $283.23 General Fee Schedule 12/1/2009

11463 $404.92 General Fee Schedule 12/1/2009

11470 $312.84 General Fee Schedule 12/1/2009

11471 $419.94 General Fee Schedule 12/1/2009

11600 $144.40 General Fee Schedule 12/1/2009

11601 $166.40 General Fee Schedule 12/1/2009

11602 $176.31 General Fee Schedule 12/1/2009

11603 $195.51 General Fee Schedule 12/1/2009

11604 $215.27 General Fee Schedule 12/1/2009

11606 $283.78 General Fee Schedule 12/1/2009

11620 $138.06 General Fee Schedule 12/1/2009

11621 $164.86 General Fee Schedule 12/1/2009

11622 $187.19 General Fee Schedule 12/1/2009

11623 $222.00 General Fee Schedule 12/1/2009

11624 $255.83 General Fee Schedule 12/1/2009

11626 $339.99 General Fee Schedule 12/1/2009

11640 $146.98 General Fee Schedule 12/1/2009

11641 $192.64 General Fee Schedule 12/1/2009

11642 $223.28 General Fee Schedule 12/1/2009

11643 $259.08 General Fee Schedule 12/1/2009

11644 $328.52 General Fee Schedule 12/1/2009

11646 $447.90 General Fee Schedule 12/1/2009

11719 $15.81 General Fee Schedule 12/1/2009

11720 $25.38 General Fee Schedule 12/1/2009

11721 $38.32 General Fee Schedule 12/1/2009

11730 $83.72 General Fee Schedule 12/1/2009

11732 $39.49 General Fee Schedule 12/1/2009

11740 $34.49 General Fee Schedule 12/1/2009

11750 $153.70 General Fee Schedule 12/1/2009

11752 $217.86 General Fee Schedule 12/1/2009

11755 $109.15 General Fee Schedule 12/1/2009

11760 $158.28 General Fee Schedule 12/1/2009

11762 $222.93 General Fee Schedule 12/1/2009

11765 $90.68 General Fee Schedule 12/1/2009

11770 $231.63 General Fee Schedule 12/1/2009

11771 $440.52 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 3 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

11772 $557.25 General Fee Schedule 12/1/2009

11900 $43.01 General Fee Schedule 12/1/2009

11901 $54.51 General Fee Schedule 12/1/2009

11920 $197.45 General Fee Schedule 12/1/2009

11921 $220.43 General Fee Schedule 12/1/2009

11950 $73.53 General Fee Schedule 12/1/2009

11951 $100.75 General Fee Schedule 12/1/2009

11960 $752.09 General Fee Schedule 12/1/2009

11970 $518.95 General Fee Schedule 12/1/2009

11971 $406.20 General Fee Schedule 12/1/2009

11976 $134.85 General Fee Schedule 12/1/2009

11980 $98.59 General Fee Schedule 12/1/2009

11981 $119.47 General Fee Schedule 12/1/2009

11982 $141.34 General Fee Schedule 12/1/2009

11983 $213.72 General Fee Schedule 12/1/2009

12001 $138.93 General Fee Schedule 12/1/2009

12002 $147.86 General Fee Schedule 12/1/2009

12004 $173.49 General Fee Schedule 12/1/2009

12005 $216.61 General Fee Schedule 12/1/2009

12006 $269.77 General Fee Schedule 12/1/2009

12007 $305.32 General Fee Schedule 12/1/2009

12011 $146.72 General Fee Schedule 12/1/2009

12013 $161.09 General Fee Schedule 12/1/2009

12014 $191.24 General Fee Schedule 12/1/2009

12015 $240.65 General Fee Schedule 12/1/2009

12016 $285.98 General Fee Schedule 12/1/2009

12017 $262.71 General Fee Schedule 12/1/2009

12018 $312.54 General Fee Schedule 12/1/2009

12020 $242.62 General Fee Schedule 12/1/2009

12021 $141.97 General Fee Schedule 12/1/2009

12031 $167.26 General Fee Schedule 12/1/2009

12032 $232.67 General Fee Schedule 12/1/2009

12034 $230.91 General Fee Schedule 12/1/2009

12035 $323.85 General Fee Schedule 12/1/2009

12036 $365.64 General Fee Schedule 12/1/2009

12037 $411.86 General Fee Schedule 12/1/2009

12041 $185.35 General Fee Schedule 12/1/2009

12042 $223.59 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 4 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

12044 $240.77 General Fee Schedule 12/1/2009

12045 $335.05 General Fee Schedule 12/1/2009

12046 $405.54 General Fee Schedule 12/1/2009

12047 $416.89 General Fee Schedule 12/1/2009

12051 $214.54 General Fee Schedule 12/1/2009

12052 $223.38 General Fee Schedule 12/1/2009

12053 $239.64 General Fee Schedule 12/1/2009

12054 $265.76 General Fee Schedule 12/1/2009

12055 $339.88 General Fee Schedule 12/1/2009

12056 $454.04 General Fee Schedule 12/1/2009

12057 $459.57 General Fee Schedule 12/1/2009

13100 $268.42 General Fee Schedule 12/1/2009

13101 $319.79 General Fee Schedule 12/1/2009

13102 $92.41 General Fee Schedule 12/1/2009

13120 $278.44 General Fee Schedule 12/1/2009

13121 $341.78 General Fee Schedule 12/1/2009

13122 $112.46 General Fee Schedule 12/1/2009

13131 $304.50 General Fee Schedule 12/1/2009

13132 $443.02 General Fee Schedule 12/1/2009

13133 $147.59 General Fee Schedule 12/1/2009

13151 $346.77 General Fee Schedule 12/1/2009

13152 $464.89 General Fee Schedule 12/1/2009

13153 $166.58 General Fee Schedule 12/1/2009

13160 $702.77 General Fee Schedule 12/1/2009

14000 $516.79 General Fee Schedule 12/1/2009

14001 $678.07 General Fee Schedule 12/1/2009

14020 $571.55 General Fee Schedule 12/1/2009

14021 $758.22 General Fee Schedule 12/1/2009

14040 $627.11 General Fee Schedule 12/1/2009

14041 $831.54 General Fee Schedule 12/1/2009

14060 $652.82 General Fee Schedule 12/1/2009

14061 $898.04 General Fee Schedule 12/1/2009

14301 $964.40 General Fee Schedule 1/1/2010

14302 $215.56 General Fee Schedule 1/1/2010

14350 $661.98 General Fee Schedule 12/1/2009

15002 $257.38 General Fee Schedule 12/1/2009

15003 $57.06 General Fee Schedule 12/1/2009

15004 $310.86 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 5 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

15005 $96.75 General Fee Schedule 12/1/2009

15040 $241.96 General Fee Schedule 12/1/2009

15050 $422.54 General Fee Schedule 12/1/2009

15100 $825.22 General Fee Schedule 12/1/2009

15101 $202.72 General Fee Schedule 12/1/2009

15110 $778.28 General Fee Schedule 12/1/2009

15111 $124.55 General Fee Schedule 12/1/2009

15115 $735.08 General Fee Schedule 12/1/2009

15116 $161.99 General Fee Schedule 12/1/2009

15120 $787.16 General Fee Schedule 12/1/2009

15121 $269.90 General Fee Schedule 12/1/2009

15130 $642.30 General Fee Schedule 12/1/2009

15131 $101.79 General Fee Schedule 12/1/2009

15135 $786.72 General Fee Schedule 12/1/2009

15136 $95.28 General Fee Schedule 12/1/2009

15150 $648.15 General Fee Schedule 12/1/2009

15151 $131.73 General Fee Schedule 12/1/2009

15152 $161.99 General Fee Schedule 12/1/2009

15155 $652.07 General Fee Schedule 12/1/2009

15156 $171.99 General Fee Schedule 12/1/2009

15157 $190.22 General Fee Schedule 12/1/2009

15200 $666.27 General Fee Schedule 12/1/2009

15201 $145.50 General Fee Schedule 12/1/2009

15220 $647.73 General Fee Schedule 12/1/2009

15221 $131.23 General Fee Schedule 12/1/2009

15240 $730.57 General Fee Schedule 12/1/2009

15241 $163.62 General Fee Schedule 12/1/2009

15260 $761.95 General Fee Schedule 12/1/2009

15261 $185.76 General Fee Schedule 12/1/2009

15271 $137.17 General Fee Schedule 2/3/2012

15272 $26.00 General Fee Schedule 2/3/2012

15273 $283.28 General Fee Schedule 2/3/2012

15274 $66.48 General Fee Schedule 2/3/2012

15275 $147.95 General Fee Schedule 2/3/2012

15276 $32.46 General Fee Schedule 2/3/2012

15277 $286.19 General Fee Schedule 2/3/2012

15278 $78.36 General Fee Schedule 2/3/2012

15570 $789.31 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 6 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

15572 $724.81 General Fee Schedule 12/1/2009

15574 $789.10 General Fee Schedule 12/1/2009

15576 $699.92 General Fee Schedule 12/1/2009

15600 $343.93 General Fee Schedule 12/1/2009

15610 $266.41 General Fee Schedule 12/1/2009

15620 $392.62 General Fee Schedule 12/1/2009

15630 $379.68 General Fee Schedule 12/1/2009

15650 $412.49 General Fee Schedule 12/1/2009

15731 $859.02 General Fee Schedule 12/1/2009

15732 $1,375.54 General Fee Schedule 12/1/2009

15734 $1,397.42 General Fee Schedule 12/1/2009

15736 $1,337.72 General Fee Schedule 12/1/2009

15738 $1,399.02 General Fee Schedule 12/1/2009

15740 $764.48 General Fee Schedule 12/1/2009

15750 $799.23 General Fee Schedule 12/1/2009

15756 $2,223.12 General Fee Schedule 12/1/2009

15757 $2,233.51 General Fee Schedule 12/1/2009

15758 $2,239.56 General Fee Schedule 12/1/2009

15760 $710.42 General Fee Schedule 12/1/2009

15770 $555.54 General Fee Schedule 12/1/2009

15777 $208.67 General Fee Schedule 2/3/2012

15781 $435.83 General Fee Schedule 12/1/2009

15782 $516.37 General Fee Schedule 12/1/2009

15786 $197.19 General Fee Schedule 12/1/2009

15787 $51.44 General Fee Schedule 12/1/2009

15788 $314.89 General Fee Schedule 12/1/2009

15789 $474.09 General Fee Schedule 12/1/2009

15792 $319.71 General Fee Schedule 12/1/2009

15793 $366.23 General Fee Schedule 12/1/2009

15819 $641.68 General Fee Schedule 12/1/2009

15830 $935.62 General Fee Schedule 12/1/2009

15834 $737.61 General Fee Schedule 12/1/2009

15840 $899.02 General Fee Schedule 12/1/2009

15841 $1,498.98 General Fee Schedule 12/1/2009

15842 $2,419.97 General Fee Schedule 12/1/2009

15845 $831.83 General Fee Schedule 12/1/2009

15847 $0.00 General by Report 1/1/2007

15850 $17.39 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 7 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

15851 $92.79 General Fee Schedule 12/1/2009

15852 $99.64 General Fee Schedule 12/1/2009

15860 $113.01 General Fee Schedule 12/1/2009

15920 $533.10 General Fee Schedule 12/1/2009

15922 $678.33 General Fee Schedule 12/1/2009

15931 $594.60 General Fee Schedule 12/1/2009

15933 $739.98 General Fee Schedule 12/1/2009

15934 $826.48 General Fee Schedule 12/1/2009

15935 $988.16 General Fee Schedule 12/1/2009

15936 $820.00 General Fee Schedule 12/1/2009

15937 $956.12 General Fee Schedule 12/1/2009

15940 $617.30 General Fee Schedule 12/1/2009

15941 $822.33 General Fee Schedule 12/1/2009

15944 $793.68 General Fee Schedule 12/1/2009

15945 $883.68 General Fee Schedule 12/1/2009

15946 $1,433.93 General Fee Schedule 12/1/2009

15950 $512.48 General Fee Schedule 12/1/2009

15951 $734.27 General Fee Schedule 12/1/2009

15952 $760.16 General Fee Schedule 12/1/2009

15953 $857.38 General Fee Schedule 12/1/2009

15956 $1,044.38 General Fee Schedule 12/1/2009

15958 $1,053.47 General Fee Schedule 12/1/2009

15999 $764.36 General Fee Schedule 12/1/2009

16000 $66.56 General Fee Schedule 12/1/2009

16020 $77.80 General Fee Schedule 12/1/2009

16025 $138.56 General Fee Schedule 12/1/2009

16030 $163.21 General Fee Schedule 12/1/2009

16035 $214.34 General Fee Schedule 12/1/2009

16036 $85.35 General Fee Schedule 12/1/2009

17000 $57.40 General Fee Schedule 12/1/2009

17003 $9.90 General Fee Schedule 12/1/2009

17004 $190.59 General Fee Schedule 12/1/2009

17106 $346.71 General Fee Schedule 12/1/2009

17107 $622.13 General Fee Schedule 12/1/2009

17108 $845.44 General Fee Schedule 12/1/2009

17110 $82.29 General Fee Schedule 12/1/2009

17111 $94.42 General Fee Schedule 12/1/2009

17250 $63.14 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 8 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

17260 $80.33 General Fee Schedule 12/1/2009

17261 $102.01 General Fee Schedule 12/1/2009

17262 $127.77 General Fee Schedule 12/1/2009

17263 $142.04 General Fee Schedule 12/1/2009

17264 $154.00 General Fee Schedule 12/1/2009

17266 $179.37 General Fee Schedule 12/1/2009

17270 $110.88 General Fee Schedule 12/1/2009

17271 $120.53 General Fee Schedule 12/1/2009

17272 $139.20 General Fee Schedule 12/1/2009

17273 $157.55 General Fee Schedule 12/1/2009

17274 $191.42 General Fee Schedule 12/1/2009

17276 $230.04 General Fee Schedule 12/1/2009

17280 $102.01 General Fee Schedule 12/1/2009

17281 $134.20 General Fee Schedule 12/1/2009

17282 $155.45 General Fee Schedule 12/1/2009

17283 $193.01 General Fee Schedule 12/1/2009

17284 $228.71 General Fee Schedule 12/1/2009

17286 $304.93 General Fee Schedule 12/1/2009

17311 $536.86 General Fee Schedule 12/1/2009

17312 $322.31 General Fee Schedule 12/1/2009

17313 $489.94 General Fee Schedule 12/1/2009

17314 $298.51 General Fee Schedule 12/1/2009

17315 $63.83 General Fee Schedule 12/1/2009

17340 $43.74 General Fee Schedule 12/1/2009

17999 $0.00 General by Report 7/1/1975

19000 $103.31 General Fee Schedule 12/1/2009

19001 $26.15 General Fee Schedule 12/1/2009

19020 $370.36 General Fee Schedule 12/1/2009

19030 $160.43 General Fee Schedule 12/1/2009

19081 $640.01 General Fee Schedule 1/1/2014

19082 $512.01 General Fee Schedule 1/1/2014

19083 $634.77 General Fee Schedule 1/1/2014

19084 $504.69 General Fee Schedule 1/1/2014

19085 $956.20 General Fee Schedule 1/1/2014

19086 $755.81 General Fee Schedule 1/1/2014

19100 $126.10 General Fee Schedule 12/1/2009

19101 $290.63 General Fee Schedule 12/1/2009

19105 $1,549.51 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 9 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

19110 $384.20 General Fee Schedule 12/1/2009

19112 $366.02 General Fee Schedule 12/1/2009

19120 $395.22 General Fee Schedule 12/1/2009

19125 $425.15 General Fee Schedule 12/1/2009

19126 $160.46 General Fee Schedule 12/1/2009

19260 $1,051.54 General Fee Schedule 12/1/2009

19271 $1,435.12 General Fee Schedule 12/1/2009

19272 $1,583.75 General Fee Schedule 12/1/2009

19281 $232.56 General Fee Schedule 1/1/2014

19282 $159.64 General Fee Schedule 1/1/2014

19283 $263.15 General Fee Schedule 1/1/2014

19284 $190.89 General Fee Schedule 1/1/2014

19285 $439.35 General Fee Schedule 1/1/2014

19286 $366.05 General Fee Schedule 1/1/2014

19287 $813.72 General Fee Schedule 1/1/2014

19288 $643.28 General Fee Schedule 1/1/2014

19296 $4,457.85 General Fee Schedule 12/1/2009

19297 $94.17 General Fee Schedule 12/1/2009

19298 $1,693.99 General Fee Schedule 12/1/2009

19300 $412.26 General Fee Schedule 12/1/2009

19301 $321.17 General Fee Schedule 12/1/2009

19302 $686.22 General Fee Schedule 12/1/2009

19303 $699.51 General Fee Schedule 12/1/2009

19304 $425.98 General Fee Schedule 12/1/2009

19305 $849.01 General Fee Schedule 12/1/2009

19306 $882.75 General Fee Schedule 12/1/2009

19307 $887.74 General Fee Schedule 12/1/2009

19316 $726.31 General Fee Schedule 12/1/2009

19318 $1,086.47 General Fee Schedule 12/1/2009

19324 $422.20 General Fee Schedule 12/1/2009

19325 $595.63 General Fee Schedule 12/1/2009

19328 $422.50 General Fee Schedule 12/1/2009

19330 $543.24 General Fee Schedule 12/1/2009

19340 $387.38 General Fee Schedule 12/1/2009

19342 $801.17 General Fee Schedule 12/1/2009

19350 $867.83 General Fee Schedule 12/1/2009

19357 $1,337.15 General Fee Schedule 12/1/2009

19361 $1,270.06 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 10 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

19364 $2,603.44 General Fee Schedule 12/1/2009

19366 $1,329.64 General Fee Schedule 12/1/2009

19367 $1,703.94 General Fee Schedule 12/1/2009

19368 $2,089.60 General Fee Schedule 12/1/2009

19369 $1,936.60 General Fee Schedule 12/1/2009

19370 $591.82 General Fee Schedule 12/1/2009

19371 $684.89 General Fee Schedule 12/1/2009

19380 $666.46 General Fee Schedule 12/1/2009

19396 $131.11 General Fee Schedule 12/1/2009

19499 $0.00 General by Report 7/1/1975

20005 $267.34 General Fee Schedule 12/1/2009

20100 $583.14 General Fee Schedule 12/1/2009

20101 $342.86 General Fee Schedule 12/1/2009

20102 $424.71 General Fee Schedule 12/1/2009

20103 $524.54 General Fee Schedule 12/1/2009

20150 $839.15 General Fee Schedule 12/1/2009

20200 $168.38 General Fee Schedule 12/1/2009

20205 $235.63 General Fee Schedule 12/1/2009

20206 $263.85 General Fee Schedule 12/1/2009

20220 $208.24 General Fee Schedule 12/1/2009

20225 $919.27 General Fee Schedule 12/1/2009

20240 $227.52 General Fee Schedule 12/1/2009

20245 $570.79 General Fee Schedule 12/1/2009

20250 $349.17 General Fee Schedule 12/1/2009

20251 $396.72 General Fee Schedule 12/1/2009

20500 $129.34 General Fee Schedule 12/1/2009

20501 $130.69 General Fee Schedule 12/1/2009

20520 $178.64 General Fee Schedule 12/1/2009

20525 $466.28 General Fee Schedule 12/1/2009

20526 $73.98 General Fee Schedule 12/1/2009

20527 $72.80 General Fee Schedule 2/3/2012

20550 $56.37 General Fee Schedule 12/1/2009

20551 $54.99 General Fee Schedule 12/1/2009

20552 $51.86 General Fee Schedule 12/1/2009

20553 $58.40 General Fee Schedule 12/1/2009

20555 $247.73 General Fee Schedule 12/1/2009

20600 $50.50 General Fee Schedule 12/1/2009

20605 $55.03 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 11 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

20610 $66.81 General Fee Schedule 12/1/2009

20612 $54.79 General Fee Schedule 12/1/2009

20615 $215.44 General Fee Schedule 12/1/2009

20650 $177.92 General Fee Schedule 12/1/2009

20660 $222.03 General Fee Schedule 12/1/2009

20661 $396.19 General Fee Schedule 12/1/2009

20662 $442.92 General Fee Schedule 12/1/2009

20663 $407.38 General Fee Schedule 12/1/2009

20664 $612.55 General Fee Schedule 12/1/2009

20665 $131.09 General Fee Schedule 12/1/2009

20670 $472.96 General Fee Schedule 12/1/2009

20680 $449.90 General Fee Schedule 12/1/2009

20690 $242.14 General Fee Schedule 12/1/2009

20692 $412.72 General Fee Schedule 12/1/2009

20693 $446.59 General Fee Schedule 12/1/2009

20694 $429.85 General Fee Schedule 12/1/2009

20696 $963.44 General Fee Schedule 12/1/2009

20697 $1,030.37 General Fee Schedule 12/1/2009

20802 $2,436.95 General Fee Schedule 12/1/2009

20805 $3,272.52 General Fee Schedule 12/1/2009

20808 $4,062.71 General Fee Schedule 12/1/2009

20816 $2,646.04 General Fee Schedule 12/1/2009

20822 $2,318.28 General Fee Schedule 12/1/2009

20824 $2,606.35 General Fee Schedule 12/1/2009

20827 $2,396.68 General Fee Schedule 12/1/2009

20838 $2,399.60 General Fee Schedule 12/1/2009

20900 $536.77 General Fee Schedule 12/1/2009

20902 $572.17 General Fee Schedule 12/1/2009

20910 $408.28 General Fee Schedule 12/1/2009

20912 $467.47 General Fee Schedule 12/1/2009

20920 $372.19 General Fee Schedule 12/1/2009

20922 $537.77 General Fee Schedule 12/1/2009

20924 $487.66 General Fee Schedule 12/1/2009

20926 $406.09 General Fee Schedule 12/1/2009

20930 $89.91 General Fee Schedule 12/1/2009

20931 $116.56 General Fee Schedule 12/1/2009

20936 $138.65 General Fee Schedule 12/1/2009

20937 $175.99 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 12 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

20938 $192.09 General Fee Schedule 12/1/2009

20950 $290.41 General Fee Schedule 12/1/2009

20955 $2,513.40 General Fee Schedule 12/1/2009

20956 $2,605.04 General Fee Schedule 12/1/2009

20957 $2,460.42 General Fee Schedule 12/1/2009

20962 $2,650.43 General Fee Schedule 12/1/2009

20969 $2,772.49 General Fee Schedule 12/1/2009

20970 $2,759.08 General Fee Schedule 12/1/2009

20972 $2,546.78 General Fee Schedule 12/1/2009

20973 $2,818.75 General Fee Schedule 12/1/2009

20974 $55.42 General Fee Schedule 7/1/2009

20975 $161.04 General Fee Schedule 7/1/2009

20979 $54.43 General Fee Schedule 12/1/2009

20982 $4,065.72 General Fee Schedule 12/1/2009

20985 $247.73 General Fee Schedule 12/1/2009

20999 $0.00 General by Report 7/1/1975

21010 $672.39 General Fee Schedule 12/1/2009

21011 $283.99 General Fee Schedule 1/1/2010

21012 $309.12 General Fee Schedule 1/1/2010

21013 $443.82 General Fee Schedule 1/1/2010

21014 $477.95 General Fee Schedule 1/1/2010

21015 $399.85 General Fee Schedule 12/1/2009

21016 $966.52 General Fee Schedule 1/1/2010

21025 $853.56 General Fee Schedule 12/1/2009

21026 $477.33 General Fee Schedule 12/1/2009

21029 $651.51 General Fee Schedule 12/1/2009

21030 $409.37 General Fee Schedule 12/1/2009

21031 $318.98 General Fee Schedule 12/1/2009

21032 $324.81 General Fee Schedule 12/1/2009

21034 $1,229.20 General Fee Schedule 12/1/2009

21040 $411.43 General Fee Schedule 12/1/2009

21044 $817.53 General Fee Schedule 12/1/2009

21045 $1,100.07 General Fee Schedule 12/1/2009

21046 $973.37 General Fee Schedule 12/1/2009

21047 $1,257.31 General Fee Schedule 12/1/2009

21048 $997.77 General Fee Schedule 12/1/2009

21049 $1,195.68 General Fee Schedule 12/1/2009

21050 $789.94 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 13 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

21060 $737.23 General Fee Schedule 12/1/2009

21070 $603.77 General Fee Schedule 12/1/2009

21073 $269.07 General Fee Schedule 12/1/2009

21076 $1,010.16 General Fee Schedule 12/1/2009

21077 $2,533.68 General Fee Schedule 12/1/2009

21079 $1,708.10 General Fee Schedule 12/1/2009

21080 $1,937.34 General Fee Schedule 12/1/2009

21081 $1,758.07 General Fee Schedule 12/1/2009

21082 $1,576.03 General Fee Schedule 12/1/2009

21083 $1,488.31 General Fee Schedule 12/1/2009

21084 $1,713.34 General Fee Schedule 12/1/2009

21085 $675.39 General Fee Schedule 12/1/2009

21086 $1,903.68 General Fee Schedule 12/1/2009

21087 $1,878.60 General Fee Schedule 12/1/2009

21088 $1,338.31 General Fee Schedule 12/1/2009

21089 $0.00 General by Report 1/1/1997

21100 $570.02 General Fee Schedule 12/1/2009

21110 $553.92 General Fee Schedule 12/1/2009

21116 $181.92 General Fee Schedule 12/1/2009

21120 $573.88 General Fee Schedule 12/1/2009

21121 $659.76 General Fee Schedule 12/1/2009

21122 $661.24 General Fee Schedule 12/1/2009

21123 $849.15 General Fee Schedule 12/1/2009

21125 $2,332.48 General Fee Schedule 12/1/2009

21127 $1,950.41 General Fee Schedule 12/1/2009

21137 $689.58 General Fee Schedule 12/1/2009

21138 $857.16 General Fee Schedule 12/1/2009

21139 $983.61 General Fee Schedule 12/1/2009

21141 $1,247.37 General Fee Schedule 12/1/2009

21142 $1,247.39 General Fee Schedule 12/1/2009

21143 $1,303.25 General Fee Schedule 12/1/2009

21145 $1,343.87 General Fee Schedule 12/1/2009

21146 $1,431.19 General Fee Schedule 12/1/2009

21147 $1,419.33 General Fee Schedule 12/1/2009

21150 $1,636.30 General Fee Schedule 12/1/2009

21151 $1,958.38 General Fee Schedule 12/1/2009

21154 $2,055.73 General Fee Schedule 12/1/2009

21155 $2,377.50 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 14 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

21159 $2,914.42 General Fee Schedule 12/1/2009

21160 $2,875.72 General Fee Schedule 12/1/2009

21172 $1,666.27 General Fee Schedule 12/1/2009

21175 $2,056.02 General Fee Schedule 12/1/2009

21179 $1,439.53 General Fee Schedule 12/1/2009

21180 $1,618.91 General Fee Schedule 12/1/2009

21181 $683.43 General Fee Schedule 12/1/2009

21182 $1,993.61 General Fee Schedule 12/1/2009

21183 $2,230.62 General Fee Schedule 12/1/2009

21184 $2,423.82 General Fee Schedule 12/1/2009

21188 $1,571.91 General Fee Schedule 12/1/2009

21193 $1,172.31 General Fee Schedule 12/1/2009

21194 $1,306.55 General Fee Schedule 12/1/2009

21195 $1,229.70 General Fee Schedule 12/1/2009

21196 $1,339.14 General Fee Schedule 12/1/2009

21198 $1,031.71 General Fee Schedule 12/1/2009

21199 $977.75 General Fee Schedule 12/1/2009

21206 $1,023.19 General Fee Schedule 12/1/2009

21208 $1,198.32 General Fee Schedule 12/1/2009

21209 $660.87 General Fee Schedule 12/1/2009

21210 $1,292.87 General Fee Schedule 12/1/2009

21215 $1,905.75 General Fee Schedule 12/1/2009

21230 $735.44 General Fee Schedule 12/1/2009

21235 $617.99 General Fee Schedule 12/1/2009

21240 $1,032.51 General Fee Schedule 12/1/2009

21242 $955.67 General Fee Schedule 12/1/2009

21243 $1,512.05 General Fee Schedule 12/1/2009

21244 $915.49 General Fee Schedule 12/1/2009

21245 $992.49 General Fee Schedule 12/1/2009

21246 $837.72 General Fee Schedule 12/1/2009

21247 $1,565.81 General Fee Schedule 12/1/2009

21248 $912.55 General Fee Schedule 12/1/2009

21249 $1,334.91 General Fee Schedule 12/1/2009

21255 $1,280.39 General Fee Schedule 12/1/2009

21256 $1,081.67 General Fee Schedule 12/1/2009

21260 $1,108.61 General Fee Schedule 12/1/2009

21261 $2,163.64 General Fee Schedule 12/1/2009

21263 $1,840.89 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 15 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

21267 $1,466.00 General Fee Schedule 12/1/2009

21268 $1,763.42 General Fee Schedule 12/1/2009

21270 $818.85 General Fee Schedule 12/1/2009

21275 $757.71 General Fee Schedule 12/1/2009

21280 $450.24 General Fee Schedule 12/1/2009

21282 $297.02 General Fee Schedule 12/1/2009

21295 $151.54 General Fee Schedule 12/1/2009

21296 $343.85 General Fee Schedule 12/1/2009

21299 $0.00 General by Report 1/1/1997

21310 $102.52 General Fee Schedule 12/1/2009

21315 $208.29 General Fee Schedule 12/1/2009

21320 $211.84 General Fee Schedule 12/1/2009

21325 $451.64 General Fee Schedule 12/1/2009

21330 $559.75 General Fee Schedule 12/1/2009

21335 $687.89 General Fee Schedule 12/1/2009

21336 $569.45 General Fee Schedule 12/1/2009

21337 $324.11 General Fee Schedule 12/1/2009

21338 $758.66 General Fee Schedule 12/1/2009

21339 $822.31 General Fee Schedule 12/1/2009

21340 $742.93 General Fee Schedule 12/1/2009

21343 $1,080.87 General Fee Schedule 12/1/2009

21344 $1,410.57 General Fee Schedule 12/1/2009

21345 $684.28 General Fee Schedule 12/1/2009

21346 $869.61 General Fee Schedule 12/1/2009

21347 $1,095.84 General Fee Schedule 12/1/2009

21348 $1,110.13 General Fee Schedule 12/1/2009

21355 $370.86 General Fee Schedule 12/1/2009

21356 $420.15 General Fee Schedule 12/1/2009

21360 $478.24 General Fee Schedule 12/1/2009

21365 $1,006.47 General Fee Schedule 12/1/2009

21366 $1,159.69 General Fee Schedule 12/1/2009

21385 $670.85 General Fee Schedule 12/1/2009

21386 $629.42 General Fee Schedule 12/1/2009

21387 $718.78 General Fee Schedule 12/1/2009

21390 $689.06 General Fee Schedule 12/1/2009

21395 $848.25 General Fee Schedule 12/1/2009

21400 $148.92 General Fee Schedule 12/1/2009

21401 $413.19 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 16 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

21406 $504.24 General Fee Schedule 12/1/2009

21407 $599.96 General Fee Schedule 12/1/2009

21408 $831.88 General Fee Schedule 12/1/2009

21421 $543.69 General Fee Schedule 12/1/2009

21422 $632.28 General Fee Schedule 12/1/2009

21423 $764.64 General Fee Schedule 12/1/2009

21431 $622.89 General Fee Schedule 12/1/2009

21432 $636.56 General Fee Schedule 12/1/2009

21433 $1,636.17 General Fee Schedule 12/1/2009

21435 $1,169.25 General Fee Schedule 12/1/2009

21436 $1,813.01 General Fee Schedule 12/1/2009

21440 $361.11 General Fee Schedule 12/1/2009

21445 $569.06 General Fee Schedule 12/1/2009

21450 $379.40 General Fee Schedule 12/1/2009

21451 $530.49 General Fee Schedule 12/1/2009

21452 $532.89 General Fee Schedule 12/1/2009

21453 $607.75 General Fee Schedule 12/1/2009

21454 $492.29 General Fee Schedule 12/1/2009

21461 $1,185.56 General Fee Schedule 12/1/2009

21462 $1,369.40 General Fee Schedule 12/1/2009

21465 $847.64 General Fee Schedule 12/1/2009

21470 $1,071.60 General Fee Schedule 12/1/2009

21480 $86.56 General Fee Schedule 12/1/2009

21485 $453.36 General Fee Schedule 12/1/2009

21490 $857.50 General Fee Schedule 12/1/2009

21495 $524.09 General Fee Schedule 12/1/2009

21497 $455.86 General Fee Schedule 12/1/2009

21499 $0.00 General by Report 1/1/1997

21501 $382.02 General Fee Schedule 12/1/2009

21502 $501.38 General Fee Schedule 12/1/2009

21510 $443.27 General Fee Schedule 12/1/2009

21550 $207.95 General Fee Schedule 12/1/2009

21552 $416.08 General Fee Schedule 1/1/2010

21554 $684.07 General Fee Schedule 1/1/2010

21555 $376.20 General Fee Schedule 12/1/2009

21556 $377.78 General Fee Schedule 12/1/2009

21557 $563.54 General Fee Schedule 12/1/2009

21558 $1,287.30 General Fee Schedule 1/1/2010

Tuesday, February 11, 2014 Page 17 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

21600 $496.62 General Fee Schedule 12/1/2009

21610 $973.57 General Fee Schedule 12/1/2009

21615 $660.06 General Fee Schedule 12/1/2009

21616 $803.47 General Fee Schedule 12/1/2009

21620 $500.64 General Fee Schedule 12/1/2009

21627 $514.09 General Fee Schedule 12/1/2009

21630 $1,165.20 General Fee Schedule 12/1/2009

21632 $1,171.96 General Fee Schedule 12/1/2009

21685 $879.99 General Fee Schedule 12/1/2009

21700 $401.95 General Fee Schedule 12/1/2009

21705 $611.28 General Fee Schedule 12/1/2009

21720 $334.85 General Fee Schedule 12/1/2009

21725 $498.15 General Fee Schedule 12/1/2009

21740 $1,010.01 General Fee Schedule 12/1/2009

21742 $377.02 General Fee Schedule 12/1/2009

21743 $414.72 General Fee Schedule 12/1/2009

21750 $681.12 General Fee Schedule 12/1/2009

21800 $86.04 General Fee Schedule 12/1/2009

21805 $229.17 General Fee Schedule 12/1/2009

21810 $467.37 General Fee Schedule 12/1/2009

21820 $117.58 General Fee Schedule 12/1/2009

21825 $543.43 General Fee Schedule 12/1/2009

21899 $0.00 General by Report 7/1/1975

21920 $196.99 General Fee Schedule 12/1/2009

21925 $371.00 General Fee Schedule 12/1/2009

21930 $411.59 General Fee Schedule 12/1/2009

21931 $436.30 General Fee Schedule 1/1/2010

21932 $626.52 General Fee Schedule 1/1/2010

21933 $691.98 General Fee Schedule 1/1/2010

21935 $1,107.79 General Fee Schedule 12/1/2009

21936 $1,342.66 General Fee Schedule 1/1/2010

22010 $791.34 General Fee Schedule 12/1/2009

22015 $784.33 General Fee Schedule 12/1/2009

22100 $707.25 General Fee Schedule 12/1/2009

22101 $709.92 General Fee Schedule 12/1/2009

22102 $721.21 General Fee Schedule 12/1/2009

22103 $146.95 General Fee Schedule 12/1/2009

22110 $900.96 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 18 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

22112 $899.13 General Fee Schedule 12/1/2009

22114 $902.25 General Fee Schedule 12/1/2009

22116 $146.88 General Fee Schedule 12/1/2009

22206 $1,770.44 General Fee Schedule 12/1/2009

22207 $1,747.57 General Fee Schedule 12/1/2009

22208 $450.40 General Fee Schedule 12/1/2009

22210 $1,634.76 General Fee Schedule 12/1/2009

22212 $1,338.85 General Fee Schedule 12/1/2009

22214 $1,358.84 General Fee Schedule 12/1/2009

22216 $384.82 General Fee Schedule 12/1/2009

22220 $1,466.17 General Fee Schedule 12/1/2009

22222 $1,353.90 General Fee Schedule 12/1/2009

22224 $1,462.11 General Fee Schedule 12/1/2009

22226 $383.44 General Fee Schedule 12/1/2009

22305 $172.03 General Fee Schedule 12/1/2009

22310 $214.22 General Fee Schedule 12/1/2009

22315 $737.18 General Fee Schedule 12/1/2009

22318 $1,470.57 General Fee Schedule 12/1/2009

22319 $1,638.13 General Fee Schedule 12/1/2009

22325 $1,253.50 General Fee Schedule 12/1/2009

22326 $1,343.86 General Fee Schedule 12/1/2009

22327 $1,301.97 General Fee Schedule 12/1/2009

22328 $287.75 General Fee Schedule 12/1/2009

22505 $116.80 General Fee Schedule 12/1/2009

22520 $2,519.81 General Fee Schedule 12/1/2009

22521 $2,298.52 General Fee Schedule 12/1/2009

22522 $251.82 General Fee Schedule 12/1/2009

22523 $606.83 General Fee Schedule 12/1/2009

22524 $580.40 General Fee Schedule 12/1/2009

22525 $278.92 General Fee Schedule 12/1/2009

22526 $1,668.66 General Fee Schedule 12/1/2009

22527 $1,350.20 General Fee Schedule 12/1/2009

22532 $1,583.52 General Fee Schedule 12/1/2009

22533 $1,466.71 General Fee Schedule 12/1/2009

22534 $378.46 General Fee Schedule 12/1/2009

22548 $1,730.84 General Fee Schedule 12/1/2009

22551 $1,718.00 General Fee Schedule 1/1/2011

22552 $401.71 General Fee Schedule 1/1/2011

Tuesday, February 11, 2014 Page 19 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

22554 $1,295.13 General Fee Schedule 12/1/2009

22556 $1,559.59 General Fee Schedule 12/1/2009

22558 $1,424.02 General Fee Schedule 12/1/2009

22585 $352.11 General Fee Schedule 12/1/2009

22586 $1,509.21 General Fee Schedule 1/31/2013

22590 $1,413.04 General Fee Schedule 12/1/2009

22595 $1,339.90 General Fee Schedule 12/1/2009

22600 $1,134.85 General Fee Schedule 12/1/2009

22610 $1,130.86 General Fee Schedule 12/1/2009

22612 $1,451.01 General Fee Schedule 12/1/2009

22614 $410.89 General Fee Schedule 12/1/2009

22630 $1,433.28 General Fee Schedule 12/1/2009

22632 $332.97 General Fee Schedule 12/1/2009

22633 $1,807.87 General Fee Schedule 2/3/2012

22634 $490.35 General Fee Schedule 2/3/2012

22800 $1,271.40 General Fee Schedule 12/1/2009

22802 $2,075.21 General Fee Schedule 12/1/2009

22804 $2,418.40 General Fee Schedule 12/1/2009

22808 $1,742.19 General Fee Schedule 12/1/2009

22810 $1,973.98 General Fee Schedule 12/1/2009

22812 $2,131.50 General Fee Schedule 12/1/2009

22818 $2,097.25 General Fee Schedule 12/1/2009

22819 $2,357.38 General Fee Schedule 12/1/2009

22830 $770.34 General Fee Schedule 12/1/2009

22840 $802.17 General Fee Schedule 12/1/2009

22841 $622.25 General Fee Schedule 12/1/2009

22842 $802.68 General Fee Schedule 12/1/2009

22843 $843.87 General Fee Schedule 12/1/2009

22844 $1,044.24 General Fee Schedule 12/1/2009

22845 $767.82 General Fee Schedule 12/1/2009

22846 $797.93 General Fee Schedule 12/1/2009

22847 $876.20 General Fee Schedule 12/1/2009

22848 $380.14 General Fee Schedule 12/1/2009

22849 $1,250.31 General Fee Schedule 12/1/2009

22850 $677.55 General Fee Schedule 12/1/2009

22851 $425.46 General Fee Schedule 12/1/2009

22852 $645.84 General Fee Schedule 12/1/2009

22855 $1,036.23 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 20 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

22856 $1,476.01 General Fee Schedule 12/1/2009

22857 $1,228.13 General Fee Schedule 12/1/2009

22861 $1,793.93 General Fee Schedule 12/1/2009

22862 $1,495.69 General Fee Schedule 12/1/2009

22864 $1,673.73 General Fee Schedule 12/1/2009

22865 $1,456.38 General Fee Schedule 12/1/2009

22899 $0.00 General by Report 7/1/1975

22900 $360.33 General Fee Schedule 12/1/2009

22901 $618.15 General Fee Schedule 1/1/2010

22902 $380.82 General Fee Schedule 1/1/2010

22903 $407.06 General Fee Schedule 1/1/2010

22904 $971.80 General Fee Schedule 1/1/2010

22905 $1,260.18 General Fee Schedule 1/1/2010

22999 $0.00 General by Report 7/1/1975

23000 $484.13 General Fee Schedule 12/1/2009

23020 $657.01 General Fee Schedule 12/1/2009

23030 $405.39 General Fee Schedule 12/1/2009

23031 $391.44 General Fee Schedule 12/1/2009

23035 $666.55 General Fee Schedule 12/1/2009

23040 $679.78 General Fee Schedule 12/1/2009

23044 $538.11 General Fee Schedule 12/1/2009

23065 $179.78 General Fee Schedule 12/1/2009

23066 $445.23 General Fee Schedule 12/1/2009

23071 $386.67 General Fee Schedule 1/1/2010

23073 $641.75 General Fee Schedule 1/1/2010

23075 $229.64 General Fee Schedule 12/1/2009

23076 $523.86 General Fee Schedule 12/1/2009

23077 $1,051.35 General Fee Schedule 12/1/2009

23078 $1,311.74 General Fee Schedule 1/1/2010

23100 $462.42 General Fee Schedule 12/1/2009

23101 $431.32 General Fee Schedule 12/1/2009

23105 $610.78 General Fee Schedule 12/1/2009

23106 $459.70 General Fee Schedule 12/1/2009

23107 $637.50 General Fee Schedule 12/1/2009

23120 $538.40 General Fee Schedule 12/1/2009

23125 $677.54 General Fee Schedule 12/1/2009

23130 $580.74 General Fee Schedule 12/1/2009

23140 $482.27 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 21 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

23145 $657.36 General Fee Schedule 12/1/2009

23146 $592.58 General Fee Schedule 12/1/2009

23150 $610.13 General Fee Schedule 12/1/2009

23155 $746.78 General Fee Schedule 12/1/2009

23156 $639.82 General Fee Schedule 12/1/2009

23170 $509.88 General Fee Schedule 12/1/2009

23172 $516.53 General Fee Schedule 12/1/2009

23174 $710.59 General Fee Schedule 12/1/2009

23180 $688.46 General Fee Schedule 12/1/2009

23182 $654.92 General Fee Schedule 12/1/2009

23184 $737.75 General Fee Schedule 12/1/2009

23190 $531.41 General Fee Schedule 12/1/2009

23195 $702.33 General Fee Schedule 12/1/2009

23200 $831.75 General Fee Schedule 12/1/2009

23210 $859.92 General Fee Schedule 12/1/2009

23220 $1,018.36 General Fee Schedule 12/1/2009

23330 $206.03 General Fee Schedule 12/1/2009

23333 $451.92 General Fee Schedule 1/1/2014

23334 $1,072.16 General Fee Schedule 1/1/2014

23335 $1,280.55 General Fee Schedule 1/1/2014

23350 $159.48 General Fee Schedule 12/1/2009

23395 $1,192.10 General Fee Schedule 12/1/2009

23397 $1,106.44 General Fee Schedule 12/1/2009

23400 $946.76 General Fee Schedule 12/1/2009

23405 $610.37 General Fee Schedule 12/1/2009

23406 $766.53 General Fee Schedule 12/1/2009

23410 $877.26 General Fee Schedule 12/1/2009

23412 $932.40 General Fee Schedule 12/1/2009

23415 $718.44 General Fee Schedule 12/1/2009

23420 $964.55 General Fee Schedule 12/1/2009

23430 $722.59 General Fee Schedule 12/1/2009

23440 $750.09 General Fee Schedule 12/1/2009

23450 $934.52 General Fee Schedule 12/1/2009

23455 $998.37 General Fee Schedule 12/1/2009

23460 $1,074.68 General Fee Schedule 12/1/2009

23462 $1,048.33 General Fee Schedule 12/1/2009

23465 $1,090.16 General Fee Schedule 12/1/2009

23466 $1,023.39 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 22 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

23470 $1,184.53 General Fee Schedule 12/1/2009

23472 $1,434.44 General Fee Schedule 12/1/2009

23473 $1,589.23 General Fee Schedule 1/31/2013

23474 $1,717.79 General Fee Schedule 1/31/2013

23480 $799.07 General Fee Schedule 12/1/2009

23485 $937.74 General Fee Schedule 12/1/2009

23490 $806.33 General Fee Schedule 12/1/2009

23491 $1,000.40 General Fee Schedule 12/1/2009

23500 $189.25 General Fee Schedule 12/1/2009

23505 $314.44 General Fee Schedule 12/1/2009

23515 $554.79 General Fee Schedule 12/1/2009

23520 $193.04 General Fee Schedule 12/1/2009

23525 $310.24 General Fee Schedule 12/1/2009

23530 $526.93 General Fee Schedule 12/1/2009

23532 $595.78 General Fee Schedule 12/1/2009

23540 $194.35 General Fee Schedule 12/1/2009

23545 $281.33 General Fee Schedule 12/1/2009

23550 $541.03 General Fee Schedule 12/1/2009

23552 $627.51 General Fee Schedule 12/1/2009

23570 $201.91 General Fee Schedule 12/1/2009

23575 $344.12 General Fee Schedule 12/1/2009

23585 $660.92 General Fee Schedule 12/1/2009

23600 $285.80 General Fee Schedule 12/1/2009

23605 $427.85 General Fee Schedule 12/1/2009

23615 $719.82 General Fee Schedule 12/1/2009

23616 $1,432.79 General Fee Schedule 12/1/2009

23620 $230.39 General Fee Schedule 12/1/2009

23625 $343.92 General Fee Schedule 12/1/2009

23630 $554.86 General Fee Schedule 12/1/2009

23650 $270.24 General Fee Schedule 12/1/2009

23655 $342.96 General Fee Schedule 12/1/2009

23660 $552.40 General Fee Schedule 12/1/2009

23665 $379.85 General Fee Schedule 12/1/2009

23670 $586.04 General Fee Schedule 12/1/2009

23675 $502.55 General Fee Schedule 12/1/2009

23680 $726.34 General Fee Schedule 12/1/2009

23700 $187.11 General Fee Schedule 12/1/2009

23800 $984.40 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 23 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

23802 $1,082.45 General Fee Schedule 12/1/2009

23900 $1,271.81 General Fee Schedule 12/1/2009

23920 $988.79 General Fee Schedule 12/1/2009

23921 $412.74 General Fee Schedule 12/1/2009

23929 $0.00 General by Report 7/1/1975

23930 $345.40 General Fee Schedule 12/1/2009

23931 $281.79 General Fee Schedule 12/1/2009

23935 $473.98 General Fee Schedule 12/1/2009

24000 $443.68 General Fee Schedule 12/1/2009

24006 $676.81 General Fee Schedule 12/1/2009

24065 $196.40 General Fee Schedule 12/1/2009

24066 $535.11 General Fee Schedule 12/1/2009

24071 $374.76 General Fee Schedule 1/1/2010

24073 $644.81 General Fee Schedule 1/1/2010

24075 $422.60 General Fee Schedule 12/1/2009

24076 $442.34 General Fee Schedule 12/1/2009

24077 $778.25 General Fee Schedule 12/1/2009

24079 $1,208.63 General Fee Schedule 1/1/2010

24100 $374.36 General Fee Schedule 12/1/2009

24101 $475.51 General Fee Schedule 12/1/2009

24102 $591.06 General Fee Schedule 12/1/2009

24105 $310.67 General Fee Schedule 12/1/2009

24110 $557.78 General Fee Schedule 12/1/2009

24115 $676.54 General Fee Schedule 12/1/2009

24116 $837.45 General Fee Schedule 12/1/2009

24120 $497.66 General Fee Schedule 12/1/2009

24125 $552.37 General Fee Schedule 12/1/2009

24126 $601.47 General Fee Schedule 12/1/2009

24130 $483.57 General Fee Schedule 12/1/2009

24134 $735.85 General Fee Schedule 12/1/2009

24136 $603.56 General Fee Schedule 12/1/2009

24138 $623.67 General Fee Schedule 12/1/2009

24140 $718.69 General Fee Schedule 12/1/2009

24145 $612.00 General Fee Schedule 12/1/2009

24147 $630.67 General Fee Schedule 12/1/2009

24149 $1,027.03 General Fee Schedule 12/1/2009

24150 $934.63 General Fee Schedule 12/1/2009

24152 $704.00 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 24 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

24155 $806.59 General Fee Schedule 12/1/2009

24160 $583.33 General Fee Schedule 12/1/2009

24164 $473.89 General Fee Schedule 12/1/2009

24200 $191.93 General Fee Schedule 12/1/2009

24201 $537.39 General Fee Schedule 12/1/2009

24220 $177.96 General Fee Schedule 12/1/2009

24300 $362.99 General Fee Schedule 12/1/2009

24301 $731.02 General Fee Schedule 12/1/2009

24305 $557.31 General Fee Schedule 12/1/2009

24310 $455.32 General Fee Schedule 12/1/2009

24320 $725.08 General Fee Schedule 12/1/2009

24330 $695.91 General Fee Schedule 12/1/2009

24331 $769.32 General Fee Schedule 12/1/2009

24332 $562.13 General Fee Schedule 12/1/2009

24340 $590.80 General Fee Schedule 12/1/2009

24341 $623.36 General Fee Schedule 12/1/2009

24342 $765.45 General Fee Schedule 12/1/2009

24343 $662.61 General Fee Schedule 12/1/2009

24344 $1,016.58 General Fee Schedule 12/1/2009

24345 $658.50 General Fee Schedule 12/1/2009

24346 $1,009.37 General Fee Schedule 12/1/2009

24357 $329.90 General Fee Schedule 12/1/2009

24358 $388.15 General Fee Schedule 12/1/2009

24359 $478.59 General Fee Schedule 12/1/2009

24360 $871.60 General Fee Schedule 12/1/2009

24361 $981.26 General Fee Schedule 12/1/2009

24362 $1,012.41 General Fee Schedule 12/1/2009

24363 $1,287.27 General Fee Schedule 12/1/2009

24365 $619.36 General Fee Schedule 12/1/2009

24366 $663.36 General Fee Schedule 12/1/2009

24370 $1,501.13 General Fee Schedule 2/1/2013

24371 $1,730.71 General Fee Schedule 2/1/2013

24400 $796.48 General Fee Schedule 12/1/2009

24410 $1,014.05 General Fee Schedule 12/1/2009

24420 $954.85 General Fee Schedule 12/1/2009

24430 $904.52 General Fee Schedule 12/1/2009

24435 $959.51 General Fee Schedule 12/1/2009

24470 $653.08 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 25 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

24495 $654.06 General Fee Schedule 12/1/2009

24498 $848.56 General Fee Schedule 12/1/2009

24500 $307.57 General Fee Schedule 12/1/2009

24505 $456.56 General Fee Schedule 12/1/2009

24515 $840.85 General Fee Schedule 12/1/2009

24516 $831.61 General Fee Schedule 12/1/2009

24530 $333.12 General Fee Schedule 12/1/2009

24535 $574.65 General Fee Schedule 12/1/2009

24538 $719.14 General Fee Schedule 12/1/2009

24545 $755.83 General Fee Schedule 12/1/2009

24546 $1,087.74 General Fee Schedule 12/1/2009

24560 $277.00 General Fee Schedule 12/1/2009

24565 $473.34 General Fee Schedule 12/1/2009

24566 $625.27 General Fee Schedule 12/1/2009

24575 $763.23 General Fee Schedule 12/1/2009

24576 $289.59 General Fee Schedule 12/1/2009

24577 $493.86 General Fee Schedule 12/1/2009

24579 $820.10 General Fee Schedule 12/1/2009

24582 $693.69 General Fee Schedule 12/1/2009

24586 $1,063.02 General Fee Schedule 12/1/2009

24587 $1,049.75 General Fee Schedule 12/1/2009

24600 $346.89 General Fee Schedule 12/1/2009

24605 $423.75 General Fee Schedule 12/1/2009

24615 $686.91 General Fee Schedule 12/1/2009

24620 $520.66 General Fee Schedule 12/1/2009

24635 $1,069.50 General Fee Schedule 12/1/2009

24640 $113.81 General Fee Schedule 12/1/2009

24650 $225.22 General Fee Schedule 12/1/2009

24655 $398.02 General Fee Schedule 12/1/2009

24665 $620.32 General Fee Schedule 12/1/2009

24666 $698.86 General Fee Schedule 12/1/2009

24670 $253.26 General Fee Schedule 12/1/2009

24675 $415.89 General Fee Schedule 12/1/2009

24685 $649.94 General Fee Schedule 12/1/2009

24800 $788.11 General Fee Schedule 12/1/2009

24802 $965.93 General Fee Schedule 12/1/2009

24900 $665.42 General Fee Schedule 12/1/2009

24920 $661.75 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 26 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

24925 $520.73 General Fee Schedule 12/1/2009

24930 $701.12 General Fee Schedule 12/1/2009

24931 $752.01 General Fee Schedule 12/1/2009

24935 $948.67 General Fee Schedule 12/1/2009

24940 $565.66 General Fee Schedule 12/1/2009

24999 $0.00 General by Report 7/1/1975

25000 $384.97 General Fee Schedule 12/1/2009

25001 $294.25 General Fee Schedule 12/1/2009

25020 $588.58 General Fee Schedule 12/1/2009

25023 $1,082.46 General Fee Schedule 12/1/2009

25024 $669.72 General Fee Schedule 12/1/2009

25025 $1,042.90 General Fee Schedule 12/1/2009

25028 $510.30 General Fee Schedule 12/1/2009

25031 $453.02 General Fee Schedule 12/1/2009

25035 $793.19 General Fee Schedule 12/1/2009

25040 $567.09 General Fee Schedule 12/1/2009

25065 $192.57 General Fee Schedule 12/1/2009

25066 $423.53 General Fee Schedule 12/1/2009

25071 $392.16 General Fee Schedule 1/1/2010

25073 $487.42 General Fee Schedule 1/1/2010

25075 $365.31 General Fee Schedule 12/1/2009

25076 $542.72 General Fee Schedule 12/1/2009

25077 $840.34 General Fee Schedule 12/1/2009

25078 $1,053.63 General Fee Schedule 1/1/2010

25085 $485.73 General Fee Schedule 12/1/2009

25100 $351.64 General Fee Schedule 12/1/2009

25101 $408.88 General Fee Schedule 12/1/2009

25105 $507.81 General Fee Schedule 12/1/2009

25107 $568.23 General Fee Schedule 12/1/2009

25109 $408.21 General Fee Schedule 12/1/2009

25110 $414.39 General Fee Schedule 12/1/2009

25111 $310.03 General Fee Schedule 12/1/2009

25112 $379.08 General Fee Schedule 12/1/2009

25115 $867.02 General Fee Schedule 12/1/2009

25116 $763.64 General Fee Schedule 12/1/2009

25118 $388.99 General Fee Schedule 12/1/2009

25119 $526.80 General Fee Schedule 12/1/2009

25120 $684.57 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 27 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

25125 $765.92 General Fee Schedule 12/1/2009

25126 $781.70 General Fee Schedule 12/1/2009

25130 $450.77 General Fee Schedule 12/1/2009

25135 $558.59 General Fee Schedule 12/1/2009

25136 $491.94 General Fee Schedule 12/1/2009

25145 $694.30 General Fee Schedule 12/1/2009

25150 $594.43 General Fee Schedule 12/1/2009

25151 $762.49 General Fee Schedule 12/1/2009

25170 $1,008.49 General Fee Schedule 12/1/2009

25210 $492.83 General Fee Schedule 12/1/2009

25215 $645.87 General Fee Schedule 12/1/2009

25230 $439.67 General Fee Schedule 12/1/2009

25240 $465.78 General Fee Schedule 12/1/2009

25246 $177.20 General Fee Schedule 12/1/2009

25248 $515.27 General Fee Schedule 12/1/2009

25250 $498.79 General Fee Schedule 12/1/2009

25251 $684.37 General Fee Schedule 12/1/2009

25259 $362.30 General Fee Schedule 12/1/2009

25260 $798.86 General Fee Schedule 12/1/2009

25263 $797.56 General Fee Schedule 12/1/2009

25265 $923.04 General Fee Schedule 12/1/2009

25270 $676.92 General Fee Schedule 12/1/2009

25272 $748.96 General Fee Schedule 12/1/2009

25274 $852.02 General Fee Schedule 12/1/2009

25275 $633.16 General Fee Schedule 12/1/2009

25280 $749.39 General Fee Schedule 12/1/2009

25290 $746.72 General Fee Schedule 12/1/2009

25295 $704.34 General Fee Schedule 12/1/2009

25300 $672.80 General Fee Schedule 12/1/2009

25301 $645.04 General Fee Schedule 12/1/2009

25310 $803.09 General Fee Schedule 12/1/2009

25312 $896.34 General Fee Schedule 12/1/2009

25315 $941.90 General Fee Schedule 12/1/2009

25316 $1,092.29 General Fee Schedule 12/1/2009

25320 $861.53 General Fee Schedule 12/1/2009

25332 $817.84 General Fee Schedule 12/1/2009

25335 $960.53 General Fee Schedule 12/1/2009

25337 $827.77 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 28 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

25350 $868.61 General Fee Schedule 12/1/2009

25355 $953.11 General Fee Schedule 12/1/2009

25360 $849.95 General Fee Schedule 12/1/2009

25365 $1,089.31 General Fee Schedule 12/1/2009

25370 $1,145.57 General Fee Schedule 12/1/2009

25375 $1,144.51 General Fee Schedule 12/1/2009

25390 $958.20 General Fee Schedule 12/1/2009

25391 $1,170.78 General Fee Schedule 12/1/2009

25392 $1,158.36 General Fee Schedule 12/1/2009

25393 $1,310.73 General Fee Schedule 12/1/2009

25394 $732.22 General Fee Schedule 12/1/2009

25400 $1,005.03 General Fee Schedule 12/1/2009

25405 $1,227.41 General Fee Schedule 12/1/2009

25415 $1,156.44 General Fee Schedule 12/1/2009

25420 $1,346.92 General Fee Schedule 12/1/2009

25425 $1,315.35 General Fee Schedule 12/1/2009

25426 $1,265.94 General Fee Schedule 12/1/2009

25430 $652.51 General Fee Schedule 12/1/2009

25431 $756.12 General Fee Schedule 12/1/2009

25440 $781.36 General Fee Schedule 12/1/2009

25441 $912.05 General Fee Schedule 12/1/2009

25442 $775.93 General Fee Schedule 12/1/2009

25443 $748.88 General Fee Schedule 12/1/2009

25444 $798.86 General Fee Schedule 12/1/2009

25445 $701.42 General Fee Schedule 12/1/2009

25446 $1,132.49 General Fee Schedule 12/1/2009

25447 $752.29 General Fee Schedule 12/1/2009

25449 $1,001.20 General Fee Schedule 12/1/2009

25450 $700.27 General Fee Schedule 12/1/2009

25455 $771.93 General Fee Schedule 12/1/2009

25490 $888.69 General Fee Schedule 12/1/2009

25491 $935.77 General Fee Schedule 12/1/2009

25492 $1,074.28 General Fee Schedule 12/1/2009

25500 $229.22 General Fee Schedule 12/1/2009

25505 $456.40 General Fee Schedule 12/1/2009

25515 $664.96 General Fee Schedule 12/1/2009

25520 $514.10 General Fee Schedule 12/1/2009

25525 $887.97 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 29 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

25526 $1,039.46 General Fee Schedule 12/1/2009

25530 $221.49 General Fee Schedule 12/1/2009

25535 $435.21 General Fee Schedule 12/1/2009

25545 $658.94 General Fee Schedule 12/1/2009

25560 $232.96 General Fee Schedule 12/1/2009

25565 $479.12 General Fee Schedule 12/1/2009

25574 $559.18 General Fee Schedule 12/1/2009

25575 $791.73 General Fee Schedule 12/1/2009

25600 $256.40 General Fee Schedule 12/1/2009

25605 $506.63 General Fee Schedule 12/1/2009

25606 $554.11 General Fee Schedule 12/1/2009

25607 $560.63 General Fee Schedule 12/1/2009

25608 $642.11 General Fee Schedule 12/1/2009

25609 $819.64 General Fee Schedule 12/1/2009

25622 $261.43 General Fee Schedule 12/1/2009

25624 $417.10 General Fee Schedule 12/1/2009

25628 $640.75 General Fee Schedule 12/1/2009

25630 $270.16 General Fee Schedule 12/1/2009

25635 $398.68 General Fee Schedule 12/1/2009

25645 $548.58 General Fee Schedule 12/1/2009

25650 $281.17 General Fee Schedule 12/1/2009

25651 $424.51 General Fee Schedule 12/1/2009

25652 $575.10 General Fee Schedule 12/1/2009

25660 $364.98 General Fee Schedule 12/1/2009

25670 $589.54 General Fee Schedule 12/1/2009

25671 $477.00 General Fee Schedule 12/1/2009

25675 $395.41 General Fee Schedule 12/1/2009

25676 $606.85 General Fee Schedule 12/1/2009

25680 $420.39 General Fee Schedule 12/1/2009

25685 $700.12 General Fee Schedule 12/1/2009

25690 $431.29 General Fee Schedule 12/1/2009

25695 $610.55 General Fee Schedule 12/1/2009

25800 $742.82 General Fee Schedule 12/1/2009

25805 $848.76 General Fee Schedule 12/1/2009

25810 $804.88 General Fee Schedule 12/1/2009

25820 $598.76 General Fee Schedule 12/1/2009

25825 $723.16 General Fee Schedule 12/1/2009

25830 $935.80 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 30 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

25900 $823.69 General Fee Schedule 12/1/2009

25905 $822.14 General Fee Schedule 12/1/2009

25907 $742.33 General Fee Schedule 12/1/2009

25909 $816.66 General Fee Schedule 12/1/2009

25915 $1,407.43 General Fee Schedule 12/1/2009

25920 $650.73 General Fee Schedule 12/1/2009

25922 $566.76 General Fee Schedule 12/1/2009

25924 $649.42 General Fee Schedule 12/1/2009

25927 $784.07 General Fee Schedule 12/1/2009

25929 $533.62 General Fee Schedule 12/1/2009

25931 $734.17 General Fee Schedule 12/1/2009

25999 $0.00 General by Report 7/1/1975

26010 $256.70 General Fee Schedule 12/1/2009

26011 $398.59 General Fee Schedule 12/1/2009

26020 $388.94 General Fee Schedule 12/1/2009

26025 $387.55 General Fee Schedule 12/1/2009

26030 $456.81 General Fee Schedule 12/1/2009

26034 $493.07 General Fee Schedule 12/1/2009

26035 $687.60 General Fee Schedule 12/1/2009

26037 $535.56 General Fee Schedule 12/1/2009

26040 $285.84 General Fee Schedule 12/1/2009

26045 $440.14 General Fee Schedule 12/1/2009

26055 $611.35 General Fee Schedule 12/1/2009

26060 $244.52 General Fee Schedule 12/1/2009

26070 $274.01 General Fee Schedule 12/1/2009

26075 $293.97 General Fee Schedule 12/1/2009

26080 $352.46 General Fee Schedule 12/1/2009

26100 $301.67 General Fee Schedule 12/1/2009

26105 $308.36 General Fee Schedule 12/1/2009

26110 $292.84 General Fee Schedule 12/1/2009

26111 $378.48 General Fee Schedule 1/1/2010

26113 $497.82 General Fee Schedule 1/1/2010

26115 $618.51 General Fee Schedule 12/1/2009

26116 $448.19 General Fee Schedule 12/1/2009

26117 $615.56 General Fee Schedule 12/1/2009

26118 $981.38 General Fee Schedule 1/1/2010

26121 $570.04 General Fee Schedule 12/1/2009

26123 $711.61 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 31 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

26125 $285.62 General Fee Schedule 12/1/2009

26130 $424.80 General Fee Schedule 12/1/2009

26135 $527.09 General Fee Schedule 12/1/2009

26140 $477.03 General Fee Schedule 12/1/2009

26145 $484.88 General Fee Schedule 12/1/2009

26160 $563.40 General Fee Schedule 12/1/2009

26170 $377.04 General Fee Schedule 12/1/2009

26180 $412.41 General Fee Schedule 12/1/2009

26185 $437.37 General Fee Schedule 12/1/2009

26200 $426.55 General Fee Schedule 12/1/2009

26205 $574.85 General Fee Schedule 12/1/2009

26210 $411.93 General Fee Schedule 12/1/2009

26215 $524.25 General Fee Schedule 12/1/2009

26230 $481.87 General Fee Schedule 12/1/2009

26235 $470.95 General Fee Schedule 12/1/2009

26236 $415.76 General Fee Schedule 12/1/2009

26250 $548.83 General Fee Schedule 12/1/2009

26260 $518.13 General Fee Schedule 12/1/2009

26262 $432.04 General Fee Schedule 12/1/2009

26320 $321.52 General Fee Schedule 12/1/2009

26340 $277.39 General Fee Schedule 12/1/2009

26341 $93.41 General Fee Schedule 2/3/2012

26350 $764.52 General Fee Schedule 12/1/2009

26352 $862.33 General Fee Schedule 12/1/2009

26356 $983.54 General Fee Schedule 12/1/2009

26357 $913.58 General Fee Schedule 12/1/2009

26358 $971.49 General Fee Schedule 12/1/2009

26370 $831.44 General Fee Schedule 12/1/2009

26372 $953.75 General Fee Schedule 12/1/2009

26373 $907.94 General Fee Schedule 12/1/2009

26390 $858.74 General Fee Schedule 12/1/2009

26392 $1,023.64 General Fee Schedule 12/1/2009

26410 $613.36 General Fee Schedule 12/1/2009

26412 $732.37 General Fee Schedule 12/1/2009

26415 $759.72 General Fee Schedule 12/1/2009

26416 $889.46 General Fee Schedule 12/1/2009

26418 $609.97 General Fee Schedule 12/1/2009

26420 $765.91 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 32 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

26426 $721.74 General Fee Schedule 12/1/2009

26428 $791.45 General Fee Schedule 12/1/2009

26432 $529.19 General Fee Schedule 12/1/2009

26433 $570.94 General Fee Schedule 12/1/2009

26434 $662.93 General Fee Schedule 12/1/2009

26437 $652.16 General Fee Schedule 12/1/2009

26440 $680.46 General Fee Schedule 12/1/2009

26442 $903.48 General Fee Schedule 12/1/2009

26445 $639.67 General Fee Schedule 12/1/2009

26449 $848.05 General Fee Schedule 12/1/2009

26450 $413.30 General Fee Schedule 12/1/2009

26455 $410.08 General Fee Schedule 12/1/2009

26460 $397.30 General Fee Schedule 12/1/2009

26471 $637.03 General Fee Schedule 12/1/2009

26474 $622.21 General Fee Schedule 12/1/2009

26476 $602.09 General Fee Schedule 12/1/2009

26477 $606.07 General Fee Schedule 12/1/2009

26478 $660.97 General Fee Schedule 12/1/2009

26479 $649.76 General Fee Schedule 12/1/2009

26480 $809.37 General Fee Schedule 12/1/2009

26483 $895.17 General Fee Schedule 12/1/2009

26485 $863.80 General Fee Schedule 12/1/2009

26489 $825.68 General Fee Schedule 12/1/2009

26490 $806.31 General Fee Schedule 12/1/2009

26492 $886.29 General Fee Schedule 12/1/2009

26494 $816.19 General Fee Schedule 12/1/2009

26496 $874.19 General Fee Schedule 12/1/2009

26497 $883.68 General Fee Schedule 12/1/2009

26498 $1,167.14 General Fee Schedule 12/1/2009

26499 $840.69 General Fee Schedule 12/1/2009

26500 $653.45 General Fee Schedule 12/1/2009

26502 $726.80 General Fee Schedule 12/1/2009

26508 $666.36 General Fee Schedule 12/1/2009

26510 $625.77 General Fee Schedule 12/1/2009

26516 $733.69 General Fee Schedule 12/1/2009

26517 $852.72 General Fee Schedule 12/1/2009

26518 $854.22 General Fee Schedule 12/1/2009

26520 $708.74 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 33 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

26525 $712.99 General Fee Schedule 12/1/2009

26530 $504.67 General Fee Schedule 12/1/2009

26531 $589.80 General Fee Schedule 12/1/2009

26535 $354.79 General Fee Schedule 12/1/2009

26536 $610.06 General Fee Schedule 12/1/2009

26540 $689.43 General Fee Schedule 12/1/2009

26541 $836.35 General Fee Schedule 12/1/2009

26542 $709.45 General Fee Schedule 12/1/2009

26545 $719.65 General Fee Schedule 12/1/2009

26546 $909.61 General Fee Schedule 12/1/2009

26548 $792.33 General Fee Schedule 12/1/2009

26550 $1,506.91 General Fee Schedule 12/1/2009

26551 $3,183.94 General Fee Schedule 12/1/2009

26553 $2,645.40 General Fee Schedule 12/1/2009

26554 $3,731.66 General Fee Schedule 12/1/2009

26555 $1,350.94 General Fee Schedule 12/1/2009

26556 $3,054.45 General Fee Schedule 12/1/2009

26560 $573.19 General Fee Schedule 12/1/2009

26561 $894.67 General Fee Schedule 12/1/2009

26562 $1,243.78 General Fee Schedule 12/1/2009

26565 $706.52 General Fee Schedule 12/1/2009

26567 $708.94 General Fee Schedule 12/1/2009

26568 $931.20 General Fee Schedule 12/1/2009

26580 $1,247.69 General Fee Schedule 12/1/2009

26587 $910.74 General Fee Schedule 12/1/2009

26590 $1,266.39 General Fee Schedule 12/1/2009

26591 $472.41 General Fee Schedule 12/1/2009

26593 $613.60 General Fee Schedule 12/1/2009

26596 $697.47 General Fee Schedule 12/1/2009

26600 $209.96 General Fee Schedule 12/1/2009

26605 $283.40 General Fee Schedule 12/1/2009

26607 $451.91 General Fee Schedule 12/1/2009

26608 $451.57 General Fee Schedule 12/1/2009

26615 $417.20 General Fee Schedule 12/1/2009

26641 $321.97 General Fee Schedule 12/1/2009

26645 $370.33 General Fee Schedule 12/1/2009

26650 $482.60 General Fee Schedule 12/1/2009

26665 $551.05 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 34 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

26670 $301.71 General Fee Schedule 12/1/2009

26675 $393.28 General Fee Schedule 12/1/2009

26676 $473.85 General Fee Schedule 12/1/2009

26685 $517.59 General Fee Schedule 12/1/2009

26686 $585.84 General Fee Schedule 12/1/2009

26700 $283.20 General Fee Schedule 12/1/2009

26705 $367.31 General Fee Schedule 12/1/2009

26706 $399.83 General Fee Schedule 12/1/2009

26715 $441.94 General Fee Schedule 12/1/2009

26720 $167.89 General Fee Schedule 12/1/2009

26725 $310.50 General Fee Schedule 12/1/2009

26727 $444.48 General Fee Schedule 12/1/2009

26735 $453.96 General Fee Schedule 12/1/2009

26740 $193.10 General Fee Schedule 12/1/2009

26742 $339.43 General Fee Schedule 12/1/2009

26746 $446.35 General Fee Schedule 12/1/2009

26750 $158.47 General Fee Schedule 12/1/2009

26755 $285.83 General Fee Schedule 12/1/2009

26756 $390.10 General Fee Schedule 12/1/2009

26765 $334.02 General Fee Schedule 12/1/2009

26770 $243.66 General Fee Schedule 12/1/2009

26775 $339.84 General Fee Schedule 12/1/2009

26776 $417.59 General Fee Schedule 12/1/2009

26785 $341.04 General Fee Schedule 12/1/2009

26820 $818.35 General Fee Schedule 12/1/2009

26841 $769.92 General Fee Schedule 12/1/2009

26842 $822.39 General Fee Schedule 12/1/2009

26843 $757.28 General Fee Schedule 12/1/2009

26844 $841.30 General Fee Schedule 12/1/2009

26850 $724.33 General Fee Schedule 12/1/2009

26852 $810.99 General Fee Schedule 12/1/2009

26860 $589.99 General Fee Schedule 12/1/2009

26861 $108.33 General Fee Schedule 12/1/2009

26862 $745.94 General Fee Schedule 12/1/2009

26863 $242.07 General Fee Schedule 12/1/2009

26910 $718.21 General Fee Schedule 12/1/2009

26951 $549.83 General Fee Schedule 12/1/2009

26952 $676.23 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 35 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

26989 $0.00 General by Report 7/1/1975

26990 $578.01 General Fee Schedule 12/1/2009

26991 $678.91 General Fee Schedule 12/1/2009

26992 $932.80 General Fee Schedule 12/1/2009

27000 $431.84 General Fee Schedule 12/1/2009

27001 $519.51 General Fee Schedule 12/1/2009

27003 $544.16 General Fee Schedule 12/1/2009

27005 $700.31 General Fee Schedule 12/1/2009

27006 $705.53 General Fee Schedule 12/1/2009

27025 $786.96 General Fee Schedule 12/1/2009

27027 $759.47 General Fee Schedule 12/1/2009

27030 $910.54 General Fee Schedule 12/1/2009

27033 $936.86 General Fee Schedule 12/1/2009

27035 $1,102.83 General Fee Schedule 12/1/2009

27036 $917.85 General Fee Schedule 12/1/2009

27040 $299.85 General Fee Schedule 12/1/2009

27041 $656.00 General Fee Schedule 12/1/2009

27043 $435.66 General Fee Schedule 1/1/2010

27045 $692.75 General Fee Schedule 1/1/2010

27047 $566.87 General Fee Schedule 12/1/2009

27048 $437.31 General Fee Schedule 12/1/2009

27049 $885.92 General Fee Schedule 12/1/2009

27050 $340.31 General Fee Schedule 12/1/2009

27052 $479.38 General Fee Schedule 12/1/2009

27054 $632.01 General Fee Schedule 12/1/2009

27057 $834.05 General Fee Schedule 12/1/2009

27059 $1,705.67 General Fee Schedule 1/1/2010

27060 $386.80 General Fee Schedule 12/1/2009

27062 $417.39 General Fee Schedule 12/1/2009

27065 $449.17 General Fee Schedule 12/1/2009

27066 $749.43 General Fee Schedule 12/1/2009

27067 $962.61 General Fee Schedule 12/1/2009

27070 $786.73 General Fee Schedule 12/1/2009

27071 $855.39 General Fee Schedule 12/1/2009

27075 $2,203.26 General Fee Schedule 12/1/2009

27076 $1,478.61 General Fee Schedule 12/1/2009

27077 $2,531.25 General Fee Schedule 12/1/2009

27078 $936.03 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 36 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27080 $444.10 General Fee Schedule 12/1/2009

27086 $236.93 General Fee Schedule 12/1/2009

27087 $604.58 General Fee Schedule 12/1/2009

27090 $798.25 General Fee Schedule 12/1/2009

27091 $1,466.42 General Fee Schedule 12/1/2009

27093 $207.72 General Fee Schedule 12/1/2009

27095 $259.26 General Fee Schedule 12/1/2009

27096 $206.08 General Fee Schedule 12/1/2009

27097 $613.67 General Fee Schedule 12/1/2009

27098 $614.29 General Fee Schedule 12/1/2009

27100 $788.33 General Fee Schedule 12/1/2009

27105 $827.59 General Fee Schedule 12/1/2009

27110 $899.29 General Fee Schedule 12/1/2009

27111 $848.83 General Fee Schedule 12/1/2009

27120 $1,206.80 General Fee Schedule 12/1/2009

27122 $1,046.60 General Fee Schedule 12/1/2009

27125 $1,018.62 General Fee Schedule 12/1/2009

27130 $1,353.08 General Fee Schedule 12/1/2009

27132 $1,574.59 General Fee Schedule 12/1/2009

27134 $1,880.73 General Fee Schedule 12/1/2009

27137 $1,421.05 General Fee Schedule 12/1/2009

27138 $1,481.27 General Fee Schedule 12/1/2009

27140 $867.76 General Fee Schedule 12/1/2009

27146 $1,190.54 General Fee Schedule 12/1/2009

27147 $1,371.54 General Fee Schedule 12/1/2009

27151 $1,275.64 General Fee Schedule 12/1/2009

27156 $1,646.13 General Fee Schedule 12/1/2009

27158 $1,246.56 General Fee Schedule 12/1/2009

27161 $1,161.03 General Fee Schedule 12/1/2009

27165 $1,240.60 General Fee Schedule 12/1/2009

27170 $1,104.48 General Fee Schedule 12/1/2009

27175 $605.64 General Fee Schedule 12/1/2009

27176 $850.53 General Fee Schedule 12/1/2009

27177 $1,045.33 General Fee Schedule 12/1/2009

27178 $822.83 General Fee Schedule 12/1/2009

27179 $921.02 General Fee Schedule 12/1/2009

27181 $970.34 General Fee Schedule 12/1/2009

27185 $694.66 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 37 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27187 $958.08 General Fee Schedule 12/1/2009

27193 $422.00 General Fee Schedule 12/1/2009

27194 $691.69 General Fee Schedule 12/1/2009

27200 $157.04 General Fee Schedule 12/1/2009

27202 $886.91 General Fee Schedule 12/1/2009

27215 $698.28 General Fee Schedule 12/1/2009

27216 $1,005.75 General Fee Schedule 12/1/2009

27217 $975.30 General Fee Schedule 12/1/2009

27218 $1,288.15 General Fee Schedule 12/1/2009

27220 $471.63 General Fee Schedule 12/1/2009

27222 $907.45 General Fee Schedule 12/1/2009

27226 $928.48 General Fee Schedule 12/1/2009

27227 $1,572.13 General Fee Schedule 12/1/2009

27228 $1,812.75 General Fee Schedule 12/1/2009

27230 $434.06 General Fee Schedule 12/1/2009

27232 $721.53 General Fee Schedule 12/1/2009

27235 $866.05 General Fee Schedule 12/1/2009

27236 $1,074.33 General Fee Schedule 12/1/2009

27238 $419.75 General Fee Schedule 12/1/2009

27240 $881.58 General Fee Schedule 12/1/2009

27244 $1,098.09 General Fee Schedule 12/1/2009

27245 $1,376.17 General Fee Schedule 12/1/2009

27246 $362.43 General Fee Schedule 12/1/2009

27248 $746.89 General Fee Schedule 12/1/2009

27250 $447.81 General Fee Schedule 12/1/2009

27252 $712.68 General Fee Schedule 12/1/2009

27253 $911.17 General Fee Schedule 12/1/2009

27254 $1,225.71 General Fee Schedule 12/1/2009

27256 $295.38 General Fee Schedule 12/1/2009

27257 $321.48 General Fee Schedule 12/1/2009

27258 $1,059.19 General Fee Schedule 12/1/2009

27259 $1,444.64 General Fee Schedule 12/1/2009

27265 $380.64 General Fee Schedule 12/1/2009

27266 $551.03 General Fee Schedule 12/1/2009

27267 $310.47 General Fee Schedule 12/1/2009

27268 $383.10 General Fee Schedule 12/1/2009

27269 $916.36 General Fee Schedule 12/1/2009

27275 $173.33 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 38 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27280 $955.76 General Fee Schedule 12/1/2009

27282 $775.77 General Fee Schedule 12/1/2009

27284 $1,545.71 General Fee Schedule 12/1/2009

27286 $1,553.69 General Fee Schedule 12/1/2009

27290 $1,498.65 General Fee Schedule 12/1/2009

27295 $1,208.87 General Fee Schedule 12/1/2009

27299 $0.00 General by Report 7/1/1975

27301 $631.84 General Fee Schedule 12/1/2009

27303 $608.27 General Fee Schedule 12/1/2009

27305 $441.04 General Fee Schedule 12/1/2009

27306 $369.25 General Fee Schedule 12/1/2009

27307 $444.29 General Fee Schedule 12/1/2009

27310 $673.24 General Fee Schedule 12/1/2009

27323 $216.80 General Fee Schedule 12/1/2009

27324 $358.10 General Fee Schedule 12/1/2009

27325 $413.84 General Fee Schedule 12/1/2009

27326 $391.11 General Fee Schedule 12/1/2009

27327 $400.03 General Fee Schedule 12/1/2009

27328 $393.59 General Fee Schedule 12/1/2009

27329 $928.78 General Fee Schedule 12/1/2009

27330 $377.97 General Fee Schedule 12/1/2009

27331 $451.48 General Fee Schedule 12/1/2009

27332 $612.68 General Fee Schedule 12/1/2009

27333 $553.95 General Fee Schedule 12/1/2009

27334 $641.98 General Fee Schedule 12/1/2009

27335 $727.82 General Fee Schedule 12/1/2009

27337 $387.24 General Fee Schedule 1/1/2010

27339 $699.49 General Fee Schedule 1/1/2010

27340 $342.28 General Fee Schedule 12/1/2009

27345 $455.75 General Fee Schedule 12/1/2009

27347 $442.81 General Fee Schedule 12/1/2009

27350 $612.23 General Fee Schedule 12/1/2009

27355 $572.97 General Fee Schedule 12/1/2009

27356 $691.98 General Fee Schedule 12/1/2009

27357 $771.93 General Fee Schedule 12/1/2009

27358 $297.52 General Fee Schedule 12/1/2009

27360 $795.72 General Fee Schedule 12/1/2009

27364 $1,466.02 General Fee Schedule 1/1/2010

Tuesday, February 11, 2014 Page 39 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27365 $1,124.53 General Fee Schedule 12/1/2009

27370 $167.52 General Fee Schedule 12/1/2009

27372 $569.43 General Fee Schedule 12/1/2009

27380 $568.75 General Fee Schedule 12/1/2009

27381 $772.42 General Fee Schedule 12/1/2009

27385 $608.03 General Fee Schedule 12/1/2009

27386 $797.36 General Fee Schedule 12/1/2009

27390 $412.42 General Fee Schedule 12/1/2009

27391 $545.30 General Fee Schedule 12/1/2009

27392 $669.50 General Fee Schedule 12/1/2009

27393 $484.54 General Fee Schedule 12/1/2009

27394 $626.36 General Fee Schedule 12/1/2009

27395 $842.57 General Fee Schedule 12/1/2009

27396 $589.63 General Fee Schedule 12/1/2009

27397 $808.03 General Fee Schedule 12/1/2009

27400 $641.93 General Fee Schedule 12/1/2009

27403 $617.40 General Fee Schedule 12/1/2009

27405 $642.78 General Fee Schedule 12/1/2009

27407 $743.05 General Fee Schedule 12/1/2009

27409 $916.22 General Fee Schedule 12/1/2009

27412 $1,555.00 General Fee Schedule 12/1/2009

27415 $1,295.00 General Fee Schedule 12/1/2009

27416 $718.10 General Fee Schedule 12/1/2009

27418 $788.71 General Fee Schedule 12/1/2009

27420 $716.45 General Fee Schedule 12/1/2009

27422 $714.53 General Fee Schedule 12/1/2009

27424 $714.65 General Fee Schedule 12/1/2009

27425 $421.86 General Fee Schedule 12/1/2009

27427 $684.95 General Fee Schedule 12/1/2009

27428 $1,009.06 General Fee Schedule 12/1/2009

27429 $1,117.81 General Fee Schedule 12/1/2009

27430 $705.82 General Fee Schedule 12/1/2009

27435 $715.32 General Fee Schedule 12/1/2009

27437 $626.19 General Fee Schedule 12/1/2009

27438 $793.13 General Fee Schedule 12/1/2009

27440 $670.11 General Fee Schedule 12/1/2009

27441 $712.22 General Fee Schedule 12/1/2009

27442 $836.44 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 40 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27443 $786.32 General Fee Schedule 12/1/2009

27445 $1,211.86 General Fee Schedule 12/1/2009

27446 $1,094.24 General Fee Schedule 12/1/2009

27447 $1,460.10 General Fee Schedule 12/1/2009

27448 $788.27 General Fee Schedule 12/1/2009

27450 $985.69 General Fee Schedule 12/1/2009

27454 $1,213.75 General Fee Schedule 12/1/2009

27455 $910.73 General Fee Schedule 12/1/2009

27457 $939.87 General Fee Schedule 12/1/2009

27465 $970.84 General Fee Schedule 12/1/2009

27466 $1,131.29 General Fee Schedule 12/1/2009

27468 $1,269.25 General Fee Schedule 12/1/2009

27470 $1,120.57 General Fee Schedule 12/1/2009

27472 $1,224.36 General Fee Schedule 12/1/2009

27475 $627.62 General Fee Schedule 12/1/2009

27477 $704.92 General Fee Schedule 12/1/2009

27479 $920.39 General Fee Schedule 12/1/2009

27485 $647.72 General Fee Schedule 12/1/2009

27486 $1,321.95 General Fee Schedule 12/1/2009

27487 $1,693.83 General Fee Schedule 12/1/2009

27488 $1,103.03 General Fee Schedule 12/1/2009

27495 $1,084.72 General Fee Schedule 12/1/2009

27496 $462.06 General Fee Schedule 12/1/2009

27497 $502.68 General Fee Schedule 12/1/2009

27498 $555.25 General Fee Schedule 12/1/2009

27499 $631.96 General Fee Schedule 12/1/2009

27500 $473.57 General Fee Schedule 12/1/2009

27501 $462.61 General Fee Schedule 12/1/2009

27502 $747.43 General Fee Schedule 12/1/2009

27503 $755.68 General Fee Schedule 12/1/2009

27506 $1,215.97 General Fee Schedule 12/1/2009

27507 $960.74 General Fee Schedule 12/1/2009

27508 $480.00 General Fee Schedule 12/1/2009

27509 $616.72 General Fee Schedule 12/1/2009

27510 $656.52 General Fee Schedule 12/1/2009

27511 $992.07 General Fee Schedule 12/1/2009

27513 $1,274.89 General Fee Schedule 12/1/2009

27514 $1,228.67 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 41 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27516 $452.96 General Fee Schedule 12/1/2009

27517 $636.41 General Fee Schedule 12/1/2009

27519 $1,064.90 General Fee Schedule 12/1/2009

27520 $282.41 General Fee Schedule 12/1/2009

27524 $728.17 General Fee Schedule 12/1/2009

27530 $350.45 General Fee Schedule 12/1/2009

27532 $577.58 General Fee Schedule 12/1/2009

27535 $859.37 General Fee Schedule 12/1/2009

27536 $1,096.12 General Fee Schedule 12/1/2009

27538 $427.17 General Fee Schedule 12/1/2009

27540 $909.91 General Fee Schedule 12/1/2009

27550 $454.65 General Fee Schedule 12/1/2009

27552 $590.16 General Fee Schedule 12/1/2009

27556 $1,041.68 General Fee Schedule 12/1/2009

27557 $1,199.31 General Fee Schedule 12/1/2009

27558 $1,237.03 General Fee Schedule 12/1/2009

27560 $326.93 General Fee Schedule 12/1/2009

27562 $419.22 General Fee Schedule 12/1/2009

27566 $864.65 General Fee Schedule 12/1/2009

27570 $138.47 General Fee Schedule 12/1/2009

27580 $1,370.99 General Fee Schedule 12/1/2009

27590 $752.72 General Fee Schedule 12/1/2009

27591 $855.28 General Fee Schedule 12/1/2009

27592 $648.00 General Fee Schedule 12/1/2009

27594 $479.30 General Fee Schedule 12/1/2009

27596 $696.45 General Fee Schedule 12/1/2009

27598 $703.71 General Fee Schedule 12/1/2009

27599 $0.00 General by Report 6/1/1981

27600 $402.84 General Fee Schedule 12/1/2009

27601 $411.34 General Fee Schedule 12/1/2009

27602 $497.29 General Fee Schedule 12/1/2009

27603 $472.97 General Fee Schedule 12/1/2009

27604 $404.83 General Fee Schedule 12/1/2009

27605 $388.57 General Fee Schedule 12/1/2009

27606 $298.62 General Fee Schedule 12/1/2009

27607 $564.42 General Fee Schedule 12/1/2009

27610 $610.24 General Fee Schedule 12/1/2009

27612 $530.77 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 42 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27613 $201.60 General Fee Schedule 12/1/2009

27614 $489.82 General Fee Schedule 12/1/2009

27615 $869.76 General Fee Schedule 12/1/2009

27616 $1,194.43 General Fee Schedule 1/1/2010

27618 $427.40 General Fee Schedule 12/1/2009

27619 $693.65 General Fee Schedule 12/1/2009

27620 $451.56 General Fee Schedule 12/1/2009

27625 $586.05 General Fee Schedule 12/1/2009

27626 $632.27 General Fee Schedule 12/1/2009

27630 $469.97 General Fee Schedule 12/1/2009

27632 $381.91 General Fee Schedule 1/1/2010

27634 $624.20 General Fee Schedule 1/1/2010

27635 $576.61 General Fee Schedule 12/1/2009

27637 $721.67 General Fee Schedule 12/1/2009

27638 $755.29 General Fee Schedule 12/1/2009

27640 $857.04 General Fee Schedule 12/1/2009

27641 $692.93 General Fee Schedule 12/1/2009

27645 $1,043.00 General Fee Schedule 12/1/2009

27646 $937.37 General Fee Schedule 12/1/2009

27647 $793.36 General Fee Schedule 12/1/2009

27648 $160.68 General Fee Schedule 12/1/2009

27650 $686.37 General Fee Schedule 12/1/2009

27652 $732.63 General Fee Schedule 12/1/2009

27654 $685.70 General Fee Schedule 12/1/2009

27656 $492.58 General Fee Schedule 12/1/2009

27658 $375.59 General Fee Schedule 12/1/2009

27659 $493.91 General Fee Schedule 12/1/2009

27664 $359.15 General Fee Schedule 12/1/2009

27665 $409.29 General Fee Schedule 12/1/2009

27675 $511.96 General Fee Schedule 12/1/2009

27676 $603.73 General Fee Schedule 12/1/2009

27680 $428.59 General Fee Schedule 12/1/2009

27681 $505.61 General Fee Schedule 12/1/2009

27685 $534.29 General Fee Schedule 12/1/2009

27686 $553.28 General Fee Schedule 12/1/2009

27687 $457.50 General Fee Schedule 12/1/2009

27690 $599.85 General Fee Schedule 12/1/2009

27691 $707.07 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 43 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27692 $115.07 General Fee Schedule 12/1/2009

27695 $488.82 General Fee Schedule 12/1/2009

27696 $583.87 General Fee Schedule 12/1/2009

27698 $649.97 General Fee Schedule 12/1/2009

27700 $598.26 General Fee Schedule 12/1/2009

27702 $967.90 General Fee Schedule 12/1/2009

27703 $1,092.65 General Fee Schedule 12/1/2009

27704 $529.68 General Fee Schedule 12/1/2009

27705 $742.47 General Fee Schedule 12/1/2009

27707 $364.02 General Fee Schedule 12/1/2009

27709 $722.47 General Fee Schedule 12/1/2009

27712 $1,003.31 General Fee Schedule 12/1/2009

27715 $1,010.44 General Fee Schedule 12/1/2009

27720 $847.63 General Fee Schedule 12/1/2009

27722 $839.89 General Fee Schedule 12/1/2009

27724 $1,235.04 General Fee Schedule 12/1/2009

27725 $1,103.39 General Fee Schedule 12/1/2009

27726 $673.79 General Fee Schedule 12/1/2009

27727 $978.98 General Fee Schedule 12/1/2009

27730 $565.53 General Fee Schedule 12/1/2009

27732 $400.69 General Fee Schedule 12/1/2009

27734 $589.27 General Fee Schedule 12/1/2009

27740 $688.78 General Fee Schedule 12/1/2009

27742 $649.67 General Fee Schedule 12/1/2009

27745 $728.77 General Fee Schedule 12/1/2009

27750 $305.43 General Fee Schedule 12/1/2009

27752 $488.28 General Fee Schedule 12/1/2009

27756 $523.59 General Fee Schedule 12/1/2009

27758 $835.12 General Fee Schedule 12/1/2009

27759 $966.58 General Fee Schedule 12/1/2009

27760 $293.34 General Fee Schedule 12/1/2009

27762 $449.02 General Fee Schedule 12/1/2009

27766 $619.92 General Fee Schedule 12/1/2009

27767 $186.73 General Fee Schedule 12/1/2009

27768 $293.35 General Fee Schedule 12/1/2009

27769 $508.84 General Fee Schedule 12/1/2009

27780 $259.90 General Fee Schedule 12/1/2009

27781 $383.31 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 44 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

27784 $538.74 General Fee Schedule 12/1/2009

27786 $278.55 General Fee Schedule 12/1/2009

27788 $390.73 General Fee Schedule 12/1/2009

27792 $579.86 General Fee Schedule 12/1/2009

27808 $289.81 General Fee Schedule 12/1/2009

27810 $440.27 General Fee Schedule 12/1/2009

27814 $769.12 General Fee Schedule 12/1/2009

27816 $276.70 General Fee Schedule 12/1/2009

27818 $459.00 General Fee Schedule 12/1/2009

27822 $855.45 General Fee Schedule 12/1/2009

27823 $972.46 General Fee Schedule 12/1/2009

27824 $266.44 General Fee Schedule 12/1/2009

27825 $500.43 General Fee Schedule 12/1/2009

27826 $683.03 General Fee Schedule 12/1/2009

27827 $1,064.11 General Fee Schedule 12/1/2009

27828 $1,201.04 General Fee Schedule 12/1/2009

27829 $477.14 General Fee Schedule 12/1/2009

27830 $315.19 General Fee Schedule 12/1/2009

27831 $353.88 General Fee Schedule 12/1/2009

27832 $497.63 General Fee Schedule 12/1/2009

27840 $321.36 General Fee Schedule 12/1/2009

27842 $449.50 General Fee Schedule 12/1/2009

27846 $708.41 General Fee Schedule 12/1/2009

27848 $832.03 General Fee Schedule 12/1/2009

27860 $171.92 General Fee Schedule 12/1/2009

27870 $978.86 General Fee Schedule 12/1/2009

27871 $668.70 General Fee Schedule 12/1/2009

27880 $761.87 General Fee Schedule 12/1/2009

27881 $847.62 General Fee Schedule 12/1/2009

27882 $611.79 General Fee Schedule 12/1/2009

27884 $556.21 General Fee Schedule 12/1/2009

27886 $631.29 General Fee Schedule 12/1/2009

27888 $682.48 General Fee Schedule 12/1/2009

27889 $657.47 General Fee Schedule 12/1/2009

27892 $514.92 General Fee Schedule 12/1/2009

27893 $508.93 General Fee Schedule 12/1/2009

27894 $727.83 General Fee Schedule 12/1/2009

27899 $0.00 General by Report 7/1/1975

Tuesday, February 11, 2014 Page 45 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

28001 $219.14 General Fee Schedule 12/1/2009

28002 $370.19 General Fee Schedule 12/1/2009

28003 $576.90 General Fee Schedule 12/1/2009

28005 $582.19 General Fee Schedule 12/1/2009

28008 $347.18 General Fee Schedule 12/1/2009

28010 $203.54 General Fee Schedule 12/1/2009

28011 $293.11 General Fee Schedule 12/1/2009

28020 $424.32 General Fee Schedule 12/1/2009

28022 $379.67 General Fee Schedule 12/1/2009

28024 $367.77 General Fee Schedule 12/1/2009

28035 $421.23 General Fee Schedule 12/1/2009

28039 $431.49 General Fee Schedule 1/1/2010

28041 $413.57 General Fee Schedule 1/1/2010

28043 $282.93 General Fee Schedule 12/1/2009

28045 $388.10 General Fee Schedule 12/1/2009

28046 $740.08 General Fee Schedule 12/1/2009

28047 $876.98 General Fee Schedule 1/1/2010

28050 $352.15 General Fee Schedule 12/1/2009

28052 $338.45 General Fee Schedule 12/1/2009

28054 $310.61 General Fee Schedule 12/1/2009

28055 $329.87 General Fee Schedule 12/1/2009

28060 $413.63 General Fee Schedule 12/1/2009

28062 $503.52 General Fee Schedule 12/1/2009

28070 $400.75 General Fee Schedule 12/1/2009

28072 $389.55 General Fee Schedule 12/1/2009

28080 $329.32 General Fee Schedule 12/1/2009

28086 $484.26 General Fee Schedule 12/1/2009

28088 $367.22 General Fee Schedule 12/1/2009

28090 $366.53 General Fee Schedule 12/1/2009

28092 $336.10 General Fee Schedule 12/1/2009

28100 $519.62 General Fee Schedule 12/1/2009

28102 $541.42 General Fee Schedule 12/1/2009

28103 $440.12 General Fee Schedule 12/1/2009

28104 $409.72 General Fee Schedule 12/1/2009

28106 $461.51 General Fee Schedule 12/1/2009

28107 $463.69 General Fee Schedule 12/1/2009

28108 $335.98 General Fee Schedule 12/1/2009

28110 $354.82 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 46 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

28111 $431.49 General Fee Schedule 12/1/2009

28112 $393.26 General Fee Schedule 12/1/2009

28113 $414.08 General Fee Schedule 12/1/2009

28114 $825.41 General Fee Schedule 12/1/2009

28116 $567.49 General Fee Schedule 12/1/2009

28118 $473.00 General Fee Schedule 12/1/2009

28119 $418.10 General Fee Schedule 12/1/2009

28120 $484.57 General Fee Schedule 12/1/2009

28122 $549.38 General Fee Schedule 12/1/2009

28124 $377.18 General Fee Schedule 12/1/2009

28126 $295.51 General Fee Schedule 12/1/2009

28130 $586.60 General Fee Schedule 12/1/2009

28140 $545.98 General Fee Schedule 12/1/2009

28150 $341.51 General Fee Schedule 12/1/2009

28153 $305.02 General Fee Schedule 12/1/2009

28160 $317.36 General Fee Schedule 12/1/2009

28171 $602.35 General Fee Schedule 12/1/2009

28173 $638.52 General Fee Schedule 12/1/2009

28175 $454.19 General Fee Schedule 12/1/2009

28190 $199.66 General Fee Schedule 12/1/2009

28192 $387.75 General Fee Schedule 12/1/2009

28193 $438.41 General Fee Schedule 12/1/2009

28200 $372.85 General Fee Schedule 12/1/2009

28202 $542.60 General Fee Schedule 12/1/2009

28208 $353.35 General Fee Schedule 12/1/2009

28210 $486.00 General Fee Schedule 12/1/2009

28220 $354.39 General Fee Schedule 12/1/2009

28222 $420.12 General Fee Schedule 12/1/2009

28225 $303.66 General Fee Schedule 12/1/2009

28226 $358.84 General Fee Schedule 12/1/2009

28230 $342.50 General Fee Schedule 12/1/2009

28232 $300.75 General Fee Schedule 12/1/2009

28234 $305.12 General Fee Schedule 12/1/2009

28238 $583.16 General Fee Schedule 12/1/2009

28240 $346.80 General Fee Schedule 12/1/2009

28250 $449.55 General Fee Schedule 12/1/2009

28260 $563.30 General Fee Schedule 12/1/2009

28261 $801.70 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 47 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

28262 $1,165.00 General Fee Schedule 12/1/2009

28264 $717.26 General Fee Schedule 12/1/2009

28270 $372.53 General Fee Schedule 12/1/2009

28272 $305.63 General Fee Schedule 12/1/2009

28280 $439.49 General Fee Schedule 12/1/2009

28285 $363.90 General Fee Schedule 12/1/2009

28286 $359.66 General Fee Schedule 12/1/2009

28288 $408.74 General Fee Schedule 12/1/2009

28289 $580.49 General Fee Schedule 12/1/2009

28290 $461.08 General Fee Schedule 12/1/2009

28292 $558.88 General Fee Schedule 12/1/2009

28293 $760.57 General Fee Schedule 12/1/2009

28294 $622.74 General Fee Schedule 12/1/2009

28296 $674.78 General Fee Schedule 12/1/2009

28297 $706.65 General Fee Schedule 12/1/2009

28298 $589.90 General Fee Schedule 12/1/2009

28299 $755.87 General Fee Schedule 12/1/2009

28300 $662.41 General Fee Schedule 12/1/2009

28302 $653.52 General Fee Schedule 12/1/2009

28304 $669.57 General Fee Schedule 12/1/2009

28305 $679.15 General Fee Schedule 12/1/2009

28306 $489.35 General Fee Schedule 12/1/2009

28307 $653.35 General Fee Schedule 12/1/2009

28308 $425.18 General Fee Schedule 12/1/2009

28309 $835.86 General Fee Schedule 12/1/2009

28310 $430.59 General Fee Schedule 12/1/2009

28312 $383.60 General Fee Schedule 12/1/2009

28313 $399.32 General Fee Schedule 12/1/2009

28315 $376.73 General Fee Schedule 12/1/2009

28320 $633.76 General Fee Schedule 12/1/2009

28322 $680.38 General Fee Schedule 12/1/2009

28340 $519.22 General Fee Schedule 12/1/2009

28341 $597.06 General Fee Schedule 12/1/2009

28344 $378.87 General Fee Schedule 12/1/2009

28345 $468.36 General Fee Schedule 12/1/2009

28360 $953.07 General Fee Schedule 12/1/2009

28400 $220.08 General Fee Schedule 12/1/2009

28405 $366.93 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 48 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

28406 $514.67 General Fee Schedule 12/1/2009

28415 $1,163.57 General Fee Schedule 12/1/2009

28420 $1,181.61 General Fee Schedule 12/1/2009

28430 $207.78 General Fee Schedule 12/1/2009

28435 $283.03 General Fee Schedule 12/1/2009

28436 $412.42 General Fee Schedule 12/1/2009

28445 $1,069.92 General Fee Schedule 12/1/2009

28446 $879.17 General Fee Schedule 12/1/2009

28450 $189.83 General Fee Schedule 12/1/2009

28455 $251.91 General Fee Schedule 12/1/2009

28456 $261.08 General Fee Schedule 12/1/2009

28465 $524.92 General Fee Schedule 12/1/2009

28470 $194.34 General Fee Schedule 12/1/2009

28475 $244.19 General Fee Schedule 12/1/2009

28476 $319.58 General Fee Schedule 12/1/2009

28485 $435.63 General Fee Schedule 12/1/2009

28490 $116.07 General Fee Schedule 12/1/2009

28495 $142.53 General Fee Schedule 12/1/2009

28496 $385.52 General Fee Schedule 12/1/2009

28505 $444.03 General Fee Schedule 12/1/2009

28510 $99.29 General Fee Schedule 12/1/2009

28515 $127.62 General Fee Schedule 12/1/2009

28525 $402.88 General Fee Schedule 12/1/2009

28530 $95.06 General Fee Schedule 12/1/2009

28531 $351.70 General Fee Schedule 12/1/2009

28540 $170.24 General Fee Schedule 12/1/2009

28545 $187.80 General Fee Schedule 12/1/2009

28546 $378.74 General Fee Schedule 12/1/2009

28555 $618.69 General Fee Schedule 12/1/2009

28570 $155.22 General Fee Schedule 12/1/2009

28575 $274.81 General Fee Schedule 12/1/2009

28576 $327.52 General Fee Schedule 12/1/2009

28585 $602.50 General Fee Schedule 12/1/2009

28600 $178.83 General Fee Schedule 12/1/2009

28605 $225.57 General Fee Schedule 12/1/2009

28606 $377.99 General Fee Schedule 12/1/2009

28615 $620.39 General Fee Schedule 12/1/2009

28630 $126.28 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 49 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

28635 $152.20 General Fee Schedule 12/1/2009

28636 $254.62 General Fee Schedule 12/1/2009

28645 $352.00 General Fee Schedule 12/1/2009

28660 $95.11 General Fee Schedule 12/1/2009

28665 $132.05 General Fee Schedule 12/1/2009

28666 $319.53 General Fee Schedule 12/1/2009

28675 $373.39 General Fee Schedule 12/1/2009

28705 $1,257.83 General Fee Schedule 12/1/2009

28715 $914.33 General Fee Schedule 12/1/2009

28725 $794.41 General Fee Schedule 12/1/2009

28730 $764.29 General Fee Schedule 12/1/2009

28735 $744.48 General Fee Schedule 12/1/2009

28737 $655.98 General Fee Schedule 12/1/2009

28740 $724.16 General Fee Schedule 12/1/2009

28750 $729.21 General Fee Schedule 12/1/2009

28755 $414.56 General Fee Schedule 12/1/2009

28760 $608.59 General Fee Schedule 12/1/2009

28800 $555.15 General Fee Schedule 12/1/2009

28805 $558.00 General Fee Schedule 12/1/2009

28810 $422.41 General Fee Schedule 12/1/2009

28820 $450.09 General Fee Schedule 12/1/2009

28825 $395.45 General Fee Schedule 12/1/2009

28890 $337.72 General Fee Schedule 12/1/2009

28899 $0.00 General by Report 7/1/1975

29000 $202.69 General Fee Schedule 12/1/2009

29010 $207.71 General Fee Schedule 12/1/2009

29015 $204.72 General Fee Schedule 12/1/2009

29020 $200.32 General Fee Schedule 12/1/2009

29025 $215.69 General Fee Schedule 12/1/2009

29035 $201.92 General Fee Schedule 12/1/2009

29040 $182.69 General Fee Schedule 12/1/2009

29044 $230.18 General Fee Schedule 12/1/2009

29046 $218.45 General Fee Schedule 12/1/2009

29049 $83.35 General Fee Schedule 12/1/2009

29055 $181.44 General Fee Schedule 12/1/2009

29058 $109.84 General Fee Schedule 12/1/2009

29065 $84.30 General Fee Schedule 12/1/2009

29075 $77.36 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 50 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

29085 $82.25 General Fee Schedule 12/1/2009

29086 $59.22 General Fee Schedule 12/1/2009

29105 $79.84 General Fee Schedule 12/1/2009

29125 $60.11 General Fee Schedule 12/1/2009

29126 $73.56 General Fee Schedule 12/1/2009

29130 $37.46 General Fee Schedule 12/1/2009

29131 $47.61 General Fee Schedule 12/1/2009

29200 $51.12 General Fee Schedule 12/1/2009

29240 $58.59 General Fee Schedule 12/1/2009

29260 $48.29 General Fee Schedule 12/1/2009

29280 $48.11 General Fee Schedule 12/1/2009

29305 $205.14 General Fee Schedule 12/1/2009

29325 $224.56 General Fee Schedule 12/1/2009

29345 $122.94 General Fee Schedule 12/1/2009

29355 $126.58 General Fee Schedule 12/1/2009

29358 $134.70 General Fee Schedule 12/1/2009

29365 $109.29 General Fee Schedule 12/1/2009

29405 $79.80 General Fee Schedule 12/1/2009

29425 $86.28 General Fee Schedule 12/1/2009

29435 $105.87 General Fee Schedule 12/1/2009

29440 $48.39 General Fee Schedule 12/1/2009

29445 $140.00 General Fee Schedule 12/1/2009

29450 $139.94 General Fee Schedule 12/1/2009

29505 $69.80 General Fee Schedule 12/1/2009

29515 $61.07 General Fee Schedule 12/1/2009

29520 $50.98 General Fee Schedule 12/1/2009

29530 $50.77 General Fee Schedule 12/1/2009

29540 $36.13 General Fee Schedule 12/1/2009

29550 $34.60 General Fee Schedule 12/1/2009

29580 $46.68 General Fee Schedule 12/1/2009

29581 $79.32 General Fee Schedule 1/1/2010

29582 $64.94 General Fee Schedule 2/3/2012

29583 $40.34 General Fee Schedule 2/3/2012

29584 $64.94 General Fee Schedule 2/3/2012

29700 $55.23 General Fee Schedule 12/1/2009

29705 $61.91 General Fee Schedule 12/1/2009

29710 $111.02 General Fee Schedule 12/1/2009

29715 $79.45 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 51 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

29720 $70.10 General Fee Schedule 12/1/2009

29730 $60.83 General Fee Schedule 12/1/2009

29740 $88.82 General Fee Schedule 12/1/2009

29750 $92.19 General Fee Schedule 12/1/2009

29799 $0.00 General by Report 7/1/1975

29800 $521.32 General Fee Schedule 12/1/2009

29804 $623.05 General Fee Schedule 12/1/2009

29805 $457.01 General Fee Schedule 12/1/2009

29806 $1,023.02 General Fee Schedule 12/1/2009

29807 $996.30 General Fee Schedule 12/1/2009

29819 $572.48 General Fee Schedule 12/1/2009

29820 $528.28 General Fee Schedule 12/1/2009

29821 $577.04 General Fee Schedule 12/1/2009

29822 $560.35 General Fee Schedule 12/1/2009

29823 $611.55 General Fee Schedule 12/1/2009

29824 $625.59 General Fee Schedule 12/1/2009

29825 $571.46 General Fee Schedule 12/1/2009

29826 $658.65 General Fee Schedule 12/1/2009

29827 $1,079.77 General Fee Schedule 12/1/2009

29828 $678.77 General Fee Schedule 12/1/2009

29830 $439.65 General Fee Schedule 12/1/2009

29834 $479.62 General Fee Schedule 12/1/2009

29835 $490.76 General Fee Schedule 12/1/2009

29836 $566.33 General Fee Schedule 12/1/2009

29837 $516.45 General Fee Schedule 12/1/2009

29838 $578.69 General Fee Schedule 12/1/2009

29840 $425.30 General Fee Schedule 12/1/2009

29843 $456.47 General Fee Schedule 12/1/2009

29844 $481.36 General Fee Schedule 12/1/2009

29845 $546.27 General Fee Schedule 12/1/2009

29846 $504.94 General Fee Schedule 12/1/2009

29847 $522.82 General Fee Schedule 12/1/2009

29848 $431.71 General Fee Schedule 12/1/2009

29850 $531.82 General Fee Schedule 12/1/2009

29851 $921.92 General Fee Schedule 12/1/2009

29855 $773.65 General Fee Schedule 12/1/2009

29856 $993.91 General Fee Schedule 12/1/2009

29860 $595.95 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 52 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

29861 $659.71 General Fee Schedule 12/1/2009

29862 $731.46 General Fee Schedule 12/1/2009

29863 $722.84 General Fee Schedule 12/1/2009

29866 $1,007.93 General Fee Schedule 12/1/2009

29867 $1,206.20 General Fee Schedule 12/1/2009

29868 $1,637.36 General Fee Schedule 12/1/2009

29870 $392.44 General Fee Schedule 12/1/2009

29871 $493.48 General Fee Schedule 12/1/2009

29873 $492.75 General Fee Schedule 12/1/2009

29874 $518.58 General Fee Schedule 12/1/2009

29875 $481.80 General Fee Schedule 12/1/2009

29876 $593.67 General Fee Schedule 12/1/2009

29877 $558.97 General Fee Schedule 12/1/2009

29879 $602.41 General Fee Schedule 12/1/2009

29880 $631.15 General Fee Schedule 12/1/2009

29881 $584.41 General Fee Schedule 12/1/2009

29882 $633.88 General Fee Schedule 12/1/2009

29883 $803.28 General Fee Schedule 12/1/2009

29884 $556.49 General Fee Schedule 12/1/2009

29885 $678.60 General Fee Schedule 12/1/2009

29886 $570.77 General Fee Schedule 12/1/2009

29887 $674.97 General Fee Schedule 12/1/2009

29888 $969.24 General Fee Schedule 12/1/2009

29889 $1,139.77 General Fee Schedule 12/1/2009

29891 $629.67 General Fee Schedule 12/1/2009

29892 $661.39 General Fee Schedule 12/1/2009

29893 $438.56 General Fee Schedule 12/1/2009

29894 $505.59 General Fee Schedule 12/1/2009

29895 $495.73 General Fee Schedule 12/1/2009

29897 $519.17 General Fee Schedule 12/1/2009

29898 $577.58 General Fee Schedule 12/1/2009

29899 $980.93 General Fee Schedule 12/1/2009

29900 $442.61 General Fee Schedule 12/1/2009

29901 $487.85 General Fee Schedule 12/1/2009

29902 $521.51 General Fee Schedule 12/1/2009

29904 $454.32 General Fee Schedule 12/1/2009

29905 $489.23 General Fee Schedule 12/1/2009

29906 $515.25 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 53 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

29907 $632.60 General Fee Schedule 12/1/2009

29914 $1,012.56 General Fee Schedule 1/1/2011

29915 $1,031.64 General Fee Schedule 1/1/2011

29916 $1,031.64 General Fee Schedule 1/1/2011

29999 $0.00 Manual Review Fee Schedule 1/1/2002

30000 $199.02 General Fee Schedule 12/1/2009

30020 $171.64 General Fee Schedule 12/1/2009

30100 $106.50 General Fee Schedule 12/1/2009

30110 $179.02 General Fee Schedule 12/1/2009

30115 $379.57 General Fee Schedule 12/1/2009

30117 $582.19 General Fee Schedule 12/1/2009

30118 $716.25 General Fee Schedule 12/1/2009

30120 $443.87 General Fee Schedule 12/1/2009

30124 $252.23 General Fee Schedule 12/1/2009

30125 $583.28 General Fee Schedule 12/1/2009

30130 $332.86 General Fee Schedule 12/1/2009

30140 $356.71 General Fee Schedule 12/1/2009

30150 $762.51 General Fee Schedule 12/1/2009

30160 $750.38 General Fee Schedule 12/1/2009

30200 $87.64 General Fee Schedule 12/1/2009

30210 $117.04 General Fee Schedule 12/1/2009

30220 $208.75 General Fee Schedule 12/1/2009

30300 $201.77 General Fee Schedule 12/1/2009

30310 $187.66 General Fee Schedule 12/1/2009

30320 $429.26 General Fee Schedule 12/1/2009

30400 $946.66 General Fee Schedule 12/1/2009

30410 $1,179.95 General Fee Schedule 12/1/2009

30420 $1,277.51 General Fee Schedule 12/1/2009

30435 $1,157.90 General Fee Schedule 12/1/2009

30450 $1,537.92 General Fee Schedule 12/1/2009

30460 $760.98 General Fee Schedule 12/1/2009

30462 $1,536.64 General Fee Schedule 12/1/2009

30465 $895.98 General Fee Schedule 12/1/2009

30520 $464.22 General Fee Schedule 12/1/2009

30540 $640.30 General Fee Schedule 12/1/2009

30545 $905.65 General Fee Schedule 12/1/2009

30560 $215.74 General Fee Schedule 12/1/2009

30580 $555.29 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 54 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

30600 $514.30 General Fee Schedule 12/1/2009

30620 $553.07 General Fee Schedule 12/1/2009

30630 $568.37 General Fee Schedule 12/1/2009

30801 $186.93 General Fee Schedule 12/1/2009

30802 $242.05 General Fee Schedule 12/1/2009

30901 $97.07 General Fee Schedule 12/1/2009

30903 $157.05 General Fee Schedule 12/1/2009

30905 $202.43 General Fee Schedule 12/1/2009

30906 $235.00 General Fee Schedule 12/1/2009

30915 $527.29 General Fee Schedule 12/1/2009

30920 $714.80 General Fee Schedule 12/1/2009

30930 $108.24 General Fee Schedule 12/1/2009

30999 $0.00 General by Report 7/1/1975

31000 $145.07 General Fee Schedule 12/1/2009

31002 $190.18 General Fee Schedule 12/1/2009

31020 $416.22 General Fee Schedule 12/1/2009

31030 $643.60 General Fee Schedule 12/1/2009

31032 $521.81 General Fee Schedule 12/1/2009

31040 $730.50 General Fee Schedule 12/1/2009

31050 $438.43 General Fee Schedule 12/1/2009

31051 $578.27 General Fee Schedule 12/1/2009

31070 $381.66 General Fee Schedule 12/1/2009

31075 $713.23 General Fee Schedule 12/1/2009

31080 $947.12 General Fee Schedule 12/1/2009

31081 $1,057.03 General Fee Schedule 12/1/2009

31084 $1,025.38 General Fee Schedule 12/1/2009

31085 $1,086.07 General Fee Schedule 12/1/2009

31086 $988.60 General Fee Schedule 12/1/2009

31087 $984.97 General Fee Schedule 12/1/2009

31090 $830.97 General Fee Schedule 12/1/2009

31200 $517.82 General Fee Schedule 12/1/2009

31201 $665.98 General Fee Schedule 12/1/2009

31205 $825.38 General Fee Schedule 12/1/2009

31225 $1,407.83 General Fee Schedule 12/1/2009

31230 $1,571.72 General Fee Schedule 12/1/2009

31231 $161.64 General Fee Schedule 12/1/2009

31233 $238.61 General Fee Schedule 12/1/2009

31235 $279.32 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 55 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

31237 $303.08 General Fee Schedule 12/1/2009

31238 $314.90 General Fee Schedule 12/1/2009

31239 $631.42 General Fee Schedule 12/1/2009

31240 $168.61 General Fee Schedule 12/1/2009

31254 $292.56 General Fee Schedule 12/1/2009

31255 $434.53 General Fee Schedule 12/1/2009

31256 $210.98 General Fee Schedule 12/1/2009

31267 $342.35 General Fee Schedule 12/1/2009

31276 $548.62 General Fee Schedule 12/1/2009

31287 $248.62 General Fee Schedule 12/1/2009

31288 $288.84 General Fee Schedule 12/1/2009

31290 $1,126.23 General Fee Schedule 12/1/2009

31291 $1,187.30 General Fee Schedule 12/1/2009

31292 $975.02 General Fee Schedule 12/1/2009

31293 $1,059.77 General Fee Schedule 12/1/2009

31294 $1,229.39 General Fee Schedule 12/1/2009

31295 $1,931.20 General Fee Schedule 1/1/2011

31296 $3,611.77 General Fee Schedule 1/1/2011

31297 $3,576.52 General Fee Schedule 1/1/2011

31299 $0.00 General by Report 1/1/1996

31300 $1,105.46 General Fee Schedule 12/1/2009

31320 $572.20 General Fee Schedule 12/1/2009

31360 $1,279.92 General Fee Schedule 12/1/2009

31365 $1,698.18 General Fee Schedule 12/1/2009

31367 $1,655.61 General Fee Schedule 12/1/2009

31368 $1,995.19 General Fee Schedule 12/1/2009

31370 $1,648.36 General Fee Schedule 12/1/2009

31375 $1,535.03 General Fee Schedule 12/1/2009

31380 $1,544.99 General Fee Schedule 12/1/2009

31382 $1,590.49 General Fee Schedule 12/1/2009

31390 $1,975.21 General Fee Schedule 12/1/2009

31395 $2,255.41 General Fee Schedule 12/1/2009

31400 $898.67 General Fee Schedule 12/1/2009

31420 $750.02 General Fee Schedule 12/1/2009

31500 $114.64 General Fee Schedule 12/1/2009

31502 $37.43 General Fee Schedule 12/1/2009

31505 $74.92 General Fee Schedule 12/1/2009

31510 $192.96 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 56 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

31511 $197.10 General Fee Schedule 12/1/2009

31512 $196.02 General Fee Schedule 12/1/2009

31513 $136.92 General Fee Schedule 12/1/2009

31515 $195.86 General Fee Schedule 12/1/2009

31520 $159.13 General Fee Schedule 12/1/2009

31525 $233.73 General Fee Schedule 12/1/2009

31526 $165.35 General Fee Schedule 12/1/2009

31527 $199.57 General Fee Schedule 12/1/2009

31528 $148.03 General Fee Schedule 12/1/2009

31529 $169.59 General Fee Schedule 12/1/2009

31530 $207.59 General Fee Schedule 12/1/2009

31531 $226.26 General Fee Schedule 12/1/2009

31535 $199.43 General Fee Schedule 12/1/2009

31536 $224.42 General Fee Schedule 12/1/2009

31540 $257.73 General Fee Schedule 12/1/2009

31541 $282.76 General Fee Schedule 12/1/2009

31545 $375.09 General Fee Schedule 12/1/2009

31546 $573.01 General Fee Schedule 12/1/2009

31560 $333.41 General Fee Schedule 12/1/2009

31561 $363.85 General Fee Schedule 12/1/2009

31570 $354.51 General Fee Schedule 12/1/2009

31571 $265.88 General Fee Schedule 12/1/2009

31575 $110.96 General Fee Schedule 12/1/2009

31576 $206.52 General Fee Schedule 12/1/2009

31577 $231.67 General Fee Schedule 12/1/2009

31578 $264.44 General Fee Schedule 12/1/2009

31579 $223.21 General Fee Schedule 12/1/2009

31580 $1,058.05 General Fee Schedule 12/1/2009

31582 $1,779.51 General Fee Schedule 12/1/2009

31584 $1,439.10 General Fee Schedule 12/1/2009

31587 $813.60 General Fee Schedule 12/1/2009

31588 $1,009.21 General Fee Schedule 12/1/2009

31590 $831.08 General Fee Schedule 12/1/2009

31595 $707.25 General Fee Schedule 12/1/2009

31599 $0.00 General by Report 7/1/1975

31600 $413.95 General Fee Schedule 12/1/2009

31601 $267.70 General Fee Schedule 12/1/2009

31603 $233.55 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 57 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

31605 $192.35 General Fee Schedule 12/1/2009

31610 $648.51 General Fee Schedule 12/1/2009

31611 $475.60 General Fee Schedule 12/1/2009

31612 $75.55 General Fee Schedule 12/1/2009

31613 $397.05 General Fee Schedule 12/1/2009

31614 $593.71 General Fee Schedule 12/1/2009

31615 $175.21 General Fee Schedule 12/1/2009

31620 $251.62 General Fee Schedule 12/1/2009

31622 $307.65 General Fee Schedule 12/1/2009

31623 $336.14 General Fee Schedule 12/1/2009

31624 $313.89 General Fee Schedule 12/1/2009

31625 $335.51 General Fee Schedule 12/1/2009

31626 $390.16 General Fee Schedule 1/1/2010

31627 $1,043.81 General Fee Schedule 1/1/2010

31628 $393.93 General Fee Schedule 12/1/2009

31629 $652.65 General Fee Schedule 12/1/2009

31630 $217.00 General Fee Schedule 12/1/2009

31631 $240.63 General Fee Schedule 12/1/2009

31632 $73.71 General Fee Schedule 12/1/2009

31633 $87.98 General Fee Schedule 12/1/2009

31634 $1,716.61 General Fee Schedule 1/1/2011

31635 $359.81 General Fee Schedule 12/1/2009

31636 $237.28 General Fee Schedule 12/1/2009

31637 $84.65 General Fee Schedule 12/1/2009

31638 $263.75 General Fee Schedule 12/1/2009

31640 $277.40 General Fee Schedule 12/1/2009

31641 $270.56 General Fee Schedule 12/1/2009

31643 $183.73 General Fee Schedule 12/1/2009

31645 $303.82 General Fee Schedule 12/1/2009

31646 $276.57 General Fee Schedule 12/1/2009

31647 $221.08 General Fee Schedule 2/4/2013

31648 $229.83 General Fee Schedule 2/4/2013

31649 $72.33 General Fee Schedule 2/4/2013

31651 $76.81 General Fee Schedule 2/4/2013

31660 $221.22 General Fee Schedule 2/4/2013

31661 $233.60 General Fee Schedule 2/5/2013

31717 $369.80 General Fee Schedule 12/1/2009

31720 $54.63 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 58 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

31725 $102.74 General Fee Schedule 12/1/2009

31730 $192.57 General Fee Schedule 12/1/2009

31750 $1,140.63 General Fee Schedule 12/1/2009

31755 $1,500.56 General Fee Schedule 12/1/2009

31760 $1,330.79 General Fee Schedule 12/1/2009

31766 $1,797.48 General Fee Schedule 12/1/2009

31770 $1,317.08 General Fee Schedule 12/1/2009

31775 $1,415.73 General Fee Schedule 12/1/2009

31780 $1,119.16 General Fee Schedule 12/1/2009

31781 $1,400.39 General Fee Schedule 12/1/2009

31785 $1,068.39 General Fee Schedule 12/1/2009

31786 $1,487.23 General Fee Schedule 12/1/2009

31800 $631.07 General Fee Schedule 12/1/2009

31805 $816.43 General Fee Schedule 12/1/2009

31820 $380.51 General Fee Schedule 12/1/2009

31825 $543.71 General Fee Schedule 12/1/2009

31830 $386.40 General Fee Schedule 12/1/2009

31899 $0.00 General by Report 7/1/1975

32035 $578.76 General Fee Schedule 12/1/2009

32036 $643.48 General Fee Schedule 12/1/2009

32096 $804.27 General Fee Schedule 2/3/2012

32097 $804.27 General Fee Schedule 2/3/2012

32098 $755.77 General Fee Schedule 2/3/2012

32100 $932.93 General Fee Schedule 12/1/2009

32110 $1,365.89 General Fee Schedule 12/1/2009

32120 $743.71 General Fee Schedule 12/1/2009

32124 $803.02 General Fee Schedule 12/1/2009

32140 $868.24 General Fee Schedule 12/1/2009

32141 $867.88 General Fee Schedule 12/1/2009

32150 $875.38 General Fee Schedule 12/1/2009

32151 $892.42 General Fee Schedule 12/1/2009

32160 $584.61 General Fee Schedule 12/1/2009

32200 $958.45 General Fee Schedule 12/1/2009

32215 $731.51 General Fee Schedule 12/1/2009

32220 $1,492.54 General Fee Schedule 12/1/2009

32225 $871.83 General Fee Schedule 12/1/2009

32310 $840.44 General Fee Schedule 12/1/2009

32320 $1,463.43 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 59 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

32400 $144.31 General Fee Schedule 12/1/2009

32405 $101.24 General Fee Schedule 12/1/2009

32440 $1,533.23 General Fee Schedule 12/1/2009

32442 $1,650.64 General Fee Schedule 12/1/2009

32445 $1,577.80 General Fee Schedule 12/1/2009

32480 $1,449.67 General Fee Schedule 12/1/2009

32482 $1,533.23 General Fee Schedule 12/1/2009

32484 $1,292.76 General Fee Schedule 12/1/2009

32486 $1,497.65 General Fee Schedule 12/1/2009

32488 $1,595.25 General Fee Schedule 12/1/2009

32491 $1,355.45 General Fee Schedule 12/1/2009

32501 $255.82 General Fee Schedule 12/1/2009

32503 $1,826.24 General Fee Schedule 12/1/2009

32504 $2,090.82 General Fee Schedule 12/1/2009

32505 $927.05 General Fee Schedule 2/3/2012

32506 $157.70 General Fee Schedule 2/3/2012

32507 $157.70 General Fee Schedule 2/3/2012

32540 $966.55 General Fee Schedule 12/1/2009

32550 $644.32 General Fee Schedule 12/1/2009

32551 $141.27 General Fee Schedule 12/1/2009

32552 $171.60 General Fee Schedule 1/1/2010

32553 $533.52 General Fee Schedule 1/1/2010

32554 $524.57 General Fee Schedule 2/5/2013

32555 $605.49 General Fee Schedule 2/5/2013

32556 $554.78 General Fee Schedule 2/19/2013

32557 $898.71 General Fee Schedule 2/19/2013

32560 $238.56 General Fee Schedule 12/1/2009

32561 $89.32 General Fee Schedule 1/1/2010

32562 $79.41 General Fee Schedule 1/1/2010

32601 $318.80 General Fee Schedule 12/1/2009

32604 $500.15 General Fee Schedule 12/1/2009

32606 $480.33 General Fee Schedule 12/1/2009

32607 $308.90 General Fee Schedule 2/3/2012

32608 $379.71 General Fee Schedule 2/6/2012

32609 $262.15 General Fee Schedule 2/6/2012

32650 $700.87 General Fee Schedule 12/1/2009

32651 $810.02 General Fee Schedule 12/1/2009

32652 $1,161.25 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 60 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

32653 $800.26 General Fee Schedule 12/1/2009

32654 $794.20 General Fee Schedule 12/1/2009

32655 $818.72 General Fee Schedule 12/1/2009

32656 $835.35 General Fee Schedule 12/1/2009

32658 $758.83 General Fee Schedule 12/1/2009

32659 $758.31 General Fee Schedule 12/1/2009

32661 $844.38 General Fee Schedule 12/1/2009

32662 $1,011.75 General Fee Schedule 12/1/2009

32663 $1,175.14 General Fee Schedule 12/1/2009

32664 $889.38 General Fee Schedule 12/1/2009

32665 $952.36 General Fee Schedule 12/1/2009

32666 $866.43 General Fee Schedule 2/6/2012

32667 $157.70 General Fee Schedule 2/6/2012

32668 $158.69 General Fee Schedule 2/6/2012

32669 $1,338.88 General Fee Schedule 2/6/2012

32670 $1,599.06 General Fee Schedule 2/6/2012

32671 $1,776.67 General Fee Schedule 2/6/2012

32672 $1,518.65 General Fee Schedule 2/6/2012

32673 $1,194.96 General Fee Schedule 2/6/2012

32674 $216.15 General Fee Schedule 2/6/2012

32701 $218.97 General Fee Schedule 2/19/2013

32800 $850.43 General Fee Schedule 12/1/2009

32810 $827.76 General Fee Schedule 12/1/2009

32815 $1,381.97 General Fee Schedule 12/1/2009

32820 $1,332.68 General Fee Schedule 12/1/2009

32850 $0.00 General by Report 1/1/1994

32851 $2,630.55 General Fee Schedule 12/1/2009

32852 $2,957.10 General Fee Schedule 12/1/2009

32853 $3,176.34 General Fee Schedule 12/1/2009

32854 $3,405.87 General Fee Schedule 12/1/2009

32855 $0.00 General by Report 1/1/2005

32856 $184.60 General Fee Schedule 1/1/2011

32900 $1,221.74 General Fee Schedule 12/1/2009

32905 $1,256.43 General Fee Schedule 12/1/2009

32906 $1,582.81 General Fee Schedule 12/1/2009

32940 $1,173.55 General Fee Schedule 12/1/2009

32960 $136.12 General Fee Schedule 12/1/2009

32997 $315.94 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 61 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

32998 $2,318.13 General Fee Schedule 12/1/2009

32999 $0.00 General by Report 7/1/1975

33010 $118.00 General Fee Schedule 12/1/2009

33011 $119.38 General Fee Schedule 12/1/2009

33015 $454.36 General Fee Schedule 12/1/2009

33020 $780.61 General Fee Schedule 12/1/2009

33025 $746.15 General Fee Schedule 12/1/2009

33030 $1,145.75 General Fee Schedule 12/1/2009

33031 $1,292.46 General Fee Schedule 12/1/2009

33050 $896.53 General Fee Schedule 12/1/2009

33120 $1,471.40 General Fee Schedule 12/1/2009

33130 $1,275.27 General Fee Schedule 12/1/2009

33140 $1,242.79 General Fee Schedule 12/1/2009

33141 $264.36 General Fee Schedule 12/1/2009

33202 $658.58 General Fee Schedule 12/1/2009

33203 $675.00 General Fee Schedule 12/1/2009

33206 $428.06 General Fee Schedule 12/1/2009

33207 $490.22 General Fee Schedule 12/1/2009

33208 $496.42 General Fee Schedule 12/1/2009

33210 $176.39 General Fee Schedule 12/1/2009

33211 $182.95 General Fee Schedule 12/1/2009

33212 $342.90 General Fee Schedule 12/1/2009

33213 $388.74 General Fee Schedule 12/1/2009

33214 $486.55 General Fee Schedule 12/1/2009

33215 $305.34 General Fee Schedule 12/1/2009

33216 $379.29 General Fee Schedule 12/1/2009

33217 $380.19 General Fee Schedule 12/1/2009

33218 $369.93 General Fee Schedule 12/1/2009

33220 $372.00 General Fee Schedule 12/1/2009

33221 $348.14 General Fee Schedule 2/6/2012

33222 $352.79 General Fee Schedule 12/1/2009

33223 $422.00 General Fee Schedule 12/1/2009

33224 $504.89 General Fee Schedule 12/1/2009

33225 $448.68 General Fee Schedule 12/1/2009

33226 $486.55 General Fee Schedule 12/1/2009

33227 $332.15 General Fee Schedule 2/6/2012

33228 $346.49 General Fee Schedule 2/6/2012

33229 $360.84 General Fee Schedule 2/6/2012

Tuesday, February 11, 2014 Page 62 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

33230 $374.90 General Fee Schedule 2/6/2012

33231 $389.24 General Fee Schedule 2/6/2012

33233 $246.88 General Fee Schedule 12/1/2009

33234 $489.25 General Fee Schedule 12/1/2009

33235 $621.50 General Fee Schedule 12/1/2009

33236 $798.68 General Fee Schedule 12/1/2009

33237 $850.39 General Fee Schedule 12/1/2009

33238 $937.90 General Fee Schedule 12/1/2009

33240 $464.27 General Fee Schedule 12/1/2009

33241 $232.96 General Fee Schedule 12/1/2009

33243 $1,338.30 General Fee Schedule 12/1/2009

33244 $869.94 General Fee Schedule 12/1/2009

33249 $861.99 General Fee Schedule 12/1/2009

33250 $1,330.39 General Fee Schedule 12/1/2009

33251 $1,483.04 General Fee Schedule 12/1/2009

33254 $1,151.91 General Fee Schedule 12/1/2009

33255 $1,387.88 General Fee Schedule 12/1/2009

33256 $1,658.78 General Fee Schedule 12/1/2009

33257 $462.13 General Fee Schedule 12/1/2009

33258 $522.79 General Fee Schedule 12/1/2009

33259 $687.09 General Fee Schedule 12/1/2009

33261 $1,481.97 General Fee Schedule 12/1/2009

33262 $361.21 General Fee Schedule 2/6/2012

33264 $389.89 General Fee Schedule 2/6/2012

33265 $1,151.91 General Fee Schedule 12/1/2009

33266 $1,578.16 General Fee Schedule 12/1/2009

33282 $306.49 General Fee Schedule 12/1/2009

33284 $222.53 General Fee Schedule 12/1/2009

33300 $1,099.12 General Fee Schedule 12/1/2009

33305 $1,298.45 General Fee Schedule 12/1/2009

33310 $1,131.46 General Fee Schedule 12/1/2009

33315 $1,348.78 General Fee Schedule 12/1/2009

33320 $1,000.54 General Fee Schedule 12/1/2009

33321 $1,214.59 General Fee Schedule 12/1/2009

33322 $1,248.92 General Fee Schedule 12/1/2009

33330 $1,275.39 General Fee Schedule 12/1/2009

33332 $1,388.46 General Fee Schedule 12/1/2009

33335 $1,761.67 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 63 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

33361 $1,326.09 General Fee Schedule 2/19/2013

33362 $1,450.94 General Fee Schedule 2/19/2013

33363 $1,502.34 General Fee Schedule 2/19/2013

33364 $1,597.32 General Fee Schedule 2/19/2013

33365 $1,753.92 General Fee Schedule 2/19/2013

33366 $1,984.13 General Fee Schedule 1/1/2014

33367 $616.77 General Fee Schedule 2/19/2013

33368 $747.48 General Fee Schedule 2/23/2013

33369 $986.83 General Fee Schedule 2/23/2013

33400 $1,778.02 General Fee Schedule 12/1/2009

33401 $1,507.90 General Fee Schedule 12/1/2009

33403 $1,572.42 General Fee Schedule 12/1/2009

33404 $1,748.47 General Fee Schedule 12/1/2009

33405 $2,160.36 General Fee Schedule 12/1/2009

33406 $2,289.38 General Fee Schedule 12/1/2009

33410 $1,982.01 General Fee Schedule 12/1/2009

33411 $2,229.21 General Fee Schedule 12/1/2009

33412 $2,539.37 General Fee Schedule 12/1/2009

33413 $2,615.75 General Fee Schedule 12/1/2009

33414 $1,812.20 General Fee Schedule 12/1/2009

33415 $1,601.64 General Fee Schedule 12/1/2009

33416 $1,790.64 General Fee Schedule 12/1/2009

33417 $1,708.30 General Fee Schedule 12/1/2009

33420 $1,265.90 General Fee Schedule 12/1/2009

33422 $1,604.17 General Fee Schedule 12/1/2009

33425 $1,629.04 General Fee Schedule 12/1/2009

33426 $2,033.09 General Fee Schedule 12/1/2009

33427 $2,416.20 General Fee Schedule 12/1/2009

33430 $2,060.28 General Fee Schedule 12/1/2009

33460 $1,416.12 General Fee Schedule 12/1/2009

33463 $1,564.07 General Fee Schedule 12/1/2009

33464 $1,660.62 General Fee Schedule 12/1/2009

33465 $1,706.10 General Fee Schedule 12/1/2009

33468 $1,769.62 General Fee Schedule 12/1/2009

33470 $1,204.68 General Fee Schedule 12/1/2009

33471 $1,309.26 General Fee Schedule 12/1/2009

33472 $1,387.03 General Fee Schedule 12/1/2009

33474 $1,372.57 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 64 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

33475 $1,969.38 General Fee Schedule 12/1/2009

33476 $1,486.89 General Fee Schedule 12/1/2009

33478 $1,612.78 General Fee Schedule 12/1/2009

33496 $1,630.14 General Fee Schedule 12/1/2009

33500 $1,511.39 General Fee Schedule 12/1/2009

33501 $1,034.93 General Fee Schedule 12/1/2009

33502 $1,294.28 General Fee Schedule 12/1/2009

33503 $1,234.82 General Fee Schedule 12/1/2009

33504 $1,471.39 General Fee Schedule 12/1/2009

33505 $1,552.78 General Fee Schedule 12/1/2009

33506 $2,028.82 General Fee Schedule 12/1/2009

33507 $1,766.23 General Fee Schedule 12/1/2009

33508 $16.77 General Fee Schedule 12/1/2009

33510 $1,830.62 General Fee Schedule 12/1/2009

33511 $1,899.74 General Fee Schedule 12/1/2009

33512 $1,990.77 General Fee Schedule 12/1/2009

33513 $2,011.91 General Fee Schedule 12/1/2009

33514 $2,046.30 General Fee Schedule 12/1/2009

33516 $2,170.91 General Fee Schedule 12/1/2009

33517 $141.43 General Fee Schedule 12/1/2009

33518 $266.14 General Fee Schedule 12/1/2009

33519 $390.13 General Fee Schedule 12/1/2009

33521 $515.22 General Fee Schedule 12/1/2009

33522 $641.61 General Fee Schedule 12/1/2009

33523 $766.35 General Fee Schedule 12/1/2009

33530 $321.93 General Fee Schedule 12/1/2009

33533 $1,878.85 General Fee Schedule 12/1/2009

33534 $2,011.01 General Fee Schedule 12/1/2009

33535 $2,125.22 General Fee Schedule 12/1/2009

33536 $2,260.27 General Fee Schedule 12/1/2009

33542 $1,709.09 General Fee Schedule 12/1/2009

33545 $2,133.13 General Fee Schedule 12/1/2009

33548 $2,318.43 General Fee Schedule 12/1/2009

33572 $243.47 General Fee Schedule 12/1/2009

33600 $1,719.52 General Fee Schedule 12/1/2009

33602 $1,658.95 General Fee Schedule 12/1/2009

33606 $1,805.98 General Fee Schedule 12/1/2009

33608 $1,845.61 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 65 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

33610 $1,803.75 General Fee Schedule 12/1/2009

33611 $1,946.18 General Fee Schedule 12/1/2009

33612 $2,051.48 General Fee Schedule 12/1/2009

33615 $1,910.55 General Fee Schedule 12/1/2009

33617 $2,169.83 General Fee Schedule 12/1/2009

33619 $2,670.90 General Fee Schedule 12/1/2009

33620 $1,719.03 General Fee Schedule 1/1/2011

33621 $922.17 General Fee Schedule 1/1/2011

33622 $3,618.29 General Fee Schedule 1/1/2011

33641 $1,264.38 General Fee Schedule 12/1/2009

33645 $1,491.05 General Fee Schedule 12/1/2009

33647 $1,694.55 General Fee Schedule 12/1/2009

33660 $1,774.06 General Fee Schedule 12/1/2009

33665 $1,715.09 General Fee Schedule 12/1/2009

33670 $1,961.58 General Fee Schedule 12/1/2009

33675 $1,831.34 General Fee Schedule 12/1/2009

33676 $1,888.69 General Fee Schedule 12/1/2009

33677 $1,963.37 General Fee Schedule 12/1/2009

33681 $1,836.93 General Fee Schedule 12/1/2009

33684 $1,727.35 General Fee Schedule 12/1/2009

33688 $1,702.51 General Fee Schedule 12/1/2009

33690 $1,170.03 General Fee Schedule 12/1/2009

33692 $1,820.81 General Fee Schedule 12/1/2009

33694 $1,980.35 General Fee Schedule 12/1/2009

33697 $2,039.04 General Fee Schedule 12/1/2009

33702 $1,581.03 General Fee Schedule 12/1/2009

33710 $1,777.23 General Fee Schedule 12/1/2009

33720 $1,577.74 General Fee Schedule 12/1/2009

33722 $1,615.51 General Fee Schedule 12/1/2009

33724 $1,315.79 General Fee Schedule 12/1/2009

33726 $1,735.26 General Fee Schedule 12/1/2009

33730 $1,977.94 General Fee Schedule 12/1/2009

33732 $1,671.63 General Fee Schedule 12/1/2009

33735 $1,197.90 General Fee Schedule 12/1/2009

33736 $1,419.43 General Fee Schedule 12/1/2009

33737 $1,325.91 General Fee Schedule 12/1/2009

33750 $1,215.90 General Fee Schedule 12/1/2009

33755 $1,254.50 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 66 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

33762 $1,296.57 General Fee Schedule 12/1/2009

33764 $1,294.47 General Fee Schedule 12/1/2009

33766 $1,405.39 General Fee Schedule 12/1/2009

33767 $1,478.03 General Fee Schedule 12/1/2009

33768 $441.32 General Fee Schedule 12/1/2009

33770 $2,127.40 General Fee Schedule 12/1/2009

33771 $1,956.27 General Fee Schedule 12/1/2009

33774 $1,862.96 General Fee Schedule 12/1/2009

33775 $1,927.56 General Fee Schedule 12/1/2009

33776 $2,029.77 General Fee Schedule 12/1/2009

33777 $2,014.70 General Fee Schedule 12/1/2009

33778 $2,335.09 General Fee Schedule 12/1/2009

33779 $2,023.84 General Fee Schedule 12/1/2009

33780 $2,391.25 General Fee Schedule 12/1/2009

33781 $2,068.29 General Fee Schedule 12/1/2009

33782 $2,774.98 General Fee Schedule 1/1/2010

33783 $3,032.25 General Fee Schedule 1/1/2010

33786 $2,273.41 General Fee Schedule 12/1/2009

33788 $1,574.99 General Fee Schedule 12/1/2009

33800 $989.05 General Fee Schedule 12/1/2009

33802 $1,075.26 General Fee Schedule 12/1/2009

33803 $1,200.75 General Fee Schedule 12/1/2009

33813 $1,278.24 General Fee Schedule 12/1/2009

33814 $1,559.92 General Fee Schedule 12/1/2009

33820 $995.74 General Fee Schedule 12/1/2009

33822 $1,067.05 General Fee Schedule 12/1/2009

33824 $1,194.49 General Fee Schedule 12/1/2009

33840 $1,222.73 General Fee Schedule 12/1/2009

33845 $1,353.15 General Fee Schedule 12/1/2009

33851 $1,296.02 General Fee Schedule 12/1/2009

33852 $1,377.86 General Fee Schedule 12/1/2009

33853 $1,885.60 General Fee Schedule 12/1/2009

33860 $2,227.63 General Fee Schedule 12/1/2009

33863 $2,602.80 General Fee Schedule 12/1/2009

33864 $2,507.98 General Fee Schedule 12/1/2009

33870 $2,554.62 General Fee Schedule 12/1/2009

33875 $1,926.50 General Fee Schedule 12/1/2009

33877 $2,406.62 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 67 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

33880 $1,830.94 General Fee Schedule 12/1/2009

33881 $1,571.41 General Fee Schedule 12/1/2009

33883 $1,159.84 General Fee Schedule 12/1/2009

33884 $434.55 General Fee Schedule 12/1/2009

33886 $1,000.48 General Fee Schedule 12/1/2009

33889 $867.14 General Fee Schedule 12/1/2009

33891 $1,104.91 General Fee Schedule 12/1/2009

33910 $1,467.43 General Fee Schedule 12/1/2009

33915 $1,190.66 General Fee Schedule 12/1/2009

33916 $1,511.17 General Fee Schedule 12/1/2009

33917 $1,489.98 General Fee Schedule 12/1/2009

33920 $1,856.78 General Fee Schedule 12/1/2009

33922 $1,387.25 General Fee Schedule 12/1/2009

33924 $303.57 General Fee Schedule 12/1/2009

33925 $1,800.85 General Fee Schedule 12/1/2009

33926 $2,442.34 General Fee Schedule 12/1/2009

33930 $582.55 General Fee Schedule 12/1/2009

33933 $0.00 General by Report 1/1/2005

33935 $3,649.19 General Fee Schedule 12/1/2009

33940 $448.30 General Fee Schedule 12/1/2009

33944 $0.00 General by Report 1/1/2005

33945 $2,572.63 General Fee Schedule 12/1/2009

33960 $1,006.45 General Fee Schedule 12/1/2009

33961 $575.45 General Fee Schedule 12/1/2009

33967 $262.24 General Fee Schedule 12/1/2009

33968 $35.00 General Fee Schedule 12/1/2009

33970 $366.88 General Fee Schedule 12/1/2009

33971 $622.92 General Fee Schedule 12/1/2009

33973 $533.53 General Fee Schedule 12/1/2009

33974 $885.67 General Fee Schedule 12/1/2009

33975 $1,130.82 General Fee Schedule 12/1/2009

33976 $1,258.06 General Fee Schedule 12/1/2009

33977 $1,220.16 General Fee Schedule 12/1/2009

33978 $1,354.90 General Fee Schedule 12/1/2009

33979 $2,525.11 General Fee Schedule 12/1/2009

33980 $3,330.33 General Fee Schedule 12/1/2009

33981 $848.76 General Fee Schedule 2/6/2012

33982 $1,985.57 General Fee Schedule 2/6/2012

Tuesday, February 11, 2014 Page 68 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

33983 $2,331.46 General Fee Schedule 2/6/2012

33990 $431.27 General Fee Schedule 2/23/2013

33991 $628.41 General Fee Schedule 2/23/2013

33992 $205.55 General Fee Schedule 2/23/2013

33993 $180.47 General Fee Schedule 2/23/2013

33999 $0.00 General by Report 7/1/1975

34001 $791.52 General Fee Schedule 12/1/2009

34051 $929.36 General Fee Schedule 12/1/2009

34101 $618.16 General Fee Schedule 12/1/2009

34111 $617.81 General Fee Schedule 12/1/2009

34151 $1,443.16 General Fee Schedule 12/1/2009

34201 $622.37 General Fee Schedule 12/1/2009

34203 $993.92 General Fee Schedule 12/1/2009

34401 $1,436.15 General Fee Schedule 12/1/2009

34421 $732.00 General Fee Schedule 12/1/2009

34451 $1,565.63 General Fee Schedule 12/1/2009

34471 $615.06 General Fee Schedule 12/1/2009

34490 $615.15 General Fee Schedule 12/1/2009

34501 $989.00 General Fee Schedule 12/1/2009

34502 $1,585.88 General Fee Schedule 12/1/2009

34510 $1,133.63 General Fee Schedule 12/1/2009

34520 $1,060.44 General Fee Schedule 12/1/2009

34530 $996.73 General Fee Schedule 12/1/2009

34800 $1,199.04 General Fee Schedule 12/1/2009

34802 $1,302.62 General Fee Schedule 12/1/2009

34803 $1,346.04 General Fee Schedule 12/1/2009

34804 $1,302.26 General Fee Schedule 12/1/2009

34805 $1,243.54 General Fee Schedule 12/1/2009

34806 $82.92 General Fee Schedule 12/1/2009

34808 $226.31 General Fee Schedule 12/1/2009

34812 $377.61 General Fee Schedule 12/1/2009

34813 $261.78 General Fee Schedule 12/1/2009

34820 $538.70 General Fee Schedule 12/1/2009

34825 $717.54 General Fee Schedule 12/1/2009

34826 $221.13 General Fee Schedule 12/1/2009

34830 $1,882.92 General Fee Schedule 12/1/2009

34831 $1,933.36 General Fee Schedule 12/1/2009

34832 $2,031.26 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 69 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

34833 $672.80 General Fee Schedule 12/1/2009

34834 $307.69 General Fee Schedule 12/1/2009

34841 $0.00 General by Report 1/1/2014

34842 $0.00 General by Report 1/1/2014

34843 $0.00 General by Report 1/1/2014

34844 $0.00 General by Report 1/1/2014

34845 $0.00 General by Report 1/1/2014

34846 $0.00 General by Report 1/1/2014

34847 $0.00 General by Report 1/1/2014

34848 $0.00 General by Report 1/1/2014

34900 $960.43 General Fee Schedule 12/1/2009

35001 $1,181.63 General Fee Schedule 12/1/2009

35002 $1,245.48 General Fee Schedule 12/1/2009

35005 $1,062.73 General Fee Schedule 12/1/2009

35011 $1,055.25 General Fee Schedule 12/1/2009

35013 $1,286.85 General Fee Schedule 12/1/2009

35021 $1,179.30 General Fee Schedule 12/1/2009

35022 $1,340.99 General Fee Schedule 12/1/2009

35045 $1,018.77 General Fee Schedule 12/1/2009

35081 $1,611.17 General Fee Schedule 12/1/2009

35082 $2,195.83 General Fee Schedule 12/1/2009

35091 $2,006.96 General Fee Schedule 12/1/2009

35092 $2,559.95 General Fee Schedule 12/1/2009

35102 $1,763.98 General Fee Schedule 12/1/2009

35103 $2,303.25 General Fee Schedule 12/1/2009

35111 $1,442.10 General Fee Schedule 12/1/2009

35112 $1,707.52 General Fee Schedule 12/1/2009

35121 $1,729.16 General Fee Schedule 12/1/2009

35122 $1,986.61 General Fee Schedule 12/1/2009

35131 $1,463.09 General Fee Schedule 12/1/2009

35132 $1,729.49 General Fee Schedule 12/1/2009

35141 $1,176.74 General Fee Schedule 12/1/2009

35142 $1,369.64 General Fee Schedule 12/1/2009

35151 $1,327.02 General Fee Schedule 12/1/2009

35152 $1,502.03 General Fee Schedule 12/1/2009

35180 $797.78 General Fee Schedule 12/1/2009

35182 $1,745.95 General Fee Schedule 12/1/2009

35184 $1,065.18 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 70 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

35188 $886.61 General Fee Schedule 12/1/2009

35189 $1,627.56 General Fee Schedule 12/1/2009

35190 $775.40 General Fee Schedule 12/1/2009

35201 $976.94 General Fee Schedule 12/1/2009

35206 $799.85 General Fee Schedule 12/1/2009

35207 $694.45 General Fee Schedule 12/1/2009

35211 $1,327.12 General Fee Schedule 12/1/2009

35216 $1,121.90 General Fee Schedule 12/1/2009

35221 $1,396.96 General Fee Schedule 12/1/2009

35226 $883.41 General Fee Schedule 12/1/2009

35231 $1,205.49 General Fee Schedule 12/1/2009

35236 $1,013.34 General Fee Schedule 12/1/2009

35241 $1,394.58 General Fee Schedule 12/1/2009

35246 $1,544.40 General Fee Schedule 12/1/2009

35251 $1,710.75 General Fee Schedule 12/1/2009

35256 $1,084.59 General Fee Schedule 12/1/2009

35261 $1,050.65 General Fee Schedule 12/1/2009

35266 $887.28 General Fee Schedule 12/1/2009

35271 $1,322.32 General Fee Schedule 12/1/2009

35276 $1,439.17 General Fee Schedule 12/1/2009

35281 $1,617.62 General Fee Schedule 12/1/2009

35286 $980.12 General Fee Schedule 12/1/2009

35301 $1,102.18 General Fee Schedule 12/1/2009

35302 $981.07 General Fee Schedule 12/1/2009

35303 $1,078.20 General Fee Schedule 12/1/2009

35304 $1,122.00 General Fee Schedule 12/1/2009

35305 $1,078.20 General Fee Schedule 12/1/2009

35306 $405.55 General Fee Schedule 12/1/2009

35311 $1,561.39 General Fee Schedule 12/1/2009

35321 $947.54 General Fee Schedule 12/1/2009

35331 $1,527.21 General Fee Schedule 12/1/2009

35341 $1,470.74 General Fee Schedule 12/1/2009

35351 $1,331.35 General Fee Schedule 12/1/2009

35355 $1,082.12 General Fee Schedule 12/1/2009

35361 $1,631.56 General Fee Schedule 12/1/2009

35363 $1,745.06 General Fee Schedule 12/1/2009

35371 $879.62 General Fee Schedule 12/1/2009

35372 $1,060.07 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 71 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

35390 $175.32 General Fee Schedule 12/1/2009

35400 $168.65 General Fee Schedule 12/1/2009

35450 $553.32 General Fee Schedule 12/1/2009

35452 $388.16 General Fee Schedule 12/1/2009

35458 $528.59 General Fee Schedule 12/1/2009

35460 $339.49 General Fee Schedule 12/1/2009

35471 $3,853.59 General Fee Schedule 12/1/2009

35472 $2,496.01 General Fee Schedule 12/1/2009

35475 $2,313.50 General Fee Schedule 12/1/2009

35476 $1,780.37 General Fee Schedule 12/1/2009

35500 $350.20 General Fee Schedule 12/1/2009

35501 $1,126.61 General Fee Schedule 12/1/2009

35506 $1,181.79 General Fee Schedule 12/1/2009

35508 $1,138.62 General Fee Schedule 12/1/2009

35509 $1,087.42 General Fee Schedule 12/1/2009

35510 $1,308.72 General Fee Schedule 12/1/2009

35511 $1,238.46 General Fee Schedule 12/1/2009

35512 $1,283.59 General Fee Schedule 12/1/2009

35515 $1,133.14 General Fee Schedule 12/1/2009

35516 $943.14 General Fee Schedule 12/1/2009

35518 $1,229.59 General Fee Schedule 12/1/2009

35521 $1,301.09 General Fee Schedule 12/1/2009

35522 $1,246.48 General Fee Schedule 12/1/2009

35523 $1,019.56 General Fee Schedule 12/1/2009

35525 $1,189.85 General Fee Schedule 12/1/2009

35526 $1,708.87 General Fee Schedule 12/1/2009

35531 $2,070.38 General Fee Schedule 12/1/2009

35533 $1,614.16 General Fee Schedule 12/1/2009

35535 $1,952.78 General Fee Schedule 12/1/2009

35536 $1,825.30 General Fee Schedule 12/1/2009

35537 $1,897.10 General Fee Schedule 12/1/2009

35538 $2,119.73 General Fee Schedule 12/1/2009

35539 $1,992.33 General Fee Schedule 12/1/2009

35540 $2,221.34 General Fee Schedule 12/1/2009

35556 $1,279.30 General Fee Schedule 12/1/2009

35558 $1,248.07 General Fee Schedule 12/1/2009

35560 $1,854.04 General Fee Schedule 12/1/2009

35563 $1,415.01 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 72 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

35565 $1,355.84 General Fee Schedule 12/1/2009

35566 $1,560.14 General Fee Schedule 12/1/2009

35570 $1,505.42 General Fee Schedule 12/1/2009

35571 $1,417.43 General Fee Schedule 12/1/2009

35572 $374.08 General Fee Schedule 12/1/2009

35583 $1,319.99 General Fee Schedule 12/1/2009

35585 $1,652.20 General Fee Schedule 12/1/2009

35587 $1,468.07 General Fee Schedule 12/1/2009

35600 $271.36 General Fee Schedule 12/1/2009

35601 $1,056.15 General Fee Schedule 12/1/2009

35606 $1,123.45 General Fee Schedule 12/1/2009

35612 $949.87 General Fee Schedule 12/1/2009

35616 $958.88 General Fee Schedule 12/1/2009

35621 $1,169.21 General Fee Schedule 12/1/2009

35623 $1,404.17 General Fee Schedule 12/1/2009

35626 $1,621.02 General Fee Schedule 12/1/2009

35631 $1,956.30 General Fee Schedule 12/1/2009

35632 $1,853.84 General Fee Schedule 12/1/2009

35633 $2,002.55 General Fee Schedule 12/1/2009

35634 $1,814.17 General Fee Schedule 12/1/2009

35636 $1,700.55 General Fee Schedule 12/1/2009

35637 $1,509.15 General Fee Schedule 12/1/2009

35638 $1,533.07 General Fee Schedule 12/1/2009

35642 $1,069.46 General Fee Schedule 12/1/2009

35645 $1,043.00 General Fee Schedule 12/1/2009

35646 $1,797.54 General Fee Schedule 12/1/2009

35647 $1,620.71 General Fee Schedule 12/1/2009

35650 $1,112.75 General Fee Schedule 12/1/2009

35654 $1,450.67 General Fee Schedule 12/1/2009

35656 $1,144.18 General Fee Schedule 12/1/2009

35661 $1,132.25 General Fee Schedule 12/1/2009

35663 $1,297.48 General Fee Schedule 12/1/2009

35665 $1,237.27 General Fee Schedule 12/1/2009

35666 $1,329.47 General Fee Schedule 12/1/2009

35671 $1,162.13 General Fee Schedule 12/1/2009

35681 $87.84 General Fee Schedule 12/1/2009

35682 $394.94 General Fee Schedule 12/1/2009

35683 $466.05 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 73 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

35685 $222.20 General Fee Schedule 12/1/2009

35686 $183.84 General Fee Schedule 12/1/2009

35691 $1,072.95 General Fee Schedule 12/1/2009

35693 $933.44 General Fee Schedule 12/1/2009

35694 $1,126.44 General Fee Schedule 12/1/2009

35695 $1,126.11 General Fee Schedule 12/1/2009

35697 $164.88 General Fee Schedule 12/1/2009

35700 $169.01 General Fee Schedule 12/1/2009

35701 $543.05 General Fee Schedule 12/1/2009

35721 $464.35 General Fee Schedule 12/1/2009

35741 $506.98 General Fee Schedule 12/1/2009

35761 $370.43 General Fee Schedule 12/1/2009

35800 $462.94 General Fee Schedule 12/1/2009

35820 $810.58 General Fee Schedule 12/1/2009

35840 $604.47 General Fee Schedule 12/1/2009

35860 $379.10 General Fee Schedule 12/1/2009

35870 $1,293.40 General Fee Schedule 12/1/2009

35875 $616.98 General Fee Schedule 12/1/2009

35876 $995.39 General Fee Schedule 12/1/2009

35879 $959.19 General Fee Schedule 12/1/2009

35881 $1,079.22 General Fee Schedule 12/1/2009

35883 $1,100.54 General Fee Schedule 12/1/2009

35884 $1,169.02 General Fee Schedule 12/1/2009

35901 $537.60 General Fee Schedule 12/1/2009

35903 $618.21 General Fee Schedule 12/1/2009

35905 $1,809.92 General Fee Schedule 12/1/2009

35907 $2,004.81 General Fee Schedule 12/1/2009

36000 $26.81 General Fee Schedule 12/1/2009

36002 $179.79 General Fee Schedule 12/1/2009

36005 $301.00 General Fee Schedule 12/1/2009

36010 $763.53 General Fee Schedule 12/1/2009

36011 $1,085.74 General Fee Schedule 12/1/2009

36012 $793.94 General Fee Schedule 12/1/2009

36013 $839.26 General Fee Schedule 12/1/2009

36014 $814.03 General Fee Schedule 12/1/2009

36015 $955.18 General Fee Schedule 12/1/2009

36100 $540.16 General Fee Schedule 12/1/2009

36120 $449.78 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 74 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

36140 $521.69 General Fee Schedule 12/1/2009

36147 $697.23 General Fee Schedule 1/1/2010

36148 $218.91 General Fee Schedule 1/1/2010

36160 $569.14 General Fee Schedule 12/1/2009

36200 $691.82 General Fee Schedule 12/1/2009

36215 $1,117.74 General Fee Schedule 12/1/2009

36216 $1,212.47 General Fee Schedule 12/1/2009

36217 $2,161.57 General Fee Schedule 12/1/2009

36218 $216.01 General Fee Schedule 12/1/2009

36221 $1,082.23 General Fee Schedule 2/23/2013

36222 $1,341.15 General Fee Schedule 2/23/2013

36223 $1,467.06 General Fee Schedule 2/23/2013

36224 $1,593.26 General Fee Schedule 2/23/2013

36225 $1,456.44 General Fee Schedule 2/23/2013

36226 $1,623.80 General Fee Schedule 2/23/2013

36227 $237.50 General Fee Schedule 2/23/2013

36228 $1,113.81 General Fee Schedule 2/23/2013

36245 $1,292.71 General Fee Schedule 12/1/2009

36246 $1,245.36 General Fee Schedule 12/1/2009

36247 $1,958.90 General Fee Schedule 12/1/2009

36248 $180.06 General Fee Schedule 12/1/2009

36251 $1,364.96 General Fee Schedule 2/6/2012

36252 $1,502.05 General Fee Schedule 2/6/2012

36253 $2,086.06 General Fee Schedule 2/6/2012

36254 $2,171.32 General Fee Schedule 2/6/2012

36260 $586.39 General Fee Schedule 12/1/2009

36261 $359.80 General Fee Schedule 12/1/2009

36262 $267.92 General Fee Schedule 12/1/2009

36299 $0.00 General by Report 1/1/1996

36400 $25.29 General Fee Schedule 12/1/2009

36405 $21.91 General Fee Schedule 12/1/2009

36406 $16.88 General Fee Schedule 12/1/2009

36410 $17.23 General Fee Schedule 12/1/2009

36415 $3.00 General Fee Schedule 1/1/2011

36420 $53.04 General Fee Schedule 12/1/2009

36425 $38.94 General Fee Schedule 12/1/2009

36430 $36.66 General Fee Schedule 12/1/2009

36440 $53.14 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 75 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

36450 $117.64 General Fee Schedule 12/1/2009

36455 $133.56 General Fee Schedule 12/1/2009

36460 $358.30 General Fee Schedule 12/1/2009

36470 $138.31 General Fee Schedule 12/1/2009

36471 $172.61 General Fee Schedule 12/1/2009

36475 $2,036.74 General Fee Schedule 12/1/2009

36476 $407.16 General Fee Schedule 12/1/2009

36478 $1,878.22 General Fee Schedule 12/1/2009

36479 $410.92 General Fee Schedule 12/1/2009

36481 $485.28 General Fee Schedule 12/1/2009

36500 $189.30 General Fee Schedule 12/1/2009

36510 $179.05 General Fee Schedule 12/1/2009

36511 $94.91 General Fee Schedule 12/1/2009

36512 $95.26 General Fee Schedule 12/1/2009

36513 $98.03 General Fee Schedule 12/1/2009

36514 $652.64 General Fee Schedule 12/1/2009

36515 $2,346.34 General Fee Schedule 12/1/2009

36516 $2,935.69 General Fee Schedule 12/1/2009

36522 $1,180.28 General Fee Schedule 12/1/2009

36555 $304.79 General Fee Schedule 12/1/2009

36556 $296.16 General Fee Schedule 12/1/2009

36557 $941.98 General Fee Schedule 12/1/2009

36558 $926.98 General Fee Schedule 12/1/2009

36560 $1,279.44 General Fee Schedule 12/1/2009

36561 $1,266.71 General Fee Schedule 12/1/2009

36563 $1,186.17 General Fee Schedule 12/1/2009

36565 $1,098.95 General Fee Schedule 12/1/2009

36566 $1,145.64 General Fee Schedule 12/1/2009

36568 $336.40 General Fee Schedule 12/1/2009

36569 $328.79 General Fee Schedule 12/1/2009

36570 $1,363.71 General Fee Schedule 12/1/2009

36571 $1,365.34 General Fee Schedule 12/1/2009

36575 $171.77 General Fee Schedule 12/1/2009

36576 $367.99 General Fee Schedule 12/1/2009

36578 $523.35 General Fee Schedule 12/1/2009

36580 $295.41 General Fee Schedule 12/1/2009

36581 $808.29 General Fee Schedule 12/1/2009

36582 $1,100.14 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 76 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

36583 $1,102.75 General Fee Schedule 12/1/2009

36584 $292.19 General Fee Schedule 12/1/2009

36585 $1,146.66 General Fee Schedule 12/1/2009

36589 $172.94 General Fee Schedule 12/1/2009

36590 $258.29 General Fee Schedule 12/1/2009

36591 $16.17 General Fee Schedule 12/1/2009

36592 $19.98 General Fee Schedule 12/1/2009

36593 $29.64 General Fee Schedule 12/1/2009

36595 $738.13 General Fee Schedule 12/1/2009

36596 $157.34 General Fee Schedule 12/1/2009

36597 $131.63 General Fee Schedule 12/1/2009

36598 $121.02 General Fee Schedule 12/1/2009

36600 $29.82 General Fee Schedule 12/1/2009

36620 $54.68 General Fee Schedule 12/1/2009

36625 $108.57 General Fee Schedule 12/1/2009

36640 $123.92 General Fee Schedule 12/1/2009

36660 $73.94 General Fee Schedule 12/1/2009

36680 $66.89 General Fee Schedule 12/1/2009

36800 $164.40 General Fee Schedule 12/1/2009

36810 $225.91 General Fee Schedule 12/1/2009

36815 $153.27 General Fee Schedule 12/1/2009

36818 $717.08 General Fee Schedule 12/1/2009

36819 $825.75 General Fee Schedule 12/1/2009

36820 $825.75 General Fee Schedule 12/1/2009

36821 $546.33 General Fee Schedule 12/1/2009

36822 $386.41 General Fee Schedule 12/1/2009

36823 $1,230.74 General Fee Schedule 12/1/2009

36825 $599.30 General Fee Schedule 12/1/2009

36830 $699.51 General Fee Schedule 12/1/2009

36831 $481.29 General Fee Schedule 12/1/2009

36832 $616.20 General Fee Schedule 12/1/2009

36833 $696.20 General Fee Schedule 12/1/2009

36835 $457.69 General Fee Schedule 12/1/2009

36838 $1,221.29 General Fee Schedule 12/1/2009

36860 $142.33 General Fee Schedule 12/1/2009

36861 $157.62 General Fee Schedule 12/1/2009

36870 $2,029.52 General Fee Schedule 12/1/2009

37140 $1,338.66 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 77 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

37145 $1,433.48 General Fee Schedule 12/1/2009

37160 $1,247.37 General Fee Schedule 12/1/2009

37180 $1,417.08 General Fee Schedule 12/1/2009

37181 $1,523.36 General Fee Schedule 12/1/2009

37182 $897.73 General Fee Schedule 12/1/2009

37183 $428.03 General Fee Schedule 12/1/2009

37184 $2,814.90 General Fee Schedule 12/1/2009

37185 $919.59 General Fee Schedule 12/1/2009

37186 $1,896.71 General Fee Schedule 12/1/2009

37187 $2,737.16 General Fee Schedule 12/1/2009

37188 $2,361.01 General Fee Schedule 12/1/2009

37191 $2,463.81 General Fee Schedule 2/6/2012

37192 $1,666.16 General Fee Schedule 2/6/2012

37193 $1,591.33 General Fee Schedule 2/6/2012

37195 $257.57 General Fee Schedule 12/1/2009

37197 $1,470.90 General Fee Schedule 2/23/2013

37200 $236.30 General Fee Schedule 12/1/2009

37202 $337.78 General Fee Schedule 12/1/2009

37211 $399.12 General Fee Schedule 2/23/2013

37212 $352.36 General Fee Schedule 2/23/2013

37213 $246.37 General Fee Schedule 2/23/2013

37214 $144.10 General Fee Schedule 2/23/2013

37215 $1,072.07 General Fee Schedule 12/1/2009

37216 $1,022.06 General Fee Schedule 12/1/2009

37217 $1,152.57 General Fee Schedule 1/1/2014

37220 $3,024.34 General Fee Schedule 1/1/2011

37221 $4,462.87 General Fee Schedule 1/1/2011

37222 $875.65 General Fee Schedule 1/1/2011

37223 $2,454.77 General Fee Schedule 1/1/2011

37224 $3,631.29 General Fee Schedule 1/1/2011

37225 $10,217.90 General Fee Schedule 1/1/2011

37226 $8,550.45 General Fee Schedule 1/1/2011

37227 $13,809.34 General Fee Schedule 1/1/2011

37228 $5,164.55 General Fee Schedule 1/1/2011

37229 $10,136.39 General Fee Schedule 1/1/2011

37230 $7,969.82 General Fee Schedule 1/1/2011

37231 $12,769.88 General Fee Schedule 1/1/2011

37232 $1,164.00 General Fee Schedule 1/1/2011

Tuesday, February 11, 2014 Page 78 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

37233 $1,426.94 General Fee Schedule 1/1/2011

37234 $3,687.36 General Fee Schedule 1/1/2011

37235 $3,944.47 General Fee Schedule 1/1/2011

37236 $2,663.65 General Fee Schedule 1/1/2014

37237 $1,158.55 General Fee Schedule 1/1/2014

37238 $3,867.64 General Fee Schedule 1/1/2014

37239 $1,921.93 General Fee Schedule 1/1/2014

37241 $4,286.54 General Fee Schedule 1/1/2014

37242 $7,201.71 General Fee Schedule 1/1/2014

37243 $9,088.79 General Fee Schedule 1/1/2014

37244 $6,383.97 General Fee Schedule 1/1/2014

37250 $113.99 General Fee Schedule 12/1/2009

37251 $87.15 General Fee Schedule 12/1/2009

37500 $712.21 General Fee Schedule 12/1/2009

37501 $0.00 General by Report 1/1/2003

37565 $658.22 General Fee Schedule 12/1/2009

37600 $709.85 General Fee Schedule 12/1/2009

37605 $810.57 General Fee Schedule 12/1/2009

37606 $440.97 General Fee Schedule 12/1/2009

37607 $388.98 General Fee Schedule 12/1/2009

37609 $282.65 General Fee Schedule 12/1/2009

37615 $385.33 General Fee Schedule 12/1/2009

37616 $993.18 General Fee Schedule 12/1/2009

37617 $1,267.91 General Fee Schedule 12/1/2009

37618 $333.52 General Fee Schedule 12/1/2009

37619 $1,625.97 General Fee Schedule 2/6/2012

37650 $496.15 General Fee Schedule 12/1/2009

37660 $1,205.95 General Fee Schedule 12/1/2009

37700 $257.76 General Fee Schedule 12/1/2009

37718 $405.11 General Fee Schedule 12/1/2009

37722 $481.72 General Fee Schedule 12/1/2009

37735 $645.79 General Fee Schedule 12/1/2009

37760 $636.61 General Fee Schedule 12/1/2009

37761 $548.38 General Fee Schedule 1/1/2010

37765 $458.41 General Fee Schedule 12/1/2009

37766 $557.98 General Fee Schedule 12/1/2009

37780 $264.05 General Fee Schedule 12/1/2009

37785 $344.86 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 79 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

37788 $1,238.03 General Fee Schedule 12/1/2009

37790 $491.87 General Fee Schedule 12/1/2009

37799 $0.00 General by Report 7/1/1975

38100 $836.82 General Fee Schedule 12/1/2009

38101 $884.55 General Fee Schedule 12/1/2009

38102 $262.80 General Fee Schedule 12/1/2009

38115 $909.73 General Fee Schedule 12/1/2009

38120 $985.75 General Fee Schedule 12/1/2009

38129 $0.00 General by Report 1/1/2000

38200 $137.22 General Fee Schedule 12/1/2009

38204 $0.00 General by Report 1/1/2003

38205 $83.26 General Fee Schedule 12/1/2009

38206 $83.26 General Fee Schedule 12/1/2009

38207 $0.00 General by Report 1/1/2003

38208 $0.00 General by Report 1/1/2003

38209 $0.00 General by Report 1/1/2003

38210 $0.00 General by Report 1/1/2003

38211 $0.00 General by Report 1/1/2003

38212 $0.00 General by Report 1/1/2003

38213 $0.00 General by Report 1/1/2003

38214 $0.00 General by Report 1/1/2003

38215 $0.00 General by Report 1/1/2003

38220 $171.12 General Fee Schedule 12/1/2009

38221 $190.20 General Fee Schedule 12/1/2009

38230 $302.02 General Fee Schedule 12/1/2009

38232 $180.69 General Fee Schedule 2/6/2012

38240 $125.52 General Fee Schedule 12/1/2009

38241 $125.87 General Fee Schedule 12/1/2009

38242 $95.48 General Fee Schedule 12/1/2009

38243 $113.00 General Fee Schedule 2/23/2013

38300 $233.01 General Fee Schedule 12/1/2009

38305 $413.96 General Fee Schedule 12/1/2009

38308 $406.33 General Fee Schedule 12/1/2009

38380 $508.27 General Fee Schedule 12/1/2009

38381 $796.19 General Fee Schedule 12/1/2009

38382 $633.18 General Fee Schedule 12/1/2009

38500 $287.96 General Fee Schedule 12/1/2009

38505 $117.64 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 80 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

38510 $463.03 General Fee Schedule 12/1/2009

38520 $425.09 General Fee Schedule 12/1/2009

38525 $374.53 General Fee Schedule 12/1/2009

38530 $496.97 General Fee Schedule 12/1/2009

38542 $402.18 General Fee Schedule 12/1/2009

38550 $431.32 General Fee Schedule 12/1/2009

38555 $898.19 General Fee Schedule 12/1/2009

38562 $643.82 General Fee Schedule 12/1/2009

38564 $642.94 General Fee Schedule 12/1/2009

38570 $531.95 General Fee Schedule 12/1/2009

38571 $799.36 General Fee Schedule 12/1/2009

38572 $947.96 General Fee Schedule 12/1/2009

38589 $0.00 General by Report 1/1/2000

38700 $556.52 General Fee Schedule 12/1/2009

38720 $887.15 General Fee Schedule 12/1/2009

38724 $942.25 General Fee Schedule 12/1/2009

38740 $601.45 General Fee Schedule 12/1/2009

38745 $773.13 General Fee Schedule 12/1/2009

38746 $268.35 General Fee Schedule 12/1/2009

38747 $267.64 General Fee Schedule 12/1/2009

38760 $768.37 General Fee Schedule 12/1/2009

38765 $1,157.68 General Fee Schedule 12/1/2009

38770 $755.46 General Fee Schedule 12/1/2009

38780 $985.95 General Fee Schedule 12/1/2009

38790 $306.61 General Fee Schedule 12/1/2009

38792 $37.21 General Fee Schedule 12/1/2009

38794 $300.89 General Fee Schedule 12/1/2009

38900 $136.42 General Fee Schedule 1/1/2011

38999 $0.00 General by Report 7/1/1975

39000 $425.35 General Fee Schedule 12/1/2009

39010 $773.59 General Fee Schedule 12/1/2009

39200 $853.21 General Fee Schedule 12/1/2009

39220 $1,077.35 General Fee Schedule 12/1/2009

39400 $410.87 General Fee Schedule 12/1/2009

39499 $0.00 General by Report 7/1/1975

39501 $791.00 General Fee Schedule 12/1/2009

39503 $5,185.65 General Fee Schedule 12/1/2009

39540 $788.84 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 81 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

39541 $847.73 General Fee Schedule 12/1/2009

39545 $837.34 General Fee Schedule 12/1/2009

39560 $733.04 General Fee Schedule 12/1/2009

39561 $1,079.07 General Fee Schedule 12/1/2009

39599 $0.00 General by Report 7/1/1975

40490 $104.62 General Fee Schedule 12/1/2009

40500 $414.52 General Fee Schedule 12/1/2009

40510 $424.95 General Fee Schedule 12/1/2009

40520 $456.67 General Fee Schedule 12/1/2009

40525 $536.77 General Fee Schedule 12/1/2009

40527 $637.85 General Fee Schedule 12/1/2009

40530 $495.13 General Fee Schedule 12/1/2009

40650 $386.40 General Fee Schedule 12/1/2009

40652 $447.68 General Fee Schedule 12/1/2009

40654 $520.42 General Fee Schedule 12/1/2009

40700 $837.27 General Fee Schedule 12/1/2009

40701 $1,056.95 General Fee Schedule 12/1/2009

40702 $828.19 General Fee Schedule 12/1/2009

40720 $923.71 General Fee Schedule 12/1/2009

40761 $986.71 General Fee Schedule 12/1/2009

40799 $0.00 General by Report 7/1/1975

40800 $151.34 General Fee Schedule 12/1/2009

40801 $246.33 General Fee Schedule 12/1/2009

40804 $168.07 General Fee Schedule 12/1/2009

40805 $268.61 General Fee Schedule 12/1/2009

40806 $76.35 General Fee Schedule 12/1/2009

40808 $131.58 General Fee Schedule 12/1/2009

40810 $154.00 General Fee Schedule 12/1/2009

40812 $226.53 General Fee Schedule 12/1/2009

40814 $315.26 General Fee Schedule 12/1/2009

40816 $332.44 General Fee Schedule 12/1/2009

40818 $277.62 General Fee Schedule 12/1/2009

40819 $243.06 General Fee Schedule 12/1/2009

40820 $188.09 General Fee Schedule 12/1/2009

40830 $202.21 General Fee Schedule 12/1/2009

40831 $265.21 General Fee Schedule 12/1/2009

40840 $709.75 General Fee Schedule 12/1/2009

40842 $719.33 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 82 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

40843 $924.45 General Fee Schedule 12/1/2009

40844 $1,227.22 General Fee Schedule 12/1/2009

40845 $1,370.89 General Fee Schedule 12/1/2009

40899 $0.00 General by Report 7/1/1975

41000 $133.75 General Fee Schedule 12/1/2009

41005 $167.14 General Fee Schedule 12/1/2009

41006 $301.49 General Fee Schedule 12/1/2009

41007 $306.68 General Fee Schedule 12/1/2009

41008 $304.77 General Fee Schedule 12/1/2009

41009 $324.92 General Fee Schedule 12/1/2009

41010 $160.77 General Fee Schedule 12/1/2009

41015 $353.91 General Fee Schedule 12/1/2009

41016 $367.77 General Fee Schedule 12/1/2009

41017 $368.46 General Fee Schedule 12/1/2009

41018 $430.52 General Fee Schedule 12/1/2009

41019 $365.59 General Fee Schedule 12/1/2009

41100 $151.30 General Fee Schedule 12/1/2009

41105 $138.38 General Fee Schedule 12/1/2009

41108 $115.20 General Fee Schedule 12/1/2009

41110 $165.14 General Fee Schedule 12/1/2009

41112 $268.43 General Fee Schedule 12/1/2009

41113 $297.51 General Fee Schedule 12/1/2009

41114 $602.07 General Fee Schedule 12/1/2009

41115 $186.37 General Fee Schedule 12/1/2009

41116 $251.39 General Fee Schedule 12/1/2009

41120 $929.55 General Fee Schedule 12/1/2009

41130 $1,017.73 General Fee Schedule 12/1/2009

41135 $1,752.41 General Fee Schedule 12/1/2009

41140 $1,976.64 General Fee Schedule 12/1/2009

41145 $2,294.77 General Fee Schedule 12/1/2009

41150 $1,803.56 General Fee Schedule 12/1/2009

41153 $1,844.05 General Fee Schedule 12/1/2009

41155 $2,069.19 General Fee Schedule 12/1/2009

41250 $174.10 General Fee Schedule 12/1/2009

41251 $207.52 General Fee Schedule 12/1/2009

41252 $258.18 General Fee Schedule 12/1/2009

41500 $408.93 General Fee Schedule 12/1/2009

41510 $410.71 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 83 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

41512 $516.82 General Fee Schedule 12/1/2009

41520 $273.22 General Fee Schedule 12/1/2009

41530 $2,441.80 General Fee Schedule 12/1/2009

41599 $0.00 General by Report 7/1/1975

41800 $138.32 General Fee Schedule 12/1/2009

41805 $144.10 General Fee Schedule 12/1/2009

41806 $239.52 General Fee Schedule 12/1/2009

41820 $158.75 General Fee Schedule 12/1/2009

41821 $31.60 General Fee Schedule 12/1/2009

41822 $233.40 General Fee Schedule 12/1/2009

41823 $334.66 General Fee Schedule 12/1/2009

41825 $160.86 General Fee Schedule 12/1/2009

41826 $183.07 General Fee Schedule 12/1/2009

41827 $333.04 General Fee Schedule 12/1/2009

41828 $264.92 General Fee Schedule 12/1/2009

41830 $314.28 General Fee Schedule 12/1/2009

41850 $23.77 General Fee Schedule 12/1/2009

41870 $190.34 General Fee Schedule 12/1/2009

41872 $282.54 General Fee Schedule 12/1/2009

41874 $300.86 General Fee Schedule 12/1/2009

41899 $0.00 Manual Review Fee Schedule 7/1/1975

42000 $139.60 General Fee Schedule 12/1/2009

42100 $126.61 General Fee Schedule 12/1/2009

42104 $156.14 General Fee Schedule 12/1/2009

42106 $200.28 General Fee Schedule 12/1/2009

42107 $382.36 General Fee Schedule 12/1/2009

42120 $659.73 General Fee Schedule 12/1/2009

42140 $194.73 General Fee Schedule 12/1/2009

42145 $589.91 General Fee Schedule 12/1/2009

42160 $221.20 General Fee Schedule 12/1/2009

42180 $209.20 General Fee Schedule 12/1/2009

42182 $294.10 General Fee Schedule 12/1/2009

42200 $856.88 General Fee Schedule 12/1/2009

42205 $912.58 General Fee Schedule 12/1/2009

42210 $1,026.91 General Fee Schedule 12/1/2009

42215 $696.87 General Fee Schedule 12/1/2009

42220 $528.60 General Fee Schedule 12/1/2009

42225 $983.35 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 84 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

42226 $925.15 General Fee Schedule 12/1/2009

42227 $934.68 General Fee Schedule 12/1/2009

42235 $735.34 General Fee Schedule 12/1/2009

42260 $771.31 General Fee Schedule 12/1/2009

42280 $133.45 General Fee Schedule 12/1/2009

42281 $170.75 General Fee Schedule 12/1/2009

42299 $0.00 General by Report 7/1/1975

42300 $176.92 General Fee Schedule 12/1/2009

42305 $413.47 General Fee Schedule 12/1/2009

42310 $142.43 General Fee Schedule 12/1/2009

42320 $210.26 General Fee Schedule 12/1/2009

42330 $199.71 General Fee Schedule 12/1/2009

42335 $305.89 General Fee Schedule 12/1/2009

42340 $399.16 General Fee Schedule 12/1/2009

42400 $88.67 General Fee Schedule 12/1/2009

42405 $273.96 General Fee Schedule 12/1/2009

42408 $393.42 General Fee Schedule 12/1/2009

42409 $272.89 General Fee Schedule 12/1/2009

42410 $605.20 General Fee Schedule 12/1/2009

42415 $1,073.01 General Fee Schedule 12/1/2009

42420 $1,236.87 General Fee Schedule 12/1/2009

42425 $833.52 General Fee Schedule 12/1/2009

42426 $1,328.42 General Fee Schedule 12/1/2009

42440 $453.37 General Fee Schedule 12/1/2009

42450 $395.13 General Fee Schedule 12/1/2009

42500 $374.90 General Fee Schedule 12/1/2009

42505 $501.60 General Fee Schedule 12/1/2009

42507 $476.63 General Fee Schedule 12/1/2009

42508 $673.02 General Fee Schedule 12/1/2009

42509 $826.68 General Fee Schedule 12/1/2009

42510 $604.39 General Fee Schedule 12/1/2009

42550 $160.91 General Fee Schedule 12/1/2009

42600 $426.48 General Fee Schedule 12/1/2009

42650 $69.80 General Fee Schedule 12/1/2009

42660 $92.95 General Fee Schedule 12/1/2009

42665 $248.71 General Fee Schedule 12/1/2009

42699 $0.00 General by Report 7/1/1975

42700 $158.09 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 85 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

42720 $389.73 General Fee Schedule 12/1/2009

42725 $726.56 General Fee Schedule 12/1/2009

42800 $132.43 General Fee Schedule 12/1/2009

42804 $179.70 General Fee Schedule 12/1/2009

42806 $205.16 General Fee Schedule 12/1/2009

42808 $201.48 General Fee Schedule 12/1/2009

42809 $155.50 General Fee Schedule 12/1/2009

42810 $331.64 General Fee Schedule 12/1/2009

42815 $513.72 General Fee Schedule 12/1/2009

42820 $274.22 General Fee Schedule 12/1/2009

42821 $297.46 General Fee Schedule 12/1/2009

42825 $249.13 General Fee Schedule 12/1/2009

42826 $243.48 General Fee Schedule 12/1/2009

42830 $194.10 General Fee Schedule 12/1/2009

42831 $209.78 General Fee Schedule 12/1/2009

42835 $180.60 General Fee Schedule 12/1/2009

42836 $233.41 General Fee Schedule 12/1/2009

42842 $739.56 General Fee Schedule 12/1/2009

42844 $1,149.02 General Fee Schedule 12/1/2009

42845 $1,800.43 General Fee Schedule 12/1/2009

42860 $174.42 General Fee Schedule 12/1/2009

42870 $517.35 General Fee Schedule 12/1/2009

42890 $1,020.79 General Fee Schedule 12/1/2009

42892 $1,244.03 General Fee Schedule 12/1/2009

42894 $1,702.19 General Fee Schedule 12/1/2009

42900 $345.18 General Fee Schedule 12/1/2009

42950 $744.55 General Fee Schedule 12/1/2009

42953 $970.89 General Fee Schedule 12/1/2009

42955 $678.84 General Fee Schedule 12/1/2009

42960 $163.95 General Fee Schedule 12/1/2009

42961 $401.09 General Fee Schedule 12/1/2009

42962 $498.27 General Fee Schedule 12/1/2009

42970 $366.13 General Fee Schedule 12/1/2009

42971 $432.57 General Fee Schedule 12/1/2009

42972 $494.78 General Fee Schedule 12/1/2009

42999 $0.00 General by Report 7/1/1975

43020 $527.84 General Fee Schedule 12/1/2009

43030 $509.26 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 86 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

43045 $1,231.94 General Fee Schedule 12/1/2009

43100 $600.10 General Fee Schedule 12/1/2009

43101 $976.34 General Fee Schedule 12/1/2009

43107 $2,348.84 General Fee Schedule 12/1/2009

43108 $1,946.23 General Fee Schedule 12/1/2009

43112 $2,541.24 General Fee Schedule 12/1/2009

43113 $2,030.83 General Fee Schedule 12/1/2009

43116 $1,881.61 General Fee Schedule 12/1/2009

43117 $2,313.22 General Fee Schedule 12/1/2009

43118 $1,894.34 General Fee Schedule 12/1/2009

43121 $1,729.27 General Fee Schedule 12/1/2009

43122 $2,325.26 General Fee Schedule 12/1/2009

43123 $1,907.02 General Fee Schedule 12/1/2009

43124 $1,631.02 General Fee Schedule 12/1/2009

43130 $752.35 General Fee Schedule 12/1/2009

43135 $978.82 General Fee Schedule 12/1/2009

43191 $126.79 General Fee Schedule 1/1/2014

43192 $151.42 General Fee Schedule 1/1/2014

43193 $180.68 General Fee Schedule 1/1/2014

43194 $164.89 General Fee Schedule 1/1/2014

43195 $181.00 General Fee Schedule 1/1/2014

43196 $198.90 General Fee Schedule 1/1/2014

43197 $177.53 General Fee Schedule 1/1/2014

43198 $198.65 General Fee Schedule 1/1/2014

43200 $207.60 General Fee Schedule 12/1/2009

43201 $244.71 General Fee Schedule 12/1/2009

43202 $268.49 General Fee Schedule 12/1/2009

43204 $207.54 General Fee Schedule 12/1/2009

43205 $207.61 General Fee Schedule 12/1/2009

43206 $0.00 General by Report 1/1/2013

43211 $247.82 General Fee Schedule 1/1/2014

43212 $196.27 General Fee Schedule 1/1/2014

43213 $1,167.76 General Fee Schedule 1/1/2014

43214 $199.49 General Fee Schedule 1/1/2014

43215 $149.04 General Fee Schedule 12/1/2009

43216 $135.84 General Fee Schedule 12/1/2009

43217 $359.55 General Fee Schedule 12/1/2009

43220 $120.14 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 87 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

43226 $132.15 General Fee Schedule 12/1/2009

43227 $197.88 General Fee Schedule 12/1/2009

43229 $691.61 General Fee Schedule 1/1/2014

43231 $175.93 General Fee Schedule 12/1/2009

43232 $246.59 General Fee Schedule 12/1/2009

43233 $236.83 General Fee Schedule 1/1/2014

43235 $276.17 General Fee Schedule 12/1/2009

43236 $339.76 General Fee Schedule 12/1/2009

43237 $222.91 General Fee Schedule 12/1/2009

43238 $276.06 General Fee Schedule 12/1/2009

43239 $314.55 General Fee Schedule 12/1/2009

43240 $373.11 General Fee Schedule 12/1/2009

43241 $144.88 General Fee Schedule 12/1/2009

43242 $393.89 General Fee Schedule 12/1/2009

43243 $249.04 General Fee Schedule 12/1/2009

43244 $274.76 General Fee Schedule 12/1/2009

43245 $176.23 General Fee Schedule 12/1/2009

43246 $236.35 General Fee Schedule 12/1/2009

43247 $186.70 General Fee Schedule 12/1/2009

43248 $174.38 General Fee Schedule 12/1/2009

43249 $160.96 General Fee Schedule 12/1/2009

43250 $177.35 General Fee Schedule 12/1/2009

43251 $203.12 General Fee Schedule 12/1/2009

43252 $0.00 General by Report 1/1/2013

43253 $274.72 General Fee Schedule 1/1/2014

43254 $285.46 General Fee Schedule 1/1/2014

43255 $262.45 General Fee Schedule 12/1/2009

43257 $300.40 General Fee Schedule 12/1/2009

43259 $280.89 General Fee Schedule 12/1/2009

43260 $322.91 General Fee Schedule 12/1/2009

43261 $339.69 General Fee Schedule 12/1/2009

43262 $399.04 General Fee Schedule 12/1/2009

43263 $394.49 General Fee Schedule 12/1/2009

43264 $479.27 General Fee Schedule 12/1/2009

43265 $537.88 General Fee Schedule 12/1/2009

43266 $236.35 General Fee Schedule 1/1/2014

43270 $691.95 General Fee Schedule 1/1/2014

43273 $118.13 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 88 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

43274 $489.27 General Fee Schedule 1/1/2014

43275 $403.35 General Fee Schedule 1/1/2014

43276 $508.97 General Fee Schedule 1/1/2014

43277 $405.77 General Fee Schedule 1/1/2014

43278 $461.44 General Fee Schedule 1/1/2014

43279 $1,121.39 General Fee Schedule 12/1/2009

43280 $992.67 General Fee Schedule 12/1/2009

43281 $1,480.06 General Fee Schedule 1/1/2010

43282 $1,665.33 General Fee Schedule 1/1/2010

43283 $162.90 General Fee Schedule 1/1/2011

43289 $0.00 General by Report 1/1/2000

43300 $609.87 General Fee Schedule 12/1/2009

43305 $1,090.29 General Fee Schedule 12/1/2009

43310 $1,482.53 General Fee Schedule 12/1/2009

43312 $1,641.73 General Fee Schedule 12/1/2009

43313 $2,579.03 General Fee Schedule 12/1/2009

43314 $2,825.03 General Fee Schedule 12/1/2009

43320 $1,178.42 General Fee Schedule 12/1/2009

43325 $1,164.22 General Fee Schedule 12/1/2009

43327 $816.55 General Fee Schedule 1/1/2011

43328 $1,202.95 General Fee Schedule 1/1/2011

43330 $1,145.17 General Fee Schedule 12/1/2009

43331 $1,212.91 General Fee Schedule 12/1/2009

43332 $1,170.88 General Fee Schedule 1/1/2011

43333 $1,271.75 General Fee Schedule 1/1/2011

43334 $1,286.71 General Fee Schedule 1/1/2011

43335 $1,386.63 General Fee Schedule 1/1/2011

43336 $1,519.51 General Fee Schedule 1/1/2011

43337 $1,657.24 General Fee Schedule 1/1/2011

43338 $134.82 General Fee Schedule 1/1/2011

43340 $1,148.19 General Fee Schedule 12/1/2009

43341 $1,247.89 General Fee Schedule 12/1/2009

43350 $947.01 General Fee Schedule 12/1/2009

43351 $1,128.31 General Fee Schedule 12/1/2009

43352 $946.65 General Fee Schedule 12/1/2009

43360 $2,064.70 General Fee Schedule 12/1/2009

43361 $2,295.67 General Fee Schedule 12/1/2009

43400 $1,208.38 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 89 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

43401 $1,282.10 General Fee Schedule 12/1/2009

43405 $1,197.98 General Fee Schedule 12/1/2009

43410 $840.14 General Fee Schedule 12/1/2009

43415 $1,487.99 General Fee Schedule 12/1/2009

43420 $856.56 General Fee Schedule 12/1/2009

43425 $1,257.27 General Fee Schedule 12/1/2009

43450 $147.45 General Fee Schedule 12/1/2009

43453 $270.25 General Fee Schedule 12/1/2009

43460 $208.01 General Fee Schedule 12/1/2009

43496 $726.11 General Fee Schedule 12/1/2009

43499 $0.00 General by Report 7/1/1975

43500 $646.33 General Fee Schedule 12/1/2009

43501 $1,148.41 General Fee Schedule 12/1/2009

43502 $1,322.94 General Fee Schedule 12/1/2009

43510 $781.19 General Fee Schedule 12/1/2009

43520 $612.63 General Fee Schedule 12/1/2009

43605 $697.67 General Fee Schedule 12/1/2009

43610 $840.34 General Fee Schedule 12/1/2009

43611 $1,028.13 General Fee Schedule 12/1/2009

43620 $1,698.70 General Fee Schedule 12/1/2009

43621 $1,734.27 General Fee Schedule 12/1/2009

43622 $1,833.95 General Fee Schedule 12/1/2009

43631 $1,288.02 General Fee Schedule 12/1/2009

43632 $1,288.02 General Fee Schedule 12/1/2009

43633 $1,315.95 General Fee Schedule 12/1/2009

43634 $1,428.89 General Fee Schedule 12/1/2009

43635 $112.81 General Fee Schedule 12/1/2009

43640 $982.43 General Fee Schedule 12/1/2009

43641 $995.49 General Fee Schedule 12/1/2009

43647 $415.36 General Fee Schedule 1/1/2011

43648 $0.00 General by Report 1/1/2007

43651 $600.27 General Fee Schedule 12/1/2009

43652 $719.29 General Fee Schedule 12/1/2009

43653 $476.32 General Fee Schedule 12/1/2009

43659 $0.00 General by Report 1/1/2000

43752 $41.55 General Fee Schedule 12/1/2009

43753 $20.55 General Fee Schedule 1/1/2011

43754 $75.60 General Fee Schedule 1/1/2011

Tuesday, February 11, 2014 Page 90 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

43755 $115.89 General Fee Schedule 1/1/2011

43756 $208.14 General Fee Schedule 1/1/2011

43757 $268.33 General Fee Schedule 1/1/2011

43760 $117.13 General Fee Schedule 12/1/2009

43761 $122.13 General Fee Schedule 12/1/2009

43800 $792.52 General Fee Schedule 12/1/2009

43810 $843.30 General Fee Schedule 12/1/2009

43820 $882.42 General Fee Schedule 12/1/2009

43825 $1,103.04 General Fee Schedule 12/1/2009

43830 $576.69 General Fee Schedule 12/1/2009

43831 $492.56 General Fee Schedule 12/1/2009

43832 $904.28 General Fee Schedule 12/1/2009

43840 $902.77 General Fee Schedule 12/1/2009

43850 $1,402.47 General Fee Schedule 12/1/2009

43855 $1,482.08 General Fee Schedule 12/1/2009

43860 $1,419.45 General Fee Schedule 12/1/2009

43865 $1,503.52 General Fee Schedule 12/1/2009

43870 $572.25 General Fee Schedule 12/1/2009

43880 $1,402.15 General Fee Schedule 12/1/2009

43881 $0.00 General by Report 1/1/2007

43882 $0.00 General by Report 1/1/2007

44005 $930.03 General Fee Schedule 12/1/2009

44010 $726.06 General Fee Schedule 12/1/2009

44015 $143.35 General Fee Schedule 12/1/2009

44020 $806.85 General Fee Schedule 12/1/2009

44021 $811.70 General Fee Schedule 12/1/2009

44025 $822.50 General Fee Schedule 12/1/2009

44050 $809.07 General Fee Schedule 12/1/2009

44055 $1,247.77 General Fee Schedule 12/1/2009

44100 $107.77 General Fee Schedule 12/1/2009

44110 $688.03 General Fee Schedule 12/1/2009

44111 $824.59 General Fee Schedule 12/1/2009

44120 $975.14 General Fee Schedule 12/1/2009

44121 $243.45 General Fee Schedule 12/1/2009

44125 $1,002.83 General Fee Schedule 12/1/2009

44126 $2,014.45 General Fee Schedule 12/1/2009

44127 $2,318.45 General Fee Schedule 12/1/2009

44128 $244.84 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 91 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

44130 $836.42 General Fee Schedule 12/1/2009

44132 $775.14 General Fee Schedule 12/1/2009

44133 $775.14 General Fee Schedule 12/1/2009

44135 $670.60 General Fee Schedule 12/1/2009

44136 $670.60 General Fee Schedule 12/1/2009

44137 $761.78 General Fee Schedule 12/1/2009

44139 $121.77 General Fee Schedule 12/1/2009

44140 $1,199.52 General Fee Schedule 12/1/2009

44141 $1,183.72 General Fee Schedule 12/1/2009

44143 $1,357.92 General Fee Schedule 12/1/2009

44144 $1,258.37 General Fee Schedule 12/1/2009

44145 $1,502.33 General Fee Schedule 12/1/2009

44146 $1,620.23 General Fee Schedule 12/1/2009

44147 $1,184.52 General Fee Schedule 12/1/2009

44150 $1,440.12 General Fee Schedule 12/1/2009

44151 $1,616.01 General Fee Schedule 12/1/2009

44155 $1,643.50 General Fee Schedule 12/1/2009

44156 $1,838.59 General Fee Schedule 12/1/2009

44157 $1,721.46 General Fee Schedule 12/1/2009

44158 $1,766.18 General Fee Schedule 12/1/2009

44160 $1,064.75 General Fee Schedule 12/1/2009

44180 $834.49 General Fee Schedule 12/1/2009

44186 $585.32 General Fee Schedule 12/1/2009

44187 $966.07 General Fee Schedule 12/1/2009

44188 $1,060.44 General Fee Schedule 12/1/2009

44202 $1,254.09 General Fee Schedule 12/1/2009

44203 $242.42 General Fee Schedule 12/1/2009

44204 $1,415.29 General Fee Schedule 12/1/2009

44205 $1,255.23 General Fee Schedule 12/1/2009

44206 $1,546.00 General Fee Schedule 12/1/2009

44207 $1,676.92 General Fee Schedule 12/1/2009

44208 $1,817.82 General Fee Schedule 12/1/2009

44210 $1,604.43 General Fee Schedule 12/1/2009

44211 $1,996.37 General Fee Schedule 12/1/2009

44212 $1,852.49 General Fee Schedule 12/1/2009

44213 $192.07 General Fee Schedule 12/1/2009

44227 $1,503.91 General Fee Schedule 12/1/2009

44238 $0.00 General by Report 1/1/2003

Tuesday, February 11, 2014 Page 92 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

44300 $710.23 General Fee Schedule 12/1/2009

44310 $913.00 General Fee Schedule 12/1/2009

44312 $477.90 General Fee Schedule 12/1/2009

44314 $865.18 General Fee Schedule 12/1/2009

44316 $1,187.82 General Fee Schedule 12/1/2009

44320 $1,020.05 General Fee Schedule 12/1/2009

44322 $808.93 General Fee Schedule 12/1/2009

44340 $478.00 General Fee Schedule 12/1/2009

44345 $898.74 General Fee Schedule 12/1/2009

44346 $981.22 General Fee Schedule 12/1/2009

44360 $144.20 General Fee Schedule 12/1/2009

44361 $159.12 General Fee Schedule 12/1/2009

44363 $191.28 General Fee Schedule 12/1/2009

44364 $204.31 General Fee Schedule 12/1/2009

44365 $182.62 General Fee Schedule 12/1/2009

44366 $240.45 General Fee Schedule 12/1/2009

44370 $265.46 General Fee Schedule 12/1/2009

44372 $241.50 General Fee Schedule 12/1/2009

44373 $192.65 General Fee Schedule 12/1/2009

44376 $286.65 General Fee Schedule 12/1/2009

44377 $300.16 General Fee Schedule 12/1/2009

44378 $385.23 General Fee Schedule 12/1/2009

44379 $409.34 General Fee Schedule 12/1/2009

44380 $62.12 General Fee Schedule 12/1/2009

44382 $74.74 General Fee Schedule 12/1/2009

44383 $164.21 General Fee Schedule 12/1/2009

44385 $190.47 General Fee Schedule 12/1/2009

44386 $316.75 General Fee Schedule 12/1/2009

44388 $292.10 General Fee Schedule 12/1/2009

44389 $357.47 General Fee Schedule 12/1/2009

44390 $402.62 General Fee Schedule 12/1/2009

44391 $477.68 General Fee Schedule 12/1/2009

44392 $384.77 General Fee Schedule 12/1/2009

44393 $437.87 General Fee Schedule 12/1/2009

44394 $451.81 General Fee Schedule 12/1/2009

44397 $256.51 General Fee Schedule 12/1/2009

44500 $25.43 General Fee Schedule 12/1/2009

44602 $910.32 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 93 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

44603 $1,051.94 General Fee Schedule 12/1/2009

44604 $912.37 General Fee Schedule 12/1/2009

44605 $1,127.31 General Fee Schedule 12/1/2009

44615 $914.32 General Fee Schedule 12/1/2009

44620 $705.12 General Fee Schedule 12/1/2009

44625 $860.43 General Fee Schedule 12/1/2009

44626 $1,426.83 General Fee Schedule 12/1/2009

44640 $1,224.29 General Fee Schedule 12/1/2009

44650 $1,275.94 General Fee Schedule 12/1/2009

44660 $1,183.11 General Fee Schedule 12/1/2009

44661 $1,380.80 General Fee Schedule 12/1/2009

44680 $883.56 General Fee Schedule 12/1/2009

44700 $912.97 General Fee Schedule 12/1/2009

44701 $168.72 General Fee Schedule 12/1/2009

44705 $0.00 General by Report 1/1/2013

44715 $0.00 General by Report 1/1/2005

44720 $264.33 General Fee Schedule 12/1/2009

44721 $385.87 General Fee Schedule 12/1/2009

44799 $0.00 General by Report 7/1/1975

44800 $668.35 General Fee Schedule 12/1/2009

44820 $709.12 General Fee Schedule 12/1/2009

44850 $633.32 General Fee Schedule 12/1/2009

44899 $0.00 General by Report 7/1/1975

44900 $597.47 General Fee Schedule 12/1/2009

44950 $578.76 General Fee Schedule 12/1/2009

44960 $715.01 General Fee Schedule 12/1/2009

44970 $514.83 General Fee Schedule 12/1/2009

44979 $0.00 General by Report 1/1/2000

45000 $293.73 General Fee Schedule 12/1/2009

45005 $224.45 General Fee Schedule 12/1/2009

45020 $313.10 General Fee Schedule 12/1/2009

45100 $238.00 General Fee Schedule 12/1/2009

45108 $298.90 General Fee Schedule 12/1/2009

45110 $1,620.51 General Fee Schedule 12/1/2009

45111 $952.32 General Fee Schedule 12/1/2009

45112 $1,698.67 General Fee Schedule 12/1/2009

45113 $1,731.04 General Fee Schedule 12/1/2009

45114 $1,541.87 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 94 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

45116 $1,390.44 General Fee Schedule 12/1/2009

45119 $1,731.80 General Fee Schedule 12/1/2009

45120 $1,395.33 General Fee Schedule 12/1/2009

45121 $1,535.14 General Fee Schedule 12/1/2009

45123 $942.94 General Fee Schedule 12/1/2009

45126 $2,549.05 General Fee Schedule 12/1/2009

45130 $927.76 General Fee Schedule 12/1/2009

45135 $1,112.82 General Fee Schedule 12/1/2009

45136 $1,578.95 General Fee Schedule 12/1/2009

45150 $341.23 General Fee Schedule 12/1/2009

45160 $876.27 General Fee Schedule 12/1/2009

45171 $548.96 General Fee Schedule 1/1/2010

45172 $757.58 General Fee Schedule 1/1/2010

45190 $573.12 General Fee Schedule 12/1/2009

45300 $68.43 General Fee Schedule 12/1/2009

45303 $659.97 General Fee Schedule 12/1/2009

45305 $133.17 General Fee Schedule 12/1/2009

45307 $144.16 General Fee Schedule 12/1/2009

45308 $103.63 General Fee Schedule 12/1/2009

45309 $181.73 General Fee Schedule 12/1/2009

45315 $157.48 General Fee Schedule 12/1/2009

45317 $146.62 General Fee Schedule 12/1/2009

45320 $166.48 General Fee Schedule 12/1/2009

45321 $68.82 General Fee Schedule 12/1/2009

45327 $92.84 General Fee Schedule 12/1/2009

45330 $117.88 General Fee Schedule 12/1/2009

45331 $152.95 General Fee Schedule 12/1/2009

45332 $246.15 General Fee Schedule 12/1/2009

45333 $241.36 General Fee Schedule 12/1/2009

45334 $151.32 General Fee Schedule 12/1/2009

45335 $170.40 General Fee Schedule 12/1/2009

45337 $132.59 General Fee Schedule 12/1/2009

45338 $275.95 General Fee Schedule 12/1/2009

45339 $248.98 General Fee Schedule 12/1/2009

45340 $290.06 General Fee Schedule 12/1/2009

45341 $143.56 General Fee Schedule 12/1/2009

45342 $219.41 General Fee Schedule 12/1/2009

45345 $160.37 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 95 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

45355 $195.16 General Fee Schedule 12/1/2009

45378 $363.69 General Fee Schedule 12/1/2009

45379 $457.05 General Fee Schedule 12/1/2009

45380 $429.93 General Fee Schedule 12/1/2009

45381 $416.20 General Fee Schedule 12/1/2009

45382 $574.75 General Fee Schedule 12/1/2009

45383 $514.60 General Fee Schedule 12/1/2009

45384 $427.64 General Fee Schedule 12/1/2009

45385 $486.81 General Fee Schedule 12/1/2009

45386 $615.78 General Fee Schedule 12/1/2009

45387 $324.44 General Fee Schedule 12/1/2009

45391 $278.77 General Fee Schedule 12/1/2009

45392 $352.20 General Fee Schedule 12/1/2009

45395 $1,771.71 General Fee Schedule 12/1/2009

45397 $1,928.38 General Fee Schedule 12/1/2009

45400 $1,035.63 General Fee Schedule 12/1/2009

45402 $1,406.30 General Fee Schedule 12/1/2009

45499 $0.00 General by Report 1/1/2006

45500 $428.11 General Fee Schedule 12/1/2009

45505 $454.06 General Fee Schedule 12/1/2009

45520 $79.10 General Fee Schedule 12/1/2009

45540 $923.94 General Fee Schedule 12/1/2009

45541 $774.05 General Fee Schedule 12/1/2009

45550 $1,293.13 General Fee Schedule 12/1/2009

45560 $619.88 General Fee Schedule 12/1/2009

45562 $895.75 General Fee Schedule 12/1/2009

45563 $1,372.32 General Fee Schedule 12/1/2009

45800 $1,003.38 General Fee Schedule 12/1/2009

45805 $1,196.98 General Fee Schedule 12/1/2009

45820 $1,028.30 General Fee Schedule 12/1/2009

45825 $1,235.76 General Fee Schedule 12/1/2009

45900 $162.47 General Fee Schedule 12/1/2009

45905 $147.06 General Fee Schedule 12/1/2009

45910 $175.27 General Fee Schedule 12/1/2009

45915 $279.82 General Fee Schedule 12/1/2009

45990 $102.40 General Fee Schedule 12/1/2009

45999 $0.00 General by Report 7/1/1975

46020 $202.76 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 96 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

46030 $98.53 General Fee Schedule 12/1/2009

46040 $401.12 General Fee Schedule 12/1/2009

46045 $284.31 General Fee Schedule 12/1/2009

46050 $138.08 General Fee Schedule 12/1/2009

46060 $353.65 General Fee Schedule 12/1/2009

46070 $180.03 General Fee Schedule 12/1/2009

46080 $187.62 General Fee Schedule 12/1/2009

46083 $145.84 General Fee Schedule 12/1/2009

46200 $277.25 General Fee Schedule 12/1/2009

46220 $144.83 General Fee Schedule 12/1/2009

46221 $177.41 General Fee Schedule 12/1/2009

46230 $215.02 General Fee Schedule 12/1/2009

46250 $348.49 General Fee Schedule 12/1/2009

46255 $397.49 General Fee Schedule 12/1/2009

46257 $328.76 General Fee Schedule 12/1/2009

46258 $356.58 General Fee Schedule 12/1/2009

46260 $380.96 General Fee Schedule 12/1/2009

46261 $423.77 General Fee Schedule 12/1/2009

46262 $445.82 General Fee Schedule 12/1/2009

46270 $330.28 General Fee Schedule 12/1/2009

46275 $352.45 General Fee Schedule 12/1/2009

46280 $364.85 General Fee Schedule 12/1/2009

46285 $301.75 General Fee Schedule 12/1/2009

46288 $428.11 General Fee Schedule 12/1/2009

46320 $141.29 General Fee Schedule 12/1/2009

46500 $140.26 General Fee Schedule 12/1/2009

46505 $219.65 General Fee Schedule 12/1/2009

46600 $74.43 General Fee Schedule 12/1/2009

46604 $367.97 General Fee Schedule 12/1/2009

46606 $164.13 General Fee Schedule 12/1/2009

46608 $214.79 General Fee Schedule 12/1/2009

46610 $194.46 General Fee Schedule 12/1/2009

46611 $190.78 General Fee Schedule 12/1/2009

46612 $278.03 General Fee Schedule 12/1/2009

46614 $164.26 General Fee Schedule 12/1/2009

46615 $200.09 General Fee Schedule 12/1/2009

46700 $528.63 General Fee Schedule 12/1/2009

46705 $423.72 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 97 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

46706 $144.71 General Fee Schedule 12/1/2009

46707 $418.91 General Fee Schedule 1/1/2010

46710 $931.28 General Fee Schedule 12/1/2009

46712 $1,955.08 General Fee Schedule 12/1/2009

46715 $431.87 General Fee Schedule 12/1/2009

46716 $909.05 General Fee Schedule 12/1/2009

46730 $1,528.51 General Fee Schedule 12/1/2009

46735 $1,815.28 General Fee Schedule 12/1/2009

46740 $1,693.65 General Fee Schedule 12/1/2009

46742 $2,086.86 General Fee Schedule 12/1/2009

46744 $2,973.55 General Fee Schedule 12/1/2009

46746 $3,372.17 General Fee Schedule 12/1/2009

46748 $3,402.04 General Fee Schedule 12/1/2009

46750 $606.09 General Fee Schedule 12/1/2009

46751 $556.51 General Fee Schedule 12/1/2009

46753 $483.87 General Fee Schedule 12/1/2009

46754 $214.73 General Fee Schedule 12/1/2009

46760 $854.22 General Fee Schedule 12/1/2009

46761 $788.94 General Fee Schedule 12/1/2009

46762 $721.98 General Fee Schedule 12/1/2009

46900 $168.27 General Fee Schedule 12/1/2009

46910 $177.99 General Fee Schedule 12/1/2009

46916 $183.78 General Fee Schedule 12/1/2009

46917 $392.32 General Fee Schedule 12/1/2009

46922 $191.69 General Fee Schedule 12/1/2009

46924 $413.71 General Fee Schedule 12/1/2009

46930 $170.93 General Fee Schedule 12/1/2009

46940 $165.97 General Fee Schedule 12/1/2009

46942 $148.30 General Fee Schedule 12/1/2009

46945 $189.55 General Fee Schedule 12/1/2009

46946 $236.62 General Fee Schedule 12/1/2009

46947 $319.75 General Fee Schedule 12/1/2009

46999 $0.00 General by Report 7/1/1975

47000 $182.93 General Fee Schedule 12/1/2009

47001 $104.23 General Fee Schedule 12/1/2009

47010 $967.31 General Fee Schedule 12/1/2009

47015 $902.45 General Fee Schedule 12/1/2009

47100 $709.66 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 98 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

47120 $2,048.67 General Fee Schedule 12/1/2009

47122 $3,109.33 General Fee Schedule 12/1/2009

47125 $2,788.46 General Fee Schedule 12/1/2009

47130 $3,015.56 General Fee Schedule 12/1/2009

47133 $805.48 General Fee Schedule 12/1/2009

47135 $4,566.52 General Fee Schedule 12/1/2009

47136 $3,862.01 General Fee Schedule 12/1/2009

47140 $3,062.95 General Fee Schedule 12/1/2009

47141 $3,703.86 General Fee Schedule 12/1/2009

47142 $4,080.95 General Fee Schedule 12/1/2009

47143 $203.55 General Fee Schedule 1/1/2011

47144 $0.00 General by Report 1/1/2005

47145 $0.00 General by Report 1/1/2005

47146 $330.79 General Fee Schedule 12/1/2009

47147 $385.87 General Fee Schedule 12/1/2009

47300 $897.57 General Fee Schedule 12/1/2009

47350 $1,147.33 General Fee Schedule 12/1/2009

47360 $1,551.10 General Fee Schedule 12/1/2009

47361 $2,653.60 General Fee Schedule 12/1/2009

47362 $1,098.90 General Fee Schedule 12/1/2009

47370 $1,125.98 General Fee Schedule 12/1/2009

47371 $1,128.04 General Fee Schedule 12/1/2009

47379 $591.41 General Fee Schedule 12/1/2009

47380 $1,306.55 General Fee Schedule 12/1/2009

47381 $1,324.17 General Fee Schedule 12/1/2009

47382 $827.21 General Fee Schedule 12/1/2009

47399 $0.00 General by Report 7/1/1975

47400 $1,819.37 General Fee Schedule 12/1/2009

47420 $1,157.29 General Fee Schedule 12/1/2009

47425 $1,156.73 General Fee Schedule 12/1/2009

47460 $1,058.07 General Fee Schedule 12/1/2009

47480 $668.60 General Fee Schedule 12/1/2009

47490 $484.58 General Fee Schedule 12/1/2009

47500 $101.70 General Fee Schedule 12/1/2009

47505 $39.28 General Fee Schedule 12/1/2009

47510 $489.61 General Fee Schedule 12/1/2009

47511 $600.21 General Fee Schedule 12/1/2009

47525 $743.24 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 99 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

47530 $1,398.15 General Fee Schedule 12/1/2009

47550 $165.32 General Fee Schedule 12/1/2009

47552 $328.74 General Fee Schedule 12/1/2009

47553 $328.36 General Fee Schedule 12/1/2009

47554 $497.51 General Fee Schedule 12/1/2009

47555 $391.53 General Fee Schedule 12/1/2009

47556 $442.81 General Fee Schedule 12/1/2009

47560 $267.99 General Fee Schedule 12/1/2009

47561 $288.09 General Fee Schedule 12/1/2009

47562 $648.57 General Fee Schedule 12/1/2009

47563 $696.48 General Fee Schedule 12/1/2009

47564 $817.49 General Fee Schedule 12/1/2009

47570 $726.00 General Fee Schedule 12/1/2009

47579 $0.00 General by Report 1/1/2000

47600 $795.45 General Fee Schedule 12/1/2009

47605 $856.14 General Fee Schedule 12/1/2009

47610 $1,082.79 General Fee Schedule 12/1/2009

47612 $1,079.18 General Fee Schedule 12/1/2009

47620 $1,181.87 General Fee Schedule 12/1/2009

47630 $541.11 General Fee Schedule 12/1/2009

47700 $927.35 General Fee Schedule 12/1/2009

47701 $1,592.39 General Fee Schedule 12/1/2009

47711 $1,333.10 General Fee Schedule 12/1/2009

47712 $1,726.62 General Fee Schedule 12/1/2009

47715 $1,099.13 General Fee Schedule 12/1/2009

47720 $941.97 General Fee Schedule 12/1/2009

47721 $1,117.31 General Fee Schedule 12/1/2009

47740 $1,082.31 General Fee Schedule 12/1/2009

47741 $1,238.36 General Fee Schedule 12/1/2009

47760 $1,485.85 General Fee Schedule 12/1/2009

47765 $1,442.55 General Fee Schedule 12/1/2009

47780 $1,526.02 General Fee Schedule 12/1/2009

47785 $1,785.56 General Fee Schedule 12/1/2009

47800 $1,349.02 General Fee Schedule 12/1/2009

47801 $904.21 General Fee Schedule 12/1/2009

47802 $1,260.52 General Fee Schedule 12/1/2009

47900 $1,162.18 General Fee Schedule 12/1/2009

47999 $0.00 General by Report 7/1/1975

Tuesday, February 11, 2014 Page 100 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

48000 $1,596.20 General Fee Schedule 12/1/2009

48001 $2,003.96 General Fee Schedule 12/1/2009

48020 $928.74 General Fee Schedule 12/1/2009

48100 $718.98 General Fee Schedule 12/1/2009

48102 $462.80 General Fee Schedule 12/1/2009

48105 $2,220.54 General Fee Schedule 12/1/2009

48120 $918.09 General Fee Schedule 12/1/2009

48140 $1,315.58 General Fee Schedule 12/1/2009

48145 $1,372.00 General Fee Schedule 12/1/2009

48146 $1,548.87 General Fee Schedule 12/1/2009

48148 $1,007.79 General Fee Schedule 12/1/2009

48150 $2,736.66 General Fee Schedule 12/1/2009

48152 $2,509.80 General Fee Schedule 12/1/2009

48153 $2,733.44 General Fee Schedule 12/1/2009

48154 $2,525.72 General Fee Schedule 12/1/2009

48155 $1,462.03 General Fee Schedule 12/1/2009

48160 $1,349.34 General Fee Schedule 12/1/2009

48400 $102.36 General Fee Schedule 12/1/2009

48500 $910.10 General Fee Schedule 12/1/2009

48510 $869.52 General Fee Schedule 12/1/2009

48520 $901.53 General Fee Schedule 12/1/2009

48540 $1,127.83 General Fee Schedule 12/1/2009

48545 $1,055.99 General Fee Schedule 12/1/2009

48547 $1,472.75 General Fee Schedule 12/1/2009

48548 $1,292.01 General Fee Schedule 12/1/2009

48550 $0.00 General by Report 1/1/1994

48551 $0.00 General by Report 1/1/2005

48552 $226.67 General Fee Schedule 12/1/2009

48554 $2,087.93 General Fee Schedule 12/1/2009

48556 $953.75 General Fee Schedule 12/1/2009

48999 $0.00 General by Report 7/1/1975

49000 $687.11 General Fee Schedule 12/1/2009

49002 $623.32 General Fee Schedule 12/1/2009

49010 $727.73 General Fee Schedule 12/1/2009

49020 $1,328.10 General Fee Schedule 12/1/2009

49040 $799.60 General Fee Schedule 12/1/2009

49060 $926.23 General Fee Schedule 12/1/2009

49062 $671.98 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 101 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

49082 $154.13 General Fee Schedule 2/6/2012

49083 $289.63 General Fee Schedule 2/6/2012

49084 $96.32 General Fee Schedule 2/6/2012

49180 $176.71 General Fee Schedule 12/1/2009

49203 $864.82 General Fee Schedule 12/1/2009

49204 $1,103.96 General Fee Schedule 12/1/2009

49205 $1,263.78 General Fee Schedule 12/1/2009

49215 $1,924.14 General Fee Schedule 12/1/2009

49220 $865.86 General Fee Schedule 12/1/2009

49250 $505.41 General Fee Schedule 12/1/2009

49255 $671.03 General Fee Schedule 12/1/2009

49320 $309.30 General Fee Schedule 12/1/2009

49321 $322.95 General Fee Schedule 12/1/2009

49322 $346.86 General Fee Schedule 12/1/2009

49323 $561.05 General Fee Schedule 12/1/2009

49324 $306.23 General Fee Schedule 12/1/2009

49325 $329.97 General Fee Schedule 12/1/2009

49326 $152.06 General Fee Schedule 12/1/2009

49327 $131.19 General Fee Schedule 1/1/2011

49329 $0.00 General by Report 1/1/2000

49400 $183.19 General Fee Schedule 12/1/2009

49402 $660.68 General Fee Schedule 12/1/2009

49405 $828.20 General Fee Schedule 1/1/2014

49406 $827.87 General Fee Schedule 1/1/2014

49407 $702.83 General Fee Schedule 1/1/2014

49411 $462.27 General Fee Schedule 1/1/2010

49412 $81.98 General Fee Schedule 1/1/2011

49418 $1,448.44 General Fee Schedule 1/1/2011

49419 $406.51 General Fee Schedule 12/1/2009

49421 $347.21 General Fee Schedule 12/1/2009

49422 $368.82 General Fee Schedule 12/1/2009

49423 $542.54 General Fee Schedule 12/1/2009

49424 $158.08 General Fee Schedule 12/1/2009

49425 $683.37 General Fee Schedule 12/1/2009

49426 $578.85 General Fee Schedule 12/1/2009

49427 $47.05 General Fee Schedule 12/1/2009

49428 $395.71 General Fee Schedule 12/1/2009

49429 $437.92 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 102 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

49435 $97.76 General Fee Schedule 12/1/2009

49436 $143.67 General Fee Schedule 12/1/2009

49440 $869.64 General Fee Schedule 12/1/2009

49441 $1,028.64 General Fee Schedule 12/1/2009

49442 $838.77 General Fee Schedule 12/1/2009

49446 $855.94 General Fee Schedule 12/1/2009

49450 $597.86 General Fee Schedule 12/1/2009

49451 $634.06 General Fee Schedule 12/1/2009

49452 $776.79 General Fee Schedule 12/1/2009

49460 $633.17 General Fee Schedule 12/1/2009

49465 $132.81 General Fee Schedule 12/1/2009

49491 $650.43 General Fee Schedule 12/1/2009

49492 $812.48 General Fee Schedule 12/1/2009

49495 $353.87 General Fee Schedule 12/1/2009

49496 $522.40 General Fee Schedule 12/1/2009

49500 $342.48 General Fee Schedule 12/1/2009

49501 $525.20 General Fee Schedule 12/1/2009

49505 $456.93 General Fee Schedule 12/1/2009

49507 $565.58 General Fee Schedule 12/1/2009

49520 $567.55 General Fee Schedule 12/1/2009

49521 $695.92 General Fee Schedule 12/1/2009

49525 $509.12 General Fee Schedule 12/1/2009

49540 $610.23 General Fee Schedule 12/1/2009

49550 $513.50 General Fee Schedule 12/1/2009

49553 $558.15 General Fee Schedule 12/1/2009

49555 $535.80 General Fee Schedule 12/1/2009

49557 $651.23 General Fee Schedule 12/1/2009

49560 $674.64 General Fee Schedule 12/1/2009

49561 $822.02 General Fee Schedule 12/1/2009

49565 $677.38 General Fee Schedule 12/1/2009

49566 $830.90 General Fee Schedule 12/1/2009

49568 $267.64 General Fee Schedule 12/1/2009

49570 $353.68 General Fee Schedule 12/1/2009

49572 $408.58 General Fee Schedule 12/1/2009

49580 $265.92 General Fee Schedule 12/1/2009

49582 $405.50 General Fee Schedule 12/1/2009

49585 $381.39 General Fee Schedule 12/1/2009

49587 $453.67 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 103 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

49590 $508.31 General Fee Schedule 12/1/2009

49600 $650.70 General Fee Schedule 12/1/2009

49605 $4,231.09 General Fee Schedule 12/1/2009

49606 $1,065.03 General Fee Schedule 12/1/2009

49610 $619.85 General Fee Schedule 12/1/2009

49611 $610.17 General Fee Schedule 12/1/2009

49650 $383.31 General Fee Schedule 12/1/2009

49651 $495.71 General Fee Schedule 12/1/2009

49652 $679.76 General Fee Schedule 12/1/2009

49653 $848.48 General Fee Schedule 12/1/2009

49654 $780.63 General Fee Schedule 12/1/2009

49655 $939.96 General Fee Schedule 12/1/2009

49656 $783.84 General Fee Schedule 12/1/2009

49657 $1,133.40 General Fee Schedule 12/1/2009

49659 $0.00 General by Report 1/1/2000

49900 $742.83 General Fee Schedule 12/1/2009

49904 $1,385.85 General Fee Schedule 12/1/2009

49905 $357.09 General Fee Schedule 12/1/2009

49906 $243.51 General Fee Schedule 12/1/2009

49999 $0.00 General by Report 7/1/1975

50010 $634.23 General Fee Schedule 12/1/2009

50020 $877.05 General Fee Schedule 12/1/2009

50040 $844.97 General Fee Schedule 12/1/2009

50045 $865.10 General Fee Schedule 12/1/2009

50060 $1,059.20 General Fee Schedule 12/1/2009

50065 $1,064.74 General Fee Schedule 12/1/2009

50070 $1,114.68 General Fee Schedule 12/1/2009

50075 $1,378.36 General Fee Schedule 12/1/2009

50080 $818.29 General Fee Schedule 12/1/2009

50081 $1,194.09 General Fee Schedule 12/1/2009

50100 $958.49 General Fee Schedule 12/1/2009

50120 $887.26 General Fee Schedule 12/1/2009

50125 $925.25 General Fee Schedule 12/1/2009

50130 $954.18 General Fee Schedule 12/1/2009

50135 $1,051.82 General Fee Schedule 12/1/2009

50200 $151.20 General Fee Schedule 12/1/2009

50205 $652.56 General Fee Schedule 12/1/2009

50220 $955.66 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 104 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

50225 $1,110.89 General Fee Schedule 12/1/2009

50230 $1,198.36 General Fee Schedule 12/1/2009

50234 $1,221.38 General Fee Schedule 12/1/2009

50236 $1,370.44 General Fee Schedule 12/1/2009

50240 $1,210.72 General Fee Schedule 12/1/2009

50250 $1,133.13 General Fee Schedule 12/1/2009

50280 $874.56 General Fee Schedule 12/1/2009

50290 $838.01 General Fee Schedule 12/1/2009

50300 $1,161.68 General Fee Schedule 12/1/2009

50320 $1,302.94 General Fee Schedule 12/1/2009

50323 $126.05 General Fee Schedule 1/1/2011

50325 $129.80 General Fee Schedule 1/1/2011

50327 $210.64 General Fee Schedule 12/1/2009

50328 $184.48 General Fee Schedule 12/1/2009

50329 $176.24 General Fee Schedule 12/1/2009

50340 $748.09 General Fee Schedule 12/1/2009

50360 $1,877.72 General Fee Schedule 12/1/2009

50365 $2,195.67 General Fee Schedule 12/1/2009

50370 $831.63 General Fee Schedule 12/1/2009

50380 $1,299.06 General Fee Schedule 12/1/2009

50382 $1,464.11 General Fee Schedule 12/1/2009

50384 $1,412.95 General Fee Schedule 12/1/2009

50385 $1,033.63 General Fee Schedule 12/1/2009

50386 $668.78 General Fee Schedule 12/1/2009

50387 $706.51 General Fee Schedule 12/1/2009

50389 $482.42 General Fee Schedule 12/1/2009

50390 $101.70 General Fee Schedule 12/1/2009

50391 $134.59 General Fee Schedule 12/1/2009

50392 $189.02 General Fee Schedule 12/1/2009

50393 $230.11 General Fee Schedule 12/1/2009

50394 $123.16 General Fee Schedule 12/1/2009

50395 $188.68 General Fee Schedule 12/1/2009

50396 $122.14 General Fee Schedule 12/1/2009

50398 $619.59 General Fee Schedule 12/1/2009

50400 $1,069.31 General Fee Schedule 12/1/2009

50405 $1,293.46 General Fee Schedule 12/1/2009

50500 $1,111.24 General Fee Schedule 12/1/2009

50520 $970.09 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 105 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

50525 $1,230.47 General Fee Schedule 12/1/2009

50526 $1,331.57 General Fee Schedule 12/1/2009

50540 $1,100.63 General Fee Schedule 12/1/2009

50541 $878.38 General Fee Schedule 12/1/2009

50542 $1,097.87 General Fee Schedule 12/1/2009

50543 $1,394.80 General Fee Schedule 12/1/2009

50544 $1,210.41 General Fee Schedule 12/1/2009

50545 $1,298.87 General Fee Schedule 12/1/2009

50546 $1,130.49 General Fee Schedule 12/1/2009

50547 $1,459.12 General Fee Schedule 12/1/2009

50548 $1,314.66 General Fee Schedule 12/1/2009

50549 $0.00 General by Report 1/1/2000

50551 $371.67 General Fee Schedule 12/1/2009

50553 $393.91 General Fee Schedule 12/1/2009

50555 $432.23 General Fee Schedule 12/1/2009

50557 $428.53 General Fee Schedule 12/1/2009

50561 $485.49 General Fee Schedule 12/1/2009

50562 $593.84 General Fee Schedule 12/1/2009

50570 $501.58 General Fee Schedule 12/1/2009

50572 $548.26 General Fee Schedule 12/1/2009

50574 $579.58 General Fee Schedule 12/1/2009

50575 $731.89 General Fee Schedule 12/1/2009

50576 $576.02 General Fee Schedule 12/1/2009

50580 $621.61 General Fee Schedule 12/1/2009

50590 $798.49 General Fee Schedule 12/1/2009

50592 $5,392.11 General Fee Schedule 12/1/2009

50593 $3,639.61 General Fee Schedule 12/1/2009

50600 $878.36 General Fee Schedule 12/1/2009

50605 $877.15 General Fee Schedule 12/1/2009

50610 $902.10 General Fee Schedule 12/1/2009

50620 $838.76 General Fee Schedule 12/1/2009

50630 $828.89 General Fee Schedule 12/1/2009

50650 $961.21 General Fee Schedule 12/1/2009

50660 $1,073.98 General Fee Schedule 12/1/2009

50684 $201.57 General Fee Schedule 12/1/2009

50686 $180.21 General Fee Schedule 12/1/2009

50688 $83.88 General Fee Schedule 12/1/2009

50690 $109.84 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 106 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

50700 $874.29 General Fee Schedule 12/1/2009

50715 $1,101.85 General Fee Schedule 12/1/2009

50722 $963.69 General Fee Schedule 12/1/2009

50725 $1,040.98 General Fee Schedule 12/1/2009

50727 $482.96 General Fee Schedule 12/1/2009

50728 $688.43 General Fee Schedule 12/1/2009

50740 $1,042.88 General Fee Schedule 12/1/2009

50750 $1,073.47 General Fee Schedule 12/1/2009

50760 $1,026.66 General Fee Schedule 12/1/2009

50770 $1,075.55 General Fee Schedule 12/1/2009

50780 $1,019.88 General Fee Schedule 12/1/2009

50782 $1,109.62 General Fee Schedule 12/1/2009

50783 $1,142.21 General Fee Schedule 12/1/2009

50785 $1,125.48 General Fee Schedule 12/1/2009

50800 $822.65 General Fee Schedule 12/1/2009

50810 $1,164.44 General Fee Schedule 12/1/2009

50815 $1,110.96 General Fee Schedule 12/1/2009

50820 $1,205.55 General Fee Schedule 12/1/2009

50825 $1,539.41 General Fee Schedule 12/1/2009

50830 $1,705.00 General Fee Schedule 12/1/2009

50840 $1,110.55 General Fee Schedule 12/1/2009

50845 $1,164.80 General Fee Schedule 12/1/2009

50860 $863.66 General Fee Schedule 12/1/2009

50900 $774.88 General Fee Schedule 12/1/2009

50920 $812.52 General Fee Schedule 12/1/2009

50930 $1,038.84 General Fee Schedule 12/1/2009

50940 $822.28 General Fee Schedule 12/1/2009

50945 $943.37 General Fee Schedule 12/1/2009

50947 $1,351.18 General Fee Schedule 12/1/2009

50948 $1,224.25 General Fee Schedule 12/1/2009

50949 $1,144.99 General Fee Schedule 12/1/2009

50951 $386.41 General Fee Schedule 12/1/2009

50953 $406.31 General Fee Schedule 12/1/2009

50955 $496.87 General Fee Schedule 12/1/2009

50957 $434.74 General Fee Schedule 12/1/2009

50961 $396.92 General Fee Schedule 12/1/2009

50970 $377.74 General Fee Schedule 12/1/2009

50972 $367.05 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 107 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

50974 $482.15 General Fee Schedule 12/1/2009

50976 $476.45 General Fee Schedule 12/1/2009

50980 $362.08 General Fee Schedule 12/1/2009

51020 $407.00 General Fee Schedule 12/1/2009

51030 $417.23 General Fee Schedule 12/1/2009

51040 $275.00 General Fee Schedule 12/1/2009

51045 $413.44 General Fee Schedule 12/1/2009

51050 $408.61 General Fee Schedule 12/1/2009

51060 $517.04 General Fee Schedule 12/1/2009

51065 $512.25 General Fee Schedule 12/1/2009

51080 $366.06 General Fee Schedule 12/1/2009

51100 $50.81 General Fee Schedule 12/1/2009

51101 $102.91 General Fee Schedule 12/1/2009

51102 $269.39 General Fee Schedule 12/1/2009

51500 $597.72 General Fee Schedule 12/1/2009

51520 $542.26 General Fee Schedule 12/1/2009

51525 $782.87 General Fee Schedule 12/1/2009

51530 $710.55 General Fee Schedule 12/1/2009

51535 $736.43 General Fee Schedule 12/1/2009

51550 $879.70 General Fee Schedule 12/1/2009

51555 $1,173.86 General Fee Schedule 12/1/2009

51565 $1,197.11 General Fee Schedule 12/1/2009

51570 $1,327.31 General Fee Schedule 12/1/2009

51575 $1,660.57 General Fee Schedule 12/1/2009

51580 $1,703.75 General Fee Schedule 12/1/2009

51585 $1,913.65 General Fee Schedule 12/1/2009

51590 $1,769.88 General Fee Schedule 12/1/2009

51595 $2,005.50 General Fee Schedule 12/1/2009

51596 $2,141.26 General Fee Schedule 12/1/2009

51597 $2,083.78 General Fee Schedule 12/1/2009

51600 $209.28 General Fee Schedule 12/1/2009

51605 $233.90 General Fee Schedule 12/1/2009

51610 $121.36 General Fee Schedule 12/1/2009

51700 $90.82 General Fee Schedule 12/1/2009

51701 $74.78 General Fee Schedule 12/1/2009

51702 $92.24 General Fee Schedule 12/1/2009

51703 $154.01 General Fee Schedule 12/1/2009

51705 $119.84 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 108 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

51710 $175.66 General Fee Schedule 12/1/2009

51715 $287.86 General Fee Schedule 12/1/2009

51720 $140.40 General Fee Schedule 12/1/2009

51725 $79.21 26 Fee Schedule (FS) 12/1/2009

51725 $176.34 TC Fee Schedule 12/1/2009

51725 $255.55 General Fee Schedule 12/1/2009

51726 $329.69 General Fee Schedule 12/1/2009

51726 $240.02 TC Fee Schedule 12/1/2009

51726 $89.67 26 Fee Schedule (FS) 12/1/2009

51727 $162.90 TC Fee Schedule 1/1/2010

51727 $267.00 General Fee Schedule 1/1/2010

51727 $104.10 26 Fee Schedule (FS) 1/1/2010

51728 $102.67 26 Fee Schedule (FS) 1/1/2010

51728 $163.86 TC Fee Schedule 1/1/2010

51728 $266.53 General Fee Schedule 1/1/2010

51729 $121.53 26 Fee Schedule (FS) 1/1/2010

51729 $165.79 TC Fee Schedule 1/1/2010

51729 $287.32 General Fee Schedule 1/1/2010

51736 $13.36 TC Fee Schedule 12/1/2009

51736 $32.13 26 Fee Schedule (FS) 12/1/2009

51736 $45.47 General Fee Schedule 12/1/2009

51741 $15.07 TC Fee Schedule 12/1/2009

51741 $59.77 26 Fee Schedule (FS) 12/1/2009

51741 $74.85 General Fee Schedule 12/1/2009

51784 $80.32 26 Fee Schedule (FS) 12/1/2009

51784 $120.86 TC Fee Schedule 12/1/2009

51784 $201.19 General Fee Schedule 12/1/2009

51785 $216.59 General Fee Schedule 12/1/2009

51785 $79.98 26 Fee Schedule (FS) 12/1/2009

51785 $136.62 TC Fee Schedule 12/1/2009

51792 $255.14 General Fee Schedule 12/1/2009

51792 $196.21 TC Fee Schedule 12/1/2009

51792 $58.91 26 Fee Schedule (FS) 12/1/2009

51797 $84.05 26 Fee Schedule (FS) 12/1/2009

51797 $182.16 TC Fee Schedule 12/1/2009

51797 $266.21 General Fee Schedule 12/1/2009

51798 $14.40 General Fee Schedule 12/1/2009

51800 $976.34 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 109 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

51820 $1,033.64 General Fee Schedule 12/1/2009

51840 $640.28 General Fee Schedule 12/1/2009

51841 $763.79 General Fee Schedule 12/1/2009

51845 $565.09 General Fee Schedule 12/1/2009

51860 $700.80 General Fee Schedule 12/1/2009

51865 $851.28 General Fee Schedule 12/1/2009

51880 $455.73 General Fee Schedule 12/1/2009

51900 $749.81 General Fee Schedule 12/1/2009

51920 $689.28 General Fee Schedule 12/1/2009

51925 $966.19 General Fee Schedule 12/1/2009

51940 $1,584.35 General Fee Schedule 12/1/2009

51960 $1,274.03 General Fee Schedule 12/1/2009

51980 $651.96 General Fee Schedule 12/1/2009

51990 $740.63 General Fee Schedule 12/1/2009

51992 $801.67 General Fee Schedule 12/1/2009

51999 $0.00 General by Report 1/1/2006

52000 $195.75 General Fee Schedule 12/1/2009

52001 $397.38 General Fee Schedule 12/1/2009

52005 $288.40 General Fee Schedule 12/1/2009

52007 $688.74 General Fee Schedule 12/1/2009

52010 $492.90 General Fee Schedule 12/1/2009

52204 $595.49 General Fee Schedule 12/1/2009

52214 $1,459.99 General Fee Schedule 12/1/2009

52224 $1,380.50 General Fee Schedule 12/1/2009

52234 $246.55 General Fee Schedule 12/1/2009

52235 $289.87 General Fee Schedule 12/1/2009

52240 $511.95 General Fee Schedule 12/1/2009

52250 $240.85 General Fee Schedule 12/1/2009

52260 $209.21 General Fee Schedule 12/1/2009

52265 $579.17 General Fee Schedule 12/1/2009

52270 $516.64 General Fee Schedule 12/1/2009

52275 $726.53 General Fee Schedule 12/1/2009

52276 $265.98 General Fee Schedule 12/1/2009

52277 $329.32 General Fee Schedule 12/1/2009

52281 $358.42 General Fee Schedule 12/1/2009

52282 $338.89 General Fee Schedule 12/1/2009

52283 $288.20 General Fee Schedule 12/1/2009

52285 $285.57 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 110 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

52287 $293.35 General Fee Schedule 2/23/2013

52290 $244.32 General Fee Schedule 12/1/2009

52300 $283.09 General Fee Schedule 12/1/2009

52301 $296.32 General Fee Schedule 12/1/2009

52305 $281.38 General Fee Schedule 12/1/2009

52310 $276.29 General Fee Schedule 12/1/2009

52315 $511.02 General Fee Schedule 12/1/2009

52317 $1,269.13 General Fee Schedule 12/1/2009

52318 $482.92 General Fee Schedule 12/1/2009

52320 $248.23 General Fee Schedule 12/1/2009

52325 $325.16 General Fee Schedule 12/1/2009

52327 $1,304.88 General Fee Schedule 12/1/2009

52330 $1,539.43 General Fee Schedule 12/1/2009

52332 $313.70 General Fee Schedule 12/1/2009

52334 $257.71 General Fee Schedule 12/1/2009

52341 $322.07 General Fee Schedule 12/1/2009

52342 $346.85 General Fee Schedule 12/1/2009

52343 $383.81 General Fee Schedule 12/1/2009

52344 $411.69 General Fee Schedule 12/1/2009

52345 $437.50 General Fee Schedule 12/1/2009

52351 $313.57 General Fee Schedule 12/1/2009

52352 $368.04 General Fee Schedule 12/1/2009

52353 $424.86 General Fee Schedule 12/1/2009

52354 $392.65 General Fee Schedule 12/1/2009

52355 $469.66 General Fee Schedule 12/1/2009

52356 $416.80 General Fee Schedule 1/1/2014

52400 $524.78 General Fee Schedule 12/1/2009

52402 $275.43 General Fee Schedule 12/1/2009

52450 $439.16 General Fee Schedule 12/1/2009

52500 $481.82 General Fee Schedule 12/1/2009

52601 $681.71 General Fee Schedule 12/1/2009

52630 $407.01 General Fee Schedule 12/1/2009

52640 $373.05 General Fee Schedule 12/1/2009

52647 $2,963.00 General Fee Schedule 12/1/2009

52648 $2,997.88 General Fee Schedule 12/1/2009

52649 $795.44 General Fee Schedule 12/1/2009

52700 $387.88 General Fee Schedule 12/1/2009

53000 $146.26 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 111 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

53010 $248.37 General Fee Schedule 12/1/2009

53020 $175.86 General Fee Schedule 12/1/2009

53025 $174.43 General Fee Schedule 12/1/2009

53040 $379.96 General Fee Schedule 12/1/2009

53060 $182.74 General Fee Schedule 12/1/2009

53080 $464.77 General Fee Schedule 12/1/2009

53085 $681.45 General Fee Schedule 12/1/2009

53200 $152.08 General Fee Schedule 12/1/2009

53210 $715.44 General Fee Schedule 12/1/2009

53215 $865.93 General Fee Schedule 12/1/2009

53220 $414.09 General Fee Schedule 12/1/2009

53230 $556.21 General Fee Schedule 12/1/2009

53235 $583.59 General Fee Schedule 12/1/2009

53240 $387.40 General Fee Schedule 12/1/2009

53250 $356.87 General Fee Schedule 12/1/2009

53260 $200.69 General Fee Schedule 12/1/2009

53265 $221.84 General Fee Schedule 12/1/2009

53270 $205.30 General Fee Schedule 12/1/2009

53275 $262.90 General Fee Schedule 12/1/2009

53400 $732.78 General Fee Schedule 12/1/2009

53405 $812.85 General Fee Schedule 12/1/2009

53410 $915.91 General Fee Schedule 12/1/2009

53415 $1,047.01 General Fee Schedule 12/1/2009

53420 $791.56 General Fee Schedule 12/1/2009

53425 $891.31 General Fee Schedule 12/1/2009

53430 $909.66 General Fee Schedule 12/1/2009

53431 $1,091.57 General Fee Schedule 12/1/2009

53440 $763.19 General Fee Schedule 12/1/2009

53442 $660.73 General Fee Schedule 12/1/2009

53444 $750.58 General Fee Schedule 12/1/2009

53445 $819.21 General Fee Schedule 12/1/2009

53446 $598.02 General Fee Schedule 12/1/2009

53447 $773.23 General Fee Schedule 12/1/2009

53448 $1,177.55 General Fee Schedule 12/1/2009

53449 $559.45 General Fee Schedule 12/1/2009

53450 $364.45 General Fee Schedule 12/1/2009

53460 $418.39 General Fee Schedule 12/1/2009

53500 $714.56 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 112 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

53502 $452.15 General Fee Schedule 12/1/2009

53505 $445.28 General Fee Schedule 12/1/2009

53510 $592.03 General Fee Schedule 12/1/2009

53515 $752.62 General Fee Schedule 12/1/2009

53520 $509.10 General Fee Schedule 12/1/2009

53600 $88.84 General Fee Schedule 12/1/2009

53601 $83.72 General Fee Schedule 12/1/2009

53605 $66.55 General Fee Schedule 12/1/2009

53620 $134.81 General Fee Schedule 12/1/2009

53621 $126.77 General Fee Schedule 12/1/2009

53660 $73.98 General Fee Schedule 12/1/2009

53661 $74.02 General Fee Schedule 12/1/2009

53665 $39.96 General Fee Schedule 12/1/2009

53850 $3,617.09 General Fee Schedule 12/1/2009

53852 $3,453.27 General Fee Schedule 12/1/2009

53855 $585.73 General Fee Schedule 1/1/2010

53860 $1,392.21 General Fee Schedule 1/1/2011

53899 $0.00 General by Report 7/1/1975

54000 $163.21 General Fee Schedule 12/1/2009

54001 $198.94 General Fee Schedule 12/1/2009

54015 $305.73 General Fee Schedule 12/1/2009

54050 $107.47 General Fee Schedule 12/1/2009

54055 $103.61 General Fee Schedule 12/1/2009

54056 $107.80 General Fee Schedule 12/1/2009

54057 $126.97 General Fee Schedule 12/1/2009

54060 $185.45 General Fee Schedule 12/1/2009

54065 $188.29 General Fee Schedule 12/1/2009

54100 $173.00 General Fee Schedule 12/1/2009

54105 $290.22 General Fee Schedule 12/1/2009

54110 $578.07 General Fee Schedule 12/1/2009

54111 $754.07 General Fee Schedule 12/1/2009

54112 $882.89 General Fee Schedule 12/1/2009

54115 $401.81 General Fee Schedule 12/1/2009

54120 $568.16 General Fee Schedule 12/1/2009

54125 $754.23 General Fee Schedule 12/1/2009

54130 $1,109.13 General Fee Schedule 12/1/2009

54135 $1,429.39 General Fee Schedule 12/1/2009

54150 $224.66 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 113 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

54160 $244.37 General Fee Schedule 12/1/2009

54161 $187.58 General Fee Schedule 12/1/2009

54162 $282.59 General Fee Schedule 12/1/2009

54163 $191.87 General Fee Schedule 12/1/2009

54164 $165.71 General Fee Schedule 12/1/2009

54200 $105.30 General Fee Schedule 12/1/2009

54205 $485.62 General Fee Schedule 12/1/2009

54220 $231.10 General Fee Schedule 12/1/2009

54231 $131.17 General Fee Schedule 12/1/2009

54235 $81.56 General Fee Schedule 12/1/2009

54240 $22.61 TC Fee Schedule 12/1/2009

54240 $69.08 26 Fee Schedule (FS) 12/1/2009

54240 $91.70 General Fee Schedule 12/1/2009

54250 $7.20 TC Fee Schedule 1/1/2006

54250 $110.28 26 Fee Schedule (FS) 1/1/2006

54250 $117.47 General Fee Schedule 1/1/2006

54300 $618.35 General Fee Schedule 12/1/2009

54304 $728.79 General Fee Schedule 12/1/2009

54308 $689.26 General Fee Schedule 12/1/2009

54312 $805.51 General Fee Schedule 12/1/2009

54316 $962.40 General Fee Schedule 12/1/2009

54318 $680.06 General Fee Schedule 12/1/2009

54322 $754.69 General Fee Schedule 12/1/2009

54324 $941.03 General Fee Schedule 12/1/2009

54326 $911.05 General Fee Schedule 12/1/2009

54328 $885.71 General Fee Schedule 12/1/2009

54332 $964.90 General Fee Schedule 12/1/2009

54336 $1,201.35 General Fee Schedule 12/1/2009

54340 $537.85 General Fee Schedule 12/1/2009

54344 $933.37 General Fee Schedule 12/1/2009

54348 $989.53 General Fee Schedule 12/1/2009

54352 $1,414.22 General Fee Schedule 12/1/2009

54360 $695.52 General Fee Schedule 12/1/2009

54380 $766.74 General Fee Schedule 12/1/2009

54385 $906.11 General Fee Schedule 12/1/2009

54390 $1,209.01 General Fee Schedule 12/1/2009

54406 $681.89 General Fee Schedule 12/1/2009

54408 $718.97 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 114 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

54410 $862.49 General Fee Schedule 12/1/2009

54411 $897.22 General Fee Schedule 12/1/2009

54415 $479.96 General Fee Schedule 12/1/2009

54416 $629.59 General Fee Schedule 12/1/2009

54417 $793.07 General Fee Schedule 12/1/2009

54420 $659.05 General Fee Schedule 12/1/2009

54430 $590.84 General Fee Schedule 12/1/2009

54435 $374.63 General Fee Schedule 12/1/2009

54440 $238.85 General Fee Schedule 12/1/2009

54450 $78.51 General Fee Schedule 12/1/2009

54500 $74.90 General Fee Schedule 12/1/2009

54505 $208.23 General Fee Schedule 12/1/2009

54512 $495.34 General Fee Schedule 12/1/2009

54520 $314.28 General Fee Schedule 12/1/2009

54522 $563.78 General Fee Schedule 12/1/2009

54530 $498.76 General Fee Schedule 12/1/2009

54535 $691.42 General Fee Schedule 12/1/2009

54550 $450.74 General Fee Schedule 12/1/2009

54560 $636.58 General Fee Schedule 12/1/2009

54600 $409.35 General Fee Schedule 12/1/2009

54620 $285.06 General Fee Schedule 12/1/2009

54640 $415.40 General Fee Schedule 12/1/2009

54650 $666.48 General Fee Schedule 12/1/2009

54660 $314.77 General Fee Schedule 12/1/2009

54670 $384.46 General Fee Schedule 12/1/2009

54680 $738.47 General Fee Schedule 12/1/2009

54690 $626.63 General Fee Schedule 12/1/2009

54692 $727.54 General Fee Schedule 12/1/2009

54699 $0.00 General by Report 1/1/2000

54700 $208.10 General Fee Schedule 12/1/2009

54800 $130.07 General Fee Schedule 12/1/2009

54830 $324.83 General Fee Schedule 12/1/2009

54840 $308.29 General Fee Schedule 12/1/2009

54860 $372.42 General Fee Schedule 12/1/2009

54861 $512.47 General Fee Schedule 12/1/2009

54865 $292.43 General Fee Schedule 12/1/2009

54900 $739.43 General Fee Schedule 12/1/2009

54901 $1,011.98 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 115 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

55000 $129.87 General Fee Schedule 12/1/2009

55040 $320.64 General Fee Schedule 12/1/2009

55041 $455.02 General Fee Schedule 12/1/2009

55060 $334.02 General Fee Schedule 12/1/2009

55100 $214.08 General Fee Schedule 12/1/2009

55110 $341.64 General Fee Schedule 12/1/2009

55120 $310.56 General Fee Schedule 12/1/2009

55150 $429.12 General Fee Schedule 12/1/2009

55175 $317.71 General Fee Schedule 12/1/2009

55180 $627.95 General Fee Schedule 12/1/2009

55200 $597.50 General Fee Schedule 12/1/2009

55250 $529.36 General Fee Schedule 12/1/2009

55300 $188.59 General Fee Schedule 12/1/2009

55450 $408.66 General Fee Schedule 12/1/2009

55500 $340.17 General Fee Schedule 12/1/2009

55520 $369.54 General Fee Schedule 12/1/2009

55530 $336.69 General Fee Schedule 12/1/2009

55535 $385.46 General Fee Schedule 12/1/2009

55540 $458.25 General Fee Schedule 12/1/2009

55550 $385.88 General Fee Schedule 12/1/2009

55559 $0.00 General by Report 1/1/2000

55600 $381.30 General Fee Schedule 12/1/2009

55605 $475.84 General Fee Schedule 12/1/2009

55650 $667.24 General Fee Schedule 12/1/2009

55680 $317.86 General Fee Schedule 12/1/2009

55700 $208.19 General Fee Schedule 12/1/2009

55705 $265.81 General Fee Schedule 12/1/2009

55706 $366.80 General Fee Schedule 12/1/2009

55720 $458.11 General Fee Schedule 12/1/2009

55725 $512.56 General Fee Schedule 12/1/2009

55801 $993.08 General Fee Schedule 12/1/2009

55810 $1,232.09 General Fee Schedule 12/1/2009

55812 $1,507.04 General Fee Schedule 12/1/2009

55815 $1,655.83 General Fee Schedule 12/1/2009

55821 $796.76 General Fee Schedule 12/1/2009

55831 $868.16 General Fee Schedule 12/1/2009

55840 $1,248.32 General Fee Schedule 12/1/2009

55842 $1,336.14 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 116 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

55845 $1,544.78 General Fee Schedule 12/1/2009

55860 $811.68 General Fee Schedule 12/1/2009

55862 $1,028.90 General Fee Schedule 12/1/2009

55865 $1,255.28 General Fee Schedule 12/1/2009

55866 $1,660.80 General Fee Schedule 12/1/2009

55873 $1,104.80 General Fee Schedule 12/1/2009

55875 $643.23 General Fee Schedule 12/1/2009

55876 $126.34 General Fee Schedule 12/1/2009

55899 $0.00 General by Report 7/1/1975

55920 $346.37 General Fee Schedule 12/1/2009

56405 $106.99 General Fee Schedule 12/1/2009

56420 $137.25 General Fee Schedule 12/1/2009

56440 $179.91 General Fee Schedule 12/1/2009

56441 $145.26 General Fee Schedule 12/1/2009

56442 $39.58 General Fee Schedule 12/1/2009

56501 $126.56 General Fee Schedule 12/1/2009

56515 $205.24 General Fee Schedule 12/1/2009

56605 $83.58 General Fee Schedule 12/1/2009

56606 $40.42 General Fee Schedule 12/1/2009

56620 $483.37 General Fee Schedule 12/1/2009

56625 $541.57 General Fee Schedule 12/1/2009

56630 $762.30 General Fee Schedule 12/1/2009

56631 $994.20 General Fee Schedule 12/1/2009

56632 $1,190.85 General Fee Schedule 12/1/2009

56633 $997.78 General Fee Schedule 12/1/2009

56634 $1,087.15 General Fee Schedule 12/1/2009

56637 $1,316.36 General Fee Schedule 12/1/2009

56640 $1,318.35 General Fee Schedule 12/1/2009

56700 $170.63 General Fee Schedule 12/1/2009

56740 $283.35 General Fee Schedule 12/1/2009

56800 $240.29 General Fee Schedule 12/1/2009

56805 $1,123.94 General Fee Schedule 12/1/2009

56810 $254.69 General Fee Schedule 12/1/2009

56820 $108.97 General Fee Schedule 12/1/2009

56821 $148.02 General Fee Schedule 12/1/2009

57000 $184.23 General Fee Schedule 12/1/2009

57010 $387.34 General Fee Schedule 12/1/2009

57020 $96.30 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 117 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

57022 $158.81 General Fee Schedule 12/1/2009

57023 $291.32 General Fee Schedule 12/1/2009

57061 $109.92 General Fee Schedule 12/1/2009

57065 $190.20 General Fee Schedule 12/1/2009

57100 $88.13 General Fee Schedule 12/1/2009

57105 $133.77 General Fee Schedule 12/1/2009

57106 $413.77 General Fee Schedule 12/1/2009

57107 $1,339.38 General Fee Schedule 12/1/2009

57109 $1,537.36 General Fee Schedule 12/1/2009

57110 $860.16 General Fee Schedule 12/1/2009

57111 $1,583.22 General Fee Schedule 12/1/2009

57112 $1,639.16 General Fee Schedule 12/1/2009

57120 $474.20 General Fee Schedule 12/1/2009

57130 $177.77 General Fee Schedule 12/1/2009

57135 $191.49 General Fee Schedule 12/1/2009

57150 $61.30 General Fee Schedule 12/1/2009

57155 $412.94 General Fee Schedule 12/1/2009

57156 $145.84 General Fee Schedule 1/1/2011

57160 $72.38 General Fee Schedule 12/1/2009

57170 $89.60 General Fee Schedule 12/1/2009

57180 $141.84 General Fee Schedule 12/1/2009

57200 $266.87 General Fee Schedule 12/1/2009

57210 $338.37 General Fee Schedule 12/1/2009

57220 $290.07 General Fee Schedule 12/1/2009

57230 $352.72 General Fee Schedule 12/1/2009

57240 $386.12 General Fee Schedule 12/1/2009

57250 $358.09 General Fee Schedule 12/1/2009

57260 $518.04 General Fee Schedule 12/1/2009

57265 $689.67 General Fee Schedule 12/1/2009

57267 $278.26 General Fee Schedule 12/1/2009

57268 $431.63 General Fee Schedule 12/1/2009

57270 $730.04 General Fee Schedule 12/1/2009

57280 $890.11 General Fee Schedule 12/1/2009

57282 $454.44 General Fee Schedule 12/1/2009

57283 $656.67 General Fee Schedule 12/1/2009

57284 $783.28 General Fee Schedule 12/1/2009

57285 $497.95 General Fee Schedule 12/1/2009

57287 $631.67 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 118 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

57288 $743.16 General Fee Schedule 12/1/2009

57289 $695.14 General Fee Schedule 12/1/2009

57291 $507.39 General Fee Schedule 12/1/2009

57292 $797.02 General Fee Schedule 12/1/2009

57295 $471.00 General Fee Schedule 12/1/2009

57296 $777.81 General Fee Schedule 12/1/2009

57300 $470.29 General Fee Schedule 12/1/2009

57305 $805.16 General Fee Schedule 12/1/2009

57307 $923.55 General Fee Schedule 12/1/2009

57308 $597.28 General Fee Schedule 12/1/2009

57310 $411.44 General Fee Schedule 12/1/2009

57311 $471.14 General Fee Schedule 12/1/2009

57320 $482.24 General Fee Schedule 12/1/2009

57330 $708.38 General Fee Schedule 12/1/2009

57335 $1,097.61 General Fee Schedule 12/1/2009

57400 $134.61 General Fee Schedule 12/1/2009

57410 $142.93 General Fee Schedule 12/1/2009

57415 $140.67 General Fee Schedule 12/1/2009

57420 $114.54 General Fee Schedule 12/1/2009

57421 $157.59 General Fee Schedule 12/1/2009

57423 $698.03 General Fee Schedule 12/1/2009

57425 $895.28 General Fee Schedule 12/1/2009

57426 $814.10 General Fee Schedule 1/1/2010

57452 $107.94 General Fee Schedule 12/1/2009

57454 $155.76 General Fee Schedule 12/1/2009

57455 $143.99 General Fee Schedule 12/1/2009

57456 $135.50 General Fee Schedule 12/1/2009

57460 $321.61 General Fee Schedule 12/1/2009

57461 $356.09 General Fee Schedule 12/1/2009

57500 $128.89 General Fee Schedule 12/1/2009

57505 $98.82 General Fee Schedule 12/1/2009

57510 $134.69 General Fee Schedule 12/1/2009

57511 $143.94 General Fee Schedule 12/1/2009

57513 $140.17 General Fee Schedule 12/1/2009

57520 $307.37 General Fee Schedule 12/1/2009

57522 $251.66 General Fee Schedule 12/1/2009

57530 $320.60 General Fee Schedule 12/1/2009

57531 $1,646.53 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 119 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

57540 $736.36 General Fee Schedule 12/1/2009

57545 $783.72 General Fee Schedule 12/1/2009

57550 $367.34 General Fee Schedule 12/1/2009

57555 $556.99 General Fee Schedule 12/1/2009

57556 $520.86 General Fee Schedule 12/1/2009

57558 $103.88 General Fee Schedule 12/1/2009

57700 $257.28 General Fee Schedule 12/1/2009

57720 $282.43 General Fee Schedule 12/1/2009

57800 $58.85 General Fee Schedule 12/1/2009

58100 $110.46 General Fee Schedule 12/1/2009

58110 $51.66 General Fee Schedule 12/1/2009

58120 $218.77 General Fee Schedule 12/1/2009

58140 $869.06 General Fee Schedule 12/1/2009

58145 $507.80 General Fee Schedule 12/1/2009

58146 $1,121.52 General Fee Schedule 12/1/2009

58150 $907.81 General Fee Schedule 12/1/2009

58152 $1,217.56 General Fee Schedule 12/1/2009

58180 $901.81 General Fee Schedule 12/1/2009

58200 $1,262.99 General Fee Schedule 12/1/2009

58210 $1,681.40 General Fee Schedule 12/1/2009

58240 $2,229.89 General Fee Schedule 12/1/2009

58260 $784.21 General Fee Schedule 12/1/2009

58262 $884.51 General Fee Schedule 12/1/2009

58263 $956.61 General Fee Schedule 12/1/2009

58267 $1,014.98 General Fee Schedule 12/1/2009

58270 $851.81 General Fee Schedule 12/1/2009

58275 $940.23 General Fee Schedule 12/1/2009

58280 $1,009.71 General Fee Schedule 12/1/2009

58285 $1,292.66 General Fee Schedule 12/1/2009

58290 $1,124.60 General Fee Schedule 12/1/2009

58291 $1,227.31 General Fee Schedule 12/1/2009

58292 $1,299.05 General Fee Schedule 12/1/2009

58293 $1,350.61 General Fee Schedule 12/1/2009

58294 $1,192.18 General Fee Schedule 12/1/2009

58300 $39.69 General Fee Schedule 12/1/2009

58301 $99.40 General Fee Schedule 12/1/2009

58340 $145.61 General Fee Schedule 12/1/2009

58345 $277.19 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 120 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

58346 $414.05 General Fee Schedule 12/1/2009

58350 $94.14 General Fee Schedule 12/1/2009

58353 $1,376.20 General Fee Schedule 12/1/2009

58356 $2,383.15 General Fee Schedule 12/1/2009

58400 $405.91 General Fee Schedule 12/1/2009

58410 $761.51 General Fee Schedule 12/1/2009

58520 $717.24 General Fee Schedule 12/1/2009

58540 $864.43 General Fee Schedule 12/1/2009

58541 $699.52 General Fee Schedule 12/1/2009

58542 $774.63 General Fee Schedule 12/1/2009

58543 $787.80 General Fee Schedule 12/1/2009

58544 $853.20 General Fee Schedule 12/1/2009

58545 $870.42 General Fee Schedule 12/1/2009

58546 $1,117.75 General Fee Schedule 12/1/2009

58548 $1,491.22 General Fee Schedule 12/1/2009

58550 $856.63 General Fee Schedule 12/1/2009

58552 $951.14 General Fee Schedule 12/1/2009

58553 $1,117.75 General Fee Schedule 12/1/2009

58554 $1,283.17 General Fee Schedule 12/1/2009

58555 $217.68 General Fee Schedule 12/1/2009

58558 $277.28 General Fee Schedule 12/1/2009

58559 $357.13 General Fee Schedule 12/1/2009

58560 $404.62 General Fee Schedule 12/1/2009

58561 $574.28 General Fee Schedule 12/1/2009

58562 $303.28 General Fee Schedule 12/1/2009

58563 $2,192.59 General Fee Schedule 12/1/2009

58565 $2,013.64 General Fee Schedule 12/1/2009

58570 $694.72 General Fee Schedule 12/1/2009

58571 $759.91 General Fee Schedule 12/1/2009

58572 $863.41 General Fee Schedule 12/1/2009

58573 $972.02 General Fee Schedule 12/1/2009

58578 $0.00 General by Report 1/1/2000

58579 $0.00 General by Report 1/1/2000

58600 $352.92 General Fee Schedule 12/1/2009

58605 $319.81 General Fee Schedule 12/1/2009

58615 $259.16 General Fee Schedule 12/1/2009

58660 $663.80 General Fee Schedule 12/1/2009

58661 $647.68 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 121 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

58662 $702.28 General Fee Schedule 12/1/2009

58670 $351.21 General Fee Schedule 12/1/2009

58671 $351.56 General Fee Schedule 12/1/2009

58672 $763.91 General Fee Schedule 12/1/2009

58673 $813.58 General Fee Schedule 12/1/2009

58679 $0.00 General by Report 1/1/2000

58700 $721.92 General Fee Schedule 12/1/2009

58720 $683.97 General Fee Schedule 12/1/2009

58740 $843.48 General Fee Schedule 12/1/2009

58760 $798.28 General Fee Schedule 12/1/2009

58770 $835.14 General Fee Schedule 12/1/2009

58800 $299.24 General Fee Schedule 12/1/2009

58805 $370.58 General Fee Schedule 12/1/2009

58820 $293.45 General Fee Schedule 12/1/2009

58822 $609.37 General Fee Schedule 12/1/2009

58825 $667.55 General Fee Schedule 12/1/2009

58900 $377.22 General Fee Schedule 12/1/2009

58920 $678.50 General Fee Schedule 12/1/2009

58925 $681.57 General Fee Schedule 12/1/2009

58940 $453.15 General Fee Schedule 12/1/2009

58943 $1,083.74 General Fee Schedule 12/1/2009

58950 $1,011.07 General Fee Schedule 12/1/2009

58951 $1,311.99 General Fee Schedule 12/1/2009

58952 $1,471.45 General Fee Schedule 12/1/2009

58953 $1,864.71 General Fee Schedule 12/1/2009

58954 $2,032.31 General Fee Schedule 12/1/2009

58956 $1,294.27 General Fee Schedule 12/1/2009

58957 $1,207.88 General Fee Schedule 12/1/2009

58958 $1,337.75 General Fee Schedule 12/1/2009

58960 $878.87 General Fee Schedule 12/1/2009

58999 $0.00 General by Report 7/1/1975

59000 $132.10 General Fee Schedule 12/1/2009

59001 $188.60 General Fee Schedule 12/1/2009

59012 $213.84 General Fee Schedule 12/1/2009

59015 $155.96 General Fee Schedule 12/1/2009

59020 $61.16 General Fee Schedule 12/1/2009

59020 $21.25 TC Fee Schedule 12/1/2009

59020 $39.91 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 122 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

59025 $40.70 General Fee Schedule 12/1/2009

59025 $32.14 26 Fee Schedule (FS) 12/1/2009

59025 $8.57 TC Fee Schedule 12/1/2009

59030 $119.41 General Fee Schedule 12/1/2009

59050 $53.59 General Fee Schedule 12/1/2009

59051 $44.37 General Fee Schedule 12/1/2009

59070 $388.59 General Fee Schedule 12/1/2009

59072 $459.69 General Fee Schedule 12/1/2009

59074 $368.74 General Fee Schedule 12/1/2009

59076 $459.69 General Fee Schedule 12/1/2009

59100 $799.00 General Fee Schedule 12/1/2009

59120 $751.01 General Fee Schedule 12/1/2009

59121 $762.78 General Fee Schedule 12/1/2009

59130 $829.20 General Fee Schedule 12/1/2009

59135 $896.85 General Fee Schedule 12/1/2009

59136 $842.74 General Fee Schedule 12/1/2009

59140 $330.93 General Fee Schedule 12/1/2009

59150 $751.48 General Fee Schedule 12/1/2009

59151 $744.85 General Fee Schedule 12/1/2009

59160 $239.70 General Fee Schedule 12/1/2009

59200 $77.80 General Fee Schedule 12/1/2009

59300 $187.36 General Fee Schedule 12/1/2009

59320 $158.56 General Fee Schedule 12/1/2009

59325 $252.16 General Fee Schedule 12/1/2009

59350 $295.45 General Fee Schedule 12/1/2009

59400 $1,909.67 General Fee Schedule 12/1/2009

59409 $968.26 General Fee Schedule 12/1/2009

59410 $1,080.18 General Fee Schedule 12/1/2009

59412 $128.04 General Fee Schedule 12/1/2009

59414 $115.70 General Fee Schedule 12/1/2009

59425 $368.78 General Fee Schedule 12/1/2009

59426 $646.10 General Fee Schedule 12/1/2009

59430 $141.60 General Fee Schedule 12/1/2009

59510 $0.00 General Fee Schedule U1 $2,164.73 11/1/2013

59514 $0.00 General Fee Schedule 11/1/2013

59515 $0.00 General Fee Schedule 11/1/2013

59525 $509.59 General Fee Schedule 12/1/2009

59610 $2,018.52 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 123 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

59612 $1,085.73 General Fee Schedule 12/1/2009

59614 $1,192.75 General Fee Schedule 12/1/2009

59618 $2,290.75 General Fee Schedule 12/1/2009

59620 $1,251.57 General Fee Schedule 12/1/2009

59622 $1,406.09 General Fee Schedule 12/1/2009

59812 $274.52 General Fee Schedule 12/1/2009

59820 $338.89 General Fee Schedule 12/1/2009

59821 $355.30 General Fee Schedule 12/1/2009

59830 $421.80 General Fee Schedule 12/1/2009

59840 $213.49 General Fee Schedule 12/1/2009

59841 $364.29 General Fee Schedule 12/1/2009

59850 $383.31 General Fee Schedule 12/1/2009

59851 $400.84 General Fee Schedule 12/1/2009

59852 $552.37 General Fee Schedule 12/1/2009

59855 $407.19 General Fee Schedule 12/1/2009

59856 $489.16 General Fee Schedule 12/1/2009

59857 $589.24 General Fee Schedule 12/1/2009

59870 $434.37 General Fee Schedule 12/1/2009

59871 $159.41 General Fee Schedule 12/1/2009

59897 $0.00 Manual Review Fee Schedule 7/1/2004

59898 $0.00 General by Report 1/1/2000

59899 $0.00 General by Report 1/1/1991

60000 $139.19 General Fee Schedule 12/1/2009

60100 $111.60 General Fee Schedule 12/1/2009

60200 $608.54 General Fee Schedule 12/1/2009

60210 $655.11 General Fee Schedule 12/1/2009

60212 $948.26 General Fee Schedule 12/1/2009

60220 $715.05 General Fee Schedule 12/1/2009

60225 $857.64 General Fee Schedule 12/1/2009

60240 $943.24 General Fee Schedule 12/1/2009

60252 $1,218.40 General Fee Schedule 12/1/2009

60254 $1,615.54 General Fee Schedule 12/1/2009

60260 $1,036.67 General Fee Schedule 12/1/2009

60270 $1,220.18 General Fee Schedule 12/1/2009

60271 $1,003.01 General Fee Schedule 12/1/2009

60280 $404.73 General Fee Schedule 12/1/2009

60281 $554.37 General Fee Schedule 12/1/2009

60300 $78.61 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 124 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

60500 $948.82 General Fee Schedule 12/1/2009

60502 $1,192.87 General Fee Schedule 12/1/2009

60505 $1,294.43 General Fee Schedule 12/1/2009

60512 $245.16 General Fee Schedule 12/1/2009

60520 $1,007.85 General Fee Schedule 12/1/2009

60521 $1,151.92 General Fee Schedule 12/1/2009

60522 $1,389.23 General Fee Schedule 12/1/2009

60540 $976.49 General Fee Schedule 12/1/2009

60545 $1,130.42 General Fee Schedule 12/1/2009

60600 $1,142.83 General Fee Schedule 12/1/2009

60605 $1,286.86 General Fee Schedule 12/1/2009

60650 $1,123.47 General Fee Schedule 12/1/2009

60659 $0.00 General by Report 1/1/2000

60699 $0.00 General by Report 7/1/1975

61000 $98.00 General Fee Schedule 12/1/2009

61001 $99.34 General Fee Schedule 12/1/2009

61020 $115.91 General Fee Schedule 12/1/2009

61026 $124.22 General Fee Schedule 12/1/2009

61050 $105.57 General Fee Schedule 12/1/2009

61055 $135.54 General Fee Schedule 12/1/2009

61070 $74.81 General Fee Schedule 12/1/2009

61105 $378.50 General Fee Schedule 12/1/2009

61107 $324.14 General Fee Schedule 12/1/2009

61108 $728.55 General Fee Schedule 12/1/2009

61120 $615.71 General Fee Schedule 12/1/2009

61140 $1,094.22 General Fee Schedule 12/1/2009

61150 $1,181.98 General Fee Schedule 12/1/2009

61151 $850.33 General Fee Schedule 12/1/2009

61154 $1,048.50 General Fee Schedule 12/1/2009

61156 $1,112.52 General Fee Schedule 12/1/2009

61210 $376.83 General Fee Schedule 12/1/2009

61215 $369.17 General Fee Schedule 12/1/2009

61250 $731.97 General Fee Schedule 12/1/2009

61253 $831.46 General Fee Schedule 12/1/2009

61304 $1,480.90 General Fee Schedule 12/1/2009

61305 $1,760.79 General Fee Schedule 12/1/2009

61312 $1,682.14 General Fee Schedule 12/1/2009

61313 $1,690.92 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 125 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

61314 $1,597.43 General Fee Schedule 12/1/2009

61315 $1,863.37 General Fee Schedule 12/1/2009

61316 $86.29 General Fee Schedule 12/1/2009

61320 $1,721.72 General Fee Schedule 12/1/2009

61321 $1,898.10 General Fee Schedule 12/1/2009

61322 $1,937.87 General Fee Schedule 12/1/2009

61323 $2,023.58 General Fee Schedule 12/1/2009

61330 $1,449.87 General Fee Schedule 12/1/2009

61332 $1,753.40 General Fee Schedule 12/1/2009

61333 $1,747.14 General Fee Schedule 12/1/2009

61334 $1,129.11 General Fee Schedule 12/1/2009

61340 $1,267.68 General Fee Schedule 12/1/2009

61343 $1,987.67 General Fee Schedule 12/1/2009

61345 $1,819.12 General Fee Schedule 12/1/2009

61440 $1,751.55 General Fee Schedule 12/1/2009

61450 $1,689.69 General Fee Schedule 12/1/2009

61458 $1,826.36 General Fee Schedule 12/1/2009

61460 $1,865.78 General Fee Schedule 12/1/2009

61470 $1,683.02 General Fee Schedule 12/1/2009

61480 $1,776.90 General Fee Schedule 12/1/2009

61490 $1,718.90 General Fee Schedule 12/1/2009

61500 $1,202.96 General Fee Schedule 12/1/2009

61501 $998.94 General Fee Schedule 12/1/2009

61510 $1,922.94 General Fee Schedule 12/1/2009

61512 $2,340.63 General Fee Schedule 12/1/2009

61514 $1,694.11 General Fee Schedule 12/1/2009

61516 $1,656.63 General Fee Schedule 12/1/2009

61517 $87.26 General Fee Schedule 12/1/2009

61518 $2,494.63 General Fee Schedule 12/1/2009

61519 $2,738.99 General Fee Schedule 12/1/2009

61520 $3,541.03 General Fee Schedule 12/1/2009

61521 $2,937.88 General Fee Schedule 12/1/2009

61522 $1,961.27 General Fee Schedule 12/1/2009

61524 $1,858.34 General Fee Schedule 12/1/2009

61526 $3,266.53 General Fee Schedule 12/1/2009

61530 $2,762.03 General Fee Schedule 12/1/2009

61531 $1,007.77 General Fee Schedule 12/1/2009

61533 $1,331.59 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 126 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

61534 $1,410.45 General Fee Schedule 12/1/2009

61535 $806.84 General Fee Schedule 12/1/2009

61536 $2,365.49 General Fee Schedule 12/1/2009

61537 $1,708.50 General Fee Schedule 12/1/2009

61538 $1,797.88 General Fee Schedule 12/1/2009

61539 $2,132.80 General Fee Schedule 12/1/2009

61540 $2,035.11 General Fee Schedule 12/1/2009

61541 $1,895.68 General Fee Schedule 12/1/2009

61542 $2,083.92 General Fee Schedule 12/1/2009

61543 $1,949.29 General Fee Schedule 12/1/2009

61544 $1,662.79 General Fee Schedule 12/1/2009

61545 $2,885.38 General Fee Schedule 12/1/2009

61546 $2,071.00 General Fee Schedule 12/1/2009

61548 $1,386.94 General Fee Schedule 12/1/2009

61550 $836.51 General Fee Schedule 12/1/2009

61552 $1,103.38 General Fee Schedule 12/1/2009

61556 $1,408.30 General Fee Schedule 12/1/2009

61557 $1,530.03 General Fee Schedule 12/1/2009

61558 $1,519.98 General Fee Schedule 12/1/2009

61559 $2,219.85 General Fee Schedule 12/1/2009

61563 $1,735.11 General Fee Schedule 12/1/2009

61564 $2,233.71 General Fee Schedule 12/1/2009

61566 $2,043.78 General Fee Schedule 12/1/2009

61567 $2,303.28 General Fee Schedule 12/1/2009

61570 $1,628.02 General Fee Schedule 12/1/2009

61571 $1,770.67 General Fee Schedule 12/1/2009

61575 $2,182.23 General Fee Schedule 12/1/2009

61576 $3,405.19 General Fee Schedule 12/1/2009

61580 $2,163.79 General Fee Schedule 12/1/2009

61581 $2,273.56 General Fee Schedule 12/1/2009

61582 $2,405.89 General Fee Schedule 12/1/2009

61583 $2,574.94 General Fee Schedule 12/1/2009

61584 $2,459.29 General Fee Schedule 12/1/2009

61585 $2,639.82 General Fee Schedule 12/1/2009

61586 $1,893.37 General Fee Schedule 12/1/2009

61590 $2,775.67 General Fee Schedule 12/1/2009

61591 $2,891.88 General Fee Schedule 12/1/2009

61592 $2,784.59 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 127 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

61595 $2,044.21 General Fee Schedule 12/1/2009

61596 $2,329.59 General Fee Schedule 12/1/2009

61597 $2,556.75 General Fee Schedule 12/1/2009

61598 $2,281.60 General Fee Schedule 12/1/2009

61600 $1,805.73 General Fee Schedule 12/1/2009

61601 $2,006.89 General Fee Schedule 12/1/2009

61605 $1,982.90 General Fee Schedule 12/1/2009

61606 $2,668.76 General Fee Schedule 12/1/2009

61607 $2,452.27 General Fee Schedule 12/1/2009

61608 $2,905.77 General Fee Schedule 12/1/2009

61609 $635.84 General Fee Schedule 12/1/2009

61610 $1,859.54 General Fee Schedule 12/1/2009

61611 $482.09 General Fee Schedule 12/1/2009

61612 $1,680.20 General Fee Schedule 12/1/2009

61613 $2,767.50 General Fee Schedule 12/1/2009

61615 $2,179.24 General Fee Schedule 12/1/2009

61616 $2,938.44 General Fee Schedule 12/1/2009

61618 $1,141.26 General Fee Schedule 12/1/2009

61619 $1,354.76 General Fee Schedule 12/1/2009

61623 $560.36 General Fee Schedule 12/1/2009

61624 $1,080.55 General Fee Schedule 12/1/2009

61626 $872.90 General Fee Schedule 12/1/2009

61630 $1,272.47 General Fee Schedule 1/1/2011

61635 $1,332.95 General Fee Schedule 1/1/2011

61640 $0.00 General by Report 1/1/2006

61641 $0.00 General by Report 1/1/2006

61642 $0.00 General by Report 1/1/2006

61680 $2,055.85 General Fee Schedule 12/1/2009

61682 $4,026.45 General Fee Schedule 12/1/2009

61684 $2,644.69 General Fee Schedule 12/1/2009

61686 $4,253.03 General Fee Schedule 12/1/2009

61690 $1,943.00 General Fee Schedule 12/1/2009

61692 $3,404.82 General Fee Schedule 12/1/2009

61697 $3,351.16 General Fee Schedule 12/1/2009

61698 $3,214.20 General Fee Schedule 12/1/2009

61700 $3,349.85 General Fee Schedule 12/1/2009

61702 $3,131.50 General Fee Schedule 12/1/2009

61703 $1,172.22 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 128 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

61705 $2,361.84 General Fee Schedule 12/1/2009

61708 $1,967.03 General Fee Schedule 12/1/2009

61710 $1,767.84 General Fee Schedule 12/1/2009

61711 $2,404.69 General Fee Schedule 12/1/2009

61720 $1,084.55 General Fee Schedule 12/1/2009

61735 $1,299.06 General Fee Schedule 12/1/2009

61750 $1,228.33 General Fee Schedule 12/1/2009

61751 $1,207.60 General Fee Schedule 12/1/2009

61760 $1,344.21 General Fee Schedule 12/1/2009

61770 $1,369.47 General Fee Schedule 12/1/2009

61781 $240.71 General Fee Schedule 1/1/2011

61782 $197.12 General Fee Schedule 1/1/2011

61783 $240.71 General Fee Schedule 1/1/2011

61790 $718.51 General Fee Schedule 12/1/2009

61791 $986.34 General Fee Schedule 12/1/2009

61796 $692.00 General Fee Schedule 12/1/2009

61797 $191.08 General Fee Schedule 12/1/2009

61798 $692.00 General Fee Schedule 12/1/2009

61799 $264.22 General Fee Schedule 12/1/2009

61800 $135.13 General Fee Schedule 12/1/2009

61850 $851.64 General Fee Schedule 12/1/2009

61860 $1,388.98 General Fee Schedule 12/1/2009

61863 $1,323.10 General Fee Schedule 12/1/2009

61864 $438.60 General Fee Schedule 12/1/2009

61867 $2,013.31 General Fee Schedule 12/1/2009

61868 $629.84 General Fee Schedule 12/1/2009

61870 $1,042.36 General Fee Schedule 12/1/2009

61875 $976.18 General Fee Schedule 12/1/2009

61880 $456.55 General Fee Schedule 12/1/2009

61885 $462.48 General Fee Schedule 12/1/2009

61886 $594.20 General Fee Schedule 12/1/2009

61888 $367.25 General Fee Schedule 12/1/2009

62000 $708.82 General Fee Schedule 12/1/2009

62005 $1,058.68 General Fee Schedule 12/1/2009

62010 $1,342.31 General Fee Schedule 12/1/2009

62100 $1,454.95 General Fee Schedule 12/1/2009

62115 $1,424.09 General Fee Schedule 12/1/2009

62116 $1,578.15 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 129 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

62117 $1,708.92 General Fee Schedule 12/1/2009

62120 $1,637.43 General Fee Schedule 12/1/2009

62121 $1,505.84 General Fee Schedule 12/1/2009

62140 $925.76 General Fee Schedule 12/1/2009

62141 $1,014.81 General Fee Schedule 12/1/2009

62142 $749.67 General Fee Schedule 12/1/2009

62143 $894.97 General Fee Schedule 12/1/2009

62145 $1,254.24 General Fee Schedule 12/1/2009

62146 $1,076.88 General Fee Schedule 12/1/2009

62147 $1,282.14 General Fee Schedule 12/1/2009

62148 $123.22 General Fee Schedule 12/1/2009

62160 $194.78 General Fee Schedule 12/1/2009

62161 $1,364.71 General Fee Schedule 12/1/2009

62162 $1,686.34 General Fee Schedule 12/1/2009

62163 $1,076.35 General Fee Schedule 12/1/2009

62164 $1,758.30 General Fee Schedule 12/1/2009

62165 $1,411.11 General Fee Schedule 12/1/2009

62180 $1,405.23 General Fee Schedule 12/1/2009

62190 $765.98 General Fee Schedule 12/1/2009

62192 $837.61 General Fee Schedule 12/1/2009

62194 $309.08 General Fee Schedule 12/1/2009

62200 $1,238.42 General Fee Schedule 12/1/2009

62201 $1,023.81 General Fee Schedule 12/1/2009

62220 $890.30 General Fee Schedule 12/1/2009

62223 $886.92 General Fee Schedule 12/1/2009

62225 $396.82 General Fee Schedule 12/1/2009

62230 $721.87 General Fee Schedule 12/1/2009

62252 $86.15 General Fee Schedule 12/1/2009

62252 $38.34 TC Fee Schedule 12/1/2009

62252 $47.80 26 Fee Schedule (FS) 12/1/2009

62256 $474.36 General Fee Schedule 12/1/2009

62258 $988.54 General Fee Schedule 12/1/2009

62263 $686.61 General Fee Schedule 12/1/2009

62264 $445.27 General Fee Schedule 12/1/2009

62267 $219.02 General Fee Schedule 12/1/2009

62268 $593.20 General Fee Schedule 12/1/2009

62269 $710.13 General Fee Schedule 12/1/2009

62270 $149.09 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 130 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

62272 $182.26 General Fee Schedule 12/1/2009

62273 $180.60 General Fee Schedule 12/1/2009

62280 $349.82 General Fee Schedule 12/1/2009

62281 $303.36 General Fee Schedule 12/1/2009

62282 $382.71 General Fee Schedule 12/1/2009

62284 $234.09 General Fee Schedule 12/1/2009

62287 $522.23 General Fee Schedule 12/1/2009

62290 $368.53 General Fee Schedule 12/1/2009

62291 $325.02 General Fee Schedule 12/1/2009

62292 $484.71 General Fee Schedule 12/1/2009

62294 $690.41 General Fee Schedule 12/1/2009

62310 $242.89 General Fee Schedule 12/1/2009

62311 $231.35 General Fee Schedule 12/1/2009

62318 $279.41 General Fee Schedule 12/1/2009

62319 $246.83 General Fee Schedule 12/1/2009

62350 $435.26 General Fee Schedule 12/1/2009

62351 $707.43 General Fee Schedule 12/1/2009

62355 $343.03 General Fee Schedule 12/1/2009

62360 $204.97 General Fee Schedule 12/1/2009

62361 $371.01 General Fee Schedule 12/1/2009

62362 $461.73 General Fee Schedule 12/1/2009

62365 $361.43 General Fee Schedule 12/1/2009

62367 $40.45 General Fee Schedule 12/1/2009

62368 $54.64 General Fee Schedule 12/1/2009

62369 $116.14 General Fee Schedule 2/6/2012

62370 $122.15 General Fee Schedule 2/6/2012

63001 $1,066.37 General Fee Schedule 12/1/2009

63003 $1,082.00 General Fee Schedule 12/1/2009

63005 $1,032.88 General Fee Schedule 12/1/2009

63011 $959.92 General Fee Schedule 12/1/2009

63012 $1,061.36 General Fee Schedule 12/1/2009

63015 $1,317.24 General Fee Schedule 12/1/2009

63016 $1,302.49 General Fee Schedule 12/1/2009

63017 $1,096.64 General Fee Schedule 12/1/2009

63020 $1,031.14 General Fee Schedule 12/1/2009

63030 $855.01 General Fee Schedule 12/1/2009

63035 $203.31 General Fee Schedule 12/1/2009

63040 $1,280.97 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 131 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

63042 $1,209.25 General Fee Schedule 12/1/2009

63043 $202.53 General Fee Schedule 12/1/2009

63044 $202.53 General Fee Schedule 12/1/2009

63045 $1,128.97 General Fee Schedule 12/1/2009

63046 $1,081.28 General Fee Schedule 12/1/2009

63047 $1,014.37 General Fee Schedule 12/1/2009

63048 $207.54 General Fee Schedule 12/1/2009

63050 $1,368.29 General Fee Schedule 12/1/2009

63051 $1,559.54 General Fee Schedule 12/1/2009

63055 $1,480.58 General Fee Schedule 12/1/2009

63056 $1,380.19 General Fee Schedule 12/1/2009

63057 $335.17 General Fee Schedule 12/1/2009

63064 $1,640.00 General Fee Schedule 12/1/2009

63066 $206.50 General Fee Schedule 12/1/2009

63075 $1,322.60 General Fee Schedule 12/1/2009

63076 $259.63 General Fee Schedule 12/1/2009

63077 $1,403.14 General Fee Schedule 12/1/2009

63078 $205.55 General Fee Schedule 12/1/2009

63081 $1,597.43 General Fee Schedule 12/1/2009

63082 $279.87 General Fee Schedule 12/1/2009

63085 $1,723.31 General Fee Schedule 12/1/2009

63086 $197.95 General Fee Schedule 12/1/2009

63087 $2,253.16 General Fee Schedule 12/1/2009

63088 $269.71 General Fee Schedule 12/1/2009

63090 $1,781.36 General Fee Schedule 12/1/2009

63091 $183.52 General Fee Schedule 12/1/2009

63101 $2,091.59 General Fee Schedule 12/1/2009

63102 $2,091.59 General Fee Schedule 12/1/2009

63103 $295.81 General Fee Schedule 12/1/2009

63170 $1,339.23 General Fee Schedule 12/1/2009

63172 $1,200.57 General Fee Schedule 12/1/2009

63173 $1,483.45 General Fee Schedule 12/1/2009

63180 $1,217.45 General Fee Schedule 12/1/2009

63182 $1,349.12 General Fee Schedule 12/1/2009

63185 $953.79 General Fee Schedule 12/1/2009

63190 $1,132.16 General Fee Schedule 12/1/2009

63191 $1,254.37 General Fee Schedule 12/1/2009

63194 $1,254.11 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 132 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

63195 $1,273.28 General Fee Schedule 12/1/2009

63196 $1,518.03 General Fee Schedule 12/1/2009

63197 $1,417.89 General Fee Schedule 12/1/2009

63198 $1,489.51 General Fee Schedule 12/1/2009

63199 $1,600.68 General Fee Schedule 12/1/2009

63200 $1,298.06 General Fee Schedule 12/1/2009

63250 $2,566.27 General Fee Schedule 12/1/2009

63251 $2,723.03 General Fee Schedule 12/1/2009

63252 $2,718.26 General Fee Schedule 12/1/2009

63265 $1,456.84 General Fee Schedule 12/1/2009

63266 $1,503.25 General Fee Schedule 12/1/2009

63267 $1,222.68 General Fee Schedule 12/1/2009

63268 $1,196.88 General Fee Schedule 12/1/2009

63270 $1,799.17 General Fee Schedule 12/1/2009

63271 $1,810.33 General Fee Schedule 12/1/2009

63272 $1,693.23 General Fee Schedule 12/1/2009

63273 $1,626.29 General Fee Schedule 12/1/2009

63275 $1,585.31 General Fee Schedule 12/1/2009

63276 $1,574.39 General Fee Schedule 12/1/2009

63277 $1,405.60 General Fee Schedule 12/1/2009

63278 $1,374.83 General Fee Schedule 12/1/2009

63280 $1,903.64 General Fee Schedule 12/1/2009

63281 $1,883.82 General Fee Schedule 12/1/2009

63282 $1,776.48 General Fee Schedule 12/1/2009

63283 $1,682.62 General Fee Schedule 12/1/2009

63285 $2,389.15 General Fee Schedule 12/1/2009

63286 $2,374.53 General Fee Schedule 12/1/2009

63287 $2,439.47 General Fee Schedule 12/1/2009

63290 $2,458.75 General Fee Schedule 12/1/2009

63295 $311.84 General Fee Schedule 12/1/2009

63300 $1,638.28 General Fee Schedule 12/1/2009

63301 $1,783.73 General Fee Schedule 12/1/2009

63302 $1,806.95 General Fee Schedule 12/1/2009

63303 $1,917.31 General Fee Schedule 12/1/2009

63304 $1,982.84 General Fee Schedule 12/1/2009

63305 $2,050.99 General Fee Schedule 12/1/2009

63306 $2,140.27 General Fee Schedule 12/1/2009

63307 $1,949.90 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 133 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

63308 $336.17 General Fee Schedule 12/1/2009

63600 $778.11 General Fee Schedule 12/1/2009

63610 $2,415.38 General Fee Schedule 12/1/2009

63615 $1,043.79 General Fee Schedule 12/1/2009

63620 $692.00 General Fee Schedule 12/1/2009

63621 $219.71 General Fee Schedule 12/1/2009

63650 $386.95 General Fee Schedule 12/1/2009

63655 $716.94 General Fee Schedule 12/1/2009

63661 $491.24 General Fee Schedule 1/1/2010

63662 $652.20 General Fee Schedule 1/1/2010

63663 $733.87 General Fee Schedule 1/1/2010

63664 $679.58 General Fee Schedule 1/1/2010

63685 $449.71 General Fee Schedule 12/1/2009

63688 $360.30 General Fee Schedule 12/1/2009

63700 $1,112.53 General Fee Schedule 12/1/2009

63702 $1,233.13 General Fee Schedule 12/1/2009

63704 $1,417.60 General Fee Schedule 12/1/2009

63706 $1,610.25 General Fee Schedule 12/1/2009

63707 $784.87 General Fee Schedule 12/1/2009

63709 $981.22 General Fee Schedule 12/1/2009

63710 $969.95 General Fee Schedule 12/1/2009

63740 $790.92 General Fee Schedule 12/1/2009

63741 $538.37 General Fee Schedule 12/1/2009

63744 $557.98 General Fee Schedule 12/1/2009

63746 $430.07 General Fee Schedule 12/1/2009

64400 $110.32 General Fee Schedule 12/1/2009

64402 $106.48 General Fee Schedule 12/1/2009

64405 $103.70 General Fee Schedule 12/1/2009

64408 $111.98 General Fee Schedule 12/1/2009

64410 $144.24 General Fee Schedule 12/1/2009

64412 $139.38 General Fee Schedule 12/1/2009

64413 $120.14 General Fee Schedule 12/1/2009

64415 $156.44 General Fee Schedule 12/1/2009

64416 $172.47 General Fee Schedule 12/1/2009

64417 $163.45 General Fee Schedule 12/1/2009

64418 $143.41 General Fee Schedule 12/1/2009

64420 $181.50 General Fee Schedule 12/1/2009

64421 $277.49 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 134 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

64425 $128.53 General Fee Schedule 12/1/2009

64430 $146.08 General Fee Schedule 12/1/2009

64435 $148.11 General Fee Schedule 12/1/2009

64445 $152.34 General Fee Schedule 12/1/2009

64446 $166.60 General Fee Schedule 12/1/2009

64447 $75.73 General Fee Schedule 12/1/2009

64448 $149.75 General Fee Schedule 12/1/2009

64449 $153.84 General Fee Schedule 12/1/2009

64450 $95.96 General Fee Schedule 12/1/2009

64455 $45.88 General Fee Schedule 12/1/2009

64479 $346.17 General Fee Schedule 12/1/2009

64480 $160.48 General Fee Schedule 12/1/2009

64483 $347.95 General Fee Schedule 12/1/2009

64484 $166.74 General Fee Schedule 12/1/2009

64490 $168.35 General Fee Schedule 1/1/2010

64491 $85.72 General Fee Schedule 1/1/2010

64492 $86.68 General Fee Schedule 1/1/2010

64493 $150.21 General Fee Schedule 1/1/2010

64494 $77.70 General Fee Schedule 1/1/2010

64495 $78.67 General Fee Schedule 1/1/2010

64505 $98.41 General Fee Schedule 12/1/2009

64508 $159.66 General Fee Schedule 12/1/2009

64510 $167.97 General Fee Schedule 12/1/2009

64517 $182.18 General Fee Schedule 12/1/2009

64520 $231.19 General Fee Schedule 12/1/2009

64530 $217.13 General Fee Schedule 12/1/2009

64550 $13.63 General Fee Schedule 7/1/2009

64553 $176.53 General Fee Schedule 7/1/2009

64555 $186.72 General Fee Schedule 7/1/2009

64561 $982.62 General Fee Schedule 7/1/2009

64565 $147.02 General Fee Schedule 7/1/2009

64566 $123.53 General Fee Schedule 1/1/2011

64568 $628.55 General Fee Schedule 1/1/2011

64569 $631.37 General Fee Schedule 1/1/2011

64570 $556.60 General Fee Schedule 1/1/2011

64575 $253.70 General Fee Schedule 10/1/2009

64580 $260.81 General Fee Schedule 7/1/2009

64581 $763.38 General Fee Schedule 7/1/2009

Tuesday, February 11, 2014 Page 135 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

64585 $276.60 General Fee Schedule 12/1/2009

64590 $261.33 General Fee Schedule 12/1/2009

64595 $267.16 General Fee Schedule 12/1/2009

64600 $465.67 General Fee Schedule 12/1/2009

64605 $571.43 General Fee Schedule 12/1/2009

64610 $634.93 General Fee Schedule 12/1/2009

64611 $97.83 General Fee Schedule 1/1/2011

64612 $164.71 General Fee Schedule 12/1/2009

64615 $138.77 General Fee Schedule 2/23/2013

64616 $121.42 General Fee Schedule 1/1/2014

64617 $184.49 General Fee Schedule 1/1/2014

64620 $290.11 General Fee Schedule 12/1/2009

64630 $217.20 General Fee Schedule 12/1/2009

64632 $73.48 General Fee Schedule 12/1/2009

64633 $426.25 General Fee Schedule 2/6/2012

64634 $193.95 General Fee Schedule 2/6/2012

64635 $418.88 General Fee Schedule 2/6/2012

64636 $174.42 General Fee Schedule 2/6/2012

64640 $260.00 General Fee Schedule 12/1/2009

64642 $136.53 General Fee Schedule 1/1/2014

64643 $90.35 General Fee Schedule 1/1/2014

64644 $155.56 General Fee Schedule 1/1/2014

64645 $110.16 General Fee Schedule 1/1/2014

64646 $146.95 General Fee Schedule 1/1/2014

64647 $170.19 General Fee Schedule 1/1/2014

64650 $58.88 General Fee Schedule 12/1/2009

64653 $68.23 General Fee Schedule 12/1/2009

64680 $337.76 General Fee Schedule 12/1/2009

64681 $465.41 General Fee Schedule 12/1/2009

64702 $316.46 General Fee Schedule 12/1/2009

64704 $310.75 General Fee Schedule 12/1/2009

64708 $435.73 General Fee Schedule 12/1/2009

64712 $501.73 General Fee Schedule 12/1/2009

64713 $688.34 General Fee Schedule 12/1/2009

64714 $583.20 General Fee Schedule 12/1/2009

64716 $470.01 General Fee Schedule 12/1/2009

64718 $472.86 General Fee Schedule 12/1/2009

64719 $368.51 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 136 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

64721 $374.61 General Fee Schedule 12/1/2009

64722 $302.04 General Fee Schedule 12/1/2009

64726 $275.47 General Fee Schedule 12/1/2009

64727 $187.60 General Fee Schedule 12/1/2009

64732 $323.86 General Fee Schedule 12/1/2009

64734 $359.27 General Fee Schedule 12/1/2009

64736 $333.11 General Fee Schedule 12/1/2009

64738 $416.28 General Fee Schedule 12/1/2009

64740 $414.86 General Fee Schedule 12/1/2009

64742 $426.17 General Fee Schedule 12/1/2009

64744 $371.35 General Fee Schedule 12/1/2009

64746 $411.24 General Fee Schedule 12/1/2009

64752 $451.13 General Fee Schedule 12/1/2009

64755 $777.74 General Fee Schedule 12/1/2009

64760 $414.70 General Fee Schedule 12/1/2009

64761 $386.20 General Fee Schedule 12/1/2009

64763 $477.95 General Fee Schedule 12/1/2009

64766 $550.97 General Fee Schedule 12/1/2009

64771 $516.51 General Fee Schedule 12/1/2009

64772 $495.06 General Fee Schedule 12/1/2009

64774 $356.20 General Fee Schedule 12/1/2009

64776 $349.82 General Fee Schedule 12/1/2009

64778 $187.29 General Fee Schedule 12/1/2009

64782 $399.21 General Fee Schedule 12/1/2009

64783 $223.82 General Fee Schedule 12/1/2009

64784 $652.64 General Fee Schedule 12/1/2009

64786 $1,023.36 General Fee Schedule 12/1/2009

64787 $258.54 General Fee Schedule 12/1/2009

64788 $321.57 General Fee Schedule 12/1/2009

64790 $755.51 General Fee Schedule 12/1/2009

64792 $963.78 General Fee Schedule 12/1/2009

64795 $187.56 General Fee Schedule 12/1/2009

64802 $573.34 General Fee Schedule 12/1/2009

64804 $884.06 General Fee Schedule 12/1/2009

64809 $776.57 General Fee Schedule 12/1/2009

64818 $624.20 General Fee Schedule 12/1/2009

64820 $695.42 General Fee Schedule 12/1/2009

64821 $632.17 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 137 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

64822 $630.48 General Fee Schedule 12/1/2009

64823 $732.76 General Fee Schedule 12/1/2009

64831 $655.44 General Fee Schedule 12/1/2009

64832 $348.10 General Fee Schedule 12/1/2009

64834 $689.17 General Fee Schedule 12/1/2009

64835 $745.22 General Fee Schedule 12/1/2009

64836 $742.13 General Fee Schedule 12/1/2009

64837 $385.67 General Fee Schedule 12/1/2009

64840 $832.25 General Fee Schedule 12/1/2009

64856 $920.45 General Fee Schedule 12/1/2009

64857 $965.60 General Fee Schedule 12/1/2009

64858 $1,120.51 General Fee Schedule 12/1/2009

64859 $262.51 General Fee Schedule 12/1/2009

64861 $1,286.42 General Fee Schedule 12/1/2009

64862 $1,307.56 General Fee Schedule 12/1/2009

64864 $828.11 General Fee Schedule 12/1/2009

64865 $1,103.55 General Fee Schedule 12/1/2009

64866 $1,129.17 General Fee Schedule 12/1/2009

64868 $982.90 General Fee Schedule 12/1/2009

64870 $960.90 General Fee Schedule 12/1/2009

64872 $123.81 General Fee Schedule 12/1/2009

64874 $181.91 General Fee Schedule 12/1/2009

64876 $206.22 General Fee Schedule 12/1/2009

64885 $1,129.96 General Fee Schedule 12/1/2009

64886 $1,336.55 General Fee Schedule 12/1/2009

64890 $1,006.16 General Fee Schedule 12/1/2009

64891 $938.72 General Fee Schedule 12/1/2009

64892 $954.39 General Fee Schedule 12/1/2009

64893 $1,030.13 General Fee Schedule 12/1/2009

64895 $1,162.06 General Fee Schedule 12/1/2009

64896 $1,275.84 General Fee Schedule 12/1/2009

64897 $1,157.65 General Fee Schedule 12/1/2009

64898 $1,251.89 General Fee Schedule 12/1/2009

64901 $621.81 General Fee Schedule 12/1/2009

64902 $714.13 General Fee Schedule 12/1/2009

64905 $900.83 General Fee Schedule 12/1/2009

64907 $1,264.83 General Fee Schedule 12/1/2009

64910 $567.06 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 138 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

64911 $690.15 General Fee Schedule 12/1/2009

64999 $0.00 General by Report 7/1/1975

65091 $546.58 General Fee Schedule 12/1/2009

65093 $575.76 General Fee Schedule 12/1/2009

65101 $610.02 General Fee Schedule 12/1/2009

65103 $638.75 General Fee Schedule 12/1/2009

65105 $700.97 General Fee Schedule 12/1/2009

65110 $1,035.05 General Fee Schedule 12/1/2009

65112 $1,230.34 General Fee Schedule 12/1/2009

65114 $1,271.85 General Fee Schedule 12/1/2009

65125 $429.31 General Fee Schedule 12/1/2009

65130 $602.32 General Fee Schedule 12/1/2009

65135 $614.76 General Fee Schedule 12/1/2009

65140 $661.95 General Fee Schedule 12/1/2009

65150 $525.51 General Fee Schedule 12/1/2009

65155 $710.98 General Fee Schedule 12/1/2009

65175 $543.73 General Fee Schedule 12/1/2009

65205 $50.35 General Fee Schedule 12/1/2009

65210 $61.54 General Fee Schedule 12/1/2009

65220 $51.05 General Fee Schedule 12/1/2009

65222 $67.75 General Fee Schedule 12/1/2009

65235 $536.02 General Fee Schedule 12/1/2009

65260 $773.38 General Fee Schedule 12/1/2009

65265 $871.22 General Fee Schedule 12/1/2009

65270 $255.85 General Fee Schedule 12/1/2009

65272 $418.27 General Fee Schedule 12/1/2009

65273 $298.41 General Fee Schedule 12/1/2009

65275 $431.44 General Fee Schedule 12/1/2009

65280 $522.39 General Fee Schedule 12/1/2009

65285 $835.61 General Fee Schedule 12/1/2009

65286 $604.04 General Fee Schedule 12/1/2009

65290 $381.76 General Fee Schedule 12/1/2009

65400 $529.77 General Fee Schedule 12/1/2009

65410 $131.75 General Fee Schedule 12/1/2009

65420 $471.85 General Fee Schedule 12/1/2009

65426 $560.12 General Fee Schedule 12/1/2009

65430 $103.32 General Fee Schedule 12/1/2009

65435 $71.13 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 139 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

65436 $308.97 General Fee Schedule 12/1/2009

65450 $271.44 General Fee Schedule 12/1/2009

65600 $308.60 General Fee Schedule 12/1/2009

65710 $881.47 General Fee Schedule 12/1/2009

65730 $986.00 General Fee Schedule 12/1/2009

65750 $1,014.62 General Fee Schedule 12/1/2009

65755 $1,007.29 General Fee Schedule 12/1/2009

65756 $906.41 General Fee Schedule 12/1/2009

65757 $0.00 General by Report 1/1/2009

65760 $967.90 General Fee Schedule 12/1/2009

65765 $967.90 General Fee Schedule 12/1/2009

65767 $967.90 General Fee Schedule 12/1/2009

65770 $1,159.99 General Fee Schedule 12/1/2009

65772 $362.47 General Fee Schedule 12/1/2009

65775 $437.17 General Fee Schedule 12/1/2009

65778 $1,191.04 General Fee Schedule 1/1/2011

65779 $1,084.08 General Fee Schedule 1/1/2011

65780 $763.39 General Fee Schedule 12/1/2009

65781 $1,165.47 General Fee Schedule 12/1/2009

65782 $1,004.93 General Fee Schedule 12/1/2009

65800 $138.46 General Fee Schedule 12/1/2009

65810 $357.13 General Fee Schedule 12/1/2009

65815 $546.57 General Fee Schedule 12/1/2009

65820 $638.11 General Fee Schedule 12/1/2009

65850 $712.89 General Fee Schedule 12/1/2009

65855 $302.69 General Fee Schedule 12/1/2009

65860 $281.51 General Fee Schedule 12/1/2009

65865 $418.54 General Fee Schedule 12/1/2009

65870 $472.49 General Fee Schedule 12/1/2009

65875 $496.25 General Fee Schedule 12/1/2009

65880 $526.74 General Fee Schedule 12/1/2009

65900 $791.72 General Fee Schedule 12/1/2009

65920 $618.40 General Fee Schedule 12/1/2009

65930 $534.09 General Fee Schedule 12/1/2009

66020 $171.30 General Fee Schedule 12/1/2009

66030 $152.00 General Fee Schedule 12/1/2009

66130 $639.96 General Fee Schedule 12/1/2009

66150 $658.73 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 140 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

66155 $654.91 General Fee Schedule 12/1/2009

66160 $758.95 General Fee Schedule 12/1/2009

66165 $639.99 General Fee Schedule 12/1/2009

66170 $909.06 General Fee Schedule 12/1/2009

66172 $1,127.08 General Fee Schedule 12/1/2009

66174 $961.59 General Fee Schedule 1/1/2011

66175 $1,096.91 General Fee Schedule 1/1/2011

66180 $954.78 General Fee Schedule 12/1/2009

66183 $1,051.89 General Fee Schedule 1/1/2014

66185 $580.98 General Fee Schedule 12/1/2009

66220 $557.11 General Fee Schedule 12/1/2009

66225 $744.66 General Fee Schedule 12/1/2009

66250 $642.05 General Fee Schedule 12/1/2009

66500 $308.24 General Fee Schedule 12/1/2009

66505 $335.19 General Fee Schedule 12/1/2009

66600 $631.62 General Fee Schedule 12/1/2009

66605 $863.59 General Fee Schedule 12/1/2009

66625 $368.89 General Fee Schedule 12/1/2009

66630 $444.27 General Fee Schedule 12/1/2009

66635 $448.77 General Fee Schedule 12/1/2009

66680 $400.04 General Fee Schedule 12/1/2009

66682 $477.02 General Fee Schedule 12/1/2009

66700 $372.50 General Fee Schedule 12/1/2009

66710 $369.41 General Fee Schedule 12/1/2009

66711 $487.31 General Fee Schedule 12/1/2009

66720 $392.01 General Fee Schedule 12/1/2009

66740 $366.67 General Fee Schedule 12/1/2009

66761 $355.69 General Fee Schedule 12/1/2009

66762 $378.46 General Fee Schedule 12/1/2009

66770 $417.38 General Fee Schedule 12/1/2009

66820 $355.92 General Fee Schedule 12/1/2009

66821 $234.88 General Fee Schedule 12/1/2009

66825 $642.31 General Fee Schedule 12/1/2009

66830 $567.19 General Fee Schedule 12/1/2009

66840 $553.95 General Fee Schedule 12/1/2009

66850 $629.05 General Fee Schedule 12/1/2009

66852 $679.37 General Fee Schedule 12/1/2009

66920 $607.41 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 141 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

66930 $688.47 General Fee Schedule 12/1/2009

66940 $620.04 General Fee Schedule 12/1/2009

66982 $880.67 General Fee Schedule 12/1/2009

66983 $561.33 General Fee Schedule 12/1/2009

66984 $662.29 General Fee Schedule 12/1/2009

66985 $591.65 General Fee Schedule 12/1/2009

66986 $808.92 General Fee Schedule 12/1/2009

66990 $84.32 General Fee Schedule 12/1/2009

66999 $0.00 General by Report 7/1/1975

67005 $396.03 General Fee Schedule 12/1/2009

67010 $462.44 General Fee Schedule 12/1/2009

67015 $499.97 General Fee Schedule 12/1/2009

67025 $592.07 General Fee Schedule 12/1/2009

67027 $711.26 General Fee Schedule 12/1/2009

67028 $194.19 General Fee Schedule 12/1/2009

67030 $395.70 General Fee Schedule 12/1/2009

67031 $305.33 General Fee Schedule 12/1/2009

67036 $791.46 General Fee Schedule 12/1/2009

67039 $1,002.58 General Fee Schedule 12/1/2009

67040 $1,162.99 General Fee Schedule 12/1/2009

67041 $870.21 General Fee Schedule 12/1/2009

67042 $996.37 General Fee Schedule 12/1/2009

67043 $1,045.74 General Fee Schedule 12/1/2009

67101 $616.32 General Fee Schedule 12/1/2009

67105 $575.72 General Fee Schedule 12/1/2009

67107 $985.15 General Fee Schedule 12/1/2009

67108 $1,332.77 General Fee Schedule 12/1/2009

67110 $706.14 General Fee Schedule 12/1/2009

67112 $1,083.65 General Fee Schedule 12/1/2009

67113 $1,048.12 General Fee Schedule 12/1/2009

67115 $375.13 General Fee Schedule 12/1/2009

67120 $534.89 General Fee Schedule 12/1/2009

67121 $722.11 General Fee Schedule 12/1/2009

67141 $410.28 General Fee Schedule 12/1/2009

67145 $412.74 General Fee Schedule 12/1/2009

67208 $479.84 General Fee Schedule 12/1/2009

67210 $580.87 General Fee Schedule 12/1/2009

67218 $1,163.20 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 142 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

67220 $886.26 General Fee Schedule 12/1/2009

67221 $309.89 General Fee Schedule 12/1/2009

67225 $27.38 General Fee Schedule 12/1/2009

67227 $490.96 General Fee Schedule 12/1/2009

67228 $906.80 General Fee Schedule 12/1/2009

67229 $755.50 General Fee Schedule 12/1/2009

67250 $665.09 General Fee Schedule 12/1/2009

67255 $697.96 General Fee Schedule 12/1/2009

67299 $0.00 General by Report 7/1/1975

67311 $475.86 General Fee Schedule 12/1/2009

67312 $575.88 General Fee Schedule 12/1/2009

67314 $528.28 General Fee Schedule 12/1/2009

67316 $646.87 General Fee Schedule 12/1/2009

67318 $554.72 General Fee Schedule 12/1/2009

67320 $241.44 General Fee Schedule 12/1/2009

67331 $226.57 General Fee Schedule 12/1/2009

67332 $250.37 General Fee Schedule 12/1/2009

67334 $221.77 General Fee Schedule 12/1/2009

67335 $138.94 General Fee Schedule 12/1/2009

67340 $274.20 General Fee Schedule 12/1/2009

67343 $519.66 General Fee Schedule 12/1/2009

67345 $208.80 General Fee Schedule 12/1/2009

67346 $151.46 General Fee Schedule 12/1/2009

67399 $0.00 General by Report 7/1/1975

67400 $782.22 General Fee Schedule 12/1/2009

67405 $656.43 General Fee Schedule 12/1/2009

67412 $758.12 General Fee Schedule 12/1/2009

67413 $772.63 General Fee Schedule 12/1/2009

67414 $864.52 General Fee Schedule 12/1/2009

67415 $97.07 General Fee Schedule 12/1/2009

67420 $1,409.95 General Fee Schedule 12/1/2009

67430 $1,056.93 General Fee Schedule 12/1/2009

67440 $1,018.26 General Fee Schedule 12/1/2009

67445 $1,064.52 General Fee Schedule 12/1/2009

67450 $1,048.49 General Fee Schedule 12/1/2009

67500 $55.16 General Fee Schedule 12/1/2009

67505 $57.01 General Fee Schedule 12/1/2009

67515 $44.78 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 143 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

67550 $805.33 General Fee Schedule 12/1/2009

67560 $819.41 General Fee Schedule 12/1/2009

67570 $1,013.19 General Fee Schedule 12/1/2009

67599 $0.00 General by Report 7/1/1975

67700 $261.32 General Fee Schedule 12/1/2009

67710 $225.64 General Fee Schedule 12/1/2009

67715 $233.70 General Fee Schedule 12/1/2009

67800 $111.15 General Fee Schedule 12/1/2009

67801 $143.12 General Fee Schedule 12/1/2009

67805 $176.11 General Fee Schedule 12/1/2009

67808 $282.27 General Fee Schedule 12/1/2009

67810 $173.55 General Fee Schedule 12/1/2009

67820 $56.27 General Fee Schedule 12/1/2009

67825 $115.26 General Fee Schedule 12/1/2009

67830 $258.40 General Fee Schedule 12/1/2009

67835 $382.41 General Fee Schedule 12/1/2009

67840 $270.15 General Fee Schedule 12/1/2009

67850 $183.37 General Fee Schedule 12/1/2009

67875 $167.85 General Fee Schedule 12/1/2009

67880 $379.84 General Fee Schedule 12/1/2009

67882 $465.86 General Fee Schedule 12/1/2009

67900 $560.95 General Fee Schedule 12/1/2009

67901 $489.46 General Fee Schedule 12/1/2009

67902 $569.24 General Fee Schedule 12/1/2009

67903 $590.06 General Fee Schedule 12/1/2009

67904 $586.13 General Fee Schedule 12/1/2009

67906 $462.13 General Fee Schedule 12/1/2009

67908 $434.97 General Fee Schedule 12/1/2009

67909 $494.36 General Fee Schedule 12/1/2009

67911 $377.73 General Fee Schedule 12/1/2009

67912 $878.34 General Fee Schedule 12/1/2009

67914 $365.97 General Fee Schedule 12/1/2009

67915 $333.69 General Fee Schedule 12/1/2009

67916 $490.54 General Fee Schedule 12/1/2009

67917 $534.74 General Fee Schedule 12/1/2009

67921 $349.34 General Fee Schedule 12/1/2009

67922 $326.32 General Fee Schedule 12/1/2009

67923 $515.62 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 144 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

67924 $539.88 General Fee Schedule 12/1/2009

67930 $341.69 General Fee Schedule 12/1/2009

67935 $545.55 General Fee Schedule 12/1/2009

67938 $238.29 General Fee Schedule 12/1/2009

67950 $533.19 General Fee Schedule 12/1/2009

67961 $528.84 General Fee Schedule 12/1/2009

67966 $579.59 General Fee Schedule 12/1/2009

67971 $645.73 General Fee Schedule 12/1/2009

67973 $841.68 General Fee Schedule 12/1/2009

67974 $837.78 General Fee Schedule 12/1/2009

67975 $607.92 General Fee Schedule 12/1/2009

67999 $0.00 General by Report 7/1/1975

68020 $103.23 General Fee Schedule 12/1/2009

68040 $58.50 General Fee Schedule 12/1/2009

68100 $166.14 General Fee Schedule 12/1/2009

68110 $212.14 General Fee Schedule 12/1/2009

68115 $299.98 General Fee Schedule 12/1/2009

68130 $497.43 General Fee Schedule 12/1/2009

68135 $136.44 General Fee Schedule 12/1/2009

68200 $38.09 General Fee Schedule 12/1/2009

68320 $603.44 General Fee Schedule 12/1/2009

68325 $523.50 General Fee Schedule 12/1/2009

68326 $507.82 General Fee Schedule 12/1/2009

68328 $584.27 General Fee Schedule 12/1/2009

68330 $517.53 General Fee Schedule 12/1/2009

68335 $508.69 General Fee Schedule 12/1/2009

68340 $472.54 General Fee Schedule 12/1/2009

68360 $451.84 General Fee Schedule 12/1/2009

68362 $515.17 General Fee Schedule 12/1/2009

68371 $366.23 General Fee Schedule 12/1/2009

68399 $0.00 General by Report 7/1/1975

68400 $270.68 General Fee Schedule 12/1/2009

68420 $305.18 General Fee Schedule 12/1/2009

68440 $109.57 General Fee Schedule 12/1/2009

68500 $777.74 General Fee Schedule 12/1/2009

68505 $806.15 General Fee Schedule 12/1/2009

68510 $350.97 General Fee Schedule 7/1/2009

68520 $556.99 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 145 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

68525 $247.71 General Fee Schedule 12/1/2009

68530 $427.51 General Fee Schedule 12/1/2009

68540 $748.85 General Fee Schedule 12/1/2009

68550 $928.30 General Fee Schedule 12/1/2009

68700 $470.84 General Fee Schedule 12/1/2009

68705 $226.08 General Fee Schedule 12/1/2009

68720 $630.44 General Fee Schedule 12/1/2009

68745 $620.47 General Fee Schedule 12/1/2009

68750 $632.56 General Fee Schedule 12/1/2009

68760 $191.43 General Fee Schedule 12/1/2009

68761 $132.63 General Fee Schedule 12/1/2009

68770 $391.88 General Fee Schedule 12/1/2009

68801 $104.77 General Fee Schedule 12/1/2009

68810 $202.44 General Fee Schedule 12/1/2009

68811 $178.05 General Fee Schedule 12/1/2009

68815 $412.19 General Fee Schedule 12/1/2009

68816 $464.24 General Fee Schedule 12/1/2009

68840 $105.10 General Fee Schedule 12/1/2009

68850 $62.39 General Fee Schedule 12/1/2009

68899 $0.00 General by Report 7/1/1975

69000 $159.06 General Fee Schedule 12/1/2009

69005 $187.98 General Fee Schedule 12/1/2009

69020 $198.22 General Fee Schedule 12/1/2009

69100 $90.85 General Fee Schedule 12/1/2009

69105 $115.68 General Fee Schedule 12/1/2009

69110 $374.20 General Fee Schedule 12/1/2009

69120 $381.34 General Fee Schedule 12/1/2009

69140 $785.73 General Fee Schedule 12/1/2009

69145 $306.96 General Fee Schedule 12/1/2009

69150 $1,019.90 General Fee Schedule 12/1/2009

69155 $1,539.07 General Fee Schedule 12/1/2009

69200 $113.63 General Fee Schedule 12/1/2009

69205 $96.34 General Fee Schedule 12/1/2009

69210 $46.84 General Fee Schedule 12/1/2009

69220 $115.60 General Fee Schedule 12/1/2009

69222 $190.33 General Fee Schedule 12/1/2009

69300 $414.79 General Fee Schedule 12/1/2009

69310 $1,004.16 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 146 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

69320 $1,450.59 General Fee Schedule 12/1/2009

69399 $0.00 General by Report 7/1/1975

69400 $108.75 General Fee Schedule 12/1/2009

69401 $68.49 General Fee Schedule 12/1/2009

69405 $228.94 General Fee Schedule 12/1/2009

69420 $163.33 General Fee Schedule 12/1/2009

69421 $146.26 General Fee Schedule 12/1/2009

69424 $110.20 General Fee Schedule 12/1/2009

69433 $169.29 General Fee Schedule 12/1/2009

69436 $160.96 General Fee Schedule 12/1/2009

69440 $614.17 General Fee Schedule 12/1/2009

69450 $471.53 General Fee Schedule 12/1/2009

69501 $684.08 General Fee Schedule 12/1/2009

69502 $909.46 General Fee Schedule 12/1/2009

69505 $1,127.14 General Fee Schedule 12/1/2009

69511 $1,158.57 General Fee Schedule 12/1/2009

69530 $1,535.35 General Fee Schedule 12/1/2009

69535 $2,591.20 General Fee Schedule 12/1/2009

69540 $178.17 General Fee Schedule 12/1/2009

69550 $964.31 General Fee Schedule 12/1/2009

69552 $1,514.64 General Fee Schedule 12/1/2009

69554 $2,420.01 General Fee Schedule 12/1/2009

69601 $982.40 General Fee Schedule 12/1/2009

69602 $1,015.72 General Fee Schedule 12/1/2009

69603 $1,210.07 General Fee Schedule 12/1/2009

69604 $1,049.84 General Fee Schedule 12/1/2009

69605 $1,483.67 General Fee Schedule 12/1/2009

69610 $373.74 General Fee Schedule 12/1/2009

69620 $625.29 General Fee Schedule 12/1/2009

69631 $792.32 General Fee Schedule 12/1/2009

69632 $989.49 General Fee Schedule 12/1/2009

69633 $948.28 General Fee Schedule 12/1/2009

69635 $1,125.89 General Fee Schedule 12/1/2009

69636 $1,292.02 General Fee Schedule 12/1/2009

69637 $1,284.69 General Fee Schedule 12/1/2009

69641 $964.32 General Fee Schedule 12/1/2009

69642 $1,254.92 General Fee Schedule 12/1/2009

69643 $1,142.16 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 147 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

69644 $1,401.68 General Fee Schedule 12/1/2009

69645 $1,364.91 General Fee Schedule 12/1/2009

69646 $1,456.48 General Fee Schedule 12/1/2009

69650 $739.74 General Fee Schedule 12/1/2009

69660 $875.51 General Fee Schedule 12/1/2009

69661 $1,155.30 General Fee Schedule 12/1/2009

69662 $1,110.50 General Fee Schedule 12/1/2009

69666 $745.61 General Fee Schedule 12/1/2009

69667 $746.34 General Fee Schedule 12/1/2009

69670 $877.57 General Fee Schedule 12/1/2009

69676 $764.13 General Fee Schedule 12/1/2009

69700 $657.80 General Fee Schedule 12/1/2009

69710 $1,404.45 General Fee Schedule 12/1/2009

69711 $801.32 General Fee Schedule 12/1/2009

69714 $1,013.46 General Fee Schedule 12/1/2009

69715 $1,270.34 General Fee Schedule 12/1/2009

69717 $1,105.31 General Fee Schedule 12/1/2009

69718 $1,349.01 General Fee Schedule 12/1/2009

69720 $1,092.84 General Fee Schedule 12/1/2009

69725 $1,753.62 General Fee Schedule 12/1/2009

69740 $1,119.62 General Fee Schedule 12/1/2009

69745 $1,196.33 General Fee Schedule 12/1/2009

69799 $0.00 General by Report 7/1/1975

69801 $678.76 General Fee Schedule 12/1/2009

69805 $979.12 General Fee Schedule 12/1/2009

69806 $889.47 General Fee Schedule 12/1/2009

69820 $814.60 General Fee Schedule 12/1/2009

69840 $874.81 General Fee Schedule 12/1/2009

69905 $848.38 General Fee Schedule 12/1/2009

69910 $971.43 General Fee Schedule 12/1/2009

69915 $1,441.92 General Fee Schedule 12/1/2009

69930 $1,201.03 General Fee Schedule 12/1/2009

69949 $0.00 General by Report 7/1/1975

69950 $1,715.69 General Fee Schedule 12/1/2009

69955 $1,861.88 General Fee Schedule 12/1/2009

69960 $1,805.63 General Fee Schedule 12/1/2009

69970 $2,039.92 General Fee Schedule 12/1/2009

69979 $0.00 General by Report 6/1/1981

Tuesday, February 11, 2014 Page 148 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

69990 $225.92 General Fee Schedule 12/1/2009

70010 $61.01 26 Fee Schedule (FS) 12/1/2009

70010 $156.19 TC Fee Schedule 12/1/2009

70010 $217.20 General Fee Schedule 12/1/2009

70015 $44.42 26 Fee Schedule (FS) 12/1/2009

70015 $48.98 TC Fee Schedule 12/1/2009

70015 $111.04 General Fee Schedule 12/1/2009

70030 $8.96 26 Fee Schedule (FS) 12/1/2009

70030 $15.07 TC Fee Schedule 12/1/2009

70030 $24.04 General Fee Schedule 12/1/2009

70100 $9.35 26 Fee Schedule (FS) 12/1/2009

70100 $18.50 TC Fee Schedule 12/1/2009

70100 $27.85 General Fee Schedule 12/1/2009

70110 $35.35 General Fee Schedule 12/1/2009

70110 $12.74 26 Fee Schedule (FS) 12/1/2009

70110 $22.61 TC Fee Schedule 12/1/2009

70120 $31.96 General Fee Schedule 12/1/2009

70120 $9.35 26 Fee Schedule (FS) 12/1/2009

70120 $22.61 TC Fee Schedule 12/1/2009

70130 $17.58 26 Fee Schedule (FS) 12/1/2009

70130 $28.44 TC Fee Schedule 12/1/2009

70130 $46.02 General Fee Schedule 12/1/2009

70134 $17.58 26 Fee Schedule (FS) 12/1/2009

70134 $26.71 TC Fee Schedule 12/1/2009

70134 $44.31 General Fee Schedule 12/1/2009

70140 $32.34 General Fee Schedule 12/1/2009

70140 $9.74 26 Fee Schedule (FS) 12/1/2009

70140 $22.61 TC Fee Schedule 12/1/2009

70150 $41.55 General Fee Schedule 12/1/2009

70150 $13.11 26 Fee Schedule (FS) 12/1/2009

70150 $28.44 TC Fee Schedule 12/1/2009

70160 $8.96 26 Fee Schedule (FS) 12/1/2009

70160 $18.50 TC Fee Schedule 12/1/2009

70160 $27.46 General Fee Schedule 12/1/2009

70170 $15.19 26 Fee Schedule (FS) 12/1/2009

70190 $33.46 General Fee Schedule 12/1/2009

70190 $10.84 26 Fee Schedule (FS) 12/1/2009

70190 $22.61 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 149 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

70200 $42.66 General Fee Schedule 12/1/2009

70200 $28.44 TC Fee Schedule 12/1/2009

70200 $14.24 26 Fee Schedule (FS) 12/1/2009

70210 $8.96 26 Fee Schedule (FS) 12/1/2009

70210 $22.61 TC Fee Schedule 12/1/2009

70210 $31.57 General Fee Schedule 12/1/2009

70220 $12.74 26 Fee Schedule (FS) 12/1/2009

70220 $28.44 TC Fee Schedule 12/1/2009

70220 $41.17 General Fee Schedule 12/1/2009

70240 $24.80 General Fee Schedule 12/1/2009

70240 $9.74 26 Fee Schedule (FS) 12/1/2009

70240 $15.07 TC Fee Schedule 12/1/2009

70250 $34.96 General Fee Schedule 12/1/2009

70250 $12.35 26 Fee Schedule (FS) 12/1/2009

70250 $22.61 TC Fee Schedule 12/1/2009

70260 $17.58 26 Fee Schedule (FS) 12/1/2009

70260 $32.54 TC Fee Schedule 12/1/2009

70260 $50.12 General Fee Schedule 12/1/2009

70300 $5.92 26 Fee Schedule (FS) 12/1/2009

70300 $9.59 TC Fee Schedule 12/1/2009

70300 $15.51 General Fee Schedule 12/1/2009

70310 $24.33 General Fee Schedule 12/1/2009

70310 $15.07 TC Fee Schedule 12/1/2009

70310 $9.25 26 Fee Schedule (FS) 12/1/2009

70320 $28.44 TC Fee Schedule 12/1/2009

70320 $40.00 General Fee Schedule 12/1/2009

70320 $11.58 26 Fee Schedule (FS) 12/1/2009

70328 $9.35 26 Fee Schedule (FS) 12/1/2009

70328 $17.47 TC Fee Schedule 12/1/2009

70328 $26.82 General Fee Schedule 12/1/2009

70330 $12.35 26 Fee Schedule (FS) 12/1/2009

70330 $30.49 TC Fee Schedule 12/1/2009

70330 $42.84 General Fee Schedule 12/1/2009

70332 $28.38 26 Fee Schedule (FS) 12/1/2009

70332 $76.39 TC Fee Schedule 12/1/2009

70332 $104.76 General Fee Schedule 12/1/2009

70336 $76.32 26 Fee Schedule (FS) 12/1/2009

70336 $404.87 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 150 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

70336 $481.18 General Fee Schedule 12/1/2009

70350 $9.21 26 Fee Schedule (FS) 12/1/2009

70350 $13.70 TC Fee Schedule 12/1/2009

70350 $23.01 General Fee Schedule 12/1/2009

70355 $10.46 26 Fee Schedule (FS) 12/1/2009

70355 $20.90 TC Fee Schedule 12/1/2009

70355 $31.36 General Fee Schedule 12/1/2009

70360 $8.96 26 Fee Schedule (FS) 12/1/2009

70360 $15.07 TC Fee Schedule 12/1/2009

70360 $24.04 General Fee Schedule 12/1/2009

70370 $16.12 26 Fee Schedule (FS) 12/1/2009

70370 $47.27 TC Fee Schedule 12/1/2009

70370 $63.39 General Fee Schedule 12/1/2009

70371 $43.39 26 Fee Schedule (FS) 12/1/2009

70371 $76.39 TC Fee Schedule 12/1/2009

70371 $119.78 General Fee Schedule 12/1/2009

70373 $22.47 26 Fee Schedule (FS) 12/1/2009

70373 $65.09 TC Fee Schedule 12/1/2009

70373 $87.55 General Fee Schedule 12/1/2009

70380 $8.96 26 Fee Schedule (FS) 12/1/2009

70380 $24.32 TC Fee Schedule 12/1/2009

70380 $33.28 General Fee Schedule 12/1/2009

70390 $19.47 26 Fee Schedule (FS) 12/1/2009

70390 $65.09 TC Fee Schedule 12/1/2009

70390 $84.55 General Fee Schedule 12/1/2009

70450 $43.78 26 Fee Schedule (FS) 12/1/2009

70450 $170.57 TC Fee Schedule 12/1/2009

70450 $214.35 General Fee Schedule 12/1/2009

70460 $262.84 General Fee Schedule 12/1/2009

70460 $58.02 26 Fee Schedule (FS) 12/1/2009

70460 $204.83 TC Fee Schedule 12/1/2009

70470 $320.99 General Fee Schedule 12/1/2009

70470 $65.47 26 Fee Schedule (FS) 12/1/2009

70470 $255.52 TC Fee Schedule 12/1/2009

70480 $65.85 26 Fee Schedule (FS) 12/1/2009

70480 $170.57 TC Fee Schedule 12/1/2009

70480 $236.44 General Fee Schedule 12/1/2009

70481 $70.74 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 151 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

70481 $204.83 TC Fee Schedule 12/1/2009

70481 $275.58 General Fee Schedule 12/1/2009

70482 $329.99 General Fee Schedule 12/1/2009

70482 $74.48 26 Fee Schedule (FS) 12/1/2009

70482 $255.52 TC Fee Schedule 12/1/2009

70486 $228.98 General Fee Schedule 12/1/2009

70486 $58.40 26 Fee Schedule (FS) 12/1/2009

70486 $170.57 TC Fee Schedule 12/1/2009

70487 $66.98 26 Fee Schedule (FS) 12/1/2009

70487 $204.83 TC Fee Schedule 12/1/2009

70487 $271.80 General Fee Schedule 12/1/2009

70488 $72.63 26 Fee Schedule (FS) 12/1/2009

70488 $255.52 TC Fee Schedule 12/1/2009

70488 $328.15 General Fee Schedule 12/1/2009

70490 $170.57 TC Fee Schedule 12/1/2009

70490 $236.44 General Fee Schedule 12/1/2009

70490 $65.85 26 Fee Schedule (FS) 12/1/2009

70491 $70.74 26 Fee Schedule (FS) 12/1/2009

70491 $204.83 TC Fee Schedule 12/1/2009

70491 $275.58 General Fee Schedule 12/1/2009

70492 $74.14 26 Fee Schedule (FS) 12/1/2009

70492 $255.52 TC Fee Schedule 12/1/2009

70492 $329.65 General Fee Schedule 12/1/2009

70496 $89.82 26 Fee Schedule (FS) 12/1/2009

70496 $383.97 TC Fee Schedule 12/1/2009

70496 $473.81 General Fee Schedule 12/1/2009

70498 $89.82 26 Fee Schedule (FS) 12/1/2009

70498 $383.97 TC Fee Schedule 12/1/2009

70498 $473.81 General Fee Schedule 12/1/2009

70540 $69.25 26 Fee Schedule (FS) 12/1/2009

70540 $397.96 TC Fee Schedule 12/1/2009

70540 $467.20 General Fee Schedule 12/1/2009

70542 $83.09 26 Fee Schedule (FS) 12/1/2009

70542 $477.74 TC Fee Schedule 12/1/2009

70542 $560.84 General Fee Schedule 12/1/2009

70543 $993.99 General Fee Schedule 12/1/2009

70543 $110.75 26 Fee Schedule (FS) 12/1/2009

70543 $883.23 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 152 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

70544 $466.61 General Fee Schedule 12/1/2009

70544 $61.74 26 Fee Schedule (FS) 12/1/2009

70544 $404.87 TC Fee Schedule 12/1/2009

70545 $61.39 26 Fee Schedule (FS) 12/1/2009

70545 $404.87 TC Fee Schedule 12/1/2009

70545 $466.26 General Fee Schedule 12/1/2009

70546 $92.44 26 Fee Schedule (FS) 12/1/2009

70546 $789.69 TC Fee Schedule 12/1/2009

70546 $882.13 General Fee Schedule 12/1/2009

70547 $466.26 General Fee Schedule 12/1/2009

70547 $61.39 26 Fee Schedule (FS) 12/1/2009

70547 $404.87 TC Fee Schedule 12/1/2009

70548 $466.26 General Fee Schedule 12/1/2009

70548 $61.39 26 Fee Schedule (FS) 12/1/2009

70548 $404.87 TC Fee Schedule 12/1/2009

70549 $92.44 26 Fee Schedule (FS) 12/1/2009

70549 $789.69 TC Fee Schedule 12/1/2009

70549 $882.13 General Fee Schedule 12/1/2009

70551 $76.32 26 Fee Schedule (FS) 12/1/2009

70551 $404.87 TC Fee Schedule 12/1/2009

70551 $481.18 General Fee Schedule 12/1/2009

70552 $485.69 TC Fee Schedule 12/1/2009

70552 $577.36 General Fee Schedule 12/1/2009

70552 $91.67 26 Fee Schedule (FS) 12/1/2009

70553 $899.47 TC Fee Schedule 12/1/2009

70553 $1,020.72 General Fee Schedule 12/1/2009

70553 $121.25 26 Fee Schedule (FS) 12/1/2009

70554 $88.03 26 Fee Schedule (FS) 12/1/2009

70554 $424.93 TC Fee Schedule 12/1/2009

70554 $512.97 General Fee Schedule 12/1/2009

70555 $25.71 26 Fee Schedule (FS) 12/1/2009

70557 $151.82 26 Fee Schedule (FS) 12/1/2009

70558 $167.70 26 Fee Schedule (FS) 12/1/2009

70559 $168.37 26 Fee Schedule (FS) 12/1/2009

71010 $9.35 26 Fee Schedule (FS) 12/1/2009

71010 $16.78 TC Fee Schedule 12/1/2009

71010 $26.13 General Fee Schedule 12/1/2009

71015 $10.84 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 153 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

71015 $18.50 TC Fee Schedule 12/1/2009

71015 $29.34 General Fee Schedule 12/1/2009

71020 $11.23 26 Fee Schedule (FS) 12/1/2009

71020 $22.61 TC Fee Schedule 12/1/2009

71020 $33.84 General Fee Schedule 12/1/2009

71021 $40.57 General Fee Schedule 12/1/2009

71021 $13.85 26 Fee Schedule (FS) 12/1/2009

71021 $26.71 TC Fee Schedule 12/1/2009

71022 $42.45 General Fee Schedule 12/1/2009

71022 $15.73 26 Fee Schedule (FS) 12/1/2009

71022 $26.71 TC Fee Schedule 12/1/2009

71023 $19.16 26 Fee Schedule (FS) 12/1/2009

71023 $28.44 TC Fee Schedule 12/1/2009

71023 $47.90 General Fee Schedule 12/1/2009

71030 $15.73 26 Fee Schedule (FS) 12/1/2009

71030 $28.44 TC Fee Schedule 12/1/2009

71030 $44.16 General Fee Schedule 12/1/2009

71034 $75.99 General Fee Schedule 12/1/2009

71034 $23.92 26 Fee Schedule (FS) 12/1/2009

71034 $52.07 TC Fee Schedule 12/1/2009

71035 $27.85 General Fee Schedule 12/1/2009

71035 $9.35 26 Fee Schedule (FS) 12/1/2009

71035 $18.50 TC Fee Schedule 12/1/2009

71100 $11.23 26 Fee Schedule (FS) 12/1/2009

71100 $20.90 TC Fee Schedule 12/1/2009

71100 $32.14 General Fee Schedule 12/1/2009

71101 $13.85 26 Fee Schedule (FS) 12/1/2009

71101 $24.32 TC Fee Schedule 12/1/2009

71101 $38.17 General Fee Schedule 12/1/2009

71110 $28.44 TC Fee Schedule 12/1/2009

71110 $13.85 26 Fee Schedule (FS) 12/1/2009

71110 $42.28 General Fee Schedule 12/1/2009

71111 $16.12 26 Fee Schedule (FS) 12/1/2009

71111 $32.54 TC Fee Schedule 12/1/2009

71111 $48.66 General Fee Schedule 12/1/2009

71120 $10.46 26 Fee Schedule (FS) 12/1/2009

71120 $23.64 TC Fee Schedule 12/1/2009

71120 $34.10 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 154 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

71130 $11.23 26 Fee Schedule (FS) 12/1/2009

71130 $25.69 TC Fee Schedule 12/1/2009

71130 $36.92 General Fee Schedule 12/1/2009

71250 $59.51 26 Fee Schedule (FS) 12/1/2009

71250 $213.73 TC Fee Schedule 12/1/2009

71250 $273.24 General Fee Schedule 12/1/2009

71260 $63.62 26 Fee Schedule (FS) 12/1/2009

71260 $255.52 TC Fee Schedule 12/1/2009

71260 $319.15 General Fee Schedule 12/1/2009

71270 $70.74 26 Fee Schedule (FS) 12/1/2009

71270 $390.66 General Fee Schedule 12/1/2009

71270 $319.92 TC Fee Schedule 12/1/2009

71275 $98.78 26 Fee Schedule (FS) 12/1/2009

71275 $438.70 TC Fee Schedule 12/1/2009

71275 $537.49 General Fee Schedule 12/1/2009

71550 $74.86 26 Fee Schedule (FS) 12/1/2009

71550 $400.03 TC Fee Schedule 12/1/2009

71550 $474.88 General Fee Schedule 12/1/2009

71551 $89.06 26 Fee Schedule (FS) 12/1/2009

71551 $479.48 TC Fee Schedule 12/1/2009

71551 $568.54 General Fee Schedule 12/1/2009

71552 $116.03 26 Fee Schedule (FS) 12/1/2009

71552 $877.70 TC Fee Schedule 12/1/2009

71552 $993.73 General Fee Schedule 12/1/2009

71555 $93.17 26 Fee Schedule (FS) 12/1/2009

71555 $404.87 TC Fee Schedule 12/1/2009

71555 $498.04 General Fee Schedule 12/1/2009

72010 $60.20 General Fee Schedule 12/1/2009

72010 $23.19 26 Fee Schedule (FS) 12/1/2009

72010 $37.00 TC Fee Schedule 12/1/2009

72020 $7.85 26 Fee Schedule (FS) 12/1/2009

72020 $15.07 TC Fee Schedule 12/1/2009

72020 $22.92 General Fee Schedule 12/1/2009

72040 $33.16 General Fee Schedule 12/1/2009

72040 $11.23 26 Fee Schedule (FS) 12/1/2009

72040 $21.93 TC Fee Schedule 12/1/2009

72050 $48.28 General Fee Schedule 12/1/2009

72050 $15.73 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 155 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

72050 $32.54 TC Fee Schedule 12/1/2009

72052 $18.70 26 Fee Schedule (FS) 12/1/2009

72052 $40.76 TC Fee Schedule 12/1/2009

72052 $59.46 General Fee Schedule 12/1/2009

72069 $29.05 General Fee Schedule 12/1/2009

72069 $17.47 TC Fee Schedule 12/1/2009

72069 $11.58 26 Fee Schedule (FS) 12/1/2009

72070 $23.64 TC Fee Schedule 12/1/2009

72070 $34.87 General Fee Schedule 12/1/2009

72070 $11.23 26 Fee Schedule (FS) 12/1/2009

72072 $11.23 26 Fee Schedule (FS) 12/1/2009

72072 $26.71 TC Fee Schedule 12/1/2009

72072 $37.95 General Fee Schedule 12/1/2009

72074 $11.23 26 Fee Schedule (FS) 12/1/2009

72074 $33.22 TC Fee Schedule 12/1/2009

72074 $44.46 General Fee Schedule 12/1/2009

72080 $11.23 26 Fee Schedule (FS) 12/1/2009

72080 $24.32 TC Fee Schedule 12/1/2009

72080 $35.56 General Fee Schedule 12/1/2009

72090 $14.24 26 Fee Schedule (FS) 12/1/2009

72090 $24.32 TC Fee Schedule 12/1/2009

72090 $38.55 General Fee Schedule 12/1/2009

72100 $35.56 General Fee Schedule 12/1/2009

72100 $11.23 26 Fee Schedule (FS) 12/1/2009

72100 $24.32 TC Fee Schedule 12/1/2009

72110 $15.73 26 Fee Schedule (FS) 12/1/2009

72110 $33.22 TC Fee Schedule 12/1/2009

72110 $48.96 General Fee Schedule 12/1/2009

72114 $61.51 General Fee Schedule 12/1/2009

72114 $18.70 26 Fee Schedule (FS) 12/1/2009

72114 $42.82 TC Fee Schedule 12/1/2009

72120 $43.78 General Fee Schedule 12/1/2009

72120 $11.23 26 Fee Schedule (FS) 12/1/2009

72120 $32.54 TC Fee Schedule 12/1/2009

72125 $59.51 26 Fee Schedule (FS) 12/1/2009

72125 $213.73 TC Fee Schedule 12/1/2009

72125 $273.24 General Fee Schedule 12/1/2009

72126 $318.03 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 156 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

72126 $255.52 TC Fee Schedule 12/1/2009

72126 $62.52 26 Fee Schedule (FS) 12/1/2009

72127 $319.92 TC Fee Schedule 12/1/2009

72127 $385.39 General Fee Schedule 12/1/2009

72127 $65.47 26 Fee Schedule (FS) 12/1/2009

72128 $59.51 26 Fee Schedule (FS) 12/1/2009

72128 $213.73 TC Fee Schedule 12/1/2009

72128 $273.24 General Fee Schedule 12/1/2009

72129 $62.52 26 Fee Schedule (FS) 12/1/2009

72129 $255.52 TC Fee Schedule 12/1/2009

72129 $318.03 General Fee Schedule 12/1/2009

72130 $65.47 26 Fee Schedule (FS) 12/1/2009

72130 $319.92 TC Fee Schedule 12/1/2009

72130 $385.39 General Fee Schedule 12/1/2009

72131 $59.51 26 Fee Schedule (FS) 12/1/2009

72131 $213.73 TC Fee Schedule 12/1/2009

72131 $273.24 General Fee Schedule 12/1/2009

72132 $62.52 26 Fee Schedule (FS) 12/1/2009

72132 $255.52 TC Fee Schedule 12/1/2009

72132 $318.03 General Fee Schedule 12/1/2009

72133 $65.47 26 Fee Schedule (FS) 12/1/2009

72133 $319.92 TC Fee Schedule 12/1/2009

72133 $385.39 General Fee Schedule 12/1/2009

72141 $82.32 26 Fee Schedule (FS) 12/1/2009

72141 $404.87 TC Fee Schedule 12/1/2009

72141 $487.19 General Fee Schedule 12/1/2009

72142 $99.13 26 Fee Schedule (FS) 12/1/2009

72142 $485.69 TC Fee Schedule 12/1/2009

72142 $584.82 General Fee Schedule 12/1/2009

72146 $82.32 26 Fee Schedule (FS) 12/1/2009

72146 $449.38 TC Fee Schedule 12/1/2009

72146 $531.71 General Fee Schedule 12/1/2009

72147 $584.48 General Fee Schedule 12/1/2009

72147 $98.78 26 Fee Schedule (FS) 12/1/2009

72147 $485.69 TC Fee Schedule 12/1/2009

72148 $525.71 General Fee Schedule 12/1/2009

72148 $76.32 26 Fee Schedule (FS) 12/1/2009

72148 $449.38 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 157 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

72149 $92.01 26 Fee Schedule (FS) 12/1/2009

72149 $485.69 TC Fee Schedule 12/1/2009

72149 $577.70 General Fee Schedule 12/1/2009

72156 $1,031.57 General Fee Schedule 12/1/2009

72156 $132.10 26 Fee Schedule (FS) 12/1/2009

72156 $899.47 TC Fee Schedule 12/1/2009

72157 $1,031.22 General Fee Schedule 12/1/2009

72157 $131.76 26 Fee Schedule (FS) 12/1/2009

72157 $899.47 TC Fee Schedule 12/1/2009

72158 $121.25 26 Fee Schedule (FS) 12/1/2009

72158 $899.47 TC Fee Schedule 12/1/2009

72158 $1,020.72 General Fee Schedule 12/1/2009

72159 $460.48 General Fee Schedule 12/1/2009

72159 $276.29 TC Fee Schedule 12/1/2009

72159 $84.02 26 Fee Schedule (FS) 12/1/2009

72170 $18.50 TC Fee Schedule 12/1/2009

72170 $27.46 General Fee Schedule 12/1/2009

72170 $8.96 26 Fee Schedule (FS) 12/1/2009

72190 $10.84 26 Fee Schedule (FS) 12/1/2009

72190 $24.32 TC Fee Schedule 12/1/2009

72190 $35.17 General Fee Schedule 12/1/2009

72191 $93.17 26 Fee Schedule (FS) 12/1/2009

72191 $426.37 TC Fee Schedule 12/1/2009

72191 $519.54 General Fee Schedule 12/1/2009

72192 $56.13 26 Fee Schedule (FS) 12/1/2009

72192 $213.73 TC Fee Schedule 12/1/2009

72192 $269.86 General Fee Schedule 12/1/2009

72193 $59.51 26 Fee Schedule (FS) 12/1/2009

72193 $247.30 TC Fee Schedule 12/1/2009

72193 $306.81 General Fee Schedule 12/1/2009

72194 $62.52 26 Fee Schedule (FS) 12/1/2009

72194 $368.73 General Fee Schedule 12/1/2009

72194 $306.21 TC Fee Schedule 12/1/2009

72195 $74.86 26 Fee Schedule (FS) 12/1/2009

72195 $400.03 TC Fee Schedule 12/1/2009

72195 $474.88 General Fee Schedule 12/1/2009

72196 $89.06 26 Fee Schedule (FS) 12/1/2009

72196 $479.48 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 158 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

72196 $568.54 General Fee Schedule 12/1/2009

72197 $116.03 26 Fee Schedule (FS) 12/1/2009

72197 $886.00 TC Fee Schedule 12/1/2009

72197 $1,002.02 General Fee Schedule 12/1/2009

72198 $92.44 26 Fee Schedule (FS) 12/1/2009

72198 $404.87 TC Fee Schedule 12/1/2009

72198 $497.30 General Fee Schedule 12/1/2009

72200 $8.96 26 Fee Schedule (FS) 12/1/2009

72200 $18.50 TC Fee Schedule 12/1/2009

72200 $27.46 General Fee Schedule 12/1/2009

72202 $32.34 General Fee Schedule 12/1/2009

72202 $9.74 26 Fee Schedule (FS) 12/1/2009

72202 $22.61 TC Fee Schedule 12/1/2009

72220 $8.96 26 Fee Schedule (FS) 12/1/2009

72220 $20.90 TC Fee Schedule 12/1/2009

72220 $29.87 General Fee Schedule 12/1/2009

72240 $218.04 General Fee Schedule 12/1/2009

72240 $46.43 26 Fee Schedule (FS) 12/1/2009

72240 $171.60 TC Fee Schedule 12/1/2009

72255 $201.93 General Fee Schedule 12/1/2009

72255 $45.75 26 Fee Schedule (FS) 12/1/2009

72255 $156.19 TC Fee Schedule 12/1/2009

72265 $41.98 26 Fee Schedule (FS) 12/1/2009

72265 $147.28 TC Fee Schedule 12/1/2009

72265 $189.27 General Fee Schedule 12/1/2009

72270 $288.71 General Fee Schedule 12/1/2009

72270 $220.94 TC Fee Schedule 12/1/2009

72270 $67.79 26 Fee Schedule (FS) 12/1/2009

72275 $79.84 TC Fee Schedule 12/1/2009

72275 $117.40 General Fee Schedule 12/1/2009

72275 $37.56 26 Fee Schedule (FS) 12/1/2009

72285 $59.52 26 Fee Schedule (FS) 12/1/2009

72285 $302.45 TC Fee Schedule 12/1/2009

72285 $361.97 General Fee Schedule 12/1/2009

72291 $58.54 26 Fee Schedule (FS) 12/1/2009

72292 $59.72 26 Fee Schedule (FS) 12/1/2009

72295 $283.60 TC Fee Schedule 12/1/2009

72295 $326.96 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 159 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

72295 $43.36 26 Fee Schedule (FS) 12/1/2009

73000 $8.23 26 Fee Schedule (FS) 12/1/2009

73000 $18.50 TC Fee Schedule 12/1/2009

73000 $26.72 General Fee Schedule 12/1/2009

73010 $27.46 General Fee Schedule 12/1/2009

73010 $18.50 TC Fee Schedule 12/1/2009

73010 $8.96 26 Fee Schedule (FS) 12/1/2009

73020 $16.78 TC Fee Schedule 12/1/2009

73020 $24.63 General Fee Schedule 12/1/2009

73020 $7.85 26 Fee Schedule (FS) 12/1/2009

73030 $9.35 26 Fee Schedule (FS) 12/1/2009

73030 $20.90 TC Fee Schedule 12/1/2009

73030 $30.23 General Fee Schedule 12/1/2009

73040 $27.69 26 Fee Schedule (FS) 12/1/2009

73040 $76.39 TC Fee Schedule 12/1/2009

73040 $104.08 General Fee Schedule 12/1/2009

73050 $10.46 26 Fee Schedule (FS) 12/1/2009

73050 $24.32 TC Fee Schedule 12/1/2009

73050 $34.78 General Fee Schedule 12/1/2009

73060 $8.96 26 Fee Schedule (FS) 12/1/2009

73060 $20.90 TC Fee Schedule 12/1/2009

73060 $29.87 General Fee Schedule 12/1/2009

73070 $7.85 26 Fee Schedule (FS) 12/1/2009

73070 $26.34 General Fee Schedule 12/1/2009

73070 $18.50 TC Fee Schedule 12/1/2009

73080 $8.96 26 Fee Schedule (FS) 12/1/2009

73080 $20.90 TC Fee Schedule 12/1/2009

73080 $29.87 General Fee Schedule 12/1/2009

73085 $28.04 26 Fee Schedule (FS) 12/1/2009

73085 $76.39 TC Fee Schedule 12/1/2009

73085 $104.43 General Fee Schedule 12/1/2009

73090 $8.23 26 Fee Schedule (FS) 12/1/2009

73090 $18.50 TC Fee Schedule 12/1/2009

73090 $26.72 General Fee Schedule 12/1/2009

73092 $8.23 26 Fee Schedule (FS) 12/1/2009

73092 $17.47 TC Fee Schedule 12/1/2009

73092 $25.70 General Fee Schedule 12/1/2009

73100 $25.70 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 160 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

73100 $8.23 26 Fee Schedule (FS) 12/1/2009

73100 $17.47 TC Fee Schedule 12/1/2009

73110 $27.79 General Fee Schedule 12/1/2009

73110 $18.83 TC Fee Schedule 12/1/2009

73110 $8.96 26 Fee Schedule (FS) 12/1/2009

73115 $27.69 26 Fee Schedule (FS) 12/1/2009

73115 $57.55 TC Fee Schedule 12/1/2009

73115 $85.25 General Fee Schedule 12/1/2009

73120 $25.70 General Fee Schedule 12/1/2009

73120 $8.23 26 Fee Schedule (FS) 12/1/2009

73120 $17.47 TC Fee Schedule 12/1/2009

73130 $27.79 General Fee Schedule 12/1/2009

73130 $8.96 26 Fee Schedule (FS) 12/1/2009

73130 $18.83 TC Fee Schedule 12/1/2009

73140 $6.73 26 Fee Schedule (FS) 12/1/2009

73140 $15.07 TC Fee Schedule 12/1/2009

73140 $21.81 General Fee Schedule 12/1/2009

73200 $178.80 TC Fee Schedule 12/1/2009

73200 $234.91 General Fee Schedule 12/1/2009

73200 $56.13 26 Fee Schedule (FS) 12/1/2009

73201 $59.51 26 Fee Schedule (FS) 12/1/2009

73201 $213.73 TC Fee Schedule 12/1/2009

73201 $273.24 General Fee Schedule 12/1/2009

73202 $62.52 26 Fee Schedule (FS) 12/1/2009

73202 $268.20 TC Fee Schedule 12/1/2009

73202 $330.71 General Fee Schedule 12/1/2009

73206 $92.83 26 Fee Schedule (FS) 12/1/2009

73206 $389.74 TC Fee Schedule 12/1/2009

73206 $482.57 General Fee Schedule 12/1/2009

73218 $69.25 26 Fee Schedule (FS) 12/1/2009

73218 $397.96 TC Fee Schedule 12/1/2009

73218 $467.20 General Fee Schedule 12/1/2009

73219 $561.18 General Fee Schedule 12/1/2009

73219 $83.44 26 Fee Schedule (FS) 12/1/2009

73219 $477.74 TC Fee Schedule 12/1/2009

73220 $993.99 General Fee Schedule 12/1/2009

73220 $110.75 26 Fee Schedule (FS) 12/1/2009

73220 $883.23 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 161 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

73221 $69.25 26 Fee Schedule (FS) 12/1/2009

73221 $397.96 TC Fee Schedule 12/1/2009

73221 $467.20 General Fee Schedule 12/1/2009

73222 $83.09 26 Fee Schedule (FS) 12/1/2009

73222 $477.74 TC Fee Schedule 12/1/2009

73222 $560.84 General Fee Schedule 12/1/2009

73223 $110.75 26 Fee Schedule (FS) 12/1/2009

73223 $883.23 TC Fee Schedule 12/1/2009

73223 $993.99 General Fee Schedule 12/1/2009

73225 $84.02 26 Fee Schedule (FS) 12/1/2009

73225 $276.29 TC Fee Schedule 12/1/2009

73225 $460.48 General Fee Schedule 12/1/2009

73500 $25.74 General Fee Schedule 12/1/2009

73500 $8.96 26 Fee Schedule (FS) 12/1/2009

73500 $16.78 TC Fee Schedule 12/1/2009

73510 $31.75 General Fee Schedule 12/1/2009

73510 $20.90 TC Fee Schedule 12/1/2009

73510 $10.84 26 Fee Schedule (FS) 12/1/2009

73520 $13.46 26 Fee Schedule (FS) 12/1/2009

73520 $24.32 TC Fee Schedule 12/1/2009

73520 $37.79 General Fee Schedule 12/1/2009

73525 $104.43 General Fee Schedule 12/1/2009

73525 $28.04 26 Fee Schedule (FS) 12/1/2009

73525 $76.39 TC Fee Schedule 12/1/2009

73530 $12.11 26 Fee Schedule (FS) 12/1/2009

73540 $20.90 TC Fee Schedule 12/1/2009

73540 $31.36 General Fee Schedule 12/1/2009

73540 $10.46 26 Fee Schedule (FS) 12/1/2009

73550 $8.96 26 Fee Schedule (FS) 12/1/2009

73550 $20.90 TC Fee Schedule 12/1/2009

73550 $29.87 General Fee Schedule 12/1/2009

73560 $8.96 26 Fee Schedule (FS) 12/1/2009

73560 $18.50 TC Fee Schedule 12/1/2009

73560 $27.46 General Fee Schedule 12/1/2009

73562 $9.35 26 Fee Schedule (FS) 12/1/2009

73562 $20.90 TC Fee Schedule 12/1/2009

73562 $30.23 General Fee Schedule 12/1/2009

73564 $11.23 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 162 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

73564 $22.61 TC Fee Schedule 12/1/2009

73564 $33.84 General Fee Schedule 12/1/2009

73565 $8.96 26 Fee Schedule (FS) 12/1/2009

73565 $17.47 TC Fee Schedule 12/1/2009

73565 $26.43 General Fee Schedule 12/1/2009

73580 $27.70 26 Fee Schedule (FS) 12/1/2009

73580 $94.89 TC Fee Schedule 12/1/2009

73580 $122.58 General Fee Schedule 12/1/2009

73590 $27.46 General Fee Schedule 12/1/2009

73590 $8.96 26 Fee Schedule (FS) 12/1/2009

73590 $18.50 TC Fee Schedule 12/1/2009

73592 $25.70 General Fee Schedule 12/1/2009

73592 $8.23 26 Fee Schedule (FS) 12/1/2009

73592 $17.47 TC Fee Schedule 12/1/2009

73600 $8.23 26 Fee Schedule (FS) 12/1/2009

73600 $17.47 TC Fee Schedule 12/1/2009

73600 $25.70 General Fee Schedule 12/1/2009

73610 $27.79 General Fee Schedule 12/1/2009

73610 $8.96 26 Fee Schedule (FS) 12/1/2009

73610 $18.83 TC Fee Schedule 12/1/2009

73615 $104.43 General Fee Schedule 12/1/2009

73615 $28.04 26 Fee Schedule (FS) 12/1/2009

73615 $76.39 TC Fee Schedule 12/1/2009

73620 $8.23 26 Fee Schedule (FS) 12/1/2009

73620 $17.47 TC Fee Schedule 12/1/2009

73620 $25.70 General Fee Schedule 12/1/2009

73630 $27.79 General Fee Schedule 12/1/2009

73630 $18.83 TC Fee Schedule 12/1/2009

73630 $8.96 26 Fee Schedule (FS) 12/1/2009

73650 $16.78 TC Fee Schedule 12/1/2009

73650 $25.02 General Fee Schedule 12/1/2009

73650 $8.23 26 Fee Schedule (FS) 12/1/2009

73660 $6.73 26 Fee Schedule (FS) 12/1/2009

73660 $15.07 TC Fee Schedule 12/1/2009

73660 $21.81 General Fee Schedule 12/1/2009

73700 $56.13 26 Fee Schedule (FS) 12/1/2009

73700 $178.80 TC Fee Schedule 12/1/2009

73700 $234.91 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 163 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

73701 $59.51 26 Fee Schedule (FS) 12/1/2009

73701 $213.73 TC Fee Schedule 12/1/2009

73701 $273.24 General Fee Schedule 12/1/2009

73702 $62.52 26 Fee Schedule (FS) 12/1/2009

73702 $268.20 TC Fee Schedule 12/1/2009

73702 $330.71 General Fee Schedule 12/1/2009

73706 $97.33 26 Fee Schedule (FS) 12/1/2009

73706 $487.07 General Fee Schedule 12/1/2009

73706 $389.74 TC Fee Schedule 12/1/2009

73718 $69.25 26 Fee Schedule (FS) 12/1/2009

73718 $397.96 TC Fee Schedule 12/1/2009

73718 $467.20 General Fee Schedule 12/1/2009

73719 $83.09 26 Fee Schedule (FS) 12/1/2009

73719 $477.74 TC Fee Schedule 12/1/2009

73719 $560.84 General Fee Schedule 12/1/2009

73720 $110.41 26 Fee Schedule (FS) 12/1/2009

73720 $883.23 TC Fee Schedule 12/1/2009

73720 $993.64 General Fee Schedule 12/1/2009

73721 $69.25 26 Fee Schedule (FS) 12/1/2009

73721 $397.96 TC Fee Schedule 12/1/2009

73721 $467.20 General Fee Schedule 12/1/2009

73722 $560.84 General Fee Schedule 12/1/2009

73722 $83.09 26 Fee Schedule (FS) 12/1/2009

73722 $477.74 TC Fee Schedule 12/1/2009

73723 $993.99 General Fee Schedule 12/1/2009

73723 $883.23 TC Fee Schedule 12/1/2009

73723 $110.75 26 Fee Schedule (FS) 12/1/2009

73725 $93.56 26 Fee Schedule (FS) 12/1/2009

73725 $404.87 TC Fee Schedule 12/1/2009

73725 $498.42 General Fee Schedule 12/1/2009

74000 $27.85 General Fee Schedule 12/1/2009

74000 $9.35 26 Fee Schedule (FS) 12/1/2009

74000 $18.50 TC Fee Schedule 12/1/2009

74010 $32.85 General Fee Schedule 12/1/2009

74010 $11.96 26 Fee Schedule (FS) 12/1/2009

74010 $20.90 TC Fee Schedule 12/1/2009

74020 $13.85 26 Fee Schedule (FS) 12/1/2009

74020 $22.61 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 164 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

74020 $36.45 General Fee Schedule 12/1/2009

74022 $26.71 TC Fee Schedule 12/1/2009

74022 $42.84 General Fee Schedule 12/1/2009

74022 $16.12 26 Fee Schedule (FS) 12/1/2009

74150 $61.01 26 Fee Schedule (FS) 12/1/2009

74150 $204.83 TC Fee Schedule 12/1/2009

74150 $265.84 General Fee Schedule 12/1/2009

74160 $65.47 26 Fee Schedule (FS) 12/1/2009

74160 $247.30 TC Fee Schedule 12/1/2009

74160 $312.77 General Fee Schedule 12/1/2009

74170 $71.86 26 Fee Schedule (FS) 12/1/2009

74170 $306.21 TC Fee Schedule 12/1/2009

74170 $378.07 General Fee Schedule 12/1/2009

74174 $103.33 26 Fee Schedule (FS) 2/6/2012

74174 $418.44 TC Fee Schedule 2/6/2012

74174 $521.77 General Fee Schedule 2/6/2012

74175 $523.70 General Fee Schedule 12/1/2009

74175 $97.33 26 Fee Schedule (FS) 12/1/2009

74175 $426.37 TC Fee Schedule 12/1/2009

74176 $208.49 General Fee Schedule 1/1/2011

74176 $83.61 26 Fee Schedule (FS) 1/1/2011

74176 $124.88 TC Fee Schedule 1/1/2011

74177 $87.62 26 Fee Schedule (FS) 1/1/2011

74177 $238.14 TC Fee Schedule 1/1/2011

74177 $325.76 General Fee Schedule 1/1/2011

74178 $97.04 26 Fee Schedule (FS) 1/1/2011

74178 $314.71 TC Fee Schedule 1/1/2011

74178 $411.76 General Fee Schedule 1/1/2011

74181 $74.86 26 Fee Schedule (FS) 12/1/2009

74181 $400.03 TC Fee Schedule 12/1/2009

74181 $474.88 General Fee Schedule 12/1/2009

74182 $89.06 26 Fee Schedule (FS) 12/1/2009

74182 $479.48 TC Fee Schedule 12/1/2009

74182 $568.54 General Fee Schedule 12/1/2009

74183 $1,002.02 General Fee Schedule 12/1/2009

74183 $116.03 26 Fee Schedule (FS) 12/1/2009

74183 $886.00 TC Fee Schedule 12/1/2009

74185 $497.30 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 165 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

74185 $404.87 TC Fee Schedule 12/1/2009

74185 $92.44 26 Fee Schedule (FS) 12/1/2009

74190 $24.44 26 Fee Schedule (FS) 12/1/2009

74210 $18.70 26 Fee Schedule (FS) 12/1/2009

74210 $42.82 TC Fee Schedule 12/1/2009

74210 $61.51 General Fee Schedule 12/1/2009

74220 $42.82 TC Fee Schedule 12/1/2009

74220 $66.40 General Fee Schedule 12/1/2009

74220 $23.58 26 Fee Schedule (FS) 12/1/2009

74230 $47.27 TC Fee Schedule 12/1/2009

74230 $74.23 General Fee Schedule 12/1/2009

74230 $26.97 26 Fee Schedule (FS) 12/1/2009

74235 $60.38 26 Fee Schedule (FS) 12/1/2009

74240 $88.29 General Fee Schedule 12/1/2009

74240 $35.32 26 Fee Schedule (FS) 12/1/2009

74240 $52.75 TC Fee Schedule 12/1/2009

74241 $89.33 General Fee Schedule 12/1/2009

74241 $53.78 TC Fee Schedule 12/1/2009

74241 $35.55 26 Fee Schedule (FS) 12/1/2009

74245 $46.78 26 Fee Schedule (FS) 12/1/2009

74245 $86.32 TC Fee Schedule 12/1/2009

74245 $133.09 General Fee Schedule 12/1/2009

74246 $95.15 General Fee Schedule 12/1/2009

74246 $35.55 26 Fee Schedule (FS) 12/1/2009

74246 $59.61 TC Fee Schedule 12/1/2009

74247 $96.86 General Fee Schedule 12/1/2009

74247 $35.55 26 Fee Schedule (FS) 12/1/2009

74247 $61.31 TC Fee Schedule 12/1/2009

74249 $46.78 26 Fee Schedule (FS) 12/1/2009

74249 $93.17 TC Fee Schedule 12/1/2009

74249 $139.94 General Fee Schedule 12/1/2009

74250 $47.27 TC Fee Schedule 12/1/2009

74250 $71.24 General Fee Schedule 12/1/2009

74250 $23.97 26 Fee Schedule (FS) 12/1/2009

74251 $33.13 26 Fee Schedule (FS) 12/1/2009

74251 $47.27 TC Fee Schedule 12/1/2009

74251 $82.82 General Fee Schedule 12/1/2009

74260 $25.47 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 166 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

74260 $53.78 TC Fee Schedule 12/1/2009

74260 $79.25 General Fee Schedule 12/1/2009

74261 $106.17 26 Fee Schedule (FS) 1/1/2010

74261 $173.82 TC Fee Schedule 1/1/2010

74261 $279.98 General Fee Schedule 1/1/2010

74262 $116.53 26 Fee Schedule (FS) 1/1/2010

74262 $264.38 TC Fee Schedule 1/1/2010

74262 $380.92 General Fee Schedule 1/1/2010

74263 $0.00 TC by Report 1/1/2010

74263 $0.00 26 by Report 1/1/2010

74263 $0.00 General by Report 1/1/2010

74270 $97.54 General Fee Schedule 12/1/2009

74270 $35.55 26 Fee Schedule (FS) 12/1/2009

74270 $62.00 TC Fee Schedule 12/1/2009

74280 $50.55 26 Fee Schedule (FS) 12/1/2009

74280 $81.19 TC Fee Schedule 12/1/2009

74280 $131.74 General Fee Schedule 12/1/2009

74283 $78.60 26 Fee Schedule (FS) 12/1/2009

74283 $92.83 TC Fee Schedule 12/1/2009

74283 $196.50 General Fee Schedule 12/1/2009

74290 $16.12 26 Fee Schedule (FS) 12/1/2009

74290 $26.71 TC Fee Schedule 12/1/2009

74290 $42.84 General Fee Schedule 12/1/2009

74291 $10.21 26 Fee Schedule (FS) 12/1/2009

74291 $15.07 TC Fee Schedule 12/1/2009

74291 $25.53 General Fee Schedule 12/1/2009

74300 $18.51 26 Fee Schedule (FS) 12/1/2009

74301 $10.74 26 Fee Schedule (FS) 12/1/2009

74305 $19.85 26 Fee Schedule (FS) 12/1/2009

74320 $141.76 General Fee Schedule 12/1/2009

74320 $114.06 TC Fee Schedule 12/1/2009

74320 $27.69 26 Fee Schedule (FS) 12/1/2009

74327 $35.93 26 Fee Schedule (FS) 12/1/2009

74327 $64.40 TC Fee Schedule 12/1/2009

74327 $100.34 General Fee Schedule 12/1/2009

74328 $35.57 26 Fee Schedule (FS) 12/1/2009

74329 $35.57 26 Fee Schedule (FS) 12/1/2009

74330 $45.58 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 167 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

74340 $27.41 26 Fee Schedule (FS) 12/1/2009

74355 $38.53 26 Fee Schedule (FS) 12/1/2009

74360 $27.75 26 Fee Schedule (FS) 12/1/2009

74363 $44.81 26 Fee Schedule (FS) 12/1/2009

74400 $86.40 General Fee Schedule 12/1/2009

74400 $25.08 26 Fee Schedule (FS) 12/1/2009

74400 $61.31 TC Fee Schedule 12/1/2009

74410 $95.98 General Fee Schedule 12/1/2009

74410 $70.91 TC Fee Schedule 12/1/2009

74410 $25.08 26 Fee Schedule (FS) 12/1/2009

74415 $25.08 26 Fee Schedule (FS) 12/1/2009

74415 $77.07 TC Fee Schedule 12/1/2009

74415 $102.16 General Fee Schedule 12/1/2009

74420 $18.51 26 Fee Schedule (FS) 12/1/2009

74425 $18.51 26 Fee Schedule (FS) 12/1/2009

74430 $16.47 26 Fee Schedule (FS) 12/1/2009

74430 $38.02 TC Fee Schedule 12/1/2009

74430 $54.49 General Fee Schedule 12/1/2009

74440 $19.47 26 Fee Schedule (FS) 12/1/2009

74440 $40.76 TC Fee Schedule 12/1/2009

74440 $60.23 General Fee Schedule 12/1/2009

74445 $39.54 26 Fee Schedule (FS) 12/1/2009

74450 $17.01 26 Fee Schedule (FS) 12/1/2009

74455 $17.19 26 Fee Schedule (FS) 12/1/2009

74455 $74.75 General Fee Schedule 12/1/2009

74455 $57.55 TC Fee Schedule 12/1/2009

74470 $27.41 26 Fee Schedule (FS) 12/1/2009

74475 $27.69 26 Fee Schedule (FS) 12/1/2009

74475 $147.28 TC Fee Schedule 12/1/2009

74475 $174.99 General Fee Schedule 12/1/2009

74480 $147.28 TC Fee Schedule 12/1/2009

74480 $174.99 General Fee Schedule 12/1/2009

74480 $27.69 26 Fee Schedule (FS) 12/1/2009

74485 $114.06 TC Fee Schedule 12/1/2009

74485 $141.77 General Fee Schedule 12/1/2009

74485 $27.70 26 Fee Schedule (FS) 12/1/2009

74710 $55.60 General Fee Schedule 12/1/2009

74710 $17.58 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 168 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

74710 $38.02 TC Fee Schedule 12/1/2009

74740 $67.08 General Fee Schedule 12/1/2009

74740 $47.27 TC Fee Schedule 12/1/2009

74740 $20.04 26 Fee Schedule (FS) 12/1/2009

74742 $31.11 26 Fee Schedule (FS) 12/1/2009

74775 $31.83 26 Fee Schedule (FS) 12/1/2009

75557 $97.40 26 Fee Schedule (FS) 12/1/2009

75557 $298.28 TC Fee Schedule 12/1/2009

75557 $395.66 General Fee Schedule 12/1/2009

75559 $124.12 26 Fee Schedule (FS) 12/1/2009

75559 $297.45 TC Fee Schedule 12/1/2009

75559 $421.57 General Fee Schedule 12/1/2009

75561 $107.73 26 Fee Schedule (FS) 12/1/2009

75561 $455.45 TC Fee Schedule 12/1/2009

75561 $563.18 General Fee Schedule 12/1/2009

75563 $128.96 26 Fee Schedule (FS) 12/1/2009

75563 $454.91 TC Fee Schedule 12/1/2009

75563 $583.87 General Fee Schedule 12/1/2009

75565 $12.06 26 Fee Schedule (FS) 1/1/2010

75565 $82.47 General Fee Schedule 1/1/2010

75565 $70.41 TC Fee Schedule 1/1/2010

75571 $26.94 26 Fee Schedule (FS) 1/1/2010

75571 $40.22 TC Fee Schedule 1/1/2010

75571 $67.15 General Fee Schedule 1/1/2010

75572 $81.73 26 Fee Schedule (FS) 1/1/2010

75572 $158.40 TC Fee Schedule 1/1/2010

75572 $240.13 General Fee Schedule 1/1/2010

75573 $117.03 26 Fee Schedule (FS) 1/1/2010

75573 $224.24 TC Fee Schedule 1/1/2010

75573 $341.27 General Fee Schedule 1/1/2010

75574 $111.37 26 Fee Schedule (FS) 1/1/2010

75574 $239.65 TC Fee Schedule 1/1/2010

75574 $351.02 General Fee Schedule 1/1/2010

75600 $481.32 General Fee Schedule 12/1/2009

75600 $26.11 26 Fee Schedule (FS) 12/1/2009

75600 $455.21 TC Fee Schedule 12/1/2009

75605 $514.63 General Fee Schedule 12/1/2009

75605 $455.21 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 169 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

75605 $59.43 26 Fee Schedule (FS) 12/1/2009

75625 $59.08 26 Fee Schedule (FS) 12/1/2009

75625 $455.21 TC Fee Schedule 12/1/2009

75625 $514.29 General Fee Schedule 12/1/2009

75630 $568.52 General Fee Schedule 12/1/2009

75630 $93.77 26 Fee Schedule (FS) 12/1/2009

75630 $474.74 TC Fee Schedule 12/1/2009

75635 $683.38 General Fee Schedule 12/1/2009

75635 $123.48 26 Fee Schedule (FS) 12/1/2009

75635 $559.89 TC Fee Schedule 12/1/2009

75658 $69.07 26 Fee Schedule (FS) 12/1/2009

75658 $455.21 TC Fee Schedule 12/1/2009

75658 $524.29 General Fee Schedule 12/1/2009

75705 $455.21 TC Fee Schedule 12/1/2009

75705 $568.85 General Fee Schedule 12/1/2009

75705 $113.63 26 Fee Schedule (FS) 12/1/2009

75710 $59.77 26 Fee Schedule (FS) 12/1/2009

75710 $455.21 TC Fee Schedule 12/1/2009

75710 $514.98 General Fee Schedule 12/1/2009

75716 $67.70 26 Fee Schedule (FS) 12/1/2009

75716 $455.21 TC Fee Schedule 12/1/2009

75716 $522.92 General Fee Schedule 12/1/2009

75726 $58.40 26 Fee Schedule (FS) 12/1/2009

75726 $455.21 TC Fee Schedule 12/1/2009

75726 $513.61 General Fee Schedule 12/1/2009

75731 $58.74 26 Fee Schedule (FS) 12/1/2009

75731 $455.21 TC Fee Schedule 12/1/2009

75731 $513.95 General Fee Schedule 12/1/2009

75733 $67.70 26 Fee Schedule (FS) 12/1/2009

75733 $455.21 TC Fee Schedule 12/1/2009

75733 $522.91 General Fee Schedule 12/1/2009

75736 $59.08 26 Fee Schedule (FS) 12/1/2009

75736 $455.21 TC Fee Schedule 12/1/2009

75736 $514.29 General Fee Schedule 12/1/2009

75741 $67.37 26 Fee Schedule (FS) 12/1/2009

75741 $455.21 TC Fee Schedule 12/1/2009

75741 $522.57 General Fee Schedule 12/1/2009

75743 $84.98 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 170 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

75743 $455.21 TC Fee Schedule 12/1/2009

75743 $540.19 General Fee Schedule 12/1/2009

75746 $58.73 26 Fee Schedule (FS) 12/1/2009

75746 $455.21 TC Fee Schedule 12/1/2009

75746 $513.94 General Fee Schedule 12/1/2009

75756 $60.79 26 Fee Schedule (FS) 12/1/2009

75756 $455.21 TC Fee Schedule 12/1/2009

75756 $516.00 General Fee Schedule 12/1/2009

75774 $473.91 General Fee Schedule 12/1/2009

75774 $18.70 26 Fee Schedule (FS) 12/1/2009

75774 $455.21 TC Fee Schedule 12/1/2009

75791 $223.78 General Fee Schedule 1/1/2010

75791 $143.95 TC Fee Schedule 1/1/2010

75791 $79.83 26 Fee Schedule (FS) 1/1/2010

75801 $42.84 26 Fee Schedule (FS) 12/1/2009

75803 $59.29 26 Fee Schedule (FS) 12/1/2009

75805 $41.81 26 Fee Schedule (FS) 12/1/2009

75807 $59.29 26 Fee Schedule (FS) 12/1/2009

75809 $28.44 TC Fee Schedule 12/1/2009

75809 $52.40 General Fee Schedule 12/1/2009

75809 $20.96 26 Fee Schedule (FS) 12/1/2009

75810 $57.80 26 Fee Schedule (FS) 12/1/2009

75820 $28.21 26 Fee Schedule (FS) 12/1/2009

75820 $34.60 TC Fee Schedule 12/1/2009

75820 $70.53 General Fee Schedule 12/1/2009

75822 $108.07 General Fee Schedule 12/1/2009

75822 $43.22 26 Fee Schedule (FS) 12/1/2009

75822 $53.43 TC Fee Schedule 12/1/2009

75825 $514.30 General Fee Schedule 12/1/2009

75825 $455.21 TC Fee Schedule 12/1/2009

75825 $59.09 26 Fee Schedule (FS) 12/1/2009

75827 $58.40 26 Fee Schedule (FS) 12/1/2009

75827 $455.21 TC Fee Schedule 12/1/2009

75827 $513.61 General Fee Schedule 12/1/2009

75831 $513.95 General Fee Schedule 12/1/2009

75831 $58.74 26 Fee Schedule (FS) 12/1/2009

75831 $455.21 TC Fee Schedule 12/1/2009

75833 $532.61 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 171 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

75833 $77.40 26 Fee Schedule (FS) 12/1/2009

75833 $455.21 TC Fee Schedule 12/1/2009

75840 $59.43 26 Fee Schedule (FS) 12/1/2009

75840 $455.21 TC Fee Schedule 12/1/2009

75840 $514.63 General Fee Schedule 12/1/2009

75842 $455.21 TC Fee Schedule 12/1/2009

75842 $531.58 General Fee Schedule 12/1/2009

75842 $76.37 26 Fee Schedule (FS) 12/1/2009

75860 $58.73 26 Fee Schedule (FS) 12/1/2009

75860 $455.21 TC Fee Schedule 12/1/2009

75860 $513.94 General Fee Schedule 12/1/2009

75870 $59.08 26 Fee Schedule (FS) 12/1/2009

75870 $455.21 TC Fee Schedule 12/1/2009

75870 $514.29 General Fee Schedule 12/1/2009

75872 $61.51 26 Fee Schedule (FS) 12/1/2009

75872 $455.21 TC Fee Schedule 12/1/2009

75872 $516.72 General Fee Schedule 12/1/2009

75880 $28.21 26 Fee Schedule (FS) 12/1/2009

75880 $34.60 TC Fee Schedule 12/1/2009

75880 $70.53 General Fee Schedule 12/1/2009

75885 $528.96 General Fee Schedule 12/1/2009

75885 $73.75 26 Fee Schedule (FS) 12/1/2009

75885 $455.21 TC Fee Schedule 12/1/2009

75887 $528.96 General Fee Schedule 12/1/2009

75887 $455.21 TC Fee Schedule 12/1/2009

75887 $73.75 26 Fee Schedule (FS) 12/1/2009

75889 $58.40 26 Fee Schedule (FS) 12/1/2009

75889 $455.21 TC Fee Schedule 12/1/2009

75889 $513.61 General Fee Schedule 12/1/2009

75891 $513.61 General Fee Schedule 12/1/2009

75891 $58.40 26 Fee Schedule (FS) 12/1/2009

75891 $455.21 TC Fee Schedule 12/1/2009

75893 $482.91 General Fee Schedule 12/1/2009

75893 $27.69 26 Fee Schedule (FS) 12/1/2009

75893 $455.21 TC Fee Schedule 12/1/2009

75894 $67.36 26 Fee Schedule (FS) 12/1/2009

75896 $67.01 26 Fee Schedule (FS) 12/1/2009

75898 $48.67 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 172 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

75901 $98.60 General Fee Schedule 12/1/2009

75901 $73.53 TC Fee Schedule 12/1/2009

75901 $25.08 26 Fee Schedule (FS) 12/1/2009

75902 $73.53 TC Fee Schedule 12/1/2009

75902 $93.72 General Fee Schedule 12/1/2009

75902 $20.20 26 Fee Schedule (FS) 12/1/2009

75945 $21.39 26 Fee Schedule (FS) 12/1/2009

75946 $21.74 26 Fee Schedule (FS) 12/1/2009

75952 $236.74 26 Fee Schedule (FS) 12/1/2009

75953 $71.65 26 Fee Schedule (FS) 12/1/2009

75954 $117.53 26 Fee Schedule (FS) 12/1/2009

75956 $382.87 26 Fee Schedule (FS) 12/1/2009

75957 $328.02 26 Fee Schedule (FS) 12/1/2009

75958 $218.68 26 Fee Schedule (FS) 12/1/2009

75959 $191.43 26 Fee Schedule (FS) 12/1/2009

75962 $28.04 26 Fee Schedule (FS) 12/1/2009

75962 $569.27 TC Fee Schedule 12/1/2009

75962 $597.32 General Fee Schedule 12/1/2009

75964 $19.03 26 Fee Schedule (FS) 12/1/2009

75964 $302.79 TC Fee Schedule 12/1/2009

75964 $321.83 General Fee Schedule 12/1/2009

75966 $68.39 26 Fee Schedule (FS) 12/1/2009

75966 $569.27 TC Fee Schedule 12/1/2009

75966 $637.66 General Fee Schedule 12/1/2009

75968 $19.03 26 Fee Schedule (FS) 12/1/2009

75968 $302.79 TC Fee Schedule 12/1/2009

75968 $321.83 General Fee Schedule 12/1/2009

75970 $42.56 26 Fee Schedule (FS) 12/1/2009

75978 $596.98 General Fee Schedule 12/1/2009

75978 $27.69 26 Fee Schedule (FS) 12/1/2009

75978 $569.27 TC Fee Schedule 12/1/2009

75980 $73.00 26 Fee Schedule (FS) 12/1/2009

75982 $73.00 26 Fee Schedule (FS) 12/1/2009

75984 $107.60 General Fee Schedule 12/1/2009

75984 $36.70 26 Fee Schedule (FS) 12/1/2009

75984 $70.91 TC Fee Schedule 12/1/2009

75989 $175.07 General Fee Schedule 12/1/2009

75989 $114.06 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 173 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

75989 $61.01 26 Fee Schedule (FS) 12/1/2009

76000 $8.61 26 Fee Schedule (FS) 12/1/2009

76000 $47.27 TC Fee Schedule 12/1/2009

76000 $55.88 General Fee Schedule 12/1/2009

76001 $34.76 26 Fee Schedule (FS) 12/1/2009

76010 $18.50 TC Fee Schedule 12/1/2009

76010 $27.85 General Fee Schedule 12/1/2009

76010 $9.35 26 Fee Schedule (FS) 12/1/2009

76080 $38.02 TC Fee Schedule 12/1/2009

76080 $65.72 General Fee Schedule 12/1/2009

76080 $26.29 26 Fee Schedule (FS) 12/1/2009

76098 $8.23 26 Fee Schedule (FS) 12/1/2009

76098 $15.07 TC Fee Schedule 12/1/2009

76098 $23.30 General Fee Schedule 12/1/2009

76100 $29.92 26 Fee Schedule (FS) 12/1/2009

76100 $45.21 TC Fee Schedule 12/1/2009

76100 $75.15 General Fee Schedule 12/1/2009

76101 $29.92 26 Fee Schedule (FS) 12/1/2009

76101 $51.38 TC Fee Schedule 12/1/2009

76101 $81.31 General Fee Schedule 12/1/2009

76102 $93.30 General Fee Schedule 12/1/2009

76102 $29.92 26 Fee Schedule (FS) 12/1/2009

76102 $63.37 TC Fee Schedule 12/1/2009

76120 $57.83 General Fee Schedule 12/1/2009

76120 $19.81 26 Fee Schedule (FS) 12/1/2009

76120 $38.02 TC Fee Schedule 12/1/2009

76125 $13.85 26 Fee Schedule (FS) 12/1/2009

76125 $28.15 TC Fee Schedule 12/1/2009

76125 $42.28 General Fee Schedule 12/1/2009

76140 $11.31 General Fee Schedule 12/1/2009

76376 $131.00 General Fee Schedule 12/1/2009

76376 $120.19 TC Fee Schedule 12/1/2009

76376 $10.81 26 Fee Schedule (FS) 12/1/2009

76377 $128.14 TC Fee Schedule 12/1/2009

76377 $170.64 General Fee Schedule 12/1/2009

76377 $42.51 26 Fee Schedule (FS) 12/1/2009

76380 $50.16 26 Fee Schedule (FS) 12/1/2009

76380 $126.38 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 174 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

76380 $176.56 General Fee Schedule 12/1/2009

76390 $424.70 General Fee Schedule 12/1/2009

76496 $0.00 General by Report 1/1/2003

76497 $0.00 General by Report 1/1/2003

76498 $0.00 General by Report 1/1/2003

76499 $0.00 26 by Report 6/1/1981

76499 $0.00 General by Report 10/1/1975

76506 $85.99 General Fee Schedule 12/1/2009

76506 $34.40 26 Fee Schedule (FS) 12/1/2009

76506 $51.38 TC Fee Schedule 12/1/2009

76510 $161.54 General Fee Schedule 12/1/2009

76510 $77.40 TC Fee Schedule 12/1/2009

76510 $64.62 26 Fee Schedule (FS) 12/1/2009

76511 $49.31 26 Fee Schedule (FS) 12/1/2009

76511 $72.27 TC Fee Schedule 12/1/2009

76511 $123.28 General Fee Schedule 12/1/2009

76512 $115.92 General Fee Schedule 12/1/2009

76512 $42.39 26 Fee Schedule (FS) 12/1/2009

76512 $65.10 TC Fee Schedule 12/1/2009

76513 $91.60 General Fee Schedule 12/1/2009

76513 $36.09 26 Fee Schedule (FS) 12/1/2009

76513 $55.49 TC Fee Schedule 12/1/2009

76514 $2.06 TC Fee Schedule 12/1/2009

76514 $4.68 26 Fee Schedule (FS) 12/1/2009

76514 $11.70 General Fee Schedule 12/1/2009

76516 $43.73 TC Fee Schedule 12/1/2009

76516 $72.85 General Fee Schedule 12/1/2009

76516 $26.61 26 Fee Schedule (FS) 12/1/2009

76519 $29.40 26 Fee Schedule (FS) 12/1/2009

76519 $47.27 TC Fee Schedule 12/1/2009

76519 $76.67 General Fee Schedule 12/1/2009

76529 $26.19 26 Fee Schedule (FS) 12/1/2009

76529 $41.03 TC Fee Schedule 12/1/2009

76529 $71.62 General Fee Schedule 12/1/2009

76536 $28.47 26 Fee Schedule (FS) 12/1/2009

76536 $51.38 TC Fee Schedule 12/1/2009

76536 $79.85 General Fee Schedule 12/1/2009

76604 $28.08 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 175 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

76604 $47.27 TC Fee Schedule 12/1/2009

76604 $75.35 General Fee Schedule 12/1/2009

76645 $26.29 26 Fee Schedule (FS) 12/1/2009

76645 $38.02 TC Fee Schedule 12/1/2009

76645 $65.72 General Fee Schedule 12/1/2009

76700 $41.89 26 Fee Schedule (FS) 12/1/2009

76700 $113.48 General Fee Schedule 12/1/2009

76700 $71.59 TC Fee Schedule 12/1/2009

76705 $30.31 26 Fee Schedule (FS) 12/1/2009

76705 $51.38 TC Fee Schedule 12/1/2009

76705 $81.69 General Fee Schedule 12/1/2009

76770 $109.41 General Fee Schedule 12/1/2009

76770 $37.82 26 Fee Schedule (FS) 12/1/2009

76770 $71.59 TC Fee Schedule 12/1/2009

76775 $81.31 General Fee Schedule 12/1/2009

76775 $29.92 26 Fee Schedule (FS) 12/1/2009

76775 $51.38 TC Fee Schedule 12/1/2009

76776 $31.80 26 Fee Schedule (FS) 12/1/2009

76776 $72.23 TC Fee Schedule 12/1/2009

76776 $104.03 General Fee Schedule 12/1/2009

76800 $107.26 General Fee Schedule 12/1/2009

76800 $50.86 TC Fee Schedule 12/1/2009

76800 $42.90 26 Fee Schedule (FS) 12/1/2009

76801 $90.94 TC Fee Schedule 12/1/2009

76801 $151.93 General Fee Schedule 12/1/2009

76801 $60.77 26 Fee Schedule (FS) 12/1/2009

76802 $39.74 26 Fee Schedule (FS) 12/1/2009

76802 $47.73 TC Fee Schedule 12/1/2009

76802 $99.34 General Fee Schedule 12/1/2009

76805 $60.67 26 Fee Schedule (FS) 12/1/2009

76805 $90.94 TC Fee Schedule 12/1/2009

76805 $151.93 General Fee Schedule 12/1/2009

76810 $44.95 26 Fee Schedule (FS) 12/1/2009

76810 $51.85 TC Fee Schedule 12/1/2009

76810 $112.37 General Fee Schedule 12/1/2009

76811 $112.77 26 Fee Schedule (FS) 12/1/2009

76811 $161.97 TC Fee Schedule 12/1/2009

76811 $281.92 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 176 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

76812 $59.66 TC Fee Schedule 12/1/2009

76812 $68.66 26 Fee Schedule (FS) 12/1/2009

76812 $171.64 General Fee Schedule 12/1/2009

76813 $56.18 26 Fee Schedule (FS) 12/1/2009

76813 $76.25 TC Fee Schedule 12/1/2009

76813 $140.45 General Fee Schedule 12/1/2009

76814 $37.55 26 Fee Schedule (FS) 12/1/2009

76814 $39.94 TC Fee Schedule 12/1/2009

76814 $93.88 General Fee Schedule 12/1/2009

76815 $40.48 26 Fee Schedule (FS) 12/1/2009

76815 $61.17 TC Fee Schedule 12/1/2009

76815 $101.65 General Fee Schedule 12/1/2009

76816 $40.58 26 Fee Schedule (FS) 12/1/2009

76816 $47.71 TC Fee Schedule 12/1/2009

76816 $101.45 General Fee Schedule 12/1/2009

76817 $110.72 General Fee Schedule 12/1/2009

76817 $44.29 26 Fee Schedule (FS) 12/1/2009

76817 $64.42 TC Fee Schedule 12/1/2009

76818 $135.94 General Fee Schedule 12/1/2009

76818 $54.38 26 Fee Schedule (FS) 12/1/2009

76818 $69.73 TC Fee Schedule 12/1/2009

76819 $48.02 26 Fee Schedule (FS) 12/1/2009

76819 $69.73 TC Fee Schedule 12/1/2009

76819 $120.67 General Fee Schedule 12/1/2009

76820 $102.51 General Fee Schedule 12/1/2009

76820 $31.95 26 Fee Schedule (FS) 12/1/2009

76820 $70.56 TC Fee Schedule 12/1/2009

76821 $114.95 General Fee Schedule 12/1/2009

76821 $44.41 26 Fee Schedule (FS) 12/1/2009

76821 $70.56 TC Fee Schedule 12/1/2009

76825 $75.72 26 Fee Schedule (FS) 12/1/2009

76825 $85.22 TC Fee Schedule 12/1/2009

76825 $189.30 General Fee Schedule 12/1/2009

76826 $82.19 General Fee Schedule 12/1/2009

76826 $32.87 26 Fee Schedule (FS) 12/1/2009

76826 $30.99 TC Fee Schedule 12/1/2009

76827 $75.04 TC Fee Schedule 12/1/2009

76827 $111.07 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 177 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

76827 $36.04 26 Fee Schedule (FS) 12/1/2009

76828 $33.79 26 Fee Schedule (FS) 12/1/2009

76828 $48.54 TC Fee Schedule 12/1/2009

76828 $84.47 General Fee Schedule 12/1/2009

76830 $35.55 26 Fee Schedule (FS) 12/1/2009

76830 $55.49 TC Fee Schedule 12/1/2009

76830 $91.04 General Fee Schedule 12/1/2009

76831 $37.15 26 Fee Schedule (FS) 12/1/2009

76831 $55.49 TC Fee Schedule 12/1/2009

76831 $92.88 General Fee Schedule 12/1/2009

76856 $35.55 26 Fee Schedule (FS) 12/1/2009

76856 $55.49 TC Fee Schedule 12/1/2009

76856 $91.04 General Fee Schedule 12/1/2009

76857 $19.47 26 Fee Schedule (FS) 12/1/2009

76857 $80.08 General Fee Schedule 12/1/2009

76857 $60.63 TC Fee Schedule 12/1/2009

76870 $32.93 26 Fee Schedule (FS) 12/1/2009

76870 $55.49 TC Fee Schedule 12/1/2009

76870 $88.43 General Fee Schedule 12/1/2009

76872 $35.55 26 Fee Schedule (FS) 12/1/2009

76872 $72.95 TC Fee Schedule 12/1/2009

76872 $108.50 General Fee Schedule 12/1/2009

76873 $63.13 26 Fee Schedule (FS) 12/1/2009

76873 $77.76 TC Fee Schedule 12/1/2009

76873 $157.83 General Fee Schedule 12/1/2009

76881 $28.56 26 Fee Schedule (FS) 1/1/2011

76881 $81.76 TC Fee Schedule 1/1/2011

76881 $110.32 General Fee Schedule 1/1/2011

76882 $29.52 General Fee Schedule 1/1/2011

76882 $9.69 TC Fee Schedule 1/1/2011

76882 $19.83 26 Fee Schedule (FS) 1/1/2011

76885 $93.31 General Fee Schedule 12/1/2009

76885 $55.49 TC Fee Schedule 12/1/2009

76885 $37.33 26 Fee Schedule (FS) 12/1/2009

76886 $31.82 26 Fee Schedule (FS) 12/1/2009

76886 $51.38 TC Fee Schedule 12/1/2009

76886 $83.19 General Fee Schedule 12/1/2009

76930 $90.61 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 178 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

76930 $35.10 26 Fee Schedule (FS) 12/1/2009

76930 $55.49 TC Fee Schedule 12/1/2009

76932 $34.75 26 Fee Schedule (FS) 12/1/2009

76936 $227.78 TC Fee Schedule 12/1/2009

76936 $331.67 General Fee Schedule 12/1/2009

76936 $103.90 26 Fee Schedule (FS) 12/1/2009

76937 $13.00 26 Fee Schedule (FS) 12/1/2009

76937 $16.47 TC Fee Schedule 12/1/2009

76937 $32.50 General Fee Schedule 12/1/2009

76940 $68.18 26 Fee Schedule (FS) 12/1/2009

76941 $49.64 26 Fee Schedule (FS) 12/1/2009

76942 $34.43 26 Fee Schedule (FS) 12/1/2009

76942 $100.01 TC Fee Schedule 12/1/2009

76942 $134.43 General Fee Schedule 12/1/2009

76945 $33.21 26 Fee Schedule (FS) 1/1/2010

76945 $55.01 TC Fee Schedule 1/1/2010

76945 $89.36 General Fee Schedule 1/1/2010

76946 $20.16 26 Fee Schedule (FS) 12/1/2009

76946 $55.49 TC Fee Schedule 12/1/2009

76946 $75.64 General Fee Schedule 12/1/2009

76948 $19.81 26 Fee Schedule (FS) 12/1/2009

76948 $55.49 TC Fee Schedule 12/1/2009

76948 $75.31 General Fee Schedule 12/1/2009

76950 $27.07 26 Fee Schedule (FS) 12/1/2009

76950 $46.78 TC Fee Schedule 12/1/2009

76950 $76.42 General Fee Schedule 12/1/2009

76965 $69.21 26 Fee Schedule (FS) 12/1/2009

76965 $270.62 General Fee Schedule 12/1/2009

76965 $201.40 TC Fee Schedule 12/1/2009

76970 $20.58 26 Fee Schedule (FS) 12/1/2009

76970 $38.02 TC Fee Schedule 12/1/2009

76970 $58.61 General Fee Schedule 12/1/2009

76975 $38.69 26 Fee Schedule (FS) 12/1/2009

76977 $29.80 TC Fee Schedule 12/1/2009

76977 $32.77 General Fee Schedule 12/1/2009

76977 $2.97 26 Fee Schedule (FS) 12/1/2009

76998 $112.09 TC Fee Schedule 1/1/2011

76998 $182.66 General Fee Schedule 1/1/2011

Tuesday, February 11, 2014 Page 179 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

76998 $65.21 26 Fee Schedule (FS) 1/1/2011

76999 $0.00 26 by Report 6/1/1981

76999 $0.00 General by Report 7/1/1975

77001 $52.69 TC Fee Schedule 12/1/2009

77001 $68.90 General Fee Schedule 12/1/2009

77001 $16.21 26 Fee Schedule (FS) 12/1/2009

77002 $40.60 TC Fee Schedule 12/1/2009

77002 $63.30 General Fee Schedule 12/1/2009

77002 $22.69 26 Fee Schedule (FS) 12/1/2009

77003 $24.42 26 Fee Schedule (FS) 12/1/2009

77003 $37.19 TC Fee Schedule 12/1/2009

77003 $61.63 General Fee Schedule 12/1/2009

77011 $51.70 26 Fee Schedule (FS) 12/1/2009

77011 $353.72 TC Fee Schedule 12/1/2009

77011 $405.41 General Fee Schedule 12/1/2009

77012 $49.32 26 Fee Schedule (FS) 12/1/2009

77012 $219.13 TC Fee Schedule 12/1/2009

77012 $268.46 General Fee Schedule 12/1/2009

77013 $201.91 26 Fee Schedule (FS) 1/1/2011

77013 $404.93 TC Fee Schedule 1/1/2011

77013 $625.52 General Fee Schedule 1/1/2011

77014 $36.45 26 Fee Schedule (FS) 12/1/2009

77014 $105.70 TC Fee Schedule 12/1/2009

77014 $142.16 General Fee Schedule 12/1/2009

77021 $65.11 26 Fee Schedule (FS) 12/1/2009

77021 $345.31 TC Fee Schedule 12/1/2009

77021 $410.42 General Fee Schedule 12/1/2009

77022 $213.33 26 Fee Schedule (FS) 1/1/2011

77022 $528.25 TC Fee Schedule 1/1/2011

77022 $765.10 General Fee Schedule 1/1/2011

77051 $2.68 26 Fee Schedule (FS) 12/1/2009

77051 $11.48 TC Fee Schedule 12/1/2009

77051 $14.14 General Fee Schedule 12/1/2009

77052 $2.68 26 Fee Schedule (FS) 12/1/2009

77052 $11.48 TC Fee Schedule 12/1/2009

77052 $14.14 General Fee Schedule 12/1/2009

77053 $84.63 General Fee Schedule 12/1/2009

77053 $15.51 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 180 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

77053 $69.11 TC Fee Schedule 12/1/2009

77054 $121.20 General Fee Schedule 12/1/2009

77054 $19.24 26 Fee Schedule (FS) 12/1/2009

77054 $101.98 TC Fee Schedule 12/1/2009

77055 $7.74 26 Fee Schedule (FS) 12/1/2009

77055 $36.58 TC Fee Schedule 12/1/2009

77055 $44.33 General Fee Schedule 12/1/2009

77056 $82.72 General Fee Schedule 12/1/2009

77056 $36.84 26 Fee Schedule (FS) 12/1/2009

77056 $45.88 TC Fee Schedule 12/1/2009

77057 $69.41 General Fee Schedule 12/1/2009

77057 $29.75 26 Fee Schedule (FS) 12/1/2009

77057 $39.67 TC Fee Schedule 12/1/2009

77058 $69.31 26 Fee Schedule (FS) 12/1/2009

77058 $594.23 TC Fee Schedule 12/1/2009

77058 $663.54 General Fee Schedule 12/1/2009

77059 $749.82 TC Fee Schedule 12/1/2009

77059 $819.13 General Fee Schedule 12/1/2009

77059 $69.31 26 Fee Schedule (FS) 12/1/2009

77071 $25.00 General Fee Schedule 12/1/2009

77072 $7.80 26 Fee Schedule (FS) 12/1/2009

77072 $11.16 TC Fee Schedule 12/1/2009

77072 $18.95 General Fee Schedule 12/1/2009

77073 $11.48 26 Fee Schedule (FS) 12/1/2009

77073 $23.87 TC Fee Schedule 12/1/2009

77073 $35.35 General Fee Schedule 12/1/2009

77074 $19.24 26 Fee Schedule (FS) 12/1/2009

77074 $34.41 TC Fee Schedule 12/1/2009

77074 $53.64 General Fee Schedule 12/1/2009

77075 $23.31 26 Fee Schedule (FS) 12/1/2009

77075 $51.46 TC Fee Schedule 12/1/2009

77075 $74.76 General Fee Schedule 12/1/2009

77076 $61.67 General Fee Schedule 12/1/2009

77076 $29.75 26 Fee Schedule (FS) 12/1/2009

77076 $31.93 TC Fee Schedule 12/1/2009

77077 $45.43 General Fee Schedule 12/1/2009

77077 $13.49 26 Fee Schedule (FS) 12/1/2009

77077 $31.92 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 181 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

77078 $10.47 26 Fee Schedule (FS) 12/1/2009

77078 $108.18 TC Fee Schedule 12/1/2009

77078 $118.65 General Fee Schedule 12/1/2009

77080 $92.14 General Fee Schedule 12/1/2009

77080 $9.38 26 Fee Schedule (FS) 12/1/2009

77080 $82.75 TC Fee Schedule 12/1/2009

77081 $33.64 General Fee Schedule 12/1/2009

77081 $9.78 26 Fee Schedule (FS) 12/1/2009

77081 $23.87 TC Fee Schedule 12/1/2009

77082 $7.41 26 Fee Schedule (FS) 12/1/2009

77082 $21.69 TC Fee Schedule 12/1/2009

77082 $29.10 General Fee Schedule 12/1/2009

77084 $381.90 TC Fee Schedule 12/1/2009

77084 $450.16 General Fee Schedule 12/1/2009

77084 $68.26 26 Fee Schedule (FS) 12/1/2009

77261 $73.54 General Fee Schedule 12/1/2009

77262 $110.93 General Fee Schedule 12/1/2009

77263 $164.74 General Fee Schedule 12/1/2009

77280 $35.93 26 Fee Schedule (FS) 12/1/2009

77280 $125.36 TC Fee Schedule 12/1/2009

77280 $161.30 General Fee Schedule 12/1/2009

77285 $53.90 26 Fee Schedule (FS) 12/1/2009

77285 $201.74 TC Fee Schedule 12/1/2009

77285 $255.64 General Fee Schedule 12/1/2009

77290 $80.09 26 Fee Schedule (FS) 12/1/2009

77290 $235.66 TC Fee Schedule 12/1/2009

77290 $315.75 General Fee Schedule 12/1/2009

77293 $101.82 26 Fee Schedule (FS) 1/1/2014

77293 $301.62 TC Fee Schedule 1/1/2014

77293 $403.44 General Fee Schedule 1/1/2014

77295 $233.93 26 Fee Schedule (FS) 12/1/2009

77295 $1,244.04 General Fee Schedule 12/1/2009

77295 $1,010.11 TC Fee Schedule 12/1/2009

77299 $0.00 26 by Report 6/1/1981

77299 $0.00 General by Report 7/1/1975

77300 $31.82 26 Fee Schedule (FS) 12/1/2009

77300 $48.30 TC Fee Schedule 12/1/2009

77300 $80.11 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 182 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

77301 $410.21 26 Fee Schedule (FS) 12/1/2009

77301 $1,010.11 TC Fee Schedule 12/1/2009

77301 $1,420.32 General Fee Schedule 12/1/2009

77305 $36.28 26 Fee Schedule (FS) 12/1/2009

77305 $67.82 TC Fee Schedule 12/1/2009

77305 $104.10 General Fee Schedule 12/1/2009

77310 $138.51 General Fee Schedule 12/1/2009

77310 $53.90 26 Fee Schedule (FS) 12/1/2009

77310 $84.60 TC Fee Schedule 12/1/2009

77315 $176.35 General Fee Schedule 12/1/2009

77315 $96.25 TC Fee Schedule 12/1/2009

77315 $70.54 26 Fee Schedule (FS) 12/1/2009

77321 $48.66 26 Fee Schedule (FS) 12/1/2009

77321 $145.91 TC Fee Schedule 12/1/2009

77321 $194.58 General Fee Schedule 12/1/2009

77326 $47.90 26 Fee Schedule (FS) 12/1/2009

77326 $85.63 TC Fee Schedule 12/1/2009

77326 $133.53 General Fee Schedule 12/1/2009

77327 $71.13 26 Fee Schedule (FS) 12/1/2009

77327 $125.36 TC Fee Schedule 12/1/2009

77327 $196.50 General Fee Schedule 12/1/2009

77328 $107.41 26 Fee Schedule (FS) 12/1/2009

77328 $178.80 TC Fee Schedule 12/1/2009

77328 $286.21 General Fee Schedule 12/1/2009

77331 $62.36 General Fee Schedule 12/1/2009

77331 $17.81 TC Fee Schedule 12/1/2009

77331 $24.95 26 Fee Schedule (FS) 12/1/2009

77332 $76.00 General Fee Schedule 12/1/2009

77332 $48.30 TC Fee Schedule 12/1/2009

77332 $27.70 26 Fee Schedule (FS) 12/1/2009

77333 $43.05 26 Fee Schedule (FS) 12/1/2009

77333 $68.85 TC Fee Schedule 12/1/2009

77333 $111.90 General Fee Schedule 12/1/2009

77334 $181.12 General Fee Schedule 12/1/2009

77334 $63.62 26 Fee Schedule (FS) 12/1/2009

77334 $117.49 TC Fee Schedule 12/1/2009

77336 $57.03 TC Fee Schedule 12/1/2009

77336 $107.90 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 183 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

77338 $215.08 26 Fee Schedule (FS) 1/1/2010

77338 $224.56 TC Fee Schedule 1/1/2010

77338 $439.64 General Fee Schedule 1/1/2010

77370 $68.00 TC Fee Schedule 12/1/2009

77370 $126.05 General Fee Schedule 12/1/2009

77371 $942.08 General Fee Schedule 12/1/2009

77372 $715.08 General Fee Schedule 12/1/2009

77373 $1,333.45 General Fee Schedule 12/1/2009

77399 $0.00 26 by Report 6/1/1981

77399 $0.00 General by Report 7/1/1975

77401 $64.09 General Fee Schedule 12/1/2009

77402 $64.09 General Fee Schedule 12/1/2009

77403 $64.09 General Fee Schedule 12/1/2009

77404 $64.09 General Fee Schedule 12/1/2009

77406 $64.09 General Fee Schedule 12/1/2009

77407 $75.26 General Fee Schedule 12/1/2009

77408 $75.26 General Fee Schedule 12/1/2009

77409 $75.26 General Fee Schedule 12/1/2009

77411 $75.26 General Fee Schedule 12/1/2009

77412 $83.74 General Fee Schedule 12/1/2009

77413 $83.74 General Fee Schedule 12/1/2009

77414 $83.74 General Fee Schedule 12/1/2009

77416 $83.74 General Fee Schedule 12/1/2009

77417 $21.36 General Fee Schedule 12/1/2009

77418 $623.15 General Fee Schedule 12/1/2009

77421 $20.20 26 Fee Schedule (FS) 12/1/2009

77421 $118.50 TC Fee Schedule 12/1/2009

77421 $138.69 General Fee Schedule 12/1/2009

77422 $63.03 General Fee Schedule 12/1/2009

77423 $81.87 General Fee Schedule 12/1/2009

77424 $0.00 General by Report 1/1/2012

77424 $0.00 TC by Report 1/1/2012

77424 $0.00 26 by Report 1/1/2012

77425 $0.00 General by Report 1/1/2012

77425 $0.00 TC by Report 1/1/2012

77425 $0.00 26 by Report 1/1/2012

77427 $168.20 General Fee Schedule 12/1/2009

77431 $95.27 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 184 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

77432 $419.49 General Fee Schedule 12/1/2009

77435 $572.42 General Fee Schedule 12/1/2009

77469 $290.24 General Fee Schedule 2/6/2012

77469 $0.00 TC by Report 1/1/2012

77469 $0.00 26 by Report 1/1/2012

77470 $107.41 26 Fee Schedule (FS) 12/1/2009

77470 $403.15 TC Fee Schedule 12/1/2009

77470 $510.56 General Fee Schedule 12/1/2009

77499 $0.00 26 by Report 6/1/1981

77499 $0.00 General by Report 7/1/1975

77520 $868.55 General Fee Schedule 1/1/2011

77522 $898.89 General Fee Schedule 1/1/2011

77523 $933.94 General Fee Schedule 1/1/2011

77525 $1,042.47 General Fee Schedule 1/1/2011

77600 $68.90 26 Fee Schedule (FS) 12/1/2009

77600 $109.17 TC Fee Schedule 12/1/2009

77600 $188.45 General Fee Schedule 12/1/2009

77605 $253.13 General Fee Schedule 12/1/2009

77605 $145.45 TC Fee Schedule 12/1/2009

77605 $92.56 26 Fee Schedule (FS) 12/1/2009

77610 $110.29 TC Fee Schedule 12/1/2009

77610 $190.73 General Fee Schedule 12/1/2009

77610 $76.29 26 Fee Schedule (FS) 12/1/2009

77615 $101.61 26 Fee Schedule (FS) 12/1/2009

77615 $146.95 TC Fee Schedule 12/1/2009

77615 $254.01 General Fee Schedule 12/1/2009

77620 $78.09 26 Fee Schedule (FS) 12/1/2009

77620 $110.29 TC Fee Schedule 12/1/2009

77620 $195.21 General Fee Schedule 12/1/2009

77750 $47.95 TC Fee Schedule 12/1/2009

77750 $119.93 26 Fee Schedule (FS) 12/1/2009

77750 $299.82 General Fee Schedule 12/1/2009

77761 $90.77 TC Fee Schedule 12/1/2009

77761 $112.53 26 Fee Schedule (FS) 12/1/2009

77761 $281.33 General Fee Schedule 12/1/2009

77762 $130.50 TC Fee Schedule 12/1/2009

77762 $169.57 26 Fee Schedule (FS) 12/1/2009

77762 $423.91 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 185 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

77763 $162.01 TC Fee Schedule 12/1/2009

77763 $240.57 26 Fee Schedule (FS) 12/1/2009

77763 $601.43 General Fee Schedule 12/1/2009

77776 $79.47 TC Fee Schedule 12/1/2009

77776 $122.68 26 Fee Schedule (FS) 12/1/2009

77776 $306.68 General Fee Schedule 12/1/2009

77777 $151.20 TC Fee Schedule 12/1/2009

77777 $194.00 26 Fee Schedule (FS) 12/1/2009

77777 $530.59 General Fee Schedule 12/1/2009

77778 $183.42 TC Fee Schedule 12/1/2009

77778 $274.58 26 Fee Schedule (FS) 12/1/2009

77778 $750.98 General Fee Schedule 12/1/2009

77785 $167.57 General Fee Schedule 12/1/2009

77785 $67.03 26 Fee Schedule (FS) 12/1/2009

77785 $99.95 TC Fee Schedule 12/1/2009

77786 $497.50 General Fee Schedule 12/1/2009

77786 $152.60 26 Fee Schedule (FS) 12/1/2009

77786 $344.90 TC Fee Schedule 12/1/2009

77787 $233.91 26 Fee Schedule (FS) 12/1/2009

77787 $505.71 TC Fee Schedule 12/1/2009

77787 $739.62 General Fee Schedule 12/1/2009

77789 $74.07 General Fee Schedule 12/1/2009

77789 $16.10 TC Fee Schedule 12/1/2009

77789 $29.62 26 Fee Schedule (FS) 12/1/2009

77790 $71.70 General Fee Schedule 12/1/2009

77790 $17.81 TC Fee Schedule 12/1/2009

77790 $28.68 26 Fee Schedule (FS) 12/1/2009

77799 $0.00 General by Report 7/1/1975

78012 $76.64 General Fee Schedule 2/23/2013

78012 $8.99 26 Fee Schedule (FS) 2/23/2013

78012 $67.66 TC Fee Schedule 2/23/2013

78013 $193.46 General Fee Schedule 2/23/2013

78013 $176.17 TC Fee Schedule 2/23/2013

78013 $17.29 26 Fee Schedule (FS) 2/23/2013

78014 $23.33 26 Fee Schedule (FS) 2/23/2013

78014 $200.47 TC Fee Schedule 2/23/2013

78014 $223.80 General Fee Schedule 2/23/2013

78015 $34.77 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 186 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78015 $93.17 TC Fee Schedule 12/1/2009

78015 $127.94 General Fee Schedule 12/1/2009

78016 $42.28 26 Fee Schedule (FS) 12/1/2009

78016 $125.70 TC Fee Schedule 12/1/2009

78016 $167.98 General Fee Schedule 12/1/2009

78018 $44.84 26 Fee Schedule (FS) 12/1/2009

78018 $196.27 TC Fee Schedule 12/1/2009

78018 $241.12 General Fee Schedule 12/1/2009

78020 $80.72 General Fee Schedule 12/1/2009

78020 $31.04 26 Fee Schedule (FS) 12/1/2009

78020 $49.68 TC Fee Schedule 12/1/2009

78070 $192.95 General Fee Schedule 12/1/2009

78070 $150.33 TC Fee Schedule 12/1/2009

78070 $42.61 26 Fee Schedule (FS) 12/1/2009

78071 $55.33 26 Fee Schedule (FS) 2/23/2013

78071 $279.63 TC Fee Schedule 2/23/2013

78071 $334.96 General Fee Schedule 2/23/2013

78072 $0.00 TC by Report 1/1/2013

78072 $76.39 26 Fee Schedule (FS) 2/25/2013

78075 $38.50 26 Fee Schedule (FS) 12/1/2009

78075 $196.27 TC Fee Schedule 12/1/2009

78075 $234.77 General Fee Schedule 12/1/2009

78099 $0.00 26 by Report 6/1/1981

78099 $0.00 General by Report 7/1/1975

78102 $102.75 General Fee Schedule 12/1/2009

78102 $28.43 26 Fee Schedule (FS) 12/1/2009

78102 $74.33 TC Fee Schedule 12/1/2009

78103 $153.63 General Fee Schedule 12/1/2009

78103 $114.74 TC Fee Schedule 12/1/2009

78103 $38.89 26 Fee Schedule (FS) 12/1/2009

78104 $41.16 26 Fee Schedule (FS) 12/1/2009

78104 $147.28 TC Fee Schedule 12/1/2009

78104 $188.44 General Fee Schedule 12/1/2009

78110 $44.67 General Fee Schedule 12/1/2009

78110 $10.07 26 Fee Schedule (FS) 12/1/2009

78110 $34.60 TC Fee Schedule 12/1/2009

78111 $104.74 General Fee Schedule 12/1/2009

78111 $11.58 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 187 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78111 $93.17 TC Fee Schedule 12/1/2009

78120 $11.96 26 Fee Schedule (FS) 12/1/2009

78120 $63.37 TC Fee Schedule 12/1/2009

78120 $75.34 General Fee Schedule 12/1/2009

78121 $104.81 TC Fee Schedule 12/1/2009

78121 $121.27 General Fee Schedule 12/1/2009

78121 $16.46 26 Fee Schedule (FS) 12/1/2009

78122 $23.54 26 Fee Schedule (FS) 12/1/2009

78122 $166.13 TC Fee Schedule 12/1/2009

78122 $189.66 General Fee Schedule 12/1/2009

78130 $31.77 26 Fee Schedule (FS) 12/1/2009

78130 $102.75 TC Fee Schedule 12/1/2009

78130 $134.52 General Fee Schedule 12/1/2009

78135 $33.27 26 Fee Schedule (FS) 12/1/2009

78135 $175.72 TC Fee Schedule 12/1/2009

78135 $208.99 General Fee Schedule 12/1/2009

78140 $31.43 26 Fee Schedule (FS) 12/1/2009

78140 $142.15 TC Fee Schedule 12/1/2009

78140 $173.57 General Fee Schedule 12/1/2009

78185 $20.92 26 Fee Schedule (FS) 12/1/2009

78185 $85.63 TC Fee Schedule 12/1/2009

78185 $106.55 General Fee Schedule 12/1/2009

78190 $58.19 26 Fee Schedule (FS) 12/1/2009

78190 $264.73 General Fee Schedule 12/1/2009

78190 $206.54 TC Fee Schedule 12/1/2009

78191 $31.43 26 Fee Schedule (FS) 12/1/2009

78191 $264.77 TC Fee Schedule 12/1/2009

78191 $296.19 General Fee Schedule 12/1/2009

78195 $209.72 General Fee Schedule 12/1/2009

78195 $62.42 26 Fee Schedule (FS) 12/1/2009

78195 $147.28 TC Fee Schedule 12/1/2009

78199 $0.00 26 by Report 1/1/1996

78199 $0.00 General by Report 1/1/1996

78201 $22.81 26 Fee Schedule (FS) 12/1/2009

78201 $85.63 TC Fee Schedule 12/1/2009

78201 $108.44 General Fee Schedule 12/1/2009

78202 $129.98 General Fee Schedule 12/1/2009

78202 $26.20 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 188 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78202 $103.79 TC Fee Schedule 12/1/2009

78205 $250.39 General Fee Schedule 12/1/2009

78205 $36.66 26 Fee Schedule (FS) 12/1/2009

78205 $213.73 TC Fee Schedule 12/1/2009

78206 $49.73 26 Fee Schedule (FS) 12/1/2009

78206 $206.82 TC Fee Schedule 12/1/2009

78206 $256.57 General Fee Schedule 12/1/2009

78215 $130.92 General Fee Schedule 12/1/2009

78215 $25.08 26 Fee Schedule (FS) 12/1/2009

78215 $105.84 TC Fee Schedule 12/1/2009

78216 $154.90 General Fee Schedule 12/1/2009

78216 $29.20 26 Fee Schedule (FS) 12/1/2009

78216 $125.70 TC Fee Schedule 12/1/2009

78226 $34.34 26 Fee Schedule (FS) 2/6/2012

78226 $268.84 TC Fee Schedule 2/6/2012

78226 $303.18 General Fee Schedule 2/6/2012

78227 $268.84 TC Fee Schedule 2/6/2012

78227 $310.19 General Fee Schedule 2/6/2012

78227 $41.34 26 Fee Schedule (FS) 2/6/2012

78230 $23.19 26 Fee Schedule (FS) 12/1/2009

78230 $79.47 TC Fee Schedule 12/1/2009

78230 $102.66 General Fee Schedule 12/1/2009

78231 $26.93 26 Fee Schedule (FS) 12/1/2009

78231 $114.74 TC Fee Schedule 12/1/2009

78231 $141.68 General Fee Schedule 12/1/2009

78232 $24.31 26 Fee Schedule (FS) 12/1/2009

78232 $127.76 TC Fee Schedule 12/1/2009

78232 $152.08 General Fee Schedule 12/1/2009

78258 $38.16 26 Fee Schedule (FS) 12/1/2009

78258 $103.79 TC Fee Schedule 12/1/2009

78258 $141.94 General Fee Schedule 12/1/2009

78261 $35.88 26 Fee Schedule (FS) 12/1/2009

78261 $148.31 TC Fee Schedule 12/1/2009

78261 $184.19 General Fee Schedule 12/1/2009

78262 $35.16 26 Fee Schedule (FS) 12/1/2009

78262 $188.61 General Fee Schedule 12/1/2009

78262 $153.44 TC Fee Schedule 12/1/2009

78264 $40.05 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 189 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78264 $149.34 TC Fee Schedule 12/1/2009

78264 $189.39 General Fee Schedule 12/1/2009

78267 $10.73 General Fee Schedule 1/24/2014

78268 $88.85 General Fee Schedule 1/24/2014

78270 $10.46 26 Fee Schedule (FS) 12/1/2009

78270 $56.53 TC Fee Schedule 12/1/2009

78270 $66.99 General Fee Schedule 12/1/2009

78271 $10.46 26 Fee Schedule (FS) 12/1/2009

78271 $59.61 TC Fee Schedule 12/1/2009

78271 $70.06 General Fee Schedule 12/1/2009

78272 $98.12 General Fee Schedule 12/1/2009

78272 $13.85 26 Fee Schedule (FS) 12/1/2009

78272 $84.26 TC Fee Schedule 12/1/2009

78278 $226.60 General Fee Schedule 12/1/2009

78278 $50.90 26 Fee Schedule (FS) 12/1/2009

78278 $175.72 TC Fee Schedule 12/1/2009

78282 $19.60 26 Fee Schedule (FS) 12/1/2009

78290 $35.16 26 Fee Schedule (FS) 12/1/2009

78290 $110.29 TC Fee Schedule 12/1/2009

78290 $145.45 General Fee Schedule 12/1/2009

78291 $156.26 General Fee Schedule 12/1/2009

78291 $45.62 26 Fee Schedule (FS) 12/1/2009

78291 $110.64 TC Fee Schedule 12/1/2009

78299 $0.00 26 by Report 6/1/1981

78299 $0.00 General by Report 7/1/1975

78300 $32.16 26 Fee Schedule (FS) 12/1/2009

78300 $90.08 TC Fee Schedule 12/1/2009

78300 $122.24 General Fee Schedule 12/1/2009

78305 $175.22 General Fee Schedule 12/1/2009

78305 $43.00 26 Fee Schedule (FS) 12/1/2009

78305 $132.21 TC Fee Schedule 12/1/2009

78306 $198.64 General Fee Schedule 12/1/2009

78306 $154.13 TC Fee Schedule 12/1/2009

78306 $44.51 26 Fee Schedule (FS) 12/1/2009

78315 $52.39 26 Fee Schedule (FS) 12/1/2009

78315 $172.64 TC Fee Schedule 12/1/2009

78315 $225.03 General Fee Schedule 12/1/2009

78320 $267.58 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 190 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78320 $53.84 26 Fee Schedule (FS) 12/1/2009

78320 $213.73 TC Fee Schedule 12/1/2009

78350 $38.64 General Fee Schedule 12/1/2009

78351 $87.10 General Fee Schedule 12/1/2009

78399 $0.00 26 by Report 1/1/1996

78399 $0.00 General by Report 1/1/1996

78414 $23.30 26 Fee Schedule (FS) 12/1/2009

78428 $122.95 General Fee Schedule 12/1/2009

78428 $41.08 26 Fee Schedule (FS) 12/1/2009

78428 $81.87 TC Fee Schedule 12/1/2009

78445 $93.25 General Fee Schedule 12/1/2009

78445 $67.82 TC Fee Schedule 12/1/2009

78445 $25.42 26 Fee Schedule (FS) 12/1/2009

78451 $64.24 26 Fee Schedule (FS) 1/1/2010

78451 $138.49 TC Fee Schedule 1/1/2010

78451 $202.73 General Fee Schedule 1/1/2010

78452 $343.55 General Fee Schedule 1/1/2010

78452 $75.95 26 Fee Schedule (FS) 1/1/2010

78452 $267.59 TC Fee Schedule 1/1/2010

78453 $175.83 General Fee Schedule 1/1/2010

78453 $46.65 26 Fee Schedule (FS) 1/1/2010

78453 $129.18 TC Fee Schedule 1/1/2010

78454 $61.87 26 Fee Schedule (FS) 1/1/2010

78454 $108.62 TC Fee Schedule 1/1/2010

78454 $170.50 General Fee Schedule 1/1/2010

78456 $146.63 TC Fee Schedule 12/1/2009

78456 $198.24 General Fee Schedule 12/1/2009

78456 $51.61 26 Fee Schedule (FS) 12/1/2009

78457 $39.66 26 Fee Schedule (FS) 12/1/2009

78457 $96.25 TC Fee Schedule 12/1/2009

78457 $135.91 General Fee Schedule 12/1/2009

78458 $47.07 26 Fee Schedule (FS) 12/1/2009

78458 $145.23 TC Fee Schedule 12/1/2009

78458 $192.30 General Fee Schedule 12/1/2009

78459 $79.14 26 Fee Schedule (FS) 12/1/2009

78459 $1,321.08 TC Fee Schedule 12/1/2009

78459 $1,397.47 General Fee Schedule 12/1/2009

78466 $35.88 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 191 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78466 $94.89 TC Fee Schedule 12/1/2009

78466 $130.77 General Fee Schedule 12/1/2009

78468 $173.37 General Fee Schedule 12/1/2009

78468 $41.16 26 Fee Schedule (FS) 12/1/2009

78468 $132.21 TC Fee Schedule 12/1/2009

78469 $236.23 General Fee Schedule 12/1/2009

78469 $189.07 TC Fee Schedule 12/1/2009

78469 $47.16 26 Fee Schedule (FS) 12/1/2009

78472 $50.86 26 Fee Schedule (FS) 12/1/2009

78472 $199.69 TC Fee Schedule 12/1/2009

78472 $250.54 General Fee Schedule 12/1/2009

78473 $374.26 General Fee Schedule 12/1/2009

78473 $76.27 26 Fee Schedule (FS) 12/1/2009

78473 $297.99 TC Fee Schedule 12/1/2009

78481 $240.27 General Fee Schedule 12/1/2009

78481 $51.19 26 Fee Schedule (FS) 12/1/2009

78481 $189.07 TC Fee Schedule 12/1/2009

78483 $76.96 26 Fee Schedule (FS) 12/1/2009

78483 $284.30 TC Fee Schedule 12/1/2009

78483 $361.25 General Fee Schedule 12/1/2009

78491 $1,397.47 General Fee Schedule 12/1/2009

78491 $1,321.08 TC Fee Schedule 12/1/2009

78491 $80.17 26 Fee Schedule (FS) 12/1/2009

78492 $1,585.31 TC Fee Schedule 12/1/2009

78492 $1,676.97 General Fee Schedule 12/1/2009

78492 $99.94 26 Fee Schedule (FS) 12/1/2009

78494 $62.04 26 Fee Schedule (FS) 12/1/2009

78494 $253.11 TC Fee Schedule 12/1/2009

78494 $315.14 General Fee Schedule 12/1/2009

78496 $26.15 26 Fee Schedule (FS) 12/1/2009

78496 $253.11 TC Fee Schedule 12/1/2009

78496 $279.25 General Fee Schedule 12/1/2009

78499 $0.00 26 by Report 6/1/1981

78499 $0.00 General by Report 7/1/1975

78579 $22.69 26 Fee Schedule (FS) 2/6/2012

78579 $138.80 TC Fee Schedule 2/6/2012

78579 $161.48 General Fee Schedule 2/6/2012

78580 $124.00 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 192 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78580 $162.15 General Fee Schedule 12/1/2009

78580 $38.16 26 Fee Schedule (FS) 12/1/2009

78582 $49.03 26 Fee Schedule (FS) 2/6/2012

78582 $249.20 TC Fee Schedule 2/6/2012

78582 $298.23 General Fee Schedule 2/6/2012

78597 $33.69 26 Fee Schedule (FS) 2/6/2012

78597 $148.78 TC Fee Schedule 2/6/2012

78597 $182.47 General Fee Schedule 2/6/2012

78598 $38.37 26 Fee Schedule (FS) 2/6/2012

78598 $241.09 TC Fee Schedule 2/6/2012

78598 $279.46 General Fee Schedule 2/6/2012

78599 $0.00 26 by Report 6/1/1981

78599 $0.00 General by Report 7/1/1975

78600 $22.81 26 Fee Schedule (FS) 12/1/2009

78600 $103.79 TC Fee Schedule 12/1/2009

78600 $126.59 General Fee Schedule 12/1/2009

78601 $122.97 TC Fee Schedule 12/1/2009

78601 $149.16 General Fee Schedule 12/1/2009

78601 $26.20 26 Fee Schedule (FS) 12/1/2009

78605 $27.31 26 Fee Schedule (FS) 12/1/2009

78605 $122.97 TC Fee Schedule 12/1/2009

78605 $150.28 General Fee Schedule 12/1/2009

78606 $32.93 26 Fee Schedule (FS) 12/1/2009

78606 $140.10 TC Fee Schedule 12/1/2009

78606 $173.02 General Fee Schedule 12/1/2009

78607 $63.92 26 Fee Schedule (FS) 12/1/2009

78607 $237.03 TC Fee Schedule 12/1/2009

78607 $300.95 General Fee Schedule 12/1/2009

78608 $77.44 26 Fee Schedule (FS) 12/1/2009

78608 $1,321.08 TC Fee Schedule 12/1/2009

78608 $1,397.47 General Fee Schedule 12/1/2009

78609 $1,397.47 General Fee Schedule 12/1/2009

78609 $77.44 26 Fee Schedule (FS) 12/1/2009

78609 $1,321.08 TC Fee Schedule 12/1/2009

78610 $73.24 General Fee Schedule 12/1/2009

78610 $57.55 TC Fee Schedule 12/1/2009

78610 $15.69 26 Fee Schedule (FS) 12/1/2009

78630 $35.16 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 193 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78630 $182.22 TC Fee Schedule 12/1/2009

78630 $217.38 General Fee Schedule 12/1/2009

78635 $124.25 General Fee Schedule 12/1/2009

78635 $32.12 26 Fee Schedule (FS) 12/1/2009

78635 $92.14 TC Fee Schedule 12/1/2009

78645 $153.19 General Fee Schedule 12/1/2009

78645 $29.20 26 Fee Schedule (FS) 12/1/2009

78645 $124.00 TC Fee Schedule 12/1/2009

78647 $46.73 26 Fee Schedule (FS) 12/1/2009

78647 $213.73 TC Fee Schedule 12/1/2009

78647 $260.47 General Fee Schedule 12/1/2009

78650 $199.26 General Fee Schedule 12/1/2009

78650 $167.49 TC Fee Schedule 12/1/2009

78650 $31.77 26 Fee Schedule (FS) 12/1/2009

78660 $77.07 TC Fee Schedule 12/1/2009

78660 $104.38 General Fee Schedule 12/1/2009

78660 $27.31 26 Fee Schedule (FS) 12/1/2009

78699 $0.00 26 by Report 6/1/1981

78699 $0.00 General by Report 7/1/1975

78700 $110.29 TC Fee Schedule 12/1/2009

78700 $133.48 General Fee Schedule 12/1/2009

78700 $23.19 26 Fee Schedule (FS) 12/1/2009

78701 $128.45 TC Fee Schedule 12/1/2009

78701 $153.53 General Fee Schedule 12/1/2009

78701 $25.08 26 Fee Schedule (FS) 12/1/2009

78707 $49.40 26 Fee Schedule (FS) 12/1/2009

78707 $161.33 TC Fee Schedule 12/1/2009

78707 $210.71 General Fee Schedule 12/1/2009

78708 $161.33 TC Fee Schedule 12/1/2009

78708 $223.80 General Fee Schedule 12/1/2009

78708 $62.47 26 Fee Schedule (FS) 12/1/2009

78709 $161.33 TC Fee Schedule 12/1/2009

78709 $233.92 General Fee Schedule 12/1/2009

78709 $72.59 26 Fee Schedule (FS) 12/1/2009

78710 $34.05 26 Fee Schedule (FS) 12/1/2009

78710 $213.73 TC Fee Schedule 12/1/2009

78710 $247.78 General Fee Schedule 12/1/2009

78725 $19.81 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 194 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78725 $65.09 TC Fee Schedule 12/1/2009

78725 $84.89 General Fee Schedule 12/1/2009

78730 $18.70 26 Fee Schedule (FS) 12/1/2009

78730 $52.75 TC Fee Schedule 12/1/2009

78730 $71.45 General Fee Schedule 12/1/2009

78740 $29.55 26 Fee Schedule (FS) 12/1/2009

78740 $77.07 TC Fee Schedule 12/1/2009

78740 $106.61 General Fee Schedule 12/1/2009

78761 $36.66 26 Fee Schedule (FS) 12/1/2009

78761 $152.43 General Fee Schedule 12/1/2009

78761 $115.77 TC Fee Schedule 12/1/2009

78799 $0.00 26 by Report 6/1/1981

78799 $0.00 General by Report 7/1/1975

78800 $34.39 26 Fee Schedule (FS) 12/1/2009

78800 $122.97 TC Fee Schedule 12/1/2009

78800 $157.36 General Fee Schedule 12/1/2009

78801 $41.47 26 Fee Schedule (FS) 12/1/2009

78801 $152.42 TC Fee Schedule 12/1/2009

78801 $193.88 General Fee Schedule 12/1/2009

78802 $44.51 26 Fee Schedule (FS) 12/1/2009

78802 $200.38 TC Fee Schedule 12/1/2009

78802 $244.89 General Fee Schedule 12/1/2009

78803 $56.81 26 Fee Schedule (FS) 12/1/2009

78803 $237.03 TC Fee Schedule 12/1/2009

78803 $293.84 General Fee Schedule 12/1/2009

78804 $55.35 26 Fee Schedule (FS) 12/1/2009

78804 $445.40 General Fee Schedule 12/1/2009

78804 $390.06 TC Fee Schedule 12/1/2009

78805 $37.77 26 Fee Schedule (FS) 12/1/2009

78805 $122.97 TC Fee Schedule 12/1/2009

78805 $160.74 General Fee Schedule 12/1/2009

78806 $277.43 General Fee Schedule 12/1/2009

78806 $44.51 26 Fee Schedule (FS) 12/1/2009

78806 $232.92 TC Fee Schedule 12/1/2009

78807 $293.84 General Fee Schedule 12/1/2009

78807 $56.80 26 Fee Schedule (FS) 12/1/2009

78807 $237.03 TC Fee Schedule 12/1/2009

78808 $39.28 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 195 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

78811 $81.39 26 Fee Schedule (FS) 12/1/2009

78811 $2,040.69 TC Fee Schedule 12/1/2009

78811 $2,117.07 General Fee Schedule 12/1/2009

78812 $100.89 26 Fee Schedule (FS) 12/1/2009

78812 $2,040.69 TC Fee Schedule 12/1/2009

78812 $2,117.07 General Fee Schedule 12/1/2009

78813 $104.62 26 Fee Schedule (FS) 12/1/2009

78813 $2,040.69 TC Fee Schedule 12/1/2009

78813 $2,117.07 General Fee Schedule 12/1/2009

78814 $2,294.18 General Fee Schedule 12/1/2009

78814 $114.73 26 Fee Schedule (FS) 12/1/2009

78814 $2,167.54 TC Fee Schedule 12/1/2009

78815 $2,294.18 General Fee Schedule 12/1/2009

78815 $126.74 26 Fee Schedule (FS) 12/1/2009

78815 $2,167.54 TC Fee Schedule 12/1/2009

78816 $129.74 26 Fee Schedule (FS) 12/1/2009

78816 $2,167.54 TC Fee Schedule 12/1/2009

78816 $2,294.18 General Fee Schedule 12/1/2009

78999 $0.00 26 by Report 6/1/1981

78999 $0.00 General by Report 6/1/1981

79005 $75.06 26 Fee Schedule (FS) 12/1/2009

79005 $187.66 General Fee Schedule 12/1/2009

79005 $94.89 TC Fee Schedule 12/1/2009

79101 $78.49 26 Fee Schedule (FS) 12/1/2009

79101 $94.89 TC Fee Schedule 12/1/2009

79101 $196.23 General Fee Schedule 12/1/2009

79200 $198.42 General Fee Schedule 12/1/2009

79200 $79.37 26 Fee Schedule (FS) 12/1/2009

79200 $94.89 TC Fee Schedule 12/1/2009

79300 $84.55 26 Fee Schedule (FS) 12/1/2009

79403 $151.37 TC Fee Schedule 12/1/2009

79403 $272.14 General Fee Schedule 12/1/2009

79403 $108.85 26 Fee Schedule (FS) 12/1/2009

79440 $79.64 26 Fee Schedule (FS) 12/1/2009

79440 $94.89 TC Fee Schedule 12/1/2009

79440 $199.10 General Fee Schedule 12/1/2009

79445 $123.59 26 Fee Schedule (FS) 12/1/2009

79999 $0.00 26 by Report 6/1/1981

Tuesday, February 11, 2014 Page 196 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

79999 $0.00 General by Report 7/1/1975

80047 $11.54 General Fee Schedule 1/24/2014

80048 $11.54 General Fee Schedule 1/24/2014

80050 $49.28 General Fee Schedule 7/1/2004

80051 $9.55 General Fee Schedule 1/24/2014

80053 $14.41 General Fee Schedule 1/24/2014

80055 $35.34 General Fee Schedule 7/1/2004

80061 $16.73 General Fee Schedule 1/24/2014

80069 $11.85 General Fee Schedule 1/24/2014

80074 $64.99 General Fee Schedule 1/24/2014

80076 $11.14 General Fee Schedule 1/24/2014

80100 $16.80 General Fee Schedule 1/1/2011

80101 $19.64 General Fee Schedule 3/10/2010

80102 $18.07 General Fee Schedule 1/24/2014

80103 $20.82 General Fee Schedule 7/1/2004

80104 $0.00 General by Report 1/1/2011

80150 $20.56 General Fee Schedule 1/24/2014

80152 $24.42 General Fee Schedule 1/24/2014

80154 $25.23 General Fee Schedule 1/24/2014

80155 $19.30 General Fee Schedule 1/1/2014

80156 $19.87 General Fee Schedule 1/24/2014

80157 $18.09 General Fee Schedule 1/24/2014

80158 $24.63 General Fee Schedule 1/24/2014

80159 $25.23 General Fee Schedule 1/1/2014

80160 $23.48 General Fee Schedule 1/24/2014

80162 $18.12 General Fee Schedule 1/24/2014

80164 $18.49 General Fee Schedule 1/24/2014

80166 $21.14 General Fee Schedule 1/24/2014

80168 $22.30 General Fee Schedule 1/24/2014

80169 $18.73 General Fee Schedule 1/1/2014

80170 $22.36 General Fee Schedule 1/24/2014

80171 $18.09 General Fee Schedule 1/1/2014

80172 $22.22 General Fee Schedule 1/24/2014

80173 $19.87 General Fee Schedule 1/24/2014

80174 $23.48 General Fee Schedule 1/24/2014

80175 $18.09 General Fee Schedule 1/1/2014

80176 $20.04 General Fee Schedule 1/24/2014

80177 $18.09 General Fee Schedule 1/1/2014

Tuesday, February 11, 2014 Page 197 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

80178 $9.02 General Fee Schedule 1/24/2014

80180 $24.63 General Fee Schedule 1/1/2014

80182 $18.49 General Fee Schedule 1/24/2014

80183 $18.09 General Fee Schedule 1/1/2014

80184 $15.62 General Fee Schedule 1/24/2014

80185 $18.09 General Fee Schedule 1/24/2014

80186 $18.78 General Fee Schedule 1/24/2014

80188 $22.64 General Fee Schedule 1/24/2014

80190 $22.85 General Fee Schedule 1/24/2014

80192 $22.85 General Fee Schedule 1/24/2014

80194 $19.92 General Fee Schedule 1/24/2014

80195 $18.73 General Fee Schedule 1/24/2014

80196 $9.68 General Fee Schedule 1/24/2014

80197 $18.73 General Fee Schedule 1/24/2014

80198 $19.30 General Fee Schedule 1/24/2014

80199 $24.63 General Fee Schedule 1/1/2014

80200 $21.99 General Fee Schedule 1/24/2014

80201 $16.27 General Fee Schedule 1/24/2014

80202 $18.49 General Fee Schedule 1/24/2014

80203 $18.09 General Fee Schedule 1/1/2014

80299 $18.68 General Fee Schedule 1/24/2014

80400 $44.50 General Fee Schedule 1/24/2014

80402 $118.63 General Fee Schedule 1/24/2014

80406 $106.76 General Fee Schedule 1/24/2014

80408 $171.21 General Fee Schedule 1/24/2014

80410 $109.60 General Fee Schedule 1/24/2014

80412 $449.69 General Fee Schedule 1/24/2014

80414 $70.45 General Fee Schedule 1/24/2014

80415 $76.24 General Fee Schedule 1/24/2014

80416 $180.03 General Fee Schedule 1/24/2014

80417 $60.01 General Fee Schedule 1/24/2014

80418 $790.72 General Fee Schedule 1/24/2014

80420 $98.29 General Fee Schedule 1/24/2014

80422 $62.86 General Fee Schedule 1/24/2014

80424 $48.72 General Fee Schedule 1/24/2014

80426 $202.47 General Fee Schedule 1/24/2014

80428 $91.00 General Fee Schedule 1/24/2014

80430 $107.07 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 198 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

80432 $183.10 General Fee Schedule 1/24/2014

80434 $138.03 General Fee Schedule 1/24/2014

80435 $140.54 General Fee Schedule 1/24/2014

80436 $124.37 General Fee Schedule 1/24/2014

80438 $68.77 General Fee Schedule 1/24/2014

80439 $91.70 General Fee Schedule 1/24/2014

80440 $79.32 General Fee Schedule 1/24/2014

80500 $20.66 General Fee Schedule 1/24/2014

80502 $67.12 General Fee Schedule 1/24/2014

81000 $4.32 General Fee Schedule 1/24/2014

81001 $4.32 General Fee Schedule 1/24/2014

81002 $3.49 General Fee Schedule 1/24/2014

81003 $3.06 General Fee Schedule 1/24/2014

81005 $2.96 General Fee Schedule 1/24/2014

81007 $3.50 General Fee Schedule 1/24/2014

81015 $4.15 General Fee Schedule 1/24/2014

81020 $5.03 General Fee Schedule 1/24/2014

81025 $8.63 General Fee Schedule 1/24/2014

81050 $4.09 General Fee Schedule 1/24/2014

81099 $0.00 General by Report 6/1/1981

81500 $0.00 General by Report 1/1/2013

81503 $0.00 General by Report 1/1/2013

81506 $0.00 General by Report 1/1/2013

81508 $0.00 General by Report 1/1/2013

81509 $0.00 General by Report 1/1/2013

81510 $0.00 General by Report 1/1/2013

81511 $0.00 General by Report 1/1/2013

81512 $0.00 General by Report 1/1/2013

81599 $0.00 General by Report 1/1/2013

82000 $16.90 General Fee Schedule 1/24/2014

82003 $27.61 General Fee Schedule 1/24/2014

82009 $4.47 General Fee Schedule 1/24/2014

82010 $11.15 General Fee Schedule 1/24/2014

82013 $15.24 General Fee Schedule 1/24/2014

82016 $18.91 General Fee Schedule 1/24/2014

82017 $23.01 General Fee Schedule 1/24/2014

82024 $52.70 General Fee Schedule 1/24/2014

82030 $35.19 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 199 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

82040 $6.75 General Fee Schedule 1/24/2014

82042 $7.06 General Fee Schedule 1/24/2014

82043 $7.89 General Fee Schedule 1/24/2014

82044 $6.24 General Fee Schedule 1/24/2014

82045 $46.31 General Fee Schedule 1/24/2014

82055 $14.74 General Fee Schedule 1/24/2014

82075 $16.44 General Fee Schedule 1/24/2014

82085 $13.24 General Fee Schedule 1/24/2014

82088 $55.60 General Fee Schedule 1/24/2014

82101 $40.95 General Fee Schedule 1/24/2014

82103 $18.33 General Fee Schedule 1/24/2014

82104 $19.73 General Fee Schedule 1/24/2014

82105 $22.89 General Fee Schedule 1/24/2014

82106 $22.89 General Fee Schedule 1/24/2014

82107 $87.88 General Fee Schedule 1/24/2014

82108 $25.52 General Fee Schedule 1/24/2014

82120 $5.14 General Fee Schedule 1/24/2014

82127 $18.91 General Fee Schedule 1/24/2014

82128 $18.91 General Fee Schedule 1/24/2014

82131 $23.01 General Fee Schedule 1/24/2014

82135 $22.45 General Fee Schedule 1/24/2014

82136 $23.01 General Fee Schedule 1/24/2014

82139 $23.01 General Fee Schedule 1/24/2014

82140 $19.88 General Fee Schedule 1/24/2014

82143 $9.37 General Fee Schedule 1/24/2014

82145 $21.20 General Fee Schedule 1/24/2014

82150 $8.84 General Fee Schedule 1/24/2014

82154 $39.34 General Fee Schedule 1/24/2014

82157 $39.94 General Fee Schedule 1/24/2014

82160 $34.11 General Fee Schedule 1/24/2014

82163 $27.99 General Fee Schedule 1/24/2014

82164 $19.92 General Fee Schedule 1/24/2014

82172 $21.14 General Fee Schedule 1/24/2014

82175 $25.89 General Fee Schedule 1/24/2014

82180 $13.48 General Fee Schedule 1/24/2014

82190 $20.34 General Fee Schedule 1/24/2014

82205 $15.62 General Fee Schedule 1/24/2014

82232 $22.07 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 200 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

82239 $23.37 General Fee Schedule 1/24/2014

82240 $36.26 General Fee Schedule 1/24/2014

82247 $6.84 General Fee Schedule 1/24/2014

82248 $6.84 General Fee Schedule 1/24/2014

82252 $6.21 General Fee Schedule 1/24/2014

82261 $23.01 General Fee Schedule 1/24/2014

82270 $4.44 General Fee Schedule 1/24/2014

82271 $4.44 General Fee Schedule 1/24/2014

82272 $4.44 General Fee Schedule 1/24/2014

82274 $21.70 General Fee Schedule 1/24/2014

82286 $9.40 General Fee Schedule 1/24/2014

82300 $31.58 General Fee Schedule 1/24/2014

82306 $40.40 General Fee Schedule 1/24/2014

82308 $36.54 General Fee Schedule 1/24/2014

82310 $7.04 General Fee Schedule 1/24/2014

82330 $18.65 General Fee Schedule 1/24/2014

82331 $7.06 General Fee Schedule 1/24/2014

82340 $8.23 General Fee Schedule 1/24/2014

82355 $15.79 General Fee Schedule 1/24/2014

82360 $17.56 General Fee Schedule 1/24/2014

82365 $17.59 General Fee Schedule 1/24/2014

82370 $17.09 General Fee Schedule 1/24/2014

82373 $24.63 General Fee Schedule 1/24/2014

82374 $6.67 General Fee Schedule 1/24/2014

82375 $16.81 General Fee Schedule 1/24/2014

82376 $7.12 General Fee Schedule 1/24/2014

82378 $25.88 General Fee Schedule 1/24/2014

82379 $23.01 General Fee Schedule 1/24/2014

82380 $12.58 General Fee Schedule 1/24/2014

82382 $23.46 General Fee Schedule 1/24/2014

82383 $34.19 General Fee Schedule 1/24/2014

82384 $24.36 General Fee Schedule 1/24/2014

82387 $28.39 General Fee Schedule 1/24/2014

82390 $14.65 General Fee Schedule 1/24/2014

82397 $19.27 General Fee Schedule 1/24/2014

82415 $17.29 General Fee Schedule 1/24/2014

82435 $6.27 General Fee Schedule 1/24/2014

82436 $5.86 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 201 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

82438 $5.19 General Fee Schedule 1/24/2014

82441 $8.19 General Fee Schedule 1/24/2014

82465 $5.93 General Fee Schedule 1/24/2014

82480 $10.75 General Fee Schedule 1/24/2014

82482 $10.48 General Fee Schedule 1/24/2014

82485 $28.17 General Fee Schedule 1/24/2014

82486 $24.63 General Fee Schedule 1/24/2014

82487 $21.79 General Fee Schedule 1/24/2014

82488 $29.15 General Fee Schedule 1/24/2014

82489 $25.23 General Fee Schedule 1/24/2014

82491 $24.63 General Fee Schedule 1/24/2014

82492 $24.63 General Fee Schedule 1/24/2014

82495 $26.54 General Fee Schedule 1/24/2014

82507 $37.93 General Fee Schedule 1/24/2014

82520 $20.68 General Fee Schedule 1/24/2014

82523 $25.50 General Fee Schedule 1/24/2014

82525 $16.93 General Fee Schedule 1/24/2014

82528 $30.72 General Fee Schedule 1/24/2014

82530 $22.80 General Fee Schedule 1/24/2014

82533 $22.24 General Fee Schedule 1/24/2014

82540 $6.32 General Fee Schedule 1/24/2014

82541 $24.63 General Fee Schedule 1/24/2014

82542 $24.63 General Fee Schedule 1/24/2014

82543 $24.63 General Fee Schedule 1/24/2014

82544 $24.63 General Fee Schedule 1/24/2014

82550 $8.88 General Fee Schedule 1/24/2014

82552 $18.28 General Fee Schedule 1/24/2014

82553 $15.75 General Fee Schedule 1/24/2014

82554 $16.19 General Fee Schedule 1/24/2014

82565 $6.99 General Fee Schedule 1/24/2014

82570 $6.86 General Fee Schedule 1/24/2014

82575 $12.89 General Fee Schedule 1/24/2014

82585 $11.71 General Fee Schedule 1/24/2014

82595 $8.83 General Fee Schedule 1/24/2014

82600 $26.46 General Fee Schedule 1/24/2014

82607 $20.56 General Fee Schedule 1/24/2014

82608 $19.54 General Fee Schedule 1/24/2014

82610 $18.54 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 202 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

82615 $11.14 General Fee Schedule 1/24/2014

82626 $34.48 General Fee Schedule 1/24/2014

82627 $30.33 General Fee Schedule 1/24/2014

82633 $42.26 General Fee Schedule 1/24/2014

82634 $39.94 General Fee Schedule 1/24/2014

82638 $16.71 General Fee Schedule 1/24/2014

82646 $6.47 General Fee Schedule 1/24/2014

82649 $35.07 General Fee Schedule 1/24/2014

82651 $35.22 General Fee Schedule 1/24/2014

82652 $52.53 General Fee Schedule 1/24/2014

82654 $18.89 General Fee Schedule 1/24/2014

82656 $15.74 General Fee Schedule 3/1/2013

82657 $24.63 General Fee Schedule 1/24/2014

82658 $24.63 General Fee Schedule 1/24/2014

82664 $46.87 General Fee Schedule 1/24/2014

82666 $29.31 General Fee Schedule 1/24/2014

82668 $25.65 General Fee Schedule 1/24/2014

82670 $38.12 General Fee Schedule 1/24/2014

82671 $44.07 General Fee Schedule 1/24/2014

82672 $29.60 General Fee Schedule 1/24/2014

82677 $32.99 General Fee Schedule 1/24/2014

82679 $34.05 General Fee Schedule 1/24/2014

82690 $23.58 General Fee Schedule 1/24/2014

82693 $20.32 General Fee Schedule 1/24/2014

82696 $32.18 General Fee Schedule 1/24/2014

82705 $6.94 General Fee Schedule 1/24/2014

82710 $22.93 General Fee Schedule 1/24/2014

82715 $12.18 General Fee Schedule 1/24/2014

82725 $18.16 General Fee Schedule 1/24/2014

82726 $24.63 General Fee Schedule 1/24/2014

82728 $18.59 General Fee Schedule 1/24/2014

82731 $87.88 General Fee Schedule 1/24/2014

82735 $25.29 General Fee Schedule 1/24/2014

82742 $27.00 General Fee Schedule 1/24/2014

82746 $20.06 General Fee Schedule 1/24/2014

82747 $23.63 General Fee Schedule 1/24/2014

82757 $23.66 General Fee Schedule 1/24/2014

82759 $29.31 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 203 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

82760 $15.27 General Fee Schedule 1/24/2014

82775 $28.74 General Fee Schedule 1/24/2014

82776 $11.44 General Fee Schedule 1/24/2014

82777 $30.01 General Fee Schedule 1/24/2014

82784 $8.12 General Fee Schedule 1/24/2014

82785 $22.47 General Fee Schedule 1/24/2014

82787 $10.94 General Fee Schedule 1/24/2014

82800 $11.54 General Fee Schedule 1/24/2014

82803 $26.40 General Fee Schedule 1/24/2014

82805 $38.71 General Fee Schedule 1/24/2014

82810 $11.91 General Fee Schedule 1/24/2014

82820 $13.63 General Fee Schedule 1/24/2014

82930 $6.45 General Fee Schedule 1/24/2014

82938 $24.14 General Fee Schedule 1/24/2014

82941 $24.06 General Fee Schedule 1/24/2014

82943 $19.49 General Fee Schedule 1/24/2014

82945 $5.36 General Fee Schedule 1/24/2014

82946 $20.56 General Fee Schedule 1/24/2014

82947 $5.36 General Fee Schedule 1/24/2014

82948 $4.32 General Fee Schedule 1/24/2014

82950 $6.48 General Fee Schedule 1/24/2014

82951 $17.56 General Fee Schedule 1/24/2014

82952 $3.20 General Fee Schedule 1/24/2014

82953 $20.67 General Fee Schedule 1/24/2014

82955 $13.22 General Fee Schedule 1/24/2014

82960 $8.26 General Fee Schedule 1/24/2014

82962 $3.20 General Fee Schedule 1/24/2014

82963 $29.31 General Fee Schedule 1/24/2014

82965 $10.55 General Fee Schedule 1/24/2014

82975 $21.62 General Fee Schedule 1/24/2014

82977 $9.82 General Fee Schedule 1/24/2014

82978 $19.45 General Fee Schedule 1/24/2014

82979 $9.40 General Fee Schedule 1/24/2014

82980 $24.89 General Fee Schedule 1/24/2014

82985 $20.56 General Fee Schedule 1/24/2014

83001 $25.35 General Fee Schedule 1/24/2014

83002 $25.26 General Fee Schedule 1/24/2014

83003 $22.76 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 204 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

83008 $22.90 General Fee Schedule 1/24/2014

83009 $88.85 General Fee Schedule 1/24/2014

83010 $17.16 General Fee Schedule 1/24/2014

83012 $23.46 General Fee Schedule 1/24/2014

83013 $88.85 General Fee Schedule 1/24/2014

83014 $10.73 General Fee Schedule 1/24/2014

83015 $16.25 General Fee Schedule 1/24/2014

83018 $29.96 General Fee Schedule 1/24/2014

83020 $19.02 26 Fee Schedule (FS) 1/24/2014

83020 $17.56 General Fee Schedule 1/24/2014

83021 $24.63 General Fee Schedule 1/24/2014

83026 $3.23 General Fee Schedule 1/24/2014

83030 $11.28 General Fee Schedule 1/24/2014

83033 $8.13 General Fee Schedule 1/24/2014

83036 $13.24 General Fee Schedule 1/24/2014

83037 $13.24 General Fee Schedule 1/24/2014

83045 $6.76 General Fee Schedule 1/24/2014

83050 $10.00 General Fee Schedule 1/24/2014

83051 $9.98 General Fee Schedule 1/24/2014

83055 $6.71 General Fee Schedule 1/24/2014

83060 $11.28 General Fee Schedule 1/24/2014

83065 $9.40 General Fee Schedule 1/24/2014

83068 $11.54 General Fee Schedule 1/24/2014

83069 $5.39 General Fee Schedule 1/24/2014

83070 $6.48 General Fee Schedule 1/24/2014

83071 $9.37 General Fee Schedule 1/24/2014

83080 $23.01 General Fee Schedule 1/24/2014

83088 $40.29 General Fee Schedule 1/24/2014

83090 $23.01 General Fee Schedule 1/24/2014

83150 $15.24 General Fee Schedule 1/24/2014

83491 $23.90 General Fee Schedule 1/24/2014

83497 $17.59 General Fee Schedule 1/24/2014

83498 $37.07 General Fee Schedule 1/24/2014

83499 $34.40 General Fee Schedule 1/24/2014

83500 $30.90 General Fee Schedule 1/24/2014

83505 $33.17 General Fee Schedule 1/24/2014

83516 $15.74 General Fee Schedule 3/1/2013

83518 $11.56 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 205 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

83519 $18.43 General Fee Schedule 1/24/2014

83520 $17.66 General Fee Schedule 1/24/2014

83525 $15.59 General Fee Schedule 1/24/2014

83527 $17.67 General Fee Schedule 1/24/2014

83528 $21.70 General Fee Schedule 1/24/2014

83540 $8.83 General Fee Schedule 1/24/2014

83550 $11.93 General Fee Schedule 1/24/2014

83570 $12.07 General Fee Schedule 1/24/2014

83582 $19.34 General Fee Schedule 1/24/2014

83586 $17.47 General Fee Schedule 1/24/2014

83593 $35.88 General Fee Schedule 1/24/2014

83605 $14.57 General Fee Schedule 1/24/2014

83615 $8.23 General Fee Schedule 1/24/2014

83625 $17.46 General Fee Schedule 1/24/2014

83630 $26.78 General Fee Schedule 1/24/2014

83631 $26.78 General Fee Schedule 1/24/2014

83632 $27.58 General Fee Schedule 1/24/2014

83633 $7.50 General Fee Schedule 1/24/2014

83634 $15.73 General Fee Schedule 1/24/2014

83655 $16.52 General Fee Schedule 1/24/2014

83661 $29.99 General Fee Schedule 1/24/2014

83662 $25.81 General Fee Schedule 1/24/2014

83663 $25.81 General Fee Schedule 1/24/2014

83664 $25.81 General Fee Schedule 1/24/2014

83670 $12.49 General Fee Schedule 1/24/2014

83690 $9.40 General Fee Schedule 1/24/2014

83695 $17.66 General Fee Schedule 1/24/2014

83698 $46.31 General Fee Schedule 1/24/2014

83700 $15.36 General Fee Schedule 1/24/2014

83701 $33.86 General Fee Schedule 1/24/2014

83704 $43.04 General Fee Schedule 1/24/2014

83718 $9.64 General Fee Schedule 1/24/2014

83719 $9.64 General Fee Schedule 1/24/2014

83721 $13.02 General Fee Schedule 1/24/2014

83727 $23.46 General Fee Schedule 1/24/2014

83735 $9.14 General Fee Schedule 1/24/2014

83775 $10.06 General Fee Schedule 1/24/2014

83785 $33.55 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 206 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

83788 $24.63 General Fee Schedule 1/24/2014

83789 $24.63 General Fee Schedule 1/24/2014

83805 $24.04 General Fee Schedule 1/24/2014

83825 $22.18 General Fee Schedule 1/24/2014

83835 $23.11 General Fee Schedule 1/24/2014

83840 $22.28 General Fee Schedule 1/24/2014

83857 $14.65 General Fee Schedule 1/24/2014

83858 $20.21 General Fee Schedule 1/24/2014

83861 $22.54 General Fee Schedule 1/24/2014

83864 $27.17 General Fee Schedule 1/24/2014

83866 $13.44 General Fee Schedule 1/24/2014

83872 $8.00 General Fee Schedule 1/24/2014

83873 $23.47 General Fee Schedule 1/24/2014

83874 $17.62 General Fee Schedule 1/24/2014

83876 $46.31 General Fee Schedule 1/24/2014

83880 $46.31 General Fee Schedule 1/24/2014

83883 $18.54 General Fee Schedule 1/24/2014

83885 $33.43 General Fee Schedule 1/24/2014

83887 $32.31 General Fee Schedule 1/24/2014

83915 $15.21 General Fee Schedule 1/24/2014

83916 $27.43 General Fee Schedule 1/24/2014

83918 $22.45 General Fee Schedule 1/24/2014

83919 $22.45 General Fee Schedule 1/24/2014

83921 $22.45 General Fee Schedule 1/24/2014

83925 $26.54 General Fee Schedule 1/24/2014

83930 $9.02 General Fee Schedule 1/24/2014

83935 $9.30 General Fee Schedule 1/24/2014

83937 $38.57 General Fee Schedule 1/24/2014

83945 $17.56 General Fee Schedule 1/24/2014

83950 $87.88 General Fee Schedule 1/24/2014

83951 $87.88 General Fee Schedule 1/24/2014

83970 $56.31 General Fee Schedule 1/24/2014

83986 $4.07 General Fee Schedule 1/24/2014

83987 $21.66 General Fee Schedule 1/24/2014

83992 $20.05 General Fee Schedule 1/24/2014

83993 $26.78 General Fee Schedule 1/24/2014

84022 $21.25 General Fee Schedule 1/24/2014

84030 $7.50 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 207 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

84035 $5.00 General Fee Schedule 1/24/2014

84060 $10.08 General Fee Schedule 1/24/2014

84061 $10.79 General Fee Schedule 1/24/2014

84066 $13.18 General Fee Schedule 1/24/2014

84075 $7.06 General Fee Schedule 1/24/2014

84078 $9.96 General Fee Schedule 1/24/2014

84080 $20.17 General Fee Schedule 1/24/2014

84081 $22.54 General Fee Schedule 1/24/2014

84085 $9.20 General Fee Schedule 1/24/2014

84087 $14.09 General Fee Schedule 1/24/2014

84100 $6.46 General Fee Schedule 1/24/2014

84105 $7.06 General Fee Schedule 1/24/2014

84106 $5.84 General Fee Schedule 1/24/2014

84110 $11.51 General Fee Schedule 1/24/2014

84112 $87.88 General Fee Schedule 1/24/2014

84119 $11.75 General Fee Schedule 1/24/2014

84120 $20.07 General Fee Schedule 1/24/2014

84126 $34.75 General Fee Schedule 1/24/2014

84127 $15.90 General Fee Schedule 1/24/2014

84132 $6.27 General Fee Schedule 1/24/2014

84133 $5.87 General Fee Schedule 1/24/2014

84134 $19.89 General Fee Schedule 1/24/2014

84135 $26.10 General Fee Schedule 1/24/2014

84138 $25.83 General Fee Schedule 1/24/2014

84140 $28.21 General Fee Schedule 1/24/2014

84143 $31.13 General Fee Schedule 1/24/2014

84144 $28.46 General Fee Schedule 1/24/2014

84145 $36.54 General Fee Schedule 1/24/2014

84146 $26.44 General Fee Schedule 1/24/2014

84150 $34.05 General Fee Schedule 1/24/2014

84152 $25.09 General Fee Schedule 1/24/2014

84153 $25.09 General Fee Schedule 1/24/2014

84154 $25.09 General Fee Schedule 1/24/2014

84155 $5.00 General Fee Schedule 1/24/2014

84156 $5.00 General Fee Schedule 1/24/2014

84157 $5.00 General Fee Schedule 1/24/2014

84160 $7.06 General Fee Schedule 1/24/2014

84163 $20.54 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 208 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

84165 $14.65 General Fee Schedule 1/24/2014

84165 $19.02 26 Fee Schedule (FS) 1/24/2014

84166 $19.02 26 Fee Schedule (FS) 1/24/2014

84166 $24.33 General Fee Schedule 1/24/2014

84181 $19.02 26 Fee Schedule (FS) 1/24/2014

84181 $23.24 General Fee Schedule 1/24/2014

84182 $19.02 26 Fee Schedule (FS) 1/24/2014

84182 $24.55 General Fee Schedule 1/24/2014

84202 $19.57 General Fee Schedule 1/24/2014

84203 $11.74 General Fee Schedule 1/24/2014

84206 $24.30 General Fee Schedule 1/24/2014

84207 $38.33 General Fee Schedule 1/24/2014

84210 $14.81 General Fee Schedule 1/24/2014

84220 $12.88 General Fee Schedule 1/24/2014

84228 $15.87 General Fee Schedule 1/24/2014

84233 $87.88 General Fee Schedule 1/24/2014

84234 $88.51 General Fee Schedule 1/24/2014

84235 $71.40 General Fee Schedule 1/24/2014

84238 $49.89 General Fee Schedule 1/24/2014

84244 $30.01 General Fee Schedule 1/24/2014

84252 $27.61 General Fee Schedule 1/24/2014

84255 $6.22 General Fee Schedule 1/24/2014

84260 $28.29 General Fee Schedule 1/24/2014

84270 $29.65 General Fee Schedule 1/24/2014

84275 $18.33 General Fee Schedule 1/24/2014

84285 $32.12 General Fee Schedule 1/24/2014

84295 $6.56 General Fee Schedule 1/24/2014

84300 $6.64 General Fee Schedule 1/24/2014

84302 $6.64 General Fee Schedule 1/24/2014

84305 $29.00 General Fee Schedule 1/24/2014

84307 $24.94 General Fee Schedule 1/24/2014

84311 $9.54 General Fee Schedule 1/24/2014

84315 $3.43 General Fee Schedule 1/24/2014

84375 $26.75 General Fee Schedule 1/24/2014

84376 $7.50 General Fee Schedule 1/24/2014

84377 $7.50 General Fee Schedule 1/24/2014

84378 $15.73 General Fee Schedule 1/24/2014

84379 $15.73 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 209 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

84392 $6.48 General Fee Schedule 1/24/2014

84402 $34.74 General Fee Schedule 1/24/2014

84403 $35.22 General Fee Schedule 1/24/2014

84425 $28.96 General Fee Schedule 1/24/2014

84430 $15.87 General Fee Schedule 1/24/2014

84431 $22.93 General Fee Schedule 1/24/2014

84432 $21.91 General Fee Schedule 1/24/2014

84436 $9.37 General Fee Schedule 1/24/2014

84437 $8.83 General Fee Schedule 1/24/2014

84439 $12.30 General Fee Schedule 1/24/2014

84442 $20.17 General Fee Schedule 1/24/2014

84443 $22.93 General Fee Schedule 1/24/2014

84445 $69.38 General Fee Schedule 1/24/2014

84446 $19.34 General Fee Schedule 1/24/2014

84449 $24.55 General Fee Schedule 1/24/2014

84450 $7.06 General Fee Schedule 1/24/2014

84460 $7.22 General Fee Schedule 1/24/2014

84466 $17.42 General Fee Schedule 1/24/2014

84478 $7.84 General Fee Schedule 1/24/2014

84479 $8.83 General Fee Schedule 1/24/2014

84480 $19.34 General Fee Schedule 1/24/2014

84481 $23.11 General Fee Schedule 1/24/2014

84482 $21.50 General Fee Schedule 1/24/2014

84484 $13.42 General Fee Schedule 1/24/2014

84485 $10.25 General Fee Schedule 1/24/2014

84488 $9.96 General Fee Schedule 1/24/2014

84490 $10.37 General Fee Schedule 1/24/2014

84510 $14.19 General Fee Schedule 1/24/2014

84512 $10.51 General Fee Schedule 1/24/2014

84520 $5.39 General Fee Schedule 1/24/2014

84525 $5.14 General Fee Schedule 1/24/2014

84540 $6.48 General Fee Schedule 1/24/2014

84545 $9.01 General Fee Schedule 1/24/2014

84550 $6.16 General Fee Schedule 1/24/2014

84560 $6.48 General Fee Schedule 1/24/2014

84577 $17.03 General Fee Schedule 1/24/2014

84578 $4.43 General Fee Schedule 1/24/2014

84580 $4.94 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 210 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

84583 $6.86 General Fee Schedule 1/24/2014

84585 $21.14 General Fee Schedule 1/24/2014

84586 $48.20 General Fee Schedule 1/24/2014

84588 $46.31 General Fee Schedule 1/24/2014

84590 $15.83 General Fee Schedule 1/24/2014

84591 $15.83 General Fee Schedule 1/24/2014

84597 $18.71 General Fee Schedule 1/24/2014

84600 $21.93 General Fee Schedule 1/24/2014

84620 $16.16 General Fee Schedule 1/24/2014

84630 $15.53 General Fee Schedule 1/24/2014

84681 $28.15 General Fee Schedule 1/24/2014

84702 $20.54 General Fee Schedule 1/24/2014

84703 $10.26 General Fee Schedule 1/24/2014

84704 $20.54 General Fee Schedule 1/24/2014

84830 $13.68 General Fee Schedule 1/24/2014

84999 $0.00 General by Report 7/1/1975

85002 $6.15 General Fee Schedule 1/24/2014

85004 $8.83 General Fee Schedule 1/24/2014

85007 $4.69 General Fee Schedule 1/24/2014

85008 $4.69 General Fee Schedule 1/24/2014

85009 $5.08 General Fee Schedule 1/24/2014

85013 $3.23 General Fee Schedule 1/24/2014

85014 $3.23 General Fee Schedule 1/24/2014

85018 $3.23 General Fee Schedule 1/24/2014

85025 $10.61 General Fee Schedule 1/24/2014

85027 $8.83 General Fee Schedule 1/24/2014

85032 $5.87 General Fee Schedule 1/24/2014

85041 $4.11 General Fee Schedule 1/24/2014

85044 $5.87 General Fee Schedule 1/24/2014

85045 $5.45 General Fee Schedule 1/24/2014

85046 $7.61 General Fee Schedule 1/24/2014

85048 $3.46 General Fee Schedule 1/24/2014

85049 $6.11 General Fee Schedule 1/24/2014

85055 $36.53 General Fee Schedule 1/24/2014

85060 $24.19 General Fee Schedule 1/24/2014

85097 $82.30 General Fee Schedule 1/24/2014

85130 $16.22 General Fee Schedule 1/24/2014

85170 $4.94 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 211 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

85175 $6.21 General Fee Schedule 1/24/2014

85210 $17.72 General Fee Schedule 1/24/2014

85220 $24.07 General Fee Schedule 1/24/2014

85230 $24.43 General Fee Schedule 1/24/2014

85240 $24.43 General Fee Schedule 1/24/2014

85244 $27.85 General Fee Schedule 1/24/2014

85245 $31.30 General Fee Schedule 1/24/2014

85246 $31.30 General Fee Schedule 1/24/2014

85247 $31.30 General Fee Schedule 1/24/2014

85250 $25.97 General Fee Schedule 1/24/2014

85260 $24.43 General Fee Schedule 1/24/2014

85270 $24.43 General Fee Schedule 1/24/2014

85280 $26.40 General Fee Schedule 1/24/2014

85290 $22.30 General Fee Schedule 1/24/2014

85291 $12.14 General Fee Schedule 1/24/2014

85292 $25.84 General Fee Schedule 1/24/2014

85293 $25.84 General Fee Schedule 1/24/2014

85300 $16.17 General Fee Schedule 1/24/2014

85301 $14.75 General Fee Schedule 1/24/2014

85302 $16.40 General Fee Schedule 1/24/2014

85303 $18.87 General Fee Schedule 1/24/2014

85305 $15.83 General Fee Schedule 1/24/2014

85306 $20.91 General Fee Schedule 1/24/2014

85307 $20.91 General Fee Schedule 1/24/2014

85335 $17.56 General Fee Schedule 1/24/2014

85337 $14.22 General Fee Schedule 1/24/2014

85345 $5.87 General Fee Schedule 1/24/2014

85347 $5.81 General Fee Schedule 1/24/2014

85348 $5.08 General Fee Schedule 1/24/2014

85360 $11.46 General Fee Schedule 1/24/2014

85362 $8.12 General Fee Schedule 1/24/2014

85366 $11.75 General Fee Schedule 1/24/2014

85370 $15.49 General Fee Schedule 1/24/2014

85378 $9.73 General Fee Schedule 1/24/2014

85379 $13.89 General Fee Schedule 1/24/2014

85380 $13.89 General Fee Schedule 1/24/2014

85384 $11.58 General Fee Schedule 1/24/2014

85385 $11.58 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 212 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

85390 $7.05 General Fee Schedule 1/24/2014

85390 $19.02 26 Fee Schedule (FS) 1/24/2014

85396 $20.00 General Fee Schedule 1/24/2014

85397 $31.30 General Fee Schedule 1/24/2014

85400 $12.07 General Fee Schedule 1/24/2014

85410 $10.52 General Fee Schedule 1/24/2014

85415 $23.46 General Fee Schedule 1/24/2014

85420 $8.92 General Fee Schedule 1/24/2014

85421 $13.90 General Fee Schedule 1/24/2014

85441 $5.74 General Fee Schedule 1/24/2014

85445 $9.30 General Fee Schedule 1/24/2014

85460 $10.56 General Fee Schedule 1/24/2014

85461 $9.05 General Fee Schedule 1/24/2014

85475 $12.11 General Fee Schedule 1/24/2014

85520 $17.86 General Fee Schedule 1/24/2014

85525 $16.16 General Fee Schedule 1/24/2014

85530 $19.34 General Fee Schedule 1/24/2014

85536 $8.83 General Fee Schedule 1/24/2014

85540 $11.74 General Fee Schedule 1/24/2014

85547 $11.74 General Fee Schedule 1/24/2014

85549 $25.59 General Fee Schedule 1/24/2014

85555 $9.12 General Fee Schedule 1/24/2014

85557 $18.23 General Fee Schedule 1/24/2014

85576 $19.02 26 Fee Schedule (FS) 1/24/2014

85576 $20.32 General Fee Schedule 1/24/2014

85597 $24.52 General Fee Schedule 1/24/2014

85598 $24.52 General Fee Schedule 1/24/2014

85610 $5.37 General Fee Schedule 1/24/2014

85611 $5.38 General Fee Schedule 1/24/2014

85612 $13.06 General Fee Schedule 1/24/2014

85613 $13.06 General Fee Schedule 1/24/2014

85635 $13.43 General Fee Schedule 1/24/2014

85651 $4.84 General Fee Schedule 1/24/2014

85652 $3.69 General Fee Schedule 1/24/2014

85660 $7.53 General Fee Schedule 1/24/2014

85670 $7.87 General Fee Schedule 1/24/2014

85675 $9.34 General Fee Schedule 1/24/2014

85705 $13.13 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 213 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

85730 $8.19 General Fee Schedule 1/24/2014

85732 $8.83 General Fee Schedule 1/24/2014

85810 $15.92 General Fee Schedule 1/24/2014

85999 $0.00 General by Report 7/1/1975

86000 $9.52 General Fee Schedule 1/24/2014

86001 $7.12 General Fee Schedule 1/24/2014

86003 $7.12 General Fee Schedule 1/24/2014

86005 $10.88 General Fee Schedule 1/24/2014

86021 $20.54 General Fee Schedule 1/24/2014

86022 $25.06 General Fee Schedule 1/24/2014

86023 $17.00 General Fee Schedule 1/24/2014

86038 $16.49 General Fee Schedule 1/24/2014

86039 $15.23 General Fee Schedule 1/24/2014

86060 $9.96 General Fee Schedule 1/24/2014

86063 $7.87 General Fee Schedule 1/24/2014

86077 $53.36 General Fee Schedule 1/24/2014

86078 $53.36 General Fee Schedule 1/24/2014

86079 $53.04 General Fee Schedule 1/24/2014

86140 $5.61 General Fee Schedule 1/24/2014

86141 $17.66 General Fee Schedule 1/24/2014

86146 $34.71 General Fee Schedule 1/24/2014

86147 $34.71 General Fee Schedule 1/24/2014

86148 $21.92 General Fee Schedule 1/24/2014

86152 $0.00 General by Report 1/1/2013

86153 $34.37 26 Fee Schedule (FS) 1/24/2014

86155 $21.81 General Fee Schedule 1/24/2014

86156 $9.14 General Fee Schedule 1/24/2014

86157 $11.00 General Fee Schedule 1/24/2014

86160 $16.38 General Fee Schedule 1/24/2014

86161 $16.38 General Fee Schedule 1/24/2014

86162 $27.72 General Fee Schedule 1/24/2014

86171 $13.66 General Fee Schedule 1/24/2014

86185 $12.20 General Fee Schedule 1/24/2014

86200 $17.66 General Fee Schedule 1/24/2014

86215 $18.08 General Fee Schedule 1/24/2014

86225 $18.74 General Fee Schedule 1/24/2014

86226 $16.52 General Fee Schedule 1/24/2014

86235 $20.32 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 214 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

86243 $27.99 General Fee Schedule 1/24/2014

86255 $16.44 General Fee Schedule 1/24/2014

86255 $19.02 26 Fee Schedule (FS) 1/24/2014

86256 $16.44 General Fee Schedule 1/24/2014

86256 $18.24 26 Fee Schedule (FS) 1/24/2014

86277 $21.47 General Fee Schedule 1/24/2014

86280 $11.17 General Fee Schedule 1/24/2014

86294 $15.76 General Fee Schedule 1/24/2014

86300 $28.39 General Fee Schedule 1/24/2014

86301 $28.39 General Fee Schedule 1/24/2014

86304 $28.39 General Fee Schedule 1/24/2014

86305 $28.39 General Fee Schedule 1/24/2014

86308 $7.06 General Fee Schedule 1/24/2014

86309 $8.83 General Fee Schedule 1/24/2014

86310 $10.06 General Fee Schedule 1/24/2014

86316 $28.39 General Fee Schedule 1/24/2014

86317 $20.45 General Fee Schedule 1/24/2014

86318 $17.66 General Fee Schedule 1/24/2014

86320 $18.24 26 Fee Schedule (FS) 1/24/2014

86320 $30.58 General Fee Schedule 1/24/2014

86325 $18.24 26 Fee Schedule (FS) 1/24/2014

86325 $30.51 General Fee Schedule 1/24/2014

86327 $30.95 General Fee Schedule 1/24/2014

86327 $21.47 26 Fee Schedule (FS) 1/24/2014

86329 $19.15 General Fee Schedule 1/24/2014

86331 $16.35 General Fee Schedule 1/24/2014

86332 $33.25 General Fee Schedule 1/24/2014

86334 $19.02 26 Fee Schedule (FS) 1/24/2014

86334 $30.48 General Fee Schedule 1/24/2014

86335 $19.02 26 Fee Schedule (FS) 1/24/2014

86335 $40.04 General Fee Schedule 1/24/2014

86336 $21.26 General Fee Schedule 1/24/2014

86337 $29.21 General Fee Schedule 1/24/2014

86340 $20.56 General Fee Schedule 1/24/2014

86341 $26.99 General Fee Schedule 1/24/2014

86343 $17.01 General Fee Schedule 1/24/2014

86344 $10.90 General Fee Schedule 1/24/2014

86352 $185.36 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 215 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

86353 $66.89 General Fee Schedule 1/24/2014

86355 $41.80 General Fee Schedule 1/24/2014

86356 $36.53 General Fee Schedule 1/24/2014

86357 $41.80 General Fee Schedule 1/24/2014

86359 $41.80 General Fee Schedule 1/24/2014

86360 $64.10 General Fee Schedule 1/24/2014

86361 $36.53 General Fee Schedule 1/24/2014

86367 $41.80 General Fee Schedule 1/24/2014

86376 $19.85 General Fee Schedule 1/24/2014

86378 $26.86 General Fee Schedule 1/24/2014

86382 $23.07 General Fee Schedule 1/24/2014

86384 $15.53 General Fee Schedule 1/24/2014

86386 $21.79 General Fee Schedule 1/24/2014

86403 $13.90 General Fee Schedule 1/24/2014

86406 $14.51 General Fee Schedule 1/24/2014

86430 $7.74 General Fee Schedule 1/24/2014

86431 $7.74 General Fee Schedule 1/24/2014

86480 $84.56 General Fee Schedule 1/24/2014

86481 $102.22 General Fee Schedule 1/24/2014

86485 $16.31 General Fee Schedule 1/24/2014

86486 $4.66 General Fee Schedule 1/24/2014

86490 $4.66 General Fee Schedule 1/24/2014

86510 $5.98 General Fee Schedule 1/24/2014

86580 $7.29 General Fee Schedule 1/24/2014

86590 $15.07 General Fee Schedule 1/24/2014

86592 $5.82 General Fee Schedule 1/24/2014

86593 $6.00 General Fee Schedule 1/24/2014

86602 $12.52 General Fee Schedule 1/24/2014

86603 $17.55 General Fee Schedule 1/24/2014

86606 $20.54 General Fee Schedule 1/24/2014

86609 $13.17 General Fee Schedule 1/24/2014

86611 $12.52 General Fee Schedule 1/24/2014

86612 $17.60 General Fee Schedule 1/24/2014

86615 $18.00 General Fee Schedule 1/24/2014

86617 $21.13 General Fee Schedule 1/24/2014

86618 $23.24 General Fee Schedule 1/24/2014

86619 $18.25 General Fee Schedule 1/24/2014

86622 $12.19 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 216 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

86625 $17.90 General Fee Schedule 1/24/2014

86628 $16.38 General Fee Schedule 1/24/2014

86631 $16.13 General Fee Schedule 1/24/2014

86632 $17.31 General Fee Schedule 1/24/2014

86635 $15.65 General Fee Schedule 1/24/2014

86638 $16.54 General Fee Schedule 1/24/2014

86641 $19.66 General Fee Schedule 1/24/2014

86644 $19.64 General Fee Schedule 1/24/2014

86645 $22.98 General Fee Schedule 1/24/2014

86648 $20.75 General Fee Schedule 1/24/2014

86651 $18.00 General Fee Schedule 1/24/2014

86652 $18.00 General Fee Schedule 1/24/2014

86653 $18.00 General Fee Schedule 1/24/2014

86654 $18.00 General Fee Schedule 1/24/2014

86658 $17.77 General Fee Schedule 1/24/2014

86663 $17.90 General Fee Schedule 1/24/2014

86664 $20.87 General Fee Schedule 1/24/2014

86665 $24.75 General Fee Schedule 1/24/2014

86666 $12.52 General Fee Schedule 1/24/2014

86668 $14.19 General Fee Schedule 1/24/2014

86671 $16.72 General Fee Schedule 1/24/2014

86674 $20.08 General Fee Schedule 1/24/2014

86677 $19.80 General Fee Schedule 1/24/2014

86682 $17.75 General Fee Schedule 1/24/2014

86684 $21.61 General Fee Schedule 1/24/2014

86687 $11.45 General Fee Schedule 1/24/2014

86688 $8.75 General Fee Schedule 1/24/2014

86689 $26.40 General Fee Schedule 1/24/2014

86692 $23.41 General Fee Schedule 1/24/2014

86694 $19.64 General Fee Schedule 1/24/2014

86695 $18.00 General Fee Schedule 1/24/2014

86696 $26.40 General Fee Schedule 1/24/2014

86698 $17.05 General Fee Schedule 1/24/2014

86701 $12.12 General Fee Schedule 1/24/2014

86702 $18.44 General Fee Schedule 1/24/2014

86703 $18.70 General Fee Schedule 1/24/2014

86704 $16.44 General Fee Schedule 1/24/2014

86705 $16.07 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 217 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

86706 $14.65 General Fee Schedule 1/24/2014

86707 $15.78 General Fee Schedule 1/24/2014

86708 $16.90 General Fee Schedule 1/24/2014

86709 $15.36 General Fee Schedule 1/24/2014

86710 $18.49 General Fee Schedule 1/24/2014

86711 $19.64 General Fee Schedule 1/24/2014

86713 $20.88 General Fee Schedule 1/24/2014

86717 $12.52 General Fee Schedule 1/24/2014

86720 $18.00 General Fee Schedule 1/24/2014

86723 $18.00 General Fee Schedule 1/24/2014

86727 $17.55 General Fee Schedule 1/24/2014

86729 $16.30 General Fee Schedule 1/24/2014

86732 $18.00 General Fee Schedule 1/24/2014

86735 $17.80 General Fee Schedule 1/24/2014

86738 $18.07 General Fee Schedule 1/24/2014

86741 $18.00 General Fee Schedule 1/24/2014

86744 $18.00 General Fee Schedule 1/24/2014

86747 $20.51 General Fee Schedule 1/24/2014

86750 $12.52 General Fee Schedule 1/24/2014

86753 $16.90 General Fee Schedule 1/24/2014

86756 $17.58 General Fee Schedule 1/24/2014

86757 $26.40 General Fee Schedule 1/24/2014

86759 $18.00 General Fee Schedule 1/24/2014

86762 $19.64 General Fee Schedule 1/24/2014

86765 $17.58 General Fee Schedule 1/24/2014

86768 $12.52 General Fee Schedule 1/24/2014

86771 $18.00 General Fee Schedule 1/24/2014

86774 $20.19 General Fee Schedule 1/24/2014

86777 $19.64 General Fee Schedule 1/24/2014

86778 $19.65 General Fee Schedule 1/24/2014

86780 $18.06 General Fee Schedule 1/24/2014

86784 $17.14 General Fee Schedule 1/24/2014

86787 $17.58 General Fee Schedule 1/24/2014

86788 $22.98 General Fee Schedule 1/24/2014

86789 $19.64 General Fee Schedule 1/24/2014

86790 $15.62 General Fee Schedule 1/24/2014

86793 $18.00 General Fee Schedule 1/24/2014

86800 $21.70 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 218 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

86803 $19.47 General Fee Schedule 1/24/2014

86804 $21.13 General Fee Schedule 1/24/2014

86805 $71.34 General Fee Schedule 1/24/2014

86806 $64.93 General Fee Schedule 1/24/2014

86807 $53.99 General Fee Schedule 1/24/2014

86808 $40.49 General Fee Schedule 1/24/2014

86812 $35.21 General Fee Schedule 1/24/2014

86813 $40.24 General Fee Schedule 1/24/2014

86816 $38.01 General Fee Schedule 1/24/2014

86817 $87.84 General Fee Schedule 1/24/2014

86821 $77.03 General Fee Schedule 1/24/2014

86822 $49.88 General Fee Schedule 1/24/2014

86825 $109.57 General Fee Schedule 1/24/2014

86826 $36.53 General Fee Schedule 1/24/2014

86828 $53.99 General Fee Schedule 1/24/2014

86829 $40.49 General Fee Schedule 1/24/2014

86830 $110.15 General Fee Schedule 1/24/2014

86831 $94.41 General Fee Schedule 1/24/2014

86832 $173.09 General Fee Schedule 1/24/2014

86833 $157.36 General Fee Schedule 1/24/2014

86834 $487.80 General Fee Schedule 1/24/2014

86835 $440.60 General Fee Schedule 1/24/2014

86849 $0.00 General by Report 1/1/1993

86850 $7.88 General Fee Schedule 7/1/2004

86860 $23.64 General Fee Schedule 7/1/2004

86870 $9.06 General Fee Schedule 7/1/2004

86880 $7.34 General Fee Schedule 1/24/2014

86885 $7.81 General Fee Schedule 1/24/2014

86886 $7.06 General Fee Schedule 1/24/2014

86890 $39.40 General Fee Schedule 7/1/2004

86891 $39.40 General Fee Schedule 7/1/2004

86900 $4.07 General Fee Schedule 1/24/2014

86901 $4.07 General Fee Schedule 1/24/2014

86902 $5.22 General Fee Schedule 1/24/2014

86904 $12.97 General Fee Schedule 1/24/2014

86905 $5.22 General Fee Schedule 1/24/2014

86906 $10.57 General Fee Schedule 1/24/2014

86910 $23.99 General Fee Schedule 7/1/2004

Tuesday, February 11, 2014 Page 219 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

86911 $7.29 General Fee Schedule 7/1/2004

86920 $149.44 General Fee Schedule 7/1/2004

86921 $0.00 General by Report 1/1/1993

86922 $0.00 General by Report 1/1/1993

86923 $0.00 General by Report 1/1/2006

86927 $23.64 General Fee Schedule 7/1/2004

86930 $7.88 General Fee Schedule 7/1/2004

86931 $23.64 General Fee Schedule 7/1/2004

86932 $23.64 General Fee Schedule 7/1/2004

86940 $11.19 General Fee Schedule 1/24/2014

86941 $16.52 General Fee Schedule 1/24/2014

86945 $0.00 General by Report 1/1/1993

86950 $76.68 General Fee Schedule 7/1/2004

86960 $0.00 General by Report 1/1/2006

86965 $10.34 General Fee Schedule 7/1/2004

86970 $42.10 General Fee Schedule 7/1/2004

86971 $38.63 General Fee Schedule 7/1/2004

86972 $38.63 General Fee Schedule 7/1/2004

86975 $135.89 General Fee Schedule 7/1/2004

86976 $135.89 General Fee Schedule 7/1/2004

86977 $135.89 General Fee Schedule 7/1/2004

86978 $135.89 General Fee Schedule 7/1/2004

86985 $23.64 General Fee Schedule 7/1/2004

86999 $0.00 General by Report 7/1/1975

87001 $18.03 General Fee Schedule 1/24/2014

87003 $22.97 General Fee Schedule 1/24/2014

87015 $9.11 General Fee Schedule 1/24/2014

87040 $14.09 General Fee Schedule 1/24/2014

87045 $12.88 General Fee Schedule 1/24/2014

87046 $12.88 General Fee Schedule 1/24/2014

87070 $10.64 General Fee Schedule 1/24/2014

87071 $12.88 General Fee Schedule 1/24/2014

87073 $12.88 General Fee Schedule 1/24/2014

87075 $12.91 General Fee Schedule 1/24/2014

87076 $10.14 General Fee Schedule 1/24/2014

87077 $10.14 General Fee Schedule 1/24/2014

87081 $9.05 General Fee Schedule 1/24/2014

87084 $10.91 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 220 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

87086 $10.91 General Fee Schedule 1/24/2014

87088 $5.46 General Fee Schedule 1/24/2014

87101 $10.14 General Fee Schedule 1/24/2014

87102 $11.46 General Fee Schedule 1/24/2014

87103 $12.30 General Fee Schedule 1/24/2014

87106 $14.09 General Fee Schedule 1/24/2014

87107 $14.09 General Fee Schedule 1/24/2014

87109 $20.99 General Fee Schedule 1/24/2014

87110 $26.73 General Fee Schedule 1/24/2014

87116 $14.74 General Fee Schedule 1/24/2014

87118 $14.93 General Fee Schedule 1/24/2014

87140 $7.61 General Fee Schedule 1/24/2014

87143 $17.09 General Fee Schedule 1/24/2014

87147 $6.08 General Fee Schedule 1/24/2014

87149 $27.36 General Fee Schedule 1/24/2014

87150 $47.87 General Fee Schedule 1/24/2014

87152 $7.13 General Fee Schedule 1/24/2014

87153 $157.38 General Fee Schedule 1/24/2014

87158 $7.13 General Fee Schedule 1/24/2014

87164 $14.65 General Fee Schedule 1/24/2014

87164 $19.02 26 Fee Schedule (FS) 1/24/2014

87166 $15.41 General Fee Schedule 1/24/2014

87168 $5.82 General Fee Schedule 1/24/2014

87169 $5.82 General Fee Schedule 1/24/2014

87172 $5.82 General Fee Schedule 1/24/2014

87176 $8.03 General Fee Schedule 1/24/2014

87177 $12.14 General Fee Schedule 1/24/2014

87181 $6.48 General Fee Schedule 1/24/2014

87184 $9.41 General Fee Schedule 1/24/2014

87185 $6.48 General Fee Schedule 1/24/2014

87186 $11.05 General Fee Schedule 1/24/2014

87187 $11.04 General Fee Schedule 1/24/2014

87188 $9.06 General Fee Schedule 1/24/2014

87190 $6.08 General Fee Schedule 1/24/2014

87197 $20.50 General Fee Schedule 1/24/2014

87205 $5.82 General Fee Schedule 1/24/2014

87206 $7.34 General Fee Schedule 1/24/2014

87207 $8.18 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 221 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

87207 $19.02 26 Fee Schedule (FS) 1/24/2014

87209 $24.52 General Fee Schedule 1/24/2014

87210 $5.82 General Fee Schedule 1/24/2014

87220 $5.82 General Fee Schedule 1/24/2014

87230 $26.94 General Fee Schedule 1/24/2014

87250 $26.68 General Fee Schedule 1/24/2014

87252 $35.56 General Fee Schedule 1/24/2014

87253 $25.01 General Fee Schedule 1/24/2014

87254 $26.68 General Fee Schedule 1/24/2014

87255 $46.20 General Fee Schedule 1/24/2014

87260 $16.36 General Fee Schedule 1/24/2014

87265 $16.36 General Fee Schedule 1/24/2014

87267 $16.36 General Fee Schedule 1/24/2014

87269 $16.36 General Fee Schedule 1/24/2014

87270 $16.36 General Fee Schedule 1/24/2014

87271 $16.36 General Fee Schedule 1/24/2014

87272 $16.36 General Fee Schedule 1/24/2014

87273 $16.36 General Fee Schedule 1/24/2014

87274 $16.36 General Fee Schedule 1/24/2014

87275 $16.36 General Fee Schedule 1/24/2014

87276 $16.36 General Fee Schedule 1/24/2014

87277 $16.36 General Fee Schedule 1/24/2014

87278 $16.36 General Fee Schedule 1/24/2014

87279 $16.36 General Fee Schedule 1/24/2014

87280 $16.36 General Fee Schedule 1/24/2014

87281 $16.36 General Fee Schedule 1/24/2014

87283 $16.36 General Fee Schedule 1/24/2014

87285 $16.36 General Fee Schedule 1/24/2014

87290 $16.36 General Fee Schedule 1/24/2014

87299 $16.36 General Fee Schedule 1/24/2014

87300 $16.36 General Fee Schedule 1/24/2014

87301 $16.36 General Fee Schedule 1/24/2014

87305 $16.36 General Fee Schedule 1/24/2014

87320 $16.36 General Fee Schedule 1/24/2014

87324 $16.36 General Fee Schedule 1/24/2014

87327 $16.36 General Fee Schedule 1/24/2014

87328 $16.36 General Fee Schedule 1/24/2014

87329 $16.36 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 222 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

87332 $16.36 General Fee Schedule 1/24/2014

87335 $16.36 General Fee Schedule 1/24/2014

87336 $16.36 General Fee Schedule 1/24/2014

87337 $16.36 General Fee Schedule 1/24/2014

87338 $13.08 General Fee Schedule 1/24/2014

87339 $16.36 General Fee Schedule 1/24/2014

87340 $14.10 General Fee Schedule 1/24/2014

87341 $14.10 General Fee Schedule 1/24/2014

87350 $15.73 General Fee Schedule 1/24/2014

87380 $22.39 General Fee Schedule 1/24/2014

87385 $16.36 General Fee Schedule 1/24/2014

87390 $24.06 General Fee Schedule 1/24/2014

87391 $24.06 General Fee Schedule 1/24/2014

87400 $16.36 General Fee Schedule 1/24/2014

87420 $16.36 General Fee Schedule 1/24/2014

87425 $16.36 General Fee Schedule 1/24/2014

87427 $16.36 General Fee Schedule 1/24/2014

87430 $16.36 General Fee Schedule 1/24/2014

87449 $16.36 General Fee Schedule 1/24/2014

87450 $13.08 General Fee Schedule 1/24/2014

87451 $13.08 General Fee Schedule 1/24/2014

87470 $27.36 General Fee Schedule 1/24/2014

87471 $47.87 General Fee Schedule 1/24/2014

87472 $58.44 General Fee Schedule 1/24/2014

87475 $27.36 General Fee Schedule 1/24/2014

87476 $47.87 General Fee Schedule 1/24/2014

87477 $21.88 General Fee Schedule 1/24/2014

87480 $27.36 General Fee Schedule 1/24/2014

87481 $47.87 General Fee Schedule 1/24/2014

87482 $21.88 General Fee Schedule 1/24/2014

87485 $27.36 General Fee Schedule 1/24/2014

87486 $47.87 General Fee Schedule 1/24/2014

87487 $58.44 General Fee Schedule 1/24/2014

87490 $27.36 General Fee Schedule 1/24/2014

87491 $47.87 General Fee Schedule 1/24/2014

87492 $21.88 General Fee Schedule 1/24/2014

87493 $47.87 General Fee Schedule 1/24/2014

87495 $27.36 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 223 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

87496 $47.87 General Fee Schedule 1/24/2014

87497 $58.44 General Fee Schedule 1/24/2014

87498 $47.87 General Fee Schedule 1/24/2014

87500 $47.87 General Fee Schedule 1/24/2014

87501 $70.01 General Fee Schedule 1/24/2014

87502 $116.09 General Fee Schedule 1/24/2014

87503 $28.33 General Fee Schedule 1/24/2014

87510 $27.36 General Fee Schedule 1/24/2014

87511 $47.87 General Fee Schedule 1/24/2014

87512 $21.88 General Fee Schedule 1/24/2014

87515 $27.36 General Fee Schedule 1/24/2014

87516 $47.87 General Fee Schedule 1/24/2014

87517 $58.44 General Fee Schedule 1/24/2014

87520 $27.36 General Fee Schedule 1/24/2014

87521 $47.87 General Fee Schedule 1/24/2014

87522 $58.44 General Fee Schedule 1/24/2014

87525 $27.36 General Fee Schedule 1/24/2014

87526 $47.87 General Fee Schedule 1/24/2014

87527 $21.88 General Fee Schedule 1/24/2014

87528 $27.36 General Fee Schedule 1/24/2014

87529 $47.87 General Fee Schedule 1/24/2014

87530 $58.44 General Fee Schedule 1/24/2014

87531 $27.36 General Fee Schedule 1/24/2014

87532 $47.87 General Fee Schedule 1/24/2014

87533 $21.88 General Fee Schedule 1/24/2014

87534 $27.36 General Fee Schedule 1/24/2014

87535 $47.87 General Fee Schedule 1/24/2014

87536 $116.09 General Fee Schedule 1/24/2014

87537 $27.36 General Fee Schedule 1/24/2014

87538 $47.87 General Fee Schedule 1/24/2014

87539 $21.88 General Fee Schedule 1/24/2014

87540 $27.36 General Fee Schedule 1/24/2014

87541 $47.87 General Fee Schedule 1/24/2014

87542 $21.88 General Fee Schedule 1/24/2014

87550 $27.36 General Fee Schedule 1/24/2014

87551 $47.87 General Fee Schedule 1/24/2014

87552 $58.44 General Fee Schedule 1/24/2014

87555 $27.36 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 224 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

87556 $47.87 General Fee Schedule 1/24/2014

87557 $58.44 General Fee Schedule 1/24/2014

87560 $27.36 General Fee Schedule 1/24/2014

87561 $47.87 General Fee Schedule 1/24/2014

87562 $58.44 General Fee Schedule 1/24/2014

87580 $27.36 General Fee Schedule 1/24/2014

87581 $47.87 General Fee Schedule 1/24/2014

87582 $21.88 General Fee Schedule 1/24/2014

87590 $27.36 General Fee Schedule 1/24/2014

87591 $47.87 General Fee Schedule 1/24/2014

87592 $21.88 General Fee Schedule 1/24/2014

87620 $27.36 General Fee Schedule 1/24/2014

87621 $47.87 General Fee Schedule 1/24/2014

87622 $21.88 General Fee Schedule 1/24/2014

87631 $175.02 General Fee Schedule 1/24/2014

87632 $291.18 General Fee Schedule 1/24/2014

87633 $568.60 General Fee Schedule 1/24/2014

87640 $47.87 General Fee Schedule 1/24/2014

87641 $47.87 General Fee Schedule 1/24/2014

87650 $27.36 General Fee Schedule 1/24/2014

87651 $47.87 General Fee Schedule 1/24/2014

87652 $21.88 General Fee Schedule 1/24/2014

87653 $47.87 General Fee Schedule 1/24/2014

87660 $27.36 General Fee Schedule 1/24/2014

87661 $47.87 General Fee Schedule 1/1/2014

87797 $27.36 General Fee Schedule 1/24/2014

87798 $47.87 General Fee Schedule 1/24/2014

87799 $58.44 General Fee Schedule 1/24/2014

87800 $54.72 General Fee Schedule 1/24/2014

87801 $95.76 General Fee Schedule 1/24/2014

87802 $16.36 General Fee Schedule 1/24/2014

87803 $16.36 General Fee Schedule 1/24/2014

87804 $16.36 General Fee Schedule 1/24/2014

87807 $16.36 General Fee Schedule 1/24/2014

87808 $16.36 General Fee Schedule 1/24/2014

87809 $16.36 General Fee Schedule 1/24/2014

87810 $16.36 General Fee Schedule 1/24/2014

87850 $16.36 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 225 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

87880 $16.36 General Fee Schedule 1/24/2014

87899 $16.36 General Fee Schedule 1/24/2014

87900 $177.82 General Fee Schedule 1/24/2014

87901 $351.22 General Fee Schedule 1/24/2014

87902 $351.22 General Fee Schedule 1/24/2014

87903 $666.64 General Fee Schedule 1/24/2014

87904 $35.56 General Fee Schedule 1/24/2014

87905 $16.67 General Fee Schedule 1/24/2014

87906 $175.62 General Fee Schedule 1/24/2014

87910 $351.22 General Fee Schedule 1/24/2014

87912 $351.22 General Fee Schedule 1/24/2014

87999 $0.00 General by Report 7/1/1975

88104 $69.83 General Fee Schedule 1/24/2014

88104 $28.67 26 Fee Schedule (FS) 1/24/2014

88104 $41.16 TC Fee Schedule 1/24/2014

88106 $19.23 26 Fee Schedule (FS) 1/24/2014

88106 $59.58 TC Fee Schedule 1/24/2014

88106 $78.81 General Fee Schedule 1/24/2014

88108 $73.76 General Fee Schedule 1/24/2014

88108 $22.40 26 Fee Schedule (FS) 1/24/2014

88108 $51.36 TC Fee Schedule 1/24/2014

88112 $59.64 General Fee Schedule 1/24/2014

88112 $27.68 26 Fee Schedule (FS) 1/24/2014

88112 $31.96 TC Fee Schedule 1/24/2014

88120 $57.96 26 Fee Schedule (FS) 1/24/2014

88120 $513.84 TC Fee Schedule 1/24/2014

88120 $571.80 General Fee Schedule 1/24/2014

88121 $494.48 General Fee Schedule 1/24/2014

88121 $444.67 TC Fee Schedule 1/24/2014

88121 $49.81 26 Fee Schedule (FS) 1/24/2014

88125 $12.99 26 Fee Schedule (FS) 1/24/2014

88125 $21.27 General Fee Schedule 1/24/2014

88125 $8.28 TC Fee Schedule 1/24/2014

88130 $20.54 General Fee Schedule 1/24/2014

88140 $10.14 General Fee Schedule 1/24/2014

88141 $30.67 General Fee Schedule 1/24/2014

88142 $20.60 General Fee Schedule 1/24/2014

88143 $18.77 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 226 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

88147 $14.42 General Fee Schedule 1/24/2014

88148 $14.42 General Fee Schedule 1/24/2014

88150 $14.42 General Fee Schedule 1/24/2014

88152 $14.42 General Fee Schedule 1/24/2014

88153 $14.42 General Fee Schedule 1/24/2014

88154 $14.42 General Fee Schedule 1/24/2014

88155 $8.18 General Fee Schedule 1/24/2014

88160 $25.86 26 Fee Schedule (FS) 1/24/2014

88160 $60.78 General Fee Schedule 1/24/2014

88160 $34.92 TC Fee Schedule 1/24/2014

88161 $24.87 26 Fee Schedule (FS) 1/24/2014

88161 $30.64 TC Fee Schedule 1/24/2014

88161 $55.52 General Fee Schedule 1/24/2014

88162 $90.92 General Fee Schedule 1/24/2014

88162 $39.57 26 Fee Schedule (FS) 1/24/2014

88162 $51.36 TC Fee Schedule 1/24/2014

88164 $14.42 General Fee Schedule 1/24/2014

88165 $14.42 General Fee Schedule 1/24/2014

88166 $14.42 General Fee Schedule 1/24/2014

88167 $14.42 General Fee Schedule 1/24/2014

88172 $16.83 TC Fee Schedule 1/24/2014

88172 $35.30 26 Fee Schedule (FS) 1/24/2014

88172 $52.13 General Fee Schedule 1/24/2014

88173 $70.41 26 Fee Schedule (FS) 1/24/2014

88173 $139.20 General Fee Schedule 1/24/2014

88173 $68.79 TC Fee Schedule 1/24/2014

88174 $19.91 General Fee Schedule 1/24/2014

88175 $25.10 General Fee Schedule 1/24/2014

88177 $6.96 TC Fee Schedule 1/24/2014

88177 $21.68 26 Fee Schedule (FS) 1/24/2014

88177 $28.64 General Fee Schedule 1/24/2014

88182 $67.26 TC Fee Schedule 1/24/2014

88182 $103.57 General Fee Schedule 1/24/2014

88182 $36.31 26 Fee Schedule (FS) 1/24/2014

88184 $80.63 General Fee Schedule 1/24/2014

88185 $49.39 General Fee Schedule 1/24/2014

88187 $70.23 General Fee Schedule 1/24/2014

88188 $88.41 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 227 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

88189 $108.80 General Fee Schedule 1/24/2014

88199 $0.00 26 by Report 6/1/1981

88199 $0.00 General by Report 7/1/1975

88230 $158.94 General Fee Schedule 1/24/2014

88233 $191.99 General Fee Schedule 1/24/2014

88235 $200.90 General Fee Schedule 1/24/2014

88237 $172.32 General Fee Schedule 1/24/2014

88239 $201.26 General Fee Schedule 1/24/2014

88240 $12.52 General Fee Schedule 1/24/2014

88241 $12.52 General Fee Schedule 1/24/2014

88245 $203.09 General Fee Schedule 1/24/2014

88248 $236.26 General Fee Schedule 1/24/2014

88249 $236.26 General Fee Schedule 1/24/2014

88261 $241.11 General Fee Schedule 1/24/2014

88262 $170.04 General Fee Schedule 1/24/2014

88263 $205.03 General Fee Schedule 1/24/2014

88264 $170.04 General Fee Schedule 1/24/2014

88267 $245.26 General Fee Schedule 1/24/2014

88269 $226.91 General Fee Schedule 1/24/2014

88271 $29.22 General Fee Schedule 1/24/2014

88272 $36.53 General Fee Schedule 1/24/2014

88273 $43.84 General Fee Schedule 1/24/2014

88274 $47.49 General Fee Schedule 1/24/2014

88275 $54.79 General Fee Schedule 1/24/2014

88280 $34.24 General Fee Schedule 1/24/2014

88283 $93.59 General Fee Schedule 1/24/2014

88285 $25.92 General Fee Schedule 1/24/2014

88289 $46.98 General Fee Schedule 1/24/2014

88291 $30.31 General Fee Schedule 1/24/2014

88299 $0.00 General by Report 7/1/1975

88300 $9.27 TC Fee Schedule 1/24/2014

88300 $13.83 General Fee Schedule 1/24/2014

88300 $4.57 26 Fee Schedule (FS) 1/24/2014

88302 $7.02 26 Fee Schedule (FS) 1/24/2014

88302 $21.10 TC Fee Schedule 1/24/2014

88302 $28.12 General Fee Schedule 1/24/2014

88304 $29.33 TC Fee Schedule 1/24/2014

88304 $40.55 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 228 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

88304 $11.23 26 Fee Schedule (FS) 1/24/2014

88305 $29.65 TC Fee Schedule 1/24/2014

88305 $37.45 26 Fee Schedule (FS) 1/24/2014

88305 $67.10 General Fee Schedule 1/24/2014

88307 $82.18 26 Fee Schedule (FS) 1/24/2014

88307 $187.50 TC Fee Schedule 1/24/2014

88307 $269.69 General Fee Schedule 1/24/2014

88309 $145.49 26 Fee Schedule (FS) 1/24/2014

88309 $266.22 TC Fee Schedule 1/24/2014

88309 $411.70 General Fee Schedule 1/24/2014

88311 $7.29 TC Fee Schedule 1/24/2014

88311 $12.27 26 Fee Schedule (FS) 1/24/2014

88311 $19.56 General Fee Schedule 1/24/2014

88312 $88.52 General Fee Schedule 1/24/2014

88312 $26.97 26 Fee Schedule (FS) 1/24/2014

88312 $61.55 TC Fee Schedule 1/24/2014

88313 $61.33 General Fee Schedule 1/24/2014

88313 $11.94 26 Fee Schedule (FS) 1/24/2014

88313 $49.39 TC Fee Schedule 1/24/2014

88314 $22.43 26 Fee Schedule (FS) 1/24/2014

88314 $50.70 TC Fee Schedule 1/24/2014

88314 $73.13 General Fee Schedule 1/24/2014

88319 $27.71 26 Fee Schedule (FS) 1/24/2014

88319 $53.00 TC Fee Schedule 1/24/2014

88319 $80.71 General Fee Schedule 1/24/2014

88321 $92.84 General Fee Schedule 1/24/2014

88323 $141.15 General Fee Schedule 1/24/2014

88323 $54.65 TC Fee Schedule 1/24/2014

88323 $86.50 26 Fee Schedule (FS) 1/24/2014

88325 $203.32 General Fee Schedule 1/24/2014

88329 $54.82 General Fee Schedule 1/24/2014

88331 $94.37 General Fee Schedule 1/24/2014

88331 $33.27 TC Fee Schedule 1/24/2014

88331 $61.10 26 Fee Schedule (FS) 1/24/2014

88332 $41.97 General Fee Schedule 1/24/2014

88332 $11.57 TC Fee Schedule 1/24/2014

88332 $30.40 26 Fee Schedule (FS) 1/24/2014

88333 $37.55 TC Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 229 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

88333 $62.29 26 Fee Schedule (FS) 1/24/2014

88333 $99.84 General Fee Schedule 1/24/2014

88334 $62.23 General Fee Schedule 1/24/2014

88334 $23.74 TC Fee Schedule 1/24/2014

88334 $38.49 26 Fee Schedule (FS) 1/24/2014

88342 $108.19 General Fee Schedule 5/1/2013

88342 $41.16 26 Fee Schedule (FS) 3/1/2013

88342 $67.03 TC Fee Schedule 3/1/2013

88343 $0.00 General by Report 1/1/2014

88346 $42.05 26 Fee Schedule (FS) 1/24/2014

88346 $58.26 TC Fee Schedule 1/24/2014

88346 $100.31 General Fee Schedule 1/24/2014

88347 $41.06 26 Fee Schedule (FS) 1/24/2014

88347 $43.14 TC Fee Schedule 1/24/2014

88347 $84.20 General Fee Schedule 1/24/2014

88348 $75.04 26 Fee Schedule (FS) 1/24/2014

88348 $574.97 TC Fee Schedule 1/24/2014

88348 $650.01 General Fee Schedule 1/24/2014

88349 $40.22 26 Fee Schedule (FS) 1/24/2014

88349 $337.63 TC Fee Schedule 1/24/2014

88349 $377.86 General Fee Schedule 1/24/2014

88355 $83.33 26 Fee Schedule (FS) 1/24/2014

88355 $84.24 TC Fee Schedule 1/24/2014

88355 $167.58 General Fee Schedule 1/24/2014

88356 $132.61 26 Fee Schedule (FS) 1/24/2014

88356 $134.07 TC Fee Schedule 1/24/2014

88356 $266.69 General Fee Schedule 1/24/2014

88358 $79.64 General Fee Schedule 1/24/2014

88358 $34.92 TC Fee Schedule 1/24/2014

88358 $44.73 26 Fee Schedule (FS) 1/24/2014

88360 $122.84 General Fee Schedule 1/24/2014

88360 $69.12 TC Fee Schedule 1/24/2014

88360 $53.72 26 Fee Schedule (FS) 1/24/2014

88361 $58.29 26 Fee Schedule (FS) 1/24/2014

88361 $90.49 TC Fee Schedule 1/24/2014

88361 $148.78 General Fee Schedule 1/24/2014

88362 $290.00 General Fee Schedule 1/24/2014

88362 $111.20 26 Fee Schedule (FS) 1/24/2014

Tuesday, February 11, 2014 Page 230 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

88362 $178.80 TC Fee Schedule 1/24/2014

88363 $21.65 General Fee Schedule 1/24/2014

88365 $107.59 TC Fee Schedule 1/24/2014

88365 $166.54 General Fee Schedule 1/24/2014

88365 $58.95 26 Fee Schedule (FS) 1/24/2014

88367 $238.97 General Fee Schedule 1/24/2014

88367 $61.66 26 Fee Schedule (FS) 1/24/2014

88367 $177.31 TC Fee Schedule 1/24/2014

88368 $217.83 General Fee Schedule 1/24/2014

88368 $153.96 TC Fee Schedule 1/24/2014

88368 $63.87 26 Fee Schedule (FS) 1/24/2014

88371 $19.02 26 Fee Schedule (FS) 1/24/2014

88371 $30.32 General Fee Schedule 1/24/2014

88372 $19.02 26 Fee Schedule (FS) 1/24/2014

88372 $31.03 General Fee Schedule 1/24/2014

88375 $0.00 General by Report 1/1/2013

88380 $78.48 26 Fee Schedule (FS) 1/24/2014

88380 $101.34 TC Fee Schedule 1/24/2014

88380 $179.82 General Fee Schedule 1/24/2014

88381 $54.28 26 Fee Schedule (FS) 1/24/2014

88381 $97.07 TC Fee Schedule 1/24/2014

88381 $151.35 General Fee Schedule 1/24/2014

88387 $34.82 General Fee Schedule 1/24/2014

88387 $5.98 TC Fee Schedule 1/24/2014

88387 $28.84 26 Fee Schedule (FS) 1/24/2014

88388 $31.69 General Fee Schedule 1/24/2014

88388 $23.41 26 Fee Schedule (FS) 1/24/2014

88388 $8.28 TC Fee Schedule 1/24/2014

88399 $0.00 26 by Report 6/1/1981

88399 $0.00 General by Report 7/1/1975

88720 $6.84 General Fee Schedule 1/24/2014

88738 $6.84 General Fee Schedule 1/24/2014

88740 $6.84 General Fee Schedule 1/24/2014

88741 $6.84 General Fee Schedule 1/24/2014

88749 $0.00 General by Report 1/1/2011

89049 $242.45 General Fee Schedule 1/24/2014

89050 $6.45 General Fee Schedule 1/24/2014

89051 $7.51 General Fee Schedule 1/24/2014

Tuesday, February 11, 2014 Page 231 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

89055 $5.82 General Fee Schedule 1/24/2014

89060 $9.76 General Fee Schedule 1/24/2014

89060 $19.02 26 Fee Schedule (FS) 1/24/2014

89125 $5.89 General Fee Schedule 1/24/2014

89160 $5.03 General Fee Schedule 1/24/2014

89190 $6.48 General Fee Schedule 1/24/2014

89220 $15.84 General Fee Schedule 1/24/2014

89230 $4.66 General Fee Schedule 1/24/2014

89240 $0.00 General by Report 1/1/2004

89300 $12.17 General Fee Schedule 1/24/2014

89310 $11.74 General Fee Schedule 1/24/2014

89320 $16.44 General Fee Schedule 1/24/2014

89321 $16.44 General Fee Schedule 1/24/2014

89322 $21.14 General Fee Schedule 1/24/2014

89330 $13.50 General Fee Schedule 1/24/2014

89331 $26.73 General Fee Schedule 1/24/2014

89398 $0.00 General by Report 1/1/2010

90281 $8.86 General Fee Schedule 7/1/2004

90283 $59.10 General Fee Schedule 7/1/2004

90284 $0.00 General by Report 1/1/2008

90287 $0.00 General by Report 1/1/1999

90288 $0.00 General by Report 1/1/1999

90291 $366.42 General Fee Schedule 7/1/2004

90296 $41.37 General Fee Schedule 7/1/2004

90371 $112.64 General Fee Schedule 1/1/2014

90375 $218.81 General Fee Schedule 1/1/2014

90376 $213.65 General Fee Schedule 1/1/2014

90378 $630.40 General Fee Schedule 7/1/2004

90384 $56.14 General Fee Schedule 7/1/2004

90385 $24.85 General Fee Schedule 1/1/2014

90386 $3.94 General Fee Schedule 7/1/2004

90389 $11.82 General Fee Schedule 7/1/2004

90393 $0.00 General by Report 1/1/1999

90396 $114.75 General Fee Schedule 7/1/2006

90399 $57.13 General Fee Schedule 7/1/2004

90460 $20.80 General Fee Schedule 3/1/2013

90461 $20.80 General Fee Schedule 3/1/2013

90471 $20.80 General Fee Schedule 3/1/2013

Tuesday, February 11, 2014 Page 232 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

90472 $20.80 General Fee Schedule 3/1/2013

90473 $20.80 General Fee Schedule 3/1/2013

90474 $20.80 General Fee Schedule 3/1/2013

90585 $119.42 General Fee Schedule 1/1/2014

90586 $119.42 General Fee Schedule 1/1/2014

90632 $51.55 General Fee Schedule 1/1/2014

90633 $34.34 General Fee Schedule VFC Antigen 4/1/2011

90634 $34.34 General Fee Schedule VFC Antigen 4/1/2011

90636 $113.28 General Fee Schedule 7/1/2004

90644 $0.00 General by Report 1/1/2010

90645 $27.32 General Fee Schedule VFC Antigen 4/1/2011

90646 $27.32 General Fee Schedule VFC Antigen 4/1/2011

90647 $20.37 General Fee Schedule VFC Antigen 4/1/2011

90648 $23.34 General Fee Schedule VFC Antigen 4/1/2011

90649 $130.00 General Fee Schedule VFC Antigen 4/1/2011

90650 $128.75 General Fee Schedule VFC Antigen 4/1/2011

90653 $0.00 General by Report 1/1/2013

90654 $18.92 General Fee Schedule VFC Antigen 10/1/2013

90655 $17.24 General Fee Schedule VFC Antigen 10/1/2013

90656 $12.40 General Fee Schedule VFC Antigen 10/1/2012

90657 $6.02 General Fee Schedule VFC Antigen 10/1/2012

90658 $11.37 General Fee Schedule VFC Antigen 4/1/2011

90660 $23.46 General Fee Schedule VFC Antigen 10/1/2012

90661 $20.66 General Fee Schedule 1/1/2014

90662 $31.82 General Fee Schedule 10/1/2013

90664 $0.00 General by Report 7/1/2010

90666 $0.00 General by Report 7/1/2010

90667 $0.00 General by Report 7/1/2010

90668 $0.00 General by Report 7/1/2010

90669 $95.49 General Fee Schedule VFC Antigen 1/1/2014

90670 $145.11 General Fee Schedule VFC Antigen 7/1/2013

90672 $24.60 General Fee Schedule 10/1/2013

90673 $36.48 General Fee Schedule 1/1/2014

90675 $236.02 General Fee Schedule 1/1/2014

90676 $81.76 General Fee Schedule 7/1/2004

90680 $83.35 General Fee Schedule VFC Antigen 4/1/2011

90681 $122.85 General Fee Schedule VFC Antigen 4/1/2011

90685 $23.23 General Fee Schedule 10/1/2013

Tuesday, February 11, 2014 Page 233 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

90686 $19.41 General Fee Schedule 10/1/2013

90687 $0.00 General by Report 1/1/2013

90688 $0.00 General by Report 1/1/2013

90690 $12.06 General Fee Schedule 4/1/2011

90691 $62.99 General Fee Schedule 1/1/2014

90692 $4.92 General Fee Schedule 7/1/2004

90693 $4.92 General Fee Schedule 7/1/2004

90696 $57.00 General Fee Schedule VFC Antigen 4/1/2011

90698 $89.65 General Fee Schedule VFC Antigen 4/1/2011

90700 $26.37 General Fee Schedule VFC Antigen 4/1/2011

90702 $13.98 General Fee Schedule VFC Antigen 4/1/2011

90703 $39.37 General Fee Schedule 1/1/2014

90704 $22.78 General Fee Schedule 1/1/2009

90705 $17.43 General Fee Schedule 10/1/2009

90706 $19.51 General Fee Schedule 7/1/2009

90707 $47.07 General Fee Schedule VFC Antigen 4/1/2011

90708 $26.60 General Fee Schedule 7/1/2004

90710 $154.07 General Fee Schedule VFC Antigen 4/1/2011

90712 $21.48 General Fee Schedule VFC Antigen 4/1/2011

90713 $29.50 General Fee Schedule VFC Antigen 4/1/2011

90714 $19.30 General Fee Schedule VFC Antigen 1/1/2014

90715 $31.84 General Fee Schedule VFC Antigen 1/1/2014

90716 $81.67 General Fee Schedule VFC Antigen 4/1/2011

90717 $75.06 General Fee Schedule 4/1/2013

90719 $8.86 General Fee Schedule 7/1/2004

90720 $53.26 General Fee Schedule VFC Antigen 4/1/2011

90721 $42.89 General Fee Schedule VFC Antigen 4/1/2011

90723 $15.00 General Fee Schedule VFC Antigen 4/1/2011

90727 $3.94 General Fee Schedule 7/1/2004

90732 $72.35 General Fee Schedule VFC Antigen 4/1/2013

90733 $106.49 General Fee Schedule 4/1/2011

90734 $127.15 General Fee Schedule VFC Antigen 4/1/2011

90735 $102.08 General Fee Schedule 4/1/2008

90736 $201.88 General Fee Schedule 1/1/2008

90738 $0.00 General by Report 1/1/2009

90739 $0.00 General by Report 1/1/2013

90740 $119.42 General Fee Schedule 10/1/2008

90743 $24.22 General Fee Schedule VFC Antigen 4/1/2011

Tuesday, February 11, 2014 Page 234 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

90744 $24.22 General Fee Schedule VFC Antigen 1/1/2012

90746 $59.71 General Fee Schedule 10/1/2008

90747 $119.42 General Fee Schedule 10/1/2008

90748 $45.62 General Fee Schedule 7/1/2004

90865 $122.64 General Fee Schedule 12/1/2009

90867 $354.69 General Fee Schedule 2/6/2012

90868 $167.61 General Fee Schedule 2/6/2012

90869 $434.21 General Fee Schedule 2/6/2012

90885 $51.42 General Fee Schedule 12/1/2009

90935 $71.41 General Fee Schedule 12/1/2009

90937 $117.07 General Fee Schedule 12/1/2009

90940 $0.00 General by Report 1/1/2001

90945 $74.41 General Fee Schedule 12/1/2009

90947 $119.69 General Fee Schedule 12/1/2009

90951 $905.84 General Fee Schedule 12/1/2009

90952 $0.00 General by Report 1/1/2009

90953 $0.00 General by Report 1/1/2009

90954 $745.86 General Fee Schedule 12/1/2009

90955 $421.84 General Fee Schedule 12/1/2009

90956 $285.57 General Fee Schedule 12/1/2009

90957 $597.58 General Fee Schedule 12/1/2009

90958 $403.07 General Fee Schedule 12/1/2009

90959 $264.32 General Fee Schedule 12/1/2009

90960 $264.33 General Fee Schedule 12/1/2009

90961 $213.56 General Fee Schedule 12/1/2009

90962 $154.51 General Fee Schedule 12/1/2009

90963 $512.14 General Fee Schedule 12/1/2009

90964 $428.31 General Fee Schedule 12/1/2009

90965 $406.99 General Fee Schedule 12/1/2009

90966 $211.38 General Fee Schedule 12/1/2009

90967 $18.24 General Fee Schedule 12/1/2009

90968 $14.31 General Fee Schedule 12/1/2009

90969 $13.96 General Fee Schedule 12/1/2009

90970 $7.72 General Fee Schedule 12/1/2009

90989 $143.08 General Fee Schedule 12/1/2009

90993 $13.38 General Fee Schedule 12/1/2009

90997 $95.69 General Fee Schedule 12/1/2009

90999 $0.00 General by Report 6/1/1981

Tuesday, February 11, 2014 Page 235 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

91010 $203.72 General Fee Schedule 12/1/2009

91010 $65.39 26 Fee Schedule (FS) 12/1/2009

91010 $138.33 TC Fee Schedule 12/1/2009

91013 $22.28 General Fee Schedule 1/1/2011

91013 $9.69 26 Fee Schedule (FS) 1/1/2011

91013 $12.58 TC Fee Schedule 1/1/2011

91020 $74.78 26 Fee Schedule (FS) 12/1/2009

91020 $140.39 TC Fee Schedule 12/1/2009

91020 $215.17 General Fee Schedule 12/1/2009

91022 $211.05 General Fee Schedule 12/1/2009

91022 $75.46 26 Fee Schedule (FS) 12/1/2009

91022 $135.60 TC Fee Schedule 12/1/2009

91030 $120.74 General Fee Schedule 12/1/2009

91030 $47.46 26 Fee Schedule (FS) 12/1/2009

91030 $73.27 TC Fee Schedule 12/1/2009

91034 $51.15 26 Fee Schedule (FS) 12/1/2009

91034 $170.18 TC Fee Schedule 12/1/2009

91034 $221.33 General Fee Schedule 12/1/2009

91035 $353.68 TC Fee Schedule 12/1/2009

91035 $436.31 General Fee Schedule 12/1/2009

91035 $82.62 26 Fee Schedule (FS) 12/1/2009

91037 $51.15 26 Fee Schedule (FS) 12/1/2009

91037 $91.08 TC Fee Schedule 12/1/2009

91037 $142.24 General Fee Schedule 12/1/2009

91038 $57.88 26 Fee Schedule (FS) 12/1/2009

91038 $65.07 TC Fee Schedule 12/1/2009

91038 $122.96 General Fee Schedule 12/1/2009

91040 $51.15 26 Fee Schedule (FS) 12/1/2009

91040 $372.52 TC Fee Schedule 12/1/2009

91040 $423.68 General Fee Schedule 12/1/2009

91065 $10.46 26 Fee Schedule (FS) 12/1/2009

91065 $48.28 TC Fee Schedule 12/1/2009

91065 $58.74 General Fee Schedule 12/1/2009

91110 $907.45 General Fee Schedule 12/1/2009

91110 $187.43 26 Fee Schedule (FS) 12/1/2009

91110 $720.03 TC Fee Schedule 12/1/2009

91111 $611.32 General Fee Schedule 12/1/2009

91111 $564.70 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 236 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

91111 $46.62 26 Fee Schedule (FS) 12/1/2009

91112 $108.78 26 Fee Schedule (FS) 2/23/2013

91112 $984.84 TC Fee Schedule 2/23/2013

91112 $1,093.63 General Fee Schedule 2/23/2013

91117 $140.61 General Fee Schedule 1/1/2011

91120 $366.69 TC Fee Schedule 12/1/2009

91120 $418.19 General Fee Schedule 12/1/2009

91120 $51.50 26 Fee Schedule (FS) 12/1/2009

91122 $157.18 TC Fee Schedule 12/1/2009

91122 $250.52 General Fee Schedule 12/1/2009

91122 $93.35 26 Fee Schedule (FS) 12/1/2009

91132 $27.75 26 Fee Schedule (FS) 1/1/2011

91132 $107.18 TC Fee Schedule 1/1/2011

91132 $134.93 General Fee Schedule 1/1/2011

91133 $35.76 26 Fee Schedule (FS) 1/1/2011

91133 $164.82 General Fee Schedule 1/1/2011

91133 $129.06 TC Fee Schedule 1/1/2011

91299 $0.00 General by Report 6/1/1981

92002 $67.86 General Fee Schedule 12/1/2009

92004 $124.04 General Fee Schedule 12/1/2009

92012 $61.81 General Fee Schedule 12/1/2009

92014 $91.77 General Fee Schedule 12/1/2009

92014 $39.52 TC Fee Schedule 12/1/2009

92015 $6.69 General Fee Schedule 12/1/2009

92018 $135.55 General Fee Schedule 12/1/2009

92019 $70.77 General Fee Schedule 12/1/2009

92020 $26.27 General Fee Schedule 12/1/2009

92025 $10.23 TC Fee Schedule 12/1/2009

92025 $14.85 26 Fee Schedule (FS) 12/1/2009

92025 $25.08 General Fee Schedule 12/1/2009

92060 $37.26 26 Fee Schedule (FS) 12/1/2009

92060 $52.67 General Fee Schedule 12/1/2009

92060 $15.41 TC Fee Schedule 12/1/2009

92071 $36.12 General Fee Schedule 2/6/2012

92072 $115.37 General Fee Schedule 2/6/2012

92081 $19.37 26 Fee Schedule (FS) 12/1/2009

92081 $27.40 TC Fee Schedule 12/1/2009

92081 $46.77 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 237 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

92082 $35.96 TC Fee Schedule 12/1/2009

92082 $59.79 General Fee Schedule 12/1/2009

92082 $23.83 26 Fee Schedule (FS) 12/1/2009

92083 $41.77 TC Fee Schedule 12/1/2009

92083 $68.96 General Fee Schedule 12/1/2009

92083 $27.17 26 Fee Schedule (FS) 12/1/2009

92100 $82.42 General Fee Schedule 12/1/2009

92132 $14.52 TC Fee Schedule 1/1/2011

92132 $20.69 26 Fee Schedule (FS) 1/1/2011

92132 $35.20 General Fee Schedule 1/1/2011

92133 $14.52 TC Fee Schedule 1/1/2011

92133 $43.20 General Fee Schedule 1/1/2011

92133 $28.68 26 Fee Schedule (FS) 1/1/2011

92134 $14.52 TC Fee Schedule 1/1/2011

92134 $28.68 26 Fee Schedule (FS) 1/1/2011

92134 $43.20 General Fee Schedule 1/1/2011

92136 $80.09 General Fee Schedule 12/1/2009

92136 $29.40 26 Fee Schedule (FS) 12/1/2009

92136 $50.69 TC Fee Schedule 12/1/2009

92140 $53.54 General Fee Schedule 12/1/2009

92225 $22.55 General Fee Schedule 12/1/2009

92226 $20.27 General Fee Schedule 12/1/2009

92227 $10.98 General Fee Schedule 1/1/2011

92228 $11.94 TC Fee Schedule 1/1/2011

92228 $16.99 26 Fee Schedule (FS) 1/1/2011

92228 $28.93 General Fee Schedule 1/1/2011

92230 $76.23 General Fee Schedule 12/1/2009

92235 $44.62 26 Fee Schedule (FS) 12/1/2009

92235 $123.72 General Fee Schedule 12/1/2009

92235 $79.10 TC Fee Schedule 12/1/2009

92240 $60.62 26 Fee Schedule (FS) 12/1/2009

92240 $194.49 TC Fee Schedule 12/1/2009

92240 $255.09 General Fee Schedule 12/1/2009

92250 $70.05 General Fee Schedule 12/1/2009

92250 $23.83 26 Fee Schedule (FS) 12/1/2009

92250 $46.22 TC Fee Schedule 12/1/2009

92260 $16.97 General Fee Schedule 12/1/2009

92265 $42.23 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 238 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

92265 $84.35 General Fee Schedule 12/1/2009

92265 $42.12 TC Fee Schedule 12/1/2009

92270 $41.78 TC Fee Schedule 12/1/2009

92270 $43.60 26 Fee Schedule (FS) 12/1/2009

92270 $85.37 General Fee Schedule 12/1/2009

92275 $54.75 26 Fee Schedule (FS) 12/1/2009

92275 $107.14 General Fee Schedule 12/1/2009

92275 $52.39 TC Fee Schedule 12/1/2009

92283 $9.30 26 Fee Schedule (FS) 12/1/2009

92283 $26.70 TC Fee Schedule 12/1/2009

92283 $36.02 General Fee Schedule 12/1/2009

92284 $12.35 26 Fee Schedule (FS) 12/1/2009

92284 $62.31 TC Fee Schedule 12/1/2009

92284 $74.67 General Fee Schedule 12/1/2009

92286 $36.09 26 Fee Schedule (FS) 12/1/2009

92286 $95.53 TC Fee Schedule 12/1/2009

92286 $131.62 General Fee Schedule 12/1/2009

92287 $113.79 General Fee Schedule 12/1/2009

92310 $218.59 General Fee Schedule 12/1/2009

92311 $80.04 General Fee Schedule 12/1/2009

92312 $86.64 General Fee Schedule 12/1/2009

92313 $72.50 General Fee Schedule 12/1/2009

92325 $14.05 General Fee Schedule 12/1/2009

92340 $36.29 General Fee Schedule 12/1/2009

92341 $36.29 General Fee Schedule 12/1/2009

92358 $18.37 General Fee Schedule 12/1/2009

92370 $3.82 General Fee Schedule 12/1/2009

92371 $3.82 General Fee Schedule 12/1/2009

92499 $0.00 Manual Review Fee Schedule 10/1/1987

92502 $98.01 General Fee Schedule 12/1/2009

92504 $24.41 General Fee Schedule 12/1/2009

92507 $58.77 General Fee Schedule 12/1/2009

92508 $27.85 General Fee Schedule 12/1/2009

92511 $147.12 General Fee Schedule 12/1/2009

92512 $60.95 General Fee Schedule 12/1/2009

92516 $58.03 General Fee Schedule 12/1/2009

92520 $47.44 General Fee Schedule 12/1/2009

92521 $110.28 General Fee Schedule 1/1/2014

Tuesday, February 11, 2014 Page 239 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

92522 $89.75 General Fee Schedule 1/1/2014

92523 $186.14 General Fee Schedule 1/1/2014

92524 $93.66 General Fee Schedule 1/1/2014

92526 $78.07 General Fee Schedule 12/1/2009

92531 $8.00 General Fee Schedule 12/1/2009

92532 $8.00 General Fee Schedule 12/1/2009

92533 $6.71 General Fee Schedule 12/1/2009

92534 $3.37 General Fee Schedule 12/1/2009

92540 $89.25 General Fee Schedule 1/1/2010

92540 $14.85 TC Fee Schedule 1/1/2010

92540 $74.41 26 Fee Schedule (FS) 1/1/2010

92541 $52.09 General Fee Schedule 12/1/2009

92541 $22.63 26 Fee Schedule (FS) 12/1/2009

92541 $29.46 TC Fee Schedule 12/1/2009

92542 $18.56 26 Fee Schedule (FS) 12/1/2009

92542 $34.24 TC Fee Schedule 12/1/2009

92542 $52.80 General Fee Schedule 12/1/2009

92543 $24.07 General Fee Schedule 12/1/2009

92543 $18.15 TC Fee Schedule 12/1/2009

92543 $5.92 26 Fee Schedule (FS) 12/1/2009

92544 $27.40 TC Fee Schedule 12/1/2009

92544 $41.88 General Fee Schedule 12/1/2009

92544 $14.49 26 Fee Schedule (FS) 12/1/2009

92545 $12.99 26 Fee Schedule (FS) 12/1/2009

92545 $24.31 TC Fee Schedule 12/1/2009

92545 $37.31 General Fee Schedule 12/1/2009

92546 $16.00 26 Fee Schedule (FS) 12/1/2009

92546 $64.37 TC Fee Schedule 12/1/2009

92546 $80.36 General Fee Schedule 12/1/2009

92547 $4.81 General Fee Schedule 12/1/2009

92548 $28.90 26 Fee Schedule (FS) 12/1/2009

92548 $72.96 TC Fee Schedule 12/1/2009

92548 $101.86 General Fee Schedule 12/1/2009

92550 $19.43 General Fee Schedule 1/1/2010

92551 $11.21 General Fee Schedule 12/1/2009

92552 $16.45 General Fee Schedule 12/1/2009

92553 $24.67 General Fee Schedule 12/1/2009

92555 $14.39 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 240 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

92556 $21.59 General Fee Schedule 12/1/2009

92557 $44.88 General Fee Schedule 12/1/2009

92558 $0.00 General by Report 1/1/2012

92559 $32.32 General Fee Schedule 12/1/2009

92560 $10.08 General Fee Schedule 12/1/2009

92561 $26.72 General Fee Schedule 12/1/2009

92562 $15.42 General Fee Schedule 12/1/2009

92563 $14.39 General Fee Schedule 12/1/2009

92564 $17.83 General Fee Schedule 12/1/2009

92565 $15.07 General Fee Schedule 12/1/2009

92567 $19.88 General Fee Schedule 12/1/2009

92568 $14.39 General Fee Schedule 12/1/2009

92570 $29.74 General Fee Schedule 1/1/2010

92571 $14.73 General Fee Schedule 12/1/2009

92572 $3.42 General Fee Schedule 12/1/2009

92575 $10.96 General Fee Schedule 12/1/2009

92576 $16.79 General Fee Schedule 12/1/2009

92577 $27.07 General Fee Schedule 12/1/2009

92579 $27.06 General Fee Schedule 12/1/2009

92582 $27.06 General Fee Schedule 12/1/2009

92583 $33.23 General Fee Schedule 12/1/2009

92584 $92.16 General Fee Schedule 12/1/2009

92585 $27.53 26 Fee Schedule (FS) 12/1/2009

92585 $68.51 TC Fee Schedule 12/1/2009

92585 $96.05 General Fee Schedule 12/1/2009

92586 $68.51 General Fee Schedule 12/1/2009

92587 $7.41 26 Fee Schedule (FS) 12/1/2009

92587 $48.66 TC Fee Schedule 12/1/2009

92587 $56.07 General Fee Schedule 12/1/2009

92588 $74.53 General Fee Schedule 12/1/2009

92588 $19.72 26 Fee Schedule (FS) 12/1/2009

92588 $54.81 TC Fee Schedule 12/1/2009

92596 $22.27 General Fee Schedule 1/1/2006

92601 $122.59 General Fee Schedule 12/1/2009

92602 $84.24 General Fee Schedule 12/1/2009

92603 $76.03 General Fee Schedule 12/1/2009

92604 $48.64 General Fee Schedule 12/1/2009

92605 $58.76 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 241 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

92606 $45.50 General Fee Schedule 12/1/2009

92607 $107.52 General Fee Schedule 12/1/2009

92608 $20.55 General Fee Schedule 12/1/2009

92609 $55.81 General Fee Schedule 12/1/2009

92610 $120.54 General Fee Schedule 12/1/2009

92611 $120.54 General Fee Schedule 12/1/2009

92612 $144.56 General Fee Schedule 12/1/2009

92613 $42.83 General Fee Schedule 12/1/2009

92614 $136.33 General Fee Schedule 12/1/2009

92615 $38.03 General Fee Schedule 12/1/2009

92616 $191.04 General Fee Schedule 12/1/2009

92617 $47.29 General Fee Schedule 12/1/2009

92618 $0.00 General by Report 1/1/2012

92620 $41.11 General Fee Schedule 12/1/2009

92621 $10.63 General Fee Schedule 12/1/2009

92625 $40.41 General Fee Schedule 12/1/2009

92626 $77.40 General Fee Schedule 12/1/2009

92627 $19.53 General Fee Schedule 12/1/2009

92630 $0.00 Manual Review Fee Schedule 2/1/2013

92633 $0.00 General by Report 1/1/2006

92640 $43.73 General Fee Schedule 12/1/2009

92700 $0.00 General by Report 1/1/2003

92920 $533.23 General Fee Schedule 2/25/2013

92921 $0.00 General by Report 1/1/2013

92924 $633.91 General Fee Schedule 2/25/2013

92925 $0.00 General by Report 1/1/2013

92928 $592.28 General Fee Schedule 2/25/2013

92929 $0.00 General by Report 1/1/2013

92933 $662.33 General Fee Schedule 2/25/2013

92934 $0.00 General by Report 1/1/2013

92937 $591.63 General Fee Schedule 2/25/2013

92938 $0.00 General by Report 1/1/2013

92941 $663.66 General Fee Schedule 2/25/2013

92943 $663.66 General Fee Schedule 2/25/2013

92944 $0.00 General by Report 1/1/2013

92950 $300.10 General Fee Schedule 12/1/2009

92953 $11.97 General Fee Schedule 12/1/2009

92960 $305.99 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 242 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

92961 $258.74 General Fee Schedule 12/1/2009

92970 $177.30 General Fee Schedule 12/1/2009

92971 $99.49 General Fee Schedule 12/1/2009

92973 $178.71 General Fee Schedule 12/1/2009

92974 $163.45 General Fee Schedule 12/1/2009

92975 $393.28 General Fee Schedule 12/1/2009

92977 $292.18 General Fee Schedule 12/1/2009

92978 $260.61 General Fee Schedule 12/1/2009

92978 $95.87 26 Fee Schedule (FS) 12/1/2009

92979 $76.82 26 Fee Schedule (FS) 12/1/2009

92979 $160.07 General Fee Schedule 12/1/2009

92986 $1,298.51 General Fee Schedule 12/1/2009

92987 $1,349.36 General Fee Schedule 12/1/2009

92990 $1,045.81 General Fee Schedule 12/1/2009

92992 $674.93 General Fee Schedule 12/1/2009

92993 $675.14 General Fee Schedule 12/1/2009

92997 $641.60 General Fee Schedule 12/1/2009

92998 $316.54 General Fee Schedule 12/1/2009

93000 $25.06 General Fee Schedule 12/1/2009

93005 $16.10 General Fee Schedule 12/1/2009

93010 $8.96 General Fee Schedule 12/1/2009

93015 $100.89 General Fee Schedule 12/1/2009

93016 $23.88 General Fee Schedule 12/1/2009

93017 $61.31 General Fee Schedule 12/1/2009

93018 $15.69 General Fee Schedule 12/1/2009

93024 $41.11 TC Fee Schedule 12/1/2009

93024 $61.94 26 Fee Schedule (FS) 12/1/2009

93024 $103.06 General Fee Schedule 12/1/2009

93025 $39.92 26 Fee Schedule (FS) 12/1/2009

93025 $254.41 TC Fee Schedule 12/1/2009

93025 $294.33 General Fee Schedule 12/1/2009

93040 $13.71 General Fee Schedule 12/1/2009

93041 $5.48 General Fee Schedule 12/1/2009

93042 $8.23 General Fee Schedule 12/1/2009

93224 $152.30 General Fee Schedule 12/1/2009

93225 $45.22 General Fee Schedule 12/1/2009

93226 $79.82 General Fee Schedule 12/1/2009

93227 $27.27 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 243 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93228 $24.25 General Fee Schedule 12/1/2009

93229 $645.16 General Fee Schedule 1/1/2011

93268 $285.15 General Fee Schedule 12/1/2009

93270 $45.22 General Fee Schedule 12/1/2009

93271 $188.11 General Fee Schedule 1/1/2010

93272 $27.27 General Fee Schedule 12/1/2009

93278 $13.42 26 Fee Schedule (FS) 12/1/2009

93278 $43.17 TC Fee Schedule 12/1/2009

93278 $56.59 General Fee Schedule 12/1/2009

93279 $17.41 TC Fee Schedule 12/1/2009

93279 $33.79 26 Fee Schedule (FS) 12/1/2009

93279 $51.20 General Fee Schedule 12/1/2009

93280 $19.84 TC Fee Schedule 12/1/2009

93280 $40.47 26 Fee Schedule (FS) 12/1/2009

93280 $60.30 General Fee Schedule 12/1/2009

93281 $23.33 TC Fee Schedule 12/1/2009

93281 $47.20 26 Fee Schedule (FS) 12/1/2009

93281 $70.53 General Fee Schedule 12/1/2009

93282 $21.15 TC Fee Schedule 12/1/2009

93282 $44.28 26 Fee Schedule (FS) 12/1/2009

93282 $65.43 General Fee Schedule 12/1/2009

93283 $23.95 TC Fee Schedule 12/1/2009

93283 $55.71 26 Fee Schedule (FS) 12/1/2009

93283 $79.66 General Fee Schedule 12/1/2009

93284 $27.06 TC Fee Schedule 12/1/2009

93284 $66.12 26 Fee Schedule (FS) 12/1/2009

93284 $93.19 General Fee Schedule 12/1/2009

93285 $16.48 TC Fee Schedule 12/1/2009

93285 $27.67 26 Fee Schedule (FS) 12/1/2009

93285 $44.15 General Fee Schedule 12/1/2009

93286 $10.73 TC Fee Schedule 12/1/2009

93286 $14.38 26 Fee Schedule (FS) 12/1/2009

93286 $25.10 General Fee Schedule 12/1/2009

93287 $31.29 General Fee Schedule 12/1/2009

93287 $12.44 TC Fee Schedule 12/1/2009

93287 $20.80 26 Fee Schedule (FS) 12/1/2009

93288 $39.38 General Fee Schedule 12/1/2009

93288 $16.79 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 244 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93288 $22.59 26 Fee Schedule (FS) 12/1/2009

93289 $19.84 TC Fee Schedule 12/1/2009

93289 $40.82 26 Fee Schedule (FS) 12/1/2009

93289 $60.65 General Fee Schedule 12/1/2009

93290 $29.80 General Fee Schedule 12/1/2009

93290 $9.63 TC Fee Schedule 12/1/2009

93290 $20.17 26 Fee Schedule (FS) 12/1/2009

93291 $37.82 General Fee Schedule 12/1/2009

93291 $14.85 TC Fee Schedule 12/1/2009

93291 $22.97 26 Fee Schedule (FS) 12/1/2009

93292 $11.80 TC Fee Schedule 12/1/2009

93292 $22.59 26 Fee Schedule (FS) 12/1/2009

93292 $34.40 General Fee Schedule 12/1/2009

93293 $37.85 TC Fee Schedule 12/1/2009

93293 $53.85 General Fee Schedule 12/1/2009

93293 $16.01 26 Fee Schedule (FS) 12/1/2009

93294 $34.47 General Fee Schedule 12/1/2009

93295 $62.08 General Fee Schedule 12/1/2009

93296 $31.52 General Fee Schedule 12/1/2009

93297 $24.25 General Fee Schedule 12/1/2009

93298 $27.67 General Fee Schedule 12/1/2009

93299 $0.00 General by Report 1/1/2009

93303 $68.00 26 Fee Schedule (FS) 12/1/2009

93303 $140.44 TC Fee Schedule 12/1/2009

93303 $208.43 General Fee Schedule 12/1/2009

93304 $39.23 26 Fee Schedule (FS) 12/1/2009

93304 $71.26 TC Fee Schedule 12/1/2009

93304 $110.47 General Fee Schedule 12/1/2009

93306 $67.25 26 Fee Schedule (FS) 12/1/2009

93306 $171.45 TC Fee Schedule 12/1/2009

93306 $238.70 General Fee Schedule 12/1/2009

93307 $48.53 26 Fee Schedule (FS) 12/1/2009

93307 $188.98 General Fee Schedule 12/1/2009

93307 $140.44 TC Fee Schedule 12/1/2009

93308 $27.99 26 Fee Schedule (FS) 12/1/2009

93308 $71.26 TC Fee Schedule 12/1/2009

93308 $99.25 General Fee Schedule 12/1/2009

93312 $254.50 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 245 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93312 $114.72 26 Fee Schedule (FS) 12/1/2009

93312 $139.78 TC Fee Schedule 12/1/2009

93313 $45.94 General Fee Schedule 12/1/2009

93314 $139.78 TC Fee Schedule 12/1/2009

93314 $205.50 General Fee Schedule 12/1/2009

93314 $65.73 26 Fee Schedule (FS) 12/1/2009

93315 $145.00 26 Fee Schedule (FS) 12/1/2009

93316 $46.62 General Fee Schedule 12/1/2009

93317 $96.34 26 Fee Schedule (FS) 12/1/2009

93318 $106.19 26 Fee Schedule (FS) 12/1/2009

93320 $20.15 26 Fee Schedule (FS) 12/1/2009

93320 $82.84 General Fee Schedule 12/1/2009

93320 $62.69 TC Fee Schedule 12/1/2009

93321 $8.19 26 Fee Schedule (FS) 12/1/2009

93321 $40.77 TC Fee Schedule 12/1/2009

93321 $48.96 General Fee Schedule 12/1/2009

93325 $110.96 General Fee Schedule 12/1/2009

93325 $4.07 26 Fee Schedule (FS) 12/1/2009

93325 $106.88 TC Fee Schedule 12/1/2009

93350 $143.45 General Fee Schedule 12/1/2009

93350 $65.10 TC Fee Schedule 12/1/2009

93350 $78.37 26 Fee Schedule (FS) 12/1/2009

93351 $90.21 26 Fee Schedule (FS) 1/1/2011

93351 $147.80 TC Fee Schedule 1/1/2011

93351 $238.00 General Fee Schedule 1/1/2011

93352 $34.34 General Fee Schedule 12/1/2009

93451 $582.49 TC Fee Schedule 1/1/2011

93451 $730.14 General Fee Schedule 1/1/2011

93451 $147.65 26 Fee Schedule (FS) 1/1/2011

93452 $258.87 26 Fee Schedule (FS) 1/1/2011

93452 $556.43 TC Fee Schedule 1/1/2011

93452 $815.30 General Fee Schedule 1/1/2011

93453 $339.26 26 Fee Schedule (FS) 1/1/2011

93453 $727.64 TC Fee Schedule 1/1/2011

93453 $1,066.90 General Fee Schedule 1/1/2011

93454 $260.88 26 Fee Schedule (FS) 1/1/2011

93454 $579.59 TC Fee Schedule 1/1/2011

93454 $840.47 General Fee Schedule 1/1/2011

Tuesday, February 11, 2014 Page 246 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93455 $301.06 26 Fee Schedule (FS) 1/1/2011

93455 $679.37 TC Fee Schedule 1/1/2011

93455 $980.43 General Fee Schedule 1/1/2011

93456 $333.81 26 Fee Schedule (FS) 1/1/2011

93456 $718.31 TC Fee Schedule 1/1/2011

93456 $1,052.11 General Fee Schedule 1/1/2011

93457 $374.37 26 Fee Schedule (FS) 1/1/2011

93457 $1,192.10 General Fee Schedule 1/1/2011

93457 $817.73 TC Fee Schedule 1/1/2011

93458 $318.32 26 Fee Schedule (FS) 1/1/2011

93458 $696.10 TC Fee Schedule 1/1/2011

93458 $1,014.42 General Fee Schedule 1/1/2011

93459 $1,120.53 General Fee Schedule 1/1/2011

93459 $358.15 26 Fee Schedule (FS) 1/1/2011

93459 $762.39 TC Fee Schedule 1/1/2011

93460 $1,200.01 General Fee Schedule 1/1/2011

93460 $399.01 26 Fee Schedule (FS) 1/1/2011

93460 $801.00 TC Fee Schedule 1/1/2011

93461 $440.27 26 Fee Schedule (FS) 1/1/2011

93461 $933.92 TC Fee Schedule 1/1/2011

93461 $1,374.19 General Fee Schedule 1/1/2011

93462 $202.68 General Fee Schedule 1/1/2011

93463 $107.34 General Fee Schedule 1/1/2011

93464 $243.29 General Fee Schedule 1/1/2011

93464 $148.69 TC Fee Schedule 1/1/2011

93464 $94.61 26 Fee Schedule (FS) 1/1/2011

93503 $142.51 General Fee Schedule 12/1/2009

93505 $236.55 26 Fee Schedule (FS) 12/1/2009

93505 $310.22 General Fee Schedule 12/1/2009

93530 $239.33 26 Fee Schedule (FS) 12/1/2009

93530 $855.92 General Fee Schedule 12/1/2009

93531 $464.86 26 Fee Schedule (FS) 12/1/2009

93531 $2,227.98 General Fee Schedule 12/1/2009

93532 $555.29 26 Fee Schedule (FS) 12/1/2009

93533 $370.33 26 Fee Schedule (FS) 12/1/2009

93561 $25.47 26 Fee Schedule (FS) 12/1/2009

93561 $45.35 General Fee Schedule 12/1/2009

93562 $8.23 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 247 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93562 $20.57 General Fee Schedule 12/1/2009

93563 $55.45 General Fee Schedule 1/1/2011

93564 $56.49 General Fee Schedule 1/1/2011

93565 $42.70 General Fee Schedule 1/1/2011

93566 $162.07 General Fee Schedule 1/1/2011

93567 $134.28 General Fee Schedule 1/1/2011

93568 $146.67 General Fee Schedule 1/1/2011

93571 $94.84 26 Fee Schedule (FS) 12/1/2009

93571 $259.58 General Fee Schedule 12/1/2009

93572 $74.09 26 Fee Schedule (FS) 12/1/2009

93580 $990.16 General Fee Schedule 12/1/2009

93581 $1,323.00 General Fee Schedule 12/1/2009

93582 $692.28 General Fee Schedule 1/1/2014

93583 $770.59 General Fee Schedule 1/1/2014

93600 $115.77 26 Fee Schedule (FS) 12/1/2009

93600 $187.37 General Fee Schedule 12/1/2009

93602 $115.77 26 Fee Schedule (FS) 12/1/2009

93602 $156.20 General Fee Schedule 12/1/2009

93603 $115.78 26 Fee Schedule (FS) 12/1/2009

93603 $177.09 General Fee Schedule 12/1/2009

93609 $271.80 26 Fee Schedule (FS) 12/1/2009

93609 $371.14 General Fee Schedule 12/1/2009

93610 $164.57 26 Fee Schedule (FS) 12/1/2009

93610 $214.25 General Fee Schedule 12/1/2009

93612 $164.92 26 Fee Schedule (FS) 12/1/2009

93612 $223.84 General Fee Schedule 12/1/2009

93613 $381.57 General Fee Schedule 12/1/2009

93615 $48.49 26 Fee Schedule (FS) 12/1/2009

93615 $60.14 General Fee Schedule 12/1/2009

93616 $75.34 26 Fee Schedule (FS) 12/1/2009

93618 $231.59 26 Fee Schedule (FS) 12/1/2009

93618 $375.80 General Fee Schedule 12/1/2009

93619 $408.99 26 Fee Schedule (FS) 12/1/2009

93619 $689.53 General Fee Schedule 12/1/2009

93620 $934.56 General Fee Schedule 12/1/2009

93620 $640.27 26 Fee Schedule (FS) 12/1/2009

93620 $310.95 TC Fee Schedule 12/1/2009

93621 $114.31 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 248 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93622 $168.68 26 Fee Schedule (FS) 12/1/2009

93623 $154.92 26 Fee Schedule (FS) 12/1/2009

93624 $72.62 TC Fee Schedule 12/1/2009

93624 $271.99 26 Fee Schedule (FS) 12/1/2009

93624 $344.62 General Fee Schedule 12/1/2009

93631 $421.65 26 Fee Schedule (FS) 12/1/2009

93640 $190.33 26 Fee Schedule (FS) 12/1/2009

93640 $451.01 General Fee Schedule 12/1/2009

93641 $322.10 26 Fee Schedule (FS) 12/1/2009

93641 $582.77 General Fee Schedule 12/1/2009

93642 $260.68 TC Fee Schedule 12/1/2009

93642 $269.54 26 Fee Schedule (FS) 12/1/2009

93642 $530.22 General Fee Schedule 12/1/2009

93650 $582.14 General Fee Schedule 12/1/2009

93653 $805.45 General Fee Schedule 2/25/2013

93654 $1,074.87 General Fee Schedule 2/25/2013

93655 $402.71 General Fee Schedule 2/25/2013

93656 $1,075.24 General Fee Schedule 2/25/2013

93657 $403.05 General Fee Schedule 2/25/2013

93660 $58.21 TC Fee Schedule 12/1/2009

93660 $100.37 26 Fee Schedule (FS) 12/1/2009

93660 $158.57 General Fee Schedule 12/1/2009

93662 $149.19 26 Fee Schedule (FS) 12/1/2009

93668 $0.00 General by Report 1/1/2001

93701 $31.51 TC Fee Schedule 12/1/2009

93701 $40.80 General Fee Schedule 12/1/2009

93701 $9.30 26 Fee Schedule (FS) 12/1/2009

93724 $144.21 TC Fee Schedule 12/1/2009

93724 $259.28 26 Fee Schedule (FS) 12/1/2009

93724 $403.49 General Fee Schedule 12/1/2009

93740 $43.70 General Fee Schedule 12/1/2009

93745 $17.02 26 Fee Schedule (FS) 1/1/2011

93745 $39.73 TC Fee Schedule 1/1/2011

93745 $56.74 General Fee Schedule 1/1/2011

93750 $49.30 General Fee Schedule 1/1/2010

93770 $8.40 General Fee Schedule 12/1/2009

93784 $68.77 General Fee Schedule 12/1/2009

93786 $31.51 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 249 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93788 $17.80 General Fee Schedule 12/1/2009

93790 $19.47 General Fee Schedule 12/1/2009

93797 $17.57 General Fee Schedule 12/1/2009

93798 $26.90 General Fee Schedule 12/1/2009

93799 $0.00 General by Report 1/1/1991

93880 $31.39 26 Fee Schedule (FS) 12/1/2009

93880 $195.94 TC Fee Schedule 12/1/2009

93880 $227.33 General Fee Schedule 12/1/2009

93882 $144.60 General Fee Schedule 12/1/2009

93882 $21.61 26 Fee Schedule (FS) 12/1/2009

93882 $122.98 TC Fee Schedule 12/1/2009

93886 $283.27 General Fee Schedule 12/1/2009

93886 $51.03 26 Fee Schedule (FS) 12/1/2009

93886 $232.25 TC Fee Schedule 12/1/2009

93888 $33.53 26 Fee Schedule (FS) 12/1/2009

93888 $146.96 TC Fee Schedule 12/1/2009

93888 $180.49 General Fee Schedule 12/1/2009

93890 $222.25 General Fee Schedule 12/1/2009

93890 $54.37 26 Fee Schedule (FS) 12/1/2009

93890 $167.88 TC Fee Schedule 12/1/2009

93892 $236.94 General Fee Schedule 12/1/2009

93892 $62.21 26 Fee Schedule (FS) 12/1/2009

93892 $174.74 TC Fee Schedule 12/1/2009

93893 $62.21 26 Fee Schedule (FS) 12/1/2009

93893 $170.28 TC Fee Schedule 12/1/2009

93893 $232.49 General Fee Schedule 12/1/2009

93922 $93.85 TC Fee Schedule 12/1/2009

93922 $106.93 General Fee Schedule 12/1/2009

93922 $13.08 26 Fee Schedule (FS) 12/1/2009

93923 $140.78 TC Fee Schedule 12/1/2009

93923 $164.67 General Fee Schedule 12/1/2009

93923 $23.88 26 Fee Schedule (FS) 12/1/2009

93924 $26.85 26 Fee Schedule (FS) 12/1/2009

93924 $167.16 TC Fee Schedule 12/1/2009

93924 $194.00 General Fee Schedule 12/1/2009

93925 $30.61 26 Fee Schedule (FS) 12/1/2009

93925 $238.06 TC Fee Schedule 12/1/2009

93925 $268.67 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 250 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93926 $20.89 26 Fee Schedule (FS) 12/1/2009

93926 $142.50 TC Fee Schedule 12/1/2009

93926 $163.39 General Fee Schedule 12/1/2009

93930 $24.62 26 Fee Schedule (FS) 12/1/2009

93930 $191.15 TC Fee Schedule 12/1/2009

93930 $215.77 General Fee Schedule 12/1/2009

93931 $16.43 26 Fee Schedule (FS) 12/1/2009

93931 $140.78 General Fee Schedule 12/1/2009

93931 $124.36 TC Fee Schedule 12/1/2009

93965 $18.31 26 Fee Schedule (FS) 12/1/2009

93965 $95.90 TC Fee Schedule 12/1/2009

93965 $114.21 General Fee Schedule 12/1/2009

93970 $36.20 26 Fee Schedule (FS) 12/1/2009

93970 $186.03 TC Fee Schedule 12/1/2009

93970 $222.23 General Fee Schedule 12/1/2009

93971 $23.54 26 Fee Schedule (FS) 12/1/2009

93971 $127.45 TC Fee Schedule 12/1/2009

93971 $150.98 General Fee Schedule 12/1/2009

93975 $94.51 26 Fee Schedule (FS) 12/1/2009

93975 $256.23 TC Fee Schedule 12/1/2009

93975 $350.74 General Fee Schedule 12/1/2009

93976 $207.39 General Fee Schedule 12/1/2009

93976 $62.13 26 Fee Schedule (FS) 12/1/2009

93976 $145.26 TC Fee Schedule 12/1/2009

93978 $194.70 General Fee Schedule 12/1/2009

93978 $159.99 TC Fee Schedule 12/1/2009

93978 $34.69 26 Fee Schedule (FS) 12/1/2009

93979 $23.15 26 Fee Schedule (FS) 12/1/2009

93979 $113.40 TC Fee Schedule 12/1/2009

93979 $136.55 General Fee Schedule 12/1/2009

93980 $160.68 General Fee Schedule 12/1/2009

93980 $65.05 26 Fee Schedule (FS) 12/1/2009

93980 $95.62 TC Fee Schedule 12/1/2009

93981 $126.98 General Fee Schedule 12/1/2009

93981 $22.47 26 Fee Schedule (FS) 12/1/2009

93981 $104.52 TC Fee Schedule 12/1/2009

93982 $32.17 General Fee Schedule 12/1/2009

93990 $13.77 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 251 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

93990 $141.81 TC Fee Schedule 12/1/2009

93990 $155.58 General Fee Schedule 12/1/2009

93998 $0.00 General by Report 1/1/2012

94002 $75.82 General Fee Schedule 12/1/2009

94003 $55.03 General Fee Schedule 12/1/2009

94004 $40.10 General Fee Schedule 12/1/2009

94005 $0.00 General by Report 1/1/2007

94010 $8.61 26 Fee Schedule (FS) 12/1/2009

94010 $21.92 TC Fee Schedule 12/1/2009

94010 $30.54 General Fee Schedule 12/1/2009

94011 $92.51 General Fee Schedule 1/1/2010

94012 $142.27 General Fee Schedule 1/1/2010

94013 $30.14 General Fee Schedule 1/1/2010

94014 $47.12 General Fee Schedule 12/1/2009

94015 $20.54 General Fee Schedule 12/1/2009

94016 $26.59 General Fee Schedule 12/1/2009

94060 $51.01 General Fee Schedule 12/1/2009

94060 $15.39 26 Fee Schedule (FS) 12/1/2009

94060 $35.63 TC Fee Schedule 12/1/2009

94070 $55.73 General Fee Schedule 12/1/2009

94070 $30.36 26 Fee Schedule (FS) 12/1/2009

94070 $25.38 TC Fee Schedule 12/1/2009

94150 $7.38 General Fee Schedule 12/1/2009

94200 $5.63 26 Fee Schedule (FS) 12/1/2009

94200 $14.72 TC Fee Schedule 12/1/2009

94200 $20.35 General Fee Schedule 12/1/2009

94250 $21.22 TC Fee Schedule 12/1/2009

94250 $26.85 General Fee Schedule 12/1/2009

94250 $5.63 26 Fee Schedule (FS) 12/1/2009

94375 $18.15 TC Fee Schedule 12/1/2009

94375 $33.54 General Fee Schedule 12/1/2009

94375 $15.39 26 Fee Schedule (FS) 12/1/2009

94400 $20.58 26 Fee Schedule (FS) 12/1/2009

94400 $26.72 TC Fee Schedule 12/1/2009

94400 $47.31 General Fee Schedule 12/1/2009

94450 $20.23 26 Fee Schedule (FS) 12/1/2009

94450 $45.92 General Fee Schedule 12/1/2009

94450 $25.69 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 252 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

94452 $15.73 26 Fee Schedule (FS) 12/1/2009

94452 $32.53 TC Fee Schedule 12/1/2009

94452 $48.27 General Fee Schedule 12/1/2009

94453 $68.51 General Fee Schedule 12/1/2009

94453 $20.23 26 Fee Schedule (FS) 12/1/2009

94453 $48.28 TC Fee Schedule 12/1/2009

94610 $55.16 General Fee Schedule 12/1/2009

94620 $82.21 TC Fee Schedule 12/1/2009

94620 $114.79 General Fee Schedule 12/1/2009

94620 $32.58 26 Fee Schedule (FS) 12/1/2009

94621 $64.05 TC Fee Schedule 12/1/2009

94621 $71.94 26 Fee Schedule (FS) 12/1/2009

94621 $136.00 General Fee Schedule 12/1/2009

94640 $10.96 General Fee Schedule 12/1/2009

94642 $28.57 General Fee Schedule 12/1/2009

94644 $29.15 General Fee Schedule 12/1/2009

94645 $11.16 General Fee Schedule 12/1/2009

94660 $52.97 General Fee Schedule 12/1/2009

94662 $38.25 General Fee Schedule 12/1/2009

94664 $12.00 General Fee Schedule 12/1/2009

94667 $19.54 General Fee Schedule 12/1/2009

94668 $16.10 General Fee Schedule 12/1/2009

94669 $32.61 General Fee Schedule 1/1/2014

94680 $13.11 26 Fee Schedule (FS) 12/1/2009

94680 $63.36 TC Fee Schedule 12/1/2009

94680 $76.47 General Fee Schedule 12/1/2009

94681 $10.13 26 Fee Schedule (FS) 12/1/2009

94681 $88.72 TC Fee Schedule 12/1/2009

94681 $98.83 General Fee Schedule 12/1/2009

94690 $72.91 General Fee Schedule 12/1/2009

94690 $3.72 26 Fee Schedule (FS) 12/1/2009

94690 $69.17 TC Fee Schedule 12/1/2009

94726 $50.09 General Fee Schedule 2/6/2012

94726 $12.00 26 Fee Schedule (FS) 2/6/2012

94726 $38.09 TC Fee Schedule 2/6/2012

94727 $12.00 26 Fee Schedule (FS) 2/6/2012

94727 $27.46 TC Fee Schedule 2/6/2012

94727 $39.46 General Fee Schedule 2/6/2012

Tuesday, February 11, 2014 Page 253 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

94728 $39.46 General Fee Schedule 2/6/2012

94728 $12.00 26 Fee Schedule (FS) 2/6/2012

94728 $27.46 TC Fee Schedule 2/6/2012

94729 $49.49 General Fee Schedule 2/6/2012

94729 $8.00 26 Fee Schedule (FS) 2/6/2012

94729 $41.49 TC Fee Schedule 2/6/2012

94750 $11.62 26 Fee Schedule (FS) 12/1/2009

94750 $44.86 TC Fee Schedule 12/1/2009

94750 $56.48 General Fee Schedule 12/1/2009

94760 $2.06 General Fee Schedule 12/1/2009

94761 $4.47 General Fee Schedule 12/1/2009

94762 $19.55 General Fee Schedule 12/1/2009

94770 $7.51 26 Fee Schedule (FS) 12/1/2009

94770 $26.72 TC Fee Schedule 12/1/2009

94770 $34.23 General Fee Schedule 12/1/2009

94772 $97.83 General Fee Schedule 12/1/2009

94774 $0.00 General by Report 1/1/2007

94775 $0.00 General by Report 1/1/2007

94776 $0.00 General by Report 1/1/2007

94777 $0.00 General by Report 1/1/2007

94780 $47.91 General Fee Schedule 2/6/2012

94781 $18.60 General Fee Schedule 2/6/2012

94799 $0.00 26 by Report 1/10/1986

94799 $0.00 General by Report 1/1/1991

95004 $3.77 General Fee Schedule 12/1/2009

95012 $15.20 General Fee Schedule 12/1/2009

95018 $20.37 General Fee Schedule 2/25/2013

95024 $5.48 General Fee Schedule 12/1/2009

95028 $8.22 General Fee Schedule 12/1/2009

95044 $7.19 General Fee Schedule 12/1/2009

95052 $8.90 General Fee Schedule 12/1/2009

95056 $6.16 General Fee Schedule 12/1/2009

95060 $12.67 General Fee Schedule 12/1/2009

95065 $7.19 General Fee Schedule 12/1/2009

95070 $79.09 General Fee Schedule 12/1/2009

95071 $101.01 General Fee Schedule 12/1/2009

95076 $111.63 General Fee Schedule 2/25/2013

95079 $79.50 General Fee Schedule 2/25/2013

Tuesday, February 11, 2014 Page 254 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

95115 $14.05 General Fee Schedule 12/1/2009

95117 $17.81 General Fee Schedule 12/1/2009

95120 $6.71 General Fee Schedule 12/1/2009

95125 $15.80 General Fee Schedule 12/1/2009

95130 $16.82 General Fee Schedule 12/1/2009

95131 $16.82 General Fee Schedule 12/1/2009

95132 $17.66 General Fee Schedule 12/1/2009

95133 $18.54 General Fee Schedule 12/1/2009

95134 $18.54 General Fee Schedule 12/1/2009

95145 $13.62 General Fee Schedule 12/1/2009

95146 $17.72 General Fee Schedule 12/1/2009

95147 $17.04 General Fee Schedule 12/1/2009

95148 $22.52 General Fee Schedule 12/1/2009

95149 $30.06 General Fee Schedule 12/1/2009

95165 $9.17 General Fee Schedule 12/1/2009

95170 $7.11 General Fee Schedule 12/1/2009

95180 $148.82 General Fee Schedule 12/1/2009

95199 $0.00 General by Report 6/1/1981

95250 $141.07 General Fee Schedule 12/1/2009

95251 $27.27 General Fee Schedule 12/1/2009

95782 $965.62 General Fee Schedule 2/23/2013

95782 $124.58 26 Fee Schedule (FS) 2/23/2013

95782 $841.05 TC Fee Schedule 2/23/2013

95783 $1,030.90 General Fee Schedule 2/23/2013

95783 $136.20 26 Fee Schedule (FS) 2/23/2013

95783 $894.70 TC Fee Schedule 2/23/2013

95800 $57.06 26 Fee Schedule (FS) 1/1/2011

95800 $139.68 TC Fee Schedule 1/1/2011

95800 $196.74 General Fee Schedule 1/1/2011

95801 $93.68 General Fee Schedule 1/1/2011

95801 $43.15 TC Fee Schedule 1/1/2011

95801 $50.53 26 Fee Schedule (FS) 1/1/2011

95803 $155.60 General Fee Schedule 1/1/2011

95803 $46.17 26 Fee Schedule (FS) 1/1/2011

95803 $109.43 TC Fee Schedule 1/1/2011

95805 $98.27 26 Fee Schedule (FS) 12/1/2009

95805 $581.79 TC Fee Schedule 12/1/2009

95805 $680.07 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 255 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

95806 $191.90 General Fee Schedule 12/1/2009

95806 $106.57 TC Fee Schedule 12/1/2009

95806 $85.33 26 Fee Schedule (FS) 12/1/2009

95807 $403.10 TC Fee Schedule 12/1/2009

95807 $488.08 General Fee Schedule 12/1/2009

95807 $84.98 26 Fee Schedule (FS) 12/1/2009

95808 $138.27 26 Fee Schedule (FS) 12/1/2009

95808 $435.97 TC Fee Schedule 12/1/2009

95808 $574.24 General Fee Schedule 12/1/2009

95810 $182.14 26 Fee Schedule (FS) 12/1/2009

95810 $574.63 TC Fee Schedule 12/1/2009

95810 $756.76 General Fee Schedule 12/1/2009

95811 $195.99 26 Fee Schedule (FS) 12/1/2009

95811 $630.09 TC Fee Schedule 12/1/2009

95811 $826.08 General Fee Schedule 12/1/2009

95812 $59.16 26 Fee Schedule (FS) 12/1/2009

95812 $126.71 TC Fee Schedule 12/1/2009

95812 $185.88 General Fee Schedule 12/1/2009

95813 $93.86 26 Fee Schedule (FS) 12/1/2009

95813 $152.04 TC Fee Schedule 12/1/2009

95813 $245.90 General Fee Schedule 12/1/2009

95816 $59.51 26 Fee Schedule (FS) 12/1/2009

95816 $115.07 TC Fee Schedule 12/1/2009

95816 $174.57 General Fee Schedule 12/1/2009

95819 $149.58 General Fee Schedule 12/1/2009

95819 $59.51 26 Fee Schedule (FS) 12/1/2009

95819 $90.07 TC Fee Schedule 12/1/2009

95822 $206.09 General Fee Schedule 12/1/2009

95822 $59.51 26 Fee Schedule (FS) 12/1/2009

95822 $146.58 TC Fee Schedule 12/1/2009

95824 $40.56 26 Fee Schedule (FS) 12/1/2009

95827 $57.45 26 Fee Schedule (FS) 12/1/2009

95827 $83.58 TC Fee Schedule 12/1/2009

95827 $141.03 General Fee Schedule 12/1/2009

95829 $1,321.01 General Fee Schedule 12/1/2009

95829 $985.68 TC Fee Schedule 12/1/2009

95829 $335.32 26 Fee Schedule (FS) 12/1/2009

95830 $182.40 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 256 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

95831 $26.90 General Fee Schedule 12/1/2009

95832 $23.18 General Fee Schedule 12/1/2009

95833 $38.69 General Fee Schedule 12/1/2009

95834 $45.76 General Fee Schedule 12/1/2009

95851 $18.85 General Fee Schedule 12/1/2009

95852 $13.49 General Fee Schedule 12/1/2009

95857 $41.69 General Fee Schedule 12/1/2009

95860 $53.17 26 Fee Schedule (FS) 12/1/2009

95860 $88.09 General Fee Schedule 12/1/2009

95860 $34.92 TC Fee Schedule 12/1/2009

95861 $27.06 TC Fee Schedule 12/1/2009

95861 $85.14 26 Fee Schedule (FS) 12/1/2009

95861 $112.21 General Fee Schedule 12/1/2009

95863 $136.93 General Fee Schedule 12/1/2009

95863 $102.67 26 Fee Schedule (FS) 12/1/2009

95863 $34.25 TC Fee Schedule 12/1/2009

95864 $109.71 26 Fee Schedule (FS) 12/1/2009

95864 $175.13 General Fee Schedule 12/1/2009

95864 $65.43 TC Fee Schedule 12/1/2009

95865 $24.32 TC Fee Schedule 12/1/2009

95865 $89.73 26 Fee Schedule (FS) 12/1/2009

95865 $114.04 General Fee Schedule 12/1/2009

95866 $7.89 TC Fee Schedule 12/1/2009

95866 $69.84 26 Fee Schedule (FS) 12/1/2009

95866 $77.73 General Fee Schedule 12/1/2009

95867 $21.23 TC Fee Schedule 12/1/2009

95867 $43.51 26 Fee Schedule (FS) 12/1/2009

95867 $64.76 General Fee Schedule 12/1/2009

95868 $25.70 TC Fee Schedule 12/1/2009

95868 $64.74 26 Fee Schedule (FS) 12/1/2009

95868 $90.43 General Fee Schedule 12/1/2009

95869 $7.89 TC Fee Schedule 12/1/2009

95869 $28.33 General Fee Schedule 12/1/2009

95869 $20.45 26 Fee Schedule (FS) 12/1/2009

95870 $7.89 TC Fee Schedule 12/1/2009

95870 $20.45 26 Fee Schedule (FS) 12/1/2009

95870 $28.33 General Fee Schedule 12/1/2009

95872 $104.50 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 257 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

95872 $22.26 TC Fee Schedule 12/1/2009

95872 $82.24 26 Fee Schedule (FS) 12/1/2009

95873 $27.98 General Fee Schedule 12/1/2009

95873 $7.54 TC Fee Schedule 12/1/2009

95873 $20.45 26 Fee Schedule (FS) 12/1/2009

95874 $7.54 TC Fee Schedule 12/1/2009

95874 $20.80 26 Fee Schedule (FS) 12/1/2009

95874 $28.33 General Fee Schedule 12/1/2009

95875 $95.90 General Fee Schedule 12/1/2009

95875 $60.28 26 Fee Schedule (FS) 12/1/2009

95875 $35.63 TC Fee Schedule 12/1/2009

95885 $34.95 TC Fee Schedule 2/6/2012

95885 $52.19 General Fee Schedule 2/6/2012

95885 $17.24 26 Fee Schedule (FS) 2/6/2012

95886 $36.82 TC Fee Schedule 2/6/2012

95886 $46.05 26 Fee Schedule (FS) 2/6/2012

95886 $82.87 General Fee Schedule 2/6/2012

95887 $36.13 26 Fee Schedule (FS) 2/6/2012

95887 $37.44 TC Fee Schedule 2/6/2012

95887 $73.57 General Fee Schedule 2/6/2012

95905 $2.79 26 Fee Schedule (FS) 1/1/2010

95905 $65.27 TC Fee Schedule 1/1/2010

95905 $68.06 General Fee Schedule 1/1/2010

95907 $39.35 TC Fee Schedule 2/23/2013

95907 $50.31 26 Fee Schedule (FS) 2/23/2013

95907 $89.66 General Fee Schedule 2/23/2013

95908 $47.45 TC Fee Schedule 2/23/2013

95908 $63.21 26 Fee Schedule (FS) 2/23/2013

95908 $110.66 General Fee Schedule 2/23/2013

95909 $57.17 TC Fee Schedule 2/23/2013

95909 $75.45 26 Fee Schedule (FS) 2/23/2013

95909 $132.62 General Fee Schedule 2/23/2013

95910 $73.71 TC Fee Schedule 2/23/2013

95910 $100.93 26 Fee Schedule (FS) 2/23/2013

95910 $174.65 General Fee Schedule 2/23/2013

95911 $85.61 TC Fee Schedule 2/23/2013

95911 $126.08 26 Fee Schedule (FS) 2/23/2013

95911 $211.69 General Fee Schedule 2/23/2013

Tuesday, February 11, 2014 Page 258 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

95912 $96.86 TC Fee Schedule 2/23/2013

95912 $151.25 26 Fee Schedule (FS) 2/23/2013

95912 $248.11 General Fee Schedule 2/23/2013

95913 $287.81 General Fee Schedule 2/25/2013

95913 $108.45 TC Fee Schedule 2/25/2013

95913 $179.36 26 Fee Schedule (FS) 2/25/2013

95921 $61.12 General Fee Schedule 12/1/2009

95921 $13.70 TC Fee Schedule 12/1/2009

95921 $47.42 26 Fee Schedule (FS) 12/1/2009

95922 $13.70 TC Fee Schedule 12/1/2009

95922 $52.48 26 Fee Schedule (FS) 12/1/2009

95922 $66.18 General Fee Schedule 12/1/2009

95923 $103.59 General Fee Schedule 12/1/2009

95923 $49.48 26 Fee Schedule (FS) 12/1/2009

95923 $54.11 TC Fee Schedule 12/1/2009

95924 $140.45 General Fee Schedule 2/25/2013

95924 $55.81 TC Fee Schedule 2/25/2013

95924 $84.64 26 Fee Schedule (FS) 2/25/2013

95925 $29.76 26 Fee Schedule (FS) 12/1/2009

95925 $33.22 TC Fee Schedule 12/1/2009

95925 $62.98 General Fee Schedule 12/1/2009

95926 $33.22 TC Fee Schedule 12/1/2009

95926 $62.98 General Fee Schedule 12/1/2009

95926 $29.75 26 Fee Schedule (FS) 12/1/2009

95927 $33.22 TC Fee Schedule 12/1/2009

95927 $64.01 General Fee Schedule 12/1/2009

95927 $30.79 26 Fee Schedule (FS) 12/1/2009

95928 $82.23 26 Fee Schedule (FS) 12/1/2009

95928 $82.52 TC Fee Schedule 12/1/2009

95928 $164.74 General Fee Schedule 12/1/2009

95929 $82.23 26 Fee Schedule (FS) 12/1/2009

95929 $89.03 TC Fee Schedule 12/1/2009

95929 $171.25 General Fee Schedule 12/1/2009

95930 $19.33 26 Fee Schedule (FS) 12/1/2009

95930 $72.25 TC Fee Schedule 12/1/2009

95930 $91.59 General Fee Schedule 12/1/2009

95933 $28.77 TC Fee Schedule 12/1/2009

95933 $32.37 26 Fee Schedule (FS) 12/1/2009

Tuesday, February 11, 2014 Page 259 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

95933 $61.15 General Fee Schedule 12/1/2009

95937 $12.34 TC Fee Schedule 12/1/2009

95937 $49.43 General Fee Schedule 12/1/2009

95937 $37.09 26 Fee Schedule (FS) 12/1/2009

95938 $42.48 26 Fee Schedule (FS) 2/6/2012

95938 $231.11 TC Fee Schedule 2/6/2012

95938 $273.59 General Fee Schedule 2/6/2012

95939 $111.81 26 Fee Schedule (FS) 2/6/2012

95939 $319.07 TC Fee Schedule 2/6/2012

95939 $430.87 General Fee Schedule 2/6/2012

95940 $0.00 26 by Report 1/1/2013

95940 $0.00 TC by Report 1/1/2013

95940 $31.09 General Fee Schedule 2/25/2013

95941 $0.00 26 by Report 1/1/2013

95941 $0.00 General by Report 1/1/2013

95941 $0.00 TC by Report 1/1/2013

95943 $0.00 TC by Report 1/1/2013

95943 $0.00 26 by Report 1/1/2013

95943 $0.00 General by Report 1/1/2013

95950 $210.80 General Fee Schedule 12/1/2009

95950 $127.84 TC Fee Schedule 12/1/2009

95950 $82.95 26 Fee Schedule (FS) 12/1/2009

95951 $329.91 26 Fee Schedule (FS) 12/1/2009

95951 $620.37 TC Fee Schedule 12/1/2009

95951 $941.48 General Fee Schedule 12/1/2009

95953 $401.17 General Fee Schedule 12/1/2009

95953 $168.92 26 Fee Schedule (FS) 12/1/2009

95953 $232.26 TC Fee Schedule 12/1/2009

95954 $245.95 General Fee Schedule 12/1/2009

95954 $111.29 TC Fee Schedule 12/1/2009

95954 $134.67 26 Fee Schedule (FS) 12/1/2009

95955 $53.03 26 Fee Schedule (FS) 12/1/2009

95955 $73.32 TC Fee Schedule 12/1/2009

95955 $126.35 General Fee Schedule 12/1/2009

95956 $499.31 TC Fee Schedule 12/1/2009

95956 $668.22 General Fee Schedule 12/1/2009

95956 $168.92 26 Fee Schedule (FS) 12/1/2009

95957 $62.35 TC Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 260 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

95957 $109.33 26 Fee Schedule (FS) 12/1/2009

95957 $171.68 General Fee Schedule 12/1/2009

95958 $64.41 TC Fee Schedule 12/1/2009

95958 $230.82 26 Fee Schedule (FS) 12/1/2009

95958 $295.23 General Fee Schedule 12/1/2009

95961 $47.27 TC Fee Schedule 12/1/2009

95961 $176.41 26 Fee Schedule (FS) 12/1/2009

95961 $223.68 General Fee Schedule 12/1/2009

95962 $47.27 TC Fee Schedule 12/1/2009

95962 $182.54 26 Fee Schedule (FS) 12/1/2009

95962 $229.81 General Fee Schedule 12/1/2009

95965 $441.73 26 Fee Schedule (FS) 12/1/2009

95966 $219.12 26 Fee Schedule (FS) 12/1/2009

95966 $304.30 TC Fee Schedule 12/1/2009

95967 $180.63 26 Fee Schedule (FS) 12/1/2009

95967 $251.45 TC Fee Schedule 12/1/2009

95970 $47.50 General Fee Schedule 12/1/2009

95971 $55.80 General Fee Schedule 12/1/2009

95972 $104.16 General Fee Schedule 12/1/2009

95973 $59.15 General Fee Schedule 12/1/2009

95974 $179.53 General Fee Schedule 12/1/2009

95975 $100.23 General Fee Schedule 12/1/2009

95978 $207.74 General Fee Schedule 12/1/2009

95979 $95.86 General Fee Schedule 12/1/2009

95980 $32.12 General Fee Schedule 12/1/2009

95981 $21.92 General Fee Schedule 12/1/2009

95982 $33.75 General Fee Schedule 12/1/2009

95990 $53.43 General Fee Schedule 12/1/2009

95991 $83.15 General Fee Schedule 12/1/2009

95992 $41.75 General Fee Schedule 1/1/2011

95999 $0.00 General by Report 1/1/1991

96000 $91.42 General Fee Schedule 12/1/2009

96001 $109.04 General Fee Schedule 12/1/2009

96002 $21.65 General Fee Schedule 12/1/2009

96003 $19.08 General Fee Schedule 12/1/2009

96004 $118.58 General Fee Schedule 12/1/2009

96020 $31.89 26 Fee Schedule (FS) 12/1/2009

96105 $58.84 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 261 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

96110 $12.05 General Fee Schedule 12/1/2009

96125 $61.49 General Fee Schedule 12/1/2009

96153 $4.89 General Fee Schedule 1/1/2011

96154 $21.55 General Fee Schedule 1/1/2011

96360 $50.04 General Fee Schedule 12/1/2009

96361 $14.96 General Fee Schedule 12/1/2009

96365 $60.78 General Fee Schedule 12/1/2009

96366 $19.97 General Fee Schedule 12/1/2009

96367 $30.91 General Fee Schedule 12/1/2009

96368 $18.69 General Fee Schedule 12/1/2009

96369 $130.46 General Fee Schedule 12/1/2009

96370 $14.68 General Fee Schedule 12/1/2009

96371 $62.65 General Fee Schedule 12/1/2009

96372 $17.52 General Fee Schedule 12/1/2009

96373 $17.87 General Fee Schedule 12/1/2009

96374 $52.84 General Fee Schedule 12/1/2009

96375 $24.76 General Fee Schedule 12/1/2009

96376 $0.00 General by Report 1/1/2009

96379 $159.40 General Fee Schedule 12/1/2009

96401 $48.51 General Fee Schedule 12/1/2009

96402 $42.25 General Fee Schedule 12/1/2009

96405 $104.65 General Fee Schedule 12/1/2009

96406 $135.31 General Fee Schedule 12/1/2009

96409 $111.65 General Fee Schedule 12/1/2009

96411 $64.91 General Fee Schedule 12/1/2009

96413 $157.37 General Fee Schedule 12/1/2009

96415 $36.11 General Fee Schedule 12/1/2009

96416 $168.70 General Fee Schedule 12/1/2009

96417 $77.28 General Fee Schedule 12/1/2009

96420 $100.74 General Fee Schedule 12/1/2009

96422 $175.03 General Fee Schedule 12/1/2009

96423 $71.95 General Fee Schedule 12/1/2009

96425 $162.71 General Fee Schedule 12/1/2009

96440 $376.39 General Fee Schedule 12/1/2009

96446 $168.56 General Fee Schedule 1/1/2011

96450 $300.80 General Fee Schedule 12/1/2009

96521 $139.25 General Fee Schedule 12/1/2009

96522 $100.90 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 262 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

96523 $25.51 General Fee Schedule 12/1/2009

96542 $177.22 General Fee Schedule 12/1/2009

96549 $0.00 Manual Review Fee Schedule 4/1/1990

96567 $68.48 General Fee Schedule 12/1/2009

96570 $58.93 General Fee Schedule 12/1/2009

96571 $28.77 General Fee Schedule 12/1/2009

96900 $15.75 General Fee Schedule 12/1/2009

96902 $0.00 General by Report 1/1/1998

96904 $57.37 General Fee Schedule 12/1/2009

96910 $35.28 General Fee Schedule 12/1/2009

96912 $44.86 General Fee Schedule 12/1/2009

96913 $60.97 General Fee Schedule 12/1/2009

96920 $132.04 General Fee Schedule 12/1/2009

96921 $135.55 General Fee Schedule 12/1/2009

96922 $201.92 General Fee Schedule 12/1/2009

96999 $0.00 General by Report 6/1/1981

97001 $73.72 General Fee Schedule 12/1/2009

97002 $38.92 General Fee Schedule 12/1/2009

97003 $78.51 General Fee Schedule 12/1/2009

97004 $46.79 General Fee Schedule 12/1/2009

97005 $53.29 General Fee Schedule 12/1/2009

97006 $53.29 General Fee Schedule 12/1/2009

97010 $16.78 General Fee Schedule 12/1/2009

97012 $14.44 General Fee Schedule 12/1/2009

97014 $14.92 General Fee Schedule 12/1/2009

97016 $13.45 General Fee Schedule 12/1/2009

97018 $6.08 General Fee Schedule 12/1/2009

97022 $14.09 General Fee Schedule 12/1/2009

97024 $5.06 General Fee Schedule 12/1/2009

97026 $4.71 General Fee Schedule 12/1/2009

97028 $5.83 General Fee Schedule 12/1/2009

97032 $15.47 General Fee Schedule 12/1/2009

97033 $19.62 General Fee Schedule 12/1/2009

97034 $13.59 General Fee Schedule 12/1/2009

97035 $11.87 General Fee Schedule 12/1/2009

97036 $22.12 General Fee Schedule 12/1/2009

97039 $12.03 General Fee Schedule 12/1/2009

97110 $27.31 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 263 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

97112 $28.32 General Fee Schedule 12/1/2009

97113 $30.68 General Fee Schedule 12/1/2009

97116 $24.01 General Fee Schedule 12/1/2009

97124 $21.73 General Fee Schedule 12/1/2009

97139 $14.53 General Fee Schedule 12/1/2009

97140 $25.50 General Fee Schedule 12/1/2009

97150 $16.93 General Fee Schedule 12/1/2009

97530 $28.29 General Fee Schedule 12/1/2009

97532 $24.18 General Fee Schedule 12/1/2009

97533 $25.54 General Fee Schedule 12/1/2009

97535 $29.01 General Fee Schedule 12/1/2009

97537 $26.62 General Fee Schedule 12/1/2009

97542 $27.31 General Fee Schedule 12/1/2009

97597 $46.71 General Fee Schedule 12/1/2009

97598 $59.66 General Fee Schedule 12/1/2009

97602 $33.43 General Fee Schedule 12/1/2009

97605 $33.56 General Fee Schedule 12/1/2009

97606 $36.18 General Fee Schedule 12/1/2009

97610 $0.00 General by Report 1/1/2014

97750 $29.01 General Fee Schedule 12/1/2009

97755 $34.21 General Fee Schedule 12/1/2009

97760 $30.05 General Fee Schedule 12/1/2009

97761 $27.65 General Fee Schedule 12/1/2009

97762 $24.72 General Fee Schedule 12/1/2009

97799 $0.00 General by Report 1/1/1991

97802 $16.44 General Fee Schedule 12/1/2009

97803 $16.44 General Fee Schedule 12/1/2009

97804 $13.11 General Fee Schedule 1/1/2011

98925 $29.01 General Fee Schedule 12/1/2009

98926 $40.16 General Fee Schedule 12/1/2009

98927 $51.74 General Fee Schedule 12/1/2009

98928 $61.33 General Fee Schedule 12/1/2009

98929 $70.61 General Fee Schedule 12/1/2009

99050 $7.65 General Fee Schedule 12/1/2009

99051 $7.65 General Fee Schedule 12/1/2009

99053 $7.65 General Fee Schedule 12/1/2009

99056 $7.65 General Fee Schedule 12/1/2009

99058 $7.65 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 264 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

99060 $7.65 General Fee Schedule 12/1/2009

99070 $47.77 General Fee Schedule 12/1/2009

99080 $22.10 General Fee Schedule 12/1/2009

99090 $15.28 General Fee Schedule 12/1/2009

99091 $15.28 General Fee Schedule 12/1/2009

99143 $60.93 General Fee Schedule 12/1/2009

99144 $91.23 General Fee Schedule 12/1/2009

99145 $22.65 General Fee Schedule 12/1/2009

99148 $60.93 General Fee Schedule 12/1/2009

99149 $91.23 General Fee Schedule 12/1/2009

99150 $22.65 General Fee Schedule 12/1/2009

99170 $118.44 26 Fee Schedule (FS) 12/1/2009

99170 $130.91 General Fee Schedule 12/1/2009

99172 $39.93 General Fee Schedule 12/1/2009

99173 $39.93 General Fee Schedule 12/1/2009

99183 $207.12 General Fee Schedule 12/1/2009

99190 $289.23 General Fee Schedule 12/1/2009

99191 $215.23 General Fee Schedule 12/1/2009

99192 $142.94 General Fee Schedule 12/1/2009

99195 $15.75 General Fee Schedule 12/1/2009

99199 $0.00 General by Report 6/1/1981

99201 $35.18 General Fee Schedule 12/1/2009

99202 $62.74 General Fee Schedule 12/1/2009

99203 $93.52 General Fee Schedule 12/1/2009

99204 $132.70 General Fee Schedule 12/1/2009

99205 $169.19 General Fee Schedule 12/1/2009

99211 $20.25 General Fee Schedule 12/1/2009

99212 $36.89 General Fee Schedule 12/1/2009

99213 $50.52 General Fee Schedule 12/1/2009

99214 $79.45 General Fee Schedule 12/1/2009

99215 $116.27 General Fee Schedule 12/1/2009

99217 $69.63 General Fee Schedule 12/1/2009

99218 $66.54 General Fee Schedule 12/1/2009

99219 $110.72 General Fee Schedule 12/1/2009

99220 $155.51 General Fee Schedule 12/1/2009

99221 $67.23 General Fee Schedule 12/1/2009

99222 $111.39 General Fee Schedule 12/1/2009

99223 $155.17 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 265 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

99224 $27.50 General Fee Schedule 1/1/2011

99225 $48.57 General Fee Schedule 1/1/2011

99226 $72.71 General Fee Schedule 1/1/2011

99231 $33.61 General Fee Schedule 12/1/2009

99232 $54.97 General Fee Schedule 12/1/2009

99233 $78.16 General Fee Schedule 12/1/2009

99234 $133.77 General Fee Schedule 12/1/2009

99235 $176.52 General Fee Schedule 12/1/2009

99236 $220.29 General Fee Schedule 12/1/2009

99238 $69.63 General Fee Schedule 12/1/2009

99239 $94.95 General Fee Schedule 12/1/2009

99241 $48.34 General Fee Schedule 12/1/2009

99242 $88.85 General Fee Schedule 12/1/2009

99243 $118.48 General Fee Schedule 12/1/2009

99244 $167.77 General Fee Schedule 12/1/2009

99245 $217.32 General Fee Schedule 12/1/2009

99251 $35.42 General Fee Schedule 12/1/2009

99252 $71.17 General Fee Schedule 12/1/2009

99253 $97.33 General Fee Schedule 12/1/2009

99254 $139.94 General Fee Schedule 12/1/2009

99255 $192.93 General Fee Schedule 12/1/2009

99281 $16.51 General Fee Schedule 12/1/2009

99282 $27.41 General Fee Schedule 12/1/2009

99283 $61.59 General Fee Schedule 12/1/2009

99284 $96.19 General Fee Schedule 12/1/2009

99285 $150.71 General Fee Schedule 12/1/2009

99288 $68.06 General Fee Schedule 12/1/2009

99291 $249.59 General Fee Schedule 12/1/2009

99292 $111.81 General Fee Schedule 12/1/2009

99304 $70.99 General Fee Schedule 12/1/2009

99305 $94.34 General Fee Schedule 12/1/2009

99306 $116.51 General Fee Schedule 12/1/2009

99307 $36.62 General Fee Schedule 12/1/2009

99308 $60.66 General Fee Schedule 12/1/2009

99309 $85.54 General Fee Schedule 12/1/2009

99310 $107.10 General Fee Schedule 12/1/2009

99315 $66.54 General Fee Schedule 12/1/2009

99316 $87.80 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 266 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

99318 $70.99 General Fee Schedule 12/1/2009

99324 $57.48 General Fee Schedule 12/1/2009

99325 $84.37 General Fee Schedule 12/1/2009

99326 $122.58 General Fee Schedule 12/1/2009

99327 $161.51 General Fee Schedule 12/1/2009

99328 $200.04 General Fee Schedule 12/1/2009

99334 $44.41 General Fee Schedule 12/1/2009

99335 $70.56 General Fee Schedule 12/1/2009

99336 $109.15 General Fee Schedule 12/1/2009

99337 $160.83 General Fee Schedule 12/1/2009

99341 $57.15 General Fee Schedule 12/1/2009

99342 $84.37 General Fee Schedule 12/1/2009

99343 $123.26 General Fee Schedule 12/1/2009

99344 $161.84 General Fee Schedule 12/1/2009

99345 $200.39 General Fee Schedule 12/1/2009

99347 $44.41 General Fee Schedule 12/1/2009

99348 $70.56 General Fee Schedule 12/1/2009

99349 $109.50 General Fee Schedule 12/1/2009

99350 $161.84 General Fee Schedule 12/1/2009

99354 $97.45 General Fee Schedule 12/1/2009

99355 $96.41 General Fee Schedule 12/1/2009

99356 $89.65 General Fee Schedule 12/1/2009

99357 $90.35 General Fee Schedule 12/1/2009

99381 $150.55 General Fee Schedule 7/1/2007

99382 $150.55 General Fee Schedule 7/1/2007

99383 $150.55 General Fee Schedule 7/1/2007

99384 $150.55 General Fee Schedule 7/1/2007

99385 $150.55 General Fee Schedule 7/1/2007

99391 $89.83 General Fee Schedule 7/1/2007

99392 $89.83 General Fee Schedule 7/1/2007

99393 $89.83 General Fee Schedule 7/1/2007

99394 $89.83 General Fee Schedule 7/1/2007

99395 $89.83 General Fee Schedule 7/1/2007

99406 $13.19 General Fee Schedule 1/1/2012

99407 $25.83 General Fee Schedule 1/1/2012

99420 $12.05 General Fee Schedule 8/1/2011

99455 $124.60 General Fee Schedule 1/1/2010

99460 $65.60 General Fee Schedule 12/1/2009

Tuesday, February 11, 2014 Page 267 of 268NM FFS CPT CODE FEE SCHEDULE

CPT CODE Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

99461 $90.79 General Fee Schedule 12/1/2009

99462 $34.47 General Fee Schedule 12/1/2009

99463 $87.80 General Fee Schedule 12/1/2009

99464 $83.30 General Fee Schedule 12/1/2009

99465 $163.28 General Fee Schedule 12/1/2009

99466 $242.82 General Fee Schedule 12/1/2009

99467 $124.51 General Fee Schedule 12/1/2009

99468 $1,026.40 General Fee Schedule 12/1/2009

99469 $445.50 General Fee Schedule 12/1/2009

99471 $896.42 General Fee Schedule 12/1/2009

99472 $445.17 General Fee Schedule 12/1/2009

99475 $511.99 General Fee Schedule 12/1/2009

99476 $303.65 General Fee Schedule 12/1/2009

99477 $304.23 General Fee Schedule 12/1/2009

99478 $157.57 General Fee Schedule 12/1/2009

99479 $143.99 General Fee Schedule 12/1/2009

99480 $138.63 General Fee Schedule 12/1/2009

99481 $0.00 General by Report 1/1/2014

99482 $0.00 General by Report 1/1/2014

99509 $0.00 General Fee Schedule 1/1/2004

Tuesday, February 11, 2014 Page 268 of 268NM FFS CPT CODE FEE SCHEDULE