preparation for bladder xray 51610 51700 irrigation of bladder 51701 insert bladder by HC120830205359

VIEWS: 13 PAGES: 457

									                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1   Mod 2   Rate Type   Price            Effective
Code                                                                                    Date
00102       ANESTH REPAIR OF CLEFT LIP                                         $21.20       20110801
00103       ANESTH BLEPHAROPLASTY                                              $21.20       20110801
00104       ANESTH ELECTROSHOCK                                                $21.20       20110801
00120       ANESTH EAR SURGERY                                                 $21.20       20110801
00124       ANESTH EAR EXAM                                                    $21.20       20110801
00126       ANESTH TYMPANOTOMY                                                 $21.20       20110801
00140       ANESTH PROCEDURES ON EYE                                           $21.20       20110801
00142       ANESTH LENS SURGERY                                                $21.20       20110801
00144       ANESTH CORNEAL TRANSPLANT                                          $21.20       20110801
00145       ANESTH VITREORETINAL SURG                                          $21.20       20110801
00147       ANESTH IRIDECTOMY                                                  $21.20       20110801
00148       ANESTH EYE EXAM                                                    $21.20       20110801
00160       ANESTH NOSE/SINUS SURGERY                                          $21.20       20110801
00162       ANESTH NOSE/SINUS SURGERY                                          $21.20       20110801
00164       ANESTH BIOPSY OF NOSE                                              $21.20       20110801
00170       ANESTH PROCEDURE ON MOUTH                                          $21.20       20110801
00172       ANESTH CLEFT PALATE REPAIR                                         $21.20       20110801
00174       ANESTH PHARYNGEAL SURGERY                                          $21.20       20110801
00176       ANESTH PHARYNGEAL SURGERY                                          $21.20       20110801
00190       ANESTH FACE/SKULL BONE SURG                                        $21.20       20110801
00192       ANESTH FACIAL BONE SURGERY                                         $21.20       20110801
00210       ANESTH CRANIAL SURG NOS                                            $21.20       20110801
00211       ANESTH CRAN SURG HEMOTOMA                                          $21.20       20110801
00212       ANESTH SKULL DRAINAGE                                              $21.20       20110801
00214       ANESTH SKULL DRAINAGE                                              $21.20       20110801
00215       ANESTH SKULL REPAIR/FRACT                                          $21.20       20110801
00216       ANESTH HEAD VESSEL SURGERY                                         $21.20       20110801
00218       ANESTH SPECIAL HEAD SURGERY                                        $21.20       20110801
00220       ANESTH INTRCRN NERVE                                               $21.20       20110801
00222       ANESTH HEAD NERVE SURGERY                                          $21.20       20110801
00300       ANESTH HEAD/NECK/PTRUNK                                            $21.20       20110801
00320       ANESTH NECK ORGAN 1YR/                                             $21.20       20110801
00322       ANESTH BIOPSY OF THYROID                                           $21.20       20110801
00326       ANESTH LARYNX/TRACH 1 YR                                           $21.20       20110801
00350       ANESTH NECK VESSEL SURGERY                                         $21.20       20110801
00352       ANESTH NECK VESSEL SURGERY                                         $21.20       20110801
00400       ANESTH SKIN EXT/PER/ATRUNK                                         $21.20       20110801
00402       ANESTH SURGERY OF BREAST                                           $21.20       20110801
00404       ANESTH SURGERY OF BREAST                                           $21.20       20110801
00406       ANESTH SURGERY OF BREAST                                           $21.20       20110801
00410       ANESTH CORRECT HEART RHYTHM                                        $21.20       20110801
00450       ANESTH SURGERY OF SHOULDER                                         $21.20       20110801
00452       ANESTH SURGERY OF SHOULDER                                         $21.20       20110801
00454       ANESTH COLLAR BONE BIOPSY                                          $21.20       20110801
00470       ANESTH REMOVAL OF RIB                                              $21.20       20110801
00472       ANESTH CHEST WALL REPAIR                                           $21.20       20110801
00474       ANESTH SURGERY OF RIB                                              $21.20       20110801
00500       ANESTH ESOPHAGEAL SURGERY                                          $21.20       20110801
00520       ANESTH CHEST PROCEDURE                                             $21.20       20110801
00522       ANESTH CHEST LINING BIOPSY                                         $21.20       20110801
00524       ANESTH CHEST DRAINAGE                                              $21.20       20110801
00528       ANES MEDIASCPY DX THORSCPY                                         $21.20       20110801
00529       ANES MEDSCPYTHORSCPY 1 LUNG                                        $21.20       20110801
00530       ANESTH PACEMAKER INSERTION                                         $21.20       20110801
00532       ANESTH VASCULAR ACCESS                                             $21.20       20110801
00534       ANESTH CARDIOVERTER/DEFIB                                          $21.20       20110801
00537       ANESTH CARDIAC ELECTROPHYS                                         $21.20       20110801
00539       ANESTH TRACH-BRONCH RECONST                                        $21.20       20110801
00540       ANESTH CHEST SURGERY                                               $21.20       20110801



                                               Page 1
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1   Mod 2   Rate Type   Price            Effective
Code                                                                                     Date
00541       ANESTH ONE LUNG VENTILATION                                         $21.20       20110801
00542       ANESTH REMVL PLEURA                                                 $21.20       20110801
00546       ANESTH LUNG CHEST WALL SURG                                         $21.20       20110801
00548       ANESTH TRACHEA BRONCHI SURG                                         $21.20       20110801
00550       ANESTH STERNAL DEBRIDEMENT                                          $21.20       20110801
00560       ANESTH HEART SURG W/O PUMP                                          $21.20       20110801
00561       ANESTH HEART SURG 1 YR                                              $21.20       20110801
00562       ANESTH HRT SURG W/PMP AGE 1                                         $21.20       20110801
00563       ANESTH HEART SURG W/ARREST                                          $21.20       20110801
00566       ANESTH CABG W/O PUMP                                                $21.20       20110801
00567       ANESTH CABG W/PUMP                                                  $21.20       20110801
00580       ANESTH HEART/LUNG TRANSPLNT                                         $21.20       20110801
00600       ANESTH SPINE CORD SURGERY                                           $21.20       20110801
00604       ANESTH SITTING PROCEDURE                                            $21.20       20110801
00620       ANESTH SPINE CORD SURGERY                                           $21.20       20110801
00622       ANESTH REMOVAL OF NERVES                                            $21.20       20110801
00625       ANES SPINE TRANTHOR W/O VENT                                        $21.20       20110801
00626       ANES SPINE TRANSTHOR W/VENT                                         $21.20       20110801
00630       ANESTH SPINE CORD SURGERY                                           $21.20       20110801
00632       ANESTH REMOVAL OF NERVES                                            $21.20       20110801
00634       ANESTH FOR CHEMONUCLEOLYSIS                                         $21.20       20110801
00635       ANESTH LUMBAR PUNCTURE                                              $21.20       20110801
00640       ANESTH SPINE MANIPULATION                                           $21.20       20110801
00670       ANESTH SPINE CORD SURGERY                                           $21.20       20110801
00700       ANESTH ABDOMINAL WALL SURG                                          $21.20       20110801
00702       ANESTH FOR LIVER BIOPSY                                             $21.20       20110801
00730       ANESTH ABDOMINAL WALL SURG                                          $21.20       20110801
00740       ANESTH UPPER GI VISUALIZE                                           $21.20       20110801
00750       ANESTH REPAIR OF HERNIA                                             $21.20       20110801
00752       ANESTH REPAIR OF HERNIA                                             $21.20       20110801
00754       ANESTH REPAIR OF HERNIA                                             $21.20       20110801
00756       ANESTH REPAIR OF HERNIA                                             $21.20       20110801
00770       ANESTH BLOOD VESSEL REPAIR                                          $21.20       20110801
00790       ANESTH SURG UPPER ABDOMEN                                           $21.20       20110801
00792       ANESTH HEMORR/EXCISE LIVER                                          $21.20       20110801
00794       ANESTH PANCREAS REMOVAL                                             $21.20       20110801
00796       ANESTH FOR LIVER TRANSPLANT                                         $21.20       20110801
00797       ANESTH SURGERY FOR OBESITY                                          $21.20       20110801
00800       ANESTH ABDOMINAL WALL SURG                                          $21.20       20110801
00810       ANESTH LOW INTESTINE SCOPE                                          $21.20       20110801
00820       ANESTH ABDOMINAL WALL SURG                                          $21.20       20110801
00830       ANESTH REPAIR OF HERNIA                                             $21.20       20110801
00832       ANESTH REPAIR OF HERNIA                                             $21.20       20110801
00834       ANESTH HERNIA REPAIR 1 YR                                           $21.20       20110801
00836       ANESTH HERNIA REPAIR PREEMIE                                        $21.20       20110801
00840       ANESTH SURG LOWER ABDOMEN                                           $21.20       20110801
00842       ANESTH AMNIOCENTESIS                                                $21.20       20110801
00844       ANESTH PELVIS SURGERY                                               $21.20       20110801
00846       ANESTH HYSTERECTOMY                                                 $21.20       20110801
00848       ANESTH PELVIC ORGAN SURG                                            $21.20       20110801
00851       ANESTH TUBAL LIGATION                                               $21.20       20110801
00860       ANESTH SURGERY OF ABDOMEN                                           $21.20       20110801
00862       ANESTH KIDNEY/URETER SURG                                           $21.20       20110801
00864       ANESTH REMOVAL OF BLADDER                                           $21.20       20110801
00865       ANESTH REMOVAL OF PROSTATE                                          $21.20       20110801
00866       ANESTH REMOVAL OF ADRENAL                                           $21.20       20110801
00868       ANESTH KIDNEY TRANSPLANT                                            $21.20       20110801
00870       ANESTH BLADDER STONE SURG                                           $21.20       20110801
00872       ANESTH KIDNEY STONE DESTRUCT                                        $21.20       20110801



                                                Page 2
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1   Mod 2   Rate Type   Price            Effective
Code                                                                                     Date
00873       ANESTH KIDNEY STONE DESTRUCT                                        $21.20       20110801
00880       ANESTH ABDOMEN VESSEL SURG                                          $21.20       20110801
00882       ANESTH MAJOR VEIN LIGATION                                          $21.20       20110801
00902       ANESTH ANORECTAL SURGERY                                            $21.20       20110801
00904       ANESTH PERINEAL SURGERY                                             $21.20       20110801
00906       ANESTH REMOVAL OF VULVA                                             $21.20       20110801
00908       ANESTH REMOVAL OF PROSTATE                                          $21.20       20110801
00910       ANESTH BLADDER SURGERY                                              $21.20       20110801
00912       ANESTH BLADDER TUMOR SURG                                           $21.20       20110801
00914       ANESTH REMOVAL OF PROSTATE                                          $21.20       20110801
00916       ANESTH BLEEDING CONTROL                                             $21.20       20110801
00918       ANESTH STONE REMOVAL                                                $21.20       20110801
00920       ANESTH GENITALIA SURGERY                                            $21.20       20110801
00921       ANESTH VASECTOMY                                                    $21.20       20110801
00922       ANESTH SPERM DUCT SURGERY                                           $21.20       20110801
00924       ANESTH TESTIS EXPLORATION                                           $21.20       20110801
00926       ANESTH REMOVAL OF TESTIS                                            $21.20       20110801
00928       ANESTH REMOVAL OF TESTIS                                            $21.20       20110801
00930       ANESTH TESTIS SUSPENSION                                            $21.20       20110801
00932       ANESTH AMPUTATION OF PENIS                                          $21.20       20110801
00934       ANESTH PENIS NODES REMOVAL                                          $21.20       20110801
00936       ANESTH PENIS NODES REMOVAL                                          $21.20       20110801
00938       ANESTH INSERT PENIS DEVICE                                          $21.20       20110801
00940       ANESTH VAGINAL PROCEDURES                                           $21.20       20110801
00942       ANESTH SURG ON VAG/URETHRAL                                         $21.20       20110801
00944       ANESTH VAGINAL HYSTERECTOMY                                         $21.20       20110801
00948       ANESTH REPAIR OF CERVIX                                             $21.20       20110801
00950       ANESTH VAGINAL ENDOSCOPY                                            $21.20       20110801
00952       ANESTH HYSTEROSCOPE/GRAPH                                           $21.20       20110801
01112       ANESTH BONE ASPIRATE/BX                                             $21.20       20110801
01120       ANESTH PELVIS SURGERY                                               $21.20       20110801
01130       ANESTH BODY CAST PROCEDURE                                          $21.20       20110801
01140       ANESTH AMPUTATION AT PELVIS                                         $21.20       20110801
01150       ANESTH PELVIC TUMOR SURGERY                                         $21.20       20110801
01160       ANESTH PELVIS PROCEDURE                                             $21.20       20110801
01170       ANESTH PELVIS SURGERY                                               $21.20       20110801
01173       ANESTH FX REPAIR PELVIS                                             $21.20       20110801
01180       ANESTH PELVIS NERVE REMOVAL                                         $21.20       20110801
01190       ANESTH PELVIS NERVE REMOVAL                                         $21.20       20110801
01200       ANESTH HIP JOINT PROCEDURE                                          $21.20       20110801
01202       ANESTH ARTHROSCOPY OF HIP                                           $21.20       20110801
01210       ANESTH HIP JOINT SURGERY                                            $21.20       20110801
01212       ANESTH HIP DISARTICULATION                                          $21.20       20110801
01214       ANESTH HIP ARTHROPLASTY                                             $21.20       20110801
01215       ANESTH REVISE HIP REPAIR                                            $21.20       20110801
01220       ANESTH PROCEDURE ON FEMUR                                           $21.20       20110801
01230       ANESTH SURGERY OF FEMUR                                             $21.20       20110801
01232       ANESTH AMPUTATION OF FEMUR                                          $21.20       20110801
01234       ANESTH RADICAL FEMUR SURG                                           $21.20       20110801
01250       ANESTH UPPER LEG SURGERY                                            $21.20       20110801
01260       ANESTH UPPER LEG VEINS SURG                                         $21.20       20110801
01270       ANESTH THIGH ARTERIES SURG                                          $21.20       20110801
01272       ANESTH FEMORAL ARTERY SURG                                          $21.20       20110801
01274       ANESTH FEMORAL EMBOLECTOMY                                          $21.20       20110801
01320       ANESTH KNEE AREA SURGERY                                            $21.20       20110801
01340       ANESTH KNEE AREA PROCEDURE                                          $21.20       20110801
01360       ANESTH KNEE AREA SURGERY                                            $21.20       20110801
01380       ANESTH KNEE JOINT PROCEDURE                                         $21.20       20110801
01382       ANESTH DX KNEE ARTHROSCOPY                                          $21.20       20110801



                                                Page 3
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1   Mod 2   Rate Type   Price            Effective
Code                                                                                    Date
01390       ANESTH KNEE AREA PROCEDURE                                         $21.20       20110801
01392       ANESTH KNEE AREA SURGERY                                           $21.20       20110801
01400       ANESTH KNEE JOINT SURGERY                                          $21.20       20110801
01402       ANESTH KNEE ARTHROPLASTY                                           $21.20       20110801
01404       ANESTH AMPUTATION AT KNEE                                          $21.20       20110801
01420       ANESTH KNEE JOINT CASTING                                          $21.20       20110801
01430       ANESTH KNEE VEINS SURGERY                                          $21.20       20110801
01432       ANESTH KNEE VESSEL SURG                                            $21.20       20110801
01440       ANESTH KNEE ARTERIES SURG                                          $21.20       20110801
01442       ANESTH KNEE ARTERY SURG                                            $21.20       20110801
01444       ANESTH KNEE ARTERY REPAIR                                          $21.20       20110801
01462       ANESTH LOWER LEG PROCEDURE                                         $21.20       20110801
01464       ANESTH ANKLE/FT ARTHROSCOPY                                        $21.20       20110801
01470       ANESTH LOWER LEG SURGERY                                           $21.20       20110801
01472       ANESTH ACHILLES TENDON SURG                                        $21.20       20110801
01474       ANESTH LOWER LEG SURGERY                                           $21.20       20110801
01480       ANESTH LOWER LEG BONE SURG                                         $21.20       20110801
01482       ANESTH RADICAL LEG SURGERY                                         $21.20       20110801
01484       ANESTH LOWER LEG REVISION                                          $21.20       20110801
01486       ANESTH ANKLE REPLACEMENT                                           $21.20       20110801
01490       ANESTH LOWER LEG CASTING                                           $21.20       20110801
01500       ANESTH LEG ARTERIES SURG                                           $21.20       20110801
01502       ANESTH LWR LEG EMBOLECTOMY                                         $21.20       20110801
01520       ANESTH LOWER LEG VEIN SURG                                         $21.20       20110801
01522       ANESTH LOWER LEG VEIN SURG                                         $21.20       20110801
01610       ANESTH SURGERY OF SHOULDER                                         $21.20       20110801
01620       ANESTH SHOULDER PROCEDURE                                          $21.20       20110801
01622       ANES DX SHOULDER ARTHROSCOPY                                       $21.20       20110801
01630       ANESTH SURGERY OF SHOULDER                                         $21.20       20110801
01634       ANESTH SHOULDER JOINT AMPUT                                        $21.20       20110801
01636       ANESTH FOREQUARTER AMPUT                                           $21.20       20110801
01638       ANESTH SHOULDER REPLACEMENT                                        $21.20       20110801
01650       ANESTH SHOULDER ARTERY SURG                                        $21.20       20110801
01652       ANESTH SHOULDER VESSEL SURG                                        $21.20       20110801
01654       ANESTH SHOULDER VESSEL SURG                                        $21.20       20110801
01656       ANESTH ARM-LEG VESSEL SURG                                         $21.20       20110801
01670       ANESTH SHOULDER VEIN SURG                                          $21.20       20110801
01680       ANESTH SHOULDER CASTING                                            $21.20       20110801
01682       ANESTH AIRPLANE CAST                                               $21.20       20110801
01710       ANESTH ELBOW AREA SURGERY                                          $21.20       20110801
01712       ANESTH UPPR ARM TENDON SURG                                        $21.20       20110801
01714       ANESTH UPPR ARM TENDON SURG                                        $21.20       20110801
01716       ANESTH BICEPS TENDON REPAIR                                        $21.20       20110801
01730       ANESTH UPPR ARM PROCEDURE                                          $21.20       20110801
01732       ANESTH DX ELBOW ARTHROSCOPY                                        $21.20       20110801
01740       ANESTH UPPER ARM SURGERY                                           $21.20       20110801
01742       ANESTH HUMERUS SURGERY                                             $21.20       20110801
01744       ANESTH HUMERUS REPAIR                                              $21.20       20110801
01756       ANESTH RADICAL HUMERUS SURG                                        $21.20       20110801
01758       ANESTH HUMERAL LESION SURG                                         $21.20       20110801
01760       ANESTH ELBOW REPLACEMENT                                           $21.20       20110801
01770       ANESTH UPPR ARM ARTERY SURG                                        $21.20       20110801
01772       ANESTH UPPR ARM EMBOLECTOMY                                        $21.20       20110801
01780       ANESTH UPPER ARM VEIN SURG                                         $21.20       20110801
01782       ANESTH UPPR ARM VEIN REPAIR                                        $21.20       20110801
01810       ANESTH LOWER ARM SURGERY                                           $21.20       20110801
01820       ANESTH LOWER ARM PROCEDURE                                         $21.20       20110801
01829       ANESTH DX WRIST ARTHROSCOPY                                        $21.20       20110801
01830       ANESTH LOWER ARM SURGERY                                           $21.20       20110801



                                               Page 4
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
01832       ANESTH WRIST REPLACEMENT                                              $21.20       20110801
01840       ANESTH LWR ARM ARTERY SURG                                            $21.20       20110801
01842       ANESTH LWR ARM EMBOLECTOMY                                            $21.20       20110801
01844       ANESTH VASCULAR SHUNT SURG                                            $21.20       20110801
01850       ANESTH LOWER ARM VEIN SURG                                            $21.20       20110801
01852       ANESTH LWR ARM VEIN REPAIR                                            $21.20       20110801
01860       ANESTH LOWER ARM CASTING                                              $21.20       20110801
01916       ANESTH DX ARTERIOGRAPHY                                               $21.20       20110801
01920       ANESTH CATHETERIZE HEART                                              $21.20       20110801
01922       ANESTH CAT OR MRI SCAN                                                $21.20       20110801
01924       ANES THER INTERVEN RAD ART                                            $21.20       20110801
01925       ANES THER INTERVEN RAD CAR                                            $21.20       20110801
01926       ANES TX INTERV RAD HRT/CRAN                                           $21.20       20110801
01930       ANES THER INTERVEN RAD VEI                                            $21.20       20110801
01931       ANES THER INTERVEN RAD TIP                                            $21.20       20110801
01932       ANES TX INTERV RAD TH VEIN                                            $21.20       20110801
01933       ANES TX INTERV RAD CRAN VEIN                                          $21.20       20110801
01935       ANESTH PERC IMG DX SP PROC                                            $21.20       20110801
01936       ANESTH PERC IMG TX SP PROC                                            $21.20       20110801
01951       ANESTH BURN LESS 4 PERCENT                                            $21.20       20110801
01952       ANESTH BURN 4-9 PERCENT                                               $21.20       20110801
01953       ANESTH BURN EACH 9 PERCENT                                            $21.20       20110801
01958       ANESTH ANTEPARTUM MANIPUL                                             $21.20       20110801
01960       ANESTH VAGINAL DELIVERY                                               $21.20       20110801
01961       ANESTH CS DELIVERY                                                    $21.20       20110801
01962       ANESTH EMER HYSTERECTOMY                                              $21.20       20110801
01963       ANESTH CS HYSTERECTOMY                                                $21.20       20110801
01965       ANESTH INC/MISSED AB PROC                                             $21.20       20110801
01966       ANESTH INDUCED AB PROCEDURE                                           $21.20       20110801
01967       ANESTH/ANALG VAG DELIVERY                                            $338.67       20080101
01968       ANES/ANALG CS DELIVER ADD-ON                                          $21.20       20110801
01969       ANESTH/ANALG CS HYST ADD-ON                                           $21.20       20110801
01990       SUPPORT FOR ORGAN DONOR                                               $21.20       20110801
01991       ANESTH NERVE BLOCK/INJ                                                $21.20       20110801
01992       ANESTH N BLOCK/INJ PRONE                                              $21.20       20110801
01996       HOSP MANAGE CONT DRUG ADMIN                                           $63.60       20110801
10021       FNA W/O IMAGE                                                         $94.90       20110801
10022       FNA W/IMAGE                                                           $93.86       20110801
10040       ACNE SURGERY                                                          $68.64       20110801
10060       DRAINAGE OF SKIN ABSCESS                                              $73.06       20110801
10061       DRAINAGE OF SKIN ABSCESS                                             $124.02       20110801
10080       DRAINAGE OF PILONIDAL CYST                                           $109.72       20110801
10081       DRAINAGE OF PILONIDAL CYST                                           $172.64       20110801
10120       REMOVE FOREIGN BODY                                                   $89.70       20110801
10121       REMOVE FOREIGN BODY                              A                   $505.90       20110101
10121       REMOVE FOREIGN BODY                                                  $173.68       20110801
10140       DRAINAGE OF HEMATOMA/FLUID                                           $102.70       20110801
10160       PUNCTURE DRAINAGE OF LESION                                           $83.72       20110801
10180       COMPLEX DRAINAGE WOUND                           A                   $551.78       20110101
10180       COMPLEX DRAINAGE WOUND                                               $156.00       20110801
11000       DEBRIDE INFECTED SKIN                                                 $35.10       20110801
11001       DEBRIDE INFECTED SKIN ADD-ON                                          $14.56       20110801
11004       DEBRIDE GENITALIA PERINEUM                                           $413.14       20110801
11005       DEBRIDE ABDOM WALL              80                                   $109.98       20110801
11005       DEBRIDE ABDOM WALL              81                                   $109.98       20110801
11005       DEBRIDE ABDOM WALL              82                                   $109.98       20110801
11005       DEBRIDE ABDOM WALL              AS                                   $109.98       20110801
11005       DEBRIDE ABDOM WALL                                                   $549.90       20110801
11006       DEBRIDE GENIT/PER/ABDOM WALL                                         $503.10       20110801



                                                 Page 5
                                     DMAP Fee for Service Fee Schedule
                                               August 2012


Procedure   Description                       Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                         Date
11008       REMOVE MESH FROM ABD WALL         80                                    $38.64       20110801
11008       REMOVE MESH FROM ABD WALL         81                                    $38.64       20110801
11008       REMOVE MESH FROM ABD WALL         82                                    $38.64       20110801
11008       REMOVE MESH FROM ABD WALL         AS                                    $38.64       20110801
11008       REMOVE MESH FROM ABD WALL                                              $193.18       20110801
11010       DEBRIDE SKIN AT FX SITE                            A                   $152.98       20110101
11010       DEBRIDE SKIN AT FX SITE                                                $310.96       20110801
11011       DEBRIDE SKIN MUSC AT FX SITE                       A                   $152.98       20110101
11011       DEBRIDE SKIN MUSC AT FX SITE                                           $345.80       20110801
11012       DEB SKIN BONE AT FX SITE                           A                   $152.98       20110101
11012       DEB SKIN BONE AT FX SITE                                               $466.70       20110801
11042       DEB SUBQ TISSUE 20 SQ CM/                          A                    $98.72       20110101
11042       DEB SUBQ TISSUE 20 SQ CM/                                               $48.36       20110801
11043       DEB MUSC/FASCIA 20 SQ CM/                          A                    $98.72       20110101
11043       DEB MUSC/FASCIA 20 SQ CM/                                              $186.16       20110801
11044       DEB BONE 20 SQ CM/                                 A                   $278.12       20110101
11044       DEB BONE 20 SQ CM/                                                     $256.10       20110801
11045       DEB SUBQ TISSUE ADD-ON                             A                    $84.67       20110101
11045       DEB SUBQ TISSUE ADD-ON                                                  $23.66       20110801
11046       DEB MUSC/FASCIA ADD-ON                             A                    $84.67       20110101
11046       DEB MUSC/FASCIA ADD-ON                                                  $41.34       20110801
11047       DEB BONE ADD-ON                                    A                   $263.23       20110101
11047       DEB BONE ADD-ON                                                         $67.86       20110801
11055       TRIM SKIN LESION                                                        $31.72       20110801
11056       TRIM SKIN LESIONS 2 TO 4                                                $38.48       20110801
11057       TRIM SKIN LESIONS OVER 4                                                $46.02       20110801
11100       BIOPSY SKIN LESION                                                      $68.38       20110801
11101       BIOPSY SKIN ADD-ON                                                      $22.36       20110801
11300       SHAVE SKIN LESION                                                       $44.98       20110801
11301       SHAVE SKIN LESION                                                       $61.62       20110801
11302       SHAVE SKIN LESION                                                       $73.58       20110801
11303       SHAVE SKIN LESION                                                       $86.58       20110801
11305       SHAVE SKIN LESION                                                       $45.50       20110801
11306       SHAVE SKIN LESION                                                       $63.44       20110801
11307       SHAVE SKIN LESION                                                       $75.14       20110801
11308       SHAVE SKIN LESION                                                       $83.20       20110801
11310       SHAVE SKIN LESION                                                       $55.90       20110801
11311       SHAVE SKIN LESION                                                       $70.98       20110801
11312       SHAVE SKIN LESION                                                       $82.42       20110801
11313       SHAVE SKIN LESION                                                      $102.96       20110801
11400       EXC TR-EXT B9MARG 0.5 CM                                                $77.22       20110801
11401       EXC TR-EXT B9MARG 0.6-1 CM                                              $95.16       20110801
11402       EXC TR-EXT B9MARG 1.1-2 CM                                             $106.08       20110801
11403       EXC TR-EXT B9MARG 2.1-3 CM                                             $122.46       20110801
11404       EXC TR-EXT B9MARG 3.1-4 CM                         A                   $484.29       20110101
11404       EXC TR-EXT B9MARG 3.1-4 CM                                             $139.10       20110801
11406       EXC TR-EXT B9MARG 4.0 CM                           A                   $505.90       20110101
11406       EXC TR-EXT B9MARG 4.0 CM                                               $199.42       20110801
11420       EXC H-F-NK-SP B9MARG 0.5                                                $77.74       20110801
11421       EXC H-F-NK-SP B9MARG 0.6-1                                             $101.14       20110801
11422       EXC H-F-NK-SP B9MARG 1.1-2                                             $112.84       20110801
11423       EXC H-F-NK-SP B9MARG 2.1-3                                             $131.30       20110801
11424       EXC H-F-NK-SP B9MARG 3.1-4                         A                   $505.90       20110101
11424       EXC H-F-NK-SP B9MARG 3.1-4                                             $151.58       20110801
11426       EXC H-F-NK-SP B9MARG 4 CM                          A                   $647.50       20110101
11426       EXC H-F-NK-SP B9MARG 4 CM                                              $218.14       20110801
11440       EXC FACE-MM B9MARG 0.5 CM                                               $85.54       20110801
11441       EXC FACE-MM B9MARG 0.6-1 CM                                            $108.42       20110801
11442       EXC FACE-MM B9MARG 1.1-2 CM                                            $121.94       20110801



                                                   Page 6
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1   Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
11443       EXC FACE-MM B9MARG 2.1-3 CM                                         $146.38       20110801
11444       EXC FACE-MM B9MARG 3.1-4 CM                     A                   $260.88       20110101
11444       EXC FACE-MM B9MARG 3.1-4 CM                                         $184.86       20110801
11446       EXC FACE-MM B9MARG 4 CM                         A                   $647.50       20110101
11446       EXC FACE-MM B9MARG 4 CM                                             $254.02       20110801
11450       REMOVAL SWEAT GLAND LESION                      A                   $647.50       20110101
11450       REMOVAL SWEAT GLAND LESION                                          $236.08       20110801
11451       REMOVAL SWEAT GLAND LESION                      A                   $647.50       20110101
11451       REMOVAL SWEAT GLAND LESION                                          $305.50       20110801
11462       REMOVAL SWEAT GLAND LESION                      A                   $647.50       20110101
11462       REMOVAL SWEAT GLAND LESION                                          $232.70       20110801
11463       REMOVAL SWEAT GLAND LESION                      A                   $647.50       20110101
11463       REMOVAL SWEAT GLAND LESION                                          $313.04       20110801
11470       REMOVAL SWEAT GLAND LESION                      A                   $647.50       20110101
11470       REMOVAL SWEAT GLAND LESION                                          $258.18       20110801
11471       REMOVAL SWEAT GLAND LESION                      A                   $647.50       20110101
11471       REMOVAL SWEAT GLAND LESION                                          $321.62       20110801
11600       EXC TR-EXT MALMARG 0.5 CM                                           $120.64       20110801
11601       EXC TR-EXT MALMARG 0.6-1 CM                                         $147.68       20110801
11602       EXC TR-EXT MALMARG 1.1-2 CM                                         $161.98       20110801
11603       EXC TR-EXT MALMARG 2.1-3 CM                                         $184.34       20110801
11604       EXC TR-EXT MALMARG 3.1-4 CM                     A                   $277.24       20110101
11604       EXC TR-EXT MALMARG 3.1-4 CM                                         $204.10       20110801
11606       EXC TR-EXT MALMARG 4 CM                         A                   $505.90       20110101
11606       EXC TR-EXT MALMARG 4 CM                                             $289.90       20110801
11620       EXC H-F-NK-SP MALMARG 0.5                                           $122.98       20110801
11621       EXC S/N/H/F/G MALMRG 0.6-1                                          $148.98       20110801
11622       EXC S/N/H/F/G MALMRG 1.1-2                                          $168.22       20110801
11623       EXC S/N/H/F/G MALMRG 2.1-3                                          $197.08       20110801
11624       EXC S/N/H/F/G MALMRG 3.1-4                      A                   $505.90       20110101
11624       EXC S/N/H/F/G MALMRG 3.1-4                                          $221.78       20110801
11626       EXC S/N/H/F/G MALMRG 4 CM                       A                   $647.50       20110101
11626       EXC S/N/H/F/G MALMRG 4 CM                                           $268.84       20110801
11640       EXC F/E/E/N/L MALMRG 0.5CM                                          $127.92       20110801
11641       EXC F/E/E/N/L MALMRG 0.6-1                                          $155.74       20110801
11642       EXC F/E/E/N/L MALMRG 1.1-2                                          $179.40       20110801
11643       EXC F/E/E/N/L MALMRG 2.1-3                                          $211.90       20110801
11644       EXC F/E/E/N/L MALMRG 3.1-4                      A                   $505.90       20110101
11644       EXC F/E/E/N/L MALMRG 3.1-4                                          $261.04       20110801
11646       EXC F/E/E/N/L MALMRG 4 CM                       A                   $647.50       20110101
11646       EXC F/E/E/N/L MALMRG 4 CM                                           $343.72       20110801
11719       TRIM NAILS                                                           $14.04       20110801
11720       DEBRIDE NAIL 1-5                                                     $20.28       20110801
11721       DEBRIDE NAIL 6 OR MORE                                               $28.60       20110801
11730       REMOVAL OF NAIL PLATE                                                $63.70       20110801
11732       REMOVE NAIL PLATE ADD-ON                                             $29.38       20110801
11740       DRAIN BLOOD FROM UNDER NAIL                                          $29.64       20110801
11750       REMOVAL OF NAIL BED                                                 $143.26       20110801
11752       REMOVE NAIL BED/FINGER TIP                                          $205.40       20110801
11755       BIOPSY NAIL UNIT                                                     $87.10       20110801
11760       REPAIR OF NAIL BED                                                  $136.50       20110801
11762       RECONSTRUCTION OF NAIL BED                                          $177.84       20110801
11765       EXCISION OF NAIL FOLD TOE                                            $86.06       20110801
11770       REMOVAL OF PILONIDAL LESION                     A                   $659.74       20110101
11770       REMOVAL OF PILONIDAL LESION                                         $173.94       20110801
11771       REMOVAL OF PILONIDAL LESION                     A                   $659.74       20110101
11771       REMOVAL OF PILONIDAL LESION                                         $361.66       20110801
11772       REMOVAL OF PILONIDAL LESION                     A                   $659.74       20110101
11772       REMOVAL OF PILONIDAL LESION                                         $437.06       20110801



                                                Page 7
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
11900       INJECTION INTO SKIN LESIONS                     A                 $19.76       20110101
11900       INJECTION INTO SKIN LESIONS                                       $37.44       20110801
11901       ADDED SKIN LESIONS INJECTION                                      $47.84       20110801
11960       INSERT TISSUE EXPANDERS                         A                $660.56       20110101
11960       INSERT TISSUE EXPANDERS                                          $621.66       20110801
11970       REPLACE TISSUE EXPANDER                         A              $1,217.14       20110101
11970       REPLACE TISSUE EXPANDER                                          $410.28       20110801
11971       REMOVE TISSUE EXPANDERS                         A                $625.87       20110101
11971       REMOVE TISSUE EXPANDERS                                          $306.80       20110801
11976       REMOVAL OF CONTRACEPTIVE CAP                                      $99.32       20110801
11980       IMPLANT HORMONE PELLETS                                           $71.50       20110801
11981       INSERT DRUG IMPLANT DEVICE                                        $91.52       20110801
11982       REMOVE DRUG IMPLANT DEVICE                                       $102.96       20110801
11983       REMOVE/INSERT DRUG IMPLANT                                       $158.34       20110801
12001       REPAIR SUPERFICIAL WOUNDS                                        $100.10       20110801
12002       REPAIR SUPERFICIAL WOUNDS                                        $106.34       20110801
12004       REPAIR SUPERFICIAL WOUNDS                                        $125.32       20110801
12005       REPAIR SUPERFICIAL WOUNDS                       A                 $50.00       20110101
12005       REPAIR SUPERFICIAL WOUNDS                                        $155.74       20110801
12006       REPAIR SUPERFICIAL WOUNDS                       A                 $50.00       20110101
12006       REPAIR SUPERFICIAL WOUNDS                                        $193.18       20110801
12007       REPAIR SUPERFICIAL WOUNDS                       A                 $50.00       20110101
12007       REPAIR SUPERFICIAL WOUNDS                                        $216.84       20110801
12011       REPAIR SUPERFICIAL WOUNDS                                        $106.34       20110801
12013       REPAIR SUPERFICIAL WOUNDS                                        $117.00       20110801
12014       REPAIR SUPERFICIAL WOUNDS                                        $137.54       20110801
12015       REPAIR SUPERFICIAL WOUNDS                                        $172.64       20110801
12016       REPAIR SUPERFICIAL WOUNDS                       A                 $50.00       20110101
12016       REPAIR SUPERFICIAL WOUNDS                                        $205.92       20110801
12017       REPAIR SUPERFICIAL WOUNDS                       A                 $50.00       20110101
12017       REPAIR SUPERFICIAL WOUNDS                                        $180.44       20110801
12018       REPAIR SUPERFICIAL WOUNDS                       A                 $50.00       20110101
12018       REPAIR SUPERFICIAL WOUNDS      80                                 $43.73       20110801
12018       REPAIR SUPERFICIAL WOUNDS      81                                 $43.73       20110801
12018       REPAIR SUPERFICIAL WOUNDS      82                                 $43.73       20110801
12018       REPAIR SUPERFICIAL WOUNDS      AS                                 $43.73       20110801
12018       REPAIR SUPERFICIAL WOUNDS                                        $218.66       20110801
12020       CLOSURE OF SPLIT WOUND                          A                $124.14       20110101
12020       CLOSURE OF SPLIT WOUND                                           $177.58       20110801
12021       CLOSURE OF SPLIT WOUND                          A                 $93.19       20110101
12021       CLOSURE OF SPLIT WOUND                                           $105.56       20110801
12031       INTMD WND REPAIR S/A/T/EXT                                       $159.12       20110801
12032       INTMD WND REPAIR S/A/T/EXT                                       $202.02       20110801
12034       INTMD WND REPAIR S/TR/EXT                       A                 $50.00       20110101
12034       INTMD WND REPAIR S/TR/EXT                                        $201.50       20110801
12035       INTMD WND REPAIR S/A/T/EXT                      A                 $50.00       20110101
12035       INTMD WND REPAIR S/A/T/EXT                                       $244.40       20110801
12036       INTMD WND REPAIR S/A/T/EXT                      A                 $93.19       20110101
12036       INTMD WND REPAIR S/A/T/EXT                                       $267.54       20110801
12037       INTMD WND REPAIR S/TR/EXT                       A                $137.59       20110101
12037       INTMD WND REPAIR S/TR/EXT                                        $300.82       20110801
12041       INTMD WND REPAIR N-HF/GENIT                                      $166.40       20110801
12042       INTMD WND REPAIR N-HF/GENIT                                      $192.40       20110801
12044       INTMD WND REPAIR N-HF/GENIT                     A                 $50.00       20110101
12044       INTMD WND REPAIR N-HF/GENIT                                      $224.90       20110801
12045       INTMD WND REPAIR N-HF/GENIT                     A                 $93.19       20110101
12045       INTMD WND REPAIR N-HF/GENIT                                      $245.44       20110801
12046       INTMD WND REPAIR N-HF/GENIT                     A                 $93.19       20110101
12046       INTMD WND REPAIR N-HF/GENIT                                      $300.30       20110801



                                                Page 8
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                        Date
12047       INTMD WND REPAIR N-HF/GENIT                       A                   $137.59       20110101
12047       INTMD WND REPAIR N-HF/GENIT      80                                    $64.06       20110801
12047       INTMD WND REPAIR N-HF/GENIT      81                                    $64.06       20110801
12047       INTMD WND REPAIR N-HF/GENIT      82                                    $64.06       20110801
12047       INTMD WND REPAIR N-HF/GENIT      AS                                    $64.06       20110801
12047       INTMD WND REPAIR N-HF/GENIT                                           $320.32       20110801
12051       INTMD WND REPAIR FACE/MM                                              $177.32       20110801
12052       INTMD WND REPAIR FACE/MM                                              $202.28       20110801
12053       INTMD WND REPAIR FACE/MM                                              $222.56       20110801
12054       INTMD WND REPAIR FACE/MM                          A                    $50.00       20110101
12054       INTMD WND REPAIR FACE/MM                                              $236.08       20110801
12055       INTMD WND REPAIR FACE/MM                          A                    $93.19       20110101
12055       INTMD WND REPAIR FACE/MM                                              $283.14       20110801
12056       INTMD WND REPAIR FACE/MM                          A                    $93.19       20110101
12056       INTMD WND REPAIR FACE/MM                                              $330.72       20110801
12057       INTMD WND REPAIR FACE/MM                          A                   $137.59       20110101
12057       INTMD WND REPAIR FACE/MM         80                                    $73.32       20110801
12057       INTMD WND REPAIR FACE/MM         81                                    $73.32       20110801
12057       INTMD WND REPAIR FACE/MM         82                                    $73.32       20110801
12057       INTMD WND REPAIR FACE/MM         AS                                    $73.32       20110801
12057       INTMD WND REPAIR FACE/MM                                              $366.60       20110801
13100       REPAIR OF WOUND OR LESION                         A                   $168.54       20110101
13100       REPAIR OF WOUND OR LESION                                             $209.30       20110801
13101       REPAIR OF WOUND OR LESION                         A                   $168.54       20110101
13101       REPAIR OF WOUND OR LESION                                             $264.94       20110801
13102       REPAIR WOUND/LESION ADD-ON                                             $72.28       20110801
13120       REPAIR OF WOUND OR LESION                         A                    $93.19       20110101
13120       REPAIR OF WOUND OR LESION                                             $217.36       20110801
13121       REPAIR OF WOUND OR LESION                         A                    $93.19       20110101
13121       REPAIR OF WOUND OR LESION                                             $295.10       20110801
13122       REPAIR WOUND/LESION ADD-ON                                             $80.34       20110801
13131       REPAIR OF WOUND OR LESION                         A                    $93.19       20110101
13131       REPAIR OF WOUND OR LESION                                             $240.50       20110801
13132       REPAIR OF WOUND OR LESION                         A                   $124.14       20110101
13132       REPAIR OF WOUND OR LESION                                             $389.74       20110801
13133       REPAIR WOUND/LESION ADD-ON                                            $113.62       20110801
13150       REPAIR OF WOUND OR LESION                         A                   $168.54       20110101
13150       REPAIR OF WOUND OR LESION                                             $239.20       20110801
13151       REPAIR OF WOUND OR LESION                         A                   $168.54       20110101
13151       REPAIR OF WOUND OR LESION                                             $272.74       20110801
13152       REPAIR OF WOUND OR LESION                         A                   $168.54       20110101
13152       REPAIR OF WOUND OR LESION                                             $377.26       20110801
13153       REPAIR WOUND/LESION ADD-ON                                            $124.54       20110801
13160       LATE CLOSURE OF WOUND                             A                   $660.56       20110101
13160       LATE CLOSURE OF WOUND                                                 $552.76       20110801
14000       SKIN TISSUE REARRANGEMENT                         A                   $471.22       20110101
14000       SKIN TISSUE REARRANGEMENT                                             $414.18       20110801
14001       SKIN TISSUE REARRANGEMENT                         A                   $483.46       20110101
14001       SKIN TISSUE REARRANGEMENT                                             $536.90       20110801
14020       SKIN TISSUE REARRANGEMENT                         A                   $483.46       20110101
14020       SKIN TISSUE REARRANGEMENT                                             $465.14       20110801
14021       SKIN TISSUE REARRANGEMENT                         A                   $483.46       20110101
14021       SKIN TISSUE REARRANGEMENT                                             $587.08       20110801
14040       SKIN TISSUE REARRANGEMENT                         A                   $471.22       20110101
14040       SKIN TISSUE REARRANGEMENT                                             $515.58       20110801
14041       SKIN TISSUE REARRANGEMENT                         A                   $483.46       20110101
14041       SKIN TISSUE REARRANGEMENT                                             $640.64       20110801
14060       SKIN TISSUE REARRANGEMENT                         A                   $483.46       20110101
14060       SKIN TISSUE REARRANGEMENT                                             $524.94       20110801



                                                  Page 9
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
14061       SKIN TISSUE REARRANGEMENT                        A                   $483.46       20110101
14061       SKIN TISSUE REARRANGEMENT                                            $686.92       20110801
14301       SKIN TISSUE REARRANGEMENT                                            $742.56       20110801
14302       SKIN TISSUE REARRANGE ADD-ON    80                                    $32.66       20110801
14302       SKIN TISSUE REARRANGE ADD-ON    81                                    $32.66       20110801
14302       SKIN TISSUE REARRANGE ADD-ON    82                                    $32.66       20110801
14302       SKIN TISSUE REARRANGE ADD-ON    AS                                    $32.66       20110801
14302       SKIN TISSUE REARRANGE ADD-ON                                         $163.28       20110801
14350       SKIN TISSUE REARRANGEMENT                        A                   $672.80       20110101
14350       SKIN TISSUE REARRANGEMENT                                            $505.18       20110801
15002       WOUND PREP TRK/ARM/LEG                           A                   $168.54       20110101
15002       WOUND PREP TRK/ARM/LEG                                               $222.30       20110801
15003       WOUND PREP ADDL 100 CM                           A                   $168.54       20110101
15003       WOUND PREP ADDL 100 CM                                                $48.62       20110801
15004       WOUND PREP F/N/HF/G                              A                   $168.54       20110101
15004       WOUND PREP F/N/HF/G                                                  $264.68       20110801
15005       WND PREP F/N/HF/G ADDL CM                        A                   $168.54       20110101
15005       WND PREP F/N/HF/G ADDL CM                                             $81.64       20110801
15040       HARVEST CULTURED SKIN GRAFT                      A                    $93.19       20110101
15040       HARVEST CULTURED SKIN GRAFT                                          $167.70       20110801
15050       SKIN PINCH GRAFT                                 A                   $168.54       20110101
15050       SKIN PINCH GRAFT                                                     $365.04       20110801
15100       SKIN SPLT GRFT TRNK/ARM/LEG                      A                   $660.56       20110101
15100       SKIN SPLT GRFT TRNK/ARM/LEG                                          $577.72       20110801
15101       SKIN SPLT GRFT T/A/L ADD-ON                      A                   $672.80       20110101
15101       SKIN SPLT GRFT T/A/L ADD-ON                                          $124.54       20110801
15110       EPIDRM AUTOGRFT TRNK/ARM/LEG                     A                   $192.02       20110101
15110       EPIDRM AUTOGRFT TRNK/ARM/LEG                                         $573.56       20110801
15111       EPIDRM AUTOGRFT T/A/L ADD-ON                     A                   $170.40       20110101
15111       EPIDRM AUTOGRFT T/A/L ADD-ON                                          $82.42       20110801
15115       EPIDRM A-GRFT FACE/NCK/HF/G                      A                   $192.02       20110101
15115       EPIDRM A-GRFT FACE/NCK/HF/G                                          $577.98       20110801
15116       EPIDRM A-GRFT F/N/HF/G ADDL                      A                   $170.40       20110101
15116       EPIDRM A-GRFT F/N/HF/G ADDL                                          $114.14       20110801
15120       SKN SPLT A-GRFT FAC/NCK/HF/G                     A                   $660.56       20110101
15120       SKN SPLT A-GRFT FAC/NCK/HF/G                                         $633.88       20110801
15121       SKN SPLT A-GRFT F/N/HF/G ADD                     A                   $672.80       20110101
15121       SKN SPLT A-GRFT F/N/HF/G ADD                                         $177.06       20110801
15130       DERM AUTOGRAFT TRNK/ARM/LEG                      A                   $471.22       20110101
15130       DERM AUTOGRAFT TRNK/ARM/LEG                                          $449.54       20110801
15131       DERM AUTOGRAFT T/A/L ADD-ON                      A                   $449.59       20110101
15131       DERM AUTOGRAFT T/A/L ADD-ON                                           $66.30       20110801
15135       DERM AUTOGRAFT FACE/NCK/HF/G                     A                   $471.22       20110101
15135       DERM AUTOGRAFT FACE/NCK/HF/G                                         $580.84       20110801
15136       DERM AUTOGRAFT F/N/HF/G ADD                      A                   $449.59       20110101
15136       DERM AUTOGRAFT F/N/HF/G ADD                                           $58.24       20110801
15150       CULT SKIN GRFT T/ARM/LEG                         A                   $192.02       20110101
15150       CULT SKIN GRFT T/ARM/LEG                                             $472.94       20110801
15151       CULT SKIN GRFT T/A/L ADDL                        A                   $170.40       20110101
15151       CULT SKIN GRFT T/A/L ADDL                                             $86.32       20110801
15152       CULT SKIN GRAFT T/A/L                            A                   $170.40       20110101
15152       CULT SKIN GRAFT T/A/L                                                $110.24       20110801
15155       CULT SKIN GRAFT F/N/HF/G                         A                   $192.02       20110101
15155       CULT SKIN GRAFT F/N/HF/G                                             $460.46       20110801
15156       CULT SKIN GRFT F/N/HFG ADD                       A                   $170.40       20110101
15156       CULT SKIN GRFT F/N/HFG ADD                                           $120.90       20110801
15157       CULT EPIDERM GRFT F/N/HFG                        A                   $170.40       20110101
15157       CULT EPIDERM GRFT F/N/HFG                                            $123.50       20110801
15200       SKIN FULL GRAFT TRUNK                            A                   $483.46       20110101



                                                 Page 10
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
15200       SKIN FULL GRAFT TRUNK                                             $542.62       20110801
15201       SKIN FULL GRAFT TRUNK ADD-ON                     A                $447.74       20110101
15201       SKIN FULL GRAFT TRUNK ADD-ON                                       $97.50       20110801
15220       SKIN FULL GRAFT SCLP/ARM/LEG                     A                $471.22       20110101
15220       SKIN FULL GRAFT SCLP/ARM/LEG                                      $511.42       20110801
15221       SKIN FULL GRAFT ADD-ON                           A                $168.54       20110101
15221       SKIN FULL GRAFT ADD-ON                                             $91.00       20110801
15240       SKIN FULL GRFT FACE/GENIT/HF                     A                $483.46       20110101
15240       SKIN FULL GRFT FACE/GENIT/HF                                      $619.32       20110801
15241       SKIN FULL GRAFT ADD-ON                           A                $168.54       20110101
15241       SKIN FULL GRAFT ADD-ON                                            $122.20       20110801
15260       SKIN FULL GRAFT EEN LIPS                         A                $471.22       20110101
15260       SKIN FULL GRAFT EEN LIPS                                          $673.66       20110801
15261       SKIN FULL GRAFT ADD-ON                           A                $447.74       20110101
15261       SKIN FULL GRAFT ADD-ON                                            $143.26       20110801
15271       SKIN SUB GRAFT TRNK/ARM/LEG                                       $102.44       20120101
15272       SKIN SUB GRAFT T/A/L ADD-ON                                        $20.80       20120101
15273       SKIN SUB GRFT T/ARM/LG CHILD                                      $226.46       20120101
15274       SKN SUB GRFT T/A/L CHILD ADD                                       $53.30       20120101
15275       SKIN SUB GRAFT FACE/NK/HF/G                                       $118.30       20120101
15276       SKIN SUB GRAFT F/N/HF/G ADDL                                       $25.74       20120101
15277       SKN SUB GRFT F/N/HF/G CHILD                                       $227.76       20120101
15278       SKN SUB GRFT F/N/HF/G CH ADD                                       $62.66       20120101
15570       FORM SKIN PEDICLE FLAP                           A                $672.80       20110101
15570       FORM SKIN PEDICLE FLAP                                            $594.62       20110801
15572       FORM SKIN PEDICLE FLAP                           A                $672.80       20110101
15572       FORM SKIN PEDICLE FLAP                                            $576.42       20110801
15574       FORM SKIN PEDICLE FLAP                           A                $672.80       20110101
15574       FORM SKIN PEDICLE FLAP                                            $606.58       20110801
15576       FORM SKIN PEDICLE FLAP                           A                $672.80       20110101
15576       FORM SKIN PEDICLE FLAP                                            $538.98       20110801
15600       SKIN GRAFT                                       A                $672.80       20110101
15600       SKIN GRAFT                                                        $213.20       20110801
15610       SKIN GRAFT                                       A                $672.80       20110101
15610       SKIN GRAFT                                                        $219.44       20110801
15620       SKIN GRAFT                                       A                $695.77       20110101
15620       SKIN GRAFT                                                        $289.38       20110801
15630       SKIN GRAFT                                       A                $672.80       20110101
15630       SKIN GRAFT                                                        $306.02       20110801
15650       TRANSFER SKIN PEDICLE FLAP                       A                $712.41       20110101
15650       TRANSFER SKIN PEDICLE FLAP                                        $339.56       20110801
15731       FOREHEAD FLAP W/VASC PEDICLE                     A                $672.80       20110101
15731       FOREHEAD FLAP W/VASC PEDICLE                                      $768.82       20110801
15732       MUSCLE-SKIN GRAFT HEAD/NECK                      A                $672.80       20110101
15732       MUSCLE-SKIN GRAFT HEAD/NECK                                     $1,016.08       20110801
15734       MUSCLE-SKIN GRAFT TRUNK                          A                $672.80       20110101
15734       MUSCLE-SKIN GRAFT TRUNK         80                                $207.53       20110801
15734       MUSCLE-SKIN GRAFT TRUNK         81                                $207.53       20110801
15734       MUSCLE-SKIN GRAFT TRUNK         82                                $207.53       20110801
15734       MUSCLE-SKIN GRAFT TRUNK         AS                                $207.53       20110801
15734       MUSCLE-SKIN GRAFT TRUNK                                         $1,037.66       20110801
15736       MUSCLE-SKIN GRAFT ARM                            A                $672.80       20110101
15736       MUSCLE-SKIN GRAFT ARM                                             $908.70       20110801
15738       MUSCLE-SKIN GRAFT LEG                            A                $672.80       20110101
15738       MUSCLE-SKIN GRAFT LEG           80                                $194.48       20110801
15738       MUSCLE-SKIN GRAFT LEG           81                                $194.48       20110801
15738       MUSCLE-SKIN GRAFT LEG           82                                $194.48       20110801
15738       MUSCLE-SKIN GRAFT LEG           AS                                $194.48       20110801
15738       MUSCLE-SKIN GRAFT LEG                                             $972.40       20110801



                                                 Page 11
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
15740       ISLAND PEDICLE FLAP GRAFT                        A                $471.22       20110101
15740       ISLAND PEDICLE FLAP GRAFT                                         $687.44       20110801
15750       NEUROVASCULAR PEDICLE GRAFT                      A                $660.56       20110101
15750       NEUROVASCULAR PEDICLE GRAFT     80                                $125.27       20110801
15750       NEUROVASCULAR PEDICLE GRAFT     81                                $125.27       20110801
15750       NEUROVASCULAR PEDICLE GRAFT     82                                $125.27       20110801
15750       NEUROVASCULAR PEDICLE GRAFT     AS                                $125.27       20110801
15750       NEUROVASCULAR PEDICLE GRAFT                                       $626.34       20110801
15756       FREE MYO/SKIN FLAP MICROVASC    80                                $325.73       20110801
15756       FREE MYO/SKIN FLAP MICROVASC    81                                $325.73       20110801
15756       FREE MYO/SKIN FLAP MICROVASC    82                                $325.73       20110801
15756       FREE MYO/SKIN FLAP MICROVASC    AS                                $325.73       20110801
15756       FREE MYO/SKIN FLAP MICROVASC                                    $1,628.64       20110801
15757       FREE SKIN FLAP MICROVASC        80                                $323.18       20110801
15757       FREE SKIN FLAP MICROVASC        81                                $323.18       20110801
15757       FREE SKIN FLAP MICROVASC        82                                $323.18       20110801
15757       FREE SKIN FLAP MICROVASC        AS                                $323.18       20110801
15757       FREE SKIN FLAP MICROVASC                                        $1,615.90       20110801
15758       FREE FASCIAL FLAP MICROVASC     80                                $321.78       20110801
15758       FREE FASCIAL FLAP MICROVASC     81                                $321.78       20110801
15758       FREE FASCIAL FLAP MICROVASC     82                                $321.78       20110801
15758       FREE FASCIAL FLAP MICROVASC     AS                                $321.78       20110801
15758       FREE FASCIAL FLAP MICROVASC                                     $1,608.88       20110801
15760       COMPOSITE SKIN GRAFT                             A                $660.56       20110101
15760       COMPOSITE SKIN GRAFT                                              $569.14       20110801
15770       DERMA-FAT-FASCIA GRAFT                           A                $672.80       20110101
15770       DERMA-FAT-FASCIA GRAFT          80                                 $90.32       20110801
15770       DERMA-FAT-FASCIA GRAFT          81                                 $90.32       20110801
15770       DERMA-FAT-FASCIA GRAFT          82                                 $90.32       20110801
15770       DERMA-FAT-FASCIA GRAFT          AS                                 $90.32       20110801
15770       DERMA-FAT-FASCIA GRAFT                                            $451.62       20110801
15822       REVISION OF UPPER EYELID                         A                $672.80       20110101
15822       REVISION OF UPPER EYELID                                          $286.78       20110801
15823       REVISION OF UPPER EYELID                         A                $712.41       20110101
15823       REVISION OF UPPER EYELID                                          $461.50       20110801
15836       EXCISE EXCESSIVE SKIN TISSUE    80                                $100.15       20110801
15836       EXCISE EXCESSIVE SKIN TISSUE    81                                $100.15       20110801
15836       EXCISE EXCESSIVE SKIN TISSUE    82                                $100.15       20110801
15836       EXCISE EXCESSIVE SKIN TISSUE    AS                                $100.15       20110801
15836       EXCISE EXCESSIVE SKIN TISSUE                                      $500.76       20110801
15840       GRAFT FOR FACE NERVE PALSY                       A                $695.77       20110101
15840       GRAFT FOR FACE NERVE PALSY                                        $698.36       20110801
15841       GRAFT FOR FACE NERVE PALSY                       A                $695.77       20110101
15841       GRAFT FOR FACE NERVE PALSY      80                                $227.50       20110801
15841       GRAFT FOR FACE NERVE PALSY      81                                $227.50       20110801
15841       GRAFT FOR FACE NERVE PALSY      82                                $227.50       20110801
15841       GRAFT FOR FACE NERVE PALSY      AS                                $227.50       20110801
15841       GRAFT FOR FACE NERVE PALSY                                      $1,137.50       20110801
15842       FLAP FOR FACE NERVE PALSY                        A                $766.96       20110101
15842       FLAP FOR FACE NERVE PALSY       80                                $347.98       20110801
15842       FLAP FOR FACE NERVE PALSY       81                                $347.98       20110801
15842       FLAP FOR FACE NERVE PALSY       82                                $347.98       20110801
15842       FLAP FOR FACE NERVE PALSY       AS                                $347.98       20110801
15842       FLAP FOR FACE NERVE PALSY                                       $1,739.92       20110801
15845       SKIN AND MUSCLE REPAIR FACE                      A                $695.77       20110101
15845       SKIN AND MUSCLE REPAIR FACE     80                                $132.60       20110801
15845       SKIN AND MUSCLE REPAIR FACE     81                                $132.60       20110801
15845       SKIN AND MUSCLE REPAIR FACE     82                                $132.60       20110801
15845       SKIN AND MUSCLE REPAIR FACE     AS                                $132.60       20110801



                                                 Page 12
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
15845       SKIN AND MUSCLE REPAIR FACE                                      $663.00       20110801
15850       REMOVAL OF SUTURES                                                $58.50       20110801
15851       REMOVAL OF SUTURES                                                $62.40       20110801
15852       DRESSING CHANGE NOT FOR BURN                                      $33.02       20110801
15860       TEST FOR BLOOD FLOW IN GRAFT                                      $79.82       20110801
15920       REMOVAL OF TAIL BONE ULCER                      A                $152.98       20110101
15920       REMOVAL OF TAIL BONE ULCER                                       $404.04       20110801
15922       REMOVAL OF TAIL BONE ULCER                      A                $695.77       20110101
15922       REMOVAL OF TAIL BONE ULCER     80                                 $99.84       20110801
15922       REMOVAL OF TAIL BONE ULCER     81                                 $99.84       20110801
15922       REMOVAL OF TAIL BONE ULCER     82                                 $99.84       20110801
15922       REMOVAL OF TAIL BONE ULCER     AS                                 $99.84       20110801
15922       REMOVAL OF TAIL BONE ULCER                                       $499.20       20110801
15931       REMOVE SACRUM PRESSURE SORE                     A                $659.74       20110101
15931       REMOVE SACRUM PRESSURE SORE                                      $458.64       20110801
15933       REMOVE SACRUM PRESSURE SORE                     A                $659.74       20110101
15933       REMOVE SACRUM PRESSURE SORE                                      $564.98       20110801
15934       REMOVE SACRUM PRESSURE SORE                     A                $672.80       20110101
15934       REMOVE SACRUM PRESSURE SORE                                      $627.38       20110801
15935       REMOVE SACRUM PRESSURE SORE                     A                $695.77       20110101
15935       REMOVE SACRUM PRESSURE SORE    80                                $149.34       20110801
15935       REMOVE SACRUM PRESSURE SORE    81                                $149.34       20110801
15935       REMOVE SACRUM PRESSURE SORE    82                                $149.34       20110801
15935       REMOVE SACRUM PRESSURE SORE    AS                                $149.34       20110801
15935       REMOVE SACRUM PRESSURE SORE                                      $746.72       20110801
15936       REMOVE SACRUM PRESSURE SORE                     A                $506.42       20110101
15936       REMOVE SACRUM PRESSURE SORE                                      $605.80       20110801
15937       REMOVE SACRUM PRESSURE SORE                     A                $695.77       20110101
15937       REMOVE SACRUM PRESSURE SORE                                      $706.94       20110801
15940       REMOVE HIP PRESSURE SORE                        A                $659.74       20110101
15940       REMOVE HIP PRESSURE SORE                                         $469.30       20110801
15941       REMOVE HIP PRESSURE SORE                        A                $659.74       20110101
15941       REMOVE HIP PRESSURE SORE                                         $609.96       20110801
15944       REMOVE HIP PRESSURE SORE                        A                $672.80       20110101
15944       REMOVE HIP PRESSURE SORE                                         $601.12       20110801
15945       REMOVE HIP PRESSURE SORE                        A                $695.77       20110101
15945       REMOVE HIP PRESSURE SORE                                         $666.90       20110801
15946       REMOVE HIP PRESSURE SORE                        A                $695.77       20110101
15946       REMOVE HIP PRESSURE SORE                                       $1,116.44       20110801
15950       REMOVE THIGH PRESSURE SORE                      A                $659.74       20110101
15950       REMOVE THIGH PRESSURE SORE                                       $388.18       20110801
15951       REMOVE THIGH PRESSURE SORE                      A                $682.70       20110101
15951       REMOVE THIGH PRESSURE SORE     80                                $109.93       20110801
15951       REMOVE THIGH PRESSURE SORE     81                                $109.93       20110801
15951       REMOVE THIGH PRESSURE SORE     82                                $109.93       20110801
15951       REMOVE THIGH PRESSURE SORE     AS                                $109.93       20110801
15951       REMOVE THIGH PRESSURE SORE                                       $549.64       20110801
15952       REMOVE THIGH PRESSURE SORE                      A                $483.46       20110101
15952       REMOVE THIGH PRESSURE SORE     80                                $115.70       20110801
15952       REMOVE THIGH PRESSURE SORE     81                                $115.70       20110801
15952       REMOVE THIGH PRESSURE SORE     82                                $115.70       20110801
15952       REMOVE THIGH PRESSURE SORE     AS                                $115.70       20110801
15952       REMOVE THIGH PRESSURE SORE                                       $578.50       20110801
15953       REMOVE THIGH PRESSURE SORE                      A                $506.42       20110101
15953       REMOVE THIGH PRESSURE SORE                                       $656.24       20110801
15956       REMOVE THIGH PRESSURE SORE                      A                $483.46       20110101
15956       REMOVE THIGH PRESSURE SORE                                       $781.04       20110801
15958       REMOVE THIGH PRESSURE SORE                      A                $506.42       20110101
15958       REMOVE THIGH PRESSURE SORE                                       $795.86       20110801



                                                Page 13
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1   Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
16000       INITIAL TREATMENT OF BURNS                                         $46.28       20110801
16020       DRESS/DEBRID P-THICK BURN S                                        $54.08       20110801
16025       DRESS/DEBRID P-THICK BURN M                      A                 $49.89       20110101
16025       DRESS/DEBRID P-THICK BURN M                                        $99.32       20110801
16030       DRESS/DEBRID P-THICK BURN L                      A                 $56.14       20110101
16030       DRESS/DEBRID P-THICK BURN L                                       $118.56       20110801
16035       INCISION OF BURN SCAB INITI                      A                 $49.39       20110101
16035       INCISION OF BURN SCAB INITI                                       $145.08       20110801
16036       ESCHAROTOMY ADDL INCISION                                          $58.76       20110801
17000       DESTRUCT PREMALG LESION                                            $53.04       20110801
17003       DESTRUCT PREMALG LES 2-14                                           $4.94       20110801
17004       DESTROY PREMAL LESIONS 15/                                        $117.00       20110801
17106       DESTRUCTION OF SKIN LESIONS                                       $229.58       20110801
17107       DESTRUCTION OF SKIN LESIONS                                       $299.52       20110801
17108       DESTRUCTION OF SKIN LESIONS                                       $424.06       20110801
17110       DESTRUCT B9 LESION 1-14                                            $72.02       20110801
17111       DESTRUCT LESION 15 OR MORE                                         $86.32       20110801
17250       CHEMICAL CAUTERY TISSUE                                            $48.88       20110801
17260       DESTRUCTION OF SKIN LESIONS                                        $63.44       20110801
17261       DESTRUCTION OF SKIN LESIONS                                        $94.90       20110801
17262       DESTRUCTION OF SKIN LESIONS                                       $115.70       20110801
17263       DESTRUCTION OF SKIN LESIONS                                       $127.66       20110801
17264       DESTRUCTION OF SKIN LESIONS                                       $136.50       20110801
17266       DESTRUCTION OF SKIN LESIONS                                       $155.48       20110801
17270       DESTRUCTION OF SKIN LESIONS                                        $99.06       20110801
17271       DESTRUCTION OF SKIN LESIONS                                       $109.20       20110801
17272       DESTRUCTION OF SKIN LESIONS                                       $124.54       20110801
17273       DESTRUCTION OF SKIN LESIONS                                       $139.10       20110801
17274       DESTRUCTION OF SKIN LESIONS                                       $164.84       20110801
17276       DESTRUCTION OF SKIN LESIONS                                       $191.36       20110801
17280       DESTRUCTION OF SKIN LESIONS                                        $92.56       20110801
17281       DESTRUCTION OF SKIN LESIONS                                       $118.30       20110801
17282       DESTRUCTION OF SKIN LESIONS                                       $137.02       20110801
17283       DESTRUCTION OF SKIN LESIONS                                       $165.62       20110801
17284       DESTRUCTION OF SKIN LESIONS                                       $192.66       20110801
17286       DESTRUCTION OF SKIN LESIONS                                       $244.66       20110801
17311       MOHS 1 STAGE H/N/HF/G                                             $454.48       20110801
17312       MOHS ADDL STAGE                                                   $270.66       20110801
17313       MOHS 1 STAGE T/A/L                                                $414.44       20110801
17314       MOHS ADDL STAGE T/A/L                                             $250.90       20110801
17315       MOHS SURG ADDL BLOCK                                               $54.60       20110801
17340       CRYOTHERAPY OF SKIN                                                $33.54       20110801
17360       SKIN PEEL THERAPY                                                  $88.92       20110801
19000       DRAINAGE OF BREAST LESION                                          $74.10       20110801
19001       DRAIN BREAST LESION ADD-ON                                         $18.72       20110801
19020       INCISION OF BREAST LESION                        A                $551.78       20110101
19020       INCISION OF BREAST LESION                                         $292.76       20110801
19030       INJECTION FOR BREAST X-RAY                                        $112.06       20110801
19100       BX BREAST PERCUT W/O IMAGE                       A                $156.46       20110101
19100       BX BREAST PERCUT W/O IMAGE                                         $94.38       20110801
19101       BIOPSY OF BREAST OPEN                            A                $680.26       20110101
19101       BIOPSY OF BREAST OPEN                                             $216.58       20110801
19102       BX BREAST PERCUT W/IMAGE                         A                $233.75       20110101
19102       BX BREAST PERCUT W/IMAGE                                          $147.68       20110801
19103       BX BREAST PERCUT W/DEVICE                        A                $448.29       20110101
19103       BX BREAST PERCUT W/DEVICE                                         $373.10       20110801
19105       CRYOSURG ABLATE FA EACH                                         $1,401.66       20110801
19110       NIPPLE EXPLORATION                               A                $680.26       20110101
19110       NIPPLE EXPLORATION                                                $304.98       20110801



                                                Page 14
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
19112       EXCISE BREAST DUCT FISTULA                       A                $692.50       20110101
19112       EXCISE BREAST DUCT FISTULA                                        $285.48       20110801
19120       REMOVAL OF BREAST LESION                         A                $692.50       20110101
19120       REMOVAL OF BREAST LESION                                          $316.42       20110801
19125       EXCISION BREAST LESION                           A                $692.50       20110101
19125       EXCISION BREAST LESION                                            $351.52       20110801
19126       EXCISION ADDL BREAST LESION                      A                $692.50       20110101
19126       EXCISION ADDL BREAST LESION                                       $112.06       20110801
19260       REMOVAL OF CHEST WALL LESION    80                                $165.36       20110801
19260       REMOVAL OF CHEST WALL LESION    81                                $165.36       20110801
19260       REMOVAL OF CHEST WALL LESION    82                                $165.36       20110801
19260       REMOVAL OF CHEST WALL LESION    AS                                $165.36       20110801
19260       REMOVAL OF CHEST WALL LESION                                      $826.80       20110801
19271       REVISION OF CHEST WALL          80                                $224.64       20110801
19271       REVISION OF CHEST WALL          81                                $224.64       20110801
19271       REVISION OF CHEST WALL          82                                $224.64       20110801
19271       REVISION OF CHEST WALL          AS                                $224.64       20110801
19271       REVISION OF CHEST WALL                                          $1,123.20       20110801
19272       EXTENSIVE CHEST WALL SURGERY    80                                $249.13       20110801
19272       EXTENSIVE CHEST WALL SURGERY    81                                $249.13       20110801
19272       EXTENSIVE CHEST WALL SURGERY    82                                $249.13       20110801
19272       EXTENSIVE CHEST WALL SURGERY    AS                                $249.13       20110801
19272       EXTENSIVE CHEST WALL SURGERY                                    $1,245.66       20110801
19290       PLACE NEEDLE WIRE BREAST                                          $109.46       20110801
19291       PLACE NEEDLE WIRE BREAST                                           $47.06       20110801
19295       PLACE BREAST CLIP PERCUT                                           $60.32       20110801
19296       PLACE PO BREAST CATH FOR RAD                     A              $1,655.77       20110101
19296       PLACE PO BREAST CATH FOR RAD    80                                $517.82       20110801
19296       PLACE PO BREAST CATH FOR RAD    81                                $517.82       20110801
19296       PLACE PO BREAST CATH FOR RAD    82                                $517.82       20110801
19296       PLACE PO BREAST CATH FOR RAD    AS                                $517.82       20110801
19296       PLACE PO BREAST CATH FOR RAD                                    $2,589.08       20110801
19297       PLACE BREAST CATH FOR RAD                                          $65.78       20110801
19298       PLACE BREAST RAD TUBE/CATHS                      A              $1,655.77       20110101
19298       PLACE BREAST RAD TUBE/CATHS     80                                $170.77       20110801
19298       PLACE BREAST RAD TUBE/CATHS     81                                $170.77       20110801
19298       PLACE BREAST RAD TUBE/CATHS     82                                $170.77       20110801
19298       PLACE BREAST RAD TUBE/CATHS     AS                                $170.77       20110801
19298       PLACE BREAST RAD TUBE/CATHS                                       $853.84       20110801
19301       PARTICAL MASTECTOMY                              A                $692.50       20110101
19301       PARTICAL MASTECTOMY                                               $431.60       20110801
19302       P-MASTECTOMY W/LN REMOVAL                        A              $1,199.88       20110101
19302       P-MASTECTOMY W/LN REMOVAL                                         $599.56       20110801
19303       MAST SIMPLE COMPLETE                             A                $941.74       20110101
19303       MAST SIMPLE COMPLETE            80                                $133.80       20110801
19303       MAST SIMPLE COMPLETE            81                                $133.80       20110801
19303       MAST SIMPLE COMPLETE            82                                $133.80       20110801
19303       MAST SIMPLE COMPLETE            AS                                $133.80       20110801
19303       MAST SIMPLE COMPLETE                                              $668.98       20110801
19304       MAST SUBQ                                        A                $941.74       20110101
19304       MAST SUBQ                                                         $376.74       20110801
19305       MAST RADICAL                    80                                $151.37       20110801
19305       MAST RADICAL                    81                                $151.37       20110801
19305       MAST RADICAL                    82                                $151.37       20110801
19305       MAST RADICAL                    AS                                $151.37       20110801
19305       MAST RADICAL                                                      $756.86       20110801
19306       MAST RAD URBAN TYPE             80                                $158.91       20110801
19306       MAST RAD URBAN TYPE             81                                $158.91       20110801
19306       MAST RAD URBAN TYPE             82                                $158.91       20110801



                                                 Page 15
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
19306       MAST RAD URBAN TYPE             AS                                $158.91       20110801
19306       MAST RAD URBAN TYPE                                               $794.56       20110801
19307       MAST MOD RAD                    80                                $159.38       20110801
19307       MAST MOD RAD                    81                                $159.38       20110801
19307       MAST MOD RAD                    82                                $159.38       20110801
19307       MAST MOD RAD                    AS                                $159.38       20110801
19307       MAST MOD RAD                                                      $796.90       20110801
19318       REDUCTION OF LARGE BREAST                        A              $1,130.05       20110101
19318       REDUCTION OF LARGE BREAST       80                                $152.78       20110801
19318       REDUCTION OF LARGE BREAST       81                                $152.78       20110801
19318       REDUCTION OF LARGE BREAST       82                                $152.78       20110801
19318       REDUCTION OF LARGE BREAST       AS                                $152.78       20110801
19318       REDUCTION OF LARGE BREAST                                         $763.88       20110801
19324       ENLARGE BREAST                                   A              $1,130.05       20110101
19324       ENLARGE BREAST                                                    $328.64       20110801
19325       ENLARGE BREAST WITH IMPLANT                      A              $1,655.77       20110101
19325       ENLARGE BREAST WITH IMPLANT                                       $437.06       20110801
19328       REMOVAL OF BREAST IMPLANT                        A                $884.91       20110101
19328       REMOVAL OF BREAST IMPLANT                                         $332.80       20110801
19330       REMOVAL OF IMPLANT MATERIAL                      A                $884.91       20110101
19330       REMOVAL OF IMPLANT MATERIAL                                       $426.14       20110801
19340       IMMEDIATE BREAST PROSTHESIS                      A              $1,094.84       20110101
19340       IMMEDIATE BREAST PROSTHESIS                                       $551.72       20110801
19342       DELAYED BREAST PROSTHESIS                        A              $1,497.14       20110101
19342       DELAYED BREAST PROSTHESIS                                         $626.86       20110801
19350       BREAST RECONSTRUCTION                            A                $715.47       20110101
19350       BREAST RECONSTRUCTION                                             $561.34       20110801
19355       CORRECT INVERTED NIPPLES                         A                $941.74       20110101
19355       CORRECT INVERTED NIPPLES                                          $476.84       20110801
19357       BREAST RECONSTRUCTION                            A              $1,536.75       20110101
19357       BREAST RECONSTRUCTION           80                                $212.00       20110801
19357       BREAST RECONSTRUCTION           81                                $212.00       20110801
19357       BREAST RECONSTRUCTION           82                                $212.00       20110801
19357       BREAST RECONSTRUCTION           AS                                $212.00       20110801
19357       BREAST RECONSTRUCTION                                           $1,060.02       20110801
19361       BREAST RECONSTR W/LAT FLAP      80                                $228.54       20110801
19361       BREAST RECONSTR W/LAT FLAP      81                                $228.54       20110801
19361       BREAST RECONSTR W/LAT FLAP      82                                $228.54       20110801
19361       BREAST RECONSTR W/LAT FLAP      AS                                $228.54       20110801
19361       BREAST RECONSTR W/LAT FLAP                                      $1,142.70       20110801
19364       BREAST RECONSTRUCTION           80                                $382.67       20110801
19364       BREAST RECONSTRUCTION           81                                $382.67       20110801
19364       BREAST RECONSTRUCTION           82                                $382.67       20110801
19364       BREAST RECONSTRUCTION           AS                                $382.67       20110801
19364       BREAST RECONSTRUCTION                                           $1,913.34       20110801
19366       BREAST RECONSTRUCTION                            A                $958.38       20110101
19366       BREAST RECONSTRUCTION           80                                $189.80       20110801
19366       BREAST RECONSTRUCTION           81                                $189.80       20110801
19366       BREAST RECONSTRUCTION           82                                $189.80       20110801
19366       BREAST RECONSTRUCTION           AS                                $189.80       20110801
19366       BREAST RECONSTRUCTION                                             $949.00       20110801
19367       BREAST RECONSTRUCTION           80                                $247.68       20110801
19367       BREAST RECONSTRUCTION           81                                $247.68       20110801
19367       BREAST RECONSTRUCTION           82                                $247.68       20110801
19367       BREAST RECONSTRUCTION           AS                                $247.68       20110801
19367       BREAST RECONSTRUCTION                                           $1,238.38       20110801
19368       BREAST RECONSTRUCTION           80                                $306.38       20110801
19368       BREAST RECONSTRUCTION           81                                $306.38       20110801
19368       BREAST RECONSTRUCTION           82                                $306.38       20110801



                                                 Page 16
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
19368       BREAST RECONSTRUCTION          AS                                $306.38       20110801
19368       BREAST RECONSTRUCTION                                          $1,531.92       20110801
19369       BREAST RECONSTRUCTION          80                                $282.26       20110801
19369       BREAST RECONSTRUCTION          81                                $282.26       20110801
19369       BREAST RECONSTRUCTION          82                                $282.26       20110801
19369       BREAST RECONSTRUCTION          AS                                $282.26       20110801
19369       BREAST RECONSTRUCTION                                          $1,411.28       20110801
19371       REMOVAL OF BREAST CAPSULE                       A                $941.74       20110101
19371       REMOVAL OF BREAST CAPSULE                                        $531.96       20110801
19380       REVISE BREAST RECONSTRUCTION                    A              $1,146.69       20110101
19380       REVISE BREAST RECONSTRUCTION                                     $523.12       20110801
20005       ID ABSCESS SUBFASCIAL                           A                $614.48       20110101
20005       ID ABSCESS SUBFASCIAL                                            $203.32       20110801
20100       EXPLORE WOUND NECK             80                                 $82.42       20110801
20100       EXPLORE WOUND NECK             81                                 $82.42       20110801
20100       EXPLORE WOUND NECK             82                                 $82.42       20110801
20100       EXPLORE WOUND NECK             AS                                 $82.42       20110801
20100       EXPLORE WOUND NECK                                               $412.10       20110801
20101       EXPLORE WOUND CHEST                                              $261.30       20110801
20102       EXPLORE WOUND ABDOMEN                                            $309.92       20110801
20103       EXPLORE WOUND EXTREMITY        80                                 $74.93       20110801
20103       EXPLORE WOUND EXTREMITY        81                                 $74.93       20110801
20103       EXPLORE WOUND EXTREMITY        82                                 $74.93       20110801
20103       EXPLORE WOUND EXTREMITY        AS                                 $74.93       20110801
20103       EXPLORE WOUND EXTREMITY                                          $374.66       20110801
20150       EXCISE EPIPHYSEAL BAR          80                                $130.94       20110801
20150       EXCISE EPIPHYSEAL BAR          81                                $130.94       20110801
20150       EXCISE EPIPHYSEAL BAR          82                                $130.94       20110801
20150       EXCISE EPIPHYSEAL BAR          AS                                $130.94       20110801
20150       EXCISE EPIPHYSEAL BAR                                            $654.68       20110801
20200       MUSCLE BIOPSY                                   A                $505.90       20110101
20200       MUSCLE BIOPSY                                                    $127.66       20110801
20205       DEEP MUSCLE BIOPSY                              A                $518.15       20110101
20205       DEEP MUSCLE BIOPSY                                               $177.06       20110801
20206       NEEDLE BIOPSY MUSCLE                            A                $233.75       20110101
20206       NEEDLE BIOPSY MUSCLE                                             $168.22       20110801
20220       BONE BIOPSY TROCAR/NEEDLE                       A                $245.29       20110101
20220       BONE BIOPSY TROCAR/NEEDLE                                        $114.40       20110801
20225       BONE BIOPSY TROCAR/NEEDLE                       A                $500.64       20110101
20225       BONE BIOPSY TROCAR/NEEDLE                                        $425.62       20110801
20240       BONE BIOPSY EXCISIONAL                          A                $647.50       20110101
20240       BONE BIOPSY EXCISIONAL                                           $154.44       20110801
20245       BONE BIOPSY EXCISIONAL                          A                $659.74       20110101
20245       BONE BIOPSY EXCISIONAL                                           $428.48       20110801
20250       OPEN BONE BIOPSY                                A                $626.73       20110101
20250       OPEN BONE BIOPSY                                                 $256.36       20110801
20251       OPEN BONE BIOPSY                                A                $626.73       20110101
20251       OPEN BONE BIOPSY               80                                 $56.42       20110801
20251       OPEN BONE BIOPSY               81                                 $56.42       20110801
20251       OPEN BONE BIOPSY               82                                 $56.42       20110801
20251       OPEN BONE BIOPSY               AS                                 $56.42       20110801
20251       OPEN BONE BIOPSY                                                 $282.10       20110801
20500       INJECTION OF SINUS TRACT                                          $75.66       20110801
20501       INJECT SINUS TRACT FOR X-RAY                                      $84.50       20110801
20520       REMOVAL OF FOREIGN BODY                                          $127.92       20110801
20525       REMOVAL OF FOREIGN BODY                         A                $659.74       20110101
20525       REMOVAL OF FOREIGN BODY                                          $307.84       20110801
20526       THER INJECTION CARP TUNNEL                                        $50.18       20110801
20527       INJ DUPUYTREN CORD W/ENZYME                                       $57.98       20120101



                                                Page 17
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
20550       INJ TENDON SHEATH/LIGAMENT                                         $38.48       20110801
20551       INJ TENDON ORIGIN/INSERTION                                        $38.74       20110801
20555       PLACE NDL MUSC/TIS FOR RT                                         $235.56       20110801
20600       DRAIN/INJECT JOINT/BURSA                                           $36.14       20110801
20605       DRAIN/INJECT JOINT/BURSA                                           $39.26       20110801
20610       DRAIN/INJECT JOINT/BURSA                                           $51.48       20110801
20615       TREATMENT OF BONE CYST                                            $144.04       20110801
20650       INSERT AND REMOVE BONE PIN                       A                $626.73       20110101
20650       INSERT AND REMOVE BONE PIN                                        $130.52       20110801
20660       APPLY REM FIXATION DEVICE                                         $169.00       20110801
20661       APPLICATION OF HEAD BRACE                                         $323.18       20110801
20662       APPLICATION OF PELVIS BRACE                      A                $705.54       20110101
20662       APPLICATION OF PELVIS BRACE                                       $309.14       20110801
20663       APPLICATION OF THIGH BRACE                       A                $705.54       20110101
20663       APPLICATION OF THIGH BRACE                                        $304.46       20110801
20664       APPLICATION OF HALO                                               $552.50       20110801
20665       REMOVAL OF FIXATION DEVICE                                         $78.00       20110801
20670       REMOVAL OF SUPPORT IMPLANT                       A                $484.29       20110101
20670       REMOVAL OF SUPPORT IMPLANT                                        $254.54       20110801
20680       REMOVAL OF SUPPORT IMPLANT                       A                $659.74       20110101
20680       REMOVAL OF SUPPORT IMPLANT      80                                 $80.13       20110801
20680       REMOVAL OF SUPPORT IMPLANT      81                                 $80.13       20110801
20680       REMOVAL OF SUPPORT IMPLANT      82                                 $80.13       20110801
20680       REMOVAL OF SUPPORT IMPLANT      AS                                 $80.13       20110801
20680       REMOVAL OF SUPPORT IMPLANT                                        $400.66       20110801
20690       APPLY BONE FIXATION DEVICE                       A                $849.00       20110101
20690       APPLY BONE FIXATION DEVICE                                        $387.92       20110801
20692       APPLY BONE FIXATION DEVICE                       A                $861.25       20110101
20692       APPLY BONE FIXATION DEVICE      80                                $145.29       20110801
20692       APPLY BONE FIXATION DEVICE      81                                $145.29       20110801
20692       APPLY BONE FIXATION DEVICE      82                                $145.29       20110801
20692       APPLY BONE FIXATION DEVICE      AS                                $145.29       20110801
20692       APPLY BONE FIXATION DEVICE                                        $726.44       20110801
20693       ADJUST BONE FIXATION DEVICE                      A                $626.73       20110101
20693       ADJUST BONE FIXATION DEVICE                                       $308.88       20110801
20694       REMOVE BONE FIXATION DEVICE                      A                $592.86       20110101
20694       REMOVE BONE FIXATION DEVICE                                       $281.06       20110801
20802       REPLANTATION ARM COMPLETE       80                                $326.72       20110801
20802       REPLANTATION ARM COMPLETE       81                                $326.72       20110801
20802       REPLANTATION ARM COMPLETE       82                                $326.72       20110801
20802       REPLANTATION ARM COMPLETE       AS                                $326.72       20110801
20802       REPLANTATION ARM COMPLETE                                       $1,633.58       20110801
20805       REPLANT FOREARM COMPLETE        80                                $432.90       20110801
20805       REPLANT FOREARM COMPLETE        81                                $432.90       20110801
20805       REPLANT FOREARM COMPLETE        82                                $432.90       20110801
20805       REPLANT FOREARM COMPLETE        AS                                $432.90       20110801
20805       REPLANT FOREARM COMPLETE                                        $2,164.50       20110801
20808       REPLANTATION HAND COMPLETE      80                                $572.94       20110801
20808       REPLANTATION HAND COMPLETE      81                                $572.94       20110801
20808       REPLANTATION HAND COMPLETE      82                                $572.94       20110801
20808       REPLANTATION HAND COMPLETE      AS                                $572.94       20110801
20808       REPLANTATION HAND COMPLETE                                      $2,864.68       20110801
20816       REPLANTATION DIGIT COMPLETE     80                                $296.19       20110801
20816       REPLANTATION DIGIT COMPLETE     81                                $296.19       20110801
20816       REPLANTATION DIGIT COMPLETE     82                                $296.19       20110801
20816       REPLANTATION DIGIT COMPLETE     AS                                $296.19       20110801
20816       REPLANTATION DIGIT COMPLETE                                     $1,480.96       20110801
20822       REPLANTATION DIGIT COMPLETE     80                                $258.44       20110801
20822       REPLANTATION DIGIT COMPLETE     81                                $258.44       20110801



                                                 Page 18
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
20822       REPLANTATION DIGIT COMPLETE     82                                $258.44       20110801
20822       REPLANTATION DIGIT COMPLETE     AS                                $258.44       20110801
20822       REPLANTATION DIGIT COMPLETE                                     $1,292.20       20110801
20824       REPLANTATION THUMB COMPLETE     80                                $303.99       20110801
20824       REPLANTATION THUMB COMPLETE     81                                $303.99       20110801
20824       REPLANTATION THUMB COMPLETE     82                                $303.99       20110801
20824       REPLANTATION THUMB COMPLETE     AS                                $303.99       20110801
20824       REPLANTATION THUMB COMPLETE                                     $1,519.96       20110801
20827       REPLANTATION THUMB COMPLETE     80                                $269.57       20110801
20827       REPLANTATION THUMB COMPLETE     81                                $269.57       20110801
20827       REPLANTATION THUMB COMPLETE     82                                $269.57       20110801
20827       REPLANTATION THUMB COMPLETE     AS                                $269.57       20110801
20827       REPLANTATION THUMB COMPLETE                                     $1,347.84       20110801
20838       REPLANTATION FOOT COMPLETE      80                                $339.35       20110801
20838       REPLANTATION FOOT COMPLETE      81                                $339.35       20110801
20838       REPLANTATION FOOT COMPLETE      82                                $339.35       20110801
20838       REPLANTATION FOOT COMPLETE      AS                                $339.35       20110801
20838       REPLANTATION FOOT COMPLETE                                      $1,696.76       20110801
20900       REMOVAL OF BONE FOR GRAFT                        A                $861.25       20110101
20900       REMOVAL OF BONE FOR GRAFT       80                                 $54.18       20110801
20900       REMOVAL OF BONE FOR GRAFT       81                                 $54.18       20110801
20900       REMOVAL OF BONE FOR GRAFT       82                                 $54.18       20110801
20900       REMOVAL OF BONE FOR GRAFT       AS                                 $54.18       20110801
20900       REMOVAL OF BONE FOR GRAFT                                         $270.92       20110801
20902       REMOVAL OF BONE FOR GRAFT                        A                $884.21       20110101
20902       REMOVAL OF BONE FOR GRAFT       80                                 $46.12       20110801
20902       REMOVAL OF BONE FOR GRAFT       81                                 $46.12       20110801
20902       REMOVAL OF BONE FOR GRAFT       82                                 $46.12       20110801
20902       REMOVAL OF BONE FOR GRAFT       AS                                 $46.12       20110801
20902       REMOVAL OF BONE FOR GRAFT                                         $230.62       20110801
20910       REMOVE CARTILAGE FOR GRAFT                       A                $672.80       20110101
20910       REMOVE CARTILAGE FOR GRAFT                                        $288.60       20110801
20912       REMOVE CARTILAGE FOR GRAFT                       A                $672.80       20110101
20912       REMOVE CARTILAGE FOR GRAFT                                        $331.24       20110801
20920       REMOVAL OF FASCIA FOR GRAFT                      A                $506.42       20110101
20920       REMOVAL OF FASCIA FOR GRAFT                                       $274.30       20110801
20922       REMOVAL OF FASCIA FOR GRAFT                      A                $483.46       20110101
20922       REMOVAL OF FASCIA FOR GRAFT     80                                 $82.11       20110801
20922       REMOVAL OF FASCIA FOR GRAFT     81                                 $82.11       20110801
20922       REMOVAL OF FASCIA FOR GRAFT     82                                 $82.11       20110801
20922       REMOVAL OF FASCIA FOR GRAFT     AS                                 $82.11       20110801
20922       REMOVAL OF FASCIA FOR GRAFT                                       $410.54       20110801
20924       REMOVAL OF TENDON FOR GRAFT                      A                $884.21       20110101
20924       REMOVAL OF TENDON FOR GRAFT     80                                 $68.22       20110801
20924       REMOVAL OF TENDON FOR GRAFT     81                                 $68.22       20110801
20924       REMOVAL OF TENDON FOR GRAFT     82                                 $68.22       20110801
20924       REMOVAL OF TENDON FOR GRAFT     AS                                 $68.22       20110801
20924       REMOVAL OF TENDON FOR GRAFT                                       $341.12       20110801
20926       REMOVAL OF TISSUE FOR GRAFT                                       $298.22       20110801
20930       SP BONE ALGRFT MORSEL ADD-ON                                       $54.75       20110801
20931       SP BONE ALGRFT STRUCT ADD-ON                                       $78.78       20110801
20936       SP BONE AGRFT LOCAL ADD-ON                                        $123.32       20110801
20937       SP BONE AGRFT MORSEL ADD-ON     80                                 $23.76       20110801
20937       SP BONE AGRFT MORSEL ADD-ON     81                                 $23.76       20110801
20937       SP BONE AGRFT MORSEL ADD-ON     82                                 $23.76       20110801
20937       SP BONE AGRFT MORSEL ADD-ON     AS                                 $23.76       20110801
20937       SP BONE AGRFT MORSEL ADD-ON                                       $118.82       20110801
20938       SP BONE AGRFT STRUCT ADD-ON     80                                 $25.95       20110801
20938       SP BONE AGRFT STRUCT ADD-ON     81                                 $25.95       20110801



                                                 Page 19
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
20938       SP BONE AGRFT STRUCT ADD-ON     82                                 $25.95       20110801
20938       SP BONE AGRFT STRUCT ADD-ON     AS                                 $25.95       20110801
20938       SP BONE AGRFT STRUCT ADD-ON                                       $129.74       20110801
20950       FLUID PRESSURE MUSCLE                                             $160.16       20110801
20955       FIBULA BONE GRAFT MICROVASC     80                                $351.88       20110801
20955       FIBULA BONE GRAFT MICROVASC     81                                $351.88       20110801
20955       FIBULA BONE GRAFT MICROVASC     82                                $351.88       20110801
20955       FIBULA BONE GRAFT MICROVASC     AS                                $351.88       20110801
20955       FIBULA BONE GRAFT MICROVASC                                     $1,759.42       20110801
20956       ILIAC BONE GRAFT MICROVASC      80                                $364.73       20110801
20956       ILIAC BONE GRAFT MICROVASC      81                                $364.73       20110801
20956       ILIAC BONE GRAFT MICROVASC      82                                $364.73       20110801
20956       ILIAC BONE GRAFT MICROVASC      AS                                $364.73       20110801
20956       ILIAC BONE GRAFT MICROVASC                                      $1,823.64       20110801
20957       MT BONE GRAFT MICROVASC         80                                $356.67       20110801
20957       MT BONE GRAFT MICROVASC         81                                $356.67       20110801
20957       MT BONE GRAFT MICROVASC         82                                $356.67       20110801
20957       MT BONE GRAFT MICROVASC         AS                                $356.67       20110801
20957       MT BONE GRAFT MICROVASC                                         $1,783.34       20110801
20962       OTHER BONE GRAFT MICROVASC      80                                $358.54       20110801
20962       OTHER BONE GRAFT MICROVASC      81                                $358.54       20110801
20962       OTHER BONE GRAFT MICROVASC      82                                $358.54       20110801
20962       OTHER BONE GRAFT MICROVASC      AS                                $358.54       20110801
20962       OTHER BONE GRAFT MICROVASC                                      $1,792.70       20110801
20969       BONE/SKIN GRAFT MICROVASC       80                                $389.84       20110801
20969       BONE/SKIN GRAFT MICROVASC       81                                $389.84       20110801
20969       BONE/SKIN GRAFT MICROVASC       82                                $389.84       20110801
20969       BONE/SKIN GRAFT MICROVASC       AS                                $389.84       20110801
20969       BONE/SKIN GRAFT MICROVASC                                       $1,949.22       20110801
20970       BONE/SKIN GRAFT ILIAC CREST     80                                $393.28       20110801
20970       BONE/SKIN GRAFT ILIAC CREST     81                                $393.28       20110801
20970       BONE/SKIN GRAFT ILIAC CREST     82                                $393.28       20110801
20970       BONE/SKIN GRAFT ILIAC CREST     AS                                $393.28       20110801
20970       BONE/SKIN GRAFT ILIAC CREST                                     $1,966.38       20110801
20972       BONE/SKIN GRAFT METATARSAL                       A              $1,683.34       20110101
20972       BONE/SKIN GRAFT METATARSAL      80                                $334.00       20110801
20972       BONE/SKIN GRAFT METATARSAL      81                                $334.00       20110801
20972       BONE/SKIN GRAFT METATARSAL      82                                $334.00       20110801
20972       BONE/SKIN GRAFT METATARSAL      AS                                $334.00       20110801
20972       BONE/SKIN GRAFT METATARSAL                                      $1,669.98       20110801
20973       BONE/SKIN GRAFT GREAT TOE                        A              $1,683.34       20110101
20973       BONE/SKIN GRAFT GREAT TOE       80                                $357.55       20110801
20973       BONE/SKIN GRAFT GREAT TOE       81                                $357.55       20110801
20973       BONE/SKIN GRAFT GREAT TOE       82                                $357.55       20110801
20973       BONE/SKIN GRAFT GREAT TOE       AS                                $357.55       20110801
20973       BONE/SKIN GRAFT GREAT TOE                                       $1,787.76       20110801
20974       ELECTRICAL BONE STIMULATION                                        $44.72       20110801
20975       ELECTRICAL BONE STIMULATION     80                                 $24.28       20110801
20975       ELECTRICAL BONE STIMULATION     81                                 $24.28       20110801
20975       ELECTRICAL BONE STIMULATION     82                                 $24.28       20110801
20975       ELECTRICAL BONE STIMULATION     AS                                 $24.28       20110801
20975       ELECTRICAL BONE STIMULATION                                       $121.42       20110801
20979       US BONE STIMULATION                                                $35.10       20110801
21010       INCISION OF JAW JOINT                            A                $685.37       20110101
21010       INCISION OF JAW JOINT                                             $502.84       20110801
21011       EXC FACE LES SC 2 CM                                              $220.48       20110801
21012       EXC FACE LES SBQ 2 CM/                                            $236.86       20110801
21013       EXC FACE TUM DEEP 2 CM                                            $342.94       20110801
21014       EXC FACE TUM DEEP 2 CM/                                           $366.08       20110801



                                                 Page 20
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
21015       RESECT FACE TUM 2 CM                            A                $560.76       20110101
21015       RESECT FACE TUM 2 CM                                             $435.50       20110801
21016       RESECT FACE TUM 2 CM/                                            $500.00       20100101
21025       EXCISION OF BONE LOWER JAW                      A              $1,118.46       20110101
21025       EXCISION OF BONE LOWER JAW                                       $591.76       20110801
21026       EXCISION OF FACIAL BONES                        A              $1,118.46       20110101
21026       EXCISION OF FACIAL BONES                                         $398.06       20110801
21029       CONTOUR OF FACE BONE LESION                     A              $1,118.46       20110101
21029       CONTOUR OF FACE BONE LESION                                      $511.16       20110801
21030       EXCISE MAX/ZYGOMA B9 TUMOR                                       $332.80       20110801
21031       REMOVE EXOSTOSIS MANDIBLE                                        $250.38       20110801
21032       REMOVE EXOSTOSIS MAXILLA                                         $254.54       20110801
21034       EXCISE MAX/ZYGOMA MAL TUMOR                     A              $1,130.71       20110101
21034       EXCISE MAX/ZYGOMA MAL TUMOR    80                                $179.66       20110801
21034       EXCISE MAX/ZYGOMA MAL TUMOR    81                                $179.66       20110801
21034       EXCISE MAX/ZYGOMA MAL TUMOR    82                                $179.66       20110801
21034       EXCISE MAX/ZYGOMA MAL TUMOR    AS                                $179.66       20110801
21034       EXCISE MAX/ZYGOMA MAL TUMOR                                      $898.30       20110801
21040       EXCISE MANDIBLE LESION                          A                $685.37       20110101
21040       EXCISE MANDIBLE LESION                                           $335.66       20110801
21044       REMOVAL OF JAW BONE LESION                      A              $1,118.46       20110101
21044       REMOVAL OF JAW BONE LESION     80                                $120.90       20110801
21044       REMOVAL OF JAW BONE LESION     81                                $120.90       20110801
21044       REMOVAL OF JAW BONE LESION     82                                $120.90       20110801
21044       REMOVAL OF JAW BONE LESION     AS                                $120.90       20110801
21044       REMOVAL OF JAW BONE LESION                                       $604.50       20110801
21045       EXTENSIVE JAW SURGERY          80                                $168.64       20110801
21045       EXTENSIVE JAW SURGERY          81                                $168.64       20110801
21045       EXTENSIVE JAW SURGERY          82                                $168.64       20110801
21045       EXTENSIVE JAW SURGERY          AS                                $168.64       20110801
21045       EXTENSIVE JAW SURGERY                                            $843.18       20110801
21046       REMOVE MANDIBLE CYST COMPLEX                    A              $1,118.46       20110101
21046       REMOVE MANDIBLE CYST COMPLEX   80                                $147.06       20110801
21046       REMOVE MANDIBLE CYST COMPLEX   81                                $147.06       20110801
21046       REMOVE MANDIBLE CYST COMPLEX   82                                $147.06       20110801
21046       REMOVE MANDIBLE CYST COMPLEX   AS                                $147.06       20110801
21046       REMOVE MANDIBLE CYST COMPLEX                                     $735.28       20110801
21047       EXCISE LWR JAW CYST W/REPAIR                    A              $1,118.46       20110101
21047       EXCISE LWR JAW CYST W/REPAIR   80                                $178.15       20110801
21047       EXCISE LWR JAW CYST W/REPAIR   81                                $178.15       20110801
21047       EXCISE LWR JAW CYST W/REPAIR   82                                $178.15       20110801
21047       EXCISE LWR JAW CYST W/REPAIR   AS                                $178.15       20110801
21047       EXCISE LWR JAW CYST W/REPAIR                                     $890.76       20110801
21048       REMOVE MAXILLA CYST COMPLEX    80                                $149.86       20110801
21048       REMOVE MAXILLA CYST COMPLEX    81                                $149.86       20110801
21048       REMOVE MAXILLA CYST COMPLEX    82                                $149.86       20110801
21048       REMOVE MAXILLA CYST COMPLEX    AS                                $149.86       20110801
21048       REMOVE MAXILLA CYST COMPLEX                                      $749.32       20110801
21049       EXCIS UPPR JAW CYST W/REPAIR   80                                $172.48       20110801
21049       EXCIS UPPR JAW CYST W/REPAIR   81                                $172.48       20110801
21049       EXCIS UPPR JAW CYST W/REPAIR   82                                $172.48       20110801
21049       EXCIS UPPR JAW CYST W/REPAIR   AS                                $172.48       20110801
21049       EXCIS UPPR JAW CYST W/REPAIR                                     $862.42       20110801
21050       REMOVAL OF JAW JOINT                            A              $1,130.71       20110101
21050       REMOVAL OF JAW JOINT                                             $596.96       20110801
21060       REMOVE JAW JOINT CARTILAGE                      A              $1,118.46       20110101
21060       REMOVE JAW JOINT CARTILAGE     80                                $110.86       20110801
21060       REMOVE JAW JOINT CARTILAGE     81                                $110.86       20110801
21060       REMOVE JAW JOINT CARTILAGE     82                                $110.86       20110801



                                                Page 21
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
21060       REMOVE JAW JOINT CARTILAGE      AS                                $110.86       20110801
21060       REMOVE JAW JOINT CARTILAGE                                        $554.32       20110801
21070       REMOVE CORONOID PROCESS                          A              $1,130.71       20110101
21070       REMOVE CORONOID PROCESS                                           $430.30       20110801
21076       PREPARE FACE/ORAL PROSTHESIS                                      $643.50       20110801
21077       PREPARE FACE/ORAL PROSTHESIS                                    $1,590.68       20110801
21079       PREPARE FACE/ORAL PROSTHESIS                                    $1,087.84       20110801
21080       PREPARE FACE/ORAL PROSTHESIS                                    $1,231.10       20110801
21081       PREPARE FACE/ORAL PROSTHESIS                                    $1,127.88       20110801
21082       PREPARE FACE/ORAL PROSTHESIS                                    $1,050.66       20110801
21083       PREPARE FACE/ORAL PROSTHESIS                                      $976.82       20110801
21084       PREPARE FACE/ORAL PROSTHESIS                                    $1,154.40       20110801
21085       PREPARE FACE/ORAL PROSTHESIS                                      $503.36       20110801
21086       PREPARE FACE/ORAL PROSTHESIS                                    $1,156.48       20110801
21087       PREPARE FACE/ORAL PROSTHESIS                                    $1,155.44       20110801
21100       MAXILLOFACIAL FIXATION                           A              $1,118.46       20110101
21100       MAXILLOFACIAL FIXATION                                            $471.12       20110801
21110       INTERDENTAL FIXATION                                              $501.54       20110801
21116       INJECTION JAW JOINT X-RAY                                          $99.32       20110801
21120       RECONSTRUCTION OF CHIN                           A                $790.42       20110101
21120       RECONSTRUCTION OF CHIN                                            $420.68       20110801
21121       RECONSTRUCTION OF CHIN                           A                $790.42       20110101
21121       RECONSTRUCTION OF CHIN          80                                $100.46       20110801
21121       RECONSTRUCTION OF CHIN          81                                $100.46       20110801
21121       RECONSTRUCTION OF CHIN          82                                $100.46       20110801
21121       RECONSTRUCTION OF CHIN          AS                                $100.46       20110801
21121       RECONSTRUCTION OF CHIN                                            $502.32       20110801
21137       REDUCTION OF FOREHEAD           80                                $100.31       20110801
21137       REDUCTION OF FOREHEAD           81                                $100.31       20110801
21137       REDUCTION OF FOREHEAD           82                                $100.31       20110801
21137       REDUCTION OF FOREHEAD           AS                                $100.31       20110801
21137       REDUCTION OF FOREHEAD                                             $501.54       20110801
21138       REDUCTION OF FOREHEAD           80                                $121.42       20110801
21138       REDUCTION OF FOREHEAD           81                                $121.42       20110801
21138       REDUCTION OF FOREHEAD           82                                $121.42       20110801
21138       REDUCTION OF FOREHEAD           AS                                $121.42       20110801
21138       REDUCTION OF FOREHEAD                                             $607.10       20110801
21139       REDUCTION OF FOREHEAD           80                                $131.82       20110801
21139       REDUCTION OF FOREHEAD           81                                $131.82       20110801
21139       REDUCTION OF FOREHEAD           82                                $131.82       20110801
21139       REDUCTION OF FOREHEAD           AS                                $131.82       20110801
21139       REDUCTION OF FOREHEAD                                             $659.10       20110801
21141       RECONSTRUCT MIDFACE LEFORT      80                                $187.56       20110801
21141       RECONSTRUCT MIDFACE LEFORT      81                                $187.56       20110801
21141       RECONSTRUCT MIDFACE LEFORT      82                                $187.56       20110801
21141       RECONSTRUCT MIDFACE LEFORT      AS                                $187.56       20110801
21141       RECONSTRUCT MIDFACE LEFORT                                        $937.82       20110801
21142       RECONSTRUCT MIDFACE LEFORT      80                                $188.86       20110801
21142       RECONSTRUCT MIDFACE LEFORT      81                                $188.86       20110801
21142       RECONSTRUCT MIDFACE LEFORT      82                                $188.86       20110801
21142       RECONSTRUCT MIDFACE LEFORT      AS                                $188.86       20110801
21142       RECONSTRUCT MIDFACE LEFORT                                        $944.32       20110801
21143       RECONSTRUCT MIDFACE LEFORT      80                                $194.84       20110801
21143       RECONSTRUCT MIDFACE LEFORT      81                                $194.84       20110801
21143       RECONSTRUCT MIDFACE LEFORT      82                                $194.84       20110801
21143       RECONSTRUCT MIDFACE LEFORT      AS                                $194.84       20110801
21143       RECONSTRUCT MIDFACE LEFORT                                        $974.22       20110801
21145       RECONSTRUCT MIDFACE LEFORT      80                                $207.27       20110801
21145       RECONSTRUCT MIDFACE LEFORT      81                                $207.27       20110801



                                                 Page 22
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
21145       RECONSTRUCT MIDFACE LEFORT     82                                $207.27       20110801
21145       RECONSTRUCT MIDFACE LEFORT     AS                                $207.27       20110801
21145       RECONSTRUCT MIDFACE LEFORT                                     $1,036.36       20110801
21146       RECONSTRUCT MIDFACE LEFORT     80                                $232.28       20110801
21146       RECONSTRUCT MIDFACE LEFORT     81                                $232.28       20110801
21146       RECONSTRUCT MIDFACE LEFORT     82                                $232.28       20110801
21146       RECONSTRUCT MIDFACE LEFORT     AS                                $232.28       20110801
21146       RECONSTRUCT MIDFACE LEFORT                                     $1,161.42       20110801
21147       RECONSTRUCT MIDFACE LEFORT     80                                $229.58       20110801
21147       RECONSTRUCT MIDFACE LEFORT     81                                $229.58       20110801
21147       RECONSTRUCT MIDFACE LEFORT     82                                $229.58       20110801
21147       RECONSTRUCT MIDFACE LEFORT     AS                                $229.58       20110801
21147       RECONSTRUCT MIDFACE LEFORT                                     $1,147.90       20110801
21150       RECONSTRUCT MIDFACE LEFORT     80                                $219.91       20110801
21150       RECONSTRUCT MIDFACE LEFORT     81                                $219.91       20110801
21150       RECONSTRUCT MIDFACE LEFORT     82                                $219.91       20110801
21150       RECONSTRUCT MIDFACE LEFORT     AS                                $219.91       20110801
21150       RECONSTRUCT MIDFACE LEFORT                                     $1,099.54       20110801
21151       RECONSTRUCT MIDFACE LEFORT     80                                $274.51       20110801
21151       RECONSTRUCT MIDFACE LEFORT     81                                $274.51       20110801
21151       RECONSTRUCT MIDFACE LEFORT     82                                $274.51       20110801
21151       RECONSTRUCT MIDFACE LEFORT     AS                                $274.51       20110801
21151       RECONSTRUCT MIDFACE LEFORT                                     $1,372.54       20110801
21154       RECONSTRUCT MIDFACE LEFORT     80                                $281.68       20110801
21154       RECONSTRUCT MIDFACE LEFORT     81                                $281.68       20110801
21154       RECONSTRUCT MIDFACE LEFORT     82                                $281.68       20110801
21154       RECONSTRUCT MIDFACE LEFORT     AS                                $281.68       20110801
21154       RECONSTRUCT MIDFACE LEFORT                                     $1,408.42       20110801
21155       RECONSTRUCT MIDFACE LEFORT     80                                $302.02       20110801
21155       RECONSTRUCT MIDFACE LEFORT     81                                $302.02       20110801
21155       RECONSTRUCT MIDFACE LEFORT     82                                $302.02       20110801
21155       RECONSTRUCT MIDFACE LEFORT     AS                                $302.02       20110801
21155       RECONSTRUCT MIDFACE LEFORT                                     $1,510.08       20110801
21159       RECONSTRUCT MIDFACE LEFORT     80                                $370.50       20110801
21159       RECONSTRUCT MIDFACE LEFORT     81                                $370.50       20110801
21159       RECONSTRUCT MIDFACE LEFORT     82                                $370.50       20110801
21159       RECONSTRUCT MIDFACE LEFORT     AS                                $370.50       20110801
21159       RECONSTRUCT MIDFACE LEFORT                                     $1,852.50       20110801
21160       RECONSTRUCT MIDFACE LEFORT     80                                $379.50       20110801
21160       RECONSTRUCT MIDFACE LEFORT     81                                $379.50       20110801
21160       RECONSTRUCT MIDFACE LEFORT     82                                $379.50       20110801
21160       RECONSTRUCT MIDFACE LEFORT     AS                                $379.50       20110801
21160       RECONSTRUCT MIDFACE LEFORT                                     $1,897.48       20110801
21172       RECONSTRUCT ORBIT/FOREHEAD     80                                $243.78       20110801
21172       RECONSTRUCT ORBIT/FOREHEAD     81                                $243.78       20110801
21172       RECONSTRUCT ORBIT/FOREHEAD     82                                $243.78       20110801
21172       RECONSTRUCT ORBIT/FOREHEAD     AS                                $243.78       20110801
21172       RECONSTRUCT ORBIT/FOREHEAD                                     $1,218.88       20110801
21175       RECONSTRUCT ORBIT/FOREHEAD     80                                $318.03       20110801
21175       RECONSTRUCT ORBIT/FOREHEAD     81                                $318.03       20110801
21175       RECONSTRUCT ORBIT/FOREHEAD     82                                $318.03       20110801
21175       RECONSTRUCT ORBIT/FOREHEAD     AS                                $318.03       20110801
21175       RECONSTRUCT ORBIT/FOREHEAD                                     $1,590.16       20110801
21179       RECONSTRUCT ENTIRE FOREHEAD    80                                $203.27       20110801
21179       RECONSTRUCT ENTIRE FOREHEAD    81                                $203.27       20110801
21179       RECONSTRUCT ENTIRE FOREHEAD    82                                $203.27       20110801
21179       RECONSTRUCT ENTIRE FOREHEAD    AS                                $203.27       20110801
21179       RECONSTRUCT ENTIRE FOREHEAD                                    $1,016.34       20110801
21180       RECONSTRUCT ENTIRE FOREHEAD    80                                $223.24       20110801



                                                Page 23
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
21180       RECONSTRUCT ENTIRE FOREHEAD     81                                $223.24       20110801
21180       RECONSTRUCT ENTIRE FOREHEAD     82                                $223.24       20110801
21180       RECONSTRUCT ENTIRE FOREHEAD     AS                                $223.24       20110801
21180       RECONSTRUCT ENTIRE FOREHEAD                                     $1,116.18       20110801
21181       CONTOUR CRANIAL BONE LESION                      A                $790.42       20110101
21181       CONTOUR CRANIAL BONE LESION                                       $472.16       20110801
21182       RECONSTRUCT CRANIAL BONE        80                                $277.52       20110801
21182       RECONSTRUCT CRANIAL BONE        81                                $277.52       20110801
21182       RECONSTRUCT CRANIAL BONE        82                                $277.52       20110801
21182       RECONSTRUCT CRANIAL BONE        AS                                $277.52       20110801
21182       RECONSTRUCT CRANIAL BONE                                        $1,387.62       20110801
21183       RECONSTRUCT CRANIAL BONE        80                                $319.07       20110801
21183       RECONSTRUCT CRANIAL BONE        81                                $319.07       20110801
21183       RECONSTRUCT CRANIAL BONE        82                                $319.07       20110801
21183       RECONSTRUCT CRANIAL BONE        AS                                $319.07       20110801
21183       RECONSTRUCT CRANIAL BONE                                        $1,595.36       20110801
21184       RECONSTRUCT CRANIAL BONE        80                                $336.13       20110801
21184       RECONSTRUCT CRANIAL BONE        81                                $336.13       20110801
21184       RECONSTRUCT CRANIAL BONE        82                                $336.13       20110801
21184       RECONSTRUCT CRANIAL BONE        AS                                $336.13       20110801
21184       RECONSTRUCT CRANIAL BONE                                        $1,680.64       20110801
21188       RECONSTRUCTION OF MIDFACE       80                                $226.51       20110801
21188       RECONSTRUCTION OF MIDFACE       81                                $226.51       20110801
21188       RECONSTRUCTION OF MIDFACE       82                                $226.51       20110801
21188       RECONSTRUCTION OF MIDFACE       AS                                $226.51       20110801
21188       RECONSTRUCTION OF MIDFACE                                       $1,132.56       20110801
21193       RECONST LWR JAW W/O GRAFT       80                                $170.61       20110801
21193       RECONST LWR JAW W/O GRAFT       81                                $170.61       20110801
21193       RECONST LWR JAW W/O GRAFT       82                                $170.61       20110801
21193       RECONST LWR JAW W/O GRAFT       AS                                $170.61       20110801
21193       RECONST LWR JAW W/O GRAFT                                         $853.06       20110801
21194       RECONST LWR JAW W/GRAFT         80                                $193.44       20110801
21194       RECONST LWR JAW W/GRAFT         81                                $193.44       20110801
21194       RECONST LWR JAW W/GRAFT         82                                $193.44       20110801
21194       RECONST LWR JAW W/GRAFT         AS                                $193.44       20110801
21194       RECONST LWR JAW W/GRAFT                                           $967.20       20110801
21195       RECONST LWR JAW W/O FIXATION    80                                $183.66       20110801
21195       RECONST LWR JAW W/O FIXATION    81                                $183.66       20110801
21195       RECONST LWR JAW W/O FIXATION    82                                $183.66       20110801
21195       RECONST LWR JAW W/O FIXATION    AS                                $183.66       20110801
21195       RECONST LWR JAW W/O FIXATION                                      $918.32       20110801
21196       RECONST LWR JAW W/FIXATION      80                                $199.37       20110801
21196       RECONST LWR JAW W/FIXATION      81                                $199.37       20110801
21196       RECONST LWR JAW W/FIXATION      82                                $199.37       20110801
21196       RECONST LWR JAW W/FIXATION      AS                                $199.37       20110801
21196       RECONST LWR JAW W/FIXATION                                        $996.84       20110801
21198       RECONSTR LWR JAW SEGMENT        80                                $157.35       20110801
21198       RECONSTR LWR JAW SEGMENT        81                                $157.35       20110801
21198       RECONSTR LWR JAW SEGMENT        82                                $157.35       20110801
21198       RECONSTR LWR JAW SEGMENT        AS                                $157.35       20110801
21198       RECONSTR LWR JAW SEGMENT                                          $786.76       20110801
21199       RECONSTR LWR JAW W/ADVANCE      80                                $141.60       20110801
21199       RECONSTR LWR JAW W/ADVANCE      81                                $141.60       20110801
21199       RECONSTR LWR JAW W/ADVANCE      82                                $141.60       20110801
21199       RECONSTR LWR JAW W/ADVANCE      AS                                $141.60       20110801
21199       RECONSTR LWR JAW W/ADVANCE                                        $707.98       20110801
21206       RECONSTRUCT UPPER JAW BONE                       A              $1,170.32       20110101
21206       RECONSTRUCT UPPER JAW BONE      80                                $161.72       20110801
21206       RECONSTRUCT UPPER JAW BONE      81                                $161.72       20110801



                                                 Page 24
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
21206       RECONSTRUCT UPPER JAW BONE      82                                $161.72       20110801
21206       RECONSTRUCT UPPER JAW BONE      AS                                $161.72       20110801
21206       RECONSTRUCT UPPER JAW BONE                                        $808.60       20110801
21208       AUGMENTATION OF FACIAL BONES                     A              $1,223.51       20110101
21208       AUGMENTATION OF FACIAL BONES                                    $1,183.78       20110801
21209       REDUCTION OF FACIAL BONES                        A              $1,170.32       20110101
21209       REDUCTION OF FACIAL BONES       80                                $113.31       20110801
21209       REDUCTION OF FACIAL BONES       81                                $113.31       20110801
21209       REDUCTION OF FACIAL BONES       82                                $113.31       20110801
21209       REDUCTION OF FACIAL BONES       AS                                $113.31       20110801
21209       REDUCTION OF FACIAL BONES                                         $566.54       20110801
21210       FACE BONE GRAFT                                  A              $1,223.51       20110101
21210       FACE BONE GRAFT                                                 $1,387.10       20110801
21215       LOWER JAW BONE GRAFT                             A              $1,223.51       20110101
21215       LOWER JAW BONE GRAFT                                              $610.09       20100101
21230       RIB CARTILAGE GRAFT                              A              $1,223.51       20110101
21230       RIB CARTILAGE GRAFT                                               $535.86       20110801
21235       EAR CARTILAGE GRAFT                              A                $790.42       20110101
21235       EAR CARTILAGE GRAFT                                               $488.28       20110801
21240       RECONSTRUCTION OF JAW JOINT                      A              $1,153.67       20110101
21240       RECONSTRUCTION OF JAW JOINT     80                                $149.60       20110801
21240       RECONSTRUCTION OF JAW JOINT     81                                $149.60       20110801
21240       RECONSTRUCTION OF JAW JOINT     82                                $149.60       20110801
21240       RECONSTRUCTION OF JAW JOINT     AS                                $149.60       20110801
21240       RECONSTRUCTION OF JAW JOINT                                       $748.02       20110801
21242       RECONSTRUCTION OF JAW JOINT                      A              $1,170.32       20110101
21242       RECONSTRUCTION OF JAW JOINT     80                                $137.75       20110801
21242       RECONSTRUCTION OF JAW JOINT     81                                $137.75       20110801
21242       RECONSTRUCTION OF JAW JOINT     82                                $137.75       20110801
21242       RECONSTRUCTION OF JAW JOINT     AS                                $137.75       20110801
21242       RECONSTRUCTION OF JAW JOINT                                       $688.74       20110801
21243       RECONSTRUCTION OF JAW JOINT                      A              $1,170.32       20110101
21243       RECONSTRUCTION OF JAW JOINT     80                                $227.71       20110801
21243       RECONSTRUCTION OF JAW JOINT     81                                $227.71       20110801
21243       RECONSTRUCTION OF JAW JOINT     82                                $227.71       20110801
21243       RECONSTRUCTION OF JAW JOINT     AS                                $227.71       20110801
21243       RECONSTRUCTION OF JAW JOINT                                     $1,138.54       20110801
21244       RECONSTRUCTION OF LOWER JAW                      A              $1,223.51       20110101
21244       RECONSTRUCTION OF LOWER JAW     80                                $143.42       20110801
21244       RECONSTRUCTION OF LOWER JAW     81                                $143.42       20110801
21244       RECONSTRUCTION OF LOWER JAW     82                                $143.42       20110801
21244       RECONSTRUCTION OF LOWER JAW     AS                                $143.42       20110801
21244       RECONSTRUCTION OF LOWER JAW                                       $717.08       20110801
21245       RECONSTRUCTION OF JAW                            A              $1,223.51       20110101
21245       RECONSTRUCTION OF JAW           80                                $152.52       20110801
21245       RECONSTRUCTION OF JAW           81                                $152.52       20110801
21245       RECONSTRUCTION OF JAW           82                                $152.52       20110801
21245       RECONSTRUCTION OF JAW           AS                                $152.52       20110801
21245       RECONSTRUCTION OF JAW                                             $762.58       20110801
21246       RECONSTRUCTION OF JAW                            A              $1,223.51       20110101
21246       RECONSTRUCTION OF JAW           80                                $115.54       20110801
21246       RECONSTRUCTION OF JAW           81                                $115.54       20110801
21246       RECONSTRUCTION OF JAW           82                                $115.54       20110801
21246       RECONSTRUCTION OF JAW           AS                                $115.54       20110801
21246       RECONSTRUCTION OF JAW                                             $577.72       20110801
21247       RECONSTRUCT LOWER JAW BONE      80                                $224.28       20110801
21247       RECONSTRUCT LOWER JAW BONE      81                                $224.28       20110801
21247       RECONSTRUCT LOWER JAW BONE      82                                $224.28       20110801
21247       RECONSTRUCT LOWER JAW BONE      AS                                $224.28       20110801



                                                 Page 25
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
21247       RECONSTRUCT LOWER JAW BONE                                     $1,121.38       20110801
21248       RECONSTRUCTION OF JAW                           A              $1,223.51       20110101
21248       RECONSTRUCTION OF JAW                                            $719.16       20110801
21249       RECONSTRUCTION OF JAW                           A              $1,223.51       20110101
21249       RECONSTRUCTION OF JAW                                            $991.12       20110801
21255       RECONSTRUCT LOWER JAW BONE     80                                $190.94       20110801
21255       RECONSTRUCT LOWER JAW BONE     81                                $190.94       20110801
21255       RECONSTRUCT LOWER JAW BONE     82                                $190.94       20110801
21255       RECONSTRUCT LOWER JAW BONE     AS                                $190.94       20110801
21255       RECONSTRUCT LOWER JAW BONE                                       $954.72       20110801
21256       RECONSTRUCTION OF ORBIT        80                                $161.77       20110801
21256       RECONSTRUCTION OF ORBIT        81                                $161.77       20110801
21256       RECONSTRUCTION OF ORBIT        82                                $161.77       20110801
21256       RECONSTRUCTION OF ORBIT        AS                                $161.77       20110801
21256       RECONSTRUCTION OF ORBIT                                          $808.86       20110801
21260       REVISE EYE SOCKETS             80                                $172.07       20110801
21260       REVISE EYE SOCKETS             81                                $172.07       20110801
21260       REVISE EYE SOCKETS             82                                $172.07       20110801
21260       REVISE EYE SOCKETS             AS                                $172.07       20110801
21260       REVISE EYE SOCKETS                                               $860.34       20110801
21261       REVISE EYE SOCKETS             80                                $314.29       20110801
21261       REVISE EYE SOCKETS             81                                $314.29       20110801
21261       REVISE EYE SOCKETS             82                                $314.29       20110801
21261       REVISE EYE SOCKETS             AS                                $314.29       20110801
21261       REVISE EYE SOCKETS                                             $1,571.44       20110801
21263       REVISE EYE SOCKETS             80                                $266.60       20110801
21263       REVISE EYE SOCKETS             81                                $266.60       20110801
21263       REVISE EYE SOCKETS             82                                $266.60       20110801
21263       REVISE EYE SOCKETS             AS                                $266.60       20110801
21263       REVISE EYE SOCKETS                                             $1,333.02       20110801
21267       REVISE EYE SOCKETS                              A              $1,223.51       20110101
21267       REVISE EYE SOCKETS             80                                $217.36       20110801
21267       REVISE EYE SOCKETS             81                                $217.36       20110801
21267       REVISE EYE SOCKETS             82                                $217.36       20110801
21267       REVISE EYE SOCKETS             AS                                $217.36       20110801
21267       REVISE EYE SOCKETS                                             $1,086.80       20110801
21268       REVISE EYE SOCKETS             80                                $271.75       20110801
21268       REVISE EYE SOCKETS             81                                $271.75       20110801
21268       REVISE EYE SOCKETS             82                                $271.75       20110801
21268       REVISE EYE SOCKETS             AS                                $271.75       20110801
21268       REVISE EYE SOCKETS                                             $1,358.76       20110801
21270       AUGMENTATION CHEEK BONE                         A              $1,170.32       20110101
21270       AUGMENTATION CHEEK BONE        80                                $125.01       20110801
21270       AUGMENTATION CHEEK BONE        81                                $125.01       20110801
21270       AUGMENTATION CHEEK BONE        82                                $125.01       20110801
21270       AUGMENTATION CHEEK BONE        AS                                $125.01       20110801
21270       AUGMENTATION CHEEK BONE                                          $625.04       20110801
21275       REVISION ORBITOFACIAL BONES                     A              $1,223.51       20110101
21275       REVISION ORBITOFACIAL BONES    80                                $112.94       20110801
21275       REVISION ORBITOFACIAL BONES    81                                $112.94       20110801
21275       REVISION ORBITOFACIAL BONES    82                                $112.94       20110801
21275       REVISION ORBITOFACIAL BONES    AS                                $112.94       20110801
21275       REVISION ORBITOFACIAL BONES                                      $564.72       20110801
21280       REVISION OF EYELID                              A              $1,170.32       20110101
21280       REVISION OF EYELID                                               $376.48       20110801
21282       REVISION OF EYELID                              A                $550.32       20110101
21282       REVISION OF EYELID                                               $247.00       20110801
21295       REVISION OF JAW MUSCLE/BONE                     A                $246.86       20110101
21295       REVISION OF JAW MUSCLE/BONE                                      $120.90       20110801



                                                Page 26
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
21296       REVISION OF JAW MUSCLE/BONE                      A                $663.74       20110101
21296       REVISION OF JAW MUSCLE/BONE                                       $289.90       20110801
21310       TREATMENT OF NOSE FRACTURE                       A                 $56.54       20110101
21310       TREATMENT OF NOSE FRACTURE                                         $71.76       20110801
21315       TREATMENT OF NOSE FRACTURE                       A                $441.97       20110101
21315       TREATMENT OF NOSE FRACTURE                                        $175.24       20110801
21320       TREATMENT OF NOSE FRACTURE                       A                $498.46       20110101
21320       TREATMENT OF NOSE FRACTURE                                        $166.66       20110801
21325       TREATMENT OF NOSE FRACTURE                       A                $720.58       20110101
21325       TREATMENT OF NOSE FRACTURE                                        $316.42       20110801
21330       TREATMENT OF NOSE FRACTURE                       A                $737.22       20110101
21330       TREATMENT OF NOSE FRACTURE                                        $382.20       20110801
21335       TREATMENT OF NOSE FRACTURE                       A                $790.42       20110101
21335       TREATMENT OF NOSE FRACTURE                                        $498.94       20110801
21336       TREAT NASAL SEPTAL FRACTURE                      A                $741.74       20110101
21336       TREAT NASAL SEPTAL FRACTURE                                       $433.94       20110801
21337       TREAT NASAL SEPTAL FRACTURE                      A                $498.46       20110101
21337       TREAT NASAL SEPTAL FRACTURE                                       $263.38       20110801
21338       TREAT NASOETHMOID FRACTURE                       A                $720.58       20110101
21338       TREAT NASOETHMOID FRACTURE                                        $496.86       20110801
21339       TREAT NASOETHMOID FRACTURE                       A                $737.22       20110101
21339       TREAT NASOETHMOID FRACTURE      80                                $111.59       20110801
21339       TREAT NASOETHMOID FRACTURE      81                                $111.59       20110801
21339       TREAT NASOETHMOID FRACTURE      82                                $111.59       20110801
21339       TREAT NASOETHMOID FRACTURE      AS                                $111.59       20110801
21339       TREAT NASOETHMOID FRACTURE                                        $557.96       20110801
21340       TREATMENT OF NOSE FRACTURE                       A              $1,153.67       20110101
21340       TREATMENT OF NOSE FRACTURE                                        $540.28       20110801
21343       TREATMENT OF SINUS FRACTURE     80                                $160.26       20110801
21343       TREATMENT OF SINUS FRACTURE     81                                $160.26       20110801
21343       TREATMENT OF SINUS FRACTURE     82                                $160.26       20110801
21343       TREATMENT OF SINUS FRACTURE     AS                                $160.26       20110801
21343       TREATMENT OF SINUS FRACTURE                                       $801.32       20110801
21344       TREATMENT OF SINUS FRACTURE     80                                $222.92       20110801
21344       TREATMENT OF SINUS FRACTURE     81                                $222.92       20110801
21344       TREATMENT OF SINUS FRACTURE     82                                $222.92       20110801
21344       TREATMENT OF SINUS FRACTURE     AS                                $222.92       20110801
21344       TREATMENT OF SINUS FRACTURE                                     $1,114.62       20110801
21345       TREAT NOSE/JAW FRACTURE                          A                $790.42       20110101
21345       TREAT NOSE/JAW FRACTURE                                           $535.86       20110801
21346       TREAT NOSE/JAW FRACTURE                                           $636.22       20110801
21347       TREAT NOSE/JAW FRACTURE         80                                $146.02       20110801
21347       TREAT NOSE/JAW FRACTURE         81                                $146.02       20110801
21347       TREAT NOSE/JAW FRACTURE         82                                $146.02       20110801
21347       TREAT NOSE/JAW FRACTURE         AS                                $146.02       20110801
21347       TREAT NOSE/JAW FRACTURE                                           $730.08       20110801
21348       TREAT NOSE/JAW FRACTURE         80                                $154.28       20110801
21348       TREAT NOSE/JAW FRACTURE         81                                $154.28       20110801
21348       TREAT NOSE/JAW FRACTURE         82                                $154.28       20110801
21348       TREAT NOSE/JAW FRACTURE         AS                                $154.28       20110801
21348       TREAT NOSE/JAW FRACTURE                                           $771.42       20110801
21355       TREAT CHEEK BONE FRACTURE                        A              $1,130.71       20110101
21355       TREAT CHEEK BONE FRACTURE                                         $292.50       20110801
21356       TREAT CHEEK BONE FRACTURE                                         $328.38       20110801
21360       TREAT CHEEK BONE FRACTURE                        A                $800.03       20110101
21360       TREAT CHEEK BONE FRACTURE       80                                 $71.86       20110801
21360       TREAT CHEEK BONE FRACTURE       81                                 $71.86       20110801
21360       TREAT CHEEK BONE FRACTURE       82                                 $71.86       20110801
21360       TREAT CHEEK BONE FRACTURE       AS                                 $71.86       20110801



                                                 Page 27
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
21360       TREAT CHEEK BONE FRACTURE                                        $359.32       20110801
21365       TREAT CHEEK BONE FRACTURE      80                                $152.78       20110801
21365       TREAT CHEEK BONE FRACTURE      81                                $152.78       20110801
21365       TREAT CHEEK BONE FRACTURE      82                                $152.78       20110801
21365       TREAT CHEEK BONE FRACTURE      AS                                $152.78       20110801
21365       TREAT CHEEK BONE FRACTURE                                        $763.88       20110801
21366       TREAT CHEEK BONE FRACTURE      80                                $170.82       20110801
21366       TREAT CHEEK BONE FRACTURE      81                                $170.82       20110801
21366       TREAT CHEEK BONE FRACTURE      82                                $170.82       20110801
21366       TREAT CHEEK BONE FRACTURE      AS                                $170.82       20110801
21366       TREAT CHEEK BONE FRACTURE                                        $854.10       20110801
21385       TREAT EYE SOCKET FRACTURE      80                                 $95.78       20110801
21385       TREAT EYE SOCKET FRACTURE      81                                 $95.78       20110801
21385       TREAT EYE SOCKET FRACTURE      82                                 $95.78       20110801
21385       TREAT EYE SOCKET FRACTURE      AS                                 $95.78       20110801
21385       TREAT EYE SOCKET FRACTURE                                        $478.92       20110801
21386       TREAT EYE SOCKET FRACTURE      80                                 $91.62       20110801
21386       TREAT EYE SOCKET FRACTURE      81                                 $91.62       20110801
21386       TREAT EYE SOCKET FRACTURE      82                                 $91.62       20110801
21386       TREAT EYE SOCKET FRACTURE      AS                                 $91.62       20110801
21386       TREAT EYE SOCKET FRACTURE                                        $458.12       20110801
21387       TREAT EYE SOCKET FRACTURE      80                                $102.34       20110801
21387       TREAT EYE SOCKET FRACTURE      81                                $102.34       20110801
21387       TREAT EYE SOCKET FRACTURE      82                                $102.34       20110801
21387       TREAT EYE SOCKET FRACTURE      AS                                $102.34       20110801
21387       TREAT EYE SOCKET FRACTURE                                        $511.68       20110801
21390       TREAT EYE SOCKET FRACTURE                       A              $1,377.50       20110101
21390       TREAT EYE SOCKET FRACTURE      80                                $107.38       20110801
21390       TREAT EYE SOCKET FRACTURE      81                                $107.38       20110801
21390       TREAT EYE SOCKET FRACTURE      82                                $107.38       20110801
21390       TREAT EYE SOCKET FRACTURE      AS                                $107.38       20110801
21390       TREAT EYE SOCKET FRACTURE                                        $536.90       20110801
21395       TREAT EYE SOCKET FRACTURE      80                                $129.84       20110801
21395       TREAT EYE SOCKET FRACTURE      81                                $129.84       20110801
21395       TREAT EYE SOCKET FRACTURE      82                                $129.84       20110801
21395       TREAT EYE SOCKET FRACTURE      AS                                $129.84       20110801
21395       TREAT EYE SOCKET FRACTURE                                        $649.22       20110801
21400       TREAT EYE SOCKET FRACTURE                       A                $268.48       20110101
21400       TREAT EYE SOCKET FRACTURE                                        $119.86       20110801
21401       TREAT EYE SOCKET FRACTURE                       A                $510.71       20110101
21401       TREAT EYE SOCKET FRACTURE      80                                 $62.92       20110801
21401       TREAT EYE SOCKET FRACTURE      81                                 $62.92       20110801
21401       TREAT EYE SOCKET FRACTURE      82                                 $62.92       20110801
21401       TREAT EYE SOCKET FRACTURE      AS                                 $62.92       20110801
21401       TREAT EYE SOCKET FRACTURE                                        $314.60       20110801
21406       TREAT EYE SOCKET FRACTURE                       A              $1,377.50       20110101
21406       TREAT EYE SOCKET FRACTURE      80                                 $72.49       20110801
21406       TREAT EYE SOCKET FRACTURE      81                                 $72.49       20110801
21406       TREAT EYE SOCKET FRACTURE      82                                 $72.49       20110801
21406       TREAT EYE SOCKET FRACTURE      AS                                 $72.49       20110801
21406       TREAT EYE SOCKET FRACTURE                                        $362.44       20110801
21407       TREAT EYE SOCKET FRACTURE                       A              $1,377.50       20110101
21407       TREAT EYE SOCKET FRACTURE      80                                 $88.14       20110801
21407       TREAT EYE SOCKET FRACTURE      81                                 $88.14       20110801
21407       TREAT EYE SOCKET FRACTURE      82                                 $88.14       20110801
21407       TREAT EYE SOCKET FRACTURE      AS                                 $88.14       20110801
21407       TREAT EYE SOCKET FRACTURE                                        $440.70       20110801
21408       TREAT EYE SOCKET FRACTURE      80                                $122.04       20110801
21408       TREAT EYE SOCKET FRACTURE      81                                $122.04       20110801



                                                Page 28
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
21408       TREAT EYE SOCKET FRACTURE       82                                $122.04       20110801
21408       TREAT EYE SOCKET FRACTURE       AS                                $122.04       20110801
21408       TREAT EYE SOCKET FRACTURE                                         $610.22       20110801
21421       TREAT MOUTH ROOF FRACTURE                        A                $720.58       20110101
21421       TREAT MOUTH ROOF FRACTURE                                         $498.68       20110801
21422       TREAT MOUTH ROOF FRACTURE       80                                 $90.06       20110801
21422       TREAT MOUTH ROOF FRACTURE       81                                 $90.06       20110801
21422       TREAT MOUTH ROOF FRACTURE       82                                 $90.06       20110801
21422       TREAT MOUTH ROOF FRACTURE       AS                                 $90.06       20110801
21422       TREAT MOUTH ROOF FRACTURE                                         $450.32       20110801
21423       TREAT MOUTH ROOF FRACTURE       80                                $109.36       20110801
21423       TREAT MOUTH ROOF FRACTURE       81                                $109.36       20110801
21423       TREAT MOUTH ROOF FRACTURE       82                                $109.36       20110801
21423       TREAT MOUTH ROOF FRACTURE       AS                                $109.36       20110801
21423       TREAT MOUTH ROOF FRACTURE                                         $546.78       20110801
21431       TREAT CRANIOFACIAL FRACTURE     80                                $102.28       20110801
21431       TREAT CRANIOFACIAL FRACTURE     81                                $102.28       20110801
21431       TREAT CRANIOFACIAL FRACTURE     82                                $102.28       20110801
21431       TREAT CRANIOFACIAL FRACTURE     AS                                $102.28       20110801
21431       TREAT CRANIOFACIAL FRACTURE                                       $511.42       20110801
21432       TREAT CRANIOFACIAL FRACTURE     80                                 $91.78       20110801
21432       TREAT CRANIOFACIAL FRACTURE     81                                 $91.78       20110801
21432       TREAT CRANIOFACIAL FRACTURE     82                                 $91.78       20110801
21432       TREAT CRANIOFACIAL FRACTURE     AS                                 $91.78       20110801
21432       TREAT CRANIOFACIAL FRACTURE                                       $458.90       20110801
21433       TREAT CRANIOFACIAL FRACTURE     80                                $234.52       20110801
21433       TREAT CRANIOFACIAL FRACTURE     81                                $234.52       20110801
21433       TREAT CRANIOFACIAL FRACTURE     82                                $234.52       20110801
21433       TREAT CRANIOFACIAL FRACTURE     AS                                $234.52       20110801
21433       TREAT CRANIOFACIAL FRACTURE                                     $1,172.60       20110801
21435       TREAT CRANIOFACIAL FRACTURE     80                                $181.17       20110801
21435       TREAT CRANIOFACIAL FRACTURE     81                                $181.17       20110801
21435       TREAT CRANIOFACIAL FRACTURE     82                                $181.17       20110801
21435       TREAT CRANIOFACIAL FRACTURE     AS                                $181.17       20110801
21435       TREAT CRANIOFACIAL FRACTURE                                       $905.84       20110801
21436       TREAT CRANIOFACIAL FRACTURE     80                                $278.20       20110801
21436       TREAT CRANIOFACIAL FRACTURE     81                                $278.20       20110801
21436       TREAT CRANIOFACIAL FRACTURE     82                                $278.20       20110801
21436       TREAT CRANIOFACIAL FRACTURE     AS                                $278.20       20110801
21436       TREAT CRANIOFACIAL FRACTURE                                     $1,391.00       20110801
21440       TREAT DENTAL RIDGE FRACTURE                      A                $224.85       20110101
21440       TREAT DENTAL RIDGE FRACTURE                                       $359.06       20110801
21445       TREAT DENTAL RIDGE FRACTURE                      A                $720.58       20110101
21445       TREAT DENTAL RIDGE FRACTURE     80                                 $99.48       20110801
21445       TREAT DENTAL RIDGE FRACTURE     81                                 $99.48       20110801
21445       TREAT DENTAL RIDGE FRACTURE     82                                 $99.48       20110801
21445       TREAT DENTAL RIDGE FRACTURE     AS                                 $99.48       20110801
21445       TREAT DENTAL RIDGE FRACTURE                                       $497.38       20110801
21450       TREAT LOWER JAW FRACTURE                         A                $111.17       20110101
21450       TREAT LOWER JAW FRACTURE                                          $374.14       20110801
21451       TREAT LOWER JAW FRACTURE                         A                $271.95       20110101
21451       TREAT LOWER JAW FRACTURE                                          $484.38       20110801
21452       TREAT LOWER JAW FRACTURE                         A                $498.46       20110101
21452       TREAT LOWER JAW FRACTURE                                          $386.62       20110801
21453       TREAT LOWER JAW FRACTURE                         A              $1,130.71       20110101
21453       TREAT LOWER JAW FRACTURE                                          $568.62       20110801
21454       TREAT LOWER JAW FRACTURE                         A                $737.22       20110101
21454       TREAT LOWER JAW FRACTURE        80                                 $75.19       20110801
21454       TREAT LOWER JAW FRACTURE        81                                 $75.19       20110801



                                                 Page 29
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
21454       TREAT LOWER JAW FRACTURE        82                                 $75.19       20110801
21454       TREAT LOWER JAW FRACTURE        AS                                 $75.19       20110801
21454       TREAT LOWER JAW FRACTURE                                          $375.96       20110801
21461       TREAT LOWER JAW FRACTURE                         A              $1,153.67       20110101
21461       TREAT LOWER JAW FRACTURE                                          $637.36       20100101
21462       TREAT LOWER JAW FRACTURE                         A              $1,170.32       20110101
21462       TREAT LOWER JAW FRACTURE                                          $707.46       20100101
21465       TREAT LOWER JAW FRACTURE                         A              $1,153.67       20110101
21465       TREAT LOWER JAW FRACTURE        80                                $127.24       20110801
21465       TREAT LOWER JAW FRACTURE        81                                $127.24       20110801
21465       TREAT LOWER JAW FRACTURE        82                                $127.24       20110801
21465       TREAT LOWER JAW FRACTURE        AS                                $127.24       20110801
21465       TREAT LOWER JAW FRACTURE                                          $636.22       20110801
21470       TREAT LOWER JAW FRACTURE        80                                $164.01       20110801
21470       TREAT LOWER JAW FRACTURE        81                                $164.01       20110801
21470       TREAT LOWER JAW FRACTURE        82                                $164.01       20110801
21470       TREAT LOWER JAW FRACTURE        AS                                $164.01       20110801
21470       TREAT LOWER JAW FRACTURE                                          $820.04       20110801
21480       RESET DISLOCATED JAW                             A                 $56.54       20110101
21480       RESET DISLOCATED JAW                                               $59.80       20110801
21485       RESET DISLOCATED JAW                             A                $498.46       20110101
21485       RESET DISLOCATED JAW                                              $437.06       20110801
21490       REPAIR DISLOCATED JAW                            A              $1,130.71       20110101
21490       REPAIR DISLOCATED JAW           80                                $126.72       20110801
21490       REPAIR DISLOCATED JAW           81                                $126.72       20110801
21490       REPAIR DISLOCATED JAW           82                                $126.72       20110801
21490       REPAIR DISLOCATED JAW           AS                                $126.72       20110801
21490       REPAIR DISLOCATED JAW                                             $633.62       20110801
21495       TREAT HYOID BONE FRACTURE                        A                $550.84       20110101
21495       TREAT HYOID BONE FRACTURE       80                                 $93.13       20110801
21495       TREAT HYOID BONE FRACTURE       81                                 $93.13       20110801
21495       TREAT HYOID BONE FRACTURE       82                                 $93.13       20110801
21495       TREAT HYOID BONE FRACTURE       AS                                 $93.13       20110801
21495       TREAT HYOID BONE FRACTURE                                         $465.66       20110801
21497       INTERDENTAL WIRING                               A                $498.46       20110101
21497       INTERDENTAL WIRING                                                $442.52       20110801
21501       DRAIN NECK/CHEST LESION                          A                $551.78       20110101
21501       DRAIN NECK/CHEST LESION                                           $294.58       20110801
21502       DRAIN CHEST LESION                               A                $614.48       20110101
21502       DRAIN CHEST LESION              80                                 $72.28       20110801
21502       DRAIN CHEST LESION              81                                 $72.28       20110801
21502       DRAIN CHEST LESION              82                                 $72.28       20110801
21502       DRAIN CHEST LESION              AS                                 $72.28       20110801
21502       DRAIN CHEST LESION                                                $361.40       20110801
21510       DRAINAGE OF BONE LESION                                           $316.94       20110801
21550       BIOPSY OF NECK/CHEST                             A                $560.76       20110101
21550       BIOPSY OF NECK/CHEST                                              $169.52       20110801
21552       EXC NECK LES SC 3 CM/                                             $316.42       20110801
21554       EXC NECK TUM DEEP 5 CM/                                           $519.48       20110801
21555       EXC NECK LES SC 3 CM                             A                $135.59       20110101
21555       EXC NECK LES SC 3 CM                                              $272.74       20110801
21556       EXC NECK TUM DEEP 5 CM                           A                $749.54       20110101
21556       EXC NECK TUM DEEP 5 CM                                            $347.62       20110801
21557       RESECT NECK TUM 5 CM            80                                $119.34       20110801
21557       RESECT NECK TUM 5 CM            81                                $119.34       20110801
21557       RESECT NECK TUM 5 CM            82                                $119.34       20110801
21557       RESECT NECK TUM 5 CM            AS                                $119.34       20110801
21557       RESECT NECK TUM 5 CM                                              $596.70       20110801
21558       RESECT NECK TUM 5 CM/                                             $975.52       20110801



                                                 Page 30
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                        Date
21600       PARTIAL REMOVAL OF RIB                            A                   $849.00       20110101
21600       PARTIAL REMOVAL OF RIB           80                                    $76.23       20110801
21600       PARTIAL REMOVAL OF RIB           81                                    $76.23       20110801
21600       PARTIAL REMOVAL OF RIB           82                                    $76.23       20110801
21600       PARTIAL REMOVAL OF RIB           AS                                    $76.23       20110801
21600       PARTIAL REMOVAL OF RIB                                                $381.16       20110801
21610       PARTIAL REMOVAL OF RIB                            A                   $849.00       20110101
21610       PARTIAL REMOVAL OF RIB           80                                   $155.12       20110801
21610       PARTIAL REMOVAL OF RIB           81                                   $155.12       20110801
21610       PARTIAL REMOVAL OF RIB           82                                   $155.12       20110801
21610       PARTIAL REMOVAL OF RIB           AS                                   $155.12       20110801
21610       PARTIAL REMOVAL OF RIB                                                $775.58       20110801
21615       REMOVAL OF RIB                   80                                    $93.60       20110801
21615       REMOVAL OF RIB                   81                                    $93.60       20110801
21615       REMOVAL OF RIB                   82                                    $93.60       20110801
21615       REMOVAL OF RIB                   AS                                    $93.60       20110801
21615       REMOVAL OF RIB                                                        $468.00       20110801
21616       REMOVAL OF RIB AND NERVES        80                                   $116.32       20110801
21616       REMOVAL OF RIB AND NERVES        81                                   $116.32       20110801
21616       REMOVAL OF RIB AND NERVES        82                                   $116.32       20110801
21616       REMOVAL OF RIB AND NERVES        AS                                   $116.32       20110801
21616       REMOVAL OF RIB AND NERVES                                             $581.62       20110801
21620       PARTIAL REMOVAL OF STERNUM       80                                    $72.07       20110801
21620       PARTIAL REMOVAL OF STERNUM       81                                    $72.07       20110801
21620       PARTIAL REMOVAL OF STERNUM       82                                    $72.07       20110801
21620       PARTIAL REMOVAL OF STERNUM       AS                                    $72.07       20110801
21620       PARTIAL REMOVAL OF STERNUM                                            $360.36       20110801
21627       STERNAL DEBRIDEMENT              80                                    $75.71       20110801
21627       STERNAL DEBRIDEMENT              81                                    $75.71       20110801
21627       STERNAL DEBRIDEMENT              82                                    $75.71       20110801
21627       STERNAL DEBRIDEMENT              AS                                    $75.71       20110801
21627       STERNAL DEBRIDEMENT                                                   $378.56       20110801
21630       EXTENSIVE STERNUM SURGERY        80                                   $175.29       20110801
21630       EXTENSIVE STERNUM SURGERY        81                                   $175.29       20110801
21630       EXTENSIVE STERNUM SURGERY        82                                   $175.29       20110801
21630       EXTENSIVE STERNUM SURGERY        AS                                   $175.29       20110801
21630       EXTENSIVE STERNUM SURGERY                                             $876.46       20110801
21632       EXTENSIVE STERNUM SURGERY        80                                   $176.12       20110801
21632       EXTENSIVE STERNUM SURGERY        81                                   $176.12       20110801
21632       EXTENSIVE STERNUM SURGERY        82                                   $176.12       20110801
21632       EXTENSIVE STERNUM SURGERY        AS                                   $176.12       20110801
21632       EXTENSIVE STERNUM SURGERY                                             $880.62       20110801
21700       REVISION OF NECK MUSCLE                           A                   $614.48       20110101
21700       REVISION OF NECK MUSCLE          80                                    $59.02       20110801
21700       REVISION OF NECK MUSCLE          81                                    $59.02       20110801
21700       REVISION OF NECK MUSCLE          82                                    $59.02       20110801
21700       REVISION OF NECK MUSCLE          AS                                    $59.02       20110801
21700       REVISION OF NECK MUSCLE                                               $295.10       20110801
21705       REVISION OF NECK MUSCLE/RIB      80                                    $87.67       20110801
21705       REVISION OF NECK MUSCLE/RIB      81                                    $87.67       20110801
21705       REVISION OF NECK MUSCLE/RIB      82                                    $87.67       20110801
21705       REVISION OF NECK MUSCLE/RIB      AS                                    $87.67       20110801
21705       REVISION OF NECK MUSCLE/RIB                                           $438.36       20110801
21720       REVISION OF NECK MUSCLE                           A                   $626.73       20110101
21720       REVISION OF NECK MUSCLE          80                                    $59.80       20110801
21720       REVISION OF NECK MUSCLE          81                                    $59.80       20110801
21720       REVISION OF NECK MUSCLE          82                                    $59.80       20110801
21720       REVISION OF NECK MUSCLE          AS                                    $59.80       20110801
21720       REVISION OF NECK MUSCLE                                               $299.00       20110801



                                                  Page 31
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
21725       REVISION OF NECK MUSCLE                         A                 $51.91       20110101
21725       REVISION OF NECK MUSCLE        80                                 $72.07       20110801
21725       REVISION OF NECK MUSCLE        81                                 $72.07       20110801
21725       REVISION OF NECK MUSCLE        82                                 $72.07       20110801
21725       REVISION OF NECK MUSCLE        AS                                 $72.07       20110801
21725       REVISION OF NECK MUSCLE                                          $360.36       20110801
21740       RECONSTRUCTION OF STERNUM      80                                $148.36       20110801
21740       RECONSTRUCTION OF STERNUM      81                                $148.36       20110801
21740       RECONSTRUCTION OF STERNUM      82                                $148.36       20110801
21740       RECONSTRUCTION OF STERNUM      AS                                $148.36       20110801
21740       RECONSTRUCTION OF STERNUM                                        $741.78       20110801
21750       REPAIR OF STERNUM SEPARATION   80                                $100.05       20110801
21750       REPAIR OF STERNUM SEPARATION   81                                $100.05       20110801
21750       REPAIR OF STERNUM SEPARATION   82                                $100.05       20110801
21750       REPAIR OF STERNUM SEPARATION   AS                                $100.05       20110801
21750       REPAIR OF STERNUM SEPARATION                                     $500.24       20110801
21800       TREATMENT OF RIB FRACTURE                       A                 $59.66       20110101
21800       TREATMENT OF RIB FRACTURE                                         $66.82       20110801
21805       TREATMENT OF RIB FRACTURE                       A                $706.54       20110101
21805       TREATMENT OF RIB FRACTURE                                        $177.32       20110801
21810       TREATMENT OF RIB FRACTURES     80                                 $69.32       20110801
21810       TREATMENT OF RIB FRACTURES     81                                 $69.32       20110801
21810       TREATMENT OF RIB FRACTURES     82                                 $69.32       20110801
21810       TREATMENT OF RIB FRACTURES     AS                                 $69.32       20110801
21810       TREATMENT OF RIB FRACTURES                                       $346.58       20110801
21820       TREAT STERNUM FRACTURE                          A                 $59.66       20110101
21820       TREAT STERNUM FRACTURE                                            $88.92       20110801
21825       TREAT STERNUM FRACTURE         80                                 $78.42       20110801
21825       TREAT STERNUM FRACTURE         81                                 $78.42       20110801
21825       TREAT STERNUM FRACTURE         82                                 $78.42       20110801
21825       TREAT STERNUM FRACTURE         AS                                 $78.42       20110801
21825       TREAT STERNUM FRACTURE                                           $392.08       20110801
21920       BIOPSY SOFT TISSUE OF BACK                                       $170.56       20110801
21925       BIOPSY SOFT TISSUE OF BACK                      A                $647.50       20110101
21925       BIOPSY SOFT TISSUE OF BACK                                       $283.92       20110801
21930       EXC BACK LES SC 3 CM                            A                $141.50       20110101
21930       EXC BACK LES SC 3 CM                                             $309.40       20110801
21931       EXC BACK LES SC 3 CM/                                            $331.24       20110801
21932       EXC BACK TUM DEEP 5 CM                                           $475.54       20110801
21933       EXC BACK TUM DEEP 5 CM/                                          $524.42       20110801
21935       RESECT BACK TUM 5 CM                            A                $560.76       20110101
21935       RESECT BACK TUM 5 CM                                             $714.22       20110801
21936       RESECT BACK TUM 5 CM/                                          $1,016.34       20110801
22010       ID P-SPINE C/T/CERV-THOR                                         $632.32       20110801
22015       ID P-SPINE L/S/LS                                                $625.56       20110801
22100       REMOVE PART OF NECK VERTEBRA   80                                $116.74       20110801
22100       REMOVE PART OF NECK VERTEBRA   81                                $116.74       20110801
22100       REMOVE PART OF NECK VERTEBRA   82                                $116.74       20110801
22100       REMOVE PART OF NECK VERTEBRA   AS                                $116.74       20110801
22100       REMOVE PART OF NECK VERTEBRA                                     $583.70       20110801
22101       REMOVE PART THORAX VERTEBRA    80                                $118.40       20110801
22101       REMOVE PART THORAX VERTEBRA    81                                $118.40       20110801
22101       REMOVE PART THORAX VERTEBRA    82                                $118.40       20110801
22101       REMOVE PART THORAX VERTEBRA    AS                                $118.40       20110801
22101       REMOVE PART THORAX VERTEBRA                                      $592.02       20110801
22102       REMOVE PART LUMBAR VERTEBRA                     A              $1,577.58       20110101
22102       REMOVE PART LUMBAR VERTEBRA    80                                $111.28       20110801
22102       REMOVE PART LUMBAR VERTEBRA    81                                $111.28       20110801
22102       REMOVE PART LUMBAR VERTEBRA    82                                $111.28       20110801



                                                Page 32
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
22102       REMOVE PART LUMBAR VERTEBRA    AS                                $111.28       20110801
22102       REMOVE PART LUMBAR VERTEBRA                                      $556.40       20110801
22103       REMOVE EXTRA SPINE SEGMENT                      A              $1,577.58       20110101
22103       REMOVE EXTRA SPINE SEGMENT     80                                 $20.18       20110801
22103       REMOVE EXTRA SPINE SEGMENT     81                                 $20.18       20110801
22103       REMOVE EXTRA SPINE SEGMENT     82                                 $20.18       20110801
22103       REMOVE EXTRA SPINE SEGMENT     AS                                 $20.18       20110801
22103       REMOVE EXTRA SPINE SEGMENT                                       $100.88       20110801
22110       REMOVE PART OF NECK VERTEBRA   80                                $143.94       20110801
22110       REMOVE PART OF NECK VERTEBRA   81                                $143.94       20110801
22110       REMOVE PART OF NECK VERTEBRA   82                                $143.94       20110801
22110       REMOVE PART OF NECK VERTEBRA   AS                                $143.94       20110801
22110       REMOVE PART OF NECK VERTEBRA                                     $719.68       20110801
22112       REMOVE PART THORAX VERTEBRA    80                                $142.84       20110801
22112       REMOVE PART THORAX VERTEBRA    81                                $142.84       20110801
22112       REMOVE PART THORAX VERTEBRA    82                                $142.84       20110801
22112       REMOVE PART THORAX VERTEBRA    AS                                $142.84       20110801
22112       REMOVE PART THORAX VERTEBRA                                      $714.22       20110801
22114       REMOVE PART LUMBAR VERTEBRA    80                                $135.20       20110801
22114       REMOVE PART LUMBAR VERTEBRA    81                                $135.20       20110801
22114       REMOVE PART LUMBAR VERTEBRA    82                                $135.20       20110801
22114       REMOVE PART LUMBAR VERTEBRA    AS                                $135.20       20110801
22114       REMOVE PART LUMBAR VERTEBRA                                      $676.00       20110801
22116       REMOVE EXTRA SPINE SEGMENT     80                                 $19.76       20110801
22116       REMOVE EXTRA SPINE SEGMENT     81                                 $19.76       20110801
22116       REMOVE EXTRA SPINE SEGMENT     82                                 $19.76       20110801
22116       REMOVE EXTRA SPINE SEGMENT     AS                                 $19.76       20110801
22116       REMOVE EXTRA SPINE SEGMENT                                        $98.80       20110801
22210       REVISION OF NECK SPINE         80                                $240.76       20110801
22210       REVISION OF NECK SPINE         81                                $240.76       20110801
22210       REVISION OF NECK SPINE         82                                $240.76       20110801
22210       REVISION OF NECK SPINE         AS                                $240.76       20110801
22210       REVISION OF NECK SPINE                                         $1,203.80       20110801
22212       REVISION OF THORAX SPINE                                         $998.40       20110801
22214       REVISION OF LUMBAR SPINE       80                                $201.29       20110801
22214       REVISION OF LUMBAR SPINE       81                                $201.29       20110801
22214       REVISION OF LUMBAR SPINE       82                                $201.29       20110801
22214       REVISION OF LUMBAR SPINE       AS                                $201.29       20110801
22214       REVISION OF LUMBAR SPINE                                       $1,006.46       20110801
22216       REVISE EXTRA SPINE SEGMENT     80                                 $51.53       20110801
22216       REVISE EXTRA SPINE SEGMENT     81                                 $51.53       20110801
22216       REVISE EXTRA SPINE SEGMENT     82                                 $51.53       20110801
22216       REVISE EXTRA SPINE SEGMENT     AS                                 $51.53       20110801
22216       REVISE EXTRA SPINE SEGMENT                                       $257.66       20110801
22220       REVISION OF NECK SPINE         80                                $218.56       20110801
22220       REVISION OF NECK SPINE         81                                $218.56       20110801
22220       REVISION OF NECK SPINE         82                                $218.56       20110801
22220       REVISION OF NECK SPINE         AS                                $218.56       20110801
22220       REVISION OF NECK SPINE                                         $1,092.78       20110801
22222       REVISION OF THORAX SPINE       80                                $199.99       20110801
22222       REVISION OF THORAX SPINE       81                                $199.99       20110801
22222       REVISION OF THORAX SPINE       82                                $199.99       20110801
22222       REVISION OF THORAX SPINE       AS                                $199.99       20110801
22222       REVISION OF THORAX SPINE                                         $999.96       20110801
22224       REVISION OF LUMBAR SPINE       80                                $214.92       20110801
22224       REVISION OF LUMBAR SPINE       81                                $214.92       20110801
22224       REVISION OF LUMBAR SPINE       82                                $214.92       20110801
22224       REVISION OF LUMBAR SPINE       AS                                $214.92       20110801
22224       REVISION OF LUMBAR SPINE                                       $1,074.58       20110801



                                                Page 33
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
22226       REVISE EXTRA SPINE SEGMENT      80                                 $51.58       20110801
22226       REVISE EXTRA SPINE SEGMENT      81                                 $51.58       20110801
22226       REVISE EXTRA SPINE SEGMENT      82                                 $51.58       20110801
22226       REVISE EXTRA SPINE SEGMENT      AS                                 $51.58       20110801
22226       REVISE EXTRA SPINE SEGMENT                                        $257.92       20110801
22305       TREAT SPINE PROCESS FRACTURE                     A                 $59.66       20110101
22305       TREAT SPINE PROCESS FRACTURE                                      $123.76       20110801
22310       TREAT SPINE FRACTURE                             A                $135.07       20110101
22310       TREAT SPINE FRACTURE                                              $199.16       20110801
22315       TREAT SPINE FRACTURE                             A                $462.00       20110101
22315       TREAT SPINE FRACTURE                                              $580.06       20110801
22318       TREAT ODONTOID FX W/O GRAFT     80                                $221.10       20110801
22318       TREAT ODONTOID FX W/O GRAFT     81                                $221.10       20110801
22318       TREAT ODONTOID FX W/O GRAFT     82                                $221.10       20110801
22318       TREAT ODONTOID FX W/O GRAFT     AS                                $221.10       20110801
22318       TREAT ODONTOID FX W/O GRAFT                                     $1,105.52       20110801
22319       TREAT ODONTOID FX W/GRAFT       80                                $245.18       20110801
22319       TREAT ODONTOID FX W/GRAFT       81                                $245.18       20110801
22319       TREAT ODONTOID FX W/GRAFT       82                                $245.18       20110801
22319       TREAT ODONTOID FX W/GRAFT       AS                                $245.18       20110801
22319       TREAT ODONTOID FX W/GRAFT                                       $1,225.90       20110801
22325       TREAT SPINE FRACTURE            80                                $193.54       20110801
22325       TREAT SPINE FRACTURE            81                                $193.54       20110801
22325       TREAT SPINE FRACTURE            82                                $193.54       20110801
22325       TREAT SPINE FRACTURE            AS                                $193.54       20110801
22325       TREAT SPINE FRACTURE                                              $967.72       20110801
22326       TREAT NECK SPINE FRACTURE       80                                $201.03       20110801
22326       TREAT NECK SPINE FRACTURE       81                                $201.03       20110801
22326       TREAT NECK SPINE FRACTURE       82                                $201.03       20110801
22326       TREAT NECK SPINE FRACTURE       AS                                $201.03       20110801
22326       TREAT NECK SPINE FRACTURE                                       $1,005.16       20110801
22327       TREAT THORAX SPINE FRACTURE     80                                $199.26       20110801
22327       TREAT THORAX SPINE FRACTURE     81                                $199.26       20110801
22327       TREAT THORAX SPINE FRACTURE     82                                $199.26       20110801
22327       TREAT THORAX SPINE FRACTURE     AS                                $199.26       20110801
22327       TREAT THORAX SPINE FRACTURE                                       $996.32       20110801
22328       TREAT EACH ADD SPINE FX         80                                 $39.83       20110801
22328       TREAT EACH ADD SPINE FX         81                                 $39.83       20110801
22328       TREAT EACH ADD SPINE FX         82                                 $39.83       20110801
22328       TREAT EACH ADD SPINE FX         AS                                 $39.83       20110801
22328       TREAT EACH ADD SPINE FX                                           $199.16       20110801
22505       MANIPULATION OF SPINE                            A                $452.90       20110101
22505       MANIPULATION OF SPINE                                              $80.60       20110801
22520       PERCUT VERTEBROPLASTY THOR                                        $427.59       20100101
22521       PERCUT VERTEBROPLASTY LUMB                                        $402.83       20100101
22532       LAT THORAX SPINE FUSION         80                                $243.31       20110801
22532       LAT THORAX SPINE FUSION         81                                $243.31       20110801
22532       LAT THORAX SPINE FUSION         82                                $243.31       20110801
22532       LAT THORAX SPINE FUSION         AS                                $243.31       20110801
22532       LAT THORAX SPINE FUSION                                         $1,216.54       20110801
22533       LAT LUMBAR SPINE FUSION         80                                $230.05       20110801
22533       LAT LUMBAR SPINE FUSION         81                                $230.05       20110801
22533       LAT LUMBAR SPINE FUSION         82                                $230.05       20110801
22533       LAT LUMBAR SPINE FUSION         AS                                $230.05       20110801
22533       LAT LUMBAR SPINE FUSION                                         $1,150.24       20110801
22534       LAT THOR/LUMB ADDL SEG          80                                 $51.32       20110801
22534       LAT THOR/LUMB ADDL SEG          81                                 $51.32       20110801
22534       LAT THOR/LUMB ADDL SEG          82                                 $51.32       20110801
22534       LAT THOR/LUMB ADDL SEG          AS                                 $51.32       20110801



                                                 Page 34
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
22534       LAT THOR/LUMB ADDL SEG                                            $256.62       20110801
22548       NECK SPINE FUSION               80                                $262.03       20110801
22548       NECK SPINE FUSION               81                                $262.03       20110801
22548       NECK SPINE FUSION               82                                $262.03       20110801
22548       NECK SPINE FUSION               AS                                $262.03       20110801
22548       NECK SPINE FUSION                                               $1,310.14       20110801
22551       NECK SPINE FUSEREMOV BEL C2     80                                $266.24       20110801
22551       NECK SPINE FUSEREMOV BEL C2     81                                $266.24       20110801
22551       NECK SPINE FUSEREMOV BEL C2     82                                $266.24       20110801
22551       NECK SPINE FUSEREMOV BEL C2     AS                                $266.24       20110801
22551       NECK SPINE FUSEREMOV BEL C2                                     $1,331.20       20110801
22552       ADDL NECK SPINE FUSION          80                                 $62.04       20110801
22552       ADDL NECK SPINE FUSION          81                                 $62.04       20110801
22552       ADDL NECK SPINE FUSION          82                                 $62.04       20110801
22552       ADDL NECK SPINE FUSION          AS                                 $62.04       20110801
22552       ADDL NECK SPINE FUSION                                            $310.18       20110801
22554       NECK SPINE FUSION               80                                $174.04       20110801
22554       NECK SPINE FUSION               81                                $174.04       20110801
22554       NECK SPINE FUSION               82                                $174.04       20110801
22554       NECK SPINE FUSION               AS                                $174.04       20110801
22554       NECK SPINE FUSION                                                 $870.22       20110801
22556       THORAX SPINE FUSION             80                                $228.70       20110801
22556       THORAX SPINE FUSION             81                                $228.70       20110801
22556       THORAX SPINE FUSION             82                                $228.70       20110801
22556       THORAX SPINE FUSION             AS                                $228.70       20110801
22556       THORAX SPINE FUSION                                             $1,143.48       20110801
22558       LUMBAR SPINE FUSION             80                                $211.85       20110801
22558       LUMBAR SPINE FUSION             81                                $211.85       20110801
22558       LUMBAR SPINE FUSION             82                                $211.85       20110801
22558       LUMBAR SPINE FUSION             AS                                $211.85       20110801
22558       LUMBAR SPINE FUSION                                             $1,059.24       20110801
22585       ADDITIONAL SPINAL FUSION        80                                 $47.53       20110801
22585       ADDITIONAL SPINAL FUSION        81                                 $47.53       20110801
22585       ADDITIONAL SPINAL FUSION        82                                 $47.53       20110801
22585       ADDITIONAL SPINAL FUSION        AS                                 $47.53       20110801
22585       ADDITIONAL SPINAL FUSION                                          $237.64       20110801
22590       SPINE SKULL SPINAL FUSION       80                                $213.41       20110801
22590       SPINE SKULL SPINAL FUSION       81                                $213.41       20110801
22590       SPINE SKULL SPINAL FUSION       82                                $213.41       20110801
22590       SPINE SKULL SPINAL FUSION       AS                                $213.41       20110801
22590       SPINE SKULL SPINAL FUSION                                       $1,067.04       20110801
22595       NECK SPINAL FUSION              80                                $202.85       20110801
22595       NECK SPINAL FUSION              81                                $202.85       20110801
22595       NECK SPINAL FUSION              82                                $202.85       20110801
22595       NECK SPINAL FUSION              AS                                $202.85       20110801
22595       NECK SPINAL FUSION                                              $1,014.26       20110801
22600       NECK SPINE FUSION               80                                $173.21       20110801
22600       NECK SPINE FUSION               81                                $173.21       20110801
22600       NECK SPINE FUSION               82                                $173.21       20110801
22600       NECK SPINE FUSION               AS                                $173.21       20110801
22600       NECK SPINE FUSION                                                 $866.06       20110801
22610       THORAX SPINE FUSION             80                                $169.94       20110801
22610       THORAX SPINE FUSION             81                                $169.94       20110801
22610       THORAX SPINE FUSION             82                                $169.94       20110801
22610       THORAX SPINE FUSION             AS                                $169.94       20110801
22610       THORAX SPINE FUSION                                               $849.68       20110801
22612       LUMBAR SPINE FUSION             80                                $218.97       20110801
22612       LUMBAR SPINE FUSION             81                                $218.97       20110801
22612       LUMBAR SPINE FUSION             82                                $218.97       20110801



                                                 Page 35
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
22612       LUMBAR SPINE FUSION             AS                                $218.97       20110801
22612       LUMBAR SPINE FUSION                                             $1,094.86       20110801
22614       SPINE FUSION EXTRA SEGMENT      80                                 $55.38       20110801
22614       SPINE FUSION EXTRA SEGMENT      81                                 $55.38       20110801
22614       SPINE FUSION EXTRA SEGMENT      82                                 $55.38       20110801
22614       SPINE FUSION EXTRA SEGMENT      AS                                 $55.38       20110801
22614       SPINE FUSION EXTRA SEGMENT                                        $276.90       20110801
22630       LUMBAR SPINE FUSION             80                                $210.65       20110801
22630       LUMBAR SPINE FUSION             81                                $210.65       20110801
22630       LUMBAR SPINE FUSION             82                                $210.65       20110801
22630       LUMBAR SPINE FUSION             AS                                $210.65       20110801
22630       LUMBAR SPINE FUSION                                             $1,053.26       20110801
22632       SPINE FUSION EXTRA SEGMENT      80                                 $45.14       20110801
22632       SPINE FUSION EXTRA SEGMENT      81                                 $45.14       20110801
22632       SPINE FUSION EXTRA SEGMENT      82                                 $45.14       20110801
22632       SPINE FUSION EXTRA SEGMENT      AS                                 $45.14       20110801
22632       SPINE FUSION EXTRA SEGMENT                                        $225.68       20110801
22633       LUMBAR SPINE FUSION COMBINED    80                                $284.91       20120101
22633       LUMBAR SPINE FUSION COMBINED    81                                $284.91       20120101
22633       LUMBAR SPINE FUSION COMBINED    82                                $284.91       20120101
22633       LUMBAR SPINE FUSION COMBINED    AS                                $284.91       20120101
22633       LUMBAR SPINE FUSION COMBINED                                    $1,424.54       20120101
22634       SPINE FUSION EXTRA SEGMENT      80                                 $76.34       20120101
22634       SPINE FUSION EXTRA SEGMENT      81                                 $76.34       20120101
22634       SPINE FUSION EXTRA SEGMENT      82                                 $76.34       20120101
22634       SPINE FUSION EXTRA SEGMENT      AS                                 $76.34       20120101
22634       SPINE FUSION EXTRA SEGMENT                                        $381.68       20120101
22800       FUSION OF SPINE                 80                                $185.28       20110801
22800       FUSION OF SPINE                 81                                $185.28       20110801
22800       FUSION OF SPINE                 82                                $185.28       20110801
22800       FUSION OF SPINE                 AS                                $185.28       20110801
22800       FUSION OF SPINE                                                   $926.38       20110801
22802       FUSION OF SPINE                 80                                $291.25       20110801
22802       FUSION OF SPINE                 81                                $291.25       20110801
22802       FUSION OF SPINE                 82                                $291.25       20110801
22802       FUSION OF SPINE                 AS                                $291.25       20110801
22802       FUSION OF SPINE                                                 $1,456.26       20110801
22804       FUSION OF SPINE                 80                                $335.97       20110801
22804       FUSION OF SPINE                 81                                $335.97       20110801
22804       FUSION OF SPINE                 82                                $335.97       20110801
22804       FUSION OF SPINE                 AS                                $335.97       20110801
22804       FUSION OF SPINE                                                 $1,679.86       20110801
22808       FUSION OF SPINE                 80                                $252.41       20110801
22808       FUSION OF SPINE                 81                                $252.41       20110801
22808       FUSION OF SPINE                 82                                $252.41       20110801
22808       FUSION OF SPINE                 AS                                $252.41       20110801
22808       FUSION OF SPINE                                                 $1,262.04       20110801
22810       FUSION OF SPINE                 80                                $282.26       20110801
22810       FUSION OF SPINE                 81                                $282.26       20110801
22810       FUSION OF SPINE                 82                                $282.26       20110801
22810       FUSION OF SPINE                 AS                                $282.26       20110801
22810       FUSION OF SPINE                                                 $1,411.28       20110801
22812       FUSION OF SPINE                 80                                $303.84       20110801
22812       FUSION OF SPINE                 81                                $303.84       20110801
22812       FUSION OF SPINE                 82                                $303.84       20110801
22812       FUSION OF SPINE                 AS                                $303.84       20110801
22812       FUSION OF SPINE                                                 $1,519.18       20110801
22818       KYPHECTOMY 1-2 SEGMENTS         80                                $300.87       20110801
22818       KYPHECTOMY 1-2 SEGMENTS         81                                $300.87       20110801



                                                 Page 36
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
22818       KYPHECTOMY 1-2 SEGMENTS          82                                $300.87       20110801
22818       KYPHECTOMY 1-2 SEGMENTS          AS                                $300.87       20110801
22818       KYPHECTOMY 1-2 SEGMENTS                                          $1,504.36       20110801
22819       KYPHECTOMY 3 OR MORE             80                                $371.02       20110801
22819       KYPHECTOMY 3 OR MORE             81                                $371.02       20110801
22819       KYPHECTOMY 3 OR MORE             82                                $371.02       20110801
22819       KYPHECTOMY 3 OR MORE             AS                                $371.02       20110801
22819       KYPHECTOMY 3 OR MORE                                             $1,855.10       20110801
22830       EXPLORATION OF SPINAL FUSION     80                                $110.08       20110801
22830       EXPLORATION OF SPINAL FUSION     81                                $110.08       20110801
22830       EXPLORATION OF SPINAL FUSION     82                                $110.08       20110801
22830       EXPLORATION OF SPINAL FUSION     AS                                $110.08       20110801
22830       EXPLORATION OF SPINAL FUSION                                       $550.42       20110801
22840       INSERT SPINE FIXATION DEVICE     80                                $107.95       20110801
22840       INSERT SPINE FIXATION DEVICE     81                                $107.95       20110801
22840       INSERT SPINE FIXATION DEVICE     82                                $107.95       20110801
22840       INSERT SPINE FIXATION DEVICE     AS                                $107.95       20110801
22840       INSERT SPINE FIXATION DEVICE                                       $539.76       20110801
22842       INSERT SPINE FIXATION DEVICE     80                                $108.16       20110801
22842       INSERT SPINE FIXATION DEVICE     81                                $108.16       20110801
22842       INSERT SPINE FIXATION DEVICE     82                                $108.16       20110801
22842       INSERT SPINE FIXATION DEVICE     AS                                $108.16       20110801
22842       INSERT SPINE FIXATION DEVICE                                       $540.80       20110801
22843       INSERT SPINE FIXATION DEVICE     80                                $114.82       20110801
22843       INSERT SPINE FIXATION DEVICE     81                                $114.82       20110801
22843       INSERT SPINE FIXATION DEVICE     82                                $114.82       20110801
22843       INSERT SPINE FIXATION DEVICE     AS                                $114.82       20110801
22843       INSERT SPINE FIXATION DEVICE                                       $574.08       20110801
22844       INSERT SPINE FIXATION DEVICE     80                                $139.31       20110801
22844       INSERT SPINE FIXATION DEVICE     81                                $139.31       20110801
22844       INSERT SPINE FIXATION DEVICE     82                                $139.31       20110801
22844       INSERT SPINE FIXATION DEVICE     AS                                $139.31       20110801
22844       INSERT SPINE FIXATION DEVICE                                       $696.54       20110801
22845       INSERT SPINE FIXATION DEVICE     80                                $103.84       20110801
22845       INSERT SPINE FIXATION DEVICE     81                                $103.84       20110801
22845       INSERT SPINE FIXATION DEVICE     82                                $103.84       20110801
22845       INSERT SPINE FIXATION DEVICE     AS                                $103.84       20110801
22845       INSERT SPINE FIXATION DEVICE                                       $519.22       20110801
22846       INSERT SPINE FIXATION DEVICE     80                                $107.74       20110801
22846       INSERT SPINE FIXATION DEVICE     81                                $107.74       20110801
22846       INSERT SPINE FIXATION DEVICE     82                                $107.74       20110801
22846       INSERT SPINE FIXATION DEVICE     AS                                $107.74       20110801
22846       INSERT SPINE FIXATION DEVICE                                       $538.72       20110801
22847       INSERT SPINE FIXATION DEVICE     80                                $122.62       20110801
22847       INSERT SPINE FIXATION DEVICE     81                                $122.62       20110801
22847       INSERT SPINE FIXATION DEVICE     82                                $122.62       20110801
22847       INSERT SPINE FIXATION DEVICE     AS                                $122.62       20110801
22847       INSERT SPINE FIXATION DEVICE                                       $613.08       20110801
22848       INSERT PELV FIXATION DEVICE      80                                 $50.96       20110801
22848       INSERT PELV FIXATION DEVICE      81                                 $50.96       20110801
22848       INSERT PELV FIXATION DEVICE      82                                 $50.96       20110801
22848       INSERT PELV FIXATION DEVICE      AS                                 $50.96       20110801
22848       INSERT PELV FIXATION DEVICE                                        $254.80       20110801
22849       REINSERT SPINAL FIXATION         80                                $178.93       20110801
22849       REINSERT SPINAL FIXATION         81                                $178.93       20110801
22849       REINSERT SPINAL FIXATION         82                                $178.93       20110801
22849       REINSERT SPINAL FIXATION         AS                                $178.93       20110801
22849       REINSERT SPINAL FIXATION                                           $894.66       20110801
22850       REMOVE SPINE FIXATION DEVICE     80                                 $97.60       20110801



                                                  Page 37
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
22850       REMOVE SPINE FIXATION DEVICE   81                                 $97.60       20110801
22850       REMOVE SPINE FIXATION DEVICE   82                                 $97.60       20110801
22850       REMOVE SPINE FIXATION DEVICE   AS                                 $97.60       20110801
22850       REMOVE SPINE FIXATION DEVICE                                     $488.02       20110801
22851       APPLY SPINE PROSTH DEVICE      80                                 $57.72       20110801
22851       APPLY SPINE PROSTH DEVICE      81                                 $57.72       20110801
22851       APPLY SPINE PROSTH DEVICE      82                                 $57.72       20110801
22851       APPLY SPINE PROSTH DEVICE      AS                                 $57.72       20110801
22851       APPLY SPINE PROSTH DEVICE                                        $288.60       20110801
22852       REMOVE SPINE FIXATION DEVICE   80                                 $93.24       20110801
22852       REMOVE SPINE FIXATION DEVICE   81                                 $93.24       20110801
22852       REMOVE SPINE FIXATION DEVICE   82                                 $93.24       20110801
22852       REMOVE SPINE FIXATION DEVICE   AS                                 $93.24       20110801
22852       REMOVE SPINE FIXATION DEVICE                                     $466.18       20110801
22855       REMOVE SPINE FIXATION DEVICE   80                                $152.57       20110801
22855       REMOVE SPINE FIXATION DEVICE   81                                $152.57       20110801
22855       REMOVE SPINE FIXATION DEVICE   82                                $152.57       20110801
22855       REMOVE SPINE FIXATION DEVICE   AS                                $152.57       20110801
22855       REMOVE SPINE FIXATION DEVICE                                     $762.84       20110801
22900       EXC ABDL TUM DEEP 5 CM                          A                $749.54       20110101
22900       EXC ABDL TUM DEEP 5 CM         80                                 $71.24       20110801
22900       EXC ABDL TUM DEEP 5 CM         81                                 $71.24       20110801
22900       EXC ABDL TUM DEEP 5 CM         82                                 $71.24       20110801
22900       EXC ABDL TUM DEEP 5 CM         AS                                 $71.24       20110801
22900       EXC ABDL TUM DEEP 5 CM                                           $356.20       20110801
22901       EXC ABDL TUM DEEP 5 CM/                                          $468.26       20110801
22902       EXC ABD LES SC 3 CM                                              $294.84       20110801
22903       EXC ABD LES SC 3 CM/                                             $309.66       20110801
22904       RESECT ABD TUM 5 CM                                              $733.72       20110801
22905       RESECT ABD TUM 5 CM/                                             $951.34       20110801
23000       REMOVAL OF CALCIUM DEPOSITS                     A                $505.90       20110101
23000       REMOVAL OF CALCIUM DEPOSITS    80                                 $71.03       20110801
23000       REMOVAL OF CALCIUM DEPOSITS    81                                 $71.03       20110801
23000       REMOVAL OF CALCIUM DEPOSITS    82                                 $71.03       20110801
23000       REMOVAL OF CALCIUM DEPOSITS    AS                                 $71.03       20110801
23000       REMOVAL OF CALCIUM DEPOSITS                                      $355.16       20110801
23020       RELEASE SHOULDER JOINT                          A              $1,204.90       20110101
23020       RELEASE SHOULDER JOINT         80                                 $93.18       20110801
23020       RELEASE SHOULDER JOINT         81                                 $93.18       20110801
23020       RELEASE SHOULDER JOINT         82                                 $93.18       20110801
23020       RELEASE SHOULDER JOINT         AS                                 $93.18       20110801
23020       RELEASE SHOULDER JOINT                                           $465.92       20110801
23030       DRAIN SHOULDER LESION                           A                $530.16       20110101
23030       DRAIN SHOULDER LESION                                            $278.98       20110801
23031       DRAIN SHOULDER BURSA                            A                $564.03       20110101
23031       DRAIN SHOULDER BURSA                                             $254.28       20110801
23035       DRAIN SHOULDER BONE LESION                      A                $626.73       20110101
23035       DRAIN SHOULDER BONE LESION     80                                 $92.46       20110801
23035       DRAIN SHOULDER BONE LESION     81                                 $92.46       20110801
23035       DRAIN SHOULDER BONE LESION     82                                 $92.46       20110801
23035       DRAIN SHOULDER BONE LESION     AS                                 $92.46       20110801
23035       DRAIN SHOULDER BONE LESION                                       $462.28       20110801
23040       EXPLORATORY SHOULDER SURGERY                    A                $861.25       20110101
23040       EXPLORATORY SHOULDER SURGERY   80                                 $97.14       20110801
23040       EXPLORATORY SHOULDER SURGERY   81                                 $97.14       20110801
23040       EXPLORATORY SHOULDER SURGERY   82                                 $97.14       20110801
23040       EXPLORATORY SHOULDER SURGERY   AS                                 $97.14       20110801
23040       EXPLORATORY SHOULDER SURGERY                                     $485.68       20110801
23044       EXPLORATORY SHOULDER SURGERY                    A                $884.21       20110101



                                                Page 38
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
23044       EXPLORATORY SHOULDER SURGERY                                     $386.36       20110801
23065       BIOPSY SHOULDER TISSUES                         A                 $66.78       20110101
23065       BIOPSY SHOULDER TISSUES                                          $143.26       20110801
23066       BIOPSY SHOULDER TISSUES                         A                $647.50       20110101
23066       BIOPSY SHOULDER TISSUES                                          $338.52       20110801
23071       EXC SHOULDER LES SC 3 CM/                                        $294.32       20110801
23073       EXC SHOULDER TUM DEEP 5 CM/                                      $487.24       20110801
23075       EXC SHOULDER LES SC 3 CM                        A                $104.25       20110101
23075       EXC SHOULDER LES SC 3 CM                                         $244.92       20110801
23076       EXC SHOULDER TUM DEEP 5 CM                      A                $560.76       20110101
23076       EXC SHOULDER TUM DEEP 5 CM                                       $367.64       20110801
23077       RESECT SHOULDER TUM 5 CM                        A                $560.76       20110101
23077       RESECT SHOULDER TUM 5 CM       80                                $159.80       20110801
23077       RESECT SHOULDER TUM 5 CM       81                                $159.80       20110801
23077       RESECT SHOULDER TUM 5 CM       82                                $159.80       20110801
23077       RESECT SHOULDER TUM 5 CM       AS                                $159.80       20110801
23077       RESECT SHOULDER TUM 5 CM                                         $798.98       20110801
23078       RESECT SHOULDER TUM 5 CM/                                        $990.08       20110801
23100       BIOPSY OF SHOULDER JOINT                        A                $614.48       20110101
23100       BIOPSY OF SHOULDER JOINT       80                                 $65.88       20110801
23100       BIOPSY OF SHOULDER JOINT       81                                 $65.88       20110801
23100       BIOPSY OF SHOULDER JOINT       82                                 $65.88       20110801
23100       BIOPSY OF SHOULDER JOINT       AS                                 $65.88       20110801
23100       BIOPSY OF SHOULDER JOINT                                         $329.42       20110801
23101       SHOULDER JOINT SURGERY                          A                $954.05       20110101
23101       SHOULDER JOINT SURGERY                                           $301.08       20110801
23105       REMOVE SHOULDER JOINT LINING                    A                $884.21       20110101
23105       REMOVE SHOULDER JOINT LINING   80                                 $85.80       20110801
23105       REMOVE SHOULDER JOINT LINING   81                                 $85.80       20110801
23105       REMOVE SHOULDER JOINT LINING   82                                 $85.80       20110801
23105       REMOVE SHOULDER JOINT LINING   AS                                 $85.80       20110801
23105       REMOVE SHOULDER JOINT LINING                                     $429.00       20110801
23106       INCISION OF COLLARBONE JOINT                    A                $884.21       20110101
23106       INCISION OF COLLARBONE JOINT                                     $323.44       20110801
23107       EXPLORE TREAT SHOULDER JOINT                    A                $884.21       20110101
23107       EXPLORE TREAT SHOULDER JOINT   80                                 $89.08       20110801
23107       EXPLORE TREAT SHOULDER JOINT   81                                 $89.08       20110801
23107       EXPLORE TREAT SHOULDER JOINT   82                                 $89.08       20110801
23107       EXPLORE TREAT SHOULDER JOINT   AS                                 $89.08       20110801
23107       EXPLORE TREAT SHOULDER JOINT                                     $445.38       20110801
23120       PARTIAL REMOVAL COLLAR BONE                     A                $900.86       20110101
23120       PARTIAL REMOVAL COLLAR BONE    80                                 $77.74       20110801
23120       PARTIAL REMOVAL COLLAR BONE    81                                 $77.74       20110801
23120       PARTIAL REMOVAL COLLAR BONE    82                                 $77.74       20110801
23120       PARTIAL REMOVAL COLLAR BONE    AS                                 $77.74       20110801
23120       PARTIAL REMOVAL COLLAR BONE                                      $388.70       20110801
23125       REMOVAL OF COLLAR BONE                          A                $900.86       20110101
23125       REMOVAL OF COLLAR BONE         80                                 $95.00       20110801
23125       REMOVAL OF COLLAR BONE         81                                 $95.00       20110801
23125       REMOVAL OF COLLAR BONE         82                                 $95.00       20110801
23125       REMOVAL OF COLLAR BONE         AS                                 $95.00       20110801
23125       REMOVAL OF COLLAR BONE                                           $475.02       20110801
23130       REMOVE SHOULDER BONE PART                       A              $1,256.75       20110101
23130       REMOVE SHOULDER BONE PART                                        $406.64       20110801
23140       REMOVAL OF BONE LESION                          A                $649.69       20110101
23140       REMOVAL OF BONE LESION                                           $349.18       20110801
23145       REMOVAL OF BONE LESION                          A                $900.86       20110101
23145       REMOVAL OF BONE LESION         80                                 $93.50       20110801
23145       REMOVAL OF BONE LESION         81                                 $93.50       20110801



                                                Page 39
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
23145       REMOVAL OF BONE LESION         82                                    $93.50       20110801
23145       REMOVAL OF BONE LESION         AS                                    $93.50       20110801
23145       REMOVAL OF BONE LESION                                              $467.48       20110801
23146       REMOVAL OF BONE LESION                          A                   $900.86       20110101
23146       REMOVAL OF BONE LESION                                              $407.94       20110801
23150       REMOVAL OF HUMERUS LESION                       A                   $884.21       20110101
23150       REMOVAL OF HUMERUS LESION      80                                    $88.76       20110801
23150       REMOVAL OF HUMERUS LESION      81                                    $88.76       20110801
23150       REMOVAL OF HUMERUS LESION      82                                    $88.76       20110801
23150       REMOVAL OF HUMERUS LESION      AS                                    $88.76       20110801
23150       REMOVAL OF HUMERUS LESION                                           $443.82       20110801
23155       REMOVAL OF HUMERUS LESION                       A                   $900.86       20110101
23155       REMOVAL OF HUMERUS LESION      80                                   $106.91       20110801
23155       REMOVAL OF HUMERUS LESION      81                                   $106.91       20110801
23155       REMOVAL OF HUMERUS LESION      82                                   $106.91       20110801
23155       REMOVAL OF HUMERUS LESION      AS                                   $106.91       20110801
23155       REMOVAL OF HUMERUS LESION                                           $534.56       20110801
23156       REMOVAL OF HUMERUS LESION                       A                   $900.86       20110101
23156       REMOVAL OF HUMERUS LESION      80                                    $90.95       20110801
23156       REMOVAL OF HUMERUS LESION      81                                    $90.95       20110801
23156       REMOVAL OF HUMERUS LESION      82                                    $90.95       20110801
23156       REMOVAL OF HUMERUS LESION      AS                                    $90.95       20110801
23156       REMOVAL OF HUMERUS LESION                                           $454.74       20110801
23170       REMOVE COLLAR BONE LESION                       A                   $849.00       20110101
23170       REMOVE COLLAR BONE LESION                                           $362.70       20110801
23172       REMOVE SHOULDER BLADE LESION                    A                   $849.00       20110101
23172       REMOVE SHOULDER BLADE LESION   80                                    $74.52       20110801
23172       REMOVE SHOULDER BLADE LESION   81                                    $74.52       20110801
23172       REMOVE SHOULDER BLADE LESION   82                                    $74.52       20110801
23172       REMOVE SHOULDER BLADE LESION   AS                                    $74.52       20110801
23172       REMOVE SHOULDER BLADE LESION                                        $372.58       20110801
23174       REMOVE HUMERUS LESION                           A                   $849.00       20110101
23174       REMOVE HUMERUS LESION          80                                   $101.76       20110801
23174       REMOVE HUMERUS LESION          81                                   $101.76       20110801
23174       REMOVE HUMERUS LESION          82                                   $101.76       20110801
23174       REMOVE HUMERUS LESION          AS                                   $101.76       20110801
23174       REMOVE HUMERUS LESION                                               $508.82       20110801
23180       REMOVE COLLAR BONE LESION                       A                   $884.21       20110101
23180       REMOVE COLLAR BONE LESION                                           $460.46       20110801
23182       REMOVE SHOULDER BLADE LESION                    A                   $884.21       20110101
23182       REMOVE SHOULDER BLADE LESION   80                                    $89.34       20110801
23182       REMOVE SHOULDER BLADE LESION   81                                    $89.34       20110801
23182       REMOVE SHOULDER BLADE LESION   82                                    $89.34       20110801
23182       REMOVE SHOULDER BLADE LESION   AS                                    $89.34       20110801
23182       REMOVE SHOULDER BLADE LESION                                        $446.68       20110801
23184       REMOVE HUMERUS LESION                           A                   $884.21       20110101
23184       REMOVE HUMERUS LESION          80                                   $100.20       20110801
23184       REMOVE HUMERUS LESION          81                                   $100.20       20110801
23184       REMOVE HUMERUS LESION          82                                   $100.20       20110801
23184       REMOVE HUMERUS LESION          AS                                   $100.20       20110801
23184       REMOVE HUMERUS LESION                                               $501.02       20110801
23190       PARTIAL REMOVAL OF SCAPULA                      A                   $884.21       20110101
23190       PARTIAL REMOVAL OF SCAPULA     80                                    $75.66       20110801
23190       PARTIAL REMOVAL OF SCAPULA     81                                    $75.66       20110801
23190       PARTIAL REMOVAL OF SCAPULA     82                                    $75.66       20110801
23190       PARTIAL REMOVAL OF SCAPULA     AS                                    $75.66       20110801
23190       PARTIAL REMOVAL OF SCAPULA                                          $378.30       20110801
23195       REMOVAL OF HEAD OF HUMERUS                      A                   $900.86       20110101
23195       REMOVAL OF HEAD OF HUMERUS     80                                   $101.71       20110801



                                                Page 40
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
23195       REMOVAL OF HEAD OF HUMERUS     81                                $101.71       20110801
23195       REMOVAL OF HEAD OF HUMERUS     82                                $101.71       20110801
23195       REMOVAL OF HEAD OF HUMERUS     AS                                $101.71       20110801
23195       REMOVAL OF HEAD OF HUMERUS                                       $508.56       20110801
23200       RESECT CLAVICLE TUMOR          80                                $187.30       20110801
23200       RESECT CLAVICLE TUMOR          81                                $187.30       20110801
23200       RESECT CLAVICLE TUMOR          82                                $187.30       20110801
23200       RESECT CLAVICLE TUMOR          AS                                $187.30       20110801
23200       RESECT CLAVICLE TUMOR                                            $936.52       20110801
23210       RESECT SCAPULA TUMOR           80                                $218.97       20110801
23210       RESECT SCAPULA TUMOR           81                                $218.97       20110801
23210       RESECT SCAPULA TUMOR           82                                $218.97       20110801
23210       RESECT SCAPULA TUMOR           AS                                $218.97       20110801
23210       RESECT SCAPULA TUMOR                                           $1,094.86       20110801
23220       RESECT PROX HUMERUS TUMOR      80                                $243.05       20110801
23220       RESECT PROX HUMERUS TUMOR      81                                $243.05       20110801
23220       RESECT PROX HUMERUS TUMOR      82                                $243.05       20110801
23220       RESECT PROX HUMERUS TUMOR      AS                                $243.05       20110801
23220       RESECT PROX HUMERUS TUMOR                                      $1,215.24       20110801
23330       REMOVE SHOULDER FOREIGN BODY                    A                $260.88       20110101
23330       REMOVE SHOULDER FOREIGN BODY                                     $150.02       20110801
23331       REMOVE SHOULDER FOREIGN BODY                    A                $625.87       20110101
23331       REMOVE SHOULDER FOREIGN BODY                                     $395.98       20110801
23332       REMOVE SHOULDER FOREIGN BODY   80                                $119.91       20110801
23332       REMOVE SHOULDER FOREIGN BODY   81                                $119.91       20110801
23332       REMOVE SHOULDER FOREIGN BODY   82                                $119.91       20110801
23332       REMOVE SHOULDER FOREIGN BODY   AS                                $119.91       20110801
23332       REMOVE SHOULDER FOREIGN BODY                                     $599.56       20110801
23350       INJECTION FOR SHOULDER X-RAY                                     $101.92       20110801
23395       MUSCLE TRANSFER SHOULDER/ARM                    A              $1,256.75       20110101
23395       MUSCLE TRANSFER SHOULDER/ARM   80                                $175.45       20110801
23395       MUSCLE TRANSFER SHOULDER/ARM   81                                $175.45       20110801
23395       MUSCLE TRANSFER SHOULDER/ARM   82                                $175.45       20110801
23395       MUSCLE TRANSFER SHOULDER/ARM   AS                                $175.45       20110801
23395       MUSCLE TRANSFER SHOULDER/ARM                                     $877.24       20110801
23397       MUSCLE TRANSFERS                                A              $2,321.22       20110101
23397       MUSCLE TRANSFERS               80                                $156.36       20110801
23397       MUSCLE TRANSFERS               81                                $156.36       20110801
23397       MUSCLE TRANSFERS               82                                $156.36       20110801
23397       MUSCLE TRANSFERS               AS                                $156.36       20110801
23397       MUSCLE TRANSFERS                                                 $781.82       20110801
23400       FIXATION OF SHOULDER BLADE                      A                $954.05       20110101
23400       FIXATION OF SHOULDER BLADE     80                                $132.50       20110801
23400       FIXATION OF SHOULDER BLADE     81                                $132.50       20110801
23400       FIXATION OF SHOULDER BLADE     82                                $132.50       20110801
23400       FIXATION OF SHOULDER BLADE     AS                                $132.50       20110801
23400       FIXATION OF SHOULDER BLADE                                       $662.48       20110801
23405       INCISION OF TENDON MUSCLE                       A                $849.00       20110101
23405       INCISION OF TENDON MUSCLE      80                                 $85.18       20110801
23405       INCISION OF TENDON MUSCLE      81                                 $85.18       20110801
23405       INCISION OF TENDON MUSCLE      82                                 $85.18       20110801
23405       INCISION OF TENDON MUSCLE      AS                                 $85.18       20110801
23405       INCISION OF TENDON MUSCLE                                        $425.88       20110801
23406       INCISE TENDONS MUSCLES                          A                $849.00       20110101
23406       INCISE TENDONS MUSCLES         80                                $106.24       20110801
23406       INCISE TENDONS MUSCLES         81                                $106.24       20110801
23406       INCISE TENDONS MUSCLES         82                                $106.24       20110801
23406       INCISE TENDONS MUSCLES         AS                                $106.24       20110801
23406       INCISE TENDONS MUSCLES                                           $531.18       20110801



                                                Page 41
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
23410       REPAIR ROTATOR CUFF ACUTE                        A              $1,256.75       20110101
23410       REPAIR ROTATOR CUFF ACUTE       80                                $112.06       20110801
23410       REPAIR ROTATOR CUFF ACUTE       81                                $112.06       20110801
23410       REPAIR ROTATOR CUFF ACUTE       82                                $112.06       20110801
23410       REPAIR ROTATOR CUFF ACUTE       AS                                $112.06       20110801
23410       REPAIR ROTATOR CUFF ACUTE                                         $560.30       20110801
23412       REPAIR ROTATOR CUFF CHRONIC                      A              $1,309.94       20110101
23412       REPAIR ROTATOR CUFF CHRONIC     80                                $116.79       20110801
23412       REPAIR ROTATOR CUFF CHRONIC     81                                $116.79       20110801
23412       REPAIR ROTATOR CUFF CHRONIC     82                                $116.79       20110801
23412       REPAIR ROTATOR CUFF CHRONIC     AS                                $116.79       20110801
23412       REPAIR ROTATOR CUFF CHRONIC                                       $583.96       20110801
23415       RELEASE OF SHOULDER LIGAMENT                     A              $1,256.75       20110101
23415       RELEASE OF SHOULDER LIGAMENT                                      $468.26       20110801
23420       REPAIR OF SHOULDER                               A              $1,309.94       20110101
23420       REPAIR OF SHOULDER              80                                $132.29       20110801
23420       REPAIR OF SHOULDER              81                                $132.29       20110801
23420       REPAIR OF SHOULDER              82                                $132.29       20110801
23420       REPAIR OF SHOULDER              AS                                $132.29       20110801
23420       REPAIR OF SHOULDER                                                $661.44       20110801
23430       REPAIR BICEPS TENDON                             A              $1,240.11       20110101
23430       REPAIR BICEPS TENDON            80                                $100.05       20110801
23430       REPAIR BICEPS TENDON            81                                $100.05       20110801
23430       REPAIR BICEPS TENDON            82                                $100.05       20110801
23430       REPAIR BICEPS TENDON            AS                                $100.05       20110801
23430       REPAIR BICEPS TENDON                                              $500.24       20110801
23440       REMOVE/TRANSPLANT TENDON                         A              $1,240.11       20110101
23440       REMOVE/TRANSPLANT TENDON        80                                $103.06       20110801
23440       REMOVE/TRANSPLANT TENDON        81                                $103.06       20110801
23440       REMOVE/TRANSPLANT TENDON        82                                $103.06       20110801
23440       REMOVE/TRANSPLANT TENDON        AS                                $103.06       20110801
23440       REMOVE/TRANSPLANT TENDON                                          $515.32       20110801
23450       REPAIR SHOULDER CAPSULE                          A              $2,268.02       20110101
23450       REPAIR SHOULDER CAPSULE         80                                $129.48       20110801
23450       REPAIR SHOULDER CAPSULE         81                                $129.48       20110801
23450       REPAIR SHOULDER CAPSULE         82                                $129.48       20110801
23450       REPAIR SHOULDER CAPSULE         AS                                $129.48       20110801
23450       REPAIR SHOULDER CAPSULE                                           $647.40       20110801
23455       REPAIR SHOULDER CAPSULE                          A              $2,321.22       20110101
23455       REPAIR SHOULDER CAPSULE         80                                $137.75       20110801
23455       REPAIR SHOULDER CAPSULE         81                                $137.75       20110801
23455       REPAIR SHOULDER CAPSULE         82                                $137.75       20110801
23455       REPAIR SHOULDER CAPSULE         AS                                $137.75       20110801
23455       REPAIR SHOULDER CAPSULE                                           $688.74       20110801
23460       REPAIR SHOULDER CAPSULE                          A              $2,268.02       20110101
23460       REPAIR SHOULDER CAPSULE         80                                $149.40       20110801
23460       REPAIR SHOULDER CAPSULE         81                                $149.40       20110801
23460       REPAIR SHOULDER CAPSULE         82                                $149.40       20110801
23460       REPAIR SHOULDER CAPSULE         AS                                $149.40       20110801
23460       REPAIR SHOULDER CAPSULE                                           $746.98       20110801
23462       REPAIR SHOULDER CAPSULE                          A              $1,309.94       20110101
23462       REPAIR SHOULDER CAPSULE         80                                $146.80       20110801
23462       REPAIR SHOULDER CAPSULE         81                                $146.80       20110801
23462       REPAIR SHOULDER CAPSULE         82                                $146.80       20110801
23462       REPAIR SHOULDER CAPSULE         AS                                $146.80       20110801
23462       REPAIR SHOULDER CAPSULE                                           $733.98       20110801
23465       REPAIR SHOULDER CAPSULE                          A              $2,268.02       20110101
23465       REPAIR SHOULDER CAPSULE         80                                $152.83       20110801
23465       REPAIR SHOULDER CAPSULE         81                                $152.83       20110801



                                                 Page 42
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
23465       REPAIR SHOULDER CAPSULE        82                                $152.83       20110801
23465       REPAIR SHOULDER CAPSULE        AS                                $152.83       20110801
23465       REPAIR SHOULDER CAPSULE                                          $764.14       20110801
23466       REPAIR SHOULDER CAPSULE                         A              $1,309.94       20110101
23466       REPAIR SHOULDER CAPSULE        80                                $152.46       20110801
23466       REPAIR SHOULDER CAPSULE        81                                $152.46       20110801
23466       REPAIR SHOULDER CAPSULE        82                                $152.46       20110801
23466       REPAIR SHOULDER CAPSULE        AS                                $152.46       20110801
23466       REPAIR SHOULDER CAPSULE                                          $762.32       20110801
23470       RECONSTRUCT SHOULDER JOINT     80                                $166.35       20110801
23470       RECONSTRUCT SHOULDER JOINT     81                                $166.35       20110801
23470       RECONSTRUCT SHOULDER JOINT     82                                $166.35       20110801
23470       RECONSTRUCT SHOULDER JOINT     AS                                $166.35       20110801
23470       RECONSTRUCT SHOULDER JOINT                                       $831.74       20110801
23472       RECONSTRUCT SHOULDER JOINT     80                                $206.44       20110801
23472       RECONSTRUCT SHOULDER JOINT     81                                $206.44       20110801
23472       RECONSTRUCT SHOULDER JOINT     82                                $206.44       20110801
23472       RECONSTRUCT SHOULDER JOINT     AS                                $206.44       20110801
23472       RECONSTRUCT SHOULDER JOINT                                     $1,032.20       20110801
23480       REVISION OF COLLAR BONE                         A              $1,240.11       20110101
23480       REVISION OF COLLAR BONE                                          $556.66       20110801
23485       REVISION OF COLLAR BONE                         A              $2,321.22       20110101
23485       REVISION OF COLLAR BONE        80                                $131.35       20110801
23485       REVISION OF COLLAR BONE        81                                $131.35       20110801
23485       REVISION OF COLLAR BONE        82                                $131.35       20110801
23485       REVISION OF COLLAR BONE        AS                                $131.35       20110801
23485       REVISION OF COLLAR BONE                                          $656.76       20110801
23490       REINFORCE CLAVICLE                              A              $1,217.14       20110101
23490       REINFORCE CLAVICLE             80                                $116.12       20110801
23490       REINFORCE CLAVICLE             81                                $116.12       20110801
23490       REINFORCE CLAVICLE             82                                $116.12       20110801
23490       REINFORCE CLAVICLE             AS                                $116.12       20110801
23490       REINFORCE CLAVICLE                                               $580.58       20110801
23491       REINFORCE SHOULDER BONES                        A              $2,228.42       20110101
23491       REINFORCE SHOULDER BONES       80                                $138.48       20110801
23491       REINFORCE SHOULDER BONES       81                                $138.48       20110801
23491       REINFORCE SHOULDER BONES       82                                $138.48       20110801
23491       REINFORCE SHOULDER BONES       AS                                $138.48       20110801
23491       REINFORCE SHOULDER BONES                                         $692.38       20110801
23500       TREAT CLAVICLE FRACTURE                         A                 $59.66       20110101
23500       TREAT CLAVICLE FRACTURE                                          $139.10       20110801
23505       TREAT CLAVICLE FRACTURE                         A                $462.00       20110101
23505       TREAT CLAVICLE FRACTURE                                          $226.46       20110801
23515       TREAT CLAVICLE FRACTURE                         A              $1,671.34       20110101
23515       TREAT CLAVICLE FRACTURE        80                                 $96.72       20110801
23515       TREAT CLAVICLE FRACTURE        81                                 $96.72       20110801
23515       TREAT CLAVICLE FRACTURE        82                                 $96.72       20110801
23515       TREAT CLAVICLE FRACTURE        AS                                 $96.72       20110801
23515       TREAT CLAVICLE FRACTURE                                          $483.60       20110801
23520       TREAT CLAVICLE DISLOCATION                      A                $135.07       20110101
23520       TREAT CLAVICLE DISLOCATION                                       $144.56       20110801
23525       TREAT CLAVICLE DISLOCATION                      A                $135.07       20110101
23525       TREAT CLAVICLE DISLOCATION                                       $230.62       20110801
23530       TREAT CLAVICLE DISLOCATION                      A              $1,190.44       20110101
23530       TREAT CLAVICLE DISLOCATION     80                                 $73.89       20110801
23530       TREAT CLAVICLE DISLOCATION     81                                 $73.89       20110801
23530       TREAT CLAVICLE DISLOCATION     82                                 $73.89       20110801
23530       TREAT CLAVICLE DISLOCATION     AS                                 $73.89       20110801
23530       TREAT CLAVICLE DISLOCATION                                       $369.46       20110801



                                                Page 43
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
23532       TREAT CLAVICLE DISLOCATION                       A                $741.74       20110101
23532       TREAT CLAVICLE DISLOCATION      80                                 $83.56       20110801
23532       TREAT CLAVICLE DISLOCATION      81                                 $83.56       20110801
23532       TREAT CLAVICLE DISLOCATION      82                                 $83.56       20110801
23532       TREAT CLAVICLE DISLOCATION      AS                                 $83.56       20110801
23532       TREAT CLAVICLE DISLOCATION                                        $417.82       20110801
23540       TREAT CLAVICLE DISLOCATION                       A                 $59.66       20110101
23540       TREAT CLAVICLE DISLOCATION                                        $142.48       20110801
23545       TREAT CLAVICLE DISLOCATION                       A                $135.07       20110101
23545       TREAT CLAVICLE DISLOCATION                                        $206.96       20110801
23550       TREAT CLAVICLE DISLOCATION                       A              $1,190.44       20110101
23550       TREAT CLAVICLE DISLOCATION      80                                 $77.01       20110801
23550       TREAT CLAVICLE DISLOCATION      81                                 $77.01       20110801
23550       TREAT CLAVICLE DISLOCATION      82                                 $77.01       20110801
23550       TREAT CLAVICLE DISLOCATION      AS                                 $77.01       20110801
23550       TREAT CLAVICLE DISLOCATION                                        $385.06       20110801
23552       TREAT CLAVICLE DISLOCATION                       A              $1,213.40       20110101
23552       TREAT CLAVICLE DISLOCATION      80                                 $88.71       20110801
23552       TREAT CLAVICLE DISLOCATION      81                                 $88.71       20110801
23552       TREAT CLAVICLE DISLOCATION      82                                 $88.71       20110801
23552       TREAT CLAVICLE DISLOCATION      AS                                 $88.71       20110801
23552       TREAT CLAVICLE DISLOCATION                                        $443.56       20110801
23570       TREAT SHOULDER BLADE FX                          A                 $59.66       20110101
23570       TREAT SHOULDER BLADE FX                                           $147.68       20110801
23575       TREAT SHOULDER BLADE FX                          A                $135.07       20110101
23575       TREAT SHOULDER BLADE FX                                           $254.54       20110801
23585       TREAT SCAPULA FRACTURE                           A              $1,671.34       20110101
23585       TREAT SCAPULA FRACTURE          80                                $132.18       20110801
23585       TREAT SCAPULA FRACTURE          81                                $132.18       20110801
23585       TREAT SCAPULA FRACTURE          82                                $132.18       20110801
23585       TREAT SCAPULA FRACTURE          AS                                $132.18       20110801
23585       TREAT SCAPULA FRACTURE                                            $660.92       20110801
23600       TREAT HUMERUS FRACTURE                           A                 $53.12       20110101
23600       TREAT HUMERUS FRACTURE                                            $206.70       20110801
23605       TREAT HUMERUS FRACTURE                                            $302.90       20110801
23615       TREAT HUMERUS FRACTURE                           A              $1,694.30       20110101
23615       TREAT HUMERUS FRACTURE          80                                $119.55       20110801
23615       TREAT HUMERUS FRACTURE          81                                $119.55       20110801
23615       TREAT HUMERUS FRACTURE          82                                $119.55       20110801
23615       TREAT HUMERUS FRACTURE          AS                                $119.55       20110801
23615       TREAT HUMERUS FRACTURE                                            $597.74       20110801
23616       TREAT HUMERUS FRACTURE                           A              $1,694.30       20110101
23616       TREAT HUMERUS FRACTURE          80                                $172.48       20110801
23616       TREAT HUMERUS FRACTURE          81                                $172.48       20110801
23616       TREAT HUMERUS FRACTURE          82                                $172.48       20110801
23616       TREAT HUMERUS FRACTURE          AS                                $172.48       20110801
23616       TREAT HUMERUS FRACTURE                                            $862.42       20110801
23620       TREAT HUMERUS FRACTURE                                            $170.56       20110801
23625       TREAT HUMERUS FRACTURE                           A                $462.00       20110101
23625       TREAT HUMERUS FRACTURE                                            $246.22       20110801
23630       TREAT HUMERUS FRACTURE                           A              $1,710.95       20110101
23630       TREAT HUMERUS FRACTURE          80                                $103.79       20110801
23630       TREAT HUMERUS FRACTURE          81                                $103.79       20110801
23630       TREAT HUMERUS FRACTURE          82                                $103.79       20110801
23630       TREAT HUMERUS FRACTURE          AS                                $103.79       20110801
23630       TREAT HUMERUS FRACTURE                                            $518.96       20110801
23650       TREAT SHOULDER DISLOCATION                       A                 $59.66       20110101
23650       TREAT SHOULDER DISLOCATION                                        $195.26       20110801
23655       TREAT SHOULDER DISLOCATION                       A                $431.28       20110101



                                                 Page 44
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
23655       TREAT SHOULDER DISLOCATION                                       $256.62       20110801
23660       TREAT SHOULDER DISLOCATION                      A              $1,190.44       20110101
23660       TREAT SHOULDER DISLOCATION     80                                 $78.21       20110801
23660       TREAT SHOULDER DISLOCATION     81                                 $78.21       20110801
23660       TREAT SHOULDER DISLOCATION     82                                 $78.21       20110801
23660       TREAT SHOULDER DISLOCATION     AS                                 $78.21       20110801
23660       TREAT SHOULDER DISLOCATION                                       $391.04       20110801
23665       TREAT DISLOCATION/FRACTURE                      A                $135.07       20110101
23665       TREAT DISLOCATION/FRACTURE                                       $275.08       20110801
23670       TREAT DISLOCATION/FRACTURE                      A              $1,671.34       20110101
23670       TREAT DISLOCATION/FRACTURE     80                                $116.90       20110801
23670       TREAT DISLOCATION/FRACTURE     81                                $116.90       20110801
23670       TREAT DISLOCATION/FRACTURE     82                                $116.90       20110801
23670       TREAT DISLOCATION/FRACTURE     AS                                $116.90       20110801
23670       TREAT DISLOCATION/FRACTURE                                       $584.48       20110801
23675       TREAT DISLOCATION/FRACTURE                      A                 $59.66       20110101
23675       TREAT DISLOCATION/FRACTURE                                       $357.24       20110801
23680       TREAT DISLOCATION/FRACTURE                      A              $1,190.44       20110101
23680       TREAT DISLOCATION/FRACTURE     80                                $125.01       20110801
23680       TREAT DISLOCATION/FRACTURE     81                                $125.01       20110801
23680       TREAT DISLOCATION/FRACTURE     82                                $125.01       20110801
23680       TREAT DISLOCATION/FRACTURE     AS                                $125.01       20110801
23680       TREAT DISLOCATION/FRACTURE                                       $625.04       20110801
23700       FIXATION OF SHOULDER                            A                $431.28       20110101
23700       FIXATION OF SHOULDER                                             $130.78       20110801
23800       FUSION OF SHOULDER JOINT                        A              $2,251.38       20110101
23800       FUSION OF SHOULDER JOINT       80                                $139.88       20110801
23800       FUSION OF SHOULDER JOINT       81                                $139.88       20110801
23800       FUSION OF SHOULDER JOINT       82                                $139.88       20110801
23800       FUSION OF SHOULDER JOINT       AS                                $139.88       20110801
23800       FUSION OF SHOULDER JOINT                                         $699.40       20110801
23802       FUSION OF SHOULDER JOINT                        A              $1,309.94       20110101
23802       FUSION OF SHOULDER JOINT       80                                $172.12       20110801
23802       FUSION OF SHOULDER JOINT       81                                $172.12       20110801
23802       FUSION OF SHOULDER JOINT       82                                $172.12       20110801
23802       FUSION OF SHOULDER JOINT       AS                                $172.12       20110801
23802       FUSION OF SHOULDER JOINT                                         $860.60       20110801
23900       AMPUTATION OF ARM GIRDLE       80                                $183.98       20110801
23900       AMPUTATION OF ARM GIRDLE       81                                $183.98       20110801
23900       AMPUTATION OF ARM GIRDLE       82                                $183.98       20110801
23900       AMPUTATION OF ARM GIRDLE       AS                                $183.98       20110801
23900       AMPUTATION OF ARM GIRDLE                                         $919.88       20110801
23920       AMPUTATION AT SHOULDER JOINT   80                                $149.19       20110801
23920       AMPUTATION AT SHOULDER JOINT   81                                $149.19       20110801
23920       AMPUTATION AT SHOULDER JOINT   82                                $149.19       20110801
23920       AMPUTATION AT SHOULDER JOINT   AS                                $149.19       20110801
23920       AMPUTATION AT SHOULDER JOINT                                     $745.94       20110801
23921       AMPUTATION FOLLOW-UP SURGERY                    A                $447.74       20110101
23921       AMPUTATION FOLLOW-UP SURGERY                                     $278.46       20110801
23930       DRAINAGE OF ARM LESION                          A                $530.16       20110101
23930       DRAINAGE OF ARM LESION                                           $232.44       20110801
23931       DRAINAGE OF ARM BURSA                                            $180.18       20110801
23935       DRAIN ARM/ELBOW BONE LESION                     A                $614.48       20110101
23935       DRAIN ARM/ELBOW BONE LESION                                      $333.58       20110801
24000       EXPLORATORY ELBOW SURGERY                       A                $884.21       20110101
24000       EXPLORATORY ELBOW SURGERY                                        $317.46       20110801
24006       RELEASE ELBOW JOINT                             A                $884.21       20110101
24006       RELEASE ELBOW JOINT            80                                 $95.99       20110801
24006       RELEASE ELBOW JOINT            81                                 $95.99       20110801



                                                Page 45
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
24006       RELEASE ELBOW JOINT             82                                    $95.99       20110801
24006       RELEASE ELBOW JOINT             AS                                    $95.99       20110801
24006       RELEASE ELBOW JOINT                                                  $479.96       20110801
24065       BIOPSY ARM/ELBOW SOFT TISSUE                                         $166.92       20110801
24066       BIOPSY ARM/ELBOW SOFT TISSUE                     A                   $505.90       20110101
24066       BIOPSY ARM/ELBOW SOFT TISSUE                                         $389.48       20110801
24071       EXC ARM/ELBOW LES SC 3 CM/                                           $285.74       20110801
24073       EX ARM/ELBOW TUM DEEP 5 CM/                                          $489.84       20110801
24075       EXC ARM/ELBOW LES SC 3 CM                        A                   $168.06       20110101
24075       EXC ARM/ELBOW LES SC 3 CM                                            $318.24       20110801
24076       EX ARM/ELBOW TUM DEEP 5 CM                       A                   $560.76       20110101
24076       EX ARM/ELBOW TUM DEEP 5 CM                                           $354.12       20110801
24077       RESECT ARM/ELBOW TUM 5 CM                        A                   $560.76       20110101
24077       RESECT ARM/ELBOW TUM 5 CM                                            $679.38       20110801
24079       RESECT ARM/ELBOW TUM 5 CM/                                           $912.60       20110801
24100       BIOPSY ELBOW JOINT LINING                        A                   $592.86       20110101
24100       BIOPSY ELBOW JOINT LINING       80                                    $54.50       20110801
24100       BIOPSY ELBOW JOINT LINING       81                                    $54.50       20110801
24100       BIOPSY ELBOW JOINT LINING       82                                    $54.50       20110801
24100       BIOPSY ELBOW JOINT LINING       AS                                    $54.50       20110801
24100       BIOPSY ELBOW JOINT LINING                                            $272.48       20110801
24101       EXPLORE/TREAT ELBOW JOINT                        A                   $884.21       20110101
24101       EXPLORE/TREAT ELBOW JOINT       80                                    $66.66       20110801
24101       EXPLORE/TREAT ELBOW JOINT       81                                    $66.66       20110801
24101       EXPLORE/TREAT ELBOW JOINT       82                                    $66.66       20110801
24101       EXPLORE/TREAT ELBOW JOINT       AS                                    $66.66       20110801
24101       EXPLORE/TREAT ELBOW JOINT                                            $333.32       20110801
24102       REMOVE ELBOW JOINT LINING                        A                   $884.21       20110101
24102       REMOVE ELBOW JOINT LINING       80                                    $82.68       20110801
24102       REMOVE ELBOW JOINT LINING       81                                    $82.68       20110801
24102       REMOVE ELBOW JOINT LINING       82                                    $82.68       20110801
24102       REMOVE ELBOW JOINT LINING       AS                                    $82.68       20110801
24102       REMOVE ELBOW JOINT LINING                                            $413.40       20110801
24105       REMOVAL OF ELBOW BURSA                           A                   $626.73       20110101
24105       REMOVAL OF ELBOW BURSA                                               $225.68       20110801
24110       REMOVE HUMERUS LESION                            A                   $614.48       20110101
24110       REMOVE HUMERUS LESION                                                $391.82       20110801
24115       REMOVE/GRAFT BONE LESION                         A                   $861.25       20110101
24115       REMOVE/GRAFT BONE LESION        80                                    $97.29       20110801
24115       REMOVE/GRAFT BONE LESION        81                                    $97.29       20110801
24115       REMOVE/GRAFT BONE LESION        82                                    $97.29       20110801
24115       REMOVE/GRAFT BONE LESION        AS                                    $97.29       20110801
24115       REMOVE/GRAFT BONE LESION                                             $486.46       20110801
24116       REMOVE/GRAFT BONE LESION                         A                   $861.25       20110101
24116       REMOVE/GRAFT BONE LESION        80                                   $117.05       20110801
24116       REMOVE/GRAFT BONE LESION        81                                   $117.05       20110801
24116       REMOVE/GRAFT BONE LESION        82                                   $117.05       20110801
24116       REMOVE/GRAFT BONE LESION        AS                                   $117.05       20110801
24116       REMOVE/GRAFT BONE LESION                                             $585.26       20110801
24120       REMOVE ELBOW LESION                              A                   $626.73       20110101
24120       REMOVE ELBOW LESION                                                  $350.74       20110801
24125       REMOVE/GRAFT BONE LESION                         A                   $861.25       20110101
24125       REMOVE/GRAFT BONE LESION        80                                    $82.32       20110801
24125       REMOVE/GRAFT BONE LESION        81                                    $82.32       20110801
24125       REMOVE/GRAFT BONE LESION        82                                    $82.32       20110801
24125       REMOVE/GRAFT BONE LESION        AS                                    $82.32       20110801
24125       REMOVE/GRAFT BONE LESION                                             $411.58       20110801
24126       REMOVE/GRAFT BONE LESION                         A                   $861.25       20110101
24126       REMOVE/GRAFT BONE LESION        80                                    $86.94       20110801



                                                 Page 46
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
24126       REMOVE/GRAFT BONE LESION       81                                 $86.94       20110801
24126       REMOVE/GRAFT BONE LESION       82                                 $86.94       20110801
24126       REMOVE/GRAFT BONE LESION       AS                                 $86.94       20110801
24126       REMOVE/GRAFT BONE LESION                                         $434.72       20110801
24130       REMOVAL OF HEAD OF RADIUS                       A                $861.25       20110101
24130       REMOVAL OF HEAD OF RADIUS                                        $338.26       20110801
24134       REMOVAL OF ARM BONE LESION                      A                $849.00       20110101
24134       REMOVAL OF ARM BONE LESION     80                                $101.50       20110801
24134       REMOVAL OF ARM BONE LESION     81                                $101.50       20110801
24134       REMOVAL OF ARM BONE LESION     82                                $101.50       20110801
24134       REMOVAL OF ARM BONE LESION     AS                                $101.50       20110801
24134       REMOVAL OF ARM BONE LESION                                       $507.52       20110801
24136       REMOVE RADIUS BONE LESION                       A                $849.00       20110101
24136       REMOVE RADIUS BONE LESION                                        $407.94       20110801
24138       REMOVE ELBOW BONE LESION                        A                $849.00       20110101
24138       REMOVE ELBOW BONE LESION       80                                 $89.49       20110801
24138       REMOVE ELBOW BONE LESION       81                                 $89.49       20110801
24138       REMOVE ELBOW BONE LESION       82                                 $89.49       20110801
24138       REMOVE ELBOW BONE LESION       AS                                 $89.49       20110801
24138       REMOVE ELBOW BONE LESION                                         $447.46       20110801
24140       PARTIAL REMOVAL OF ARM BONE                     A                $861.25       20110101
24140       PARTIAL REMOVAL OF ARM BONE    80                                 $96.25       20110801
24140       PARTIAL REMOVAL OF ARM BONE    81                                 $96.25       20110801
24140       PARTIAL REMOVAL OF ARM BONE    82                                 $96.25       20110801
24140       PARTIAL REMOVAL OF ARM BONE    AS                                 $96.25       20110801
24140       PARTIAL REMOVAL OF ARM BONE                                      $481.26       20110801
24145       PARTIAL REMOVAL OF RADIUS                       A                $861.25       20110101
24145       PARTIAL REMOVAL OF RADIUS                                        $404.30       20110801
24147       PARTIAL REMOVAL OF ELBOW                        A                $849.00       20110101
24147       PARTIAL REMOVAL OF ELBOW                                         $420.16       20110801
24149       RADICAL RESECTION OF ELBOW     80                                $157.61       20110801
24149       RADICAL RESECTION OF ELBOW     81                                $157.61       20110801
24149       RADICAL RESECTION OF ELBOW     82                                $157.61       20110801
24149       RADICAL RESECTION OF ELBOW     AS                                $157.61       20110801
24150       RESECT DISTAL HUMERUS TUMOR    80                                $196.14       20110801
24150       RESECT DISTAL HUMERUS TUMOR    81                                $196.14       20110801
24150       RESECT DISTAL HUMERUS TUMOR    82                                $196.14       20110801
24150       RESECT DISTAL HUMERUS TUMOR    AS                                $196.14       20110801
24150       RESECT DISTAL HUMERUS TUMOR                                      $980.72       20110801
24152       RESECT RADIUS TUMOR                             A              $1,492.74       20110101
24152       RESECT RADIUS TUMOR            80                                $165.20       20110801
24152       RESECT RADIUS TUMOR            81                                $165.20       20110801
24152       RESECT RADIUS TUMOR            82                                $165.20       20110801
24152       RESECT RADIUS TUMOR            AS                                $165.20       20110801
24152       RESECT RADIUS TUMOR                                              $826.02       20110801
24155       REMOVAL OF ELBOW JOINT                          A              $1,217.14       20110101
24155       REMOVAL OF ELBOW JOINT         80                                $115.44       20110801
24155       REMOVAL OF ELBOW JOINT         81                                $115.44       20110801
24155       REMOVAL OF ELBOW JOINT         82                                $115.44       20110801
24155       REMOVAL OF ELBOW JOINT         AS                                $115.44       20110801
24155       REMOVAL OF ELBOW JOINT                                           $577.20       20110801
24160       REMOVE ELBOW JOINT IMPLANT                      A                $849.00       20110101
24160       REMOVE ELBOW JOINT IMPLANT                                       $406.12       20110801
24164       REMOVE RADIUS HEAD IMPLANT                      A                $861.25       20110101
24164       REMOVE RADIUS HEAD IMPLANT                                       $333.06       20110801
24200       REMOVAL OF ARM FOREIGN BODY                                      $130.78       20110801
24201       REMOVAL OF ARM FOREIGN BODY                     A                $505.90       20110101
24201       REMOVAL OF ARM FOREIGN BODY                                      $361.66       20110801
24220       INJECTION FOR ELBOW X-RAY                                        $112.32       20110801



                                                Page 47
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
24300       MANIPULATE ELBOW W/ANESTH                                        $262.60       20110801
24301       MUSCLE/TENDON TRANSFER                          A                $884.21       20110101
24301       MUSCLE/TENDON TRANSFER         80                                $101.87       20110801
24301       MUSCLE/TENDON TRANSFER         81                                $101.87       20110801
24301       MUSCLE/TENDON TRANSFER         82                                $101.87       20110801
24301       MUSCLE/TENDON TRANSFER         AS                                $101.87       20110801
24301       MUSCLE/TENDON TRANSFER                                           $509.34       20110801
24305       ARM TENDON LENGTHENING                          A                $884.21       20110101
24305       ARM TENDON LENGTHENING                                           $388.44       20110801
24310       REVISION OF ARM TENDON                          A                $626.73       20110101
24310       REVISION OF ARM TENDON                                           $319.28       20110801
24320       REPAIR OF ARM TENDON                            A              $1,217.14       20110101
24320       REPAIR OF ARM TENDON           80                                $105.25       20110801
24320       REPAIR OF ARM TENDON           81                                $105.25       20110801
24320       REPAIR OF ARM TENDON           82                                $105.25       20110801
24320       REPAIR OF ARM TENDON           AS                                $105.25       20110801
24320       REPAIR OF ARM TENDON                                             $526.24       20110801
24330       REVISION OF ARM MUSCLES                         A              $2,228.42       20110101
24330       REVISION OF ARM MUSCLES        80                                 $96.82       20110801
24330       REVISION OF ARM MUSCLES        81                                 $96.82       20110801
24330       REVISION OF ARM MUSCLES        82                                 $96.82       20110801
24330       REVISION OF ARM MUSCLES        AS                                 $96.82       20110801
24330       REVISION OF ARM MUSCLES                                          $484.12       20110801
24331       REVISION OF ARM MUSCLES                         A              $1,217.14       20110101
24331       REVISION OF ARM MUSCLES        80                                $106.96       20110801
24331       REVISION OF ARM MUSCLES        81                                $106.96       20110801
24331       REVISION OF ARM MUSCLES        82                                $106.96       20110801
24331       REVISION OF ARM MUSCLES        AS                                $106.96       20110801
24331       REVISION OF ARM MUSCLES                                          $534.82       20110801
24332       TENOLYSIS TRICEPS                                                $408.46       20110801
24340       REPAIR OF BICEPS TENDON                         A              $1,217.14       20110101
24340       REPAIR OF BICEPS TENDON        80                                 $82.47       20110801
24340       REPAIR OF BICEPS TENDON        81                                 $82.47       20110801
24340       REPAIR OF BICEPS TENDON        82                                 $82.47       20110801
24340       REPAIR OF BICEPS TENDON        AS                                 $82.47       20110801
24340       REPAIR OF BICEPS TENDON                                          $412.36       20110801
24341       REPAIR ARM TENDON/MUSCLE                        A              $1,217.14       20110101
24341       REPAIR ARM TENDON/MUSCLE       80                                 $98.96       20110801
24341       REPAIR ARM TENDON/MUSCLE       81                                 $98.96       20110801
24341       REPAIR ARM TENDON/MUSCLE       82                                 $98.96       20110801
24341       REPAIR ARM TENDON/MUSCLE       AS                                 $98.96       20110801
24341       REPAIR ARM TENDON/MUSCLE                                         $494.78       20110801
24342       REPAIR OF RUPTURED TENDON                       A              $1,217.14       20110101
24342       REPAIR OF RUPTURED TENDON      80                                $105.82       20110801
24342       REPAIR OF RUPTURED TENDON      81                                $105.82       20110801
24342       REPAIR OF RUPTURED TENDON      82                                $105.82       20110801
24342       REPAIR OF RUPTURED TENDON      AS                                $105.82       20110801
24342       REPAIR OF RUPTURED TENDON                                        $529.10       20110801
24343       REPR ELBOW LAT LIGMNT W/TISS                                     $473.20       20110801
24345       REPR ELBW MED LIGMNT W/TISSU                    A                $849.00       20110101
24345       REPR ELBW MED LIGMNT W/TISSU                                     $470.08       20110801
24346       RECONSTRUCT ELBOW MED LIGMNT                                     $743.08       20110801
24360       RECONSTRUCT ELBOW JOINT                         A              $1,095.93       20110101
24360       RECONSTRUCT ELBOW JOINT        80                                $122.25       20110801
24360       RECONSTRUCT ELBOW JOINT        81                                $122.25       20110801
24360       RECONSTRUCT ELBOW JOINT        82                                $122.25       20110801
24360       RECONSTRUCT ELBOW JOINT        AS                                $122.25       20110801
24360       RECONSTRUCT ELBOW JOINT                                          $611.26       20110801
24361       RECONSTRUCT ELBOW JOINT                         A              $5,034.78       20110101



                                                Page 48
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
24361       RECONSTRUCT ELBOW JOINT        80                                $137.54       20110801
24361       RECONSTRUCT ELBOW JOINT        81                                $137.54       20110801
24361       RECONSTRUCT ELBOW JOINT        82                                $137.54       20110801
24361       RECONSTRUCT ELBOW JOINT        AS                                $137.54       20110801
24361       RECONSTRUCT ELBOW JOINT                                          $687.70       20110801
24362       RECONSTRUCT ELBOW JOINT                         A              $1,533.29       20110101
24362       RECONSTRUCT ELBOW JOINT        80                                $144.66       20110801
24362       RECONSTRUCT ELBOW JOINT        81                                $144.66       20110801
24362       RECONSTRUCT ELBOW JOINT        82                                $144.66       20110801
24362       RECONSTRUCT ELBOW JOINT        AS                                $144.66       20110801
24362       RECONSTRUCT ELBOW JOINT                                          $723.32       20110801
24363       REPLACE ELBOW JOINT                             A              $5,087.98       20110101
24363       REPLACE ELBOW JOINT            80                                $205.19       20110801
24363       REPLACE ELBOW JOINT            81                                $205.19       20110801
24363       REPLACE ELBOW JOINT            82                                $205.19       20110801
24363       REPLACE ELBOW JOINT            AS                                $205.19       20110801
24363       REPLACE ELBOW JOINT                                            $1,025.96       20110801
24365       RECONSTRUCT HEAD OF RADIUS                      A              $1,095.93       20110101
24365       RECONSTRUCT HEAD OF RADIUS     80                                 $86.27       20110801
24365       RECONSTRUCT HEAD OF RADIUS     81                                 $86.27       20110801
24365       RECONSTRUCT HEAD OF RADIUS     82                                 $86.27       20110801
24365       RECONSTRUCT HEAD OF RADIUS     AS                                 $86.27       20110801
24365       RECONSTRUCT HEAD OF RADIUS                                       $431.34       20110801
24366       RECONSTRUCT HEAD OF RADIUS                      A              $5,034.78       20110101
24366       RECONSTRUCT HEAD OF RADIUS     80                                 $92.25       20110801
24366       RECONSTRUCT HEAD OF RADIUS     81                                 $92.25       20110801
24366       RECONSTRUCT HEAD OF RADIUS     82                                 $92.25       20110801
24366       RECONSTRUCT HEAD OF RADIUS     AS                                 $92.25       20110801
24366       RECONSTRUCT HEAD OF RADIUS                                       $461.24       20110801
24400       REVISION OF HUMERUS                             A              $1,240.11       20110101
24400       REVISION OF HUMERUS            80                                $111.28       20110801
24400       REVISION OF HUMERUS            81                                $111.28       20110801
24400       REVISION OF HUMERUS            82                                $111.28       20110801
24400       REVISION OF HUMERUS            AS                                $111.28       20110801
24400       REVISION OF HUMERUS                                              $556.40       20110801
24410       REVISION OF HUMERUS                             A              $1,240.11       20110101
24410       REVISION OF HUMERUS            80                                $142.74       20110801
24410       REVISION OF HUMERUS            81                                $142.74       20110801
24410       REVISION OF HUMERUS            82                                $142.74       20110801
24410       REVISION OF HUMERUS            AS                                $142.74       20110801
24410       REVISION OF HUMERUS                                              $713.70       20110801
24420       REVISION OF HUMERUS                             A              $1,217.14       20110101
24420       REVISION OF HUMERUS            80                                $134.26       20110801
24420       REVISION OF HUMERUS            81                                $134.26       20110801
24420       REVISION OF HUMERUS            82                                $134.26       20110801
24420       REVISION OF HUMERUS            AS                                $134.26       20110801
24420       REVISION OF HUMERUS                                              $671.32       20110801
24430       REPAIR OF HUMERUS                               A              $2,228.42       20110101
24430       REPAIR OF HUMERUS              80                                $143.68       20110801
24430       REPAIR OF HUMERUS              81                                $143.68       20110801
24430       REPAIR OF HUMERUS              82                                $143.68       20110801
24430       REPAIR OF HUMERUS              AS                                $143.68       20110801
24430       REPAIR OF HUMERUS                                                $718.38       20110801
24435       REPAIR HUMERUS WITH GRAFT                       A              $2,251.38       20110101
24435       REPAIR HUMERUS WITH GRAFT      80                                $145.76       20110801
24435       REPAIR HUMERUS WITH GRAFT      81                                $145.76       20110801
24435       REPAIR HUMERUS WITH GRAFT      82                                $145.76       20110801
24435       REPAIR HUMERUS WITH GRAFT      AS                                $145.76       20110801
24435       REPAIR HUMERUS WITH GRAFT                                        $728.78       20110801



                                                Page 49
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                   Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                  Date
24470       REVISION OF ELBOW JOINT                        A              $1,217.14       20110101
24470       REVISION OF ELBOW JOINT       80                                 $86.53       20110801
24470       REVISION OF ELBOW JOINT       81                                 $86.53       20110801
24470       REVISION OF ELBOW JOINT       82                                 $86.53       20110801
24470       REVISION OF ELBOW JOINT       AS                                 $86.53       20110801
24470       REVISION OF ELBOW JOINT                                         $432.64       20110801
24495       DECOMPRESSION OF FOREARM                       A                $849.00       20110101
24495       DECOMPRESSION OF FOREARM                                        $445.12       20110801
24498       REINFORCE HUMERUS                              A              $2,228.42       20110101
24498       REINFORCE HUMERUS             80                                $118.20       20110801
24498       REINFORCE HUMERUS             81                                $118.20       20110801
24498       REINFORCE HUMERUS             82                                $118.20       20110801
24498       REINFORCE HUMERUS             AS                                $118.20       20110801
24498       REINFORCE HUMERUS                                               $590.98       20110801
24500       TREAT HUMERUS FRACTURE                         A                 $59.66       20110101
24500       TREAT HUMERUS FRACTURE                                          $225.68       20110801
24505       TREAT HUMERUS FRACTURE                         A                 $59.66       20110101
24505       TREAT HUMERUS FRACTURE                                          $324.74       20110801
24515       TREAT HUMERUS FRACTURE                         A              $1,694.30       20110101
24515       TREAT HUMERUS FRACTURE        80                                $118.72       20110801
24515       TREAT HUMERUS FRACTURE        81                                $118.72       20110801
24515       TREAT HUMERUS FRACTURE        82                                $118.72       20110801
24515       TREAT HUMERUS FRACTURE        AS                                $118.72       20110801
24515       TREAT HUMERUS FRACTURE                                          $593.58       20110801
24516       TREAT HUMERUS FRACTURE                         A              $1,694.30       20110101
24516       TREAT HUMERUS FRACTURE        80                                $117.31       20110801
24516       TREAT HUMERUS FRACTURE        81                                $117.31       20110801
24516       TREAT HUMERUS FRACTURE        82                                $117.31       20110801
24516       TREAT HUMERUS FRACTURE        AS                                $117.31       20110801
24516       TREAT HUMERUS FRACTURE                                          $586.56       20110801
24530       TREAT HUMERUS FRACTURE                         A                 $59.66       20110101
24530       TREAT HUMERUS FRACTURE                                          $241.80       20110801
24535       TREAT HUMERUS FRACTURE                         A                $135.07       20110101
24535       TREAT HUMERUS FRACTURE                                          $405.34       20110801
24538       TREAT HUMERUS FRACTURE                         A                $706.54       20110101
24538       TREAT HUMERUS FRACTURE                                          $500.50       20110801
24545       TREAT HUMERUS FRACTURE                         A              $1,694.30       20110101
24545       TREAT HUMERUS FRACTURE        80                                $125.32       20110801
24545       TREAT HUMERUS FRACTURE        81                                $125.32       20110801
24545       TREAT HUMERUS FRACTURE        82                                $125.32       20110801
24545       TREAT HUMERUS FRACTURE        AS                                $125.32       20110801
24545       TREAT HUMERUS FRACTURE                                          $626.60       20110801
24546       TREAT HUMERUS FRACTURE                         A              $1,710.95       20110101
24546       TREAT HUMERUS FRACTURE        80                                $142.48       20110801
24546       TREAT HUMERUS FRACTURE        81                                $142.48       20110801
24546       TREAT HUMERUS FRACTURE        82                                $142.48       20110801
24546       TREAT HUMERUS FRACTURE        AS                                $142.48       20110801
24546       TREAT HUMERUS FRACTURE                                          $712.40       20110801
24560       TREAT HUMERUS FRACTURE                         A                 $59.66       20110101
24560       TREAT HUMERUS FRACTURE                                          $202.54       20110801
24565       TREAT HUMERUS FRACTURE                         A                 $59.66       20110101
24565       TREAT HUMERUS FRACTURE                                          $338.00       20110801
24566       TREAT HUMERUS FRACTURE                         A                $706.54       20110101
24566       TREAT HUMERUS FRACTURE                                          $476.32       20110801
24575       TREAT HUMERUS FRACTURE                         A              $1,671.34       20110101
24575       TREAT HUMERUS FRACTURE        80                                 $98.75       20110801
24575       TREAT HUMERUS FRACTURE        81                                 $98.75       20110801
24575       TREAT HUMERUS FRACTURE        82                                 $98.75       20110801
24575       TREAT HUMERUS FRACTURE        AS                                 $98.75       20110801



                                               Page 50
                                      DMAP Fee for Service Fee Schedule
                                                August 2012


Procedure   Description                        Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                       Date
24575       TREAT HUMERUS FRACTURE                                               $493.74       20110801
24576       TREAT HUMERUS FRACTURE                              A                 $59.66       20110101
24576       TREAT HUMERUS FRACTURE                                               $213.72       20110801
24577       TREAT HUMERUS FRACTURE                              A                $135.07       20110101
24577       TREAT HUMERUS FRACTURE                                               $350.74       20110801
24579       TREAT HUMERUS FRACTURE                              A              $1,671.34       20110101
24579       TREAT HUMERUS FRACTURE             80                                $112.79       20110801
24579       TREAT HUMERUS FRACTURE             81                                $112.79       20110801
24579       TREAT HUMERUS FRACTURE             82                                $112.79       20110801
24579       TREAT HUMERUS FRACTURE             AS                                $112.79       20110801
24579       TREAT HUMERUS FRACTURE                                               $563.94       20110801
24582       TREAT HUMERUS FRACTURE                              A                $706.54       20110101
24582       TREAT HUMERUS FRACTURE                                               $532.74       20110801
24586       TREAT ELBOW FRACTURE                                A              $1,694.30       20110101
24586       TREAT ELBOW FRACTURE               80                                $148.77       20110801
24586       TREAT ELBOW FRACTURE               81                                $148.77       20110801
24586       TREAT ELBOW FRACTURE               82                                $148.77       20110801
24586       TREAT ELBOW FRACTURE               AS                                $148.77       20110801
24586       TREAT ELBOW FRACTURE                                                 $743.86       20110801
24587       TREAT ELBOW FRACTURE                                A              $1,710.95       20110101
24587       TREAT ELBOW FRACTURE               80                                $148.36       20110801
24587       TREAT ELBOW FRACTURE               81                                $148.36       20110801
24587       TREAT ELBOW FRACTURE               82                                $148.36       20110801
24587       TREAT ELBOW FRACTURE               AS                                $148.36       20110801
24587       TREAT ELBOW FRACTURE                                                 $741.78       20110801
24600       TREAT ELBOW DISLOCATION                             A                 $59.66       20110101
24600       TREAT ELBOW DISLOCATION                                              $237.12       20110801
24605       TREAT ELBOW DISLOCATION                             A                $452.90       20110101
24605       TREAT ELBOW DISLOCATION                                              $306.80       20110801
24615       TREAT ELBOW DISLOCATION                             A              $1,671.34       20110101
24615       TREAT ELBOW DISLOCATION            80                                 $96.46       20110801
24615       TREAT ELBOW DISLOCATION            81                                 $96.46       20110801
24615       TREAT ELBOW DISLOCATION            82                                 $96.46       20110801
24615       TREAT ELBOW DISLOCATION            AS                                 $96.46       20110801
24615       TREAT ELBOW DISLOCATION                                              $482.30       20110801
24620       TREAT ELBOW FRACTURE                                A                $462.00       20110101
24620       TREAT ELBOW FRACTURE                                                 $368.94       20110801
24635       TREAT ELBOW FRACTURE                                A              $1,671.34       20110101
24635       TREAT ELBOW FRACTURE               80                                 $96.56       20110801
24635       TREAT ELBOW FRACTURE               81                                 $96.56       20110801
24635       TREAT ELBOW FRACTURE               82                                 $96.56       20110801
24635       TREAT ELBOW FRACTURE               AS                                 $96.56       20110801
24635       TREAT ELBOW FRACTURE                                                 $482.82       20110801
24640       TREAT ELBOW DISLOCATION                                               $80.60       20110801
24650       TREAT RADIUS FRACTURE                                                $164.06       20110801
24655       TREAT RADIUS FRACTURE                               A                $135.07       20110101
24655       TREAT RADIUS FRACTURE                                                $282.62       20110801
24665       TREAT RADIUS FRACTURE                               A              $1,213.40       20110101
24665       TREAT RADIUS FRACTURE              80                                 $87.10       20110801
24665       TREAT RADIUS FRACTURE              81                                 $87.10       20110801
24665       TREAT RADIUS FRACTURE              82                                 $87.10       20110801
24665       TREAT RADIUS FRACTURE              AS                                 $87.10       20110801
24665       TREAT RADIUS FRACTURE                                                $435.50       20110801
24666       TREAT RADIUS FRACTURE                               A              $1,694.30       20110101
24666       TREAT RADIUS FRACTURE              80                                 $98.80       20110801
24666       TREAT RADIUS FRACTURE              81                                 $98.80       20110801
24666       TREAT RADIUS FRACTURE              82                                 $98.80       20110801
24666       TREAT RADIUS FRACTURE              AS                                 $98.80       20110801
24666       TREAT RADIUS FRACTURE                                                $494.00       20110801



                                                    Page 51
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
24670       TREAT ULNAR FRACTURE                            A                 $59.66       20110101
24670       TREAT ULNAR FRACTURE                                             $184.08       20110801
24675       TREAT ULNAR FRACTURE                            A                 $59.66       20110101
24675       TREAT ULNAR FRACTURE                                             $296.40       20110801
24685       TREAT ULNAR FRACTURE                            A              $1,190.44       20110101
24685       TREAT ULNAR FRACTURE           80                                 $87.31       20110801
24685       TREAT ULNAR FRACTURE           81                                 $87.31       20110801
24685       TREAT ULNAR FRACTURE           82                                 $87.31       20110801
24685       TREAT ULNAR FRACTURE           AS                                 $87.31       20110801
24685       TREAT ULNAR FRACTURE                                             $436.54       20110801
24800       FUSION OF ELBOW JOINT                           A              $1,240.11       20110101
24800       FUSION OF ELBOW JOINT          80                                $109.41       20110801
24800       FUSION OF ELBOW JOINT          81                                $109.41       20110801
24800       FUSION OF ELBOW JOINT          82                                $109.41       20110801
24800       FUSION OF ELBOW JOINT          AS                                $109.41       20110801
24800       FUSION OF ELBOW JOINT                                            $547.04       20110801
24802       FUSION/GRAFT OF ELBOW JOINT                     A              $1,256.75       20110101
24802       FUSION/GRAFT OF ELBOW JOINT    80                                $136.08       20110801
24802       FUSION/GRAFT OF ELBOW JOINT    81                                $136.08       20110801
24802       FUSION/GRAFT OF ELBOW JOINT    82                                $136.08       20110801
24802       FUSION/GRAFT OF ELBOW JOINT    AS                                $136.08       20110801
24802       FUSION/GRAFT OF ELBOW JOINT                                      $680.42       20110801
24900       AMPUTATION OF UPPER ARM        80                                 $98.07       20110801
24900       AMPUTATION OF UPPER ARM        81                                 $98.07       20110801
24900       AMPUTATION OF UPPER ARM        82                                 $98.07       20110801
24900       AMPUTATION OF UPPER ARM        AS                                 $98.07       20110801
24900       AMPUTATION OF UPPER ARM                                          $490.36       20110801
24920       AMPUTATION OF UPPER ARM        80                                 $97.24       20110801
24920       AMPUTATION OF UPPER ARM        81                                 $97.24       20110801
24920       AMPUTATION OF UPPER ARM        82                                 $97.24       20110801
24920       AMPUTATION OF UPPER ARM        AS                                 $97.24       20110801
24920       AMPUTATION OF UPPER ARM                                          $486.20       20110801
24925       AMPUTATION FOLLOW-UP SURGERY                    A                $626.73       20110101
24925       AMPUTATION FOLLOW-UP SURGERY   80                                 $75.35       20110801
24925       AMPUTATION FOLLOW-UP SURGERY   81                                 $75.35       20110801
24925       AMPUTATION FOLLOW-UP SURGERY   82                                 $75.35       20110801
24925       AMPUTATION FOLLOW-UP SURGERY   AS                                 $75.35       20110801
24925       AMPUTATION FOLLOW-UP SURGERY                                     $376.74       20110801
24930       AMPUTATION FOLLOW-UP SURGERY   80                                $103.22       20110801
24930       AMPUTATION FOLLOW-UP SURGERY   81                                $103.22       20110801
24930       AMPUTATION FOLLOW-UP SURGERY   82                                $103.22       20110801
24930       AMPUTATION FOLLOW-UP SURGERY   AS                                $103.22       20110801
24930       AMPUTATION FOLLOW-UP SURGERY                                     $516.10       20110801
24931       AMPUTATE UPPER ARM IMPLANT     80                                $108.32       20110801
24931       AMPUTATE UPPER ARM IMPLANT     81                                $108.32       20110801
24931       AMPUTATE UPPER ARM IMPLANT     82                                $108.32       20110801
24931       AMPUTATE UPPER ARM IMPLANT     AS                                $108.32       20110801
24931       AMPUTATE UPPER ARM IMPLANT                                       $541.58       20110801
24935       REVISION OF AMPUTATION                                           $724.62       20110801
24940       REVISION OF UPPER ARM          80                                $174.76       20110801
24940       REVISION OF UPPER ARM          81                                $174.76       20110801
24940       REVISION OF UPPER ARM          82                                $174.76       20110801
24940       REVISION OF UPPER ARM          AS                                $174.76       20110801
24940       REVISION OF UPPER ARM                                            $873.79       20110801
25000       INCISION OF TENDON SHEATH                       A                $626.73       20110101
25000       INCISION OF TENDON SHEATH                                        $229.32       20110801
25001       INCISE FLEXOR CARPI RADIALIS                                     $222.04       20110801
25020       DECOMPRESS FOREARM 1 SPACE                      A                $861.25       20110101
25020       DECOMPRESS FOREARM 1 SPACE                                       $381.16       20110801



                                                Page 52
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
25023       DECOMPRESS FOREARM 1 SPACE                      A                   $861.25       20110101
25023       DECOMPRESS FOREARM 1 SPACE                                          $745.42       20110801
25024       DECOMPRESS FOREARM 2 SPACES                     A                   $861.25       20110101
25024       DECOMPRESS FOREARM 2 SPACES                                         $525.46       20110801
25025       DECOMPRESS FOREARM 2 SPACES                     A                   $861.25       20110101
25025       DECOMPRESS FOREARM 2 SPACES                                         $822.64       20110801
25028       DRAINAGE OF FOREARM LESION                      A                   $592.86       20110101
25028       DRAINAGE OF FOREARM LESION                                          $342.42       20110801
25031       DRAINAGE OF FOREARM BURSA                       A                   $614.48       20110101
25031       DRAINAGE OF FOREARM BURSA                                           $249.86       20110801
25035       TREAT FOREARM BONE LESION                       A                   $614.48       20110101
25035       TREAT FOREARM BONE LESION                                           $421.98       20110801
25040       EXPLORE/TREAT WRIST JOINT                       A                   $900.86       20110101
25040       EXPLORE/TREAT WRIST JOINT                                           $382.72       20110801
25065       BIOPSY FOREARM SOFT TISSUES                     A                    $93.34       20110101
25065       BIOPSY FOREARM SOFT TISSUES                                         $165.88       20110801
25066       BIOPSY FOREARM SOFT TISSUES                     A                   $647.50       20110101
25066       BIOPSY FOREARM SOFT TISSUES                                         $248.82       20110801
25071       EXC FOREARM LES SC 3 CM/                                            $299.26       20110801
25073       EXC FOREARM TUM DEEP 3 CM/                                          $372.58       20110801
25075       EXC FOREARM LES SC 3 CM                         A                   $112.65       20110101
25075       EXC FOREARM LES SC 3 CM                                             $245.96       20110801
25076       EXC FOREARM TUM DEEP 3 CM                       A                   $560.76       20110101
25076       EXC FOREARM TUM DEEP 3 CM                                           $348.66       20110801
25077       RESECT FOREARM/WRIST TUM3CM                     A                   $560.76       20110101
25077       RESECT FOREARM/WRIST TUM3CM                                         $599.82       20110801
25078       RESECT FORARM/WRIST TUM 3CM                                         $797.16       20110801
25085       INCISION OF WRIST CAPSULE                       A                   $626.73       20110101
25085       INCISION OF WRIST CAPSULE      80                                    $61.78       20110801
25085       INCISION OF WRIST CAPSULE      81                                    $61.78       20110801
25085       INCISION OF WRIST CAPSULE      82                                    $61.78       20110801
25085       INCISION OF WRIST CAPSULE      AS                                    $61.78       20110801
25085       INCISION OF WRIST CAPSULE                                           $308.88       20110801
25100       BIOPSY OF WRIST JOINT                           A                   $614.48       20110101
25100       BIOPSY OF WRIST JOINT                                               $230.88       20110801
25101       EXPLORE/TREAT WRIST JOINT                       A                   $861.25       20110101
25101       EXPLORE/TREAT WRIST JOINT                                           $270.92       20110801
25105       REMOVE WRIST JOINT LINING                       A                   $884.21       20110101
25105       REMOVE WRIST JOINT LINING                                           $328.64       20110801
25107       REMOVE WRIST JOINT CARTILAGE                    A                   $861.25       20110101
25107       REMOVE WRIST JOINT CARTILAGE   80                                    $82.84       20110801
25107       REMOVE WRIST JOINT CARTILAGE   81                                    $82.84       20110801
25107       REMOVE WRIST JOINT CARTILAGE   82                                    $82.84       20110801
25107       REMOVE WRIST JOINT CARTILAGE   AS                                    $82.84       20110801
25107       REMOVE WRIST JOINT CARTILAGE                                        $414.18       20110801
25109       EXCISE TENDON FOREARM/WRIST                                         $354.64       20110801
25110       REMOVE WRIST TENDON LESION                      A                   $626.73       20110101
25110       REMOVE WRIST TENDON LESION                                          $237.38       20110801
25111       REMOVE WRIST TENDON LESION                      A                   $626.73       20110101
25111       REMOVE WRIST TENDON LESION                                          $210.60       20110801
25112       REREMOVE WRIST TENDON LESION                    A                   $649.69       20110101
25112       REREMOVE WRIST TENDON LESION                                        $256.62       20110801
25115       REMOVE WRIST/FOREARM LESION                     A                   $649.69       20110101
25115       REMOVE WRIST/FOREARM LESION                                         $536.64       20110801
25116       REMOVE WRIST/FOREARM LESION                     A                   $649.69       20110101
25116       REMOVE WRIST/FOREARM LESION                                         $429.26       20110801
25118       EXCISE WRIST TENDON SHEATH                      A                   $849.00       20110101
25118       EXCISE WRIST TENDON SHEATH                                          $255.84       20110801
25119       PARTIAL REMOVAL OF ULNA                         A                   $861.25       20110101



                                                Page 53
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
25119       PARTIAL REMOVAL OF ULNA        80                                    $67.81       20110801
25119       PARTIAL REMOVAL OF ULNA        81                                    $67.81       20110801
25119       PARTIAL REMOVAL OF ULNA        82                                    $67.81       20110801
25119       PARTIAL REMOVAL OF ULNA        AS                                    $67.81       20110801
25119       PARTIAL REMOVAL OF ULNA                                             $339.04       20110801
25120       REMOVAL OF FOREARM LESION                       A                   $861.25       20110101
25120       REMOVAL OF FOREARM LESION                                           $362.44       20110801
25125       REMOVE/GRAFT FOREARM LESION                     A                   $861.25       20110101
25125       REMOVE/GRAFT FOREARM LESION                                         $427.70       20110801
25126       REMOVE/GRAFT FOREARM LESION                     A                   $861.25       20110101
25126       REMOVE/GRAFT FOREARM LESION    80                                    $85.80       20110801
25126       REMOVE/GRAFT FOREARM LESION    81                                    $85.80       20110801
25126       REMOVE/GRAFT FOREARM LESION    82                                    $85.80       20110801
25126       REMOVE/GRAFT FOREARM LESION    AS                                    $85.80       20110801
25126       REMOVE/GRAFT FOREARM LESION                                         $429.00       20110801
25130       REMOVAL OF WRIST LESION                         A                   $861.25       20110101
25130       REMOVAL OF WRIST LESION                                             $301.34       20110801
25135       REMOVE GRAFT WRIST LESION                       A                   $861.25       20110101
25135       REMOVE GRAFT WRIST LESION      80                                    $76.02       20110801
25135       REMOVE GRAFT WRIST LESION      81                                    $76.02       20110801
25135       REMOVE GRAFT WRIST LESION      82                                    $76.02       20110801
25135       REMOVE GRAFT WRIST LESION      AS                                    $76.02       20110801
25135       REMOVE GRAFT WRIST LESION                                           $380.12       20110801
25136       REMOVE GRAFT WRIST LESION                       A                   $861.25       20110101
25136       REMOVE GRAFT WRIST LESION      80                                    $66.35       20110801
25136       REMOVE GRAFT WRIST LESION      81                                    $66.35       20110801
25136       REMOVE GRAFT WRIST LESION      82                                    $66.35       20110801
25136       REMOVE GRAFT WRIST LESION      AS                                    $66.35       20110801
25136       REMOVE GRAFT WRIST LESION                                           $331.76       20110801
25145       REMOVE FOREARM BONE LESION                      A                   $849.00       20110101
25145       REMOVE FOREARM BONE LESION     80                                    $74.88       20110801
25145       REMOVE FOREARM BONE LESION     81                                    $74.88       20110801
25145       REMOVE FOREARM BONE LESION     82                                    $74.88       20110801
25145       REMOVE FOREARM BONE LESION     AS                                    $74.88       20110801
25145       REMOVE FOREARM BONE LESION                                          $374.40       20110801
25150       PARTIAL REMOVAL OF ULNA                         A                   $849.00       20110101
25150       PARTIAL REMOVAL OF ULNA                                             $386.88       20110801
25151       PARTIAL REMOVAL OF RADIUS                       A                   $849.00       20110101
25151       PARTIAL REMOVAL OF RADIUS      80                                    $84.66       20110801
25151       PARTIAL REMOVAL OF RADIUS      81                                    $84.66       20110801
25151       PARTIAL REMOVAL OF RADIUS      82                                    $84.66       20110801
25151       PARTIAL REMOVAL OF RADIUS      AS                                    $84.66       20110801
25151       PARTIAL REMOVAL OF RADIUS                                           $423.28       20110801
25170       RESECT RADIUS/ULNAR TUMOR      80                                   $189.64       20110801
25170       RESECT RADIUS/ULNAR TUMOR      81                                   $189.64       20110801
25170       RESECT RADIUS/ULNAR TUMOR      82                                   $189.64       20110801
25170       RESECT RADIUS/ULNAR TUMOR      AS                                   $189.64       20110801
25170       RESECT RADIUS/ULNAR TUMOR                                           $948.22       20110801
25210       REMOVAL OF WRIST BONE                           A                   $861.25       20110101
25210       REMOVAL OF WRIST BONE                                               $329.68       20110801
25215       REMOVAL OF WRIST BONES                          A                   $884.21       20110101
25215       REMOVAL OF WRIST BONES         80                                    $84.45       20110801
25215       REMOVAL OF WRIST BONES         81                                    $84.45       20110801
25215       REMOVAL OF WRIST BONES         82                                    $84.45       20110801
25215       REMOVAL OF WRIST BONES         AS                                    $84.45       20110801
25215       REMOVAL OF WRIST BONES                                              $422.24       20110801
25230       PARTIAL REMOVAL OF RADIUS                       A                   $884.21       20110101
25230       PARTIAL REMOVAL OF RADIUS                                           $290.42       20110801
25240       PARTIAL REMOVAL OF ULNA                         A                   $884.21       20110101



                                                Page 54
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
25240       PARTIAL REMOVAL OF ULNA                                          $293.02       20110801
25246       INJECTION FOR WRIST X-RAY                                        $114.14       20110801
25248       REMOVE FOREARM FOREIGN BODY                     A                $614.48       20110101
25248       REMOVE FOREARM FOREIGN BODY                                      $293.02       20110801
25250       REMOVAL OF WRIST PROSTHESIS                     A                $827.38       20110101
25250       REMOVAL OF WRIST PROSTHESIS    80                                 $70.67       20110801
25250       REMOVAL OF WRIST PROSTHESIS    81                                 $70.67       20110801
25250       REMOVAL OF WRIST PROSTHESIS    82                                 $70.67       20110801
25250       REMOVAL OF WRIST PROSTHESIS    AS                                 $70.67       20110801
25250       REMOVAL OF WRIST PROSTHESIS                                      $353.34       20110801
25251       REMOVAL OF WRIST PROSTHESIS                     A                $827.38       20110101
25251       REMOVAL OF WRIST PROSTHESIS    80                                 $97.19       20110801
25251       REMOVAL OF WRIST PROSTHESIS    81                                 $97.19       20110801
25251       REMOVAL OF WRIST PROSTHESIS    82                                 $97.19       20110801
25251       REMOVAL OF WRIST PROSTHESIS    AS                                 $97.19       20110801
25251       REMOVAL OF WRIST PROSTHESIS                                      $485.94       20110801
25259       MANIPULATE WRIST W/ANESTHES                                      $263.90       20110801
25260       REPAIR FOREARM TENDON/MUSCLE                    A                $884.21       20110101
25260       REPAIR FOREARM TENDON/MUSCLE                                     $449.54       20110801
25263       REPAIR FOREARM TENDON/MUSCLE                    A                $849.00       20110101
25263       REPAIR FOREARM TENDON/MUSCLE   80                                 $89.91       20110801
25263       REPAIR FOREARM TENDON/MUSCLE   81                                 $89.91       20110801
25263       REPAIR FOREARM TENDON/MUSCLE   82                                 $89.91       20110801
25263       REPAIR FOREARM TENDON/MUSCLE   AS                                 $89.91       20110801
25263       REPAIR FOREARM TENDON/MUSCLE                                     $449.54       20110801
25265       REPAIR FOREARM TENDON/MUSCLE                    A                $861.25       20110101
25265       REPAIR FOREARM TENDON/MUSCLE   80                                $106.96       20110801
25265       REPAIR FOREARM TENDON/MUSCLE   81                                $106.96       20110801
25265       REPAIR FOREARM TENDON/MUSCLE   82                                $106.96       20110801
25265       REPAIR FOREARM TENDON/MUSCLE   AS                                $106.96       20110801
25265       REPAIR FOREARM TENDON/MUSCLE                                     $534.82       20110801
25270       REPAIR FOREARM TENDON/MUSCLE                    A                $884.21       20110101
25270       REPAIR FOREARM TENDON/MUSCLE                                     $358.02       20110801
25272       REPAIR FOREARM TENDON/MUSCLE                    A                $861.25       20110101
25272       REPAIR FOREARM TENDON/MUSCLE                                     $402.48       20110801
25274       REPAIR FOREARM TENDON/MUSCLE                    A                $884.21       20110101
25274       REPAIR FOREARM TENDON/MUSCLE                                     $481.26       20110801
25275       REPAIR FOREARM TENDON SHEATH                    A                $884.21       20110101
25275       REPAIR FOREARM TENDON SHEATH                                     $455.00       20110801
25280       REVISE WRIST/FOREARM TENDON                     A                $884.21       20110101
25280       REVISE WRIST/FOREARM TENDON                                      $408.46       20110801
25290       INCISE WRIST/FOREARM TENDON                     A                $861.25       20110101
25290       INCISE WRIST/FOREARM TENDON                                      $338.26       20110801
25295       RELEASE WRIST/FOREARM TENDON                    A                $626.73       20110101
25295       RELEASE WRIST/FOREARM TENDON                                     $379.60       20110801
25300       FUSION OF TENDONS AT WRIST                      A                $861.25       20110101
25300       FUSION OF TENDONS AT WRIST     80                                 $92.72       20110801
25300       FUSION OF TENDONS AT WRIST     81                                 $92.72       20110801
25300       FUSION OF TENDONS AT WRIST     82                                 $92.72       20110801
25300       FUSION OF TENDONS AT WRIST     AS                                 $92.72       20110801
25300       FUSION OF TENDONS AT WRIST                                       $463.58       20110801
25301       FUSION OF TENDONS AT WRIST                      A                $861.25       20110101
25301       FUSION OF TENDONS AT WRIST     80                                 $87.46       20110801
25301       FUSION OF TENDONS AT WRIST     81                                 $87.46       20110801
25301       FUSION OF TENDONS AT WRIST     82                                 $87.46       20110801
25301       FUSION OF TENDONS AT WRIST     AS                                 $87.46       20110801
25301       FUSION OF TENDONS AT WRIST                                       $437.32       20110801
25310       TRANSPLANT FOREARM TENDON                       A              $1,217.14       20110101
25310       TRANSPLANT FOREARM TENDON      80                                 $88.66       20110801



                                                Page 55
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
25310       TRANSPLANT FOREARM TENDON      81                                 $88.66       20110801
25310       TRANSPLANT FOREARM TENDON      82                                 $88.66       20110801
25310       TRANSPLANT FOREARM TENDON      AS                                 $88.66       20110801
25310       TRANSPLANT FOREARM TENDON                                        $443.30       20110801
25312       TRANSPLANT FOREARM TENDON                       A              $1,240.11       20110101
25312       TRANSPLANT FOREARM TENDON      80                                $103.17       20110801
25312       TRANSPLANT FOREARM TENDON      81                                $103.17       20110801
25312       TRANSPLANT FOREARM TENDON      82                                $103.17       20110801
25312       TRANSPLANT FOREARM TENDON      AS                                $103.17       20110801
25312       TRANSPLANT FOREARM TENDON                                        $515.84       20110801
25315       REVISE PALSY HAND TENDONS                       A              $1,217.14       20110101
25315       REVISE PALSY HAND TENDONS      80                                $110.81       20110801
25315       REVISE PALSY HAND TENDONS      81                                $110.81       20110801
25315       REVISE PALSY HAND TENDONS      82                                $110.81       20110801
25315       REVISE PALSY HAND TENDONS      AS                                $110.81       20110801
25315       REVISE PALSY HAND TENDONS                                        $554.06       20110801
25316       REVISE PALSY HAND TENDONS                       A              $2,228.42       20110101
25316       REVISE PALSY HAND TENDONS      80                                $127.04       20110801
25316       REVISE PALSY HAND TENDONS      81                                $127.04       20110801
25316       REVISE PALSY HAND TENDONS      82                                $127.04       20110801
25316       REVISE PALSY HAND TENDONS      AS                                $127.04       20110801
25316       REVISE PALSY HAND TENDONS                                        $635.18       20110801
25320       REPAIR/REVISE WRIST JOINT                       A              $1,217.14       20110101
25320       REPAIR/REVISE WRIST JOINT      80                                $131.92       20110801
25320       REPAIR/REVISE WRIST JOINT      81                                $131.92       20110801
25320       REPAIR/REVISE WRIST JOINT      82                                $131.92       20110801
25320       REPAIR/REVISE WRIST JOINT      AS                                $131.92       20110801
25320       REPAIR/REVISE WRIST JOINT                                        $659.62       20110801
25332       REVISE WRIST JOINT                              A              $1,095.93       20110101
25332       REVISE WRIST JOINT             80                                $114.19       20110801
25332       REVISE WRIST JOINT             81                                $114.19       20110801
25332       REVISE WRIST JOINT             82                                $114.19       20110801
25332       REVISE WRIST JOINT             AS                                $114.19       20110801
25332       REVISE WRIST JOINT                                               $570.96       20110801
25335       REALIGNMENT OF HAND                             A              $1,217.14       20110101
25335       REALIGNMENT OF HAND            80                                $119.86       20110801
25335       REALIGNMENT OF HAND            81                                $119.86       20110801
25335       REALIGNMENT OF HAND            82                                $119.86       20110801
25335       REALIGNMENT OF HAND            AS                                $119.86       20110801
25335       REALIGNMENT OF HAND                                              $599.30       20110801
25337       RECONSTRUCT ULNA/RADIOULNAR                     A              $1,256.75       20110101
25337       RECONSTRUCT ULNA/RADIOULNAR                                      $599.82       20110801
25350       REVISION OF RADIUS                              A              $1,217.14       20110101
25350       REVISION OF RADIUS             80                                 $97.14       20110801
25350       REVISION OF RADIUS             81                                 $97.14       20110801
25350       REVISION OF RADIUS             82                                 $97.14       20110801
25350       REVISION OF RADIUS             AS                                 $97.14       20110801
25350       REVISION OF RADIUS                                               $485.68       20110801
25355       REVISION OF RADIUS                              A              $1,217.14       20110101
25355       REVISION OF RADIUS             80                                $109.93       20110801
25355       REVISION OF RADIUS             81                                $109.93       20110801
25355       REVISION OF RADIUS             82                                $109.93       20110801
25355       REVISION OF RADIUS             AS                                $109.93       20110801
25355       REVISION OF RADIUS                                               $549.64       20110801
25360       REVISION OF ULNA                                A              $1,217.14       20110101
25360       REVISION OF ULNA               80                                 $94.54       20110801
25360       REVISION OF ULNA               81                                 $94.54       20110801
25360       REVISION OF ULNA               82                                 $94.54       20110801
25360       REVISION OF ULNA               AS                                 $94.54       20110801



                                                Page 56
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
25360       REVISION OF ULNA                                                  $472.68       20110801
25365       REVISE RADIUS ULNA                               A              $1,217.14       20110101
25365       REVISE RADIUS ULNA              80                                $129.74       20110801
25365       REVISE RADIUS ULNA              81                                $129.74       20110801
25365       REVISE RADIUS ULNA              82                                $129.74       20110801
25365       REVISE RADIUS ULNA              AS                                $129.74       20110801
25365       REVISE RADIUS ULNA                                                $648.70       20110801
25370       REVISE RADIUS OR ULNA                            A              $1,217.14       20110101
25370       REVISE RADIUS OR ULNA           80                                $141.96       20110801
25370       REVISE RADIUS OR ULNA           81                                $141.96       20110801
25370       REVISE RADIUS OR ULNA           82                                $141.96       20110801
25370       REVISE RADIUS OR ULNA           AS                                $141.96       20110801
25370       REVISE RADIUS OR ULNA                                             $709.80       20110801
25375       REVISE RADIUS ULNA                               A              $1,240.11       20110101
25375       REVISE RADIUS ULNA              80                                $125.79       20110801
25375       REVISE RADIUS ULNA              81                                $125.79       20110801
25375       REVISE RADIUS ULNA              82                                $125.79       20110801
25375       REVISE RADIUS ULNA              AS                                $125.79       20110801
25375       REVISE RADIUS ULNA                                                $628.94       20110801
25390       SHORTEN RADIUS OR ULNA                           A              $1,217.14       20110101
25390       SHORTEN RADIUS OR ULNA          80                                $110.34       20110801
25390       SHORTEN RADIUS OR ULNA          81                                $110.34       20110801
25390       SHORTEN RADIUS OR ULNA          82                                $110.34       20110801
25390       SHORTEN RADIUS OR ULNA          AS                                $110.34       20110801
25390       SHORTEN RADIUS OR ULNA                                            $551.72       20110801
25391       LENGTHEN RADIUS OR ULNA                          A              $1,240.11       20110101
25391       LENGTHEN RADIUS OR ULNA         80                                $141.75       20110801
25391       LENGTHEN RADIUS OR ULNA         81                                $141.75       20110801
25391       LENGTHEN RADIUS OR ULNA         82                                $141.75       20110801
25391       LENGTHEN RADIUS OR ULNA         AS                                $141.75       20110801
25391       LENGTHEN RADIUS OR ULNA                                           $708.76       20110801
25392       SHORTEN RADIUS ULNA                              A                $861.25       20110101
25392       SHORTEN RADIUS ULNA             80                                $144.46       20110801
25392       SHORTEN RADIUS ULNA             81                                $144.46       20110801
25392       SHORTEN RADIUS ULNA             82                                $144.46       20110801
25392       SHORTEN RADIUS ULNA             AS                                $144.46       20110801
25392       SHORTEN RADIUS ULNA                                               $722.28       20110801
25393       LENGTHEN RADIUS ULNA                             A              $1,240.11       20110101
25393       LENGTHEN RADIUS ULNA            80                                $161.04       20110801
25393       LENGTHEN RADIUS ULNA            81                                $161.04       20110801
25393       LENGTHEN RADIUS ULNA            82                                $161.04       20110801
25393       LENGTHEN RADIUS ULNA            AS                                $161.04       20110801
25393       LENGTHEN RADIUS ULNA                                              $805.22       20110801
25394       REPAIR CARPAL BONE SHORTEN                                        $529.36       20110801
25400       REPAIR RADIUS OR ULNA                            A              $1,217.14       20110101
25400       REPAIR RADIUS OR ULNA           80                                $115.70       20110801
25400       REPAIR RADIUS OR ULNA           81                                $115.70       20110801
25400       REPAIR RADIUS OR ULNA           82                                $115.70       20110801
25400       REPAIR RADIUS OR ULNA           AS                                $115.70       20110801
25400       REPAIR RADIUS OR ULNA                                             $578.50       20110801
25405       REPAIR/GRAFT RADIUS OR ULNA                      A              $2,251.38       20110101
25405       REPAIR/GRAFT RADIUS OR ULNA     80                                $147.89       20110801
25405       REPAIR/GRAFT RADIUS OR ULNA     81                                $147.89       20110801
25405       REPAIR/GRAFT RADIUS OR ULNA     82                                $147.89       20110801
25405       REPAIR/GRAFT RADIUS OR ULNA     AS                                $147.89       20110801
25405       REPAIR/GRAFT RADIUS OR ULNA                                       $739.44       20110801
25415       REPAIR RADIUS ULNA                               A              $2,228.42       20110101
25415       REPAIR RADIUS ULNA              80                                $139.67       20110801
25415       REPAIR RADIUS ULNA              81                                $139.67       20110801



                                                 Page 57
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
25415       REPAIR RADIUS ULNA              82                                $139.67       20110801
25415       REPAIR RADIUS ULNA              AS                                $139.67       20110801
25415       REPAIR RADIUS ULNA                                                $698.36       20110801
25420       REPAIR/GRAFT RADIUS ULNA                         A              $2,251.38       20110101
25420       REPAIR/GRAFT RADIUS ULNA        80                                $166.50       20110801
25420       REPAIR/GRAFT RADIUS ULNA        81                                $166.50       20110801
25420       REPAIR/GRAFT RADIUS ULNA        82                                $166.50       20110801
25420       REPAIR/GRAFT RADIUS ULNA        AS                                $166.50       20110801
25420       REPAIR/GRAFT RADIUS ULNA                                          $832.52       20110801
25425       REPAIR/GRAFT RADIUS OR ULNA                      A              $1,217.14       20110101
25425       REPAIR/GRAFT RADIUS OR ULNA     80                                $142.17       20110801
25425       REPAIR/GRAFT RADIUS OR ULNA     81                                $142.17       20110801
25425       REPAIR/GRAFT RADIUS OR ULNA     82                                $142.17       20110801
25425       REPAIR/GRAFT RADIUS OR ULNA     AS                                $142.17       20110801
25425       REPAIR/GRAFT RADIUS OR ULNA                                       $710.84       20110801
25426       REPAIR/GRAFT RADIUS ULNA                         A              $1,240.11       20110101
25426       REPAIR/GRAFT RADIUS ULNA        80                                $152.98       20110801
25426       REPAIR/GRAFT RADIUS ULNA        81                                $152.98       20110801
25426       REPAIR/GRAFT RADIUS ULNA        82                                $152.98       20110801
25426       REPAIR/GRAFT RADIUS ULNA        AS                                $152.98       20110801
25426       REPAIR/GRAFT RADIUS ULNA                                          $764.92       20110801
25430       VASC GRAFT INTO CARPAL BONE                                       $477.36       20110801
25431       REPAIR NONUNION CARPAL BONE                                       $530.14       20110801
25440       REPAIR/GRAFT WRIST BONE                          A              $2,251.38       20110101
25440       REPAIR/GRAFT WRIST BONE         80                                $104.68       20110801
25440       REPAIR/GRAFT WRIST BONE         81                                $104.68       20110801
25440       REPAIR/GRAFT WRIST BONE         82                                $104.68       20110801
25440       REPAIR/GRAFT WRIST BONE         AS                                $104.68       20110801
25440       REPAIR/GRAFT WRIST BONE                                           $523.38       20110801
25441       RECONSTRUCT WRIST JOINT                          A              $5,034.78       20110101
25441       RECONSTRUCT WRIST JOINT         80                                $125.27       20110801
25441       RECONSTRUCT WRIST JOINT         81                                $125.27       20110801
25441       RECONSTRUCT WRIST JOINT         82                                $125.27       20110801
25441       RECONSTRUCT WRIST JOINT         AS                                $125.27       20110801
25441       RECONSTRUCT WRIST JOINT                                           $626.34       20110801
25442       RECONSTRUCT WRIST JOINT                          A              $5,034.78       20110101
25442       RECONSTRUCT WRIST JOINT         80                                $107.17       20110801
25442       RECONSTRUCT WRIST JOINT         81                                $107.17       20110801
25442       RECONSTRUCT WRIST JOINT         82                                $107.17       20110801
25442       RECONSTRUCT WRIST JOINT         AS                                $107.17       20110801
25442       RECONSTRUCT WRIST JOINT                                           $535.86       20110801
25443       RECONSTRUCT WRIST JOINT                          A              $1,533.29       20110101
25443       RECONSTRUCT WRIST JOINT         80                                $105.82       20110801
25443       RECONSTRUCT WRIST JOINT         81                                $105.82       20110801
25443       RECONSTRUCT WRIST JOINT         82                                $105.82       20110801
25443       RECONSTRUCT WRIST JOINT         AS                                $105.82       20110801
25443       RECONSTRUCT WRIST JOINT                                           $529.10       20110801
25444       RECONSTRUCT WRIST JOINT                          A              $1,533.29       20110101
25444       RECONSTRUCT WRIST JOINT         80                                $103.01       20110801
25444       RECONSTRUCT WRIST JOINT         81                                $103.01       20110801
25444       RECONSTRUCT WRIST JOINT         82                                $103.01       20110801
25444       RECONSTRUCT WRIST JOINT         AS                                $103.01       20110801
25444       RECONSTRUCT WRIST JOINT                                           $515.06       20110801
25445       RECONSTRUCT WRIST JOINT                          A              $1,533.29       20110101
25445       RECONSTRUCT WRIST JOINT                                           $486.72       20110801
25446       WRIST REPLACEMENT                                A              $5,087.98       20110101
25446       WRIST REPLACEMENT               80                                $160.06       20110801
25446       WRIST REPLACEMENT               81                                $160.06       20110801
25446       WRIST REPLACEMENT               82                                $160.06       20110801



                                                 Page 58
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
25446       WRIST REPLACEMENT               AS                                $160.06       20110801
25446       WRIST REPLACEMENT                                                 $800.28       20110801
25447       REPAIR WRIST JOINTS                              A              $1,095.93       20110101
25447       REPAIR WRIST JOINTS             80                                $110.76       20110801
25447       REPAIR WRIST JOINTS             81                                $110.76       20110801
25447       REPAIR WRIST JOINTS             82                                $110.76       20110801
25447       REPAIR WRIST JOINTS             AS                                $110.76       20110801
25447       REPAIR WRIST JOINTS                                               $553.80       20110801
25449       REMOVE WRIST JOINT IMPLANT                       A              $1,095.93       20110101
25449       REMOVE WRIST JOINT IMPLANT      80                                $141.34       20110801
25449       REMOVE WRIST JOINT IMPLANT      81                                $141.34       20110801
25449       REMOVE WRIST JOINT IMPLANT      82                                $141.34       20110801
25449       REMOVE WRIST JOINT IMPLANT      AS                                $141.34       20110801
25449       REMOVE WRIST JOINT IMPLANT                                        $706.68       20110801
25450       REVISION OF WRIST JOINT                          A              $1,217.14       20110101
25450       REVISION OF WRIST JOINT                                           $405.08       20110801
25455       REVISION OF WRIST JOINT                          A              $1,217.14       20110101
25455       REVISION OF WRIST JOINT                                           $441.48       20110801
25490       REINFORCE RADIUS                                 A              $1,217.14       20110101
25490       REINFORCE RADIUS                80                                 $98.18       20110801
25490       REINFORCE RADIUS                81                                 $98.18       20110801
25490       REINFORCE RADIUS                82                                 $98.18       20110801
25490       REINFORCE RADIUS                AS                                 $98.18       20110801
25490       REINFORCE RADIUS                                                  $490.88       20110801
25491       REINFORCE ULNA                                   A              $1,217.14       20110101
25491       REINFORCE ULNA                  80                                $106.39       20110801
25491       REINFORCE ULNA                  81                                $106.39       20110801
25491       REINFORCE ULNA                  82                                $106.39       20110801
25491       REINFORCE ULNA                  AS                                $106.39       20110801
25491       REINFORCE ULNA                                                    $531.96       20110801
25492       REINFORCE RADIUS AND ULNA                        A              $1,217.14       20110101
25492       REINFORCE RADIUS AND ULNA       80                                $128.34       20110801
25492       REINFORCE RADIUS AND ULNA       81                                $128.34       20110801
25492       REINFORCE RADIUS AND ULNA       82                                $128.34       20110801
25492       REINFORCE RADIUS AND ULNA       AS                                $128.34       20110801
25492       REINFORCE RADIUS AND ULNA                                         $641.68       20110801
25500       TREAT FRACTURE OF RADIUS                                          $169.00       20110801
25505       TREAT FRACTURE OF RADIUS                         A                $135.07       20110101
25505       TREAT FRACTURE OF RADIUS                                          $326.56       20110801
25515       TREAT FRACTURE OF RADIUS                         A              $1,190.44       20110101
25515       TREAT FRACTURE OF RADIUS        80                                 $89.70       20110801
25515       TREAT FRACTURE OF RADIUS        81                                 $89.70       20110801
25515       TREAT FRACTURE OF RADIUS        82                                 $89.70       20110801
25515       TREAT FRACTURE OF RADIUS        AS                                 $89.70       20110801
25515       TREAT FRACTURE OF RADIUS                                          $448.50       20110801
25520       TREAT FRACTURE OF RADIUS                         A                $135.07       20110101
25520       TREAT FRACTURE OF RADIUS                                          $362.96       20110801
25525       TREAT FRACTURE OF RADIUS                         A              $1,213.40       20110101
25525       TREAT FRACTURE OF RADIUS        80                                $106.91       20110801
25525       TREAT FRACTURE OF RADIUS        81                                $106.91       20110801
25525       TREAT FRACTURE OF RADIUS        82                                $106.91       20110801
25525       TREAT FRACTURE OF RADIUS        AS                                $106.91       20110801
25525       TREAT FRACTURE OF RADIUS                                          $534.56       20110801
25526       TREAT FRACTURE OF RADIUS                         A              $1,230.05       20110101
25526       TREAT FRACTURE OF RADIUS        80                                $132.29       20110801
25526       TREAT FRACTURE OF RADIUS        81                                $132.29       20110801
25526       TREAT FRACTURE OF RADIUS        82                                $132.29       20110801
25526       TREAT FRACTURE OF RADIUS        AS                                $132.29       20110801
25526       TREAT FRACTURE OF RADIUS                                          $661.44       20110801



                                                 Page 59
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
25530       TREAT FRACTURE OF ULNA                                            $163.28       20110801
25535       TREAT FRACTURE OF ULNA                           A                 $59.66       20110101
25535       TREAT FRACTURE OF ULNA                                            $316.68       20110801
25545       TREAT FRACTURE OF ULNA                           A              $1,190.44       20110101
25545       TREAT FRACTURE OF ULNA          80                                 $83.51       20110801
25545       TREAT FRACTURE OF ULNA          81                                 $83.51       20110801
25545       TREAT FRACTURE OF ULNA          82                                 $83.51       20110801
25545       TREAT FRACTURE OF ULNA          AS                                 $83.51       20110801
25545       TREAT FRACTURE OF ULNA                                            $417.56       20110801
25560       TREAT FRACTURE RADIUS ULNA                                        $171.86       20110801
25565       TREAT FRACTURE RADIUS ULNA                       A                $135.07       20110101
25565       TREAT FRACTURE RADIUS ULNA                                        $341.12       20110801
25574       TREAT FRACTURE RADIUS ULNA                       A              $1,671.34       20110101
25574       TREAT FRACTURE RADIUS ULNA      80                                 $89.86       20110801
25574       TREAT FRACTURE RADIUS ULNA      81                                 $89.86       20110801
25574       TREAT FRACTURE RADIUS ULNA      82                                 $89.86       20110801
25574       TREAT FRACTURE RADIUS ULNA      AS                                 $89.86       20110801
25574       TREAT FRACTURE RADIUS ULNA                                        $449.28       20110801
25575       TREAT FRACTURE RADIUS/ULNA                       A              $1,671.34       20110101
25575       TREAT FRACTURE RADIUS/ULNA      80                                $121.26       20110801
25575       TREAT FRACTURE RADIUS/ULNA      81                                $121.26       20110801
25575       TREAT FRACTURE RADIUS/ULNA      82                                $121.26       20110801
25575       TREAT FRACTURE RADIUS/ULNA      AS                                $121.26       20110801
25575       TREAT FRACTURE RADIUS/ULNA                                        $606.32       20110801
25600       TREAT FRACTURE RADIUS/ULNA                                        $185.64       20110801
25605       TREAT FRACTURE RADIUS/ULNA                       A                $135.07       20110101
25605       TREAT FRACTURE RADIUS/ULNA                                        $407.16       20110801
25606       TREAT FX DISTAL RADIAL                           A                $718.78       20110101
25606       TREAT FX DISTAL RADIAL                                            $445.90       20110801
25607       TREAT FX RAD EXTRA-ARTICUL                       A              $1,710.95       20110101
25607       TREAT FX RAD EXTRA-ARTICUL      80                                 $97.34       20110801
25607       TREAT FX RAD EXTRA-ARTICUL      81                                 $97.34       20110801
25607       TREAT FX RAD EXTRA-ARTICUL      82                                 $97.34       20110801
25607       TREAT FX RAD EXTRA-ARTICUL      AS                                 $97.34       20110801
25607       TREAT FX RAD EXTRA-ARTICUL                                        $486.72       20110801
25608       TREAT FX RAD INTRA-ARTICUL                       A              $1,710.95       20110101
25608       TREAT FX RAD INTRA-ARTICUL                                        $548.60       20110801
25609       TREAT FX RADIAL 3 FRAG                           A              $1,710.95       20110101
25609       TREAT FX RADIAL 3 FRAG                                            $700.18       20110801
25622       TREAT WRIST BONE FRACTURE                                         $191.36       20110801
25624       TREAT WRIST BONE FRACTURE                        A                $135.07       20110101
25624       TREAT WRIST BONE FRACTURE                                         $299.78       20110801
25628       TREAT WRIST BONE FRACTURE                        A              $1,190.44       20110101
25628       TREAT WRIST BONE FRACTURE       80                                 $96.72       20110801
25628       TREAT WRIST BONE FRACTURE       81                                 $96.72       20110801
25628       TREAT WRIST BONE FRACTURE       82                                 $96.72       20110801
25628       TREAT WRIST BONE FRACTURE       AS                                 $96.72       20110801
25628       TREAT WRIST BONE FRACTURE                                         $483.60       20110801
25630       TREAT WRIST BONE FRACTURE                                         $195.00       20110801
25635       TREAT WRIST BONE FRACTURE                        A                $135.07       20110101
25635       TREAT WRIST BONE FRACTURE                                         $286.52       20110801
25645       TREAT WRIST BONE FRACTURE                        A              $1,190.44       20110101
25645       TREAT WRIST BONE FRACTURE       80                                 $76.13       20110801
25645       TREAT WRIST BONE FRACTURE       81                                 $76.13       20110801
25645       TREAT WRIST BONE FRACTURE       82                                 $76.13       20110801
25645       TREAT WRIST BONE FRACTURE       AS                                 $76.13       20110801
25645       TREAT WRIST BONE FRACTURE                                         $380.64       20110801
25650       TREAT WRIST BONE FRACTURE                                         $204.10       20110801
25651       PIN ULNAR STYLOID FRACTURE                                        $318.24       20110801



                                                 Page 60
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
25652       TREAT FRACTURE ULNAR STYLOID                                      $415.48       20110801
25660       TREAT WRIST DISLOCATION                          A                 $59.66       20110101
25660       TREAT WRIST DISLOCATION                                           $268.58       20110801
25670       TREAT WRIST DISLOCATION                          A                $718.78       20110101
25670       TREAT WRIST DISLOCATION         80                                 $81.74       20110801
25670       TREAT WRIST DISLOCATION         81                                 $81.74       20110801
25670       TREAT WRIST DISLOCATION         82                                 $81.74       20110801
25670       TREAT WRIST DISLOCATION         AS                                 $81.74       20110801
25670       TREAT WRIST DISLOCATION                                           $408.72       20110801
25671       PIN RADIOULNAR DISLOCATION                       A                $684.91       20110101
25671       PIN RADIOULNAR DISLOCATION                                        $349.18       20110801
25675       TREAT WRIST DISLOCATION                          A                 $59.66       20110101
25675       TREAT WRIST DISLOCATION                                           $281.32       20110801
25676       TREAT WRIST DISLOCATION                          A                $706.54       20110101
25676       TREAT WRIST DISLOCATION         80                                 $84.55       20110801
25676       TREAT WRIST DISLOCATION         81                                 $84.55       20110801
25676       TREAT WRIST DISLOCATION         82                                 $84.55       20110801
25676       TREAT WRIST DISLOCATION         AS                                 $84.55       20110801
25676       TREAT WRIST DISLOCATION                                           $422.76       20110801
25680       TREAT WRIST FRACTURE                             A                 $59.66       20110101
25680       TREAT WRIST FRACTURE                                              $308.62       20110801
25685       TREAT WRIST FRACTURE                             A                $718.78       20110101
25685       TREAT WRIST FRACTURE            80                                 $98.96       20110801
25685       TREAT WRIST FRACTURE            81                                 $98.96       20110801
25685       TREAT WRIST FRACTURE            82                                 $98.96       20110801
25685       TREAT WRIST FRACTURE            AS                                 $98.96       20110801
25685       TREAT WRIST FRACTURE                                              $494.78       20110801
25690       TREAT WRIST DISLOCATION                          A                $462.00       20110101
25690       TREAT WRIST DISLOCATION                                           $311.74       20110801
25695       TREAT WRIST DISLOCATION                          A                $706.54       20110101
25695       TREAT WRIST DISLOCATION         80                                 $85.28       20110801
25695       TREAT WRIST DISLOCATION         81                                 $85.28       20110801
25695       TREAT WRIST DISLOCATION         82                                 $85.28       20110801
25695       TREAT WRIST DISLOCATION         AS                                 $85.28       20110801
25695       TREAT WRIST DISLOCATION                                           $426.40       20110801
25800       FUSION OF WRIST JOINT                            A              $2,251.38       20110101
25800       FUSION OF WRIST JOINT           80                                $100.05       20110801
25800       FUSION OF WRIST JOINT           81                                $100.05       20110801
25800       FUSION OF WRIST JOINT           82                                $100.05       20110801
25800       FUSION OF WRIST JOINT           AS                                $100.05       20110801
25800       FUSION OF WRIST JOINT                                             $500.24       20110801
25805       FUSION/GRAFT OF WRIST JOINT                      A              $1,256.75       20110101
25805       FUSION/GRAFT OF WRIST JOINT     80                                $115.86       20110801
25805       FUSION/GRAFT OF WRIST JOINT     81                                $115.86       20110801
25805       FUSION/GRAFT OF WRIST JOINT     82                                $115.86       20110801
25805       FUSION/GRAFT OF WRIST JOINT     AS                                $115.86       20110801
25805       FUSION/GRAFT OF WRIST JOINT                                       $579.28       20110801
25810       FUSION/GRAFT OF WRIST JOINT                      A              $2,268.02       20110101
25810       FUSION/GRAFT OF WRIST JOINT     80                                $117.57       20110801
25810       FUSION/GRAFT OF WRIST JOINT     81                                $117.57       20110801
25810       FUSION/GRAFT OF WRIST JOINT     82                                $117.57       20110801
25810       FUSION/GRAFT OF WRIST JOINT     AS                                $117.57       20110801
25810       FUSION/GRAFT OF WRIST JOINT                                       $587.86       20110801
25820       FUSION OF HAND BONES                             A              $1,240.11       20110101
25820       FUSION OF HAND BONES            80                                 $82.11       20110801
25820       FUSION OF HAND BONES            81                                 $82.11       20110801
25820       FUSION OF HAND BONES            82                                 $82.11       20110801
25820       FUSION OF HAND BONES            AS                                 $82.11       20110801
25820       FUSION OF HAND BONES                                              $410.54       20110801



                                                 Page 61
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
25825       FUSE HAND BONES WITH GRAFT                      A              $2,268.02       20110101
25825       FUSE HAND BONES WITH GRAFT     80                                $101.40       20110801
25825       FUSE HAND BONES WITH GRAFT     81                                $101.40       20110801
25825       FUSE HAND BONES WITH GRAFT     82                                $101.40       20110801
25825       FUSE HAND BONES WITH GRAFT     AS                                $101.40       20110801
25825       FUSE HAND BONES WITH GRAFT                                       $507.00       20110801
25830       FUSION RADIOULNAR JNT/ULNA                      A              $2,268.02       20110101
25830       FUSION RADIOULNAR JNT/ULNA     80                                $127.45       20110801
25830       FUSION RADIOULNAR JNT/ULNA     81                                $127.45       20110801
25830       FUSION RADIOULNAR JNT/ULNA     82                                $127.45       20110801
25830       FUSION RADIOULNAR JNT/ULNA     AS                                $127.45       20110801
25830       FUSION RADIOULNAR JNT/ULNA                                       $637.26       20110801
25900       AMPUTATION OF FOREARM          80                                $100.31       20110801
25900       AMPUTATION OF FOREARM          81                                $100.31       20110801
25900       AMPUTATION OF FOREARM          82                                $100.31       20110801
25900       AMPUTATION OF FOREARM          AS                                $100.31       20110801
25900       AMPUTATION OF FOREARM                                            $501.54       20110801
25905       AMPUTATION OF FOREARM          80                                 $98.96       20110801
25905       AMPUTATION OF FOREARM          81                                 $98.96       20110801
25905       AMPUTATION OF FOREARM          82                                 $98.96       20110801
25905       AMPUTATION OF FOREARM          AS                                 $98.96       20110801
25905       AMPUTATION OF FOREARM                                            $494.78       20110801
25907       AMPUTATION FOLLOW-UP SURGERY                    A                $626.73       20110101
25907       AMPUTATION FOLLOW-UP SURGERY   80                                 $86.58       20110801
25907       AMPUTATION FOLLOW-UP SURGERY   81                                 $86.58       20110801
25907       AMPUTATION FOLLOW-UP SURGERY   82                                 $86.58       20110801
25907       AMPUTATION FOLLOW-UP SURGERY   AS                                 $86.58       20110801
25907       AMPUTATION FOLLOW-UP SURGERY                                     $432.90       20110801
25909       AMPUTATION FOLLOW-UP SURGERY   80                                 $96.93       20110801
25909       AMPUTATION FOLLOW-UP SURGERY   81                                 $96.93       20110801
25909       AMPUTATION FOLLOW-UP SURGERY   82                                 $96.93       20110801
25909       AMPUTATION FOLLOW-UP SURGERY   AS                                 $96.93       20110801
25909       AMPUTATION FOLLOW-UP SURGERY                                     $484.64       20110801
25915       AMPUTATION OF FOREARM          80                                $160.21       20110801
25915       AMPUTATION OF FOREARM          81                                $160.21       20110801
25915       AMPUTATION OF FOREARM          82                                $160.21       20110801
25915       AMPUTATION OF FOREARM          AS                                $160.21       20110801
25915       AMPUTATION OF FOREARM                                            $801.06       20110801
25920       AMPUTATE HAND AT WRIST         80                                 $92.98       20110801
25920       AMPUTATE HAND AT WRIST         81                                 $92.98       20110801
25920       AMPUTATE HAND AT WRIST         82                                 $92.98       20110801
25920       AMPUTATE HAND AT WRIST         AS                                 $92.98       20110801
25920       AMPUTATE HAND AT WRIST                                           $464.88       20110801
25922       AMPUTATE HAND AT WRIST                          A                $626.73       20110101
25922       AMPUTATE HAND AT WRIST         80                                 $72.75       20110801
25922       AMPUTATE HAND AT WRIST         81                                 $72.75       20110801
25922       AMPUTATE HAND AT WRIST         82                                 $72.75       20110801
25922       AMPUTATE HAND AT WRIST         AS                                 $72.75       20110801
25922       AMPUTATE HAND AT WRIST                                           $363.74       20110801
25924       AMPUTATION FOLLOW-UP SURGERY   80                                 $90.69       20110801
25924       AMPUTATION FOLLOW-UP SURGERY   81                                 $90.69       20110801
25924       AMPUTATION FOLLOW-UP SURGERY   82                                 $90.69       20110801
25924       AMPUTATION FOLLOW-UP SURGERY   AS                                 $90.69       20110801
25924       AMPUTATION FOLLOW-UP SURGERY                                     $453.44       20110801
25927       AMPUTATION OF HAND                                               $529.36       20110801
25929       AMPUTATION FOLLOW-UP SURGERY                    A                $483.46       20110101
25929       AMPUTATION FOLLOW-UP SURGERY   80                                 $77.12       20110801
25929       AMPUTATION FOLLOW-UP SURGERY   81                                 $77.12       20110801
25929       AMPUTATION FOLLOW-UP SURGERY   82                                 $77.12       20110801



                                                Page 62
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
25929       AMPUTATION FOLLOW-UP SURGERY   AS                                    $77.12       20110801
25929       AMPUTATION FOLLOW-UP SURGERY                                        $385.58       20110801
25931       AMPUTATION FOLLOW-UP SURGERY                                        $474.24       20110801
26010       DRAINAGE OF FINGER ABSCESS                                          $164.58       20110801
26011       DRAINAGE OF FINGER ABSCESS                      A                   $367.10       20110101
26011       DRAINAGE OF FINGER ABSCESS                                          $248.30       20110801
26020       DRAIN HAND TENDON SHEATH                        A                   $494.96       20110101
26020       DRAIN HAND TENDON SHEATH                                            $285.22       20110801
26025       DRAINAGE OF PALM BURSA                          A                   $473.34       20110101
26025       DRAINAGE OF PALM BURSA                                              $277.68       20110801
26030       DRAINAGE OF PALM BURSAS                         A                   $494.96       20110101
26030       DRAINAGE OF PALM BURSAS                                             $328.12       20110801
26034       TREAT HAND BONE LESION                          A                   $494.96       20110101
26034       TREAT HAND BONE LESION                                              $355.94       20110801
26035       DECOMPRESS FINGERS/HAND                         A                   $546.16       20110101
26035       DECOMPRESS FINGERS/HAND                                             $564.72       20110801
26037       DECOMPRESS FINGERS/HAND                                             $382.98       20110801
26040       RELEASE PALM CONTRACTURE                        A                   $799.26       20110101
26040       RELEASE PALM CONTRACTURE                                            $202.54       20110801
26045       RELEASE PALM CONTRACTURE                        A                   $776.30       20110101
26045       RELEASE PALM CONTRACTURE                                            $309.92       20110801
26055       INCISE FINGER TENDON SHEATH                     A                   $494.96       20110101
26055       INCISE FINGER TENDON SHEATH                                         $362.70       20110801
26060       INCISION OF FINGER TENDON                       A                   $494.96       20110101
26060       INCISION OF FINGER TENDON                                           $174.20       20110801
26070       EXPLORE/TREAT HAND JOINT                        A                   $494.96       20110101
26070       EXPLORE/TREAT HAND JOINT                                            $200.46       20110801
26075       EXPLORE/TREAT FINGER JOINT                      A                   $530.17       20110101
26075       EXPLORE/TREAT FINGER JOINT                                          $211.38       20110801
26080       EXPLORE/TREAT FINGER JOINT                      A                   $530.17       20110101
26080       EXPLORE/TREAT FINGER JOINT                                          $254.02       20110801
26100       BIOPSY HAND JOINT LINING                        A                   $494.96       20110101
26100       BIOPSY HAND JOINT LINING                                            $215.54       20110801
26105       BIOPSY FINGER JOINT LINING                      A                   $473.34       20110101
26105       BIOPSY FINGER JOINT LINING                                          $219.18       20110801
26110       BIOPSY FINGER JOINT LINING                      A                   $473.34       20110101
26110       BIOPSY FINGER JOINT LINING                                          $209.82       20110801
26111       EXC HAND LES SC 1.5 CM/                                             $290.16       20110801
26113       EXC HAND TUM DEEP 1.5 CM/                                           $381.16       20110801
26115       EXC HAND LES SC 1.5 CM                          A                   $229.62       20110101
26115       EXC HAND LES SC 1.5 CM                                              $378.82       20110801
26116       EXC HAND TUM DEEP 1.5 CM                        A                   $560.76       20110101
26116       EXC HAND TUM DEEP 1.5 CM                                            $349.96       20110801
26117       EXC HAND TUM RA 3 CM                            A                   $560.76       20110101
26117       EXC HAND TUM RA 3 CM                                                $484.64       20110801
26118       EXC HAND TUM RA 3 CM/                                               $749.06       20110801
26121       RELEASE PALM CONTRACTURE                        A                   $799.26       20110101
26121       RELEASE PALM CONTRACTURE                                            $399.62       20110801
26123       RELEASE PALM CONTRACTURE                        A                   $799.26       20110101
26123       RELEASE PALM CONTRACTURE                                            $554.06       20110801
26125       RELEASE PALM CONTRACTURE                        A                   $530.17       20110101
26125       RELEASE PALM CONTRACTURE                                            $193.18       20110801
26130       REMOVE WRIST JOINT LINING                       A                   $507.20       20110101
26130       REMOVE WRIST JOINT LINING                                           $303.16       20110801
26135       REVISE FINGER JOINT EACH                        A                   $799.26       20110101
26135       REVISE FINGER JOINT EACH                                            $367.90       20110801
26140       REVISE FINGER JOINT EACH                        A                   $494.96       20110101
26140       REVISE FINGER JOINT EACH                                            $335.92       20110801
26145       TENDON EXCISION PALM/FINGER                     A                   $507.20       20110101



                                                Page 63
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
26145       TENDON EXCISION PALM/FINGER                                          $341.12       20110801
26160       REMOVE TENDON SHEATH LESION                      A                   $507.20       20110101
26160       REMOVE TENDON SHEATH LESION                                          $366.60       20110801
26170       REMOVAL OF PALM TENDON EACH                      A                   $507.20       20110101
26170       REMOVAL OF PALM TENDON EACH                                          $268.58       20110801
26180       REMOVAL OF FINGER TENDON                         A                   $507.20       20110101
26180       REMOVAL OF FINGER TENDON                                             $293.02       20110801
26185       REMOVE FINGER BONE                               A                   $530.17       20110101
26185       REMOVE FINGER BONE              80                                    $71.76       20110801
26185       REMOVE FINGER BONE              81                                    $71.76       20110801
26185       REMOVE FINGER BONE              82                                    $71.76       20110801
26185       REMOVE FINGER BONE              AS                                    $71.76       20110801
26185       REMOVE FINGER BONE                                                   $358.80       20110801
26200       REMOVE HAND BONE LESION                          A                   $494.96       20110101
26200       REMOVE HAND BONE LESION                                              $300.04       20110801
26205       REMOVE/GRAFT BONE LESION                         A                   $776.30       20110101
26205       REMOVE/GRAFT BONE LESION                                             $405.08       20110801
26210       REMOVAL OF FINGER LESION                         A                   $494.96       20110101
26210       REMOVAL OF FINGER LESION                                             $291.98       20110801
26215       REMOVE/GRAFT FINGER LESION                       A                   $507.20       20110101
26215       REMOVE/GRAFT FINGER LESION                                           $374.92       20110801
26230       PARTIAL REMOVAL OF HAND BONE                     A                   $599.61       20110101
26230       PARTIAL REMOVAL OF HAND BONE                                         $334.10       20110801
26235       PARTIAL REMOVAL FINGER BONE                      A                   $507.20       20110101
26235       PARTIAL REMOVAL FINGER BONE                                          $329.68       20110801
26236       PARTIAL REMOVAL FINGER BONE                      A                   $507.20       20110101
26236       PARTIAL REMOVAL FINGER BONE                                          $293.02       20110801
26250       EXTENSIVE HAND SURGERY                           A                   $507.20       20110101
26250       EXTENSIVE HAND SURGERY                                               $647.66       20110801
26260       RESECT PROX FINGER TUMOR                         A                   $507.20       20110101
26260       RESECT PROX FINGER TUMOR        80                                   $100.46       20110801
26260       RESECT PROX FINGER TUMOR        81                                   $100.46       20110801
26260       RESECT PROX FINGER TUMOR        82                                   $100.46       20110801
26260       RESECT PROX FINGER TUMOR        AS                                   $100.46       20110801
26260       RESECT PROX FINGER TUMOR                                             $502.32       20110801
26262       RESECT DISTAL FINGER TUMOR                       A                   $494.96       20110101
26262       RESECT DISTAL FINGER TUMOR      80                                    $78.47       20110801
26262       RESECT DISTAL FINGER TUMOR      81                                    $78.47       20110801
26262       RESECT DISTAL FINGER TUMOR      82                                    $78.47       20110801
26262       RESECT DISTAL FINGER TUMOR      AS                                    $78.47       20110801
26262       RESECT DISTAL FINGER TUMOR                                           $392.34       20110801
26320       REMOVAL OF IMPLANT FROM HAND                     A                   $505.90       20110101
26320       REMOVAL OF IMPLANT FROM HAND                                         $228.28       20110801
26340       MANIPULATE FINGER W/ANESTH                                           $210.08       20110801
26341       MANIPULAT PALM CORD POST INJ                                          $75.40       20120101
26350       REPAIR FINGER/HAND TENDON                        A                   $742.43       20110101
26350       REPAIR FINGER/HAND TENDON                                            $468.00       20110801
26352       REPAIR/GRAFT HAND TENDON                         A                   $799.26       20110101
26352       REPAIR/GRAFT HAND TENDON        80                                   $107.17       20110801
26352       REPAIR/GRAFT HAND TENDON        81                                   $107.17       20110801
26352       REPAIR/GRAFT HAND TENDON        82                                   $107.17       20110801
26352       REPAIR/GRAFT HAND TENDON        AS                                   $107.17       20110801
26352       REPAIR/GRAFT HAND TENDON                                             $535.86       20110801
26356       REPAIR FINGER/HAND TENDON                        A                   $799.26       20110101
26356       REPAIR FINGER/HAND TENDON                                            $712.66       20110801
26357       REPAIR FINGER/HAND TENDON                        A                   $799.26       20110101
26357       REPAIR FINGER/HAND TENDON       80                                   $114.76       20110801
26357       REPAIR FINGER/HAND TENDON       81                                   $114.76       20110801
26357       REPAIR FINGER/HAND TENDON       82                                   $114.76       20110801



                                                 Page 64
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
26357       REPAIR FINGER/HAND TENDON       AS                                   $114.76       20110801
26357       REPAIR FINGER/HAND TENDON                                            $573.82       20110801
26358       REPAIR/GRAFT HAND TENDON                         A                   $799.26       20110101
26358       REPAIR/GRAFT HAND TENDON        80                                   $121.58       20110801
26358       REPAIR/GRAFT HAND TENDON        81                                   $121.58       20110801
26358       REPAIR/GRAFT HAND TENDON        82                                   $121.58       20110801
26358       REPAIR/GRAFT HAND TENDON        AS                                   $121.58       20110801
26358       REPAIR/GRAFT HAND TENDON                                             $607.88       20110801
26370       REPAIR FINGER/HAND TENDON                        A                   $799.26       20110101
26370       REPAIR FINGER/HAND TENDON                                            $505.70       20110801
26372       REPAIR/GRAFT HAND TENDON                         A                   $799.26       20110101
26372       REPAIR/GRAFT HAND TENDON        80                                   $117.68       20110801
26372       REPAIR/GRAFT HAND TENDON        81                                   $117.68       20110801
26372       REPAIR/GRAFT HAND TENDON        82                                   $117.68       20110801
26372       REPAIR/GRAFT HAND TENDON        AS                                   $117.68       20110801
26372       REPAIR/GRAFT HAND TENDON                                             $588.38       20110801
26373       REPAIR FINGER/HAND TENDON                        A                   $776.30       20110101
26373       REPAIR FINGER/HAND TENDON       80                                   $112.16       20110801
26373       REPAIR FINGER/HAND TENDON       81                                   $112.16       20110801
26373       REPAIR FINGER/HAND TENDON       82                                   $112.16       20110801
26373       REPAIR FINGER/HAND TENDON       AS                                   $112.16       20110801
26373       REPAIR FINGER/HAND TENDON                                            $560.82       20110801
26390       REVISE HAND/FINGER TENDON                        A                   $799.26       20110101
26390       REVISE HAND/FINGER TENDON       80                                   $110.71       20110801
26390       REVISE HAND/FINGER TENDON       81                                   $110.71       20110801
26390       REVISE HAND/FINGER TENDON       82                                   $110.71       20110801
26390       REVISE HAND/FINGER TENDON       AS                                   $110.71       20110801
26390       REVISE HAND/FINGER TENDON                                            $553.54       20110801
26392       REPAIR/GRAFT HAND TENDON                         A                   $776.30       20110101
26392       REPAIR/GRAFT HAND TENDON        80                                   $128.96       20110801
26392       REPAIR/GRAFT HAND TENDON        81                                   $128.96       20110801
26392       REPAIR/GRAFT HAND TENDON        82                                   $128.96       20110801
26392       REPAIR/GRAFT HAND TENDON        AS                                   $128.96       20110801
26392       REPAIR/GRAFT HAND TENDON                                             $644.80       20110801
26410       REPAIR HAND TENDON                               A                   $507.20       20110101
26410       REPAIR HAND TENDON                                                   $371.02       20110801
26412       REPAIR/GRAFT HAND TENDON                         A                   $776.30       20110101
26412       REPAIR/GRAFT HAND TENDON        80                                    $90.27       20110801
26412       REPAIR/GRAFT HAND TENDON        81                                    $90.27       20110801
26412       REPAIR/GRAFT HAND TENDON        82                                    $90.27       20110801
26412       REPAIR/GRAFT HAND TENDON        AS                                    $90.27       20110801
26412       REPAIR/GRAFT HAND TENDON                                             $451.36       20110801
26415       EXCISION HAND/FINGER TENDON                      A                   $799.26       20110101
26415       EXCISION HAND/FINGER TENDON                                          $473.20       20110801
26416       GRAFT HAND OR FINGER TENDON                      A                   $776.30       20110101
26416       GRAFT HAND OR FINGER TENDON                                          $540.54       20110801
26418       REPAIR FINGER TENDON                             A                   $530.17       20110101
26418       REPAIR FINGER TENDON                                                 $374.66       20110801
26420       REPAIR/GRAFT FINGER TENDON                       A                   $799.26       20110101
26420       REPAIR/GRAFT FINGER TENDON      80                                    $94.38       20110801
26420       REPAIR/GRAFT FINGER TENDON      81                                    $94.38       20110801
26420       REPAIR/GRAFT FINGER TENDON      82                                    $94.38       20110801
26420       REPAIR/GRAFT FINGER TENDON      AS                                    $94.38       20110801
26420       REPAIR/GRAFT FINGER TENDON                                           $471.90       20110801
26426       REPAIR FINGER/HAND TENDON                        A                   $776.30       20110101
26426       REPAIR FINGER/HAND TENDON                                            $370.24       20110801
26428       REPAIR/GRAFT FINGER TENDON                       A                   $776.30       20110101
26428       REPAIR/GRAFT FINGER TENDON                                           $497.12       20110801
26432       REPAIR FINGER TENDON                             A                   $507.20       20110101



                                                 Page 65
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
26432       REPAIR FINGER TENDON                                                $325.26       20110801
26433       REPAIR FINGER TENDON                            A                   $507.20       20110101
26433       REPAIR FINGER TENDON                                                $348.66       20110801
26434       REPAIR/GRAFT FINGER TENDON                      A                   $776.30       20110101
26434       REPAIR/GRAFT FINGER TENDON     80                                    $84.55       20110801
26434       REPAIR/GRAFT FINGER TENDON     81                                    $84.55       20110801
26434       REPAIR/GRAFT FINGER TENDON     82                                    $84.55       20110801
26434       REPAIR/GRAFT FINGER TENDON     AS                                    $84.55       20110801
26434       REPAIR/GRAFT FINGER TENDON                                          $422.76       20110801
26437       REALIGNMENT OF TENDONS                          A                   $507.20       20110101
26437       REALIGNMENT OF TENDONS                                              $408.46       20110801
26440       RELEASE PALM/FINGER TENDON                      A                   $507.20       20110101
26440       RELEASE PALM/FINGER TENDON                                          $408.20       20110801
26442       RELEASE PALM FINGER TENDON                      A                   $776.30       20110101
26442       RELEASE PALM FINGER TENDON                                          $632.06       20110801
26445       RELEASE HAND/FINGER TENDON                      A                   $507.20       20110101
26445       RELEASE HAND/FINGER TENDON                                          $378.82       20110801
26449       RELEASE FOREARM/HAND TENDON                     A                   $776.30       20110101
26449       RELEASE FOREARM/HAND TENDON                                         $498.94       20110801
26450       INCISION OF PALM TENDON                         A                   $507.20       20110101
26450       INCISION OF PALM TENDON                                             $264.68       20110801
26455       INCISION OF FINGER TENDON                       A                   $507.20       20110101
26455       INCISION OF FINGER TENDON                                           $263.12       20110801
26460       INCISE HAND/FINGER TENDON                       A                   $507.20       20110101
26460       INCISE HAND/FINGER TENDON                                           $255.32       20110801
26471       FUSION OF FINGER TENDONS                        A                   $494.96       20110101
26471       FUSION OF FINGER TENDONS                                            $403.26       20110801
26474       FUSION OF FINGER TENDONS                        A                   $494.96       20110101
26474       FUSION OF FINGER TENDONS       80                                    $78.00       20110801
26474       FUSION OF FINGER TENDONS       81                                    $78.00       20110801
26474       FUSION OF FINGER TENDONS       82                                    $78.00       20110801
26474       FUSION OF FINGER TENDONS       AS                                    $78.00       20110801
26474       FUSION OF FINGER TENDONS                                            $390.00       20110801
26476       TENDON LENGTHENING                              A                   $473.34       20110101
26476       TENDON LENGTHENING                                                  $380.64       20110801
26477       TENDON SHORTENING                               A                   $473.34       20110101
26477       TENDON SHORTENING                                                   $381.16       20110801
26478       LENGTHENING OF HAND TENDON                      A                   $473.34       20110101
26478       LENGTHENING OF HAND TENDON                                          $411.58       20110801
26479       SHORTENING OF HAND TENDON                       A                   $473.34       20110101
26479       SHORTENING OF HAND TENDON      80                                    $81.90       20110801
26479       SHORTENING OF HAND TENDON      81                                    $81.90       20110801
26479       SHORTENING OF HAND TENDON      82                                    $81.90       20110801
26479       SHORTENING OF HAND TENDON      AS                                    $81.90       20110801
26479       SHORTENING OF HAND TENDON                                           $409.50       20110801
26480       TRANSPLANT HAND TENDON                          A                   $776.30       20110101
26480       TRANSPLANT HAND TENDON         80                                    $99.06       20110801
26480       TRANSPLANT HAND TENDON         81                                    $99.06       20110801
26480       TRANSPLANT HAND TENDON         82                                    $99.06       20110801
26480       TRANSPLANT HAND TENDON         AS                                    $99.06       20110801
26480       TRANSPLANT HAND TENDON                                              $495.30       20110801
26483       TRANSPLANT/GRAFT HAND TENDON                    A                   $776.30       20110101
26483       TRANSPLANT/GRAFT HAND TENDON   80                                   $111.75       20110801
26483       TRANSPLANT/GRAFT HAND TENDON   81                                   $111.75       20110801
26483       TRANSPLANT/GRAFT HAND TENDON   82                                   $111.75       20110801
26483       TRANSPLANT/GRAFT HAND TENDON   AS                                   $111.75       20110801
26483       TRANSPLANT/GRAFT HAND TENDON                                        $558.74       20110801
26485       TRANSPLANT PALM TENDON                          A                   $764.05       20110101
26485       TRANSPLANT PALM TENDON         80                                   $107.02       20110801



                                                Page 66
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
26485       TRANSPLANT PALM TENDON         81                                   $107.02       20110801
26485       TRANSPLANT PALM TENDON         82                                   $107.02       20110801
26485       TRANSPLANT PALM TENDON         AS                                   $107.02       20110801
26485       TRANSPLANT PALM TENDON                                              $535.08       20110801
26489       TRANSPLANT/GRAFT PALM TENDON                    A                   $776.30       20110101
26489       TRANSPLANT/GRAFT PALM TENDON                                        $594.88       20110801
26490       REVISE THUMB TENDON                             A                   $776.30       20110101
26490       REVISE THUMB TENDON                                                 $522.34       20110801
26492       TENDON TRANSFER WITH GRAFT                      A                   $776.30       20110101
26492       TENDON TRANSFER WITH GRAFT     80                                   $116.74       20110801
26492       TENDON TRANSFER WITH GRAFT     81                                   $116.74       20110801
26492       TENDON TRANSFER WITH GRAFT     82                                   $116.74       20110801
26492       TENDON TRANSFER WITH GRAFT     AS                                   $116.74       20110801
26492       TENDON TRANSFER WITH GRAFT                                          $583.70       20110801
26494       HAND TENDON/MUSCLE TRANSFER                     A                   $776.30       20110101
26494       HAND TENDON/MUSCLE TRANSFER    80                                   $105.66       20110801
26494       HAND TENDON/MUSCLE TRANSFER    81                                   $105.66       20110801
26494       HAND TENDON/MUSCLE TRANSFER    82                                   $105.66       20110801
26494       HAND TENDON/MUSCLE TRANSFER    AS                                   $105.66       20110801
26494       HAND TENDON/MUSCLE TRANSFER                                         $528.32       20110801
26496       REVISE THUMB TENDON                             A                   $776.30       20110101
26496       REVISE THUMB TENDON                                                 $569.40       20110801
26497       FINGER TENDON TRANSFER                          A                   $776.30       20110101
26497       FINGER TENDON TRANSFER         80                                   $114.87       20110801
26497       FINGER TENDON TRANSFER         81                                   $114.87       20110801
26497       FINGER TENDON TRANSFER         82                                   $114.87       20110801
26497       FINGER TENDON TRANSFER         AS                                   $114.87       20110801
26497       FINGER TENDON TRANSFER                                              $574.34       20110801
26498       FINGER TENDON TRANSFER                          A                   $799.26       20110101
26498       FINGER TENDON TRANSFER         80                                   $153.45       20110801
26498       FINGER TENDON TRANSFER         81                                   $153.45       20110801
26498       FINGER TENDON TRANSFER         82                                   $153.45       20110801
26498       FINGER TENDON TRANSFER         AS                                   $153.45       20110801
26498       FINGER TENDON TRANSFER                                              $767.26       20110801
26499       REVISION OF FINGER                              A                   $776.30       20110101
26499       REVISION OF FINGER             80                                   $109.77       20110801
26499       REVISION OF FINGER             81                                   $109.77       20110801
26499       REVISION OF FINGER             82                                   $109.77       20110801
26499       REVISION OF FINGER             AS                                   $109.77       20110801
26499       REVISION OF FINGER                                                  $548.86       20110801
26500       HAND TENDON RECONSTRUCTION                      A                   $530.17       20110101
26500       HAND TENDON RECONSTRUCTION                                          $412.62       20110801
26502       HAND TENDON RECONSTRUCTION                      A                   $799.26       20110101
26502       HAND TENDON RECONSTRUCTION     80                                    $93.39       20110801
26502       HAND TENDON RECONSTRUCTION     81                                    $93.39       20110801
26502       HAND TENDON RECONSTRUCTION     82                                    $93.39       20110801
26502       HAND TENDON RECONSTRUCTION     AS                                    $93.39       20110801
26502       HAND TENDON RECONSTRUCTION                                          $466.96       20110801
26508       RELEASE THUMB CONTRACTURE                       A                   $507.20       20110101
26508       RELEASE THUMB CONTRACTURE                                           $412.10       20110801
26510       THUMB TENDON TRANSFER                           A                   $776.30       20110101
26510       THUMB TENDON TRANSFER                                               $392.60       20110801
26516       FUSION OF KNUCKLE JOINT                         A                   $742.43       20110101
26516       FUSION OF KNUCKLE JOINT                                             $463.06       20110801
26517       FUSION OF KNUCKLE JOINTS                        A                   $776.30       20110101
26517       FUSION OF KNUCKLE JOINTS       80                                   $109.56       20110801
26517       FUSION OF KNUCKLE JOINTS       81                                   $109.56       20110801
26517       FUSION OF KNUCKLE JOINTS       82                                   $109.56       20110801
26517       FUSION OF KNUCKLE JOINTS       AS                                   $109.56       20110801



                                                Page 67
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
26517       FUSION OF KNUCKLE JOINTS                                         $547.82       20110801
26518       FUSION OF KNUCKLE JOINTS                        A                $776.30       20110101
26518       FUSION OF KNUCKLE JOINTS       80                                $110.92       20110801
26518       FUSION OF KNUCKLE JOINTS       81                                $110.92       20110801
26518       FUSION OF KNUCKLE JOINTS       82                                $110.92       20110801
26518       FUSION OF KNUCKLE JOINTS       AS                                $110.92       20110801
26518       FUSION OF KNUCKLE JOINTS                                         $554.58       20110801
26520       RELEASE KNUCKLE CONTRACTURE                     A                $507.20       20110101
26520       RELEASE KNUCKLE CONTRACTURE                                      $428.22       20110801
26525       RELEASE FINGER CONTRACTURE                      A                $507.20       20110101
26525       RELEASE FINGER CONTRACTURE                                       $429.00       20110801
26530       REVISE KNUCKLE JOINT                            A              $1,056.32       20110101
26530       REVISE KNUCKLE JOINT           80                                 $71.50       20110801
26530       REVISE KNUCKLE JOINT           81                                 $71.50       20110801
26530       REVISE KNUCKLE JOINT           82                                 $71.50       20110801
26530       REVISE KNUCKLE JOINT           AS                                 $71.50       20110801
26530       REVISE KNUCKLE JOINT                                             $357.50       20110801
26531       REVISE KNUCKLE WITH IMPLANT                     A              $1,586.48       20110101
26531       REVISE KNUCKLE WITH IMPLANT    80                                 $83.25       20110801
26531       REVISE KNUCKLE WITH IMPLANT    81                                 $83.25       20110801
26531       REVISE KNUCKLE WITH IMPLANT    82                                 $83.25       20110801
26531       REVISE KNUCKLE WITH IMPLANT    AS                                 $83.25       20110801
26531       REVISE KNUCKLE WITH IMPLANT                                      $416.26       20110801
26535       REVISE FINGER JOINT                             A              $1,095.93       20110101
26535       REVISE FINGER JOINT                                              $270.40       20110801
26536       REVISE/IMPLANT FINGER JOINT                     A              $1,533.29       20110101
26536       REVISE/IMPLANT FINGER JOINT    80                                 $89.60       20110801
26536       REVISE/IMPLANT FINGER JOINT    81                                 $89.60       20110801
26536       REVISE/IMPLANT FINGER JOINT    82                                 $89.60       20110801
26536       REVISE/IMPLANT FINGER JOINT    AS                                 $89.60       20110801
26536       REVISE/IMPLANT FINGER JOINT                                      $447.98       20110801
26540       REPAIR HAND JOINT                               A                $530.17       20110101
26540       REPAIR HAND JOINT                                                $434.72       20110801
26541       REPAIR HAND JOINT WITH GRAFT                    A                $869.10       20110101
26541       REPAIR HAND JOINT WITH GRAFT   80                                $106.39       20110801
26541       REPAIR HAND JOINT WITH GRAFT   81                                $106.39       20110801
26541       REPAIR HAND JOINT WITH GRAFT   82                                $106.39       20110801
26541       REPAIR HAND JOINT WITH GRAFT   AS                                $106.39       20110801
26541       REPAIR HAND JOINT WITH GRAFT                                     $531.96       20110801
26542       REPAIR HAND JOINT WITH GRAFT                    A                $530.17       20110101
26542       REPAIR HAND JOINT WITH GRAFT                                     $448.50       20110801
26545       RECONSTRUCT FINGER JOINT                        A                $799.26       20110101
26545       RECONSTRUCT FINGER JOINT                                         $458.64       20110801
26546       REPAIR NONUNION HAND                            A                $799.26       20110101
26546       REPAIR NONUNION HAND           80                                $130.00       20110801
26546       REPAIR NONUNION HAND           81                                $130.00       20110801
26546       REPAIR NONUNION HAND           82                                $130.00       20110801
26546       REPAIR NONUNION HAND           AS                                $130.00       20110801
26546       REPAIR NONUNION HAND                                             $650.00       20110801
26548       RECONSTRUCT FINGER JOINT                        A                $799.26       20110101
26548       RECONSTRUCT FINGER JOINT                                         $505.18       20110801
26550       CONSTRUCT THUMB REPLACEMENT                     A                $764.05       20110101
26550       CONSTRUCT THUMB REPLACEMENT    80                                $207.95       20110801
26550       CONSTRUCT THUMB REPLACEMENT    81                                $207.95       20110801
26550       CONSTRUCT THUMB REPLACEMENT    82                                $207.95       20110801
26550       CONSTRUCT THUMB REPLACEMENT    AS                                $207.95       20110801
26550       CONSTRUCT THUMB REPLACEMENT                                    $1,039.74       20110801
26551       GREAT TOE-HAND TRANSFER        80                                $438.88       20110801
26551       GREAT TOE-HAND TRANSFER        81                                $438.88       20110801



                                                Page 68
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
26551       GREAT TOE-HAND TRANSFER         82                                $438.88       20110801
26551       GREAT TOE-HAND TRANSFER         AS                                $438.88       20110801
26551       GREAT TOE-HAND TRANSFER                                         $2,194.40       20110801
26553       SINGLE TRANSFER TOE-HAND        80                                $377.10       20110801
26553       SINGLE TRANSFER TOE-HAND        81                                $377.10       20110801
26553       SINGLE TRANSFER TOE-HAND        82                                $377.10       20110801
26553       SINGLE TRANSFER TOE-HAND        AS                                $377.10       20110801
26553       SINGLE TRANSFER TOE-HAND                                        $1,885.52       20110801
26554       DOUBLE TRANSFER TOE-HAND        80                                $462.64       20110801
26554       DOUBLE TRANSFER TOE-HAND        81                                $462.64       20110801
26554       DOUBLE TRANSFER TOE-HAND        82                                $462.64       20110801
26554       DOUBLE TRANSFER TOE-HAND        AS                                $462.64       20110801
26554       DOUBLE TRANSFER TOE-HAND                                        $2,313.22       20110801
26555       POSITIONAL CHANGE OF FINGER                      A                $776.30       20110101
26555       POSITIONAL CHANGE OF FINGER     80                                $185.22       20110801
26555       POSITIONAL CHANGE OF FINGER     81                                $185.22       20110801
26555       POSITIONAL CHANGE OF FINGER     82                                $185.22       20110801
26555       POSITIONAL CHANGE OF FINGER     AS                                $185.22       20110801
26555       POSITIONAL CHANGE OF FINGER                                       $926.12       20110801
26556       TOE JOINT TRANSFER              80                                $376.58       20110801
26556       TOE JOINT TRANSFER              81                                $376.58       20110801
26556       TOE JOINT TRANSFER              82                                $376.58       20110801
26556       TOE JOINT TRANSFER              AS                                $376.58       20110801
26556       TOE JOINT TRANSFER                                              $1,882.92       20110801
26560       REPAIR OF WEB FINGER                             A                $494.96       20110101
26560       REPAIR OF WEB FINGER            80                                 $75.40       20110801
26560       REPAIR OF WEB FINGER            81                                 $75.40       20110801
26560       REPAIR OF WEB FINGER            82                                 $75.40       20110801
26560       REPAIR OF WEB FINGER            AS                                 $75.40       20110801
26560       REPAIR OF WEB FINGER                                              $377.00       20110801
26561       REPAIR OF WEB FINGER                             A                $776.30       20110101
26561       REPAIR OF WEB FINGER            80                                $120.85       20110801
26561       REPAIR OF WEB FINGER            81                                $120.85       20110801
26561       REPAIR OF WEB FINGER            82                                $120.85       20110801
26561       REPAIR OF WEB FINGER            AS                                $120.85       20110801
26561       REPAIR OF WEB FINGER                                              $604.24       20110801
26562       REPAIR OF WEB FINGER                             A                $799.26       20110101
26562       REPAIR OF WEB FINGER            80                                $164.11       20110801
26562       REPAIR OF WEB FINGER            81                                $164.11       20110801
26562       REPAIR OF WEB FINGER            82                                $164.11       20110801
26562       REPAIR OF WEB FINGER            AS                                $164.11       20110801
26562       REPAIR OF WEB FINGER                                              $820.56       20110801
26565       CORRECT METACARPAL FLAW                          A                $815.90       20110101
26565       CORRECT METACARPAL FLAW         80                                 $89.80       20110801
26565       CORRECT METACARPAL FLAW         81                                 $89.80       20110801
26565       CORRECT METACARPAL FLAW         82                                 $89.80       20110801
26565       CORRECT METACARPAL FLAW         AS                                 $89.80       20110801
26565       CORRECT METACARPAL FLAW                                           $449.02       20110801
26567       CORRECT FINGER DEFORMITY                         A                $815.90       20110101
26567       CORRECT FINGER DEFORMITY                                          $450.06       20110801
26568       LENGTHEN METACARPAL/FINGER                       A                $776.30       20110101
26568       LENGTHEN METACARPAL/FINGER      80                                $118.66       20110801
26568       LENGTHEN METACARPAL/FINGER      81                                $118.66       20110801
26568       LENGTHEN METACARPAL/FINGER      82                                $118.66       20110801
26568       LENGTHEN METACARPAL/FINGER      AS                                $118.66       20110801
26568       LENGTHEN METACARPAL/FINGER                                        $593.32       20110801
26580       REPAIR HAND DEFORMITY                            A                $546.81       20110101
26580       REPAIR HAND DEFORMITY           80                                $193.91       20110801
26580       REPAIR HAND DEFORMITY           81                                $193.91       20110801



                                                 Page 69
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
26580       REPAIR HAND DEFORMITY            82                                $193.91       20110801
26580       REPAIR HAND DEFORMITY            AS                                $193.91       20110801
26580       REPAIR HAND DEFORMITY                                              $969.54       20110801
26587       RECONSTRUCT EXTRA FINGER                          A                $546.81       20110101
26587       RECONSTRUCT EXTRA FINGER         80                                $131.92       20110801
26587       RECONSTRUCT EXTRA FINGER         81                                $131.92       20110801
26587       RECONSTRUCT EXTRA FINGER         82                                $131.92       20110801
26587       RECONSTRUCT EXTRA FINGER         AS                                $131.92       20110801
26587       RECONSTRUCT EXTRA FINGER                                           $659.62       20110801
26590       REPAIR FINGER DEFORMITY                           A                $546.81       20110101
26590       REPAIR FINGER DEFORMITY          80                                $175.97       20110801
26590       REPAIR FINGER DEFORMITY          81                                $175.97       20110801
26590       REPAIR FINGER DEFORMITY          82                                $175.97       20110801
26590       REPAIR FINGER DEFORMITY          AS                                $175.97       20110801
26590       REPAIR FINGER DEFORMITY                                            $879.84       20110801
26591       REPAIR MUSCLES OF HAND                            A                $776.30       20110101
26591       REPAIR MUSCLES OF HAND                                             $284.70       20110801
26593       RELEASE MUSCLES OF HAND                           A                $507.20       20110101
26593       RELEASE MUSCLES OF HAND                                            $391.82       20110801
26596       EXCISION CONSTRICTING TISSUE                      A                $494.96       20110101
26596       EXCISION CONSTRICTING TISSUE     80                                 $98.85       20110801
26596       EXCISION CONSTRICTING TISSUE     81                                 $98.85       20110801
26596       EXCISION CONSTRICTING TISSUE     82                                 $98.85       20110801
26596       EXCISION CONSTRICTING TISSUE     AS                                 $98.85       20110801
26596       EXCISION CONSTRICTING TISSUE                                       $494.26       20110801
26600       TREAT METACARPAL FRACTURE                                          $181.22       20110801
26605       TREAT METACARPAL FRACTURE                         A                 $59.66       20110101
26605       TREAT METACARPAL FRACTURE                                          $204.36       20110801
26607       TREAT METACARPAL FRACTURE                         A                $462.00       20110101
26607       TREAT METACARPAL FRACTURE                                          $293.54       20110801
26608       TREAT METACARPAL FRACTURE                         A                $741.74       20110101
26608       TREAT METACARPAL FRACTURE                                          $314.86       20110801
26615       TREAT METACARPAL FRACTURE                         A              $1,213.40       20110101
26615       TREAT METACARPAL FRACTURE                                          $373.36       20110801
26641       TREAT THUMB DISLOCATION                                            $238.16       20110801
26645       TREAT THUMB FRACTURE                              A                $135.07       20110101
26645       TREAT THUMB FRACTURE                                               $270.40       20110801
26650       TREAT THUMB FRACTURE                              A                $706.54       20110101
26650       TREAT THUMB FRACTURE                                               $315.12       20110801
26665       TREAT THUMB FRACTURE                              A              $1,213.40       20110101
26665       TREAT THUMB FRACTURE                                               $413.92       20110801
26670       TREAT HAND DISLOCATION                                             $214.50       20110801
26675       TREAT HAND DISLOCATION                            A                $135.07       20110101
26675       TREAT HAND DISLOCATION                                             $287.82       20110801
26676       PIN HAND DISLOCATION                              A                $706.54       20110101
26676       PIN HAND DISLOCATION                                               $330.20       20110801
26685       TREAT HAND DISLOCATION                            A                $718.78       20110101
26685       TREAT HAND DISLOCATION                                             $379.08       20110801
26686       TREAT HAND DISLOCATION                            A              $1,671.34       20110101
26686       TREAT HAND DISLOCATION           80                                 $83.36       20110801
26686       TREAT HAND DISLOCATION           81                                 $83.36       20110801
26686       TREAT HAND DISLOCATION           82                                 $83.36       20110801
26686       TREAT HAND DISLOCATION           AS                                 $83.36       20110801
26686       TREAT HAND DISLOCATION                                             $416.78       20110801
26700       TREAT KNUCKLE DISLOCATION                                          $205.40       20110801
26705       TREAT KNUCKLE DISLOCATION                         A                 $59.66       20110101
26705       TREAT KNUCKLE DISLOCATION                                          $263.64       20110801
26706       PIN KNUCKLE DISLOCATION                           A                $462.00       20110101
26706       PIN KNUCKLE DISLOCATION                                            $287.82       20110801



                                                  Page 70
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
26715       TREAT KNUCKLE DISLOCATION                        A                   $741.74       20110101
26715       TREAT KNUCKLE DISLOCATION                                            $372.58       20110801
26720       TREAT FINGER FRACTURE EACH                                           $123.76       20110801
26725       TREAT FINGER FRACTURE EACH                                           $218.40       20110801
26727       TREAT FINGER FRACTURE EACH                       A                   $811.58       20110101
26727       TREAT FINGER FRACTURE EACH                                           $309.66       20110801
26735       TREAT FINGER FRACTURE EACH                       A                   $741.74       20110101
26735       TREAT FINGER FRACTURE EACH                                           $388.70       20110801
26740       TREAT FINGER FRACTURE EACH                                           $143.26       20110801
26742       TREAT FINGER FRACTURE EACH                       A                    $59.66       20110101
26742       TREAT FINGER FRACTURE EACH                                           $239.20       20110801
26746       TREAT FINGER FRACTURE EACH                       A                   $758.39       20110101
26746       TREAT FINGER FRACTURE EACH                                           $483.60       20110801
26750       TREAT FINGER FRACTURE EACH                                           $115.96       20110801
26755       TREAT FINGER FRACTURE EACH                                           $201.76       20110801
26756       PIN FINGER FRACTURE EACH                         A                   $706.54       20110101
26756       PIN FINGER FRACTURE EACH                                             $273.52       20110801
26765       TREAT FINGER FRACTURE EACH                       A                   $741.74       20110101
26765       TREAT FINGER FRACTURE EACH                                           $320.06       20110801
26770       TREAT FINGER DISLOCATION                                             $174.98       20110801
26775       TREAT FINGER DISLOCATION                                             $245.44       20110801
26776       PIN FINGER DISLOCATION                           A                   $706.54       20110101
26776       PIN FINGER DISLOCATION                                               $290.42       20110801
26785       TREAT FINGER DISLOCATION                         A                   $706.54       20110101
26785       TREAT FINGER DISLOCATION                                             $349.70       20110801
26820       THUMB FUSION WITH GRAFT                          A                   $815.90       20110101
26820       THUMB FUSION WITH GRAFT         80                                   $104.31       20110801
26820       THUMB FUSION WITH GRAFT         81                                   $104.31       20110801
26820       THUMB FUSION WITH GRAFT         82                                   $104.31       20110801
26820       THUMB FUSION WITH GRAFT         AS                                   $104.31       20110801
26820       THUMB FUSION WITH GRAFT                                              $521.56       20110801
26841       FUSION OF THUMB                                  A                   $799.26       20110101
26841       FUSION OF THUMB                                                      $481.52       20110801
26842       THUMB FUSION WITH GRAFT                          A                   $799.26       20110101
26842       THUMB FUSION WITH GRAFT         80                                   $104.78       20110801
26842       THUMB FUSION WITH GRAFT         81                                   $104.78       20110801
26842       THUMB FUSION WITH GRAFT         82                                   $104.78       20110801
26842       THUMB FUSION WITH GRAFT         AS                                   $104.78       20110801
26842       THUMB FUSION WITH GRAFT                                              $523.90       20110801
26843       FUSION OF HAND JOINT                             A                   $776.30       20110101
26843       FUSION OF HAND JOINT            80                                    $97.40       20110801
26843       FUSION OF HAND JOINT            81                                    $97.40       20110801
26843       FUSION OF HAND JOINT            82                                    $97.40       20110801
26843       FUSION OF HAND JOINT            AS                                    $97.40       20110801
26843       FUSION OF HAND JOINT                                                 $486.98       20110801
26844       FUSION/GRAFT OF HAND JOINT                       A                   $776.30       20110101
26844       FUSION/GRAFT OF HAND JOINT      80                                   $108.68       20110801
26844       FUSION/GRAFT OF HAND JOINT      81                                   $108.68       20110801
26844       FUSION/GRAFT OF HAND JOINT      82                                   $108.68       20110801
26844       FUSION/GRAFT OF HAND JOINT      AS                                   $108.68       20110801
26844       FUSION/GRAFT OF HAND JOINT                                           $543.40       20110801
26850       FUSION OF KNUCKLE                                A                   $799.26       20110101
26850       FUSION OF KNUCKLE                                                    $457.86       20110801
26852       FUSION OF KNUCKLE WITH GRAFT                     A                   $799.26       20110101
26852       FUSION OF KNUCKLE WITH GRAFT    80                                   $105.25       20110801
26852       FUSION OF KNUCKLE WITH GRAFT    81                                   $105.25       20110801
26852       FUSION OF KNUCKLE WITH GRAFT    82                                   $105.25       20110801
26852       FUSION OF KNUCKLE WITH GRAFT    AS                                   $105.25       20110801
26852       FUSION OF KNUCKLE WITH GRAFT                                         $526.24       20110801



                                                 Page 71
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
26860       FUSION OF FINGER JOINT                            A                $776.30       20110101
26860       FUSION OF FINGER JOINT                                             $367.38       20110801
26861       FUSION OF FINGER JNT ADD-ON                       A                $764.05       20110101
26861       FUSION OF FINGER JNT ADD-ON                                         $72.80       20110801
26862       FUSION/GRAFT OF FINGER JOINT                      A                $799.26       20110101
26862       FUSION/GRAFT OF FINGER JOINT     80                                 $95.73       20110801
26862       FUSION/GRAFT OF FINGER JOINT     81                                 $95.73       20110801
26862       FUSION/GRAFT OF FINGER JOINT     82                                 $95.73       20110801
26862       FUSION/GRAFT OF FINGER JOINT     AS                                 $95.73       20110801
26862       FUSION/GRAFT OF FINGER JOINT                                       $478.66       20110801
26863       FUSE/GRAFT ADDED JOINT                            A                $776.30       20110101
26863       FUSE/GRAFT ADDED JOINT           80                                 $32.66       20110801
26863       FUSE/GRAFT ADDED JOINT           81                                 $32.66       20110801
26863       FUSE/GRAFT ADDED JOINT           82                                 $32.66       20110801
26863       FUSE/GRAFT ADDED JOINT           AS                                 $32.66       20110801
26863       FUSE/GRAFT ADDED JOINT                                             $163.28       20110801
26910       AMPUTATE METACARPAL BONE                          A                $776.30       20110101
26910       AMPUTATE METACARPAL BONE                                           $473.98       20110801
26951       AMPUTATION OF FINGER/THUMB                        A                $494.96       20110101
26951       AMPUTATION OF FINGER/THUMB                                         $417.30       20110801
26952       AMPUTATION OF FINGER/THUMB                        A                $530.17       20110101
26952       AMPUTATION OF FINGER/THUMB                                         $427.18       20110801
26990       DRAINAGE OF PELVIS LESION                         A                $592.86       20110101
26990       DRAINAGE OF PELVIS LESION                                          $416.00       20110801
26991       DRAINAGE OF PELVIS BURSA                          A                $592.86       20110101
26991       DRAINAGE OF PELVIS BURSA                                           $461.76       20110801
26992       DRAINAGE OF BONE LESION                                            $652.08       20110801
27000       INCISION OF HIP TENDON                            A                $614.48       20110101
27000       INCISION OF HIP TENDON                                             $297.18       20110801
27001       INCISION OF HIP TENDON                            A                $861.25       20110101
27001       INCISION OF HIP TENDON           80                                 $72.70       20110801
27001       INCISION OF HIP TENDON           81                                 $72.70       20110801
27001       INCISION OF HIP TENDON           82                                 $72.70       20110801
27001       INCISION OF HIP TENDON           AS                                 $72.70       20110801
27001       INCISION OF HIP TENDON                                             $363.48       20110801
27003       INCISION OF HIP TENDON                            A                $861.25       20110101
27003       INCISION OF HIP TENDON           80                                 $79.20       20110801
27003       INCISION OF HIP TENDON           81                                 $79.20       20110801
27003       INCISION OF HIP TENDON           82                                 $79.20       20110801
27003       INCISION OF HIP TENDON           AS                                 $79.20       20110801
27003       INCISION OF HIP TENDON                                             $395.98       20110801
27005       INCISION OF HIP TENDON           80                                 $98.54       20110801
27005       INCISION OF HIP TENDON           81                                 $98.54       20110801
27005       INCISION OF HIP TENDON           82                                 $98.54       20110801
27005       INCISION OF HIP TENDON           AS                                 $98.54       20110801
27005       INCISION OF HIP TENDON                                             $492.70       20110801
27006       INCISION OF HIP TENDONS          80                                 $99.63       20110801
27006       INCISION OF HIP TENDONS          81                                 $99.63       20110801
27006       INCISION OF HIP TENDONS          82                                 $99.63       20110801
27006       INCISION OF HIP TENDONS          AS                                 $99.63       20110801
27006       INCISION OF HIP TENDONS                                            $498.16       20110801
27025       INCISION OF HIP/THIGH FASCIA                                       $614.90       20110801
27030       DRAINAGE OF HIP JOINT            80                                $128.54       20110801
27030       DRAINAGE OF HIP JOINT            81                                $128.54       20110801
27030       DRAINAGE OF HIP JOINT            82                                $128.54       20110801
27030       DRAINAGE OF HIP JOINT            AS                                $128.54       20110801
27030       DRAINAGE OF HIP JOINT                                              $642.72       20110801
27033       EXPLORATION OF HIP JOINT                          A              $1,217.14       20110101
27033       EXPLORATION OF HIP JOINT         80                                $133.22       20110801



                                                  Page 72
                                     DMAP Fee for Service Fee Schedule
                                               August 2012


Procedure   Description                       Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                      Date
27033       EXPLORATION OF HIP JOINT          81                                $133.22       20110801
27033       EXPLORATION OF HIP JOINT          82                                $133.22       20110801
27033       EXPLORATION OF HIP JOINT          AS                                $133.22       20110801
27033       EXPLORATION OF HIP JOINT                                            $666.12       20110801
27035       DENERVATION OF HIP JOINT          80                                $154.28       20110801
27035       DENERVATION OF HIP JOINT          81                                $154.28       20110801
27035       DENERVATION OF HIP JOINT          82                                $154.28       20110801
27035       DENERVATION OF HIP JOINT          AS                                $154.28       20110801
27035       DENERVATION OF HIP JOINT                                            $771.42       20110801
27036       EXCISION OF HIP JOINT/MUSCLE      80                                $136.97       20110801
27036       EXCISION OF HIP JOINT/MUSCLE      81                                $136.97       20110801
27036       EXCISION OF HIP JOINT/MUSCLE      82                                $136.97       20110801
27036       EXCISION OF HIP JOINT/MUSCLE      AS                                $136.97       20110801
27036       EXCISION OF HIP JOINT/MUSCLE                                        $684.84       20110801
27040       BIOPSY OF SOFT TISSUES                             A                $260.88       20110101
27040       BIOPSY OF SOFT TISSUES                                              $224.64       20110801
27041       BIOPSY OF SOFT TISSUES                             A                $277.24       20110101
27041       BIOPSY OF SOFT TISSUES                                              $465.66       20110801
27043       EXC HIP PELVIS LES SC 3 CM/                                         $749.54       20100101
27045       EXC HIP/PELV TUM DEEP 5 CM/                                         $525.72       20110801
27047       EXC HIP/PELVIS LES SC 3 CM                         A                $160.12       20110101
27047       EXC HIP/PELVIS LES SC 3 CM                                          $330.72       20110801
27048       EXC HIP/PELV TUM DEEP 5 CM                         A                $560.76       20110101
27048       EXC HIP/PELV TUM DEEP 5 CM        80                                 $80.03       20110801
27048       EXC HIP/PELV TUM DEEP 5 CM        81                                 $80.03       20110801
27048       EXC HIP/PELV TUM DEEP 5 CM        82                                 $80.03       20110801
27048       EXC HIP/PELV TUM DEEP 5 CM        AS                                 $80.03       20110801
27048       EXC HIP/PELV TUM DEEP 5 CM                                          $400.14       20110801
27049       RESECT HIP/PELV TUM 5 CM                           A                $560.76       20110101
27049       RESECT HIP/PELV TUM 5 CM          80                                $178.20       20110801
27049       RESECT HIP/PELV TUM 5 CM          81                                $178.20       20110801
27049       RESECT HIP/PELV TUM 5 CM          82                                $178.20       20110801
27049       RESECT HIP/PELV TUM 5 CM          AS                                $178.20       20110801
27049       RESECT HIP/PELV TUM 5 CM                                            $891.02       20110801
27050       BIOPSY OF SACROILIAC JOINT                         A                $626.73       20110101
27050       BIOPSY OF SACROILIAC JOINT                                          $245.44       20110801
27052       BIOPSY OF HIP JOINT                                A                $626.73       20110101
27052       BIOPSY OF HIP JOINT               80                                 $76.08       20110801
27052       BIOPSY OF HIP JOINT               81                                 $76.08       20110801
27052       BIOPSY OF HIP JOINT               82                                 $76.08       20110801
27052       BIOPSY OF HIP JOINT               AS                                 $76.08       20110801
27052       BIOPSY OF HIP JOINT                                                 $380.38       20110801
27054       REMOVAL OF HIP JOINT LINING       80                                 $92.14       20110801
27054       REMOVAL OF HIP JOINT LINING       81                                 $92.14       20110801
27054       REMOVAL OF HIP JOINT LINING       82                                 $92.14       20110801
27054       REMOVAL OF HIP JOINT LINING       AS                                 $92.14       20110801
27054       REMOVAL OF HIP JOINT LINING                                         $460.72       20110801
27059       RESECT HIP/PELV TUM 5 CM/                                         $1,289.34       20110801
27060       REMOVAL OF ISCHIAL BURSA                           A                $666.34       20110101
27060       REMOVAL OF ISCHIAL BURSA                                            $290.94       20110801
27062       REMOVE FEMUR LESION/BURSA                          A                $666.34       20110101
27062       REMOVE FEMUR LESION/BURSA                                           $302.90       20110801
27065       REMOVE HIP BONE LES SUPER                          A                $666.34       20110101
27065       REMOVE HIP BONE LES SUPER         80                                 $67.81       20110801
27065       REMOVE HIP BONE LES SUPER         81                                 $67.81       20110801
27065       REMOVE HIP BONE LES SUPER         82                                 $67.81       20110801
27065       REMOVE HIP BONE LES SUPER         AS                                 $67.81       20110801
27065       REMOVE HIP BONE LES SUPER                                           $339.04       20110801
27066       REMOVE HIP BONE LES DEEP                           A                $900.86       20110101



                                                   Page 73
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27066       REMOVE HIP BONE LES DEEP        80                                $109.77       20110801
27066       REMOVE HIP BONE LES DEEP        81                                $109.77       20110801
27066       REMOVE HIP BONE LES DEEP        82                                $109.77       20110801
27066       REMOVE HIP BONE LES DEEP        AS                                $109.77       20110801
27066       REMOVE HIP BONE LES DEEP                                          $548.86       20110801
27067       REMOVE/GRAFT HIP BONE LESION                     A                $900.86       20110101
27067       REMOVE/GRAFT HIP BONE LESION    80                                $140.87       20110801
27067       REMOVE/GRAFT HIP BONE LESION    81                                $140.87       20110801
27067       REMOVE/GRAFT HIP BONE LESION    82                                $140.87       20110801
27067       REMOVE/GRAFT HIP BONE LESION    AS                                $140.87       20110801
27067       REMOVE/GRAFT HIP BONE LESION                                      $704.34       20110801
27070       PART REMOVE HIP BONE SUPER      80                                $115.23       20110801
27070       PART REMOVE HIP BONE SUPER      81                                $115.23       20110801
27070       PART REMOVE HIP BONE SUPER      82                                $115.23       20110801
27070       PART REMOVE HIP BONE SUPER      AS                                $115.23       20110801
27070       PART REMOVE HIP BONE SUPER                                        $576.16       20110801
27071       PART REMOVAL HIP BONE DEEP      80                                $123.34       20110801
27071       PART REMOVAL HIP BONE DEEP      81                                $123.34       20110801
27071       PART REMOVAL HIP BONE DEEP      82                                $123.34       20110801
27071       PART REMOVAL HIP BONE DEEP      AS                                $123.34       20110801
27071       PART REMOVAL HIP BONE DEEP                                        $616.72       20110801
27075       RESECT HIP TUMOR                80                                $290.52       20110801
27075       RESECT HIP TUMOR                81                                $290.52       20110801
27075       RESECT HIP TUMOR                82                                $290.52       20110801
27075       RESECT HIP TUMOR                AS                                $290.52       20110801
27075       RESECT HIP TUMOR                                                $1,452.62       20110801
27076       RESECT HIP TUM INCL ACETABUL    80                                $323.23       20110801
27076       RESECT HIP TUM INCL ACETABUL    81                                $323.23       20110801
27076       RESECT HIP TUM INCL ACETABUL    82                                $323.23       20110801
27076       RESECT HIP TUM INCL ACETABUL    AS                                $323.23       20110801
27076       RESECT HIP TUM INCL ACETABUL                                    $1,616.16       20110801
27077       RESECT HIP TUM W/INNOM BONE     80                                $386.10       20110801
27077       RESECT HIP TUM W/INNOM BONE     81                                $386.10       20110801
27077       RESECT HIP TUM W/INNOM BONE     82                                $386.10       20110801
27077       RESECT HIP TUM W/INNOM BONE     AS                                $386.10       20110801
27077       RESECT HIP TUM W/INNOM BONE                                     $1,930.50       20110801
27078       RSECT HIP TUM INCL FEMUR        80                                $255.16       20110801
27078       RSECT HIP TUM INCL FEMUR        81                                $255.16       20110801
27078       RSECT HIP TUM INCL FEMUR        82                                $255.16       20110801
27078       RSECT HIP TUM INCL FEMUR        AS                                $255.16       20110801
27078       RSECT HIP TUM INCL FEMUR                                        $1,275.82       20110801
27080       REMOVAL OF TAIL BONE                             A                $849.00       20110101
27080       REMOVAL OF TAIL BONE            80                                 $67.86       20110801
27080       REMOVAL OF TAIL BONE            81                                 $67.86       20110801
27080       REMOVAL OF TAIL BONE            82                                 $67.86       20110801
27080       REMOVAL OF TAIL BONE            AS                                 $67.86       20110801
27080       REMOVAL OF TAIL BONE                                              $339.30       20110801
27086       REMOVE HIP FOREIGN BODY                          A                $260.88       20110101
27086       REMOVE HIP FOREIGN BODY                                           $160.16       20110801
27087       REMOVE HIP FOREIGN BODY                          A                $626.73       20110101
27087       REMOVE HIP FOREIGN BODY         80                                 $85.80       20110801
27087       REMOVE HIP FOREIGN BODY         81                                 $85.80       20110801
27087       REMOVE HIP FOREIGN BODY         82                                 $85.80       20110801
27087       REMOVE HIP FOREIGN BODY         AS                                 $85.80       20110801
27087       REMOVE HIP FOREIGN BODY                                           $429.00       20110801
27090       REMOVAL OF HIP PROSTHESIS       80                                $112.89       20110801
27090       REMOVAL OF HIP PROSTHESIS       81                                $112.89       20110801
27090       REMOVAL OF HIP PROSTHESIS       82                                $112.89       20110801
27090       REMOVAL OF HIP PROSTHESIS       AS                                $112.89       20110801



                                                 Page 74
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
27090       REMOVAL OF HIP PROSTHESIS                                        $564.46       20110801
27091       REMOVAL OF HIP PROSTHESIS      80                                $219.91       20110801
27091       REMOVAL OF HIP PROSTHESIS      81                                $219.91       20110801
27091       REMOVAL OF HIP PROSTHESIS      82                                $219.91       20110801
27091       REMOVAL OF HIP PROSTHESIS      AS                                $219.91       20110801
27091       REMOVAL OF HIP PROSTHESIS                                      $1,099.54       20110801
27093       INJECTION FOR HIP X-RAY                                          $127.40       20110801
27095       INJECTION FOR HIP X-RAY                                          $154.70       20110801
27096       INJECT SACROILIAC JOINT                                          $120.64       20110801
27097       REVISION OF HIP TENDON                          A                $861.25       20110101
27097       REVISION OF HIP TENDON         80                                 $90.58       20110801
27097       REVISION OF HIP TENDON         81                                 $90.58       20110801
27097       REVISION OF HIP TENDON         82                                 $90.58       20110801
27097       REVISION OF HIP TENDON         AS                                 $90.58       20110801
27097       REVISION OF HIP TENDON                                           $452.92       20110801
27098       TRANSFER TENDON TO PELVIS                       A                $861.25       20110101
27098       TRANSFER TENDON TO PELVIS      80                                 $85.64       20110801
27098       TRANSFER TENDON TO PELVIS      81                                 $85.64       20110801
27098       TRANSFER TENDON TO PELVIS      82                                 $85.64       20110801
27098       TRANSFER TENDON TO PELVIS      AS                                 $85.64       20110801
27098       TRANSFER TENDON TO PELVIS                                        $428.22       20110801
27100       TRANSFER OF ABDOMINAL MUSCLE                    A              $1,240.11       20110101
27100       TRANSFER OF ABDOMINAL MUSCLE   80                                $111.38       20110801
27100       TRANSFER OF ABDOMINAL MUSCLE   81                                $111.38       20110801
27100       TRANSFER OF ABDOMINAL MUSCLE   82                                $111.38       20110801
27100       TRANSFER OF ABDOMINAL MUSCLE   AS                                $111.38       20110801
27100       TRANSFER OF ABDOMINAL MUSCLE                                     $556.92       20110801
27105       TRANSFER OF SPINAL MUSCLE                       A              $1,240.11       20110101
27105       TRANSFER OF SPINAL MUSCLE      80                                $117.31       20110801
27105       TRANSFER OF SPINAL MUSCLE      81                                $117.31       20110801
27105       TRANSFER OF SPINAL MUSCLE      82                                $117.31       20110801
27105       TRANSFER OF SPINAL MUSCLE      AS                                $117.31       20110801
27105       TRANSFER OF SPINAL MUSCLE                                        $586.56       20110801
27110       TRANSFER OF ILIOPSOAS MUSCLE                    A              $1,240.11       20110101
27110       TRANSFER OF ILIOPSOAS MUSCLE   80                                $130.73       20110801
27110       TRANSFER OF ILIOPSOAS MUSCLE   81                                $130.73       20110801
27110       TRANSFER OF ILIOPSOAS MUSCLE   82                                $130.73       20110801
27110       TRANSFER OF ILIOPSOAS MUSCLE   AS                                $130.73       20110801
27110       TRANSFER OF ILIOPSOAS MUSCLE                                     $653.64       20110801
27111       TRANSFER OF ILIOPSOAS MUSCLE                    A              $1,240.11       20110101
27111       TRANSFER OF ILIOPSOAS MUSCLE   80                                $117.88       20110801
27111       TRANSFER OF ILIOPSOAS MUSCLE   81                                $117.88       20110801
27111       TRANSFER OF ILIOPSOAS MUSCLE   82                                $117.88       20110801
27111       TRANSFER OF ILIOPSOAS MUSCLE   AS                                $117.88       20110801
27111       TRANSFER OF ILIOPSOAS MUSCLE                                     $589.42       20110801
27120       RECONSTRUCTION OF HIP SOCKET   80                                $176.90       20110801
27120       RECONSTRUCTION OF HIP SOCKET   81                                $176.90       20110801
27120       RECONSTRUCTION OF HIP SOCKET   82                                $176.90       20110801
27120       RECONSTRUCTION OF HIP SOCKET   AS                                $176.90       20110801
27120       RECONSTRUCTION OF HIP SOCKET                                     $884.52       20110801
27122       RECONSTRUCTION OF HIP SOCKET   80                                $150.90       20110801
27122       RECONSTRUCTION OF HIP SOCKET   81                                $150.90       20110801
27122       RECONSTRUCTION OF HIP SOCKET   82                                $150.90       20110801
27122       RECONSTRUCTION OF HIP SOCKET   AS                                $150.90       20110801
27122       RECONSTRUCTION OF HIP SOCKET                                     $754.52       20110801
27125       PARTIAL HIP REPLACEMENT        80                                $154.75       20110801
27125       PARTIAL HIP REPLACEMENT        81                                $154.75       20110801
27125       PARTIAL HIP REPLACEMENT        82                                $154.75       20110801
27125       PARTIAL HIP REPLACEMENT        AS                                $154.75       20110801



                                                Page 75
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
27125       PARTIAL HIP REPLACEMENT                                            $773.76       20110801
27130       TOTAL HIP ARTHROPLASTY           80                                $198.59       20110801
27130       TOTAL HIP ARTHROPLASTY           81                                $198.59       20110801
27130       TOTAL HIP ARTHROPLASTY           82                                $198.59       20110801
27130       TOTAL HIP ARTHROPLASTY           AS                                $198.59       20110801
27130       TOTAL HIP ARTHROPLASTY                                             $992.94       20110801
27132       TOTAL HIP ARTHROPLASTY           80                                $232.18       20110801
27132       TOTAL HIP ARTHROPLASTY           81                                $232.18       20110801
27132       TOTAL HIP ARTHROPLASTY           82                                $232.18       20110801
27132       TOTAL HIP ARTHROPLASTY           AS                                $232.18       20110801
27132       TOTAL HIP ARTHROPLASTY                                           $1,160.90       20110801
27134       REVISE HIP JOINT REPLACEMENT     80                                $267.96       20110801
27134       REVISE HIP JOINT REPLACEMENT     81                                $267.96       20110801
27134       REVISE HIP JOINT REPLACEMENT     82                                $267.96       20110801
27134       REVISE HIP JOINT REPLACEMENT     AS                                $267.96       20110801
27134       REVISE HIP JOINT REPLACEMENT                                     $1,339.78       20110801
27137       REVISE HIP JOINT REPLACEMENT     80                                $204.57       20110801
27137       REVISE HIP JOINT REPLACEMENT     81                                $204.57       20110801
27137       REVISE HIP JOINT REPLACEMENT     82                                $204.57       20110801
27137       REVISE HIP JOINT REPLACEMENT     AS                                $204.57       20110801
27137       REVISE HIP JOINT REPLACEMENT                                     $1,022.84       20110801
27138       REVISE HIP JOINT REPLACEMENT     80                                $212.94       20110801
27138       REVISE HIP JOINT REPLACEMENT     81                                $212.94       20110801
27138       REVISE HIP JOINT REPLACEMENT     82                                $212.94       20110801
27138       REVISE HIP JOINT REPLACEMENT     AS                                $212.94       20110801
27138       REVISE HIP JOINT REPLACEMENT                                     $1,064.70       20110801
27140       TRANSPLANT FEMUR RIDGE           80                                $122.36       20110801
27140       TRANSPLANT FEMUR RIDGE           81                                $122.36       20110801
27140       TRANSPLANT FEMUR RIDGE           82                                $122.36       20110801
27140       TRANSPLANT FEMUR RIDGE           AS                                $122.36       20110801
27140       TRANSPLANT FEMUR RIDGE                                             $611.78       20110801
27146       INCISION OF HIP BONE             80                                $174.20       20110801
27146       INCISION OF HIP BONE             81                                $174.20       20110801
27146       INCISION OF HIP BONE             82                                $174.20       20110801
27146       INCISION OF HIP BONE             AS                                $174.20       20110801
27146       INCISION OF HIP BONE                                               $871.00       20110801
27147       REVISION OF HIP BONE             80                                $201.66       20110801
27147       REVISION OF HIP BONE             81                                $201.66       20110801
27147       REVISION OF HIP BONE             82                                $201.66       20110801
27147       REVISION OF HIP BONE             AS                                $201.66       20110801
27147       REVISION OF HIP BONE                                             $1,008.28       20110801
27151       INCISION OF HIP BONES            80                                $212.37       20110801
27151       INCISION OF HIP BONES            81                                $212.37       20110801
27151       INCISION OF HIP BONES            82                                $212.37       20110801
27151       INCISION OF HIP BONES            AS                                $212.37       20110801
27151       INCISION OF HIP BONES                                            $1,061.84       20110801
27156       REVISION OF HIP BONES            80                                $235.46       20110801
27156       REVISION OF HIP BONES            81                                $235.46       20110801
27156       REVISION OF HIP BONES            82                                $235.46       20110801
27156       REVISION OF HIP BONES            AS                                $235.46       20110801
27156       REVISION OF HIP BONES                                            $1,177.28       20110801
27158       REVISION OF PELVIS               80                                $190.48       20110801
27158       REVISION OF PELVIS               81                                $190.48       20110801
27158       REVISION OF PELVIS               82                                $190.48       20110801
27158       REVISION OF PELVIS               AS                                $190.48       20110801
27158       REVISION OF PELVIS                                                 $952.38       20110801
27161       INCISION OF NECK OF FEMUR        80                                $166.82       20110801
27161       INCISION OF NECK OF FEMUR        81                                $166.82       20110801
27161       INCISION OF NECK OF FEMUR        82                                $166.82       20110801



                                                  Page 76
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27161       INCISION OF NECK OF FEMUR       AS                                $166.82       20110801
27161       INCISION OF NECK OF FEMUR                                         $834.08       20110801
27165       INCISION/FIXATION OF FEMUR      80                                $187.98       20110801
27165       INCISION/FIXATION OF FEMUR      81                                $187.98       20110801
27165       INCISION/FIXATION OF FEMUR      82                                $187.98       20110801
27165       INCISION/FIXATION OF FEMUR      AS                                $187.98       20110801
27165       INCISION/FIXATION OF FEMUR                                        $939.90       20110801
27170       REPAIR/GRAFT FEMUR HEAD/NECK    80                                $161.98       20110801
27170       REPAIR/GRAFT FEMUR HEAD/NECK    81                                $161.98       20110801
27170       REPAIR/GRAFT FEMUR HEAD/NECK    82                                $161.98       20110801
27170       REPAIR/GRAFT FEMUR HEAD/NECK    AS                                $161.98       20110801
27170       REPAIR/GRAFT FEMUR HEAD/NECK                                      $809.90       20110801
27175       TREAT SLIPPED EPIPHYSIS                                           $451.36       20110801
27176       TREAT SLIPPED EPIPHYSIS         80                                $124.23       20110801
27176       TREAT SLIPPED EPIPHYSIS         81                                $124.23       20110801
27176       TREAT SLIPPED EPIPHYSIS         82                                $124.23       20110801
27176       TREAT SLIPPED EPIPHYSIS         AS                                $124.23       20110801
27176       TREAT SLIPPED EPIPHYSIS                                           $621.14       20110801
27177       TREAT SLIPPED EPIPHYSIS         80                                $151.79       20110801
27177       TREAT SLIPPED EPIPHYSIS         81                                $151.79       20110801
27177       TREAT SLIPPED EPIPHYSIS         82                                $151.79       20110801
27177       TREAT SLIPPED EPIPHYSIS         AS                                $151.79       20110801
27177       TREAT SLIPPED EPIPHYSIS                                           $758.94       20110801
27178       TREAT SLIPPED EPIPHYSIS         80                                $123.60       20110801
27178       TREAT SLIPPED EPIPHYSIS         81                                $123.60       20110801
27178       TREAT SLIPPED EPIPHYSIS         82                                $123.60       20110801
27178       TREAT SLIPPED EPIPHYSIS         AS                                $123.60       20110801
27178       TREAT SLIPPED EPIPHYSIS                                           $618.02       20110801
27179       REVISE HEAD/NECK OF FEMUR       80                                $132.70       20110801
27179       REVISE HEAD/NECK OF FEMUR       81                                $132.70       20110801
27179       REVISE HEAD/NECK OF FEMUR       82                                $132.70       20110801
27179       REVISE HEAD/NECK OF FEMUR       AS                                $132.70       20110801
27179       REVISE HEAD/NECK OF FEMUR                                         $663.52       20110801
27181       TREAT SLIPPED EPIPHYSIS         80                                $152.15       20110801
27181       TREAT SLIPPED EPIPHYSIS         81                                $152.15       20110801
27181       TREAT SLIPPED EPIPHYSIS         82                                $152.15       20110801
27181       TREAT SLIPPED EPIPHYSIS         AS                                $152.15       20110801
27181       TREAT SLIPPED EPIPHYSIS                                           $760.76       20110801
27185       REVISION OF FEMUR EPIPHYSIS                                       $423.80       20110801
27187       REINFORCE HIP BONES             80                                $135.62       20110801
27187       REINFORCE HIP BONES             81                                $135.62       20110801
27187       REINFORCE HIP BONES             82                                $135.62       20110801
27187       REINFORCE HIP BONES             AS                                $135.62       20110801
27187       REINFORCE HIP BONES                                               $678.08       20110801
27193       TREAT PELVIC RING FRACTURE                       A                 $59.66       20110101
27193       TREAT PELVIC RING FRACTURE                                        $313.56       20110801
27194       TREAT PELVIC RING FRACTURE                       A                $452.90       20110101
27194       TREAT PELVIC RING FRACTURE                                        $476.06       20110801
27200       TREAT TAIL BONE FRACTURE                                          $114.66       20110801
27202       TREAT TAIL BONE FRACTURE                         A              $1,178.19       20110101
27202       TREAT TAIL BONE FRACTURE        80                                 $82.78       20110801
27202       TREAT TAIL BONE FRACTURE        81                                 $82.78       20110801
27202       TREAT TAIL BONE FRACTURE        82                                 $82.78       20110801
27202       TREAT TAIL BONE FRACTURE        AS                                 $82.78       20110801
27202       TREAT TAIL BONE FRACTURE                                          $413.92       20110801
27215       TREAT PELVIC FRACTURES                                            $454.74       20110801
27216       TREAT PELVIC RING FRACTURE                                        $671.58       20110801
27217       TREAT PELVIC RING FRACTURE                                        $635.18       20110801
27218       TREAT PELVIC RING FRACTURE                                        $868.92       20110801



                                                 Page 77
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27220       TREAT HIP SOCKET FRACTURE                                         $353.08       20110801
27222       TREAT HIP SOCKET FRACTURE                                         $666.90       20110801
27226       TREAT HIP WALL FRACTURE         80                                $142.74       20110801
27226       TREAT HIP WALL FRACTURE         81                                $142.74       20110801
27226       TREAT HIP WALL FRACTURE         82                                $142.74       20110801
27226       TREAT HIP WALL FRACTURE         AS                                $142.74       20110801
27226       TREAT HIP WALL FRACTURE                                           $713.70       20110801
27227       TREAT HIP FRACTURES             80                                $229.74       20110801
27227       TREAT HIP FRACTURES             81                                $229.74       20110801
27227       TREAT HIP FRACTURES             82                                $229.74       20110801
27227       TREAT HIP FRACTURES             AS                                $229.74       20110801
27227       TREAT HIP FRACTURES                                             $1,148.68       20110801
27228       TREAT HIP FRACTURES             80                                $262.86       20110801
27228       TREAT HIP FRACTURES             81                                $262.86       20110801
27228       TREAT HIP FRACTURES             82                                $262.86       20110801
27228       TREAT HIP FRACTURES             AS                                $262.86       20110801
27228       TREAT HIP FRACTURES                                             $1,314.30       20110801
27230       TREAT THIGH FRACTURE                             A                 $59.66       20110101
27230       TREAT THIGH FRACTURE                                              $314.34       20110801
27232       TREAT THIGH FRACTURE                                              $526.50       20110801
27235       TREAT THIGH FRACTURE                                              $620.62       20110801
27236       TREAT THIGH FRACTURE            80                                $163.54       20110801
27236       TREAT THIGH FRACTURE            81                                $163.54       20110801
27236       TREAT THIGH FRACTURE            82                                $163.54       20110801
27236       TREAT THIGH FRACTURE            AS                                $163.54       20110801
27236       TREAT THIGH FRACTURE                                              $817.70       20110801
27238       TREAT THIGH FRACTURE                             A                $135.07       20110101
27238       TREAT THIGH FRACTURE                                              $304.46       20110801
27240       TREAT THIGH FRACTURE                                              $652.08       20110801
27244       TREAT THIGH FRACTURE            80                                $168.22       20110801
27244       TREAT THIGH FRACTURE            81                                $168.22       20110801
27244       TREAT THIGH FRACTURE            82                                $168.22       20110801
27244       TREAT THIGH FRACTURE            AS                                $168.22       20110801
27244       TREAT THIGH FRACTURE                                              $841.10       20110801
27245       TREAT THIGH FRACTURE            80                                $170.72       20110801
27245       TREAT THIGH FRACTURE            81                                $170.72       20110801
27245       TREAT THIGH FRACTURE            82                                $170.72       20110801
27245       TREAT THIGH FRACTURE            AS                                $170.72       20110801
27245       TREAT THIGH FRACTURE                                              $853.58       20110801
27246       TREAT THIGH FRACTURE                             A                $135.07       20110101
27246       TREAT THIGH FRACTURE                                              $255.58       20110801
27248       TREAT THIGH FRACTURE            80                                $102.39       20110801
27248       TREAT THIGH FRACTURE            81                                $102.39       20110801
27248       TREAT THIGH FRACTURE            82                                $102.39       20110801
27248       TREAT THIGH FRACTURE            AS                                $102.39       20110801
27248       TREAT THIGH FRACTURE                                              $511.94       20110801
27250       TREAT HIP DISLOCATION                            A                 $59.66       20110101
27250       TREAT HIP DISLOCATION                                             $151.58       20110801
27252       TREAT HIP DISLOCATION                            A                $452.90       20110101
27252       TREAT HIP DISLOCATION                                             $515.84       20110801
27253       TREAT HIP DISLOCATION           80                                $128.86       20110801
27253       TREAT HIP DISLOCATION           81                                $128.86       20110801
27253       TREAT HIP DISLOCATION           82                                $128.86       20110801
27253       TREAT HIP DISLOCATION           AS                                $128.86       20110801
27253       TREAT HIP DISLOCATION                                             $644.28       20110801
27254       TREAT HIP DISLOCATION           80                                $173.99       20110801
27254       TREAT HIP DISLOCATION           81                                $173.99       20110801
27254       TREAT HIP DISLOCATION           82                                $173.99       20110801
27254       TREAT HIP DISLOCATION           AS                                $173.99       20110801



                                                 Page 78
                                     DMAP Fee for Service Fee Schedule
                                               August 2012


Procedure   Description                       Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                      Date
27254       TREAT HIP DISLOCATION                                               $869.96       20110801
27256       TREAT HIP DISLOCATION                                               $198.38       20110801
27257       TREAT HIP DISLOCATION                              A                $465.14       20110101
27257       TREAT HIP DISLOCATION                                               $229.84       20110801
27258       TREAT HIP DISLOCATION             80                                $151.48       20110801
27258       TREAT HIP DISLOCATION             81                                $151.48       20110801
27258       TREAT HIP DISLOCATION             82                                $151.48       20110801
27258       TREAT HIP DISLOCATION             AS                                $151.48       20110801
27258       TREAT HIP DISLOCATION                                               $757.38       20110801
27259       TREAT HIP DISLOCATION             80                                $212.78       20110801
27259       TREAT HIP DISLOCATION             81                                $212.78       20110801
27259       TREAT HIP DISLOCATION             82                                $212.78       20110801
27259       TREAT HIP DISLOCATION             AS                                $212.78       20110801
27259       TREAT HIP DISLOCATION                                             $1,063.92       20110801
27265       TREAT HIP DISLOCATION                              A                 $59.66       20110101
27265       TREAT HIP DISLOCATION                                               $264.42       20110801
27266       TREAT HIP DISLOCATION                              A                $452.90       20110101
27266       TREAT HIP DISLOCATION                                               $390.52       20110801
27267       CLTX THIGH FX                                      A                 $53.12       20110101
27267       CLTX THIGH FX                                                       $284.18       20110801
27268       CLTX THIGH FX W/MNPJ                                                $350.48       20110801
27269       OPTX THIGH FX                                                       $838.76       20110801
27275       MANIPULATION OF HIP JOINT                          A                $452.90       20110101
27275       MANIPULATION OF HIP JOINT                                           $119.34       20110801
27280       FUSION OF SACROILIAC JOINT        80                                $140.35       20110801
27280       FUSION OF SACROILIAC JOINT        81                                $140.35       20110801
27280       FUSION OF SACROILIAC JOINT        82                                $140.35       20110801
27280       FUSION OF SACROILIAC JOINT        AS                                $140.35       20110801
27280       FUSION OF SACROILIAC JOINT                                          $701.74       20110801
27282       FUSION OF PUBIC BONES             80                                $111.59       20110801
27282       FUSION OF PUBIC BONES             81                                $111.59       20110801
27282       FUSION OF PUBIC BONES             82                                $111.59       20110801
27282       FUSION OF PUBIC BONES             AS                                $111.59       20110801
27282       FUSION OF PUBIC BONES                                               $557.96       20110801
27284       FUSION OF HIP JOINT               80                                $216.22       20110801
27284       FUSION OF HIP JOINT               81                                $216.22       20110801
27284       FUSION OF HIP JOINT               82                                $216.22       20110801
27284       FUSION OF HIP JOINT               AS                                $216.22       20110801
27284       FUSION OF HIP JOINT                                               $1,081.08       20110801
27286       FUSION OF HIP JOINT               80                                $228.44       20110801
27286       FUSION OF HIP JOINT               81                                $228.44       20110801
27286       FUSION OF HIP JOINT               82                                $228.44       20110801
27286       FUSION OF HIP JOINT               AS                                $228.44       20110801
27286       FUSION OF HIP JOINT                                               $1,142.18       20110801
27290       AMPUTATION OF LEG AT HIP          80                                $218.66       20110801
27290       AMPUTATION OF LEG AT HIP          81                                $218.66       20110801
27290       AMPUTATION OF LEG AT HIP          82                                $218.66       20110801
27290       AMPUTATION OF LEG AT HIP          AS                                $218.66       20110801
27290       AMPUTATION OF LEG AT HIP                                          $1,093.30       20110801
27295       AMPUTATION OF LEG AT HIP          80                                $174.72       20110801
27295       AMPUTATION OF LEG AT HIP          81                                $174.72       20110801
27295       AMPUTATION OF LEG AT HIP          82                                $174.72       20110801
27295       AMPUTATION OF LEG AT HIP          AS                                $174.72       20110801
27295       AMPUTATION OF LEG AT HIP                                            $873.60       20110801
27301       DRAIN THIGH/KNEE LESION                            A                $564.03       20110101
27301       DRAIN THIGH/KNEE LESION                                             $438.36       20110801
27303       DRAINAGE OF BONE LESION           80                                 $86.22       20110801
27303       DRAINAGE OF BONE LESION           81                                 $86.22       20110801
27303       DRAINAGE OF BONE LESION           82                                 $86.22       20110801



                                                   Page 79
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
27303       DRAINAGE OF BONE LESION         AS                                    $86.22       20110801
27303       DRAINAGE OF BONE LESION                                              $431.08       20110801
27305       INCISE THIGH TENDON FASCIA                       A                   $614.48       20110101
27305       INCISE THIGH TENDON FASCIA      80                                    $63.28       20110801
27305       INCISE THIGH TENDON FASCIA      81                                    $63.28       20110801
27305       INCISE THIGH TENDON FASCIA      82                                    $63.28       20110801
27305       INCISE THIGH TENDON FASCIA      AS                                    $63.28       20110801
27305       INCISE THIGH TENDON FASCIA                                           $316.42       20110801
27306       INCISION OF THIGH TENDON                         A                   $626.73       20110101
27306       INCISION OF THIGH TENDON        80                                    $51.01       20110801
27306       INCISION OF THIGH TENDON        81                                    $51.01       20110801
27306       INCISION OF THIGH TENDON        82                                    $51.01       20110801
27306       INCISION OF THIGH TENDON        AS                                    $51.01       20110801
27306       INCISION OF THIGH TENDON                                             $255.06       20110801
27307       INCISION OF THIGH TENDONS                        A                   $626.73       20110101
27307       INCISION OF THIGH TENDONS       80                                    $62.92       20110801
27307       INCISION OF THIGH TENDONS       81                                    $62.92       20110801
27307       INCISION OF THIGH TENDONS       82                                    $62.92       20110801
27307       INCISION OF THIGH TENDONS       AS                                    $62.92       20110801
27307       INCISION OF THIGH TENDONS                                            $314.60       20110801
27310       EXPLORATION OF KNEE JOINT                        A                   $884.21       20110101
27310       EXPLORATION OF KNEE JOINT       80                                    $98.54       20110801
27310       EXPLORATION OF KNEE JOINT       81                                    $98.54       20110801
27310       EXPLORATION OF KNEE JOINT       82                                    $98.54       20110801
27310       EXPLORATION OF KNEE JOINT       AS                                    $98.54       20110801
27310       EXPLORATION OF KNEE JOINT                                            $492.70       20110801
27323       BIOPSY THIGH SOFT TISSUES                        A                   $260.88       20110101
27323       BIOPSY THIGH SOFT TISSUES                                            $176.54       20110801
27324       BIOPSY THIGH SOFT TISSUES                        A                   $625.87       20110101
27324       BIOPSY THIGH SOFT TISSUES                                            $259.74       20110801
27325       NEURECTOMY HAMSTRING                             A                   $535.29       20110101
27325       NEURECTOMY HAMSTRING                                                 $361.14       20110801
27326       NEURECTOMY POPLITEAL                             A                   $535.29       20110101
27326       NEURECTOMY POPLITEAL                                                 $331.76       20110801
27327       EXC THIGH/KNEE LES SC 3 CM                       A                   $145.81       20110101
27327       EXC THIGH/KNEE LES SC 3 CM                                           $284.70       20110801
27328       EXC THIGH/KNEE TUM DEEP 5CM                      A                   $560.76       20110101
27328       EXC THIGH/KNEE TUM DEEP 5CM                                          $391.04       20110801
27329       RESECT THIGH/KNEE TUM 5 CM                       A                   $560.76       20110101
27329       RESECT THIGH/KNEE TUM 5 CM      80                                   $142.58       20110801
27329       RESECT THIGH/KNEE TUM 5 CM      81                                   $142.58       20110801
27329       RESECT THIGH/KNEE TUM 5 CM      82                                   $142.58       20110801
27329       RESECT THIGH/KNEE TUM 5 CM      AS                                   $142.58       20110801
27329       RESECT THIGH/KNEE TUM 5 CM                                           $712.92       20110801
27330       BIOPSY KNEE JOINT LINING                         A                   $884.21       20110101
27330       BIOPSY KNEE JOINT LINING                                             $267.28       20110801
27331       EXPLORE/TREAT KNEE JOINT                         A                   $884.21       20110101
27331       EXPLORE/TREAT KNEE JOINT        80                                    $63.44       20110801
27331       EXPLORE/TREAT KNEE JOINT        81                                    $63.44       20110801
27331       EXPLORE/TREAT KNEE JOINT        82                                    $63.44       20110801
27331       EXPLORE/TREAT KNEE JOINT        AS                                    $63.44       20110801
27331       EXPLORE/TREAT KNEE JOINT                                             $317.20       20110801
27332       REMOVAL OF KNEE CARTILAGE                        A                   $884.21       20110101
27332       REMOVAL OF KNEE CARTILAGE       80                                    $86.01       20110801
27332       REMOVAL OF KNEE CARTILAGE       81                                    $86.01       20110801
27332       REMOVAL OF KNEE CARTILAGE       82                                    $86.01       20110801
27332       REMOVAL OF KNEE CARTILAGE       AS                                    $86.01       20110801
27332       REMOVAL OF KNEE CARTILAGE                                            $430.04       20110801
27333       REMOVAL OF KNEE CARTILAGE                        A                   $884.21       20110101



                                                 Page 80
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
27333       REMOVAL OF KNEE CARTILAGE       80                                    $78.16       20110801
27333       REMOVAL OF KNEE CARTILAGE       81                                    $78.16       20110801
27333       REMOVAL OF KNEE CARTILAGE       82                                    $78.16       20110801
27333       REMOVAL OF KNEE CARTILAGE       AS                                    $78.16       20110801
27333       REMOVAL OF KNEE CARTILAGE                                            $390.78       20110801
27334       REMOVE KNEE JOINT LINING                         A                   $884.21       20110101
27334       REMOVE KNEE JOINT LINING        80                                    $91.88       20110801
27334       REMOVE KNEE JOINT LINING        81                                    $91.88       20110801
27334       REMOVE KNEE JOINT LINING        82                                    $91.88       20110801
27334       REMOVE KNEE JOINT LINING        AS                                    $91.88       20110801
27334       REMOVE KNEE JOINT LINING                                             $459.42       20110801
27335       REMOVE KNEE JOINT LINING                         A                   $884.21       20110101
27335       REMOVE KNEE JOINT LINING        80                                   $103.64       20110801
27335       REMOVE KNEE JOINT LINING        81                                   $103.64       20110801
27335       REMOVE KNEE JOINT LINING        82                                   $103.64       20110801
27335       REMOVE KNEE JOINT LINING        AS                                   $103.64       20110801
27335       REMOVE KNEE JOINT LINING                                             $518.18       20110801
27337       EXC THIGH/KNEE LES SC 3 CM/                                          $295.10       20110801
27339       EXC THIGH/KNEE TUM DEP 5CM/                                          $531.18       20110801
27340       REMOVAL OF KNEECAP BURSA                         A                   $626.73       20110101
27340       REMOVAL OF KNEECAP BURSA                                             $243.62       20110801
27345       REMOVAL OF KNEE CYST                             A                   $649.69       20110101
27345       REMOVAL OF KNEE CYST            80                                    $64.48       20110801
27345       REMOVAL OF KNEE CYST            81                                    $64.48       20110801
27345       REMOVAL OF KNEE CYST            82                                    $64.48       20110801
27345       REMOVAL OF KNEE CYST            AS                                    $64.48       20110801
27345       REMOVAL OF KNEE CYST                                                 $322.40       20110801
27347       REMOVE KNEE CYST                                 A                   $649.69       20110101
27347       REMOVE KNEE CYST                80                                    $69.94       20110801
27347       REMOVE KNEE CYST                81                                    $69.94       20110801
27347       REMOVE KNEE CYST                82                                    $69.94       20110801
27347       REMOVE KNEE CYST                AS                                    $69.94       20110801
27347       REMOVE KNEE CYST                                                     $349.70       20110801
27350       REMOVAL OF KNEECAP                               A                   $884.21       20110101
27350       REMOVAL OF KNEECAP              80                                    $87.72       20110801
27350       REMOVAL OF KNEECAP              81                                    $87.72       20110801
27350       REMOVAL OF KNEECAP              82                                    $87.72       20110801
27350       REMOVAL OF KNEECAP              AS                                    $87.72       20110801
27350       REMOVAL OF KNEECAP                                                   $438.62       20110801
27355       REMOVE FEMUR LESION                              A                   $861.25       20110101
27355       REMOVE FEMUR LESION             80                                    $81.22       20110801
27355       REMOVE FEMUR LESION             81                                    $81.22       20110801
27355       REMOVE FEMUR LESION             82                                    $81.22       20110801
27355       REMOVE FEMUR LESION             AS                                    $81.22       20110801
27355       REMOVE FEMUR LESION                                                  $406.12       20110801
27356       REMOVE FEMUR LESION/GRAFT                        A                   $884.21       20110101
27356       REMOVE FEMUR LESION/GRAFT       80                                    $99.63       20110801
27356       REMOVE FEMUR LESION/GRAFT       81                                    $99.63       20110801
27356       REMOVE FEMUR LESION/GRAFT       82                                    $99.63       20110801
27356       REMOVE FEMUR LESION/GRAFT       AS                                    $99.63       20110801
27356       REMOVE FEMUR LESION/GRAFT                                            $498.16       20110801
27357       REMOVE FEMUR LESION/GRAFT                        A                   $900.86       20110101
27357       REMOVE FEMUR LESION/GRAFT       80                                   $110.03       20110801
27357       REMOVE FEMUR LESION/GRAFT       81                                   $110.03       20110801
27357       REMOVE FEMUR LESION/GRAFT       82                                   $110.03       20110801
27357       REMOVE FEMUR LESION/GRAFT       AS                                   $110.03       20110801
27357       REMOVE FEMUR LESION/GRAFT                                            $550.16       20110801
27358       REMOVE FEMUR LESION/FIXATION                     A                   $900.86       20110101
27358       REMOVE FEMUR LESION/FIXATION    80                                    $39.62       20110801



                                                 Page 81
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27358       REMOVE FEMUR LESION/FIXATION    81                                 $39.62       20110801
27358       REMOVE FEMUR LESION/FIXATION    82                                 $39.62       20110801
27358       REMOVE FEMUR LESION/FIXATION    AS                                 $39.62       20110801
27358       REMOVE FEMUR LESION/FIXATION                                      $198.12       20110801
27360       PARTIAL REMOVAL LEG BONES                        A                $900.86       20110101
27360       PARTIAL REMOVAL LEG BONES       80                                $115.02       20110801
27360       PARTIAL REMOVAL LEG BONES       81                                $115.02       20110801
27360       PARTIAL REMOVAL LEG BONES       82                                $115.02       20110801
27360       PARTIAL REMOVAL LEG BONES       AS                                $115.02       20110801
27360       PARTIAL REMOVAL LEG BONES                                         $575.12       20110801
27364       RESECT THIGH/KNEE TUM 5 CM/                                     $1,110.46       20110801
27365       RESECT FEMUR/KNEE TUMOR         80                                $261.66       20110801
27365       RESECT FEMUR/KNEE TUMOR         81                                $261.66       20110801
27365       RESECT FEMUR/KNEE TUMOR         82                                $261.66       20110801
27365       RESECT FEMUR/KNEE TUMOR         AS                                $261.66       20110801
27365       RESECT FEMUR/KNEE TUMOR                                         $1,308.32       20110801
27370       INJECTION FOR KNEE X-RAY                                          $110.76       20110801
27372       REMOVAL OF FOREIGN BODY                          A                $752.54       20110101
27372       REMOVAL OF FOREIGN BODY                                           $392.08       20110801
27380       REPAIR OF KNEECAP TENDON                         A                $592.86       20110101
27380       REPAIR OF KNEECAP TENDON        80                                 $79.46       20110801
27380       REPAIR OF KNEECAP TENDON        81                                 $79.46       20110801
27380       REPAIR OF KNEECAP TENDON        82                                 $79.46       20110801
27380       REPAIR OF KNEECAP TENDON        AS                                 $79.46       20110801
27380       REPAIR OF KNEECAP TENDON                                          $397.28       20110801
27381       REPAIR/GRAFT KNEECAP TENDON                      A                $626.73       20110101
27381       REPAIR/GRAFT KNEECAP TENDON     80                                $108.21       20110801
27381       REPAIR/GRAFT KNEECAP TENDON     81                                $108.21       20110801
27381       REPAIR/GRAFT KNEECAP TENDON     82                                $108.21       20110801
27381       REPAIR/GRAFT KNEECAP TENDON     AS                                $108.21       20110801
27381       REPAIR/GRAFT KNEECAP TENDON                                       $541.06       20110801
27385       REPAIR OF THIGH MUSCLE                           A                $626.73       20110101
27385       REPAIR OF THIGH MUSCLE          80                                 $85.02       20110801
27385       REPAIR OF THIGH MUSCLE          81                                 $85.02       20110801
27385       REPAIR OF THIGH MUSCLE          82                                 $85.02       20110801
27385       REPAIR OF THIGH MUSCLE          AS                                 $85.02       20110801
27385       REPAIR OF THIGH MUSCLE                                            $425.10       20110801
27386       REPAIR/GRAFT OF THIGH MUSCLE                     A                $626.73       20110101
27386       REPAIR/GRAFT OF THIGH MUSCLE    80                                $112.37       20110801
27386       REPAIR/GRAFT OF THIGH MUSCLE    81                                $112.37       20110801
27386       REPAIR/GRAFT OF THIGH MUSCLE    82                                $112.37       20110801
27386       REPAIR/GRAFT OF THIGH MUSCLE    AS                                $112.37       20110801
27386       REPAIR/GRAFT OF THIGH MUSCLE                                      $561.86       20110801
27390       INCISION OF THIGH TENDON                         A                $592.86       20110101
27390       INCISION OF THIGH TENDON        80                                 $59.12       20110801
27390       INCISION OF THIGH TENDON        81                                 $59.12       20110801
27390       INCISION OF THIGH TENDON        82                                 $59.12       20110801
27390       INCISION OF THIGH TENDON        AS                                 $59.12       20110801
27390       INCISION OF THIGH TENDON                                          $295.62       20110801
27391       INCISION OF THIGH TENDONS                        A                $614.48       20110101
27391       INCISION OF THIGH TENDONS       80                                 $77.06       20110801
27391       INCISION OF THIGH TENDONS       81                                 $77.06       20110801
27391       INCISION OF THIGH TENDONS       82                                 $77.06       20110801
27391       INCISION OF THIGH TENDONS       AS                                 $77.06       20110801
27391       INCISION OF THIGH TENDONS                                         $385.32       20110801
27392       INCISION OF THIGH TENDONS                        A                $626.73       20110101
27392       INCISION OF THIGH TENDONS       80                                 $95.11       20110801
27392       INCISION OF THIGH TENDONS       81                                 $95.11       20110801
27392       INCISION OF THIGH TENDONS       82                                 $95.11       20110801



                                                 Page 82
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27392       INCISION OF THIGH TENDONS       AS                                 $95.11       20110801
27392       INCISION OF THIGH TENDONS                                         $475.54       20110801
27393       LENGTHENING OF THIGH TENDON                      A                $849.00       20110101
27393       LENGTHENING OF THIGH TENDON     80                                 $68.12       20110801
27393       LENGTHENING OF THIGH TENDON     81                                 $68.12       20110801
27393       LENGTHENING OF THIGH TENDON     82                                 $68.12       20110801
27393       LENGTHENING OF THIGH TENDON     AS                                 $68.12       20110801
27393       LENGTHENING OF THIGH TENDON                                       $340.60       20110801
27394       LENGTHENING OF THIGH TENDONS                     A                $861.25       20110101
27394       LENGTHENING OF THIGH TENDONS    80                                 $87.98       20110801
27394       LENGTHENING OF THIGH TENDONS    81                                 $87.98       20110801
27394       LENGTHENING OF THIGH TENDONS    82                                 $87.98       20110801
27394       LENGTHENING OF THIGH TENDONS    AS                                 $87.98       20110801
27394       LENGTHENING OF THIGH TENDONS                                      $439.92       20110801
27395       LENGTHENING OF THIGH TENDONS                     A              $1,217.14       20110101
27395       LENGTHENING OF THIGH TENDONS    80                                $119.13       20110801
27395       LENGTHENING OF THIGH TENDONS    81                                $119.13       20110801
27395       LENGTHENING OF THIGH TENDONS    82                                $119.13       20110801
27395       LENGTHENING OF THIGH TENDONS    AS                                $119.13       20110801
27395       LENGTHENING OF THIGH TENDONS                                      $595.66       20110801
27396       TRANSPLANT OF THIGH TENDON                       A                $861.25       20110101
27396       TRANSPLANT OF THIGH TENDON      80                                 $82.78       20110801
27396       TRANSPLANT OF THIGH TENDON      81                                 $82.78       20110801
27396       TRANSPLANT OF THIGH TENDON      82                                 $82.78       20110801
27396       TRANSPLANT OF THIGH TENDON      AS                                 $82.78       20110801
27396       TRANSPLANT OF THIGH TENDON                                        $413.92       20110801
27397       TRANSPLANTS OF THIGH TENDONS                     A              $1,217.14       20110101
27397       TRANSPLANTS OF THIGH TENDONS    80                                $123.34       20110801
27397       TRANSPLANTS OF THIGH TENDONS    81                                $123.34       20110801
27397       TRANSPLANTS OF THIGH TENDONS    82                                $123.34       20110801
27397       TRANSPLANTS OF THIGH TENDONS    AS                                $123.34       20110801
27397       TRANSPLANTS OF THIGH TENDONS                                      $616.72       20110801
27400       REVISE THIGH MUSCLES/TENDONS                     A              $1,217.14       20110101
27400       REVISE THIGH MUSCLES/TENDONS    80                                 $93.18       20110801
27400       REVISE THIGH MUSCLES/TENDONS    81                                 $93.18       20110801
27400       REVISE THIGH MUSCLES/TENDONS    82                                 $93.18       20110801
27400       REVISE THIGH MUSCLES/TENDONS    AS                                 $93.18       20110801
27400       REVISE THIGH MUSCLES/TENDONS                                      $465.92       20110801
27403       REPAIR OF KNEE CARTILAGE                         A                $884.21       20110101
27403       REPAIR OF KNEE CARTILAGE        80                                 $86.53       20110801
27403       REPAIR OF KNEE CARTILAGE        81                                 $86.53       20110801
27403       REPAIR OF KNEE CARTILAGE        82                                 $86.53       20110801
27403       REPAIR OF KNEE CARTILAGE        AS                                 $86.53       20110801
27403       REPAIR OF KNEE CARTILAGE                                          $432.64       20110801
27405       REPAIR OF KNEE LIGAMENT                          A              $1,240.11       20110101
27405       REPAIR OF KNEE LIGAMENT         80                                 $91.36       20110801
27405       REPAIR OF KNEE LIGAMENT         81                                 $91.36       20110801
27405       REPAIR OF KNEE LIGAMENT         82                                 $91.36       20110801
27405       REPAIR OF KNEE LIGAMENT         AS                                 $91.36       20110801
27405       REPAIR OF KNEE LIGAMENT                                           $456.82       20110801
27407       REPAIR OF KNEE LIGAMENT                          A              $2,251.38       20110101
27407       REPAIR OF KNEE LIGAMENT         80                                $105.09       20110801
27407       REPAIR OF KNEE LIGAMENT         81                                $105.09       20110801
27407       REPAIR OF KNEE LIGAMENT         82                                $105.09       20110801
27407       REPAIR OF KNEE LIGAMENT         AS                                $105.09       20110801
27407       REPAIR OF KNEE LIGAMENT                                           $525.46       20110801
27409       REPAIR OF KNEE LIGAMENTS                         A              $1,240.11       20110101
27409       REPAIR OF KNEE LIGAMENTS        80                                $131.20       20110801
27409       REPAIR OF KNEE LIGAMENTS        81                                $131.20       20110801



                                                 Page 83
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
27409       REPAIR OF KNEE LIGAMENTS       82                                $131.20       20110801
27409       REPAIR OF KNEE LIGAMENTS       AS                                $131.20       20110801
27409       REPAIR OF KNEE LIGAMENTS                                         $655.98       20110801
27412       AUTOCHONDROCYTE IMPLANT KNEE   80                                $226.46       20110801
27412       AUTOCHONDROCYTE IMPLANT KNEE                                   $1,132.30       20110801
27415       OSTEOCHONDRAL KNEE ALLOGRAFT   80                                $186.78       20110801
27415       OSTEOCHONDRAL KNEE ALLOGRAFT                                     $933.92       20110801
27416       OSTEOCHONDRAL KNEE AUTOGRAFT                                     $660.92       20110801
27418       REPAIR DEGENERATED KNEECAP                      A              $1,217.14       20110101
27418       REPAIR DEGENERATED KNEECAP     80                                $113.10       20110801
27418       REPAIR DEGENERATED KNEECAP     81                                $113.10       20110801
27418       REPAIR DEGENERATED KNEECAP     82                                $113.10       20110801
27418       REPAIR DEGENERATED KNEECAP     AS                                $113.10       20110801
27418       REPAIR DEGENERATED KNEECAP                                       $565.50       20110801
27420       REVISION OF UNSTABLE KNEECAP                    A              $1,217.14       20110101
27420       REVISION OF UNSTABLE KNEECAP   80                                $101.14       20110801
27420       REVISION OF UNSTABLE KNEECAP   81                                $101.14       20110801
27420       REVISION OF UNSTABLE KNEECAP   82                                $101.14       20110801
27420       REVISION OF UNSTABLE KNEECAP   AS                                $101.14       20110801
27420       REVISION OF UNSTABLE KNEECAP                                     $505.70       20110801
27422       REVISION OF UNSTABLE KNEECAP                    A              $1,309.94       20110101
27422       REVISION OF UNSTABLE KNEECAP   80                                $100.78       20110801
27422       REVISION OF UNSTABLE KNEECAP   81                                $100.78       20110801
27422       REVISION OF UNSTABLE KNEECAP   82                                $100.78       20110801
27422       REVISION OF UNSTABLE KNEECAP   AS                                $100.78       20110801
27422       REVISION OF UNSTABLE KNEECAP                                     $503.88       20110801
27424       REVISION/REMOVAL OF KNEECAP                     A              $1,217.14       20110101
27424       REVISION/REMOVAL OF KNEECAP    80                                $101.04       20110801
27424       REVISION/REMOVAL OF KNEECAP    81                                $101.04       20110801
27424       REVISION/REMOVAL OF KNEECAP    82                                $101.04       20110801
27424       REVISION/REMOVAL OF KNEECAP    AS                                $101.04       20110801
27424       REVISION/REMOVAL OF KNEECAP                                      $505.18       20110801
27425       LAT RETINACULAR RELEASE OPEN                    A                $954.05       20110101
27425       LAT RETINACULAR RELEASE OPEN                                     $295.88       20110801
27427       RECONSTRUCTION KNEE                             A              $1,217.14       20110101
27427       RECONSTRUCTION KNEE            80                                 $97.19       20110801
27427       RECONSTRUCTION KNEE            81                                 $97.19       20110801
27427       RECONSTRUCTION KNEE            82                                 $97.19       20110801
27427       RECONSTRUCTION KNEE            AS                                 $97.19       20110801
27427       RECONSTRUCTION KNEE                                              $485.94       20110801
27428       RECONSTRUCTION KNEE                             A              $2,251.38       20110101
27428       RECONSTRUCTION KNEE            80                                $150.85       20110801
27428       RECONSTRUCTION KNEE            81                                $150.85       20110801
27428       RECONSTRUCTION KNEE            82                                $150.85       20110801
27428       RECONSTRUCTION KNEE            AS                                $150.85       20110801
27428       RECONSTRUCTION KNEE                                              $754.26       20110801
27429       RECONSTRUCTION KNEE                             A              $2,251.38       20110101
27429       RECONSTRUCTION KNEE            80                                $169.36       20110801
27429       RECONSTRUCTION KNEE            81                                $169.36       20110801
27429       RECONSTRUCTION KNEE            82                                $169.36       20110801
27429       RECONSTRUCTION KNEE            AS                                $169.36       20110801
27429       RECONSTRUCTION KNEE                                              $846.82       20110801
27430       REVISION OF THIGH MUSCLES                       A              $1,240.11       20110101
27430       REVISION OF THIGH MUSCLES      80                                $100.20       20110801
27430       REVISION OF THIGH MUSCLES      81                                $100.20       20110801
27430       REVISION OF THIGH MUSCLES      82                                $100.20       20110801
27430       REVISION OF THIGH MUSCLES      AS                                $100.20       20110801
27430       REVISION OF THIGH MUSCLES                                        $501.02       20110801
27435       INCISION OF KNEE JOINT                          A              $1,240.11       20110101



                                                Page 84
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
27435       INCISION OF KNEE JOINT           80                                $108.63       20110801
27435       INCISION OF KNEE JOINT           81                                $108.63       20110801
27435       INCISION OF KNEE JOINT           82                                $108.63       20110801
27435       INCISION OF KNEE JOINT           AS                                $108.63       20110801
27435       INCISION OF KNEE JOINT                                             $543.14       20110801
27437       REVISE KNEECAP                                    A              $1,079.29       20110101
27437       REVISE KNEECAP                                                     $445.64       20110801
27438       REVISE KNEECAP WITH IMPLANT                       A              $1,533.29       20110101
27438       REVISE KNEECAP WITH IMPLANT      80                                $114.30       20110801
27438       REVISE KNEECAP WITH IMPLANT      81                                $114.30       20110801
27438       REVISE KNEECAP WITH IMPLANT      82                                $114.30       20110801
27438       REVISE KNEECAP WITH IMPLANT      AS                                $114.30       20110801
27438       REVISE KNEECAP WITH IMPLANT                                        $571.48       20110801
27440       REVISION OF KNEE JOINT                            A              $1,278.32       20110101
27440       REVISION OF KNEE JOINT           80                                $105.35       20110801
27440       REVISION OF KNEE JOINT           81                                $105.35       20110801
27440       REVISION OF KNEE JOINT           82                                $105.35       20110801
27440       REVISION OF KNEE JOINT           AS                                $105.35       20110801
27440       REVISION OF KNEE JOINT                                             $526.76       20110801
27441       REVISION OF KNEE JOINT                            A              $1,095.93       20110101
27441       REVISION OF KNEE JOINT           80                                $108.84       20110801
27441       REVISION OF KNEE JOINT           81                                $108.84       20110801
27441       REVISION OF KNEE JOINT           82                                $108.84       20110801
27441       REVISION OF KNEE JOINT           AS                                $108.84       20110801
27441       REVISION OF KNEE JOINT                                             $544.18       20110801
27442       REVISION OF KNEE JOINT                            A              $1,095.93       20110101
27442       REVISION OF KNEE JOINT           80                                $118.25       20110801
27442       REVISION OF KNEE JOINT           81                                $118.25       20110801
27442       REVISION OF KNEE JOINT           82                                $118.25       20110801
27442       REVISION OF KNEE JOINT           AS                                $118.25       20110801
27442       REVISION OF KNEE JOINT                                             $591.24       20110801
27443       REVISION OF KNEE JOINT                            A              $1,095.93       20110101
27443       REVISION OF KNEE JOINT           80                                $110.71       20110801
27443       REVISION OF KNEE JOINT           81                                $110.71       20110801
27443       REVISION OF KNEE JOINT           82                                $110.71       20110801
27443       REVISION OF KNEE JOINT           AS                                $110.71       20110801
27443       REVISION OF KNEE JOINT                                             $553.54       20110801
27445       REVISION OF KNEE JOINT           80                                $172.59       20110801
27445       REVISION OF KNEE JOINT           81                                $172.59       20110801
27445       REVISION OF KNEE JOINT           82                                $172.59       20110801
27445       REVISION OF KNEE JOINT           AS                                $172.59       20110801
27445       REVISION OF KNEE JOINT                                             $862.94       20110801
27446       REVISION OF KNEE JOINT           80                                $152.41       20110801
27446       REVISION OF KNEE JOINT           81                                $152.41       20110801
27446       REVISION OF KNEE JOINT           82                                $152.41       20110801
27446       REVISION OF KNEE JOINT           AS                                $152.41       20110801
27446       REVISION OF KNEE JOINT                                             $762.06       20110801
27447       TOTAL KNEE ARTHROPLASTY          80                                $212.37       20110801
27447       TOTAL KNEE ARTHROPLASTY          81                                $212.37       20110801
27447       TOTAL KNEE ARTHROPLASTY          82                                $212.37       20110801
27447       TOTAL KNEE ARTHROPLASTY          AS                                $212.37       20110801
27447       TOTAL KNEE ARTHROPLASTY                                          $1,061.84       20110801
27448       INCISION OF THIGH                80                                $111.44       20110801
27448       INCISION OF THIGH                81                                $111.44       20110801
27448       INCISION OF THIGH                82                                $111.44       20110801
27448       INCISION OF THIGH                AS                                $111.44       20110801
27448       INCISION OF THIGH                                                  $557.18       20110801
27450       INCISION OF THIGH                80                                $139.05       20110801
27450       INCISION OF THIGH                81                                $139.05       20110801



                                                  Page 85
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
27450       INCISION OF THIGH              82                                   $139.05       20110801
27450       INCISION OF THIGH              AS                                   $139.05       20110801
27450       INCISION OF THIGH                                                   $695.24       20110801
27454       REALIGNMENT OF THIGH BONE      80                                   $176.38       20110801
27454       REALIGNMENT OF THIGH BONE      81                                   $176.38       20110801
27454       REALIGNMENT OF THIGH BONE      82                                   $176.38       20110801
27454       REALIGNMENT OF THIGH BONE      AS                                   $176.38       20110801
27454       REALIGNMENT OF THIGH BONE                                           $881.92       20110801
27455       REALIGNMENT OF KNEE            80                                   $128.23       20110801
27455       REALIGNMENT OF KNEE            81                                   $128.23       20110801
27455       REALIGNMENT OF KNEE            82                                   $128.23       20110801
27455       REALIGNMENT OF KNEE            AS                                   $128.23       20110801
27455       REALIGNMENT OF KNEE                                                 $641.16       20110801
27457       REALIGNMENT OF KNEE            80                                   $131.98       20110801
27457       REALIGNMENT OF KNEE            81                                   $131.98       20110801
27457       REALIGNMENT OF KNEE            82                                   $131.98       20110801
27457       REALIGNMENT OF KNEE            AS                                   $131.98       20110801
27457       REALIGNMENT OF KNEE                                                 $659.88       20110801
27465       SHORTENING OF THIGH BONE       80                                   $169.73       20110801
27465       SHORTENING OF THIGH BONE       81                                   $169.73       20110801
27465       SHORTENING OF THIGH BONE       82                                   $169.73       20110801
27465       SHORTENING OF THIGH BONE       AS                                   $169.73       20110801
27465       SHORTENING OF THIGH BONE                                            $848.64       20110801
27466       LENGTHENING OF THIGH BONE      80                                   $162.14       20110801
27466       LENGTHENING OF THIGH BONE      81                                   $162.14       20110801
27466       LENGTHENING OF THIGH BONE      82                                   $162.14       20110801
27466       LENGTHENING OF THIGH BONE      AS                                   $162.14       20110801
27466       LENGTHENING OF THIGH BONE                                           $810.68       20110801
27468       SHORTEN/LENGTHEN THIGHS        80                                   $183.35       20110801
27468       SHORTEN/LENGTHEN THIGHS        81                                   $183.35       20110801
27468       SHORTEN/LENGTHEN THIGHS        82                                   $183.35       20110801
27468       SHORTEN/LENGTHEN THIGHS        AS                                   $183.35       20110801
27468       SHORTEN/LENGTHEN THIGHS                                             $916.76       20110801
27470       REPAIR OF THIGH                80                                   $161.51       20110801
27470       REPAIR OF THIGH                81                                   $161.51       20110801
27470       REPAIR OF THIGH                82                                   $161.51       20110801
27470       REPAIR OF THIGH                AS                                   $161.51       20110801
27470       REPAIR OF THIGH                                                     $807.56       20110801
27472       REPAIR/GRAFT OF THIGH          80                                   $174.25       20110801
27472       REPAIR/GRAFT OF THIGH          81                                   $174.25       20110801
27472       REPAIR/GRAFT OF THIGH          82                                   $174.25       20110801
27472       REPAIR/GRAFT OF THIGH          AS                                   $174.25       20110801
27472       REPAIR/GRAFT OF THIGH                                               $871.26       20110801
27475       SURGERY TO STOP LEG GROWTH                                          $445.90       20110801
27477       SURGERY TO STOP LEG GROWTH                                          $495.56       20110801
27479       SURGERY TO STOP LEG GROWTH     80                                   $115.60       20110801
27479       SURGERY TO STOP LEG GROWTH     81                                   $115.60       20110801
27479       SURGERY TO STOP LEG GROWTH     82                                   $115.60       20110801
27479       SURGERY TO STOP LEG GROWTH     AS                                   $115.60       20110801
27479       SURGERY TO STOP LEG GROWTH                                          $577.98       20110801
27485       SURGERY TO STOP LEG GROWTH                                          $453.44       20110801
27486       REVISE/REPLACE KNEE JOINT      80                                   $194.06       20110801
27486       REVISE/REPLACE KNEE JOINT      81                                   $194.06       20110801
27486       REVISE/REPLACE KNEE JOINT      82                                   $194.06       20110801
27486       REVISE/REPLACE KNEE JOINT      AS                                   $194.06       20110801
27486       REVISE/REPLACE KNEE JOINT                                           $970.32       20110801
27487       REVISE/REPLACE KNEE JOINT      80                                   $244.24       20110801
27487       REVISE/REPLACE KNEE JOINT      81                                   $244.24       20110801
27487       REVISE/REPLACE KNEE JOINT      82                                   $244.24       20110801



                                                Page 86
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
27487       REVISE/REPLACE KNEE JOINT      AS                                $244.24       20110801
27487       REVISE/REPLACE KNEE JOINT                                      $1,221.22       20110801
27488       REMOVAL OF KNEE PROSTHESIS     80                                $164.63       20110801
27488       REMOVAL OF KNEE PROSTHESIS     81                                $164.63       20110801
27488       REMOVAL OF KNEE PROSTHESIS     82                                $164.63       20110801
27488       REMOVAL OF KNEE PROSTHESIS     AS                                $164.63       20110801
27488       REMOVAL OF KNEE PROSTHESIS                                       $823.16       20110801
27495       REINFORCE THIGH                80                                $154.96       20110801
27495       REINFORCE THIGH                81                                $154.96       20110801
27495       REINFORCE THIGH                82                                $154.96       20110801
27495       REINFORCE THIGH                AS                                $154.96       20110801
27495       REINFORCE THIGH                                                  $774.80       20110801
27496       DECOMPRESSION OF THIGH/KNEE                     A                $900.86       20110101
27496       DECOMPRESSION OF THIGH/KNEE                                      $346.84       20110801
27497       DECOMPRESSION OF THIGH/KNEE                     A                $626.73       20110101
27497       DECOMPRESSION OF THIGH/KNEE                                      $375.70       20110801
27498       DECOMPRESSION OF THIGH/KNEE                     A                $861.25       20110101
27498       DECOMPRESSION OF THIGH/KNEE    80                                 $82.73       20110801
27498       DECOMPRESSION OF THIGH/KNEE    81                                 $82.73       20110801
27498       DECOMPRESSION OF THIGH/KNEE    82                                 $82.73       20110801
27498       DECOMPRESSION OF THIGH/KNEE    AS                                 $82.73       20110801
27498       DECOMPRESSION OF THIGH/KNEE                                      $413.66       20110801
27499       DECOMPRESSION OF THIGH/KNEE                     A                $861.25       20110101
27499       DECOMPRESSION OF THIGH/KNEE    80                                 $90.64       20110801
27499       DECOMPRESSION OF THIGH/KNEE    81                                 $90.64       20110801
27499       DECOMPRESSION OF THIGH/KNEE    82                                 $90.64       20110801
27499       DECOMPRESSION OF THIGH/KNEE    AS                                 $90.64       20110801
27499       DECOMPRESSION OF THIGH/KNEE                                      $453.18       20110801
27500       TREATMENT OF THIGH FRACTURE                     A                $135.07       20110101
27500       TREATMENT OF THIGH FRACTURE                                      $341.90       20110801
27501       TREATMENT OF THIGH FRACTURE                     A                 $59.66       20110101
27501       TREATMENT OF THIGH FRACTURE                                      $336.44       20110801
27502       TREATMENT OF THIGH FRACTURE                     A                $462.00       20110101
27502       TREATMENT OF THIGH FRACTURE                                      $535.08       20110801
27503       TREATMENT OF THIGH FRACTURE                     A                 $59.66       20110101
27503       TREATMENT OF THIGH FRACTURE                                      $544.70       20110801
27506       TREATMENT OF THIGH FRACTURE    80                                $183.14       20110801
27506       TREATMENT OF THIGH FRACTURE    81                                $183.14       20110801
27506       TREATMENT OF THIGH FRACTURE    82                                $183.14       20110801
27506       TREATMENT OF THIGH FRACTURE    AS                                $183.14       20110801
27506       TREATMENT OF THIGH FRACTURE                                      $915.72       20110801
27507       TREATMENT OF THIGH FRACTURE    80                                $134.32       20110801
27507       TREATMENT OF THIGH FRACTURE    81                                $134.32       20110801
27507       TREATMENT OF THIGH FRACTURE    82                                $134.32       20110801
27507       TREATMENT OF THIGH FRACTURE    AS                                $134.32       20110801
27507       TREATMENT OF THIGH FRACTURE                                      $671.58       20110801
27508       TREATMENT OF THIGH FRACTURE                     A                 $59.66       20110101
27508       TREATMENT OF THIGH FRACTURE                                      $345.80       20110801
27509       TREATMENT OF THIGH FRACTURE                     A                $718.78       20110101
27509       TREATMENT OF THIGH FRACTURE                                      $432.64       20110801
27510       TREATMENT OF THIGH FRACTURE                     A                $135.07       20110101
27510       TREATMENT OF THIGH FRACTURE                                      $472.68       20110801
27511       TREATMENT OF THIGH FRACTURE    80                                $139.41       20110801
27511       TREATMENT OF THIGH FRACTURE    81                                $139.41       20110801
27511       TREATMENT OF THIGH FRACTURE    82                                $139.41       20110801
27511       TREATMENT OF THIGH FRACTURE    AS                                $139.41       20110801
27511       TREATMENT OF THIGH FRACTURE                                      $697.06       20110801
27513       TREATMENT OF THIGH FRACTURE    80                                $174.67       20110801
27513       TREATMENT OF THIGH FRACTURE    81                                $174.67       20110801



                                                Page 87
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                       Date
27513       TREATMENT OF THIGH FRACTURE     82                                   $174.67       20110801
27513       TREATMENT OF THIGH FRACTURE     AS                                   $174.67       20110801
27513       TREATMENT OF THIGH FRACTURE                                          $873.34       20110801
27514       TREATMENT OF THIGH FRACTURE     80                                   $137.49       20110801
27514       TREATMENT OF THIGH FRACTURE     81                                   $137.49       20110801
27514       TREATMENT OF THIGH FRACTURE     82                                   $137.49       20110801
27514       TREATMENT OF THIGH FRACTURE     AS                                   $137.49       20110801
27514       TREATMENT OF THIGH FRACTURE                                          $687.44       20110801
27516       TREAT THIGH FX GROWTH PLATE                      A                    $59.66       20110101
27516       TREAT THIGH FX GROWTH PLATE                                          $327.08       20110801
27517       TREAT THIGH FX GROWTH PLATE                      A                    $59.66       20110101
27517       TREAT THIGH FX GROWTH PLATE                                          $459.94       20110801
27519       TREAT THIGH FX GROWTH PLATE     80                                   $125.27       20110801
27519       TREAT THIGH FX GROWTH PLATE     81                                   $125.27       20110801
27519       TREAT THIGH FX GROWTH PLATE     82                                   $125.27       20110801
27519       TREAT THIGH FX GROWTH PLATE     AS                                   $125.27       20110801
27519       TREAT THIGH FX GROWTH PLATE                                          $626.34       20110801
27520       TREAT KNEECAP FRACTURE                           A                    $59.66       20110101
27520       TREAT KNEECAP FRACTURE                                               $205.40       20110801
27524       TREAT KNEECAP FRACTURE          80                                   $102.13       20110801
27524       TREAT KNEECAP FRACTURE          81                                   $102.13       20110801
27524       TREAT KNEECAP FRACTURE          82                                   $102.13       20110801
27524       TREAT KNEECAP FRACTURE          AS                                   $102.13       20110801
27524       TREAT KNEECAP FRACTURE                                               $510.64       20110801
27530       TREAT KNEE FRACTURE                              A                    $59.66       20110101
27530       TREAT KNEE FRACTURE                                                  $256.88       20110801
27532       TREAT KNEE FRACTURE                              A                   $462.00       20110101
27532       TREAT KNEE FRACTURE                                                  $408.20       20110801
27535       TREAT KNEE FRACTURE             80                                   $124.85       20110801
27535       TREAT KNEE FRACTURE             81                                   $124.85       20110801
27535       TREAT KNEE FRACTURE             82                                   $124.85       20110801
27535       TREAT KNEE FRACTURE             AS                                   $124.85       20110801
27535       TREAT KNEE FRACTURE                                                  $624.26       20110801
27536       TREAT KNEE FRACTURE             80                                   $162.97       20110801
27536       TREAT KNEE FRACTURE             81                                   $162.97       20110801
27536       TREAT KNEE FRACTURE             82                                   $162.97       20110801
27536       TREAT KNEE FRACTURE             AS                                   $162.97       20110801
27536       TREAT KNEE FRACTURE                                                  $814.84       20110801
27538       TREAT KNEE FRACTURES                             A                    $59.66       20110101
27538       TREAT KNEE FRACTURES                                                 $306.80       20110801
27540       TREAT KNEE FRACTURE             80                                   $111.38       20110801
27540       TREAT KNEE FRACTURE             81                                   $111.38       20110801
27540       TREAT KNEE FRACTURE             82                                   $111.38       20110801
27540       TREAT KNEE FRACTURE             AS                                   $111.38       20110801
27540       TREAT KNEE FRACTURE                                                  $556.92       20110801
27550       TREAT KNEE DISLOCATION                           A                    $59.66       20110101
27550       TREAT KNEE DISLOCATION                                               $326.56       20110801
27552       TREAT KNEE DISLOCATION                           A                   $431.28       20110101
27552       TREAT KNEE DISLOCATION                                               $418.86       20110801
27556       TREAT KNEE DISLOCATION          80                                   $123.24       20110801
27556       TREAT KNEE DISLOCATION          81                                   $123.24       20110801
27556       TREAT KNEE DISLOCATION          82                                   $123.24       20110801
27556       TREAT KNEE DISLOCATION          AS                                   $123.24       20110801
27556       TREAT KNEE DISLOCATION                                               $616.20       20110801
27557       TREAT KNEE DISLOCATION          80                                   $147.68       20110801
27557       TREAT KNEE DISLOCATION          81                                   $147.68       20110801
27557       TREAT KNEE DISLOCATION          82                                   $147.68       20110801
27557       TREAT KNEE DISLOCATION          AS                                   $147.68       20110801
27557       TREAT KNEE DISLOCATION                                               $738.40       20110801



                                                 Page 88
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
27558       TREAT KNEE DISLOCATION         80                                $167.28       20110801
27558       TREAT KNEE DISLOCATION         81                                $167.28       20110801
27558       TREAT KNEE DISLOCATION         82                                $167.28       20110801
27558       TREAT KNEE DISLOCATION         AS                                $167.28       20110801
27558       TREAT KNEE DISLOCATION                                           $836.42       20110801
27560       TREAT KNEECAP DISLOCATION                       A                 $59.66       20110101
27560       TREAT KNEECAP DISLOCATION                                        $242.84       20110801
27562       TREAT KNEECAP DISLOCATION                       A                $431.28       20110101
27562       TREAT KNEECAP DISLOCATION                                        $313.30       20110801
27566       TREAT KNEECAP DISLOCATION                       A              $1,178.19       20110101
27566       TREAT KNEECAP DISLOCATION      80                                $121.68       20110801
27566       TREAT KNEECAP DISLOCATION      81                                $121.68       20110801
27566       TREAT KNEECAP DISLOCATION      82                                $121.68       20110801
27566       TREAT KNEECAP DISLOCATION      AS                                $121.68       20110801
27566       TREAT KNEECAP DISLOCATION                                        $608.40       20110801
27570       FIXATION OF KNEE JOINT                          A                $431.28       20110101
27570       FIXATION OF KNEE JOINT                                            $99.06       20110801
27580       FUSION OF KNEE                 80                                $197.81       20110801
27580       FUSION OF KNEE                 81                                $197.81       20110801
27580       FUSION OF KNEE                 82                                $197.81       20110801
27580       FUSION OF KNEE                 AS                                $197.81       20110801
27580       FUSION OF KNEE                                                   $989.04       20110801
27590       AMPUTATE LEG AT THIGH          80                                $116.01       20110801
27590       AMPUTATE LEG AT THIGH          81                                $116.01       20110801
27590       AMPUTATE LEG AT THIGH          82                                $116.01       20110801
27590       AMPUTATE LEG AT THIGH          AS                                $116.01       20110801
27590       AMPUTATE LEG AT THIGH                                            $580.06       20110801
27591       AMPUTATE LEG AT THIGH          80                                $126.46       20110801
27591       AMPUTATE LEG AT THIGH          81                                $126.46       20110801
27591       AMPUTATE LEG AT THIGH          82                                $126.46       20110801
27591       AMPUTATE LEG AT THIGH          AS                                $126.46       20110801
27591       AMPUTATE LEG AT THIGH                                            $632.32       20110801
27592       AMPUTATE LEG AT THIGH          80                                 $97.86       20110801
27592       AMPUTATE LEG AT THIGH          81                                 $97.86       20110801
27592       AMPUTATE LEG AT THIGH          82                                 $97.86       20110801
27592       AMPUTATE LEG AT THIGH          AS                                 $97.86       20110801
27592       AMPUTATE LEG AT THIGH                                            $489.32       20110801
27594       AMPUTATION FOLLOW-UP SURGERY                    A                $626.73       20110101
27594       AMPUTATION FOLLOW-UP SURGERY                                     $353.86       20110801
27596       AMPUTATION FOLLOW-UP SURGERY                                     $511.94       20110801
27598       AMPUTATE LOWER LEG AT KNEE     80                                $103.53       20110801
27598       AMPUTATE LOWER LEG AT KNEE     81                                $103.53       20110801
27598       AMPUTATE LOWER LEG AT KNEE     82                                $103.53       20110801
27598       AMPUTATE LOWER LEG AT KNEE     AS                                $103.53       20110801
27598       AMPUTATE LOWER LEG AT KNEE                                       $517.66       20110801
27600       DECOMPRESSION OF LOWER LEG                      A                $626.73       20110101
27600       DECOMPRESSION OF LOWER LEG                                       $291.46       20110801
27601       DECOMPRESSION OF LOWER LEG                      A                $626.73       20110101
27601       DECOMPRESSION OF LOWER LEG                                       $304.46       20110801
27602       DECOMPRESSION OF LOWER LEG                      A                $626.73       20110101
27602       DECOMPRESSION OF LOWER LEG     80                                 $72.02       20110801
27602       DECOMPRESSION OF LOWER LEG     81                                 $72.02       20110801
27602       DECOMPRESSION OF LOWER LEG     82                                 $72.02       20110801
27602       DECOMPRESSION OF LOWER LEG     AS                                 $72.02       20110801
27602       DECOMPRESSION OF LOWER LEG                                       $360.10       20110801
27603       DRAIN LOWER LEG LESION                          A                $551.78       20110101
27603       DRAIN LOWER LEG LESION                                           $349.70       20110801
27604       DRAIN LOWER LEG BURSA                           A                $614.48       20110101
27604       DRAIN LOWER LEG BURSA                                            $305.24       20110801



                                                Page 89
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
27605       INCISION OF ACHILLES TENDON                     A                   $588.75       20110101
27605       INCISION OF ACHILLES TENDON                                         $233.74       20110801
27606       INCISION OF ACHILLES TENDON                     A                   $592.86       20110101
27606       INCISION OF ACHILLES TENDON                                         $199.16       20110801
27607       TREAT LOWER LEG BONE LESION                     A                   $614.48       20110101
27607       TREAT LOWER LEG BONE LESION                                         $417.56       20110801
27610       EXPLORE/TREAT ANKLE JOINT                       A                   $849.00       20110101
27610       EXPLORE/TREAT ANKLE JOINT                                           $444.34       20110801
27612       EXPLORATION OF ANKLE JOINT                      A                   $861.25       20110101
27612       EXPLORATION OF ANKLE JOINT     80                                    $76.75       20110801
27612       EXPLORATION OF ANKLE JOINT     81                                    $76.75       20110801
27612       EXPLORATION OF ANKLE JOINT     82                                    $76.75       20110801
27612       EXPLORATION OF ANKLE JOINT     AS                                    $76.75       20110801
27612       EXPLORATION OF ANKLE JOINT                                          $383.76       20110801
27613       BIOPSY LOWER LEG SOFT TISSUE                                        $164.84       20110801
27614       BIOPSY LOWER LEG SOFT TISSUE                    A                   $647.50       20110101
27614       BIOPSY LOWER LEG SOFT TISSUE                                        $375.18       20110801
27615       RESECT LEG/ANKLE TUM 5 CM                       A                   $560.76       20110101
27615       RESECT LEG/ANKLE TUM 5 CM                                           $693.94       20110801
27616       RESECT LEG/ANKLE TUM 5 CM/                                          $905.84       20110801
27618       EXC LEG/ANKLE TUM 3 CM                          A                   $150.35       20110101
27618       EXC LEG/ANKLE TUM 3 CM                                              $288.60       20110801
27619       EXC LEG/ANKLE TUM DEEP 5 CM                     A                   $560.76       20110101
27619       EXC LEG/ANKLE TUM DEEP 5 CM                                         $346.06       20110801
27620       EXPLORE/TREAT ANKLE JOINT                       A                   $884.21       20110101
27620       EXPLORE/TREAT ANKLE JOINT      80                                    $62.35       20110801
27620       EXPLORE/TREAT ANKLE JOINT      81                                    $62.35       20110801
27620       EXPLORE/TREAT ANKLE JOINT      82                                    $62.35       20110801
27620       EXPLORE/TREAT ANKLE JOINT      AS                                    $62.35       20110801
27620       EXPLORE/TREAT ANKLE JOINT                                           $311.74       20110801
27625       REMOVE ANKLE JOINT LINING                       A                   $884.21       20110101
27625       REMOVE ANKLE JOINT LINING      80                                    $79.66       20110801
27625       REMOVE ANKLE JOINT LINING      81                                    $79.66       20110801
27625       REMOVE ANKLE JOINT LINING      82                                    $79.66       20110801
27625       REMOVE ANKLE JOINT LINING      AS                                    $79.66       20110801
27625       REMOVE ANKLE JOINT LINING                                           $398.32       20110801
27626       REMOVE ANKLE JOINT LINING                       A                   $884.21       20110101
27626       REMOVE ANKLE JOINT LINING      80                                    $86.58       20110801
27626       REMOVE ANKLE JOINT LINING      81                                    $86.58       20110801
27626       REMOVE ANKLE JOINT LINING      82                                    $86.58       20110801
27626       REMOVE ANKLE JOINT LINING      AS                                    $86.58       20110801
27626       REMOVE ANKLE JOINT LINING                                           $432.90       20110801
27630       REMOVAL OF TENDON LESION                        A                   $626.73       20110101
27630       REMOVAL OF TENDON LESION                                            $355.16       20110801
27632       EXC LEG/ANKLE LES SC 3 CM/                                          $291.46       20110801
27634       EXC LEG/ANKLE TUM DEP 5 CM/                                         $474.76       20110801
27635       REMOVE LOWER LEG BONE LESION                    A                   $861.25       20110101
27635       REMOVE LOWER LEG BONE LESION                                        $401.96       20110801
27637       REMOVE/GRAFT LEG BONE LESION                    A                   $861.25       20110101
27637       REMOVE/GRAFT LEG BONE LESION   80                                   $102.60       20110801
27637       REMOVE/GRAFT LEG BONE LESION   81                                   $102.60       20110801
27637       REMOVE/GRAFT LEG BONE LESION   82                                   $102.60       20110801
27637       REMOVE/GRAFT LEG BONE LESION   AS                                   $102.60       20110801
27637       REMOVE/GRAFT LEG BONE LESION                                        $512.98       20110801
27638       REMOVE/GRAFT LEG BONE LESION                    A                   $861.25       20110101
27638       REMOVE/GRAFT LEG BONE LESION   80                                   $106.34       20110801
27638       REMOVE/GRAFT LEG BONE LESION   81                                   $106.34       20110801
27638       REMOVE/GRAFT LEG BONE LESION   82                                   $106.34       20110801
27638       REMOVE/GRAFT LEG BONE LESION   AS                                   $106.34       20110801



                                                Page 90
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27638       REMOVE/GRAFT LEG BONE LESION                                      $531.70       20110801
27640       PARTIAL REMOVAL OF TIBIA                         A              $1,204.90       20110101
27640       PARTIAL REMOVAL OF TIBIA                                          $584.74       20110801
27641       PARTIAL REMOVAL OF FIBULA                        A                $849.00       20110101
27641       PARTIAL REMOVAL OF FIBULA                                         $468.26       20110801
27645       RESECT TIBIA TUMOR              80                                $224.48       20110801
27645       RESECT TIBIA TUMOR              81                                $224.48       20110801
27645       RESECT TIBIA TUMOR              82                                $224.48       20110801
27645       RESECT TIBIA TUMOR              AS                                $224.48       20110801
27645       RESECT TIBIA TUMOR                                              $1,122.42       20110801
27646       RESECT FIBULA TUMOR             80                                $193.18       20110801
27646       RESECT FIBULA TUMOR             81                                $193.18       20110801
27646       RESECT FIBULA TUMOR             82                                $193.18       20110801
27646       RESECT FIBULA TUMOR             AS                                $193.18       20110801
27646       RESECT FIBULA TUMOR                                               $965.90       20110801
27647       RESECT TALUS/CALCANEUS TUM                       A              $1,217.14       20110101
27647       RESECT TALUS/CALCANEUS TUM      80                                $150.38       20110801
27647       RESECT TALUS/CALCANEUS TUM      81                                $150.38       20110801
27647       RESECT TALUS/CALCANEUS TUM      82                                $150.38       20110801
27647       RESECT TALUS/CALCANEUS TUM      AS                                $150.38       20110801
27647       RESECT TALUS/CALCANEUS TUM                                        $751.92       20110801
27648       INJECTION FOR ANKLE X-RAY                                         $107.12       20110801
27650       REPAIR ACHILLES TENDON                           A              $1,217.14       20110101
27650       REPAIR ACHILLES TENDON          80                                 $91.10       20110801
27650       REPAIR ACHILLES TENDON          81                                 $91.10       20110801
27650       REPAIR ACHILLES TENDON          82                                 $91.10       20110801
27650       REPAIR ACHILLES TENDON          AS                                 $91.10       20110801
27650       REPAIR ACHILLES TENDON                                            $455.52       20110801
27652       REPAIR/GRAFT ACHILLES TENDON                     A              $2,228.42       20110101
27652       REPAIR/GRAFT ACHILLES TENDON                                      $491.66       20110801
27654       REPAIR OF ACHILLES TENDON                        A              $1,217.14       20110101
27654       REPAIR OF ACHILLES TENDON       80                                 $97.60       20110801
27654       REPAIR OF ACHILLES TENDON       81                                 $97.60       20110801
27654       REPAIR OF ACHILLES TENDON       82                                 $97.60       20110801
27654       REPAIR OF ACHILLES TENDON       AS                                 $97.60       20110801
27654       REPAIR OF ACHILLES TENDON                                         $488.02       20110801
27656       REPAIR LEG FASCIA DEFECT                         A                $614.48       20110101
27656       REPAIR LEG FASCIA DEFECT        80                                 $73.94       20110801
27656       REPAIR LEG FASCIA DEFECT        81                                 $73.94       20110801
27656       REPAIR LEG FASCIA DEFECT        82                                 $73.94       20110801
27656       REPAIR LEG FASCIA DEFECT        AS                                 $73.94       20110801
27656       REPAIR LEG FASCIA DEFECT                                          $369.72       20110801
27658       REPAIR OF LEG TENDON EACH                        A                $592.86       20110101
27658       REPAIR OF LEG TENDON EACH       80                                 $51.58       20110801
27658       REPAIR OF LEG TENDON EACH       81                                 $51.58       20110801
27658       REPAIR OF LEG TENDON EACH       82                                 $51.58       20110801
27658       REPAIR OF LEG TENDON EACH       AS                                 $51.58       20110801
27658       REPAIR OF LEG TENDON EACH                                         $257.92       20110801
27659       REPAIR OF LEG TENDON EACH                        A                $614.48       20110101
27659       REPAIR OF LEG TENDON EACH       80                                 $66.98       20110801
27659       REPAIR OF LEG TENDON EACH       81                                 $66.98       20110801
27659       REPAIR OF LEG TENDON EACH       82                                 $66.98       20110801
27659       REPAIR OF LEG TENDON EACH       AS                                 $66.98       20110801
27659       REPAIR OF LEG TENDON EACH                                         $334.88       20110801
27664       REPAIR OF LEG TENDON EACH                        A                $849.00       20110101
27664       REPAIR OF LEG TENDON EACH                                         $245.96       20110801
27665       REPAIR OF LEG TENDON EACH                        A                $849.00       20110101
27665       REPAIR OF LEG TENDON EACH       80                                 $56.52       20110801
27665       REPAIR OF LEG TENDON EACH       81                                 $56.52       20110801



                                                 Page 91
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
27665       REPAIR OF LEG TENDON EACH      82                                 $56.52       20110801
27665       REPAIR OF LEG TENDON EACH      AS                                 $56.52       20110801
27665       REPAIR OF LEG TENDON EACH                                        $282.62       20110801
27675       REPAIR LOWER LEG TENDONS                        A                $614.48       20110101
27675       REPAIR LOWER LEG TENDONS       80                                 $68.38       20110801
27675       REPAIR LOWER LEG TENDONS       81                                 $68.38       20110801
27675       REPAIR LOWER LEG TENDONS       82                                 $68.38       20110801
27675       REPAIR LOWER LEG TENDONS       AS                                 $68.38       20110801
27675       REPAIR LOWER LEG TENDONS                                         $341.90       20110801
27676       REPAIR LOWER LEG TENDONS                        A                $861.25       20110101
27676       REPAIR LOWER LEG TENDONS       80                                 $84.86       20110801
27676       REPAIR LOWER LEG TENDONS       81                                 $84.86       20110801
27676       REPAIR LOWER LEG TENDONS       82                                 $84.86       20110801
27676       REPAIR LOWER LEG TENDONS       AS                                 $84.86       20110801
27676       REPAIR LOWER LEG TENDONS                                         $424.32       20110801
27680       RELEASE OF LOWER LEG TENDON                     A                $861.25       20110101
27680       RELEASE OF LOWER LEG TENDON                                      $293.02       20110801
27681       RELEASE OF LOWER LEG TENDONS                    A                $849.00       20110101
27681       RELEASE OF LOWER LEG TENDONS                                     $356.98       20110801
27685       REVISION OF LOWER LEG TENDON                    A                $861.25       20110101
27685       REVISION OF LOWER LEG TENDON   80                                 $84.19       20110801
27685       REVISION OF LOWER LEG TENDON   81                                 $84.19       20110801
27685       REVISION OF LOWER LEG TENDON   82                                 $84.19       20110801
27685       REVISION OF LOWER LEG TENDON   AS                                 $84.19       20110801
27685       REVISION OF LOWER LEG TENDON                                     $420.94       20110801
27686       REVISE LOWER LEG TENDONS                        A                $861.25       20110101
27686       REVISE LOWER LEG TENDONS                                         $379.60       20110801
27687       REVISION OF CALF TENDON                         A                $861.25       20110101
27687       REVISION OF CALF TENDON        80                                 $62.61       20110801
27687       REVISION OF CALF TENDON        81                                 $62.61       20110801
27687       REVISION OF CALF TENDON        82                                 $62.61       20110801
27687       REVISION OF CALF TENDON        AS                                 $62.61       20110801
27687       REVISION OF CALF TENDON                                          $313.04       20110801
27690       REVISE LOWER LEG TENDON                         A              $1,240.11       20110101
27690       REVISE LOWER LEG TENDON        80                                 $86.68       20110801
27690       REVISE LOWER LEG TENDON        81                                 $86.68       20110801
27690       REVISE LOWER LEG TENDON        82                                 $86.68       20110801
27690       REVISE LOWER LEG TENDON        AS                                 $86.68       20110801
27690       REVISE LOWER LEG TENDON                                          $433.42       20110801
27691       REVISE LOWER LEG TENDON                         A              $1,240.11       20110101
27691       REVISE LOWER LEG TENDON        80                                $102.44       20110801
27691       REVISE LOWER LEG TENDON        81                                $102.44       20110801
27691       REVISE LOWER LEG TENDON        82                                $102.44       20110801
27691       REVISE LOWER LEG TENDON        AS                                $102.44       20110801
27691       REVISE LOWER LEG TENDON                                          $512.20       20110801
27692       REVISE ADDITIONAL LEG TENDON                    A              $1,217.14       20110101
27692       REVISE ADDITIONAL LEG TENDON   80                                 $15.29       20110801
27692       REVISE ADDITIONAL LEG TENDON   81                                 $15.29       20110801
27692       REVISE ADDITIONAL LEG TENDON   82                                 $15.29       20110801
27692       REVISE ADDITIONAL LEG TENDON   AS                                 $15.29       20110801
27692       REVISE ADDITIONAL LEG TENDON                                      $76.44       20110801
27695       REPAIR OF ANKLE LIGAMENT                        A                $849.00       20110101
27695       REPAIR OF ANKLE LIGAMENT                                         $333.58       20110801
27696       REPAIR OF ANKLE LIGAMENTS                       A                $849.00       20110101
27696       REPAIR OF ANKLE LIGAMENTS                                        $391.56       20110801
27698       REPAIR OF ANKLE LIGAMENT                        A                $849.00       20110101
27698       REPAIR OF ANKLE LIGAMENT       80                                 $89.18       20110801
27698       REPAIR OF ANKLE LIGAMENT       81                                 $89.18       20110801
27698       REPAIR OF ANKLE LIGAMENT       82                                 $89.18       20110801



                                                Page 92
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27698       REPAIR OF ANKLE LIGAMENT        AS                                 $89.18       20110801
27698       REPAIR OF ANKLE LIGAMENT                                          $445.90       20110801
27700       REVISION OF ANKLE JOINT                          A              $1,095.93       20110101
27700       REVISION OF ANKLE JOINT         80                                 $83.72       20110801
27700       REVISION OF ANKLE JOINT         81                                 $83.72       20110801
27700       REVISION OF ANKLE JOINT         82                                 $83.72       20110801
27700       REVISION OF ANKLE JOINT         AS                                 $83.72       20110801
27700       REVISION OF ANKLE JOINT                                           $418.60       20110801
27702       RECONSTRUCT ANKLE JOINT         80                                $135.41       20110801
27702       RECONSTRUCT ANKLE JOINT         81                                $135.41       20110801
27702       RECONSTRUCT ANKLE JOINT         82                                $135.41       20110801
27702       RECONSTRUCT ANKLE JOINT         AS                                $135.41       20110801
27702       RECONSTRUCT ANKLE JOINT                                           $677.04       20110801
27703       RECONSTRUCTION ANKLE JOINT      80                                $157.35       20110801
27703       RECONSTRUCTION ANKLE JOINT      81                                $157.35       20110801
27703       RECONSTRUCTION ANKLE JOINT      82                                $157.35       20110801
27703       RECONSTRUCTION ANKLE JOINT      AS                                $157.35       20110801
27703       RECONSTRUCTION ANKLE JOINT                                        $786.76       20110801
27704       REMOVAL OF ANKLE IMPLANT                         A                $614.48       20110101
27704       REMOVAL OF ANKLE IMPLANT                                          $386.88       20110801
27705       INCISION OF TIBIA                                A              $1,204.90       20110101
27705       INCISION OF TIBIA               80                                $104.31       20110801
27705       INCISION OF TIBIA               81                                $104.31       20110801
27705       INCISION OF TIBIA               82                                $104.31       20110801
27705       INCISION OF TIBIA               AS                                $104.31       20110801
27705       INCISION OF TIBIA                                                 $521.56       20110801
27707       INCISION OF FIBULA                               A                $614.48       20110101
27707       INCISION OF FIBULA                                                $267.80       20110801
27709       INCISION OF TIBIA FIBULA                         A                $849.00       20110101
27709       INCISION OF TIBIA FIBULA        80                                $158.03       20110801
27709       INCISION OF TIBIA FIBULA        81                                $158.03       20110801
27709       INCISION OF TIBIA FIBULA        82                                $158.03       20110801
27709       INCISION OF TIBIA FIBULA        AS                                $158.03       20110801
27709       INCISION OF TIBIA FIBULA                                          $790.14       20110801
27712       REALIGNMENT OF LOWER LEG        80                                $150.44       20110801
27712       REALIGNMENT OF LOWER LEG        81                                $150.44       20110801
27712       REALIGNMENT OF LOWER LEG        82                                $150.44       20110801
27712       REALIGNMENT OF LOWER LEG        AS                                $150.44       20110801
27712       REALIGNMENT OF LOWER LEG                                          $752.18       20110801
27715       REVISION OF LOWER LEG           80                                $146.17       20110801
27715       REVISION OF LOWER LEG           81                                $146.17       20110801
27715       REVISION OF LOWER LEG           82                                $146.17       20110801
27715       REVISION OF LOWER LEG           AS                                $146.17       20110801
27715       REVISION OF LOWER LEG                                             $730.86       20110801
27720       REPAIR OF TIBIA                 80                                $119.81       20110801
27720       REPAIR OF TIBIA                 81                                $119.81       20110801
27720       REPAIR OF TIBIA                 82                                $119.81       20110801
27720       REPAIR OF TIBIA                 AS                                $119.81       20110801
27720       REPAIR OF TIBIA                                                   $599.04       20110801
27722       REPAIR/GRAFT OF TIBIA           80                                $119.96       20110801
27722       REPAIR/GRAFT OF TIBIA           81                                $119.96       20110801
27722       REPAIR/GRAFT OF TIBIA           82                                $119.96       20110801
27722       REPAIR/GRAFT OF TIBIA           AS                                $119.96       20110801
27722       REPAIR/GRAFT OF TIBIA                                             $599.82       20110801
27724       REPAIR/GRAFT OF TIBIA           80                                $175.81       20110801
27724       REPAIR/GRAFT OF TIBIA           81                                $175.81       20110801
27724       REPAIR/GRAFT OF TIBIA           82                                $175.81       20110801
27724       REPAIR/GRAFT OF TIBIA           AS                                $175.81       20110801
27724       REPAIR/GRAFT OF TIBIA                                             $879.06       20110801



                                                 Page 93
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27725       REPAIR OF LOWER LEG             80                                $165.36       20110801
27725       REPAIR OF LOWER LEG             81                                $165.36       20110801
27725       REPAIR OF LOWER LEG             82                                $165.36       20110801
27725       REPAIR OF LOWER LEG             AS                                $165.36       20110801
27725       REPAIR OF LOWER LEG                                               $826.80       20110801
27726       REPAIR FIBULA NONUNION                           A              $1,457.14       20110101
27726       REPAIR FIBULA NONUNION                                            $648.18       20110801
27727       REPAIR OF LOWER LEG             80                                $135.41       20110801
27727       REPAIR OF LOWER LEG             81                                $135.41       20110801
27727       REPAIR OF LOWER LEG             82                                $135.41       20110801
27727       REPAIR OF LOWER LEG             AS                                $135.41       20110801
27727       REPAIR OF LOWER LEG                                               $677.04       20110801
27730       REPAIR OF TIBIA EPIPHYSIS                        A                $849.00       20110101
27730       REPAIR OF TIBIA EPIPHYSIS                                         $392.34       20110801
27732       REPAIR OF FIBULA EPIPHYSIS                       A                $849.00       20110101
27732       REPAIR OF FIBULA EPIPHYSIS                                        $280.54       20110801
27734       REPAIR LOWER LEG EPIPHYSES                       A                $849.00       20110101
27734       REPAIR LOWER LEG EPIPHYSES                                        $382.72       20110801
27740       REPAIR OF LEG EPIPHYSES                          A                $849.00       20110101
27740       REPAIR OF LEG EPIPHYSES         80                                 $91.73       20110801
27740       REPAIR OF LEG EPIPHYSES         81                                 $91.73       20110801
27740       REPAIR OF LEG EPIPHYSES         82                                 $91.73       20110801
27740       REPAIR OF LEG EPIPHYSES         AS                                 $91.73       20110801
27740       REPAIR OF LEG EPIPHYSES                                           $458.64       20110801
27742       REPAIR OF LEG EPIPHYSES                          A              $1,204.90       20110101
27742       REPAIR OF LEG EPIPHYSES         80                                 $97.76       20110801
27742       REPAIR OF LEG EPIPHYSES         81                                 $97.76       20110801
27742       REPAIR OF LEG EPIPHYSES         82                                 $97.76       20110801
27742       REPAIR OF LEG EPIPHYSES         AS                                 $97.76       20110801
27742       REPAIR OF LEG EPIPHYSES                                           $488.80       20110801
27745       REINFORCE TIBIA                                  A              $2,228.42       20110101
27745       REINFORCE TIBIA                 80                                $102.80       20110801
27745       REINFORCE TIBIA                 81                                $102.80       20110801
27745       REINFORCE TIBIA                 82                                $102.80       20110801
27745       REINFORCE TIBIA                 AS                                $102.80       20110801
27745       REINFORCE TIBIA                                                   $514.02       20110801
27750       TREATMENT OF TIBIA FRACTURE                      A                 $59.66       20110101
27750       TREATMENT OF TIBIA FRACTURE                                       $221.00       20110801
27752       TREATMENT OF TIBIA FRACTURE                      A                $462.00       20110101
27752       TREATMENT OF TIBIA FRACTURE                                       $354.38       20110801
27756       TREATMENT OF TIBIA FRACTURE                      A                $718.78       20110101
27756       TREATMENT OF TIBIA FRACTURE     80                                 $77.06       20110801
27756       TREATMENT OF TIBIA FRACTURE     81                                 $77.06       20110801
27756       TREATMENT OF TIBIA FRACTURE     82                                 $77.06       20110801
27756       TREATMENT OF TIBIA FRACTURE     AS                                 $77.06       20110801
27756       TREATMENT OF TIBIA FRACTURE                                       $385.32       20110801
27758       TREATMENT OF TIBIA FRACTURE                      A              $1,213.40       20110101
27758       TREATMENT OF TIBIA FRACTURE     80                                $121.11       20110801
27758       TREATMENT OF TIBIA FRACTURE     81                                $121.11       20110801
27758       TREATMENT OF TIBIA FRACTURE     82                                $121.11       20110801
27758       TREATMENT OF TIBIA FRACTURE     AS                                $121.11       20110801
27758       TREATMENT OF TIBIA FRACTURE                                       $605.54       20110801
27759       TREATMENT OF TIBIA FRACTURE                      A              $1,694.30       20110101
27759       TREATMENT OF TIBIA FRACTURE     80                                $136.92       20110801
27759       TREATMENT OF TIBIA FRACTURE     81                                $136.92       20110801
27759       TREATMENT OF TIBIA FRACTURE     82                                $136.92       20110801
27759       TREATMENT OF TIBIA FRACTURE     AS                                $136.92       20110801
27759       TREATMENT OF TIBIA FRACTURE                                       $684.58       20110801
27760       CLTX MEDIAL ANKLE FX                             A                 $59.66       20110101



                                                 Page 94
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
27760       CLTX MEDIAL ANKLE FX                                              $213.72       20110801
27762       CLTX MED ANKLE FX W/MNPJ                         A                $462.00       20110101
27762       CLTX MED ANKLE FX W/MNPJ                                          $316.94       20110801
27766       OPTX MEDIAL ANKLE FX                             A              $1,190.44       20110101
27766       OPTX MEDIAL ANKLE FX                                              $410.54       20110801
27767       CLTX POST ANKLE FX                               A                 $53.12       20110101
27767       CLTX POST ANKLE FX                                                $174.98       20110801
27768       CLTX POST ANKLE FX W/MNPJ                        A                 $53.12       20110101
27768       CLTX POST ANKLE FX W/MNPJ                                         $277.68       20110801
27769       OPTX POST ANKLE FX                               A              $1,457.14       20110101
27769       OPTX POST ANKLE FX                                                $481.00       20110801
27780       TREATMENT OF FIBULA FRACTURE                     A                 $59.66       20110101
27780       TREATMENT OF FIBULA FRACTURE                                      $192.14       20110801
27781       TREATMENT OF FIBULA FRACTURE                     A                $462.00       20110101
27781       TREATMENT OF FIBULA FRACTURE                                      $275.86       20110801
27784       TREATMENT OF FIBULA FRACTURE                     A              $1,190.44       20110101
27784       TREATMENT OF FIBULA FRACTURE                                      $477.88       20110801
27786       TREATMENT OF ANKLE FRACTURE                      A                 $59.66       20110101
27786       TREATMENT OF ANKLE FRACTURE                                       $202.28       20110801
27788       TREATMENT OF ANKLE FRACTURE                      A                 $59.66       20110101
27788       TREATMENT OF ANKLE FRACTURE                                       $276.64       20110801
27792       TREATMENT OF ANKLE FRACTURE                      A              $1,190.44       20110101
27792       TREATMENT OF ANKLE FRACTURE                                       $479.44       20110801
27808       TREATMENT OF ANKLE FRACTURE                      A                 $59.66       20110101
27808       TREATMENT OF ANKLE FRACTURE                                       $211.90       20110801
27810       TREATMENT OF ANKLE FRACTURE                      A                $135.07       20110101
27810       TREATMENT OF ANKLE FRACTURE                                       $310.44       20110801
27814       TREATMENT OF ANKLE FRACTURE                      A              $1,190.44       20110101
27814       TREATMENT OF ANKLE FRACTURE     80                                $105.14       20110801
27814       TREATMENT OF ANKLE FRACTURE     81                                $105.14       20110801
27814       TREATMENT OF ANKLE FRACTURE     82                                $105.14       20110801
27814       TREATMENT OF ANKLE FRACTURE     AS                                $105.14       20110801
27814       TREATMENT OF ANKLE FRACTURE                                       $525.72       20110801
27816       TREATMENT OF ANKLE FRACTURE                      A                 $59.66       20110101
27816       TREATMENT OF ANKLE FRACTURE                                       $201.24       20110801
27818       TREATMENT OF ANKLE FRACTURE                      A                $135.07       20110101
27818       TREATMENT OF ANKLE FRACTURE                                       $320.06       20110801
27822       TREATMENT OF ANKLE FRACTURE                      A              $1,190.44       20110101
27822       TREATMENT OF ANKLE FRACTURE     80                                $115.08       20110801
27822       TREATMENT OF ANKLE FRACTURE     81                                $115.08       20110801
27822       TREATMENT OF ANKLE FRACTURE     82                                $115.08       20110801
27822       TREATMENT OF ANKLE FRACTURE     AS                                $115.08       20110801
27822       TREATMENT OF ANKLE FRACTURE                                       $575.38       20110801
27823       TREATMENT OF ANKLE FRACTURE                      A              $1,671.34       20110101
27823       TREATMENT OF ANKLE FRACTURE     80                                $131.04       20110801
27823       TREATMENT OF ANKLE FRACTURE     81                                $131.04       20110801
27823       TREATMENT OF ANKLE FRACTURE     82                                $131.04       20110801
27823       TREATMENT OF ANKLE FRACTURE     AS                                $131.04       20110801
27823       TREATMENT OF ANKLE FRACTURE                                       $655.20       20110801
27824       TREAT LOWER LEG FRACTURE                         A                 $59.66       20110101
27824       TREAT LOWER LEG FRACTURE                                          $202.28       20110801
27825       TREAT LOWER LEG FRACTURE                         A                $462.00       20110101
27825       TREAT LOWER LEG FRACTURE                                          $364.00       20110801
27826       TREAT LOWER LEG FRACTURE                         A              $1,190.44       20110101
27826       TREAT LOWER LEG FRACTURE        80                                $112.48       20110801
27826       TREAT LOWER LEG FRACTURE        81                                $112.48       20110801
27826       TREAT LOWER LEG FRACTURE        82                                $112.48       20110801
27826       TREAT LOWER LEG FRACTURE        AS                                $112.48       20110801
27826       TREAT LOWER LEG FRACTURE                                          $562.38       20110801



                                                 Page 95
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
27827       TREAT LOWER LEG FRACTURE                          A              $1,671.34       20110101
27827       TREAT LOWER LEG FRACTURE         80                                $147.89       20110801
27827       TREAT LOWER LEG FRACTURE         81                                $147.89       20110801
27827       TREAT LOWER LEG FRACTURE         82                                $147.89       20110801
27827       TREAT LOWER LEG FRACTURE         AS                                $147.89       20110801
27827       TREAT LOWER LEG FRACTURE                                           $739.44       20110801
27828       TREAT LOWER LEG FRACTURE                          A              $1,694.30       20110101
27828       TREAT LOWER LEG FRACTURE         80                                $177.58       20110801
27828       TREAT LOWER LEG FRACTURE         81                                $177.58       20110801
27828       TREAT LOWER LEG FRACTURE         82                                $177.58       20110801
27828       TREAT LOWER LEG FRACTURE         AS                                $177.58       20110801
27828       TREAT LOWER LEG FRACTURE                                           $887.90       20110801
27829       TREAT LOWER LEG JOINT                             A              $1,178.19       20110101
27829       TREAT LOWER LEG JOINT            80                                 $91.05       20110801
27829       TREAT LOWER LEG JOINT            81                                 $91.05       20110801
27829       TREAT LOWER LEG JOINT            82                                 $91.05       20110801
27829       TREAT LOWER LEG JOINT            AS                                 $91.05       20110801
27829       TREAT LOWER LEG JOINT                                              $455.26       20110801
27830       TREAT LOWER LEG DISLOCATION                       A                 $59.66       20110101
27830       TREAT LOWER LEG DISLOCATION                                        $237.90       20110801
27831       TREAT LOWER LEG DISLOCATION                       A                $462.00       20110101
27831       TREAT LOWER LEG DISLOCATION                                        $256.88       20110801
27832       TREAT LOWER LEG DISLOCATION                       A              $1,178.19       20110101
27832       TREAT LOWER LEG DISLOCATION      80                                 $98.96       20110801
27832       TREAT LOWER LEG DISLOCATION      81                                 $98.96       20110801
27832       TREAT LOWER LEG DISLOCATION      82                                 $98.96       20110801
27832       TREAT LOWER LEG DISLOCATION      AS                                 $98.96       20110801
27832       TREAT LOWER LEG DISLOCATION                                        $494.78       20110801
27840       TREAT ANKLE DISLOCATION                           A                $135.07       20110101
27840       TREAT ANKLE DISLOCATION                                            $238.94       20110801
27842       TREAT ANKLE DISLOCATION                           A                $431.28       20110101
27842       TREAT ANKLE DISLOCATION                                            $327.86       20110801
27846       TREAT ANKLE DISLOCATION                           A              $1,190.44       20110101
27846       TREAT ANKLE DISLOCATION          80                                $100.31       20110801
27846       TREAT ANKLE DISLOCATION          81                                $100.31       20110801
27846       TREAT ANKLE DISLOCATION          82                                $100.31       20110801
27846       TREAT ANKLE DISLOCATION          AS                                $100.31       20110801
27846       TREAT ANKLE DISLOCATION                                            $501.54       20110801
27848       TREAT ANKLE DISLOCATION                           A              $1,190.44       20110101
27848       TREAT ANKLE DISLOCATION          80                                $113.31       20110801
27848       TREAT ANKLE DISLOCATION          81                                $113.31       20110801
27848       TREAT ANKLE DISLOCATION          82                                $113.31       20110801
27848       TREAT ANKLE DISLOCATION          AS                                $113.31       20110801
27848       TREAT ANKLE DISLOCATION                                            $566.54       20110801
27860       FIXATION OF ANKLE JOINT                           A                $431.28       20110101
27860       FIXATION OF ANKLE JOINT                                            $119.60       20110801
27870       FUSION OF ANKLE JOINT OPEN                        A              $2,251.38       20110101
27870       FUSION OF ANKLE JOINT OPEN       80                                $143.57       20110801
27870       FUSION OF ANKLE JOINT OPEN       81                                $143.57       20110801
27870       FUSION OF ANKLE JOINT OPEN       82                                $143.57       20110801
27870       FUSION OF ANKLE JOINT OPEN       AS                                $143.57       20110801
27870       FUSION OF ANKLE JOINT OPEN                                         $717.86       20110801
27871       FUSION OF TIBIOFIBULAR JOINT                      A              $2,251.38       20110101
27871       FUSION OF TIBIOFIBULAR JOINT     80                                 $94.38       20110801
27871       FUSION OF TIBIOFIBULAR JOINT     81                                 $94.38       20110801
27871       FUSION OF TIBIOFIBULAR JOINT     82                                 $94.38       20110801
27871       FUSION OF TIBIOFIBULAR JOINT     AS                                 $94.38       20110801
27871       FUSION OF TIBIOFIBULAR JOINT                                       $471.90       20110801
27880       AMPUTATION OF LOWER LEG          80                                $131.09       20110801



                                                  Page 96
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1    Mod 2   Rate Type   Price             Effective
Code                                                                                      Date
27880       AMPUTATION OF LOWER LEG        81                                   $131.09       20110801
27880       AMPUTATION OF LOWER LEG        82                                   $131.09       20110801
27880       AMPUTATION OF LOWER LEG        AS                                   $131.09       20110801
27880       AMPUTATION OF LOWER LEG                                             $655.46       20110801
27881       AMPUTATION OF LOWER LEG        80                                   $123.76       20110801
27881       AMPUTATION OF LOWER LEG        81                                   $123.76       20110801
27881       AMPUTATION OF LOWER LEG        82                                   $123.76       20110801
27881       AMPUTATION OF LOWER LEG        AS                                   $123.76       20110801
27881       AMPUTATION OF LOWER LEG                                             $618.80       20110801
27882       AMPUTATION OF LOWER LEG        80                                    $88.09       20110801
27882       AMPUTATION OF LOWER LEG        81                                    $88.09       20110801
27882       AMPUTATION OF LOWER LEG        82                                    $88.09       20110801
27882       AMPUTATION OF LOWER LEG        AS                                    $88.09       20110801
27882       AMPUTATION OF LOWER LEG                                             $440.44       20110801
27884       AMPUTATION FOLLOW-UP SURGERY                    A                   $626.73       20110101
27884       AMPUTATION FOLLOW-UP SURGERY                                        $408.46       20110801
27886       AMPUTATION FOLLOW-UP SURGERY                                        $466.44       20110801
27888       AMPUTATION OF FOOT AT ANKLE    80                                    $96.88       20110801
27888       AMPUTATION OF FOOT AT ANKLE    81                                    $96.88       20110801
27888       AMPUTATION OF FOOT AT ANKLE    82                                    $96.88       20110801
27888       AMPUTATION OF FOOT AT ANKLE    AS                                    $96.88       20110801
27888       AMPUTATION OF FOOT AT ANKLE                                         $484.38       20110801
27889       AMPUTATION OF FOOT AT ANKLE                     A                   $861.25       20110101
27889       AMPUTATION OF FOOT AT ANKLE                                         $481.00       20110801
27892       DECOMPRESSION OF LEG                            A                   $861.25       20110101
27892       DECOMPRESSION OF LEG                                                $378.82       20110801
27893       DECOMPRESSION OF LEG                            A                   $861.25       20110101
27893       DECOMPRESSION OF LEG                                                $381.68       20110801
27894       DECOMPRESSION OF LEG                            A                   $861.25       20110101
27894       DECOMPRESSION OF LEG           80                                   $118.40       20110801
27894       DECOMPRESSION OF LEG           81                                   $118.40       20110801
27894       DECOMPRESSION OF LEG           82                                   $118.40       20110801
27894       DECOMPRESSION OF LEG           AS                                   $118.40       20110801
27894       DECOMPRESSION OF LEG                                                $592.02       20110801
28001       DRAINAGE OF BURSA OF FOOT                                           $176.80       20110801
28002       TREATMENT OF FOOT INFECTION                     A                   $626.73       20110101
28002       TREATMENT OF FOOT INFECTION                                         $336.96       20110801
28003       TREATMENT OF FOOT INFECTION                     A                   $626.73       20110101
28003       TREATMENT OF FOOT INFECTION                                         $456.04       20110801
28005       TREAT FOOT BONE LESION                          A                   $622.62       20110101
28005       TREAT FOOT BONE LESION                                              $416.52       20110801
28008       INCISION OF FOOT FASCIA                         A                   $622.62       20110101
28008       INCISION OF FOOT FASCIA                                             $279.76       20110801
28010       INCISION OF TOE TENDON                                              $155.48       20110801
28011       INCISION OF TOE TENDONS                         A                   $622.62       20110101
28011       INCISION OF TOE TENDONS                                             $220.74       20110801
28020       EXPLORATION OF FOOT JOINT                       A                   $610.38       20110101
28020       EXPLORATION OF FOOT JOINT                                           $336.70       20110801
28022       EXPLORATION OF FOOT JOINT                       A                   $610.38       20110101
28022       EXPLORATION OF FOOT JOINT                                           $308.36       20110801
28024       EXPLORATION OF TOE JOINT                        A                   $610.38       20110101
28024       EXPLORATION OF TOE JOINT                                            $291.98       20110801
28035       DECOMPRESSION OF TIBIA NERVE                    A                   $570.50       20110101
28035       DECOMPRESSION OF TIBIA NERVE                                        $338.52       20110801
28039       EXC FOOT/TOE TUM SC 1.5 CM/                                         $333.58       20110801
28041       EXC FOOT/TOE TUM DEP 1.5CM/                                         $314.60       20110801
28043       EXC FOOT/TOE TUM SC 1.5 CM                      A                   $113.56       20110101
28043       EXC FOOT/TOE TUM SC 1.5 CM                                          $240.24       20110801
28045       EXC FOOT/TOE TUM DEEP 1.5CM                     A                   $155.80       20110101



                                                Page 97
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
28045       EXC FOOT/TOE TUM DEEP 1.5CM                                       $330.20       20110801
28046       RESECT FOOT/TOE TUMOR 3 CM                       A                $560.76       20110101
28046       RESECT FOOT/TOE TUMOR 3 CM                                        $516.88       20110801
28047       RESECT FOOT/TOE TUMOR 3 CM/                                       $663.00       20110801
28050       BIOPSY OF FOOT JOINT LINING                      A                $610.38       20110101
28050       BIOPSY OF FOOT JOINT LINING                                       $291.20       20110801
28052       BIOPSY OF FOOT JOINT LINING                      A                $610.38       20110101
28052       BIOPSY OF FOOT JOINT LINING                                       $277.94       20110801
28054       BIOPSY OF TOE JOINT LINING                       A                $610.38       20110101
28054       BIOPSY OF TOE JOINT LINING                                        $250.64       20110801
28055       NEURECTOMY FOOT                                  A                $570.50       20110101
28055       NEURECTOMY FOOT                                                   $267.28       20110801
28060       PARTIAL REMOVAL FOOT FASCIA                      A                $610.38       20110101
28060       PARTIAL REMOVAL FOOT FASCIA                                       $331.24       20110801
28062       REMOVAL OF FOOT FASCIA                           A                $622.62       20110101
28062       REMOVAL OF FOOT FASCIA                                            $385.58       20110801
28070       REMOVAL OF FOOT JOINT LINING                     A                $622.62       20110101
28070       REMOVAL OF FOOT JOINT LINING                                      $327.86       20110801
28072       REMOVAL OF FOOT JOINT LINING                     A                $622.62       20110101
28072       REMOVAL OF FOOT JOINT LINING                                      $328.12       20110801
28080       REMOVAL OF FOOT LESION                           A                $622.62       20110101
28080       REMOVAL OF FOOT LESION                                            $326.04       20110801
28086       EXCISE FOOT TENDON SHEATH                        A                $610.38       20110101
28086       EXCISE FOOT TENDON SHEATH       80                                 $69.89       20110801
28086       EXCISE FOOT TENDON SHEATH       81                                 $69.89       20110801
28086       EXCISE FOOT TENDON SHEATH       82                                 $69.89       20110801
28086       EXCISE FOOT TENDON SHEATH       AS                                 $69.89       20110801
28086       EXCISE FOOT TENDON SHEATH                                         $349.44       20110801
28088       EXCISE FOOT TENDON SHEATH                        A                $610.38       20110101
28088       EXCISE FOOT TENDON SHEATH                                         $296.40       20110801
28090       REMOVAL OF FOOT LESION                           A                $622.62       20110101
28090       REMOVAL OF FOOT LESION                                            $299.00       20110801
28092       REMOVAL OF TOE LESIONS                           A                $622.62       20110101
28092       REMOVAL OF TOE LESIONS                                            $270.40       20110801
28100       REMOVAL OF ANKLE/HEEL LESION                     A                $610.38       20110101
28100       REMOVAL OF ANKLE/HEEL LESION    80                                 $76.96       20110801
28100       REMOVAL OF ANKLE/HEEL LESION    81                                 $76.96       20110801
28100       REMOVAL OF ANKLE/HEEL LESION    82                                 $76.96       20110801
28100       REMOVAL OF ANKLE/HEEL LESION    AS                                 $76.96       20110801
28100       REMOVAL OF ANKLE/HEEL LESION                                      $384.80       20110801
28102       REMOVE/GRAFT FOOT LESION                         A              $1,360.09       20110101
28102       REMOVE/GRAFT FOOT LESION        80                                 $71.76       20110801
28102       REMOVE/GRAFT FOOT LESION        81                                 $71.76       20110801
28102       REMOVE/GRAFT FOOT LESION        82                                 $71.76       20110801
28102       REMOVE/GRAFT FOOT LESION        AS                                 $71.76       20110801
28102       REMOVE/GRAFT FOOT LESION                                          $358.80       20110801
28103       REMOVE/GRAFT FOOT LESION                         A              $1,360.09       20110101
28103       REMOVE/GRAFT FOOT LESION        80                                 $58.86       20110801
28103       REMOVE/GRAFT FOOT LESION        81                                 $58.86       20110801
28103       REMOVE/GRAFT FOOT LESION        82                                 $58.86       20110801
28103       REMOVE/GRAFT FOOT LESION        AS                                 $58.86       20110801
28103       REMOVE/GRAFT FOOT LESION                                          $294.32       20110801
28104       REMOVAL OF FOOT LESION                           A                $610.38       20110101
28104       REMOVAL OF FOOT LESION          80                                 $65.88       20110801
28104       REMOVAL OF FOOT LESION          81                                 $65.88       20110801
28104       REMOVAL OF FOOT LESION          82                                 $65.88       20110801
28104       REMOVAL OF FOOT LESION          AS                                 $65.88       20110801
28104       REMOVAL OF FOOT LESION                                            $329.42       20110801
28106       REMOVE/GRAFT FOOT LESION                         A              $1,360.09       20110101



                                                 Page 98
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
28106       REMOVE/GRAFT FOOT LESION        80                                 $62.76       20110801
28106       REMOVE/GRAFT FOOT LESION        81                                 $62.76       20110801
28106       REMOVE/GRAFT FOOT LESION        82                                 $62.76       20110801
28106       REMOVE/GRAFT FOOT LESION        AS                                 $62.76       20110801
28106       REMOVE/GRAFT FOOT LESION                                          $313.82       20110801
28107       REMOVE/GRAFT FOOT LESION                         A              $1,360.09       20110101
28107       REMOVE/GRAFT FOOT LESION        80                                 $71.03       20110801
28107       REMOVE/GRAFT FOOT LESION        81                                 $71.03       20110801
28107       REMOVE/GRAFT FOOT LESION        82                                 $71.03       20110801
28107       REMOVE/GRAFT FOOT LESION        AS                                 $71.03       20110801
28107       REMOVE/GRAFT FOOT LESION                                          $355.16       20110801
28108       REMOVAL OF TOE LESIONS                                            $277.68       20110801
28110       PART REMOVAL OF METATARSAL                       A                $622.62       20110101
28110       PART REMOVAL OF METATARSAL                                        $291.98       20110801
28111       PART REMOVAL OF METATARSAL                       A                $622.62       20110101
28111       PART REMOVAL OF METATARSAL                                        $331.24       20110801
28112       PART REMOVAL OF METATARSAL                       A                $622.62       20110101
28112       PART REMOVAL OF METATARSAL                                        $314.34       20110801
28113       PART REMOVAL OF METATARSAL                       A                $622.62       20110101
28113       PART REMOVAL OF METATARSAL                                        $381.68       20110801
28114       REMOVAL OF METATARSAL HEADS                      A                $622.62       20110101
28114       REMOVAL OF METATARSAL HEADS     80                                $139.67       20110801
28114       REMOVAL OF METATARSAL HEADS     81                                $139.67       20110801
28114       REMOVAL OF METATARSAL HEADS     82                                $139.67       20110801
28114       REMOVAL OF METATARSAL HEADS     AS                                $139.67       20110801
28114       REMOVAL OF METATARSAL HEADS                                       $698.36       20110801
28116       REVISION OF FOOT                                 A                $622.62       20110101
28116       REVISION OF FOOT                                                  $490.36       20110801
28118       REMOVAL OF HEEL BONE                             A                $645.58       20110101
28118       REMOVAL OF HEEL BONE            80                                 $75.87       20110801
28118       REMOVAL OF HEEL BONE            81                                 $75.87       20110801
28118       REMOVAL OF HEEL BONE            82                                 $75.87       20110801
28118       REMOVAL OF HEEL BONE            AS                                 $75.87       20110801
28118       REMOVAL OF HEEL BONE                                              $379.34       20110801
28119       REMOVAL OF HEEL SPUR                             A                $645.58       20110101
28119       REMOVAL OF HEEL SPUR                                              $336.70       20110801
28120       PART REMOVAL OF ANKLE/HEEL                       A                $715.42       20110101
28120       PART REMOVAL OF ANKLE/HEEL                                        $457.60       20110801
28122       PARTIAL REMOVAL OF FOOT BONE                     A                $622.62       20110101
28122       PARTIAL REMOVAL OF FOOT BONE    80                                 $86.58       20110801
28122       PARTIAL REMOVAL OF FOOT BONE    81                                 $86.58       20110801
28122       PARTIAL REMOVAL OF FOOT BONE    82                                 $86.58       20110801
28122       PARTIAL REMOVAL OF FOOT BONE    AS                                 $86.58       20110801
28122       PARTIAL REMOVAL OF FOOT BONE                                      $432.90       20110801
28124       PARTIAL REMOVAL OF TOE                                            $307.58       20110801
28126       PARTIAL REMOVAL OF TOE                           A                $622.62       20110101
28126       PARTIAL REMOVAL OF TOE                                            $250.38       20110801
28130       REMOVAL OF ANKLE BONE                            A                $622.62       20110101
28130       REMOVAL OF ANKLE BONE           80                                 $89.96       20110801
28130       REMOVAL OF ANKLE BONE           81                                 $89.96       20110801
28130       REMOVAL OF ANKLE BONE           82                                 $89.96       20110801
28130       REMOVAL OF ANKLE BONE           AS                                 $89.96       20110801
28130       REMOVAL OF ANKLE BONE                                             $449.80       20110801
28140       REMOVAL OF METATARSAL                            A                $622.62       20110101
28140       REMOVAL OF METATARSAL                                             $408.20       20110801
28150       REMOVAL OF TOE                                   A                $622.62       20110101
28150       REMOVAL OF TOE                                                    $278.72       20110801
28153       PARTIAL REMOVAL OF TOE                           A                $622.62       20110101
28153       PARTIAL REMOVAL OF TOE                                            $261.04       20110801



                                                 Page 99
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
28160       PARTIAL REMOVAL OF TOE                            A                $622.62       20110101
28160       PARTIAL REMOVAL OF TOE                                             $267.80       20110801
28171       RESECT TARSAL TUMOR                               A                $622.62       20110101
28171       RESECT TARSAL TUMOR             80                                 $119.18       20110801
28171       RESECT TARSAL TUMOR             81                                 $119.18       20110801
28171       RESECT TARSAL TUMOR             82                                 $119.18       20110801
28171       RESECT TARSAL TUMOR             AS                                 $119.18       20110801
28171       RESECT TARSAL TUMOR                                                $595.92       20110801
28173       RESECT METATARSAL TUMOR                           A                $622.62       20110101
28173       RESECT METATARSAL TUMOR                                            $535.08       20110801
28175       RESECT PHALANX OF TOE TUMOR                       A                $622.62       20110101
28175       RESECT PHALANX OF TOE TUMOR                                        $334.10       20110801
28190       REMOVAL OF FOOT FOREIGN BODY                                       $159.90       20110801
28192       REMOVAL OF FOOT FOREIGN BODY                      A                $505.90       20110101
28192       REMOVAL OF FOOT FOREIGN BODY                                       $304.72       20110801
28193       REMOVAL OF FOOT FOREIGN BODY                      A                $277.24       20110101
28193       REMOVAL OF FOOT FOREIGN BODY                                       $348.66       20110801
28200       REPAIR OF FOOT TENDON                             A                $622.62       20110101
28200       REPAIR OF FOOT TENDON                                              $303.94       20110801
28202       REPAIR/GRAFT OF FOOT TENDON                       A                $622.62       20110101
28202       REPAIR/GRAFT OF FOOT TENDON     80                                  $79.82       20110801
28202       REPAIR/GRAFT OF FOOT TENDON     81                                  $79.82       20110801
28202       REPAIR/GRAFT OF FOOT TENDON     82                                  $79.82       20110801
28202       REPAIR/GRAFT OF FOOT TENDON     AS                                  $79.82       20110801
28202       REPAIR/GRAFT OF FOOT TENDON                                        $399.10       20110801
28208       REPAIR OF FOOT TENDON                             A                $622.62       20110101
28208       REPAIR OF FOOT TENDON                                              $296.40       20110801
28210       REPAIR/GRAFT OF FOOT TENDON                       A              $1,360.09       20110101
28210       REPAIR/GRAFT OF FOOT TENDON     80                                  $75.14       20110801
28210       REPAIR/GRAFT OF FOOT TENDON     81                                  $75.14       20110801
28210       REPAIR/GRAFT OF FOOT TENDON     82                                  $75.14       20110801
28210       REPAIR/GRAFT OF FOOT TENDON     AS                                  $75.14       20110801
28210       REPAIR/GRAFT OF FOOT TENDON                                        $375.70       20110801
28220       RELEASE OF FOOT TENDON                                             $289.38       20110801
28222       RELEASE OF FOOT TENDONS                           A                $588.75       20110101
28222       RELEASE OF FOOT TENDONS                                            $332.54       20110801
28225       RELEASE OF FOOT TENDON                            A                $588.75       20110101
28225       RELEASE OF FOOT TENDON                                             $253.24       20110801
28226       RELEASE OF FOOT TENDONS                           A                $588.75       20110101
28226       RELEASE OF FOOT TENDONS                                            $296.40       20110801
28230       INCISION OF FOOT TENDONS                                           $277.68       20110801
28232       INCISION OF TOE TENDON                                             $247.78       20110801
28234       INCISION OF FOOT TENDON                           A                $610.38       20110101
28234       INCISION OF FOOT TENDON                                            $258.96       20110801
28238       REVISION OF FOOT TENDON                           A              $1,360.09       20110101
28238       REVISION OF FOOT TENDON         80                                  $88.50       20110801
28238       REVISION OF FOOT TENDON         81                                  $88.50       20110801
28238       REVISION OF FOOT TENDON         82                                  $88.50       20110801
28238       REVISION OF FOOT TENDON         AS                                  $88.50       20110801
28238       REVISION OF FOOT TENDON                                            $442.52       20110801
28240       RELEASE OF BIG TOE                                A                $610.38       20110101
28240       RELEASE OF BIG TOE                                                 $286.26       20110801
28250       REVISION OF FOOT FASCIA                           A                $622.62       20110101
28250       REVISION OF FOOT FASCIA         80                                  $73.48       20110801
28250       REVISION OF FOOT FASCIA         81                                  $73.48       20110801
28250       REVISION OF FOOT FASCIA         82                                  $73.48       20110801
28250       REVISION OF FOOT FASCIA         AS                                  $73.48       20110801
28250       REVISION OF FOOT FASCIA                                            $367.38       20110801
28260       RELEASE OF MIDFOOT JOINT                          A                $622.62       20110101



                                                 Page 100
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
28260       RELEASE OF MIDFOOT JOINT        80                                  $89.86       20110801
28260       RELEASE OF MIDFOOT JOINT        81                                  $89.86       20110801
28260       RELEASE OF MIDFOOT JOINT        82                                  $89.86       20110801
28260       RELEASE OF MIDFOOT JOINT        AS                                  $89.86       20110801
28260       RELEASE OF MIDFOOT JOINT                                           $449.28       20110801
28261       REVISION OF FOOT TENDON                           A                $622.62       20110101
28261       REVISION OF FOOT TENDON                                            $639.08       20110801
28262       REVISION OF FOOT AND ANKLE                        A                $645.58       20110101
28262       REVISION OF FOOT AND ANKLE      80                                 $183.56       20110801
28262       REVISION OF FOOT AND ANKLE      81                                 $183.56       20110801
28262       REVISION OF FOOT AND ANKLE      82                                 $183.56       20110801
28262       REVISION OF FOOT AND ANKLE      AS                                 $183.56       20110801
28262       REVISION OF FOOT AND ANKLE                                         $917.80       20110801
28264       RELEASE OF MIDFOOT JOINT                          A              $1,326.22       20110101
28264       RELEASE OF MIDFOOT JOINT        80                                 $109.46       20110801
28264       RELEASE OF MIDFOOT JOINT        81                                 $109.46       20110801
28264       RELEASE OF MIDFOOT JOINT        82                                 $109.46       20110801
28264       RELEASE OF MIDFOOT JOINT        AS                                 $109.46       20110801
28264       RELEASE OF MIDFOOT JOINT                                           $547.30       20110801
28270       RELEASE OF FOOT CONTRACTURE                       A                $622.62       20110101
28270       RELEASE OF FOOT CONTRACTURE                                        $312.00       20110801
28272       RELEASE OF TOE JOINT EACH                                          $252.72       20110801
28280       FUSION OF TOES                                    A                $610.38       20110101
28280       FUSION OF TOES                                                     $339.04       20110801
28285       REPAIR OF HAMMERTOE                               A                $622.62       20110101
28285       REPAIR OF HAMMERTOE                                                $301.34       20110801
28286       REPAIR OF HAMMERTOE                               A                $645.58       20110101
28286       REPAIR OF HAMMERTOE                                                $292.24       20110801
28288       PARTIAL REMOVAL OF FOOT BONE                      A                $622.62       20110101
28288       PARTIAL REMOVAL OF FOOT BONE                                       $384.54       20110801
28289       REPAIR HALLUX RIGIDUS                             A                $622.62       20110101
28289       REPAIR HALLUX RIGIDUS           80                                  $95.99       20110801
28289       REPAIR HALLUX RIGIDUS           81                                  $95.99       20110801
28289       REPAIR HALLUX RIGIDUS           82                                  $95.99       20110801
28289       REPAIR HALLUX RIGIDUS           AS                                  $95.99       20110801
28289       REPAIR HALLUX RIGIDUS                                              $479.96       20110801
28290       CORRECTION OF BUNION                              A                $843.75       20110101
28290       CORRECTION OF BUNION                                               $372.84       20110801
28293       CORRECTION OF BUNION                              A                $856.00       20110101
28293       CORRECTION OF BUNION                                               $678.86       20110801
28294       CORRECTION OF BUNION                              A                $856.00       20110101
28294       CORRECTION OF BUNION            80                                  $97.55       20110801
28294       CORRECTION OF BUNION            81                                  $97.55       20110801
28294       CORRECTION OF BUNION            82                                  $97.55       20110801
28294       CORRECTION OF BUNION            AS                                  $97.55       20110801
28294       CORRECTION OF BUNION                                               $487.76       20110801
28296       CORRECTION OF BUNION                              A                $856.00       20110101
28296       CORRECTION OF BUNION            80                                  $94.54       20110801
28296       CORRECTION OF BUNION            81                                  $94.54       20110801
28296       CORRECTION OF BUNION            82                                  $94.54       20110801
28296       CORRECTION OF BUNION            AS                                  $94.54       20110801
28296       CORRECTION OF BUNION                                               $472.68       20110801
28297       CORRECTION OF BUNION                              A                $856.00       20110101
28297       CORRECTION OF BUNION            80                                 $108.11       20110801
28297       CORRECTION OF BUNION            81                                 $108.11       20110801
28297       CORRECTION OF BUNION            82                                 $108.11       20110801
28297       CORRECTION OF BUNION            AS                                 $108.11       20110801
28297       CORRECTION OF BUNION                                               $540.54       20110801
28298       CORRECTION OF BUNION                              A                $856.00       20110101



                                                 Page 101
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
28298       CORRECTION OF BUNION            80                                  $93.39       20110801
28298       CORRECTION OF BUNION            81                                  $93.39       20110801
28298       CORRECTION OF BUNION            82                                  $93.39       20110801
28298       CORRECTION OF BUNION            AS                                  $93.39       20110801
28298       CORRECTION OF BUNION                                               $466.96       20110801
28299       CORRECTION OF BUNION                              A                $895.61       20110101
28299       CORRECTION OF BUNION            80                                 $119.24       20110801
28299       CORRECTION OF BUNION            81                                 $119.24       20110801
28299       CORRECTION OF BUNION            82                                 $119.24       20110801
28299       CORRECTION OF BUNION            AS                                 $119.24       20110801
28299       CORRECTION OF BUNION                                               $596.18       20110801
28300       INCISION OF HEEL BONE                             A              $1,347.85       20110101
28300       INCISION OF HEEL BONE           80                                  $91.26       20110801
28300       INCISION OF HEEL BONE           81                                  $91.26       20110801
28300       INCISION OF HEEL BONE           82                                  $91.26       20110801
28300       INCISION OF HEEL BONE           AS                                  $91.26       20110801
28300       INCISION OF HEEL BONE                                              $456.30       20110801
28302       INCISION OF ANKLE BONE                            A                $610.38       20110101
28302       INCISION OF ANKLE BONE          80                                  $93.44       20110801
28302       INCISION OF ANKLE BONE          81                                  $93.44       20110801
28302       INCISION OF ANKLE BONE          82                                  $93.44       20110801
28302       INCISION OF ANKLE BONE          AS                                  $93.44       20110801
28302       INCISION OF ANKLE BONE                                             $467.22       20110801
28304       INCISION OF MIDFOOT BONES                         A              $1,347.85       20110101
28304       INCISION OF MIDFOOT BONES       80                                 $104.21       20110801
28304       INCISION OF MIDFOOT BONES       81                                 $104.21       20110801
28304       INCISION OF MIDFOOT BONES       82                                 $104.21       20110801
28304       INCISION OF MIDFOOT BONES       AS                                 $104.21       20110801
28304       INCISION OF MIDFOOT BONES                                          $521.04       20110801
28305       INCISE/GRAFT MIDFOOT BONES                        A              $1,360.09       20110101
28305       INCISE/GRAFT MIDFOOT BONES      80                                  $92.92       20110801
28305       INCISE/GRAFT MIDFOOT BONES      81                                  $92.92       20110801
28305       INCISE/GRAFT MIDFOOT BONES      82                                  $92.92       20110801
28305       INCISE/GRAFT MIDFOOT BONES      AS                                  $92.92       20110801
28305       INCISE/GRAFT MIDFOOT BONES                                         $464.62       20110801
28306       INCISION OF METATARSAL                            A                $645.58       20110101
28306       INCISION OF METATARSAL          80                                  $78.73       20110801
28306       INCISION OF METATARSAL          81                                  $78.73       20110801
28306       INCISION OF METATARSAL          82                                  $78.73       20110801
28306       INCISION OF METATARSAL          AS                                  $78.73       20110801
28306       INCISION OF METATARSAL                                             $393.64       20110801
28307       INCISION OF METATARSAL                            A                $645.58       20110101
28307       INCISION OF METATARSAL                                             $476.58       20110801
28308       INCISION OF METATARSAL                            A                $610.38       20110101
28308       INCISION OF METATARSAL          80                                  $71.19       20110801
28308       INCISION OF METATARSAL          81                                  $71.19       20110801
28308       INCISION OF METATARSAL          82                                  $71.19       20110801
28308       INCISION OF METATARSAL          AS                                  $71.19       20110801
28308       INCISION OF METATARSAL                                             $355.94       20110801
28309       INCISION OF METATARSALS                           A              $1,383.06       20110101
28309       INCISION OF METATARSALS         80                                 $123.50       20110801
28309       INCISION OF METATARSALS         81                                 $123.50       20110801
28309       INCISION OF METATARSALS         82                                 $123.50       20110801
28309       INCISION OF METATARSALS         AS                                 $123.50       20110801
28309       INCISION OF METATARSALS                                            $617.50       20110801
28310       REVISION OF BIG TOE                               A                $622.62       20110101
28310       REVISION OF BIG TOE                                                $346.32       20110801
28312       REVISION OF TOE                                   A                $622.62       20110101
28312       REVISION OF TOE                                                    $319.28       20110801



                                                 Page 102
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
28313       REPAIR DEFORMITY OF TOE                          A                $610.38       20110101
28313       REPAIR DEFORMITY OF TOE                                           $338.26       20110801
28315       REMOVAL OF SESAMOID BONE                         A                $645.58       20110101
28315       REMOVAL OF SESAMOID BONE                                          $306.80       20110801
28320       REPAIR OF FOOT BONES                             A              $1,383.06       20110101
28320       REPAIR OF FOOT BONES           80                                  $85.80       20110801
28320       REPAIR OF FOOT BONES           81                                  $85.80       20110801
28320       REPAIR OF FOOT BONES           82                                  $85.80       20110801
28320       REPAIR OF FOOT BONES           AS                                  $85.80       20110801
28320       REPAIR OF FOOT BONES                                              $429.00       20110801
28322       REPAIR OF METATARSALS                            A              $1,383.06       20110101
28322       REPAIR OF METATARSALS          80                                 $102.08       20110801
28322       REPAIR OF METATARSALS          81                                 $102.08       20110801
28322       REPAIR OF METATARSALS          82                                 $102.08       20110801
28322       REPAIR OF METATARSALS          AS                                 $102.08       20110801
28322       REPAIR OF METATARSALS                                             $510.38       20110801
28340       RESECT ENLARGED TOE TISSUE                       A                $645.58       20110101
28340       RESECT ENLARGED TOE TISSUE                                        $393.38       20110801
28341       RESECT ENLARGED TOE                              A                $645.58       20110101
28341       RESECT ENLARGED TOE                                               $454.22       20110801
28344       REPAIR EXTRA TOES                                A                $645.58       20110101
28344       REPAIR EXTRA TOES                                                 $299.00       20110801
28345       REPAIR WEBBED TOES                               A                $645.58       20110101
28345       REPAIR WEBBED TOES                                                $360.88       20110801
28360       RECONSTRUCT CLEFT FOOT         80                                 $136.55       20110801
28360       RECONSTRUCT CLEFT FOOT         81                                 $136.55       20110801
28360       RECONSTRUCT CLEFT FOOT         82                                 $136.55       20110801
28360       RECONSTRUCT CLEFT FOOT         AS                                 $136.55       20110801
28360       RECONSTRUCT CLEFT FOOT                                            $682.76       20110801
28400       TREATMENT OF HEEL FRACTURE                       A                 $59.66       20110101
28400       TREATMENT OF HEEL FRACTURE                                        $159.64       20110801
28405       TREATMENT OF HEEL FRACTURE                       A                $462.00       20110101
28405       TREATMENT OF HEEL FRACTURE                                        $255.58       20110801
28406       TREATMENT OF HEEL FRACTURE                       A                $706.54       20110101
28406       TREATMENT OF HEEL FRACTURE                                        $352.82       20110801
28415       TREAT HEEL FRACTURE                              A              $1,671.34       20110101
28415       TREAT HEEL FRACTURE            80                                 $154.80       20110801
28415       TREAT HEEL FRACTURE            81                                 $154.80       20110801
28415       TREAT HEEL FRACTURE            82                                 $154.80       20110801
28415       TREAT HEEL FRACTURE            AS                                 $154.80       20110801
28415       TREAT HEEL FRACTURE                                               $774.02       20110801
28420       TREAT/GRAFT HEEL FRACTURE                        A              $1,213.40       20110101
28420       TREAT/GRAFT HEEL FRACTURE      80                                 $166.66       20110801
28420       TREAT/GRAFT HEEL FRACTURE      81                                 $166.66       20110801
28420       TREAT/GRAFT HEEL FRACTURE      82                                 $166.66       20110801
28420       TREAT/GRAFT HEEL FRACTURE      AS                                 $166.66       20110801
28420       TREAT/GRAFT HEEL FRACTURE                                         $833.30       20110801
28430       TREATMENT OF ANKLE FRACTURE                                       $150.02       20110801
28435       TREATMENT OF ANKLE FRACTURE                      A                 $59.66       20110101
28435       TREATMENT OF ANKLE FRACTURE                                       $217.36       20110801
28436       TREATMENT OF ANKLE FRACTURE                      A                $706.54       20110101
28436       TREATMENT OF ANKLE FRACTURE                                       $289.12       20110801
28445       TREAT ANKLE FRACTURE                             A              $1,190.44       20110101
28445       TREAT ANKLE FRACTURE           80                                 $146.69       20110801
28445       TREAT ANKLE FRACTURE           81                                 $146.69       20110801
28445       TREAT ANKLE FRACTURE           82                                 $146.69       20110801
28445       TREAT ANKLE FRACTURE           AS                                 $146.69       20110801
28445       TREAT ANKLE FRACTURE                                              $733.46       20110801
28446       OSTEOCHONDRAL TALUS AUTOGRFT                     A              $1,683.34       20110101



                                                Page 103
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
28446       OSTEOCHONDRAL TALUS AUTOGRFT                                      $822.90       20110801
28450       TREAT MIDFOOT FRACTURE EACH                                       $138.32       20110801
28455       TREAT MIDFOOT FRACTURE EACH                                       $192.14       20110801
28456       TREAT MIDFOOT FRACTURE                           A                $706.54       20110101
28456       TREAT MIDFOOT FRACTURE                                            $191.88       20110801
28465       TREAT MIDFOOT FRACTURE EACH                      A              $1,190.44       20110101
28465       TREAT MIDFOOT FRACTURE EACH                                       $418.08       20110801
28470       TREAT METATARSAL FRACTURE                                         $137.02       20110801
28475       TREAT METATARSAL FRACTURE                                         $170.82       20110801
28476       TREAT METATARSAL FRACTURE                        A                $706.54       20110101
28476       TREAT METATARSAL FRACTURE                                         $225.68       20110801
28485       TREAT METATARSAL FRACTURE                        A              $1,213.40       20110101
28485       TREAT METATARSAL FRACTURE                                         $361.66       20110801
28490       TREAT BIG TOE FRACTURE                                             $89.96       20110801
28495       TREAT BIG TOE FRACTURE                                            $112.32       20110801
28496       TREAT BIG TOE FRACTURE                           A                $706.54       20110101
28496       TREAT BIG TOE FRACTURE                                            $270.40       20110801
28505       TREAT BIG TOE FRACTURE                           A                $718.78       20110101
28505       TREAT BIG TOE FRACTURE                                            $437.32       20110801
28510       TREATMENT OF TOE FRACTURE                                          $77.48       20110801
28515       TREATMENT OF TOE FRACTURE                                         $101.66       20110801
28525       TREAT TOE FRACTURE                               A                $718.78       20110101
28525       TREAT TOE FRACTURE                                                $368.42       20110801
28530       TREAT SESAMOID BONE FRACTURE                                       $73.58       20110801
28531       TREAT SESAMOID BONE FRACTURE                     A                $718.78       20110101
28531       TREAT SESAMOID BONE FRACTURE                                      $256.62       20110801
28540       TREAT FOOT DISLOCATION                                            $131.04       20110801
28545       TREAT FOOT DISLOCATION                           A                $684.91       20110101
28545       TREAT FOOT DISLOCATION                                            $170.56       20110801
28546       TREAT FOOT DISLOCATION                           A                $706.54       20110101
28546       TREAT FOOT DISLOCATION                                            $320.84       20110801
28555       REPAIR FOOT DISLOCATION                          A              $1,178.19       20110101
28555       REPAIR FOOT DISLOCATION        80                                 $114.92       20110801
28555       REPAIR FOOT DISLOCATION        81                                 $114.92       20110801
28555       REPAIR FOOT DISLOCATION        82                                 $114.92       20110801
28555       REPAIR FOOT DISLOCATION        AS                                 $114.92       20110801
28555       REPAIR FOOT DISLOCATION                                           $574.60       20110801
28570       TREAT FOOT DISLOCATION                                            $109.72       20110801
28575       TREAT FOOT DISLOCATION                           A                $462.00       20110101
28575       TREAT FOOT DISLOCATION                                            $223.34       20110801
28576       TREAT FOOT DISLOCATION                           A                $718.78       20110101
28576       TREAT FOOT DISLOCATION                                            $246.74       20110801
28585       REPAIR FOOT DISLOCATION                          A                $718.78       20110101
28585       REPAIR FOOT DISLOCATION        80                                 $122.82       20110801
28585       REPAIR FOOT DISLOCATION        81                                 $122.82       20110801
28585       REPAIR FOOT DISLOCATION        82                                 $122.82       20110801
28585       REPAIR FOOT DISLOCATION        AS                                 $122.82       20110801
28585       REPAIR FOOT DISLOCATION                                           $614.12       20110801
28600       TREAT FOOT DISLOCATION                                            $138.32       20110801
28605       TREAT FOOT DISLOCATION                           A                 $59.66       20110101
28605       TREAT FOOT DISLOCATION                                            $187.98       20110801
28606       TREAT FOOT DISLOCATION                           A                $706.54       20110101
28606       TREAT FOOT DISLOCATION                                            $263.12       20110801
28615       REPAIR FOOT DISLOCATION                          A              $1,190.44       20110101
28615       REPAIR FOOT DISLOCATION        80                                 $106.60       20110801
28615       REPAIR FOOT DISLOCATION        81                                 $106.60       20110801
28615       REPAIR FOOT DISLOCATION        82                                 $106.60       20110801
28615       REPAIR FOOT DISLOCATION        AS                                 $106.60       20110801
28615       REPAIR FOOT DISLOCATION                                           $533.00       20110801



                                                Page 104
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                      Date
28630       TREAT TOE DISLOCATION                                                $98.28       20110801
28635       TREAT TOE DISLOCATION                              A                $431.28       20110101
28635       TREAT TOE DISLOCATION                                               $114.40       20110801
28636       TREAT TOE DISLOCATION                              A                $718.78       20110101
28636       TREAT TOE DISLOCATION                                               $191.10       20110801
28645       REPAIR TOE DISLOCATION                             A                $718.78       20110101
28645       REPAIR TOE DISLOCATION                                              $414.96       20110801
28660       TREAT TOE DISLOCATION                                                $72.80       20110801
28665       TREAT TOE DISLOCATION                              A                $431.28       20110101
28665       TREAT TOE DISLOCATION                                               $102.96       20110801
28666       TREAT TOE DISLOCATION                              A                $718.78       20110101
28666       TREAT TOE DISLOCATION                                               $135.72       20110801
28675       REPAIR OF TOE DISLOCATION                          A                $718.78       20110101
28675       REPAIR OF TOE DISLOCATION                                           $378.82       20110801
28705       FUSION OF FOOT BONES                               A              $1,383.06       20110101
28705       FUSION OF FOOT BONES             80                                 $180.49       20110801
28705       FUSION OF FOOT BONES             81                                 $180.49       20110801
28705       FUSION OF FOOT BONES             82                                 $180.49       20110801
28705       FUSION OF FOOT BONES             AS                                 $180.49       20110801
28705       FUSION OF FOOT BONES                                                $902.46       20110801
28715       FUSION OF FOOT BONES                               A              $2,251.38       20110101
28715       FUSION OF FOOT BONES             80                                 $134.16       20110801
28715       FUSION OF FOOT BONES             81                                 $134.16       20110801
28715       FUSION OF FOOT BONES             82                                 $134.16       20110801
28715       FUSION OF FOOT BONES             AS                                 $134.16       20110801
28715       FUSION OF FOOT BONES                                                $670.80       20110801
28725       FUSION OF FOOT BONES                               A              $1,383.06       20110101
28725       FUSION OF FOOT BONES             80                                 $109.46       20110801
28725       FUSION OF FOOT BONES             81                                 $109.46       20110801
28725       FUSION OF FOOT BONES             82                                 $109.46       20110801
28725       FUSION OF FOOT BONES             AS                                 $109.46       20110801
28725       FUSION OF FOOT BONES                                                $547.30       20110801
28730       FUSION OF FOOT BONES                               A              $1,383.06       20110101
28730       FUSION OF FOOT BONES             80                                 $115.54       20110801
28730       FUSION OF FOOT BONES             81                                 $115.54       20110801
28730       FUSION OF FOOT BONES             82                                 $115.54       20110801
28730       FUSION OF FOOT BONES             AS                                 $115.54       20110801
28730       FUSION OF FOOT BONES                                                $577.72       20110801
28735       FUSION OF FOOT BONES                               A              $1,383.06       20110101
28735       FUSION OF FOOT BONES             80                                 $109.82       20110801
28735       FUSION OF FOOT BONES             81                                 $109.82       20110801
28735       FUSION OF FOOT BONES             82                                 $109.82       20110801
28735       FUSION OF FOOT BONES             AS                                 $109.82       20110801
28735       FUSION OF FOOT BONES                                                $549.12       20110801
28737       REVISION OF FOOT BONES                             A              $1,399.70       20110101
28737       REVISION OF FOOT BONES           80                                  $95.89       20110801
28737       REVISION OF FOOT BONES           81                                  $95.89       20110801
28737       REVISION OF FOOT BONES           82                                  $95.89       20110801
28737       REVISION OF FOOT BONES           AS                                  $95.89       20110801
28737       REVISION OF FOOT BONES                                              $479.44       20110801
28740       FUSION OF FOOT BONES                               A              $1,383.06       20110101
28740       FUSION OF FOOT BONES             80                                 $112.37       20110801
28740       FUSION OF FOOT BONES             81                                 $112.37       20110801
28740       FUSION OF FOOT BONES             82                                 $112.37       20110801
28740       FUSION OF FOOT BONES             AS                                 $112.37       20110801
28740       FUSION OF FOOT BONES                                                $561.86       20110801
28750       FUSION OF BIG TOE JOINT                            A              $1,383.06       20110101
28750       FUSION OF BIG TOE JOINT                                             $546.26       20110801
28755       FUSION OF BIG TOE JOINT                            A                $645.58       20110101



                                                  Page 105
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
28755       FUSION OF BIG TOE JOINT                                            $324.74       20110801
28760       FUSION OF BIG TOE JOINT                           A              $1,383.06       20110101
28760       FUSION OF BIG TOE JOINT         80                                 $103.27       20110801
28760       FUSION OF BIG TOE JOINT         81                                 $103.27       20110801
28760       FUSION OF BIG TOE JOINT         82                                 $103.27       20110801
28760       FUSION OF BIG TOE JOINT         AS                                 $103.27       20110801
28760       FUSION OF BIG TOE JOINT                                            $516.36       20110801
28800       AMPUTATION OF MIDFOOT           80                                  $78.73       20110801
28800       AMPUTATION OF MIDFOOT           81                                  $78.73       20110801
28800       AMPUTATION OF MIDFOOT           82                                  $78.73       20110801
28800       AMPUTATION OF MIDFOOT           AS                                  $78.73       20110801
28800       AMPUTATION OF MIDFOOT                                              $393.64       20110801
28805       AMPUTATION THRU METATARSAL      80                                 $106.50       20110801
28805       AMPUTATION THRU METATARSAL      81                                 $106.50       20110801
28805       AMPUTATION THRU METATARSAL      82                                 $106.50       20110801
28805       AMPUTATION THRU METATARSAL      AS                                 $106.50       20110801
28805       AMPUTATION THRU METATARSAL                                         $532.48       20110801
28810       AMPUTATION TOE METATARSAL                         A                $610.38       20110101
28810       AMPUTATION TOE METATARSAL                                          $308.62       20110801
28820       AMPUTATION OF TOE                                 A                $610.38       20110101
28820       AMPUTATION OF TOE                                                  $347.36       20110801
28825       PARTIAL AMPUTATION OF TOE                         A                $610.38       20110101
28825       PARTIAL AMPUTATION OF TOE                                          $382.46       20110801
29000       APPLICATION OF BODY CAST                                           $164.06       20110801
29010       APPLICATION OF BODY CAST                                           $146.90       20110801
29015       APPLICATION OF BODY CAST                                           $157.04       20110801
29020       APPLICATION OF BODY CAST                                           $141.44       20110801
29025       APPLICATION OF BODY CAST                                           $172.90       20110801
29035       APPLICATION OF BODY CAST                                           $154.44       20110801
29040       APPLICATION OF BODY CAST                                           $152.36       20110801
29044       APPLICATION OF BODY CAST                                           $168.22       20110801
29046       APPLICATION OF BODY CAST                                           $182.26       20110801
29049       APPLICATION OF FIGURE EIGHT                                         $58.24       20110801
29055       APPLICATION OF SHOULDER CAST                                       $135.98       20110801
29058       APPLICATION OF SHOULDER CAST                                        $73.06       20110801
29065       APPLICATION OF LONG ARM CAST                                        $61.10       20110801
29075       APPLICATION OF FOREARM CAST                                         $56.68       20110801
29085       APPLY HAND/WRIST CAST                                               $60.06       20110801
29086       APPLY FINGER CAST                                                   $46.80       20110801
29105       APPLY LONG ARM SPLINT                                               $55.90       20110801
29125       APPLY FOREARM SPLINT                                                $43.94       20110801
29126       APPLY FOREARM SPLINT                                                $50.44       20110801
29130       APPLICATION OF FINGER SPLINT                                        $26.52       20110801
29131       APPLICATION OF FINGER SPLINT                                        $33.28       20110801
29200       STRAPPING OF CHEST                                                  $35.10       20110801
29240       STRAPPING OF SHOULDER                                               $38.22       20110801
29260       STRAPPING OF ELBOW OR WRIST                                         $33.54       20110801
29280       STRAPPING OF HAND OR FINGER                                         $32.50       20110801
29305       APPLICATION OF HIP CAST                                            $152.62       20110801
29325       APPLICATION OF HIP CASTS                                           $169.78       20110801
29345       APPLICATION OF LONG LEG CAST                                        $87.88       20110801
29355       APPLICATION OF LONG LEG CAST                                        $90.74       20110801
29358       APPLY LONG LEG CAST BRACE                                           $99.58       20110801
29365       APPLICATION OF LONG LEG CAST                                        $78.78       20110801
29405       APPLY SHORT LEG CAST                                                $57.20       20110801
29425       APPLY SHORT LEG CAST                                                $61.62       20110801
29435       APPLY SHORT LEG CAST                                                $76.96       20110801
29440       ADDITION OF WALKER TO CAST                                          $34.32       20110801
29445       APPLY RIGID LEG CAST                                                $94.64       20110801



                                                 Page 106
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
29450       APPLICATION OF LEG CAST                                            $99.06       20110801
29505       APPLICATION LONG LEG SPLINT                                        $49.92       20110801
29515       APPLICATION LOWER LEG SPLINT                                       $46.28       20110801
29520       STRAPPING OF HIP                                                   $32.50       20110801
29530       STRAPPING OF KNEE                                                  $34.06       20110801
29540       STRAPPING OF ANKLE AND/OR FT                                       $27.56       20110801
29550       STRAPPING OF TOES                                                  $27.04       20110801
29580       APPLICATION OF PASTE BOOT                                          $34.32       20110801
29581       APPLY MULTLAY COMPRS LWR LEG                                       $62.14       20110801
29582       APPLY MULTLAY COMPRS UPR LEG                                       $53.30       20120101
29583       APPLY MULTLAY COMPRS UPR ARM                                       $33.02       20120101
29584       APPL MULTLAY COMPRS ARM/HAND                                       $53.30       20120101
29590       APPLICATION OF FOOT SPLINT                                         $36.14       20110801
29700       REMOVAL/REVISION OF CAST                                           $41.86       20110801
29705       REMOVAL/REVISION OF CAST                                           $43.68       20110801
29710       REMOVAL/REVISION OF CAST                                           $78.78       20110801
29715       REMOVAL/REVISION OF CAST                                           $57.20       20110801
29720       REPAIR OF BODY CAST                                                $51.74       20110801
29730       WINDOWING OF CAST                                                  $42.38       20110801
29740       WEDGING OF CAST                                                    $60.58       20110801
29750       WEDGING OF CLUBFOOT CAST                                           $68.38       20110801
29800       JAW ARTHROSCOPY/SURGERY                          A                $816.73       20110101
29800       JAW ARTHROSCOPY/SURGERY                                           $352.82       20110801
29804       JAW ARTHROSCOPY/SURGERY                          A                $816.73       20110101
29804       JAW ARTHROSCOPY/SURGERY        80                                  $88.04       20110801
29804       JAW ARTHROSCOPY/SURGERY        81                                  $88.04       20110801
29804       JAW ARTHROSCOPY/SURGERY        82                                  $88.04       20110801
29804       JAW ARTHROSCOPY/SURGERY        AS                                  $88.04       20110801
29804       JAW ARTHROSCOPY/SURGERY                                           $440.18       20110801
29805       SHOULDER ARTHROSCOPY DX                          A                $816.73       20110101
29805       SHOULDER ARTHROSCOPY DX                                           $316.42       20110801
29806       SHOULDER ARTHROSCOPY/SURGERY                     A              $1,270.96       20110101
29806       SHOULDER ARTHROSCOPY/SURGERY                                      $725.14       20110801
29807       SHOULDER ARTHROSCOPY/SURGERY                     A              $1,270.96       20110101
29807       SHOULDER ARTHROSCOPY/SURGERY                                      $706.16       20110801
29819       SHOULDER ARTHROSCOPY/SURGERY                     A              $1,270.96       20110101
29819       SHOULDER ARTHROSCOPY/SURGERY                                      $396.24       20110801
29820       SHOULDER ARTHROSCOPY/SURGERY                     A              $1,270.96       20110101
29820       SHOULDER ARTHROSCOPY/SURGERY   80                                  $73.06       20110801
29820       SHOULDER ARTHROSCOPY/SURGERY   81                                  $73.06       20110801
29820       SHOULDER ARTHROSCOPY/SURGERY   82                                  $73.06       20110801
29820       SHOULDER ARTHROSCOPY/SURGERY   AS                                  $73.06       20110801
29820       SHOULDER ARTHROSCOPY/SURGERY                                      $365.30       20110801
29821       SHOULDER ARTHROSCOPY/SURGERY                     A              $1,270.96       20110101
29821       SHOULDER ARTHROSCOPY/SURGERY   80                                  $79.98       20110801
29821       SHOULDER ARTHROSCOPY/SURGERY   81                                  $79.98       20110801
29821       SHOULDER ARTHROSCOPY/SURGERY   82                                  $79.98       20110801
29821       SHOULDER ARTHROSCOPY/SURGERY   AS                                  $79.98       20110801
29821       SHOULDER ARTHROSCOPY/SURGERY                                      $399.88       20110801
29822       SHOULDER ARTHROSCOPY/SURGERY                     A                $816.73       20110101
29822       SHOULDER ARTHROSCOPY/SURGERY   80                                  $77.74       20110801
29822       SHOULDER ARTHROSCOPY/SURGERY   81                                  $77.74       20110801
29822       SHOULDER ARTHROSCOPY/SURGERY   82                                  $77.74       20110801
29822       SHOULDER ARTHROSCOPY/SURGERY   AS                                  $77.74       20110801
29822       SHOULDER ARTHROSCOPY/SURGERY                                      $388.70       20110801
29823       SHOULDER ARTHROSCOPY/SURGERY                     A              $1,270.96       20110101
29823       SHOULDER ARTHROSCOPY/SURGERY   80                                  $84.97       20110801
29823       SHOULDER ARTHROSCOPY/SURGERY   81                                  $84.97       20110801
29823       SHOULDER ARTHROSCOPY/SURGERY   82                                  $84.97       20110801



                                                Page 107
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
29823       SHOULDER ARTHROSCOPY/SURGERY   AS                                  $84.97       20110801
29823       SHOULDER ARTHROSCOPY/SURGERY                                      $424.84       20110801
29824       SHOULDER ARTHROSCOPY/SURGERY                     A                $856.34       20110101
29824       SHOULDER ARTHROSCOPY/SURGERY   80                                  $91.26       20110801
29824       SHOULDER ARTHROSCOPY/SURGERY   81                                  $91.26       20110801
29824       SHOULDER ARTHROSCOPY/SURGERY   82                                  $91.26       20110801
29824       SHOULDER ARTHROSCOPY/SURGERY   AS                                  $91.26       20110801
29824       SHOULDER ARTHROSCOPY/SURGERY                                      $456.30       20110801
29825       SHOULDER ARTHROSCOPY/SURGERY                     A              $1,270.96       20110101
29825       SHOULDER ARTHROSCOPY/SURGERY   80                                  $79.20       20110801
29825       SHOULDER ARTHROSCOPY/SURGERY   81                                  $79.20       20110801
29825       SHOULDER ARTHROSCOPY/SURGERY   82                                  $79.20       20110801
29825       SHOULDER ARTHROSCOPY/SURGERY   AS                                  $79.20       20110801
29825       SHOULDER ARTHROSCOPY/SURGERY                                      $395.98       20110801
29826       SHOULDER ARTHROSCOPY/SURGERY                     A              $1,270.96       20110101
29826       SHOULDER ARTHROSCOPY/SURGERY   80                                  $90.79       20110801
29826       SHOULDER ARTHROSCOPY/SURGERY   81                                  $90.79       20110801
29826       SHOULDER ARTHROSCOPY/SURGERY   82                                  $90.79       20110801
29826       SHOULDER ARTHROSCOPY/SURGERY   AS                                  $90.79       20110801
29826       SHOULDER ARTHROSCOPY/SURGERY                                      $453.96       20110801
29827       ARTHROSCOP ROTATOR CUFF REPR                     A              $1,310.57       20110101
29827       ARTHROSCOP ROTATOR CUFF REPR   80                                 $147.99       20110801
29827       ARTHROSCOP ROTATOR CUFF REPR   81                                 $147.99       20110801
29827       ARTHROSCOP ROTATOR CUFF REPR   82                                 $147.99       20110801
29827       ARTHROSCOP ROTATOR CUFF REPR   AS                                 $147.99       20110801
29827       ARTHROSCOP ROTATOR CUFF REPR                                      $739.96       20110801
29828       ARTHROSCOPY BICEPS TENODESIS                     A              $1,564.50       20110101
29828       ARTHROSCOPY BICEPS TENODESIS                                      $624.78       20110801
29830       ELBOW ARTHROSCOPY                                A                $816.73       20110101
29830       ELBOW ARTHROSCOPY                                                 $305.50       20110801
29834       ELBOW ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29834       ELBOW ARTHROSCOPY/SURGERY      80                                  $66.40       20110801
29834       ELBOW ARTHROSCOPY/SURGERY      81                                  $66.40       20110801
29834       ELBOW ARTHROSCOPY/SURGERY      82                                  $66.40       20110801
29834       ELBOW ARTHROSCOPY/SURGERY      AS                                  $66.40       20110801
29834       ELBOW ARTHROSCOPY/SURGERY                                         $332.02       20110801
29835       ELBOW ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29835       ELBOW ARTHROSCOPY/SURGERY      80                                  $68.17       20110801
29835       ELBOW ARTHROSCOPY/SURGERY      81                                  $68.17       20110801
29835       ELBOW ARTHROSCOPY/SURGERY      82                                  $68.17       20110801
29835       ELBOW ARTHROSCOPY/SURGERY      AS                                  $68.17       20110801
29835       ELBOW ARTHROSCOPY/SURGERY                                         $340.86       20110801
29836       ELBOW ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29836       ELBOW ARTHROSCOPY/SURGERY      80                                  $78.78       20110801
29836       ELBOW ARTHROSCOPY/SURGERY      81                                  $78.78       20110801
29836       ELBOW ARTHROSCOPY/SURGERY      82                                  $78.78       20110801
29836       ELBOW ARTHROSCOPY/SURGERY      AS                                  $78.78       20110801
29836       ELBOW ARTHROSCOPY/SURGERY                                         $393.90       20110801
29837       ELBOW ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29837       ELBOW ARTHROSCOPY/SURGERY      80                                  $71.45       20110801
29837       ELBOW ARTHROSCOPY/SURGERY      81                                  $71.45       20110801
29837       ELBOW ARTHROSCOPY/SURGERY      82                                  $71.45       20110801
29837       ELBOW ARTHROSCOPY/SURGERY      AS                                  $71.45       20110801
29837       ELBOW ARTHROSCOPY/SURGERY                                         $357.24       20110801
29838       ELBOW ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29838       ELBOW ARTHROSCOPY/SURGERY                                         $399.62       20110801
29840       WRIST ARTHROSCOPY                                A                $816.73       20110101
29840       WRIST ARTHROSCOPY                                                 $302.12       20110801
29843       WRIST ARTHROSCOPY/SURGERY                        A                $816.73       20110101



                                                Page 108
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
29843       WRIST ARTHROSCOPY/SURGERY                                         $323.96       20110801
29844       WRIST ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29844       WRIST ARTHROSCOPY/SURGERY                                         $334.10       20110801
29845       WRIST ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29845       WRIST ARTHROSCOPY/SURGERY                                         $385.06       20110801
29846       WRIST ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29846       WRIST ARTHROSCOPY/SURGERY                                         $350.74       20110801
29847       WRIST ARTHROSCOPY/SURGERY                        A              $1,270.96       20110101
29847       WRIST ARTHROSCOPY/SURGERY      80                                  $73.37       20110801
29847       WRIST ARTHROSCOPY/SURGERY      81                                  $73.37       20110801
29847       WRIST ARTHROSCOPY/SURGERY      82                                  $73.37       20110801
29847       WRIST ARTHROSCOPY/SURGERY      AS                                  $73.37       20110801
29847       WRIST ARTHROSCOPY/SURGERY                                         $366.86       20110801
29848       WRIST ENDOSCOPY/SURGERY                          A                $975.35       20110101
29848       WRIST ENDOSCOPY/SURGERY                                           $338.00       20110801
29850       KNEE ARTHROSCOPY/SURGERY                         A                $839.70       20110101
29850       KNEE ARTHROSCOPY/SURGERY                                          $397.28       20110801
29851       KNEE ARTHROSCOPY/SURGERY                         A              $1,293.92       20110101
29851       KNEE ARTHROSCOPY/SURGERY       80                                 $127.14       20110801
29851       KNEE ARTHROSCOPY/SURGERY       81                                 $127.14       20110801
29851       KNEE ARTHROSCOPY/SURGERY       82                                 $127.14       20110801
29851       KNEE ARTHROSCOPY/SURGERY       AS                                 $127.14       20110801
29851       KNEE ARTHROSCOPY/SURGERY                                          $635.70       20110801
29855       TIBIAL ARTHROSCOPY/SURGERY                       A              $1,293.92       20110101
29855       TIBIAL ARTHROSCOPY/SURGERY     80                                 $106.76       20110801
29855       TIBIAL ARTHROSCOPY/SURGERY     81                                 $106.76       20110801
29855       TIBIAL ARTHROSCOPY/SURGERY     82                                 $106.76       20110801
29855       TIBIAL ARTHROSCOPY/SURGERY     AS                                 $106.76       20110801
29855       TIBIAL ARTHROSCOPY/SURGERY                                        $533.78       20110801
29856       TIBIAL ARTHROSCOPY/SURGERY                       A              $1,293.92       20110101
29856       TIBIAL ARTHROSCOPY/SURGERY     80                                 $136.45       20110801
29856       TIBIAL ARTHROSCOPY/SURGERY     81                                 $136.45       20110801
29856       TIBIAL ARTHROSCOPY/SURGERY     82                                 $136.45       20110801
29856       TIBIAL ARTHROSCOPY/SURGERY     AS                                 $136.45       20110801
29856       TIBIAL ARTHROSCOPY/SURGERY                                        $682.24       20110801
29860       HIP ARTHROSCOPY DX                               A              $1,293.92       20110101
29860       HIP ARTHROSCOPY DX                                                $445.38       20110801
29861       HIP ARTHRO W/FB REMOVAL                          A              $1,293.92       20110101
29861       HIP ARTHRO W/FB REMOVAL        80                                  $98.28       20110801
29861       HIP ARTHRO W/FB REMOVAL        81                                  $98.28       20110801
29861       HIP ARTHRO W/FB REMOVAL        82                                  $98.28       20110801
29861       HIP ARTHRO W/FB REMOVAL        AS                                  $98.28       20110801
29861       HIP ARTHRO W/FB REMOVAL                                           $491.40       20110801
29862       HIP ARTHR0 W/DEBRIDEMENT                         A              $1,429.58       20110101
29862       HIP ARTHR0 W/DEBRIDEMENT       80                                 $110.34       20110801
29862       HIP ARTHR0 W/DEBRIDEMENT       81                                 $110.34       20110801
29862       HIP ARTHR0 W/DEBRIDEMENT       82                                 $110.34       20110801
29862       HIP ARTHR0 W/DEBRIDEMENT       AS                                 $110.34       20110801
29862       HIP ARTHR0 W/DEBRIDEMENT                                          $551.72       20110801
29863       HIP ARTHR0 W/SYNOVECTOMY                         A              $1,293.92       20110101
29863       HIP ARTHR0 W/SYNOVECTOMY       80                                 $110.14       20110801
29863       HIP ARTHR0 W/SYNOVECTOMY       81                                 $110.14       20110801
29863       HIP ARTHR0 W/SYNOVECTOMY       82                                 $110.14       20110801
29863       HIP ARTHR0 W/SYNOVECTOMY       AS                                 $110.14       20110801
29863       HIP ARTHR0 W/SYNOVECTOMY                                          $550.68       20110801
29870       KNEE ARTHROSCOPY DX                              A                $816.73       20110101
29870       KNEE ARTHROSCOPY DX                                               $388.96       20110801
29871       KNEE ARTHROSCOPY/DRAINAGE                        A                $816.73       20110101
29871       KNEE ARTHROSCOPY/DRAINAGE                                         $345.02       20110801



                                                Page 109
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                   Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
29873       KNEE ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29873       KNEE ARTHROSCOPY/SURGERY                                         $346.84       20110801
29874       KNEE ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29874       KNEE ARTHROSCOPY/SURGERY      80                                  $72.64       20110801
29874       KNEE ARTHROSCOPY/SURGERY      81                                  $72.64       20110801
29874       KNEE ARTHROSCOPY/SURGERY      82                                  $72.64       20110801
29874       KNEE ARTHROSCOPY/SURGERY      AS                                  $72.64       20110801
29874       KNEE ARTHROSCOPY/SURGERY                                         $363.22       20110801
29875       KNEE ARTHROSCOPY/SURGERY                        A                $839.70       20110101
29875       KNEE ARTHROSCOPY/SURGERY      80                                  $66.77       20110801
29875       KNEE ARTHROSCOPY/SURGERY      81                                  $66.77       20110801
29875       KNEE ARTHROSCOPY/SURGERY      82                                  $66.77       20110801
29875       KNEE ARTHROSCOPY/SURGERY      AS                                  $66.77       20110801
29875       KNEE ARTHROSCOPY/SURGERY                                         $333.84       20110801
29876       KNEE ARTHROSCOPY/SURGERY                        A                $839.70       20110101
29876       KNEE ARTHROSCOPY/SURGERY                                         $442.52       20110801
29877       KNEE ARTHROSCOPY/SURGERY                        A                $839.70       20110101
29877       KNEE ARTHROSCOPY/SURGERY      80                                  $83.77       20110801
29877       KNEE ARTHROSCOPY/SURGERY      81                                  $83.77       20110801
29877       KNEE ARTHROSCOPY/SURGERY      82                                  $83.77       20110801
29877       KNEE ARTHROSCOPY/SURGERY      AS                                  $83.77       20110801
29877       KNEE ARTHROSCOPY/SURGERY                                         $418.86       20110801
29879       KNEE ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29879       KNEE ARTHROSCOPY/SURGERY      80                                  $89.60       20110801
29879       KNEE ARTHROSCOPY/SURGERY      81                                  $89.60       20110801
29879       KNEE ARTHROSCOPY/SURGERY      82                                  $89.60       20110801
29879       KNEE ARTHROSCOPY/SURGERY      AS                                  $89.60       20110801
29879       KNEE ARTHROSCOPY/SURGERY                                         $447.98       20110801
29880       KNEE ARTHROSCOPY/SURGERY                        A                $839.70       20110101
29880       KNEE ARTHROSCOPY/SURGERY      80                                  $93.44       20110801
29880       KNEE ARTHROSCOPY/SURGERY      81                                  $93.44       20110801
29880       KNEE ARTHROSCOPY/SURGERY      82                                  $93.44       20110801
29880       KNEE ARTHROSCOPY/SURGERY      AS                                  $93.44       20110801
29880       KNEE ARTHROSCOPY/SURGERY                                         $467.22       20110801
29881       KNEE ARTHROSCOPY/SURGERY                        A                $839.70       20110101
29881       KNEE ARTHROSCOPY/SURGERY      80                                  $87.20       20110801
29881       KNEE ARTHROSCOPY/SURGERY      81                                  $87.20       20110801
29881       KNEE ARTHROSCOPY/SURGERY      82                                  $87.20       20110801
29881       KNEE ARTHROSCOPY/SURGERY      AS                                  $87.20       20110801
29881       KNEE ARTHROSCOPY/SURGERY                                         $436.02       20110801
29882       KNEE ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29882       KNEE ARTHROSCOPY/SURGERY                                         $471.90       20110801
29883       KNEE ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29883       KNEE ARTHROSCOPY/SURGERY      80                                 $114.50       20110801
29883       KNEE ARTHROSCOPY/SURGERY      81                                 $114.50       20110801
29883       KNEE ARTHROSCOPY/SURGERY      82                                 $114.50       20110801
29883       KNEE ARTHROSCOPY/SURGERY      AS                                 $114.50       20110801
29883       KNEE ARTHROSCOPY/SURGERY                                         $572.52       20110801
29884       KNEE ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29884       KNEE ARTHROSCOPY/SURGERY      80                                  $83.56       20110801
29884       KNEE ARTHROSCOPY/SURGERY      81                                  $83.56       20110801
29884       KNEE ARTHROSCOPY/SURGERY      82                                  $83.56       20110801
29884       KNEE ARTHROSCOPY/SURGERY      AS                                  $83.56       20110801
29884       KNEE ARTHROSCOPY/SURGERY                                         $417.82       20110801
29885       KNEE ARTHROSCOPY/SURGERY                        A              $1,270.96       20110101
29885       KNEE ARTHROSCOPY/SURGERY      80                                 $101.35       20110801
29885       KNEE ARTHROSCOPY/SURGERY      81                                 $101.35       20110801
29885       KNEE ARTHROSCOPY/SURGERY      82                                 $101.35       20110801
29885       KNEE ARTHROSCOPY/SURGERY      AS                                 $101.35       20110801



                                               Page 110
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                   Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                   Date
29885       KNEE ARTHROSCOPY/SURGERY                                         $506.74       20110801
29886       KNEE ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29886       KNEE ARTHROSCOPY/SURGERY                                         $427.44       20110801
29887       KNEE ARTHROSCOPY/SURGERY                        A                $816.73       20110101
29887       KNEE ARTHROSCOPY/SURGERY      80                                 $100.78       20110801
29887       KNEE ARTHROSCOPY/SURGERY      81                                 $100.78       20110801
29887       KNEE ARTHROSCOPY/SURGERY      82                                 $100.78       20110801
29887       KNEE ARTHROSCOPY/SURGERY      AS                                 $100.78       20110801
29887       KNEE ARTHROSCOPY/SURGERY                                         $503.88       20110801
29888       KNEE ARTHROSCOPY/SURGERY                        A              $2,228.42       20110101
29888       KNEE ARTHROSCOPY/SURGERY      80                                 $135.46       20110801
29888       KNEE ARTHROSCOPY/SURGERY      81                                 $135.46       20110801
29888       KNEE ARTHROSCOPY/SURGERY      82                                 $135.46       20110801
29888       KNEE ARTHROSCOPY/SURGERY      AS                                 $135.46       20110801
29888       KNEE ARTHROSCOPY/SURGERY                                         $677.30       20110801
29889       KNEE ARTHROSCOPY/SURGERY                        A              $2,228.42       20110101
29889       KNEE ARTHROSCOPY/SURGERY      80                                 $166.30       20110801
29889       KNEE ARTHROSCOPY/SURGERY      81                                 $166.30       20110801
29889       KNEE ARTHROSCOPY/SURGERY      82                                 $166.30       20110801
29889       KNEE ARTHROSCOPY/SURGERY      AS                                 $166.30       20110801
29889       KNEE ARTHROSCOPY/SURGERY                                         $831.48       20110801
29891       ANKLE ARTHROSCOPY/SURGERY                       A              $1,270.96       20110101
29891       ANKLE ARTHROSCOPY/SURGERY     80                                  $94.43       20110801
29891       ANKLE ARTHROSCOPY/SURGERY     81                                  $94.43       20110801
29891       ANKLE ARTHROSCOPY/SURGERY     82                                  $94.43       20110801
29891       ANKLE ARTHROSCOPY/SURGERY     AS                                  $94.43       20110801
29891       ANKLE ARTHROSCOPY/SURGERY                                        $472.16       20110801
29892       ANKLE ARTHROSCOPY/SURGERY                       A              $2,228.42       20110101
29892       ANKLE ARTHROSCOPY/SURGERY     80                                  $99.37       20110801
29892       ANKLE ARTHROSCOPY/SURGERY     81                                  $99.37       20110801
29892       ANKLE ARTHROSCOPY/SURGERY     82                                  $99.37       20110801
29892       ANKLE ARTHROSCOPY/SURGERY     AS                                  $99.37       20110801
29892       ANKLE ARTHROSCOPY/SURGERY                                        $496.86       20110801
29893       SCOPE PLANTAR FASCIOTOMY                        A                $765.27       20110101
29893       SCOPE PLANTAR FASCIOTOMY                                         $392.86       20110801
29894       ANKLE ARTHROSCOPY/SURGERY                       A                $816.73       20110101
29894       ANKLE ARTHROSCOPY/SURGERY     80                                  $70.15       20110801
29894       ANKLE ARTHROSCOPY/SURGERY     81                                  $70.15       20110801
29894       ANKLE ARTHROSCOPY/SURGERY     82                                  $70.15       20110801
29894       ANKLE ARTHROSCOPY/SURGERY     AS                                  $70.15       20110801
29894       ANKLE ARTHROSCOPY/SURGERY                                        $350.74       20110801
29895       ANKLE ARTHROSCOPY/SURGERY                       A                $816.73       20110101
29895       ANKLE ARTHROSCOPY/SURGERY     80                                  $67.44       20110801
29895       ANKLE ARTHROSCOPY/SURGERY     81                                  $67.44       20110801
29895       ANKLE ARTHROSCOPY/SURGERY     82                                  $67.44       20110801
29895       ANKLE ARTHROSCOPY/SURGERY     AS                                  $67.44       20110801
29895       ANKLE ARTHROSCOPY/SURGERY                                        $337.22       20110801
29897       ANKLE ARTHROSCOPY/SURGERY                       A                $816.73       20110101
29897       ANKLE ARTHROSCOPY/SURGERY     80                                  $70.88       20110801
29897       ANKLE ARTHROSCOPY/SURGERY     81                                  $70.88       20110801
29897       ANKLE ARTHROSCOPY/SURGERY     82                                  $70.88       20110801
29897       ANKLE ARTHROSCOPY/SURGERY     AS                                  $70.88       20110801
29897       ANKLE ARTHROSCOPY/SURGERY                                        $354.38       20110801
29898       ANKLE ARTHROSCOPY/SURGERY                       A                $816.73       20110101
29898       ANKLE ARTHROSCOPY/SURGERY     80                                  $78.94       20110801
29898       ANKLE ARTHROSCOPY/SURGERY     81                                  $78.94       20110801
29898       ANKLE ARTHROSCOPY/SURGERY     82                                  $78.94       20110801
29898       ANKLE ARTHROSCOPY/SURGERY     AS                                  $78.94       20110801
29898       ANKLE ARTHROSCOPY/SURGERY                                        $394.68       20110801



                                               Page 111
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
29899       ANKLE ARTHROSCOPY/SURGERY                         A              $1,270.96       20110101
29899       ANKLE ARTHROSCOPY/SURGERY       80                                 $143.99       20110801
29899       ANKLE ARTHROSCOPY/SURGERY       81                                 $143.99       20110801
29899       ANKLE ARTHROSCOPY/SURGERY       82                                 $143.99       20110801
29899       ANKLE ARTHROSCOPY/SURGERY       AS                                 $143.99       20110801
29899       ANKLE ARTHROSCOPY/SURGERY                                          $719.94       20110801
29900       MCP JOINT ARTHROSCOPY DX                                           $288.34       20110801
29901       MCP JOINT ARTHROSCOPY SURG                                         $343.72       20110801
29902       MCP JOINT ARTHROSCOPY SURG                                         $397.02       20110801
29904       SUBTALAR ARTHRO W/FB RMVL                         A                $958.87       20110101
29904       SUBTALAR ARTHRO W/FB RMVL                                          $424.84       20110801
29905       SUBTALAR ARTHRO W/EXC                             A                $958.87       20110101
29905       SUBTALAR ARTHRO W/EXC                                              $458.38       20110801
29906       SUBTALAR ARTHRO W/DEB                             A                $958.87       20110101
29906       SUBTALAR ARTHRO W/DEB                                              $482.56       20110801
29907       SUBTALAR ARTHRO W/FUSION                          A              $1,564.50       20110101
29907       SUBTALAR ARTHRO W/FUSION                                           $587.34       20110801
30000       DRAINAGE OF NOSE LESION                                            $151.32       20110801
30020       DRAINAGE OF NOSE LESION                                            $147.68       20110801
30100       INTRANASAL BIOPSY                                                   $91.52       20110801
30110       REMOVAL OF NOSE POLYPS                                             $148.98       20110801
30115       REMOVAL OF NOSE POLYPS                            A                $498.46       20110101
30115       REMOVAL OF NOSE POLYPS                                             $287.30       20110801
30117       REMOVAL OF INTRANASAL LESION                      A                $510.71       20110101
30117       REMOVAL OF INTRANASAL LESION                                       $544.96       20110801
30118       REMOVAL OF INTRANASAL LESION                      A                $697.62       20110101
30118       REMOVAL OF INTRANASAL LESION                                       $522.34       20110801
30124       REMOVAL OF NOSE LESION                            A                $244.19       20110101
30124       REMOVAL OF NOSE LESION                                             $183.56       20110801
30125       REMOVAL OF NOSE LESION                            A              $1,118.46       20110101
30125       REMOVAL OF NOSE LESION          80                                  $82.84       20110801
30125       REMOVAL OF NOSE LESION          81                                  $82.84       20110801
30125       REMOVAL OF NOSE LESION          82                                  $82.84       20110801
30125       REMOVAL OF NOSE LESION          AS                                  $82.84       20110801
30125       REMOVAL OF NOSE LESION                                             $414.18       20110801
30130       EXCISE INFERIOR TURBINATE                         A                $510.71       20110101
30130       EXCISE INFERIOR TURBINATE                                          $251.16       20110801
30140       RESECT INFERIOR TURBINATE                         A                $685.37       20110101
30140       RESECT INFERIOR TURBINATE                                          $287.30       20110801
30150       PARTIAL REMOVAL OF NOSE                           A              $1,130.71       20110101
30150       PARTIAL REMOVAL OF NOSE                                            $531.70       20110801
30160       REMOVAL OF NOSE                                   A              $1,153.67       20110101
30160       REMOVAL OF NOSE                 80                                 $106.70       20110801
30160       REMOVAL OF NOSE                 81                                 $106.70       20110801
30160       REMOVAL OF NOSE                 82                                 $106.70       20110801
30160       REMOVAL OF NOSE                 AS                                 $106.70       20110801
30160       REMOVAL OF NOSE                                                    $533.52       20110801
30200       INJECTION TREATMENT OF NOSE                                         $73.58       20110801
30210       NASAL SINUS THERAPY                                                 $97.24       20110801
30220       INSERT NASAL SEPTAL BUTTON                                         $191.88       20110801
30300       REMOVE NASAL FOREIGN BODY                                          $147.42       20110801
30310       REMOVE NASAL FOREIGN BODY                         A                $476.85       20110101
30310       REMOVE NASAL FOREIGN BODY                                          $137.28       20110801
30320       REMOVE NASAL FOREIGN BODY                         A                $498.46       20110101
30320       REMOVE NASAL FOREIGN BODY                                          $302.64       20110801
30400       RECONSTRUCTION OF NOSE                            A              $1,153.67       20110101
30400       RECONSTRUCTION OF NOSE                                             $692.38       20110801
30410       RECONSTRUCTION OF NOSE                            A              $1,170.32       20110101
30410       RECONSTRUCTION OF NOSE          80                                 $163.75       20110801



                                                 Page 112
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
30410       RECONSTRUCTION OF NOSE          81                                 $163.75       20110801
30410       RECONSTRUCTION OF NOSE          82                                 $163.75       20110801
30410       RECONSTRUCTION OF NOSE          AS                                 $163.75       20110801
30410       RECONSTRUCTION OF NOSE                                             $818.74       20110801
30420       RECONSTRUCTION OF NOSE                            A              $1,170.32       20110101
30420       RECONSTRUCTION OF NOSE                                             $933.92       20110801
30430       REVISION OF NOSE                                  A                $697.62       20110101
30430       REVISION OF NOSE                80                                 $122.46       20110801
30430       REVISION OF NOSE                81                                 $122.46       20110801
30430       REVISION OF NOSE                82                                 $122.46       20110801
30430       REVISION OF NOSE                AS                                 $122.46       20110801
30430       REVISION OF NOSE                                                   $612.30       20110801
30435       REVISION OF NOSE                                  A              $1,170.32       20110101
30435       REVISION OF NOSE                80                                 $158.13       20110801
30435       REVISION OF NOSE                81                                 $158.13       20110801
30435       REVISION OF NOSE                82                                 $158.13       20110801
30435       REVISION OF NOSE                AS                                 $158.13       20110801
30435       REVISION OF NOSE                                                   $790.66       20110801
30450       REVISION OF NOSE                                  A              $1,223.51       20110101
30450       REVISION OF NOSE                80                                 $210.91       20110801
30450       REVISION OF NOSE                81                                 $210.91       20110801
30450       REVISION OF NOSE                82                                 $210.91       20110801
30450       REVISION OF NOSE                AS                                 $210.91       20110801
30450       REVISION OF NOSE                                                 $1,054.56       20110801
30460       REVISION OF NOSE                                  A              $1,223.51       20110101
30460       REVISION OF NOSE                80                                 $106.86       20110801
30460       REVISION OF NOSE                81                                 $106.86       20110801
30460       REVISION OF NOSE                82                                 $106.86       20110801
30460       REVISION OF NOSE                AS                                 $106.86       20110801
30460       REVISION OF NOSE                                                   $534.30       20110801
30462       REVISION OF NOSE                                  A              $1,289.34       20110101
30462       REVISION OF NOSE                80                                 $207.43       20110801
30462       REVISION OF NOSE                81                                 $207.43       20110801
30462       REVISION OF NOSE                82                                 $207.43       20110801
30462       REVISION OF NOSE                AS                                 $207.43       20110801
30462       REVISION OF NOSE                                                 $1,037.14       20110801
30465       REPAIR NASAL STENOSIS                             A              $1,289.34       20110101
30465       REPAIR NASAL STENOSIS           80                                 $133.33       20110801
30465       REPAIR NASAL STENOSIS           81                                 $133.33       20110801
30465       REPAIR NASAL STENOSIS           82                                 $133.33       20110801
30465       REPAIR NASAL STENOSIS           AS                                 $133.33       20110801
30465       REPAIR NASAL STENOSIS                                              $666.64       20110801
30520       REPAIR OF NASAL SEPTUM                            A                $720.58       20110101
30520       REPAIR OF NASAL SEPTUM                                             $412.62       20110801
30540       REPAIR NASAL DEFECT                               A              $1,170.32       20110101
30540       REPAIR NASAL DEFECT             80                                  $91.21       20110801
30540       REPAIR NASAL DEFECT             81                                  $91.21       20110801
30540       REPAIR NASAL DEFECT             82                                  $91.21       20110801
30540       REPAIR NASAL DEFECT             AS                                  $91.21       20110801
30540       REPAIR NASAL DEFECT                                                $456.04       20110801
30545       REPAIR NASAL DEFECT                               A              $1,170.32       20110101
30545       REPAIR NASAL DEFECT             80                                 $122.20       20110801
30545       REPAIR NASAL DEFECT             81                                 $122.20       20110801
30545       REPAIR NASAL DEFECT             82                                 $122.20       20110801
30545       REPAIR NASAL DEFECT             AS                                 $122.20       20110801
30545       REPAIR NASAL DEFECT                                                $611.00       20110801
30560       RELEASE OF NASAL ADHESIONS                        A                $111.17       20110101
30560       RELEASE OF NASAL ADHESIONS                                         $174.72       20110801
30580       REPAIR UPPER JAW FISTULA                          A              $1,153.67       20110101



                                                 Page 113
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
30580       REPAIR UPPER JAW FISTULA                                           $419.64       20110801
30600       REPAIR MOUTH/NOSE FISTULA                         A              $1,153.67       20110101
30600       REPAIR MOUTH/NOSE FISTULA                                          $384.80       20110801
30620       INTRANASAL RECONSTRUCTION                         A              $1,223.51       20110101
30620       INTRANASAL RECONSTRUCTION                                          $414.44       20110801
30630       REPAIR NASAL SEPTUM DEFECT                        A                $790.42       20110101
30630       REPAIR NASAL SEPTUM DEFECT                                         $421.72       20110801
30801       ABLATE INF TURBINATE SUPERF                       A                $246.86       20110101
30801       ABLATE INF TURBINATE SUPERF                                        $146.64       20110801
30802       ABLATE INF TURBINATE SUBMUC                       A                $476.85       20110101
30802       ABLATE INF TURBINATE SUBMUC                                        $190.06       20110801
30901       CONTROL OF NOSEBLEED                                                $69.94       20110801
30903       CONTROL OF NOSEBLEED                              A                 $41.57       20110101
30903       CONTROL OF NOSEBLEED                                               $128.96       20110801
30905       CONTROL OF NOSEBLEED                              A                 $41.57       20110101
30905       CONTROL OF NOSEBLEED                                               $160.42       20110801
30906       REPEAT CONTROL OF NOSEBLEED                       A                 $41.57       20110101
30906       REPEAT CONTROL OF NOSEBLEED                                        $183.30       20110801
30915       LIGATION NASAL SINUS ARTERY                       A                $724.00       20110101
30915       LIGATION NASAL SINUS ARTERY                                        $392.86       20110801
30920       LIGATION UPPER JAW ARTERY                         A                $736.25       20110101
30920       LIGATION UPPER JAW ARTERY                                          $567.06       20110801
30930       THER FX NASAL INF TURBINATE                       A                $533.67       20110101
30930       THER FX NASAL INF TURBINATE                                         $82.16       20110801
31000       IRRIGATION MAXILLARY SINUS                                         $117.00       20110801
31002       IRRIGATION SPHENOID SINUS                                          $134.42       20110801
31020       EXPLORATION MAXILLARY SINUS                       A                $685.37       20110101
31020       EXPLORATION MAXILLARY SINUS                                        $315.12       20110801
31030       EXPLORATION MAXILLARY SINUS                       A              $1,130.71       20110101
31030       EXPLORATION MAXILLARY SINUS                                        $457.34       20110801
31032       EXPLORE SINUS REMOVE POLYPS                       A              $1,153.67       20110101
31032       EXPLORE SINUS REMOVE POLYPS                                        $384.80       20110801
31040       EXPLORATION BEHIND UPPER JAW                                       $509.60       20110801
31050       EXPLORATION SPHENOID SINUS                        A              $1,118.46       20110101
31050       EXPLORATION SPHENOID SINUS                                         $330.72       20110801
31051       SPHENOID SINUS SURGERY                            A              $1,153.67       20110101
31051       SPHENOID SINUS SURGERY                                             $433.42       20110801
31070       EXPLORATION OF FRONTAL SINUS                      A                $685.37       20110101
31070       EXPLORATION OF FRONTAL SINUS                                       $292.24       20110801
31075       EXPLORATION OF FRONTAL SINUS                      A              $1,153.67       20110101
31075       EXPLORATION OF FRONTAL SINUS    80                                 $106.13       20110801
31075       EXPLORATION OF FRONTAL SINUS    81                                 $106.13       20110801
31075       EXPLORATION OF FRONTAL SINUS    82                                 $106.13       20110801
31075       EXPLORATION OF FRONTAL SINUS    AS                                 $106.13       20110801
31075       EXPLORATION OF FRONTAL SINUS                                       $530.66       20110801
31080       REMOVAL OF FRONTAL SINUS                          A              $1,153.67       20110101
31080       REMOVAL OF FRONTAL SINUS        80                                 $137.54       20110801
31080       REMOVAL OF FRONTAL SINUS        81                                 $137.54       20110801
31080       REMOVAL OF FRONTAL SINUS        82                                 $137.54       20110801
31080       REMOVAL OF FRONTAL SINUS        AS                                 $137.54       20110801
31080       REMOVAL OF FRONTAL SINUS                                           $687.70       20110801
31081       REMOVAL OF FRONTAL SINUS                          A              $1,153.67       20110101
31081       REMOVAL OF FRONTAL SINUS        80                                 $179.66       20110801
31081       REMOVAL OF FRONTAL SINUS        81                                 $179.66       20110801
31081       REMOVAL OF FRONTAL SINUS        82                                 $179.66       20110801
31081       REMOVAL OF FRONTAL SINUS        AS                                 $179.66       20110801
31081       REMOVAL OF FRONTAL SINUS                                           $898.30       20110801
31084       REMOVAL OF FRONTAL SINUS                          A              $1,153.67       20110101
31084       REMOVAL OF FRONTAL SINUS        80                                 $159.59       20110801



                                                 Page 114
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
31084       REMOVAL OF FRONTAL SINUS       81                                 $159.59       20110801
31084       REMOVAL OF FRONTAL SINUS       82                                 $159.59       20110801
31084       REMOVAL OF FRONTAL SINUS       AS                                 $159.59       20110801
31084       REMOVAL OF FRONTAL SINUS                                          $797.94       20110801
31085       REMOVAL OF FRONTAL SINUS                         A              $1,153.67       20110101
31085       REMOVAL OF FRONTAL SINUS       80                                 $187.67       20110801
31085       REMOVAL OF FRONTAL SINUS       81                                 $187.67       20110801
31085       REMOVAL OF FRONTAL SINUS       82                                 $187.67       20110801
31085       REMOVAL OF FRONTAL SINUS       AS                                 $187.67       20110801
31085       REMOVAL OF FRONTAL SINUS                                          $938.34       20110801
31086       REMOVAL OF FRONTAL SINUS                         A              $1,153.67       20110101
31086       REMOVAL OF FRONTAL SINUS       80                                 $152.31       20110801
31086       REMOVAL OF FRONTAL SINUS       81                                 $152.31       20110801
31086       REMOVAL OF FRONTAL SINUS       82                                 $152.31       20110801
31086       REMOVAL OF FRONTAL SINUS       AS                                 $152.31       20110801
31086       REMOVAL OF FRONTAL SINUS                                          $761.54       20110801
31087       REMOVAL OF FRONTAL SINUS                         A              $1,153.67       20110101
31087       REMOVAL OF FRONTAL SINUS       80                                 $149.08       20110801
31087       REMOVAL OF FRONTAL SINUS       81                                 $149.08       20110801
31087       REMOVAL OF FRONTAL SINUS       82                                 $149.08       20110801
31087       REMOVAL OF FRONTAL SINUS       AS                                 $149.08       20110801
31087       REMOVAL OF FRONTAL SINUS                                          $745.42       20110801
31090       EXPLORATION OF SINUSES                           A              $1,170.32       20110101
31090       EXPLORATION OF SINUSES                                            $680.94       20110801
31200       REMOVAL OF ETHMOID SINUS                         A              $1,118.46       20110101
31200       REMOVAL OF ETHMOID SINUS                                          $363.74       20110801
31201       REMOVAL OF ETHMOID SINUS                         A              $1,170.32       20110101
31201       REMOVAL OF ETHMOID SINUS                                          $494.26       20110801
31205       REMOVAL OF ETHMOID SINUS                         A              $1,130.71       20110101
31205       REMOVAL OF ETHMOID SINUS       80                                 $118.04       20110801
31205       REMOVAL OF ETHMOID SINUS       81                                 $118.04       20110801
31205       REMOVAL OF ETHMOID SINUS       82                                 $118.04       20110801
31205       REMOVAL OF ETHMOID SINUS       AS                                 $118.04       20110801
31205       REMOVAL OF ETHMOID SINUS                                          $590.20       20110801
31225       REMOVAL OF UPPER JAW           80                                 $254.07       20110801
31225       REMOVAL OF UPPER JAW           81                                 $254.07       20110801
31225       REMOVAL OF UPPER JAW           82                                 $254.07       20110801
31225       REMOVAL OF UPPER JAW           AS                                 $254.07       20110801
31225       REMOVAL OF UPPER JAW                                            $1,270.36       20110801
31230       REMOVAL OF UPPER JAW           80                                 $284.39       20110801
31230       REMOVAL OF UPPER JAW           81                                 $284.39       20110801
31230       REMOVAL OF UPPER JAW           82                                 $284.39       20110801
31230       REMOVAL OF UPPER JAW           AS                                 $284.39       20110801
31230       REMOVAL OF UPPER JAW                                            $1,421.94       20110801
31231       NASAL ENDOSCOPY DX                                                $125.06       20110801
31233       NASAL/SINUS ENDOSCOPY DX                         A                 $60.82       20110101
31233       NASAL/SINUS ENDOSCOPY DX                                          $176.54       20110801
31235       NASAL/SINUS ENDOSCOPY DX                         A                $584.26       20110101
31235       NASAL/SINUS ENDOSCOPY DX                                          $201.76       20110801
31237       NASAL/SINUS ENDOSCOPY SURG                       A                $605.89       20110101
31237       NASAL/SINUS ENDOSCOPY SURG                                        $218.14       20110801
31238       NASAL/SINUS ENDOSCOPY SURG                       A                $584.26       20110101
31238       NASAL/SINUS ENDOSCOPY SURG                                        $225.16       20110801
31239       NASAL/SINUS ENDOSCOPY SURG                       A                $824.12       20110101
31239       NASAL/SINUS ENDOSCOPY SURG                                        $460.72       20110801
31240       NASAL/SINUS ENDOSCOPY SURG                       A                $605.89       20110101
31240       NASAL/SINUS ENDOSCOPY SURG                                        $113.62       20110801
31254       REVISION OF ETHMOID SINUS                        A                $801.16       20110101
31254       REVISION OF ETHMOID SINUS                                         $194.22       20110801



                                                Page 115
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
31255       REMOVAL OF ETHMOID SINUS                          A                $840.77       20110101
31255       REMOVAL OF ETHMOID SINUS                                           $285.22       20110801
31256       EXPLORATION MAXILLARY SINUS                       A                $801.16       20110101
31256       EXPLORATION MAXILLARY SINUS                                        $140.14       20110801
31267       ENDOSCOPY MAXILLARY SINUS                         A                $801.16       20110101
31267       ENDOSCOPY MAXILLARY SINUS                                          $225.94       20110801
31276       SINUS ENDOSCOPY SURGICAL                          A                $801.16       20110101
31276       SINUS ENDOSCOPY SURGICAL                                           $360.36       20110801
31287       NASAL/SINUS ENDOSCOPY SURG                        A                $801.16       20110101
31287       NASAL/SINUS ENDOSCOPY SURG                                         $165.10       20110801
31288       NASAL/SINUS ENDOSCOPY SURG                        A                $801.16       20110101
31288       NASAL/SINUS ENDOSCOPY SURG                                         $191.36       20110801
31291       NASAL/SINUS ENDOSCOPY SURG                                         $859.82       20110801
31292       NASAL/SINUS ENDOSCOPY SURG                                         $700.18       20110801
31293       NASAL/SINUS ENDOSCOPY SURG                                         $763.10       20110801
31294       NASAL/SINUS ENDOSCOPY SURG                                         $875.42       20110801
31295       SINUS ENDO W/BALLOON DIL                          A                $959.17       20110101
31295       SINUS ENDO W/BALLOON DIL        80                                 $312.62       20110801
31295       SINUS ENDO W/BALLOON DIL        81                                 $312.62       20110801
31295       SINUS ENDO W/BALLOON DIL        82                                 $312.62       20110801
31295       SINUS ENDO W/BALLOON DIL        AS                                 $312.62       20110801
31295       SINUS ENDO W/BALLOON DIL                                         $1,563.12       20110801
31296       SINUS ENDO W/BALLOON DIL                          A                $959.17       20110101
31296       SINUS ENDO W/BALLOON DIL        80                                 $584.53       20110801
31296       SINUS ENDO W/BALLOON DIL        81                                 $584.53       20110801
31296       SINUS ENDO W/BALLOON DIL        82                                 $584.53       20110801
31296       SINUS ENDO W/BALLOON DIL        AS                                 $584.53       20110801
31296       SINUS ENDO W/BALLOON DIL                                         $2,922.66       20110801
31297       SINUS ENDO W/BALLOON DIL                          A                $959.17       20110101
31297       SINUS ENDO W/BALLOON DIL                                         $2,895.10       20110801
31300       REMOVAL OF LARYNX LESION                          A                $737.22       20110101
31300       REMOVAL OF LARYNX LESION        80                                 $172.17       20110801
31300       REMOVAL OF LARYNX LESION        81                                 $172.17       20110801
31300       REMOVAL OF LARYNX LESION        82                                 $172.17       20110801
31300       REMOVAL OF LARYNX LESION        AS                                 $172.17       20110801
31300       REMOVAL OF LARYNX LESION                                           $860.86       20110801
31320       DIAGNOSTIC INCISION LARYNX                        A              $1,118.46       20110101
31320       DIAGNOSTIC INCISION LARYNX                                         $434.98       20110801
31360       REMOVAL OF LARYNX               80                                 $280.70       20110801
31360       REMOVAL OF LARYNX               81                                 $280.70       20110801
31360       REMOVAL OF LARYNX               82                                 $280.70       20110801
31360       REMOVAL OF LARYNX               AS                                 $280.70       20110801
31360       REMOVAL OF LARYNX                                                $1,403.48       20110801
31365       REMOVAL OF LARYNX               80                                 $350.22       20110801
31365       REMOVAL OF LARYNX               81                                 $350.22       20110801
31365       REMOVAL OF LARYNX               82                                 $350.22       20110801
31365       REMOVAL OF LARYNX               AS                                 $350.22       20110801
31365       REMOVAL OF LARYNX                                                $1,751.10       20110801
31367       PARTIAL REMOVAL OF LARYNX       80                                 $300.04       20110801
31367       PARTIAL REMOVAL OF LARYNX       81                                 $300.04       20110801
31367       PARTIAL REMOVAL OF LARYNX       82                                 $300.04       20110801
31367       PARTIAL REMOVAL OF LARYNX       AS                                 $300.04       20110801
31367       PARTIAL REMOVAL OF LARYNX                                        $1,500.20       20110801
31368       PARTIAL REMOVAL OF LARYNX       80                                 $333.79       20110801
31368       PARTIAL REMOVAL OF LARYNX       81                                 $333.79       20110801
31368       PARTIAL REMOVAL OF LARYNX       82                                 $333.79       20110801
31368       PARTIAL REMOVAL OF LARYNX       AS                                 $333.79       20110801
31368       PARTIAL REMOVAL OF LARYNX                                        $1,668.94       20110801
31370       PARTIAL REMOVAL OF LARYNX       80                                 $281.27       20110801



                                                 Page 116
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
31370       PARTIAL REMOVAL OF LARYNX      81                                 $281.27       20110801
31370       PARTIAL REMOVAL OF LARYNX      82                                 $281.27       20110801
31370       PARTIAL REMOVAL OF LARYNX      AS                                 $281.27       20110801
31370       PARTIAL REMOVAL OF LARYNX                                       $1,406.34       20110801
31375       PARTIAL REMOVAL OF LARYNX      80                                 $266.50       20110801
31375       PARTIAL REMOVAL OF LARYNX      81                                 $266.50       20110801
31375       PARTIAL REMOVAL OF LARYNX      82                                 $266.50       20110801
31375       PARTIAL REMOVAL OF LARYNX      AS                                 $266.50       20110801
31375       PARTIAL REMOVAL OF LARYNX                                       $1,332.50       20110801
31380       PARTIAL REMOVAL OF LARYNX      80                                 $262.29       20110801
31380       PARTIAL REMOVAL OF LARYNX      81                                 $262.29       20110801
31380       PARTIAL REMOVAL OF LARYNX      82                                 $262.29       20110801
31380       PARTIAL REMOVAL OF LARYNX      AS                                 $262.29       20110801
31380       PARTIAL REMOVAL OF LARYNX                                       $1,311.44       20110801
31382       PARTIAL REMOVAL OF LARYNX      80                                 $288.13       20110801
31382       PARTIAL REMOVAL OF LARYNX      81                                 $288.13       20110801
31382       PARTIAL REMOVAL OF LARYNX      82                                 $288.13       20110801
31382       PARTIAL REMOVAL OF LARYNX      AS                                 $288.13       20110801
31382       PARTIAL REMOVAL OF LARYNX                                       $1,440.66       20110801
31390       REMOVAL OF LARYNX PHARYNX      80                                 $389.27       20110801
31390       REMOVAL OF LARYNX PHARYNX      81                                 $389.27       20110801
31390       REMOVAL OF LARYNX PHARYNX      82                                 $389.27       20110801
31390       REMOVAL OF LARYNX PHARYNX      AS                                 $389.27       20110801
31390       REMOVAL OF LARYNX PHARYNX                                       $1,946.36       20110801
31395       RECONSTRUCT LARYNX PHARYNX     80                                 $410.80       20110801
31395       RECONSTRUCT LARYNX PHARYNX     81                                 $410.80       20110801
31395       RECONSTRUCT LARYNX PHARYNX     82                                 $410.80       20110801
31395       RECONSTRUCT LARYNX PHARYNX     AS                                 $410.80       20110801
31395       RECONSTRUCT LARYNX PHARYNX                                      $2,054.00       20110801
31400       REVISION OF LARYNX                               A              $1,118.46       20110101
31400       REVISION OF LARYNX             80                                 $136.08       20110801
31400       REVISION OF LARYNX             81                                 $136.08       20110801
31400       REVISION OF LARYNX             82                                 $136.08       20110801
31400       REVISION OF LARYNX             AS                                 $136.08       20110801
31400       REVISION OF LARYNX                                                $680.42       20110801
31420       REMOVAL OF EPIGLOTTIS                            A              $1,118.46       20110101
31420       REMOVAL OF EPIGLOTTIS          80                                 $114.71       20110801
31420       REMOVAL OF EPIGLOTTIS          81                                 $114.71       20110801
31420       REMOVAL OF EPIGLOTTIS          82                                 $114.71       20110801
31420       REMOVAL OF EPIGLOTTIS          AS                                 $114.71       20110801
31420       REMOVAL OF EPIGLOTTIS                                             $573.56       20110801
31500       INSERT EMERGENCY AIRWAY                                            $79.04       20110801
31502       CHANGE OF WINDPIPE AIRWAY                                          $24.70       20110801
31505       DIAGNOSTIC LARYNGOSCOPY                                            $55.12       20110801
31510       LARYNGOSCOPY WITH BIOPSY                         A                $605.89       20110101
31510       LARYNGOSCOPY WITH BIOPSY                                          $141.96       20110801
31511       REMOVE FOREIGN BODY LARYNX                       A                 $60.82       20110101
31511       REMOVE FOREIGN BODY LARYNX                                        $142.48       20110801
31512       REMOVAL OF LARYNX LESION                         A                $605.89       20110101
31512       REMOVAL OF LARYNX LESION                                          $140.66       20110801
31513       INJECTION INTO VOCAL CORD                        A                 $60.82       20110101
31513       INJECTION INTO VOCAL CORD                                          $93.34       20110801
31515       LARYNGOSCOPY FOR ASPIRATION                      A                $584.26       20110101
31515       LARYNGOSCOPY FOR ASPIRATION                                       $140.14       20110801
31520       DX LARYNGOSCOPY NEWBORN                                           $109.46       20110801
31525       DX LARYNGOSCOPY EXCL NB                          A                $584.26       20110101
31525       DX LARYNGOSCOPY EXCL NB                                           $169.26       20110801
31526       DX LARYNGOSCOPY W/OPER SCOPE                     A                $605.89       20110101
31526       DX LARYNGOSCOPY W/OPER SCOPE                                      $111.80       20110801



                                                Page 117
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
31527       LARYNGOSCOPY FOR TREATMENT                       A                $767.30       20110101
31527       LARYNGOSCOPY FOR TREATMENT                                        $137.54       20110801
31528       LARYNGOSCOPY AND DILATION                        A                $605.89       20110101
31528       LARYNGOSCOPY AND DILATION                                         $102.44       20110801
31529       LARYNGOSCOPY AND DILATION                        A                $605.89       20110101
31529       LARYNGOSCOPY AND DILATION                                         $114.92       20110801
31530       LARYNGOSCOPY W/FB REMOVAL                        A                $605.89       20110101
31530       LARYNGOSCOPY W/FB REMOVAL                                         $140.66       20110801
31531       LARYNGOSCOPY W/FB OP SCOPE                       A                $618.13       20110101
31531       LARYNGOSCOPY W/FB OP SCOPE                                        $151.58       20110801
31535       LARYNGOSCOPY W/BIOPSY                            A                $605.89       20110101
31535       LARYNGOSCOPY W/BIOPSY                                             $134.94       20110801
31536       LARYNGOSCOPY W/BX OP SCOPE                       A                $618.13       20110101
31536       LARYNGOSCOPY W/BX OP SCOPE                                        $150.54       20110801
31540       LARYNGOSCOPY W/EXC OF TUMOR                      A                $618.13       20110101
31540       LARYNGOSCOPY W/EXC OF TUMOR                                       $173.16       20110801
31541       LARYNSCOP W/TUMR EXC SCOPE                       A                $641.10       20110101
31541       LARYNSCOP W/TUMR EXC SCOPE                                        $189.28       20110801
31545       REMOVE VC LESION W/SCOPE                                          $259.22       20110801
31546       REMOVE VC LESION SCOPE/GRAFT                                      $392.34       20110801
31560       LARYNGOSCOP W/ARYTENOIDECTOM                     A                $840.77       20110101
31560       LARYNGOSCOP W/ARYTENOIDECTOM                                      $224.38       20110801
31561       LARYNSCOP REMVE CART SCOP                        A                $840.77       20110101
31561       LARYNSCOP REMVE CART SCOP                                         $245.44       20110801
31570       LARYNGOSCOPE W/VC INJ                            A                $605.89       20110101
31570       LARYNGOSCOPE W/VC INJ                                             $234.26       20110801
31571       LARYNGOSCOP W/VC INJ SCOPE                       A                $788.91       20110101
31571       LARYNGOSCOP W/VC INJ SCOPE                                        $178.62       20110801
31575       DIAGNOSTIC LARYNGOSCOPY                                            $77.48       20110801
31576       LARYNGOSCOPY WITH BIOPSY                         A                $605.89       20110101
31576       LARYNGOSCOPY WITH BIOPSY                                          $151.32       20110801
31577       REMOVE FOREIGN BODY LARYNX                       A                $151.28       20110101
31577       REMOVE FOREIGN BODY LARYNX                                        $163.80       20110801
31578       REMOVAL OF LARYNX LESION                         A                $788.91       20110101
31578       REMOVAL OF LARYNX LESION                                          $190.32       20110801
31579       DIAGNOSTIC LARYNGOSCOPY                                           $146.90       20110801
31580       REVISION OF LARYNX                               A              $1,170.32       20110101
31580       REVISION OF LARYNX             80                                 $164.74       20110801
31580       REVISION OF LARYNX             81                                 $164.74       20110801
31580       REVISION OF LARYNX             82                                 $164.74       20110801
31580       REVISION OF LARYNX             AS                                 $164.74       20110801
31580       REVISION OF LARYNX                                                $823.68       20110801
31582       REVISION OF LARYNX                               A              $1,170.32       20110101
31582       REVISION OF LARYNX                                              $1,300.52       20110801
31584       TREAT LARYNX FRACTURE          80                                 $207.43       20110801
31584       TREAT LARYNX FRACTURE          81                                 $207.43       20110801
31584       TREAT LARYNX FRACTURE          82                                 $207.43       20110801
31584       TREAT LARYNX FRACTURE          AS                                 $207.43       20110801
31584       TREAT LARYNX FRACTURE                                           $1,037.14       20110801
31587       REVISION OF LARYNX             80                                 $137.80       20110801
31587       REVISION OF LARYNX             81                                 $137.80       20110801
31587       REVISION OF LARYNX             82                                 $137.80       20110801
31587       REVISION OF LARYNX             AS                                 $137.80       20110801
31587       REVISION OF LARYNX                                                $689.00       20110801
31588       REVISION OF LARYNX                               A              $1,170.32       20110101
31588       REVISION OF LARYNX             80                                 $156.16       20110801
31588       REVISION OF LARYNX             81                                 $156.16       20110801
31588       REVISION OF LARYNX             82                                 $156.16       20110801
31588       REVISION OF LARYNX             AS                                 $156.16       20110801



                                                Page 118
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
31588       REVISION OF LARYNX                                                $780.78       20110801
31590       REINNERVATE LARYNX                               A              $1,170.32       20110101
31590       REINNERVATE LARYNX             80                                 $119.60       20110801
31590       REINNERVATE LARYNX             81                                 $119.60       20110801
31590       REINNERVATE LARYNX             82                                 $119.60       20110801
31590       REINNERVATE LARYNX             AS                                 $119.60       20110801
31590       REINNERVATE LARYNX                                                $598.00       20110801
31595       LARYNX NERVE SURGERY                             A              $1,118.46       20110101
31595       LARYNX NERVE SURGERY           80                                 $104.10       20110801
31595       LARYNX NERVE SURGERY           81                                 $104.10       20110801
31595       LARYNX NERVE SURGERY           82                                 $104.10       20110801
31595       LARYNX NERVE SURGERY           AS                                 $104.10       20110801
31595       LARYNX NERVE SURGERY                                              $520.52       20110801
31600       INCISION OF WINDPIPE                                              $282.62       20110801
31601       INCISION OF WINDPIPE           80                                  $36.92       20110801
31601       INCISION OF WINDPIPE           81                                  $36.92       20110801
31601       INCISION OF WINDPIPE           82                                  $36.92       20110801
31601       INCISION OF WINDPIPE           AS                                  $36.92       20110801
31601       INCISION OF WINDPIPE                                              $184.60       20110801
31603       INCISION OF WINDPIPE                                              $159.38       20110801
31605       INCISION OF WINDPIPE                                              $131.04       20110801
31610       INCISION OF WINDPIPE                                              $486.72       20110801
31611       SURGERY/SPEECH PROSTHESIS                        A                $697.62       20110101
31611       SURGERY/SPEECH PROSTHESIS      80                                  $72.70       20110801
31611       SURGERY/SPEECH PROSTHESIS      81                                  $72.70       20110801
31611       SURGERY/SPEECH PROSTHESIS      82                                  $72.70       20110801
31611       SURGERY/SPEECH PROSTHESIS      AS                                  $72.70       20110801
31611       SURGERY/SPEECH PROSTHESIS                                         $363.48       20110801
31612       PUNCTURE/CLEAR WINDPIPE                          A                $663.74       20110101
31612       PUNCTURE/CLEAR WINDPIPE                                            $54.60       20110801
31613       REPAIR WINDPIPE OPENING                          A                $685.37       20110101
31613       REPAIR WINDPIPE OPENING                                           $302.64       20110801
31614       REPAIR WINDPIPE OPENING                          A              $1,118.46       20110101
31614       REPAIR WINDPIPE OPENING                                           $505.44       20110801
31615       VISUALIZATION OF WINDPIPE                        A                $246.86       20110101
31615       VISUALIZATION OF WINDPIPE                                         $124.28       20110801
31622       DX BRONCHOSCOPE/WASH                             A                $312.98       20110101
31622       DX BRONCHOSCOPE/WASH                                              $214.76       20110801
31623       DX BRONCHOSCOPE/BRUSH                            A                $334.61       20110101
31623       DX BRONCHOSCOPE/BRUSH                                             $232.44       20110801
31624       DX BRONCHOSCOPE/LAVAGE                           A                $334.61       20110101
31624       DX BRONCHOSCOPE/LAVAGE                                            $216.84       20110801
31625       BRONCHOSCOPY W/BIOPSYS                           A                $334.61       20110101
31625       BRONCHOSCOPY W/BIOPSYS                                            $234.00       20110801
31626       BRONCHOSCOPY W/MARKERS                                            $303.68       20110801
31628       BRONCHOSCOPY/LUNG BX EACH                        A                $334.61       20110101
31628       BRONCHOSCOPY/LUNG BX EACH                                         $276.90       20110801
31629       BRONCHOSCOPY/NEEDLE BX EACH                      A                $334.61       20110101
31629       BRONCHOSCOPY/NEEDLE BX EACH                                       $423.28       20110801
31630       BRONCHOSCOPY DILATE/FX REPR                      A                $707.93       20110101
31630       BRONCHOSCOPY DILATE/FX REPR                                       $146.12       20110801
31631       BRONCHOSCOPY DILATE W/STENT                      A                $707.93       20110101
31631       BRONCHOSCOPY DILATE W/STENT                                       $166.40       20110801
31632       BRONCHOSCOPY/LUNG BX ADDL                                          $49.92       20110801
31633       BRONCHOSCOPY/NEEDLE BX ADDL                                        $61.36       20110801
31634       BRONCH W/BALLOON OCCLUSION                       A                $325.46       20110101
31634       BRONCH W/BALLOON OCCLUSION     80                                 $277.21       20110801
31634       BRONCH W/BALLOON OCCLUSION     81                                 $277.21       20110801
31634       BRONCH W/BALLOON OCCLUSION     82                                 $277.21       20110801



                                                Page 119
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
31634       BRONCH W/BALLOON OCCLUSION     AS                                 $277.21       20110801
31634       BRONCH W/BALLOON OCCLUSION                                      $1,386.06       20110801
31635       BRONCHOSCOPY W/FB REMOVAL                        A                $334.61       20110101
31635       BRONCHOSCOPY W/FB REMOVAL                                         $240.76       20110801
31636       BRONCHOSCOPY BRONCH STENTS                                        $161.72       20110801
31637       BRONCHOSCOPY STENT ADD-ON                                          $55.12       20110801
31638       BRONCHOSCOPY REVISE STENT                                         $184.86       20110801
31640       BRONCHOSCOPY W/TUMOR EXCISE                      A                $707.93       20110101
31640       BRONCHOSCOPY W/TUMOR EXCISE                                       $186.42       20110801
31641       BRONCHOSCOPY TREAT BLOCKAGE                      A                $707.93       20110101
31641       BRONCHOSCOPY TREAT BLOCKAGE                                       $185.64       20110801
31643       DIAG BRONCHOSCOPE/CATHETER                       A                $334.61       20110101
31643       DIAG BRONCHOSCOPE/CATHETER                                        $125.58       20110801
31645       BRONCHOSCOPY CLEAR AIRWAYS                       A                $312.98       20110101
31645       BRONCHOSCOPY CLEAR AIRWAYS                                        $209.82       20110801
31646       BRONCHOSCOPY RECLEAR AIRWAY                      A                $312.98       20110101
31646       BRONCHOSCOPY RECLEAR AIRWAY                                       $190.32       20110801
31656       BRONCHOSCOPY INJ FOR X-RAY                       A                $312.98       20110101
31656       BRONCHOSCOPY INJ FOR X-RAY                                         $85.13       20100101
31715       INJECTION FOR BRONCHUS X-RAY                                       $39.00       20110801
31717       BRONCHIAL BRUSH BIOPSY                           A                $151.28       20110101
31717       BRONCHIAL BRUSH BIOPSY                                            $196.30       20110801
31720       CLEARANCE OF AIRWAYS                             A                 $18.81       20110101
31720       CLEARANCE OF AIRWAYS                                               $36.92       20110801
31725       CLEARANCE OF AIRWAYS                                               $67.60       20110801
31730       INTRO WINDPIPE WIRE/TUBE                         A                $151.28       20110101
31730       INTRO WINDPIPE WIRE/TUBE                                          $633.62       20110801
31750       REPAIR OF WINDPIPE                               A              $1,170.32       20110101
31750       REPAIR OF WINDPIPE             80                                 $184.13       20110801
31750       REPAIR OF WINDPIPE             81                                 $184.13       20110801
31750       REPAIR OF WINDPIPE             82                                 $184.13       20110801
31750       REPAIR OF WINDPIPE             AS                                 $184.13       20110801
31750       REPAIR OF WINDPIPE                                                $920.66       20110801
31755       REPAIR OF WINDPIPE                               A              $1,118.46       20110101
31755       REPAIR OF WINDPIPE             80                                 $231.87       20110801
31755       REPAIR OF WINDPIPE             81                                 $231.87       20110801
31755       REPAIR OF WINDPIPE             82                                 $231.87       20110801
31755       REPAIR OF WINDPIPE             AS                                 $231.87       20110801
31755       REPAIR OF WINDPIPE                                              $1,159.34       20110801
31760       REPAIR OF WINDPIPE             80                                 $199.63       20110801
31760       REPAIR OF WINDPIPE             81                                 $199.63       20110801
31760       REPAIR OF WINDPIPE             82                                 $199.63       20110801
31760       REPAIR OF WINDPIPE             AS                                 $199.63       20110801
31760       REPAIR OF WINDPIPE                                                $998.14       20110801
31766       RECONSTRUCTION OF WINDPIPE     80                                 $262.24       20110801
31766       RECONSTRUCTION OF WINDPIPE     81                                 $262.24       20110801
31766       RECONSTRUCTION OF WINDPIPE     82                                 $262.24       20110801
31766       RECONSTRUCTION OF WINDPIPE     AS                                 $262.24       20110801
31766       RECONSTRUCTION OF WINDPIPE                                      $1,311.18       20110801
31770       REPAIR/GRAFT OF BRONCHUS       80                                 $193.75       20110801
31770       REPAIR/GRAFT OF BRONCHUS       81                                 $193.75       20110801
31770       REPAIR/GRAFT OF BRONCHUS       82                                 $193.75       20110801
31770       REPAIR/GRAFT OF BRONCHUS       AS                                 $193.75       20110801
31770       REPAIR/GRAFT OF BRONCHUS                                          $968.76       20110801
31775       RECONSTRUCT BRONCHUS           80                                 $201.14       20110801
31775       RECONSTRUCT BRONCHUS           81                                 $201.14       20110801
31775       RECONSTRUCT BRONCHUS           82                                 $201.14       20110801
31775       RECONSTRUCT BRONCHUS           AS                                 $201.14       20110801
31775       RECONSTRUCT BRONCHUS                                            $1,005.68       20110801



                                                Page 120
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
31780       RECONSTRUCT WINDPIPE           80                                 $168.64       20110801
31780       RECONSTRUCT WINDPIPE           81                                 $168.64       20110801
31780       RECONSTRUCT WINDPIPE           82                                 $168.64       20110801
31780       RECONSTRUCT WINDPIPE           AS                                 $168.64       20110801
31780       RECONSTRUCT WINDPIPE                                              $843.18       20110801
31781       RECONSTRUCT WINDPIPE           80                                 $212.37       20110801
31781       RECONSTRUCT WINDPIPE           81                                 $212.37       20110801
31781       RECONSTRUCT WINDPIPE           82                                 $212.37       20110801
31781       RECONSTRUCT WINDPIPE           AS                                 $212.37       20110801
31781       RECONSTRUCT WINDPIPE                                            $1,061.84       20110801
31785       REMOVE WINDPIPE LESION         80                                 $152.83       20110801
31785       REMOVE WINDPIPE LESION         81                                 $152.83       20110801
31785       REMOVE WINDPIPE LESION         82                                 $152.83       20110801
31785       REMOVE WINDPIPE LESION         AS                                 $152.83       20110801
31785       REMOVE WINDPIPE LESION                                            $764.14       20110801
31786       REMOVE WINDPIPE LESION         80                                 $213.56       20110801
31786       REMOVE WINDPIPE LESION         81                                 $213.56       20110801
31786       REMOVE WINDPIPE LESION         82                                 $213.56       20110801
31786       REMOVE WINDPIPE LESION         AS                                 $213.56       20110801
31786       REMOVE WINDPIPE LESION                                          $1,067.82       20110801
31800       REPAIR OF WINDPIPE INJURY                                         $477.10       20110801
31805       REPAIR OF WINDPIPE INJURY      80                                 $119.55       20110801
31805       REPAIR OF WINDPIPE INJURY      81                                 $119.55       20110801
31805       REPAIR OF WINDPIPE INJURY      82                                 $119.55       20110801
31805       REPAIR OF WINDPIPE INJURY      AS                                 $119.55       20110801
31805       REPAIR OF WINDPIPE INJURY                                         $597.74       20110801
31820       CLOSURE OF WINDPIPE LESION                       A                $663.74       20110101
31820       CLOSURE OF WINDPIPE LESION                                        $291.98       20110801
31825       REPAIR OF WINDPIPE DEFECT                        A                $685.37       20110101
31825       REPAIR OF WINDPIPE DEFECT                                         $408.98       20110801
31830       REVISE WINDPIPE SCAR                             A                $685.37       20110101
31830       REVISE WINDPIPE SCAR                                              $293.80       20110801
32035       THORACOSTOMY W/RIB RESECTION   80                                 $101.97       20110801
32035       THORACOSTOMY W/RIB RESECTION   81                                 $101.97       20110801
32035       THORACOSTOMY W/RIB RESECTION   82                                 $101.97       20110801
32035       THORACOSTOMY W/RIB RESECTION   AS                                 $101.97       20110801
32035       THORACOSTOMY W/RIB RESECTION                                      $509.86       20110801
32036       THORACOSTOMY W/FLAP DRAINAGE   80                                 $110.66       20110801
32036       THORACOSTOMY W/FLAP DRAINAGE   81                                 $110.66       20110801
32036       THORACOSTOMY W/FLAP DRAINAGE   82                                 $110.66       20110801
32036       THORACOSTOMY W/FLAP DRAINAGE   AS                                 $110.66       20110801
32036       THORACOSTOMY W/FLAP DRAINAGE                                      $553.28       20110801
32096       OPEN WEDGE/BX LUNG INFILTR     80                                 $126.10       20120101
32096       OPEN WEDGE/BX LUNG INFILTR     81                                 $126.10       20120101
32096       OPEN WEDGE/BX LUNG INFILTR     82                                 $126.10       20120101
32096       OPEN WEDGE/BX LUNG INFILTR     AS                                 $126.10       20120101
32096       OPEN WEDGE/BX LUNG INFILTR                                        $630.50       20120101
32097       OPEN WEDGE/BX LUNG NODULE      80                                 $126.10       20120101
32097       OPEN WEDGE/BX LUNG NODULE      81                                 $126.10       20120101
32097       OPEN WEDGE/BX LUNG NODULE      82                                 $126.10       20120101
32097       OPEN WEDGE/BX LUNG NODULE      AS                                 $126.10       20120101
32097       OPEN WEDGE/BX LUNG NODULE                                         $630.50       20120101
32098       OPEN BIOPSY OF LUNG PLEURA     80                                 $118.51       20120101
32098       OPEN BIOPSY OF LUNG PLEURA     81                                 $118.51       20120101
32098       OPEN BIOPSY OF LUNG PLEURA     82                                 $118.51       20120101
32098       OPEN BIOPSY OF LUNG PLEURA     AS                                 $118.51       20120101
32098       OPEN BIOPSY OF LUNG PLEURA                                        $592.54       20120101
32100       EXPLORATION OF CHEST           80                                 $138.58       20110801
32100       EXPLORATION OF CHEST           81                                 $138.58       20110801



                                                Page 121
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
32100       EXPLORATION OF CHEST            82                                 $138.58       20110801
32100       EXPLORATION OF CHEST            AS                                 $138.58       20110801
32100       EXPLORATION OF CHEST                                               $692.90       20110801
32110       EXPLORE/REPAIR CHEST            80                                 $209.92       20110801
32110       EXPLORE/REPAIR CHEST            81                                 $209.92       20110801
32110       EXPLORE/REPAIR CHEST            82                                 $209.92       20110801
32110       EXPLORE/REPAIR CHEST            AS                                 $209.92       20110801
32110       EXPLORE/REPAIR CHEST                                             $1,049.62       20110801
32120       RE-EXPLORATION OF CHEST         80                                 $125.94       20110801
32120       RE-EXPLORATION OF CHEST         81                                 $125.94       20110801
32120       RE-EXPLORATION OF CHEST         82                                 $125.94       20110801
32120       RE-EXPLORATION OF CHEST         AS                                 $125.94       20110801
32120       RE-EXPLORATION OF CHEST                                            $629.72       20110801
32124       EXPLORE CHEST FREE ADHESIONS    80                                 $133.74       20110801
32124       EXPLORE CHEST FREE ADHESIONS    81                                 $133.74       20110801
32124       EXPLORE CHEST FREE ADHESIONS    82                                 $133.74       20110801
32124       EXPLORE CHEST FREE ADHESIONS    AS                                 $133.74       20110801
32124       EXPLORE CHEST FREE ADHESIONS                                       $668.72       20110801
32140       REMOVAL OF LUNG LESIONS         80                                 $143.16       20110801
32140       REMOVAL OF LUNG LESIONS         81                                 $143.16       20110801
32140       REMOVAL OF LUNG LESIONS         82                                 $143.16       20110801
32140       REMOVAL OF LUNG LESIONS         AS                                 $143.16       20110801
32140       REMOVAL OF LUNG LESIONS                                            $715.78       20110801
32141       REMOVE/TREAT LUNG LESIONS       80                                 $221.05       20110801
32141       REMOVE/TREAT LUNG LESIONS       81                                 $221.05       20110801
32141       REMOVE/TREAT LUNG LESIONS       82                                 $221.05       20110801
32141       REMOVE/TREAT LUNG LESIONS       AS                                 $221.05       20110801
32141       REMOVE/TREAT LUNG LESIONS                                        $1,105.26       20110801
32150       REMOVAL OF LUNG LESIONS         80                                 $144.14       20110801
32150       REMOVAL OF LUNG LESIONS         81                                 $144.14       20110801
32150       REMOVAL OF LUNG LESIONS         82                                 $144.14       20110801
32150       REMOVAL OF LUNG LESIONS         AS                                 $144.14       20110801
32150       REMOVAL OF LUNG LESIONS                                            $720.72       20110801
32151       REMOVE LUNG FOREIGN BODY        80                                 $146.33       20110801
32151       REMOVE LUNG FOREIGN BODY        81                                 $146.33       20110801
32151       REMOVE LUNG FOREIGN BODY        82                                 $146.33       20110801
32151       REMOVE LUNG FOREIGN BODY        AS                                 $146.33       20110801
32151       REMOVE LUNG FOREIGN BODY                                           $731.64       20110801
32160       OPEN CHEST HEART MASSAGE        80                                 $111.54       20110801
32160       OPEN CHEST HEART MASSAGE        81                                 $111.54       20110801
32160       OPEN CHEST HEART MASSAGE        82                                 $111.54       20110801
32160       OPEN CHEST HEART MASSAGE        AS                                 $111.54       20110801
32160       OPEN CHEST HEART MASSAGE                                           $557.70       20110801
32200       DRAIN OPEN LUNG LESION          80                                 $162.29       20110801
32200       DRAIN OPEN LUNG LESION          81                                 $162.29       20110801
32200       DRAIN OPEN LUNG LESION          82                                 $162.29       20110801
32200       DRAIN OPEN LUNG LESION          AS                                 $162.29       20110801
32200       DRAIN OPEN LUNG LESION                                             $811.46       20110801
32201       DRAIN PERCUT LUNG LESION        80                                 $131.39       20080101
32201       DRAIN PERCUT LUNG LESION        81                                 $131.39       20080101
32201       DRAIN PERCUT LUNG LESION        82                                 $131.39       20080101
32201       DRAIN PERCUT LUNG LESION                                           $624.52       20110801
32215       TREAT CHEST LINING              80                                 $115.39       20110801
32215       TREAT CHEST LINING              81                                 $115.39       20110801
32215       TREAT CHEST LINING              82                                 $115.39       20110801
32215       TREAT CHEST LINING              AS                                 $115.39       20110801
32215       TREAT CHEST LINING                                                 $576.94       20110801
32220       RELEASE OF LUNG                 80                                 $230.46       20110801
32220       RELEASE OF LUNG                 81                                 $230.46       20110801



                                                 Page 122
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
32220       RELEASE OF LUNG                82                                 $230.46       20110801
32220       RELEASE OF LUNG                AS                                 $230.46       20110801
32220       RELEASE OF LUNG                                                 $1,152.32       20110801
32225       PARTIAL RELEASE OF LUNG        80                                 $143.83       20110801
32225       PARTIAL RELEASE OF LUNG        81                                 $143.83       20110801
32225       PARTIAL RELEASE OF LUNG        82                                 $143.83       20110801
32225       PARTIAL RELEASE OF LUNG        AS                                 $143.83       20110801
32225       PARTIAL RELEASE OF LUNG                                           $719.16       20110801
32310       REMOVAL OF CHEST LINING        80                                 $132.55       20110801
32310       REMOVAL OF CHEST LINING        81                                 $132.55       20110801
32310       REMOVAL OF CHEST LINING        82                                 $132.55       20110801
32310       REMOVAL OF CHEST LINING        AS                                 $132.55       20110801
32310       REMOVAL OF CHEST LINING                                           $662.74       20110801
32320       FREE/REMOVE CHEST LINING       80                                 $231.24       20110801
32320       FREE/REMOVE CHEST LINING       81                                 $231.24       20110801
32320       FREE/REMOVE CHEST LINING       82                                 $231.24       20110801
32320       FREE/REMOVE CHEST LINING       AS                                 $231.24       20110801
32320       FREE/REMOVE CHEST LINING                                        $1,156.22       20110801
32400       NEEDLE BIOPSY CHEST LINING                       A                $296.06       20110101
32400       NEEDLE BIOPSY CHEST LINING                                        $104.78       20110801
32405       PERCUT BX LUNG/MEDIASTINUM                       A                $296.06       20110101
32405       PERCUT BX LUNG/MEDIASTINUM                                         $72.02       20110801
32420       PUNCTURE/CLEAR LUNG                              A                $176.07       20110101
32420       PUNCTURE/CLEAR LUNG                                                $80.60       20110801
32421       THORACENTESIS FOR ASPIRATION                     A                $176.07       20110101
32421       THORACENTESIS FOR ASPIRATION                                      $108.16       20110801
32440       REMOVE LUNG PNEUMONECTOMY      80                                 $229.42       20110801
32440       REMOVE LUNG PNEUMONECTOMY      81                                 $229.42       20110801
32440       REMOVE LUNG PNEUMONECTOMY      82                                 $229.42       20110801
32440       REMOVE LUNG PNEUMONECTOMY      AS                                 $229.42       20110801
32440       REMOVE LUNG PNEUMONECTOMY                                       $1,147.12       20110801
32442       SLEEVE PNEUMONECTOMY           80                                 $404.30       20110801
32442       SLEEVE PNEUMONECTOMY           81                                 $404.30       20110801
32442       SLEEVE PNEUMONECTOMY           82                                 $404.30       20110801
32442       SLEEVE PNEUMONECTOMY           AS                                 $404.30       20110801
32442       SLEEVE PNEUMONECTOMY                                            $2,021.50       20110801
32445       REMOVAL OF LUNG EXTRAPLEURAL   80                                 $506.38       20110801
32445       REMOVAL OF LUNG EXTRAPLEURAL   81                                 $506.38       20110801
32445       REMOVAL OF LUNG EXTRAPLEURAL   82                                 $506.38       20110801
32445       REMOVAL OF LUNG EXTRAPLEURAL   AS                                 $506.38       20110801
32445       REMOVAL OF LUNG EXTRAPLEURAL                                    $2,531.88       20110801
32480       PARTIAL REMOVAL OF LUNG        80                                 $216.79       20110801
32480       PARTIAL REMOVAL OF LUNG        81                                 $216.79       20110801
32480       PARTIAL REMOVAL OF LUNG        82                                 $216.79       20110801
32480       PARTIAL REMOVAL OF LUNG        AS                                 $216.79       20110801
32480       PARTIAL REMOVAL OF LUNG                                         $1,083.94       20110801
32482       BILOBECTOMY                    80                                 $231.66       20110801
32482       BILOBECTOMY                    81                                 $231.66       20110801
32482       BILOBECTOMY                    82                                 $231.66       20110801
32482       BILOBECTOMY                    AS                                 $231.66       20110801
32482       BILOBECTOMY                                                     $1,158.30       20110801
32484       SEGMENTECTOMY                  80                                 $210.34       20110801
32484       SEGMENTECTOMY                  81                                 $210.34       20110801
32484       SEGMENTECTOMY                  82                                 $210.34       20110801
32484       SEGMENTECTOMY                  AS                                 $210.34       20110801
32484       SEGMENTECTOMY                                                   $1,051.70       20110801
32486       SLEEVE LOBECTOMY               80                                 $343.15       20110801
32486       SLEEVE LOBECTOMY               81                                 $343.15       20110801
32486       SLEEVE LOBECTOMY               82                                 $343.15       20110801



                                                Page 123
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
32486       SLEEVE LOBECTOMY                AS                                 $343.15       20110801
32486       SLEEVE LOBECTOMY                                                 $1,715.74       20110801
32488       COMPLETION PNEUMONECTOMY        80                                 $347.15       20110801
32488       COMPLETION PNEUMONECTOMY        81                                 $347.15       20110801
32488       COMPLETION PNEUMONECTOMY        82                                 $347.15       20110801
32488       COMPLETION PNEUMONECTOMY        AS                                 $347.15       20110801
32488       COMPLETION PNEUMONECTOMY                                         $1,735.76       20110801
32501       REPAIR BRONCHUS ADD-ON          80                                  $36.40       20110801
32501       REPAIR BRONCHUS ADD-ON          81                                  $36.40       20110801
32501       REPAIR BRONCHUS ADD-ON          82                                  $36.40       20110801
32501       REPAIR BRONCHUS ADD-ON          AS                                  $36.40       20110801
32501       REPAIR BRONCHUS ADD-ON                                             $182.00       20110801
32503       RESECT APICAL LUNG TUMOR        80                                 $264.16       20110801
32503       RESECT APICAL LUNG TUMOR        81                                 $264.16       20110801
32503       RESECT APICAL LUNG TUMOR        82                                 $264.16       20110801
32503       RESECT APICAL LUNG TUMOR        AS                                 $264.16       20110801
32503       RESECT APICAL LUNG TUMOR                                         $1,320.80       20110801
32504       RESECT APICAL LUNG TUM/CHEST    80                                 $302.48       20110801
32504       RESECT APICAL LUNG TUM/CHEST    81                                 $302.48       20110801
32504       RESECT APICAL LUNG TUM/CHEST    82                                 $302.48       20110801
32504       RESECT APICAL LUNG TUM/CHEST    AS                                 $302.48       20110801
32504       RESECT APICAL LUNG TUM/CHEST                                     $1,512.42       20110801
32505       WEDGE RESECT OF LUNG INITIAL    80                                 $145.44       20120101
32505       WEDGE RESECT OF LUNG INITIAL    81                                 $145.44       20120101
32505       WEDGE RESECT OF LUNG INITIAL    82                                 $145.44       20120101
32505       WEDGE RESECT OF LUNG INITIAL    AS                                 $145.44       20120101
32505       WEDGE RESECT OF LUNG INITIAL                                       $727.22       20120101
32506       WEDGE RESECT OF LUNG ADD-ON     80                                  $24.54       20120101
32506       WEDGE RESECT OF LUNG ADD-ON     81                                  $24.54       20120101
32506       WEDGE RESECT OF LUNG ADD-ON     82                                  $24.54       20120101
32506       WEDGE RESECT OF LUNG ADD-ON     AS                                  $24.54       20120101
32506       WEDGE RESECT OF LUNG ADD-ON                                        $122.72       20120101
32540       REMOVAL OF LUNG LESION          80                                 $249.34       20110801
32540       REMOVAL OF LUNG LESION          81                                 $249.34       20110801
32540       REMOVAL OF LUNG LESION          82                                 $249.34       20110801
32540       REMOVAL OF LUNG LESION          AS                                 $249.34       20110801
32540       REMOVAL OF LUNG LESION                                           $1,246.70       20110801
32550       INSERT PLEURAL CATH                               A                $976.18       20110101
32550       INSERT PLEURAL CATH                                                $539.50       20110801
32551       INSERTION OF CHEST TUBE                                            $125.06       20110801
32552       REMOVE LUNG CATHETER                                               $130.52       20110801
32553       INS MARK THOR FOR RT PERQ                                          $417.56       20110801
32560       TREAT PLEURODESIS W/AGENT                                          $180.70       20110801
32561       LYSE CHEST FIBRIN INIT DAY                                          $67.60       20110801
32562       LYSE CHEST FIBRIN SUBQ DAY                                          $60.58       20110801
32601       THORACOSCOPY DIAGNOSTIC                                            $225.42       20110801
32604       THORACOSCOPY WBX SAC                                               $355.42       20110801
32606       THORACOSCOPY W/BX MED SPACE                                        $340.08       20110801
32607       THORACOSCOPY W/BX INFILTRATE                                       $241.54       20120101
32608       THORACOSCOPY W/BX NODULE                                           $296.66       20120101
32609       THORACOSCOPY W/BX PLEURA                                           $205.14       20120101
32650       THORACOSCOPY W/PLEURODESIS      80                                  $96.62       20110801
32650       THORACOSCOPY W/PLEURODESIS      81                                  $96.62       20110801
32650       THORACOSCOPY W/PLEURODESIS      82                                  $96.62       20110801
32650       THORACOSCOPY W/PLEURODESIS      AS                                  $96.62       20110801
32650       THORACOSCOPY W/PLEURODESIS                                         $483.08       20110801
32651       THORACOSCOPY REMOVE CORTEX      80                                 $156.88       20110801
32651       THORACOSCOPY REMOVE CORTEX      81                                 $156.88       20110801
32651       THORACOSCOPY REMOVE CORTEX      82                                 $156.88       20110801



                                                 Page 124
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
32651       THORACOSCOPY REMOVE CORTEX     AS                                 $156.88       20110801
32651       THORACOSCOPY REMOVE CORTEX                                        $784.42       20110801
32652       THORACOSCOPY REM TOTL CORTEX   80                                 $238.94       20110801
32652       THORACOSCOPY REM TOTL CORTEX   81                                 $238.94       20110801
32652       THORACOSCOPY REM TOTL CORTEX   82                                 $238.94       20110801
32652       THORACOSCOPY REM TOTL CORTEX   AS                                 $238.94       20110801
32652       THORACOSCOPY REM TOTL CORTEX                                    $1,194.70       20110801
32653       THORACOSCOPY REMOV FB/FIBRIN   80                                 $151.37       20110801
32653       THORACOSCOPY REMOV FB/FIBRIN   81                                 $151.37       20110801
32653       THORACOSCOPY REMOV FB/FIBRIN   82                                 $151.37       20110801
32653       THORACOSCOPY REMOV FB/FIBRIN   AS                                 $151.37       20110801
32653       THORACOSCOPY REMOV FB/FIBRIN                                      $756.86       20110801
32654       THORACOSCOPY CONTRL BLEEDING   80                                 $169.31       20110801
32654       THORACOSCOPY CONTRL BLEEDING   81                                 $169.31       20110801
32654       THORACOSCOPY CONTRL BLEEDING   82                                 $169.31       20110801
32654       THORACOSCOPY CONTRL BLEEDING   AS                                 $169.31       20110801
32654       THORACOSCOPY CONTRL BLEEDING                                      $846.56       20110801
32655       THORACOSCOPY RESECT BULLAE     80                                 $137.70       20110801
32655       THORACOSCOPY RESECT BULLAE     81                                 $137.70       20110801
32655       THORACOSCOPY RESECT BULLAE     82                                 $137.70       20110801
32655       THORACOSCOPY RESECT BULLAE     AS                                 $137.70       20110801
32655       THORACOSCOPY RESECT BULLAE                                        $688.48       20110801
32656       THORACOSCOPY W/PLEURECTOMY     80                                 $115.80       20110801
32656       THORACOSCOPY W/PLEURECTOMY     81                                 $115.80       20110801
32656       THORACOSCOPY W/PLEURECTOMY     82                                 $115.80       20110801
32656       THORACOSCOPY W/PLEURECTOMY     AS                                 $115.80       20110801
32656       THORACOSCOPY W/PLEURECTOMY                                        $579.02       20110801
32658       THORACOSCOPY W/SAC FB REMOVE   80                                 $104.10       20110801
32658       THORACOSCOPY W/SAC FB REMOVE   81                                 $104.10       20110801
32658       THORACOSCOPY W/SAC FB REMOVE   82                                 $104.10       20110801
32658       THORACOSCOPY W/SAC FB REMOVE   AS                                 $104.10       20110801
32658       THORACOSCOPY W/SAC FB REMOVE                                      $520.52       20110801
32659       THORACOSCOPY W/SAC DRAINAGE    80                                 $106.50       20110801
32659       THORACOSCOPY W/SAC DRAINAGE    81                                 $106.50       20110801
32659       THORACOSCOPY W/SAC DRAINAGE    82                                 $106.50       20110801
32659       THORACOSCOPY W/SAC DRAINAGE    AS                                 $106.50       20110801
32659       THORACOSCOPY W/SAC DRAINAGE                                       $532.48       20110801
32661       THORACOSCOPY W/PERICARD EXC    80                                 $116.38       20110801
32661       THORACOSCOPY W/PERICARD EXC    81                                 $116.38       20110801
32661       THORACOSCOPY W/PERICARD EXC    82                                 $116.38       20110801
32661       THORACOSCOPY W/PERICARD EXC    AS                                 $116.38       20110801
32661       THORACOSCOPY W/PERICARD EXC                                       $581.88       20110801
32662       THORACOSCOPY W/MEDIAST EXC     80                                 $130.57       20110801
32662       THORACOSCOPY W/MEDIAST EXC     81                                 $130.57       20110801
32662       THORACOSCOPY W/MEDIAST EXC     82                                 $130.57       20110801
32662       THORACOSCOPY W/MEDIAST EXC     AS                                 $130.57       20110801
32662       THORACOSCOPY W/MEDIAST EXC                                        $652.86       20110801
32663       THORACOSCOPY W/LOBECTOMY       80                                 $204.36       20110801
32663       THORACOSCOPY W/LOBECTOMY       81                                 $204.36       20110801
32663       THORACOSCOPY W/LOBECTOMY       82                                 $204.36       20110801
32663       THORACOSCOPY W/LOBECTOMY       AS                                 $204.36       20110801
32663       THORACOSCOPY W/LOBECTOMY                                        $1,021.80       20110801
32664       THORACOSCOPY W/ TH NRV EXC     80                                 $123.14       20110801
32664       THORACOSCOPY W/ TH NRV EXC     81                                 $123.14       20110801
32664       THORACOSCOPY W/ TH NRV EXC     82                                 $123.14       20110801
32664       THORACOSCOPY W/ TH NRV EXC     AS                                 $123.14       20110801
32664       THORACOSCOPY W/ TH NRV EXC                                        $615.68       20110801
32665       THORACOSCOP W/ESOPH MUSC EXC   80                                 $178.67       20110801
32665       THORACOSCOP W/ESOPH MUSC EXC   81                                 $178.67       20110801



                                                Page 125
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
32665       THORACOSCOP W/ESOPH MUSC EXC   82                                 $178.67       20110801
32665       THORACOSCOP W/ESOPH MUSC EXC   AS                                 $178.67       20110801
32665       THORACOSCOP W/ESOPH MUSC EXC                                      $893.36       20110801
32666       THORACOSCOPY W/WEDGE RESECT    80                                 $136.03       20120101
32666       THORACOSCOPY W/WEDGE RESECT    81                                 $136.03       20120101
32666       THORACOSCOPY W/WEDGE RESECT    82                                 $136.03       20120101
32666       THORACOSCOPY W/WEDGE RESECT    AS                                 $136.03       20120101
32666       THORACOSCOPY W/WEDGE RESECT                                       $680.16       20120101
32667       THORACOSCOPY W/W RESECT ADDL   80                                  $24.54       20120101
32667       THORACOSCOPY W/W RESECT ADDL   81                                  $24.54       20120101
32667       THORACOSCOPY W/W RESECT ADDL   82                                  $24.54       20120101
32667       THORACOSCOPY W/W RESECT ADDL   AS                                  $24.54       20120101
32667       THORACOSCOPY W/W RESECT ADDL                                      $122.72       20120101
32669       THORACOSCOPY REMOVE SEGMENT    80                                 $209.56       20120101
32669       THORACOSCOPY REMOVE SEGMENT    81                                 $209.56       20120101
32669       THORACOSCOPY REMOVE SEGMENT    82                                 $209.56       20120101
32669       THORACOSCOPY REMOVE SEGMENT    AS                                 $209.56       20120101
32669       THORACOSCOPY REMOVE SEGMENT                                     $1,047.80       20120101
32670       THORACOSCOPY BILOBECTOMY       80                                 $250.07       20120101
32670       THORACOSCOPY BILOBECTOMY       81                                 $250.07       20120101
32670       THORACOSCOPY BILOBECTOMY       82                                 $250.07       20120101
32670       THORACOSCOPY BILOBECTOMY       AS                                 $250.07       20120101
32670       THORACOSCOPY BILOBECTOMY                                        $1,250.34       20120101
32671       THORACOSCOPY PNEUMONECTOMY     80                                 $277.63       20120101
32671       THORACOSCOPY PNEUMONECTOMY     81                                 $277.63       20120101
32671       THORACOSCOPY PNEUMONECTOMY     82                                 $277.63       20120101
32671       THORACOSCOPY PNEUMONECTOMY     AS                                 $277.63       20120101
32671       THORACOSCOPY PNEUMONECTOMY                                      $1,388.14       20120101
32672       THORACOSCOPY FOR LVRS          80                                 $237.48       20120101
32672       THORACOSCOPY FOR LVRS          81                                 $237.48       20120101
32672       THORACOSCOPY FOR LVRS          82                                 $237.48       20120101
32672       THORACOSCOPY FOR LVRS          AS                                 $237.48       20120101
32672       THORACOSCOPY FOR LVRS                                           $1,187.42       20120101
32673       THORACOSCOPY W/THYMUS RESECT   80                                 $187.15       20120101
32673       THORACOSCOPY W/THYMUS RESECT   81                                 $187.15       20120101
32673       THORACOSCOPY W/THYMUS RESECT   82                                 $187.15       20120101
32673       THORACOSCOPY W/THYMUS RESECT   AS                                 $187.15       20120101
32673       THORACOSCOPY W/THYMUS RESECT                                      $935.74       20120101
32674       THORACOSCOPY LYMPH NODE EXC    80                                  $33.64       20120101
32674       THORACOSCOPY LYMPH NODE EXC    81                                  $33.64       20120101
32674       THORACOSCOPY LYMPH NODE EXC    82                                  $33.64       20120101
32674       THORACOSCOPY LYMPH NODE EXC    AS                                  $33.64       20120101
32674       THORACOSCOPY LYMPH NODE EXC                                       $168.22       20120101
32800       REPAIR LUNG HERNIA             80                                 $133.28       20110801
32800       REPAIR LUNG HERNIA             81                                 $133.28       20110801
32800       REPAIR LUNG HERNIA             82                                 $133.28       20110801
32800       REPAIR LUNG HERNIA             AS                                 $133.28       20110801
32800       REPAIR LUNG HERNIA                                                $666.38       20110801
32810       CLOSE CHEST AFTER DRAINAGE     80                                 $130.26       20110801
32810       CLOSE CHEST AFTER DRAINAGE     81                                 $130.26       20110801
32810       CLOSE CHEST AFTER DRAINAGE     82                                 $130.26       20110801
32810       CLOSE CHEST AFTER DRAINAGE     AS                                 $130.26       20110801
32810       CLOSE CHEST AFTER DRAINAGE                                        $651.30       20110801
32815       CLOSE BRONCHIAL FISTULA        80                                 $402.01       20110801
32815       CLOSE BRONCHIAL FISTULA        81                                 $402.01       20110801
32815       CLOSE BRONCHIAL FISTULA        82                                 $402.01       20110801
32815       CLOSE BRONCHIAL FISTULA        AS                                 $402.01       20110801
32815       CLOSE BRONCHIAL FISTULA                                         $2,010.06       20110801
32820       RECONSTRUCT INJURED CHEST      80                                 $194.79       20110801



                                                Page 126
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
32820       RECONSTRUCT INJURED CHEST       81                                 $194.79       20110801
32820       RECONSTRUCT INJURED CHEST       82                                 $194.79       20110801
32820       RECONSTRUCT INJURED CHEST       AS                                 $194.79       20110801
32820       RECONSTRUCT INJURED CHEST                                          $973.96       20110801
32851       LUNG TRANSPLANT SINGLE          80                                 $375.13       20110801
32851       LUNG TRANSPLANT SINGLE          81                                 $375.13       20110801
32851       LUNG TRANSPLANT SINGLE          82                                 $375.13       20110801
32851       LUNG TRANSPLANT SINGLE          AS                                 $375.13       20110801
32851       LUNG TRANSPLANT SINGLE                                           $1,875.64       20110801
32852       LUNG TRANSPLANT WITH BYPASS     80                                 $415.17       20110801
32852       LUNG TRANSPLANT WITH BYPASS     81                                 $415.17       20110801
32852       LUNG TRANSPLANT WITH BYPASS     82                                 $415.17       20110801
32852       LUNG TRANSPLANT WITH BYPASS     AS                                 $415.17       20110801
32852       LUNG TRANSPLANT WITH BYPASS                                      $2,075.84       20110801
32853       LUNG TRANSPLANT DOUBLE          80                                 $447.10       20110801
32853       LUNG TRANSPLANT DOUBLE          81                                 $447.10       20110801
32853       LUNG TRANSPLANT DOUBLE          82                                 $447.10       20110801
32853       LUNG TRANSPLANT DOUBLE          AS                                 $447.10       20110801
32853       LUNG TRANSPLANT DOUBLE                                           $2,235.48       20110801
32854       LUNG TRANSPLANT WITH BYPASS     80                                 $488.80       20110801
32854       LUNG TRANSPLANT WITH BYPASS     81                                 $488.80       20110801
32854       LUNG TRANSPLANT WITH BYPASS     82                                 $488.80       20110801
32854       LUNG TRANSPLANT WITH BYPASS     AS                                 $488.80       20110801
32854       LUNG TRANSPLANT WITH BYPASS                                      $2,444.00       20110801
32856       PREPARE DONOR LUNG DOUBLE                                          $358.07       20081013
32900       REMOVAL OF RIBS                 80                                 $199.00       20110801
32900       REMOVAL OF RIBS                 81                                 $199.00       20110801
32900       REMOVAL OF RIBS                 82                                 $199.00       20110801
32900       REMOVAL OF RIBS                 AS                                 $199.00       20110801
32900       REMOVAL OF RIBS                                                    $995.02       20110801
32905       REVISE REPAIR CHEST WALL        80                                 $194.53       20110801
32905       REVISE REPAIR CHEST WALL        81                                 $194.53       20110801
32905       REVISE REPAIR CHEST WALL        82                                 $194.53       20110801
32905       REVISE REPAIR CHEST WALL        AS                                 $194.53       20110801
32905       REVISE REPAIR CHEST WALL                                           $972.66       20110801
32906       REVISE REPAIR CHEST WALL        80                                 $241.38       20110801
32906       REVISE REPAIR CHEST WALL        81                                 $241.38       20110801
32906       REVISE REPAIR CHEST WALL        82                                 $241.38       20110801
32906       REVISE REPAIR CHEST WALL        AS                                 $241.38       20110801
32906       REVISE REPAIR CHEST WALL                                         $1,206.92       20110801
32940       REVISION OF LUNG                80                                 $178.67       20110801
32940       REVISION OF LUNG                81                                 $178.67       20110801
32940       REVISION OF LUNG                82                                 $178.67       20110801
32940       REVISION OF LUNG                AS                                 $178.67       20110801
32940       REVISION OF LUNG                                                   $893.36       20110801
32960       THERAPEUTIC PNEUMOTHORAX                                           $101.66       20110801
32997       TOTAL LUNG LAVAGE                                                  $258.18       20110801
33010       DRAINAGE OF HEART SAC                             A                $176.07       20110101
33010       DRAINAGE OF HEART SAC                                               $91.26       20110801
33011       REPEAT DRAINAGE OF HEART SAC                      A                $176.07       20110101
33011       REPEAT DRAINAGE OF HEART SAC                                        $90.74       20110801
33015       INCISION OF HEART SAC                                              $385.06       20110801
33020       INCISION OF HEART SAC           80                                 $127.40       20110801
33020       INCISION OF HEART SAC           81                                 $127.40       20110801
33020       INCISION OF HEART SAC           82                                 $127.40       20110801
33020       INCISION OF HEART SAC           AS                                 $127.40       20110801
33020       INCISION OF HEART SAC                                              $637.00       20110801
33025       INCISION OF HEART SAC           80                                 $116.95       20110801
33025       INCISION OF HEART SAC           81                                 $116.95       20110801



                                                 Page 127
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
33025       INCISION OF HEART SAC           82                                 $116.95       20110801
33025       INCISION OF HEART SAC           AS                                 $116.95       20110801
33025       INCISION OF HEART SAC                                              $584.74       20110801
33030       PARTIAL REMOVAL OF HEART SAC    80                                 $188.08       20110801
33030       PARTIAL REMOVAL OF HEART SAC    81                                 $188.08       20110801
33030       PARTIAL REMOVAL OF HEART SAC    82                                 $188.08       20110801
33030       PARTIAL REMOVAL OF HEART SAC    AS                                 $188.08       20110801
33030       PARTIAL REMOVAL OF HEART SAC                                       $940.42       20110801
33031       PARTIAL REMOVAL OF HEART SAC    80                                 $210.13       20110801
33031       PARTIAL REMOVAL OF HEART SAC    81                                 $210.13       20110801
33031       PARTIAL REMOVAL OF HEART SAC    82                                 $210.13       20110801
33031       PARTIAL REMOVAL OF HEART SAC    AS                                 $210.13       20110801
33031       PARTIAL REMOVAL OF HEART SAC                                     $1,050.66       20110801
33050       RESECT HEART SAC LESION         80                                 $145.29       20110801
33050       RESECT HEART SAC LESION         81                                 $145.29       20110801
33050       RESECT HEART SAC LESION         82                                 $145.29       20110801
33050       RESECT HEART SAC LESION         AS                                 $145.29       20110801
33050       RESECT HEART SAC LESION                                            $726.44       20110801
33120       REMOVAL OF HEART LESION         80                                 $228.70       20110801
33120       REMOVAL OF HEART LESION         81                                 $228.70       20110801
33120       REMOVAL OF HEART LESION         82                                 $228.70       20110801
33120       REMOVAL OF HEART LESION         AS                                 $228.70       20110801
33120       REMOVAL OF HEART LESION                                          $1,143.48       20110801
33130       REMOVAL OF HEART LESION         80                                 $212.52       20110801
33130       REMOVAL OF HEART LESION         81                                 $212.52       20110801
33130       REMOVAL OF HEART LESION         82                                 $212.52       20110801
33130       REMOVAL OF HEART LESION         AS                                 $212.52       20110801
33130       REMOVAL OF HEART LESION                                          $1,062.62       20110801
33140       HEART REVASCULARIZE TMR                                          $1,168.70       20110801
33141       HEART TMR W/OTHER PROCEDURE     80                                  $20.70       20110801
33141       HEART TMR W/OTHER PROCEDURE     81                                  $20.70       20110801
33141       HEART TMR W/OTHER PROCEDURE     82                                  $20.70       20110801
33141       HEART TMR W/OTHER PROCEDURE     AS                                  $20.70       20110801
33141       HEART TMR W/OTHER PROCEDURE                                        $103.48       20110801
33202       INSERT EPICARD ELTRD OPEN                                          $569.14       20110801
33203       INSERT EPICARD ELTRD ENDO                                          $601.64       20110801
33206       INSERT HEART PM ATRIAL                                             $345.80       20110801
33207       INSERT HEART PM VENTRICULAR                                        $368.94       20110801
33208       INSRT HEART PM ATRIAL VENT                                         $399.10       20110801
33210       INSERT ELECTRD/PM CATH SNGL                                        $137.80       20110801
33211       INSERT CARD ELECTRODES DUAL                                        $139.10       20110801
33212       INSERT PULSE GEN SNGL LEAD                                         $256.36       20110801
33213       INSERT PULSE GEN DUAL LEADS                                        $293.28       20110801
33214       UPGRADE OF PACEMAKER SYSTEM                                        $364.78       20110801
33215       REPOSITION PACING-DEFIB LEAD                                       $231.92       20110801
33216       INSERT 1 ELECTRODE PM-DEFIB                                        $286.52       20110801
33217       INSERT 2 ELECTRODE PM-DEFIB                                        $284.18       20110801
33218       REPAIR LEAD PACE-DEFIB ONE                                         $297.44       20110801
33220       REPAIR LEAD PACE-DEFIB DUAL                                        $300.56       20110801
33221       INSERT PULSE GEN MULT LEADS                                        $273.52       20120101
33222       REVISE POCKET PACEMAKER                           A                $471.22       20110101
33222       REVISE POCKET PACEMAKER                                            $261.04       20110801
33223       REVISE POCKET FOR DEFIB                                            $315.64       20110801
33224       INSERT PACING LEAD CONNECT                                         $388.18       20110801
33225       L VENTRIC PACING LEAD ADD-ON                                       $350.74       20110801
33226       REPOSITION L VENTRIC LEAD                                          $373.62       20110801
33227       REMOVEREPLACE PM GEN SINGL                                         $261.04       20120101
33228       REMVREPLC PM GEN DUAL LEAD                                         $272.22       20120101
33229       REMVREPLC PM GEN MULT LEADS                                        $205.40       20120101



                                                 Page 128
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
33230       INSRT PULSE GEN W/DUAL LEADS                                      $294.32       20120101
33231       INSRT PULSE GEN W/MULT LEADS                                      $305.50       20120101
33233       REMOVAL OF PM GENERATOR                                           $181.22       20110801
33234       REMOVAL OF PACEMAKER SYSTEM                                       $369.98       20110801
33235       REMOVAL PACEMAKER ELECTRODE                                       $482.04       20110801
33236       REMOVE ELECTRODE/THORACOTOMY                                      $574.60       20110801
33237       REMOVE ELECTRODE/THORACOTOMY                                      $622.96       20110801
33238       REMOVE ELECTRODE/THORACOTOMY   80                                 $136.60       20110801
33238       REMOVE ELECTRODE/THORACOTOMY   81                                 $136.60       20110801
33238       REMOVE ELECTRODE/THORACOTOMY   82                                 $136.60       20110801
33238       REMOVE ELECTRODE/THORACOTOMY   AS                                 $136.60       20110801
33238       REMOVE ELECTRODE/THORACOTOMY                                      $683.02       20110801
33240       INSRT PULSE GEN W/SINGL LEAD                                      $353.86       20110801
33241       REMOVE PULSE GENERATOR                                            $171.08       20110801
33243       REMOVE ELTRD/THORACOTOMY       80                                 $203.16       20110801
33243       REMOVE ELTRD/THORACOTOMY       81                                 $203.16       20110801
33243       REMOVE ELTRD/THORACOTOMY       82                                 $203.16       20110801
33243       REMOVE ELTRD/THORACOTOMY       AS                                 $203.16       20110801
33243       REMOVE ELTRD/THORACOTOMY                                        $1,015.82       20110801
33244       REMOVE ELTRD TRANSVEN                                             $651.30       20110801
33249       NSERT PACE-DEFIB W/LEAD                                           $693.42       20110801
33250       ABLATE HEART DYSRHYTHM FOCUS   80                                 $216.94       20110801
33250       ABLATE HEART DYSRHYTHM FOCUS   81                                 $216.94       20110801
33250       ABLATE HEART DYSRHYTHM FOCUS   82                                 $216.94       20110801
33250       ABLATE HEART DYSRHYTHM FOCUS   AS                                 $216.94       20110801
33250       ABLATE HEART DYSRHYTHM FOCUS                                    $1,084.72       20110801
33251       ABLATE HEART DYSRHYTHM FOCUS   80                                 $240.60       20110801
33251       ABLATE HEART DYSRHYTHM FOCUS   81                                 $240.60       20110801
33251       ABLATE HEART DYSRHYTHM FOCUS   82                                 $240.60       20110801
33251       ABLATE HEART DYSRHYTHM FOCUS   AS                                 $240.60       20110801
33251       ABLATE HEART DYSRHYTHM FOCUS                                    $1,203.02       20110801
33254       ABLATE ATRIA LMTD              80                                 $201.19       20110801
33254       ABLATE ATRIA LMTD              81                                 $201.19       20110801
33254       ABLATE ATRIA LMTD              82                                 $201.19       20110801
33254       ABLATE ATRIA LMTD              AS                                 $201.19       20110801
33254       ABLATE ATRIA LMTD                                               $1,005.94       20110801
33255       ABLATE ATRIA W/O BYPASS EXT    80                                 $245.44       20110801
33255       ABLATE ATRIA W/O BYPASS EXT    81                                 $245.44       20110801
33255       ABLATE ATRIA W/O BYPASS EXT    82                                 $245.44       20110801
33255       ABLATE ATRIA W/O BYPASS EXT    AS                                 $245.44       20110801
33255       ABLATE ATRIA W/O BYPASS EXT                                     $1,227.20       20110801
33256       ABLATE ATRIA W/BYPASS EXTEN    80                                 $292.03       20110801
33256       ABLATE ATRIA W/BYPASS EXTEN    81                                 $292.03       20110801
33256       ABLATE ATRIA W/BYPASS EXTEN    82                                 $292.03       20110801
33256       ABLATE ATRIA W/BYPASS EXTEN    AS                                 $292.03       20110801
33256       ABLATE ATRIA W/BYPASS EXTEN                                     $1,460.16       20110801
33257       ABLATE ATRIA LMTD ADD-ON       80                                  $85.70       20110801
33257       ABLATE ATRIA LMTD ADD-ON                                          $428.48       20110801
33258       ABLATE ATRIA X10SV ADD-ON                                         $482.56       20110801
33259       ABLATE ATRIA W/BYPASS ADD-ON   80                                 $124.70       20110801
33259       ABLATE ATRIA W/BYPASS ADD-ON                                      $623.48       20110801
33261       ABLATE HEART DYSRHYTHM FOCUS   80                                 $239.88       20110801
33261       ABLATE HEART DYSRHYTHM FOCUS   81                                 $239.88       20110801
33261       ABLATE HEART DYSRHYTHM FOCUS   82                                 $239.88       20110801
33261       ABLATE HEART DYSRHYTHM FOCUS   AS                                 $239.88       20110801
33261       ABLATE HEART DYSRHYTHM FOCUS                                    $1,199.38       20110801
33262       REMVREPLC CVD GEN SING LEAD                                       $283.66       20120101
33263       REMVREPLC CVD GEN DUAL LEAD                                       $294.84       20120101
33264       REMVREPLC CVD GEN MULT LEAD                                       $306.02       20120101



                                                Page 129
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                      Date
33265       ABLATE ATRIA LMTD ENDO           80                                 $199.68       20110801
33265       ABLATE ATRIA LMTD ENDO           81                                 $199.68       20110801
33265       ABLATE ATRIA LMTD ENDO           82                                 $199.68       20110801
33265       ABLATE ATRIA LMTD ENDO           AS                                 $199.68       20110801
33265       ABLATE ATRIA LMTD ENDO                                              $998.40       20110801
33266       ABLATE ATRIA X10SV ENDO          80                                 $273.47       20110801
33266       ABLATE ATRIA X10SV ENDO          81                                 $273.47       20110801
33266       ABLATE ATRIA X10SV ENDO          82                                 $273.47       20110801
33266       ABLATE ATRIA X10SV ENDO          AS                                 $273.47       20110801
33266       ABLATE ATRIA X10SV ENDO                                           $1,367.34       20110801
33282       IMPLANT PAT-ACTIVE HT RECORD                                        $246.22       20110801
33284       REMOVE PAT-ACTIVE HT RECORD                                         $176.80       20110801
33300       REPAIR OF HEART WOUND            80                                 $354.80       20110801
33300       REPAIR OF HEART WOUND            81                                 $354.80       20110801
33300       REPAIR OF HEART WOUND            82                                 $354.80       20110801
33300       REPAIR OF HEART WOUND            AS                                 $354.80       20110801
33300       REPAIR OF HEART WOUND                                             $1,773.98       20110801
33305       REPAIR OF HEART WOUND            80                                 $597.84       20110801
33305       REPAIR OF HEART WOUND            81                                 $597.84       20110801
33305       REPAIR OF HEART WOUND            82                                 $597.84       20110801
33305       REPAIR OF HEART WOUND            AS                                 $597.84       20110801
33305       REPAIR OF HEART WOUND                                             $2,989.22       20110801
33310       EXPLORATORY HEART SURGERY        80                                 $170.87       20110801
33310       EXPLORATORY HEART SURGERY        81                                 $170.87       20110801
33310       EXPLORATORY HEART SURGERY        82                                 $170.87       20110801
33310       EXPLORATORY HEART SURGERY        AS                                 $170.87       20110801
33310       EXPLORATORY HEART SURGERY                                           $854.36       20110801
33315       EXPLORATORY HEART SURGERY        80                                 $218.92       20110801
33315       EXPLORATORY HEART SURGERY        81                                 $218.92       20110801
33315       EXPLORATORY HEART SURGERY        82                                 $218.92       20110801
33315       EXPLORATORY HEART SURGERY        AS                                 $218.92       20110801
33315       EXPLORATORY HEART SURGERY                                         $1,094.60       20110801
33320       REPAIR MAJOR BLOOD VESSELS       80                                 $156.10       20110801
33320       REPAIR MAJOR BLOOD VESSELS       81                                 $156.10       20110801
33320       REPAIR MAJOR BLOOD VESSELS       82                                 $156.10       20110801
33320       REPAIR MAJOR BLOOD VESSELS       AS                                 $156.10       20110801
33320       REPAIR MAJOR BLOOD VESSELS                                          $780.52       20110801
33321       REPAIR MAJOR VESSEL              80                                 $174.41       20110801
33321       REPAIR MAJOR VESSEL              81                                 $174.41       20110801
33321       REPAIR MAJOR VESSEL              82                                 $174.41       20110801
33321       REPAIR MAJOR VESSEL              AS                                 $174.41       20110801
33321       REPAIR MAJOR VESSEL                                                 $872.04       20110801
33322       REPAIR MAJOR BLOOD VESSELS       80                                 $205.40       20110801
33322       REPAIR MAJOR BLOOD VESSELS       81                                 $205.40       20110801
33322       REPAIR MAJOR BLOOD VESSELS       82                                 $205.40       20110801
33322       REPAIR MAJOR BLOOD VESSELS       AS                                 $205.40       20110801
33322       REPAIR MAJOR BLOOD VESSELS                                        $1,027.00       20110801
33330       INSERT MAJOR VESSEL GRAFT        80                                 $211.90       20110801
33330       INSERT MAJOR VESSEL GRAFT        81                                 $211.90       20110801
33330       INSERT MAJOR VESSEL GRAFT        82                                 $211.90       20110801
33330       INSERT MAJOR VESSEL GRAFT        AS                                 $211.90       20110801
33330       INSERT MAJOR VESSEL GRAFT                                         $1,059.50       20110801
33332       INSERT MAJOR VESSEL GRAFT        80                                 $206.65       20110801
33332       INSERT MAJOR VESSEL GRAFT        81                                 $206.65       20110801
33332       INSERT MAJOR VESSEL GRAFT        82                                 $206.65       20110801
33332       INSERT MAJOR VESSEL GRAFT        AS                                 $206.65       20110801
33332       INSERT MAJOR VESSEL GRAFT                                         $1,033.24       20110801
33335       INSERT MAJOR VESSEL GRAFT        80                                 $279.08       20110801
33335       INSERT MAJOR VESSEL GRAFT        81                                 $279.08       20110801



                                                  Page 130
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
33335       INSERT MAJOR VESSEL GRAFT      82                                 $279.08       20110801
33335       INSERT MAJOR VESSEL GRAFT      AS                                 $279.08       20110801
33335       INSERT MAJOR VESSEL GRAFT                                       $1,395.42       20110801
33400       REPAIR OF AORTIC VALVE         80                                 $338.94       20110801
33400       REPAIR OF AORTIC VALVE         81                                 $338.94       20110801
33400       REPAIR OF AORTIC VALVE         82                                 $338.94       20110801
33400       REPAIR OF AORTIC VALVE         AS                                 $338.94       20110801
33400       REPAIR OF AORTIC VALVE                                          $1,694.68       20110801
33401       VALVULOPLASTY OPEN             80                                 $214.08       20110801
33401       VALVULOPLASTY OPEN             81                                 $214.08       20110801
33401       VALVULOPLASTY OPEN             82                                 $214.08       20110801
33401       VALVULOPLASTY OPEN             AS                                 $214.08       20110801
33401       VALVULOPLASTY OPEN                                              $1,070.42       20110801
33403       VALVULOPLASTY W/CP BYPASS      80                                 $221.78       20110801
33403       VALVULOPLASTY W/CP BYPASS      81                                 $221.78       20110801
33403       VALVULOPLASTY W/CP BYPASS      82                                 $221.78       20110801
33403       VALVULOPLASTY W/CP BYPASS      AS                                 $221.78       20110801
33403       VALVULOPLASTY W/CP BYPASS                                       $1,108.90       20110801
33404       PREPARE HEART-AORTA CONDUIT    80                                 $261.14       20110801
33404       PREPARE HEART-AORTA CONDUIT    81                                 $261.14       20110801
33404       PREPARE HEART-AORTA CONDUIT    82                                 $261.14       20110801
33404       PREPARE HEART-AORTA CONDUIT    AS                                 $261.14       20110801
33404       PREPARE HEART-AORTA CONDUIT                                     $1,305.72       20110801
33405       REPLACEMENT OF AORTIC VALVE    80                                 $341.17       20110801
33405       REPLACEMENT OF AORTIC VALVE    81                                 $341.17       20110801
33405       REPLACEMENT OF AORTIC VALVE    82                                 $341.17       20110801
33405       REPLACEMENT OF AORTIC VALVE    AS                                 $341.17       20110801
33405       REPLACEMENT OF AORTIC VALVE                                     $1,705.86       20110801
33406       REPLACEMENT OF AORTIC VALVE    80                                 $427.44       20110801
33406       REPLACEMENT OF AORTIC VALVE    81                                 $427.44       20110801
33406       REPLACEMENT OF AORTIC VALVE    82                                 $427.44       20110801
33406       REPLACEMENT OF AORTIC VALVE    AS                                 $427.44       20110801
33406       REPLACEMENT OF AORTIC VALVE                                     $2,137.20       20110801
33410       REPLACEMENT OF AORTIC VALVE    80                                 $377.62       20110801
33410       REPLACEMENT OF AORTIC VALVE    81                                 $377.62       20110801
33410       REPLACEMENT OF AORTIC VALVE    82                                 $377.62       20110801
33410       REPLACEMENT OF AORTIC VALVE    AS                                 $377.62       20110801
33410       REPLACEMENT OF AORTIC VALVE                                     $1,888.12       20110801
33411       REPLACEMENT OF AORTIC VALVE    80                                 $497.07       20110801
33411       REPLACEMENT OF AORTIC VALVE    81                                 $497.07       20110801
33411       REPLACEMENT OF AORTIC VALVE    82                                 $497.07       20110801
33411       REPLACEMENT OF AORTIC VALVE    AS                                 $497.07       20110801
33411       REPLACEMENT OF AORTIC VALVE                                     $2,485.34       20110801
33412       REPLACEMENT OF AORTIC VALVE    80                                 $366.70       20110801
33412       REPLACEMENT OF AORTIC VALVE    81                                 $366.70       20110801
33412       REPLACEMENT OF AORTIC VALVE    82                                 $366.70       20110801
33412       REPLACEMENT OF AORTIC VALVE    AS                                 $366.70       20110801
33412       REPLACEMENT OF AORTIC VALVE                                     $1,833.52       20110801
33413       REPLACEMENT OF AORTIC VALVE    80                                 $480.64       20110801
33413       REPLACEMENT OF AORTIC VALVE    81                                 $480.64       20110801
33413       REPLACEMENT OF AORTIC VALVE    82                                 $480.64       20110801
33413       REPLACEMENT OF AORTIC VALVE    AS                                 $480.64       20110801
33413       REPLACEMENT OF AORTIC VALVE                                     $2,403.18       20110801
33414       REPAIR OF AORTIC VALVE         80                                 $322.50       20110801
33414       REPAIR OF AORTIC VALVE         81                                 $322.50       20110801
33414       REPAIR OF AORTIC VALVE         82                                 $322.50       20110801
33414       REPAIR OF AORTIC VALVE         AS                                 $322.50       20110801
33414       REPAIR OF AORTIC VALVE                                          $1,612.52       20110801
33415       REVISION SUBVALVULAR TISSUE    80                                 $298.79       20110801



                                                Page 131
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
33415       REVISION SUBVALVULAR TISSUE     81                                 $298.79       20110801
33415       REVISION SUBVALVULAR TISSUE     82                                 $298.79       20110801
33415       REVISION SUBVALVULAR TISSUE     AS                                 $298.79       20110801
33415       REVISION SUBVALVULAR TISSUE                                      $1,493.96       20110801
33416       REVISE VENTRICLE MUSCLE         80                                 $299.88       20110801
33416       REVISE VENTRICLE MUSCLE         81                                 $299.88       20110801
33416       REVISE VENTRICLE MUSCLE         82                                 $299.88       20110801
33416       REVISE VENTRICLE MUSCLE         AS                                 $299.88       20110801
33416       REVISE VENTRICLE MUSCLE                                          $1,499.42       20110801
33417       REPAIR OF AORTIC VALVE          80                                 $247.31       20110801
33417       REPAIR OF AORTIC VALVE          81                                 $247.31       20110801
33417       REPAIR OF AORTIC VALVE          82                                 $247.31       20110801
33417       REPAIR OF AORTIC VALVE          AS                                 $247.31       20110801
33417       REPAIR OF AORTIC VALVE                                           $1,236.56       20110801
33420       REVISION OF MITRAL VALVE                                         $1,002.56       20110801
33422       REVISION OF MITRAL VALVE        80                                 $249.55       20110801
33422       REVISION OF MITRAL VALVE        81                                 $249.55       20110801
33422       REVISION OF MITRAL VALVE        82                                 $249.55       20110801
33422       REVISION OF MITRAL VALVE        AS                                 $249.55       20110801
33422       REVISION OF MITRAL VALVE                                         $1,247.74       20110801
33425       REPAIR OF MITRAL VALVE          80                                 $399.98       20110801
33425       REPAIR OF MITRAL VALVE          81                                 $399.98       20110801
33425       REPAIR OF MITRAL VALVE          82                                 $399.98       20110801
33425       REPAIR OF MITRAL VALVE          AS                                 $399.98       20110801
33425       REPAIR OF MITRAL VALVE                                           $1,999.92       20110801
33426       REPAIR OF MITRAL VALVE          80                                 $355.21       20110801
33426       REPAIR OF MITRAL VALVE          81                                 $355.21       20110801
33426       REPAIR OF MITRAL VALVE          82                                 $355.21       20110801
33426       REPAIR OF MITRAL VALVE          AS                                 $355.21       20110801
33426       REPAIR OF MITRAL VALVE                                           $1,776.06       20110801
33427       REPAIR OF MITRAL VALVE          80                                 $366.50       20110801
33427       REPAIR OF MITRAL VALVE          81                                 $366.50       20110801
33427       REPAIR OF MITRAL VALVE          82                                 $366.50       20110801
33427       REPAIR OF MITRAL VALVE          AS                                 $366.50       20110801
33427       REPAIR OF MITRAL VALVE                                           $1,832.48       20110801
33430       REPLACEMENT OF MITRAL VALVE     80                                 $415.17       20110801
33430       REPLACEMENT OF MITRAL VALVE     81                                 $415.17       20110801
33430       REPLACEMENT OF MITRAL VALVE     82                                 $415.17       20110801
33430       REPLACEMENT OF MITRAL VALVE     AS                                 $415.17       20110801
33430       REPLACEMENT OF MITRAL VALVE                                      $2,075.84       20110801
33460       REVISION OF TRICUSPID VALVE     80                                 $374.19       20110801
33460       REVISION OF TRICUSPID VALVE     81                                 $374.19       20110801
33460       REVISION OF TRICUSPID VALVE     82                                 $374.19       20110801
33460       REVISION OF TRICUSPID VALVE     AS                                 $374.19       20110801
33460       REVISION OF TRICUSPID VALVE                                      $1,870.96       20110801
33463       VALVULOPLASTY TRICUSPID         80                                 $453.54       20110801
33463       VALVULOPLASTY TRICUSPID         81                                 $453.54       20110801
33463       VALVULOPLASTY TRICUSPID         82                                 $453.54       20110801
33463       VALVULOPLASTY TRICUSPID         AS                                 $453.54       20110801
33463       VALVULOPLASTY TRICUSPID                                          $2,267.72       20110801
33464       VALVULOPLASTY TRICUSPID         80                                 $360.52       20110801
33464       VALVULOPLASTY TRICUSPID         81                                 $360.52       20110801
33464       VALVULOPLASTY TRICUSPID         82                                 $360.52       20110801
33464       VALVULOPLASTY TRICUSPID         AS                                 $360.52       20110801
33464       VALVULOPLASTY TRICUSPID                                          $1,802.58       20110801
33465       REPLACE TRICUSPID VALVE         80                                 $405.24       20110801
33465       REPLACE TRICUSPID VALVE         81                                 $405.24       20110801
33465       REPLACE TRICUSPID VALVE         82                                 $405.24       20110801
33465       REPLACE TRICUSPID VALVE         AS                                 $405.24       20110801



                                                 Page 132
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
33465       REPLACE TRICUSPID VALVE                                         $2,026.18       20110801
33468       REVISION OF TRICUSPID VALVE    80                                 $277.68       20110801
33468       REVISION OF TRICUSPID VALVE    81                                 $277.68       20110801
33468       REVISION OF TRICUSPID VALVE    82                                 $277.68       20110801
33468       REVISION OF TRICUSPID VALVE    AS                                 $277.68       20110801
33468       REVISION OF TRICUSPID VALVE                                     $1,388.40       20110801
33470       REVISION OF PULMONARY VALVE    80                                 $181.64       20110801
33470       REVISION OF PULMONARY VALVE    81                                 $181.64       20110801
33470       REVISION OF PULMONARY VALVE    82                                 $181.64       20110801
33470       REVISION OF PULMONARY VALVE    AS                                 $181.64       20110801
33470       REVISION OF PULMONARY VALVE                                       $908.18       20110801
33471       VALVOTOMY PULMONARY VALVE      80                                 $180.23       20110801
33471       VALVOTOMY PULMONARY VALVE      81                                 $180.23       20110801
33471       VALVOTOMY PULMONARY VALVE      82                                 $180.23       20110801
33471       VALVOTOMY PULMONARY VALVE      AS                                 $180.23       20110801
33471       VALVOTOMY PULMONARY VALVE                                         $901.16       20110801
33472       REVISION OF PULMONARY VALVE    80                                 $180.91       20110801
33472       REVISION OF PULMONARY VALVE    81                                 $180.91       20110801
33472       REVISION OF PULMONARY VALVE    82                                 $180.91       20110801
33472       REVISION OF PULMONARY VALVE    AS                                 $180.91       20110801
33472       REVISION OF PULMONARY VALVE                                       $904.54       20110801
33474       REVISION OF PULMONARY VALVE    80                                 $312.10       20110801
33474       REVISION OF PULMONARY VALVE    81                                 $312.10       20110801
33474       REVISION OF PULMONARY VALVE    82                                 $312.10       20110801
33474       REVISION OF PULMONARY VALVE    AS                                 $312.10       20110801
33474       REVISION OF PULMONARY VALVE                                     $1,560.52       20110801
33475       REPLACEMENT PULMONARY VALVE    80                                 $345.96       20110801
33475       REPLACEMENT PULMONARY VALVE    81                                 $345.96       20110801
33475       REPLACEMENT PULMONARY VALVE    82                                 $345.96       20110801
33475       REPLACEMENT PULMONARY VALVE    AS                                 $345.96       20110801
33475       REPLACEMENT PULMONARY VALVE                                     $1,729.78       20110801
33476       REVISION OF HEART CHAMBER      80                                 $222.14       20110801
33476       REVISION OF HEART CHAMBER      81                                 $222.14       20110801
33476       REVISION OF HEART CHAMBER      82                                 $222.14       20110801
33476       REVISION OF HEART CHAMBER      AS                                 $222.14       20110801
33476       REVISION OF HEART CHAMBER                                       $1,110.72       20110801
33478       REVISION OF HEART CHAMBER      80                                 $232.44       20110801
33478       REVISION OF HEART CHAMBER      81                                 $232.44       20110801
33478       REVISION OF HEART CHAMBER      82                                 $232.44       20110801
33478       REVISION OF HEART CHAMBER      AS                                 $232.44       20110801
33478       REVISION OF HEART CHAMBER                                       $1,162.20       20110801
33496       REPAIR PROSTH VALVE CLOT       80                                 $247.47       20110801
33496       REPAIR PROSTH VALVE CLOT       81                                 $247.47       20110801
33496       REPAIR PROSTH VALVE CLOT       82                                 $247.47       20110801
33496       REPAIR PROSTH VALVE CLOT       AS                                 $247.47       20110801
33496       REPAIR PROSTH VALVE CLOT                                        $1,237.34       20110801
33500       REPAIR HEART VESSEL FISTULA    80                                 $233.32       20110801
33500       REPAIR HEART VESSEL FISTULA    81                                 $233.32       20110801
33500       REPAIR HEART VESSEL FISTULA    82                                 $233.32       20110801
33500       REPAIR HEART VESSEL FISTULA    AS                                 $233.32       20110801
33500       REPAIR HEART VESSEL FISTULA                                     $1,166.62       20110801
33501       REPAIR HEART VESSEL FISTULA    80                                 $165.20       20110801
33501       REPAIR HEART VESSEL FISTULA    81                                 $165.20       20110801
33501       REPAIR HEART VESSEL FISTULA    82                                 $165.20       20110801
33501       REPAIR HEART VESSEL FISTULA    AS                                 $165.20       20110801
33501       REPAIR HEART VESSEL FISTULA                                       $826.02       20110801
33502       CORONARY ARTERY CORRECTION     80                                 $187.62       20110801
33502       CORONARY ARTERY CORRECTION     81                                 $187.62       20110801
33502       CORONARY ARTERY CORRECTION     82                                 $187.62       20110801



                                                Page 133
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
33502       CORONARY ARTERY CORRECTION     AS                                 $187.62       20110801
33502       CORONARY ARTERY CORRECTION                                        $938.08       20110801
33503       CORONARY ARTERY GRAFT          80                                 $198.90       20110801
33503       CORONARY ARTERY GRAFT          81                                 $198.90       20110801
33503       CORONARY ARTERY GRAFT          82                                 $198.90       20110801
33503       CORONARY ARTERY GRAFT          AS                                 $198.90       20110801
33503       CORONARY ARTERY GRAFT                                             $994.50       20110801
33504       CORONARY ARTERY GRAFT          80                                 $214.97       20110801
33504       CORONARY ARTERY GRAFT          81                                 $214.97       20110801
33504       CORONARY ARTERY GRAFT          82                                 $214.97       20110801
33504       CORONARY ARTERY GRAFT          AS                                 $214.97       20110801
33504       CORONARY ARTERY GRAFT                                           $1,074.84       20110801
33505       REPAIR ARTERY W/TUNNEL         80                                 $305.45       20110801
33505       REPAIR ARTERY W/TUNNEL         81                                 $305.45       20110801
33505       REPAIR ARTERY W/TUNNEL         82                                 $305.45       20110801
33505       REPAIR ARTERY W/TUNNEL         AS                                 $305.45       20110801
33505       REPAIR ARTERY W/TUNNEL                                          $1,527.24       20110801
33506       REPAIR ARTERY TRANSLOCATION    80                                 $303.73       20110801
33506       REPAIR ARTERY TRANSLOCATION    81                                 $303.73       20110801
33506       REPAIR ARTERY TRANSLOCATION    82                                 $303.73       20110801
33506       REPAIR ARTERY TRANSLOCATION    AS                                 $303.73       20110801
33506       REPAIR ARTERY TRANSLOCATION                                     $1,518.66       20110801
33507       REPAIR ART INTRAMURAL          80                                 $255.68       20110801
33507       REPAIR ART INTRAMURAL          81                                 $255.68       20110801
33507       REPAIR ART INTRAMURAL          82                                 $255.68       20110801
33507       REPAIR ART INTRAMURAL          AS                                 $255.68       20110801
33507       REPAIR ART INTRAMURAL                                           $1,278.42       20110801
33508       ENDOSCOPIC VEIN HARVEST        80                                   $2.39       20110801
33508       ENDOSCOPIC VEIN HARVEST        81                                   $2.39       20110801
33508       ENDOSCOPIC VEIN HARVEST        82                                   $2.39       20110801
33508       ENDOSCOPIC VEIN HARVEST        AS                                   $2.39       20110801
33508       ENDOSCOPIC VEIN HARVEST                                            $11.96       20110801
33510       CABG VEIN SINGLE               80                                 $290.52       20110801
33510       CABG VEIN SINGLE               81                                 $290.52       20110801
33510       CABG VEIN SINGLE               82                                 $290.52       20110801
33510       CABG VEIN SINGLE               AS                                 $290.52       20110801
33510       CABG VEIN SINGLE                                                $1,452.62       20110801
33511       CABG VEIN TWO                  80                                 $318.29       20110801
33511       CABG VEIN TWO                  81                                 $318.29       20110801
33511       CABG VEIN TWO                  82                                 $318.29       20110801
33511       CABG VEIN TWO                  AS                                 $318.29       20110801
33511       CABG VEIN TWO                                                   $1,591.46       20110801
33512       CABG VEIN THREE                80                                 $360.72       20110801
33512       CABG VEIN THREE                81                                 $360.72       20110801
33512       CABG VEIN THREE                82                                 $360.72       20110801
33512       CABG VEIN THREE                AS                                 $360.72       20110801
33512       CABG VEIN THREE                                                 $1,803.62       20110801
33513       CABG VEIN FOUR                 80                                 $369.20       20110801
33513       CABG VEIN FOUR                 81                                 $369.20       20110801
33513       CABG VEIN FOUR                 82                                 $369.20       20110801
33513       CABG VEIN FOUR                 AS                                 $369.20       20110801
33513       CABG VEIN FOUR                                                  $1,846.00       20110801
33514       CABG VEIN FIVE                 80                                 $391.82       20110801
33514       CABG VEIN FIVE                 81                                 $391.82       20110801
33514       CABG VEIN FIVE                 82                                 $391.82       20110801
33514       CABG VEIN FIVE                 AS                                 $391.82       20110801
33514       CABG VEIN FIVE                                                  $1,959.10       20110801
33516       CABG VEIN SIX OR MORE          80                                 $407.37       20110801
33516       CABG VEIN SIX OR MORE          81                                 $407.37       20110801



                                                Page 134
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
33516       CABG VEIN SIX OR MORE          82                                 $407.37       20110801
33516       CABG VEIN SIX OR MORE          AS                                 $407.37       20110801
33516       CABG VEIN SIX OR MORE                                           $2,036.84       20110801
33517       CABG ARTERY-VEIN SINGLE        80                                  $27.92       20110801
33517       CABG ARTERY-VEIN SINGLE        81                                  $27.92       20110801
33517       CABG ARTERY-VEIN SINGLE        82                                  $27.92       20110801
33517       CABG ARTERY-VEIN SINGLE        AS                                  $27.92       20110801
33517       CABG ARTERY-VEIN SINGLE                                           $139.62       20110801
33518       CABG ARTERY-VEIN TWO           80                                  $61.20       20110801
33518       CABG ARTERY-VEIN TWO           81                                  $61.20       20110801
33518       CABG ARTERY-VEIN TWO           82                                  $61.20       20110801
33518       CABG ARTERY-VEIN TWO           AS                                  $61.20       20110801
33518       CABG ARTERY-VEIN TWO                                              $306.02       20110801
33519       CABG ARTERY-VEIN THREE         80                                  $81.22       20110801
33519       CABG ARTERY-VEIN THREE         81                                  $81.22       20110801
33519       CABG ARTERY-VEIN THREE         82                                  $81.22       20110801
33519       CABG ARTERY-VEIN THREE         AS                                  $81.22       20110801
33519       CABG ARTERY-VEIN THREE                                            $406.12       20110801
33521       CABG ARTERY-VEIN FOUR          80                                  $97.86       20110801
33521       CABG ARTERY-VEIN FOUR          81                                  $97.86       20110801
33521       CABG ARTERY-VEIN FOUR          82                                  $97.86       20110801
33521       CABG ARTERY-VEIN FOUR          AS                                  $97.86       20110801
33521       CABG ARTERY-VEIN FOUR                                             $489.32       20110801
33522       CABG ARTERY-VEIN FIVE          80                                 $110.29       20110801
33522       CABG ARTERY-VEIN FIVE          81                                 $110.29       20110801
33522       CABG ARTERY-VEIN FIVE          82                                 $110.29       20110801
33522       CABG ARTERY-VEIN FIVE          AS                                 $110.29       20110801
33522       CABG ARTERY-VEIN FIVE                                             $551.46       20110801
33523       CABG ART-VEIN SIX OR MORE      80                                 $125.27       20110801
33523       CABG ART-VEIN SIX OR MORE      81                                 $125.27       20110801
33523       CABG ART-VEIN SIX OR MORE      82                                 $125.27       20110801
33523       CABG ART-VEIN SIX OR MORE      AS                                 $125.27       20110801
33523       CABG ART-VEIN SIX OR MORE                                         $626.34       20110801
33530       CORONARY ARTERY BYPASS/REOP    80                                  $77.95       20110801
33530       CORONARY ARTERY BYPASS/REOP    81                                  $77.95       20110801
33530       CORONARY ARTERY BYPASS/REOP    82                                  $77.95       20110801
33530       CORONARY ARTERY BYPASS/REOP    AS                                  $77.95       20110801
33530       CORONARY ARTERY BYPASS/REOP                                       $389.74       20110801
33533       CABG ARTERIAL SINGLE           80                                 $281.37       20110801
33533       CABG ARTERIAL SINGLE           81                                 $281.37       20110801
33533       CABG ARTERIAL SINGLE           82                                 $281.37       20110801
33533       CABG ARTERIAL SINGLE           AS                                 $281.37       20110801
33533       CABG ARTERIAL SINGLE                                            $1,406.86       20110801
33534       CABG ARTERIAL TWO              80                                 $329.94       20110801
33534       CABG ARTERIAL TWO              81                                 $329.94       20110801
33534       CABG ARTERIAL TWO              82                                 $329.94       20110801
33534       CABG ARTERIAL TWO              AS                                 $329.94       20110801
33534       CABG ARTERIAL TWO                                               $1,649.70       20110801
33535       CABG ARTERIAL THREE            80                                 $367.48       20110801
33535       CABG ARTERIAL THREE            81                                 $367.48       20110801
33535       CABG ARTERIAL THREE            82                                 $367.48       20110801
33535       CABG ARTERIAL THREE            AS                                 $367.48       20110801
33535       CABG ARTERIAL THREE                                             $1,837.42       20110801
33536       CABG ARTERIAL FOUR OR MORE     80                                 $394.99       20110801
33536       CABG ARTERIAL FOUR OR MORE     81                                 $394.99       20110801
33536       CABG ARTERIAL FOUR OR MORE     82                                 $394.99       20110801
33536       CABG ARTERIAL FOUR OR MORE     AS                                 $394.99       20110801
33536       CABG ARTERIAL FOUR OR MORE                                      $1,974.96       20110801
33542       REMOVAL OF HEART LESION        80                                 $386.31       20110801



                                                Page 135
                                 DMAP Fee for Service Fee Schedule
                                           August 2012


Procedure   Description                   Mod 1    Mod 2   Rate Type   Price          Effective
Code                                                                                  Date
33542       REMOVAL OF HEART LESION      81                                 $386.31       20110801
33542       REMOVAL OF HEART LESION      82                                 $386.31       20110801
33542       REMOVAL OF HEART LESION      AS                                 $386.31       20110801
33542       REMOVAL OF HEART LESION                                       $1,931.54       20110801
33545       REPAIR OF HEART DAMAGE       80                                 $454.43       20110801
33545       REPAIR OF HEART DAMAGE       81                                 $454.43       20110801
33545       REPAIR OF HEART DAMAGE       82                                 $454.43       20110801
33545       REPAIR OF HEART DAMAGE       AS                                 $454.43       20110801
33545       REPAIR OF HEART DAMAGE                                        $2,272.14       20110801
33548       RESTORE/REMODEL VENTRICLE    80                                 $442.52       20110801
33548       RESTORE/REMODEL VENTRICLE    81                                 $442.52       20110801
33548       RESTORE/REMODEL VENTRICLE    82                                 $442.52       20110801
33548       RESTORE/REMODEL VENTRICLE    AS                                 $442.52       20110801
33548       RESTORE/REMODEL VENTRICLE                                     $2,212.60       20110801
33572       OPEN CORONARY ENDARTERECTOMY 80                                  $34.79       20110801
33572       OPEN CORONARY ENDARTERECTOMY 81                                  $34.79       20110801
33572       OPEN CORONARY ENDARTERECTOMY 82                                  $34.79       20110801
33572       OPEN CORONARY ENDARTERECTOMY AS                                  $34.79       20110801
33572       OPEN CORONARY ENDARTERECTOMY                                    $173.94       20110801
33600       CLOSURE OF VALVE             80                                 $250.74       20110801
33600       CLOSURE OF VALVE             81                                 $250.74       20110801
33600       CLOSURE OF VALVE             82                                 $250.74       20110801
33600       CLOSURE OF VALVE             AS                                 $250.74       20110801
33600       CLOSURE OF VALVE                                              $1,253.72       20110801
33602       CLOSURE OF VALVE             80                                 $242.01       20110801
33602       CLOSURE OF VALVE             81                                 $242.01       20110801
33602       CLOSURE OF VALVE             82                                 $242.01       20110801
33602       CLOSURE OF VALVE             AS                                 $242.01       20110801
33602       CLOSURE OF VALVE                                              $1,210.04       20110801
33606       ANASTOMOSIS/ARTERY-AORTA     80                                 $261.30       20110801
33606       ANASTOMOSIS/ARTERY-AORTA     81                                 $261.30       20110801
33606       ANASTOMOSIS/ARTERY-AORTA     82                                 $261.30       20110801
33606       ANASTOMOSIS/ARTERY-AORTA     AS                                 $261.30       20110801
33606       ANASTOMOSIS/ARTERY-AORTA                                      $1,306.50       20110801
33608       REPAIR ANOMALY W/CONDUIT     80                                 $265.82       20110801
33608       REPAIR ANOMALY W/CONDUIT     81                                 $265.82       20110801
33608       REPAIR ANOMALY W/CONDUIT     82                                 $265.82       20110801
33608       REPAIR ANOMALY W/CONDUIT     AS                                 $265.82       20110801
33608       REPAIR ANOMALY W/CONDUIT                                      $1,329.12       20110801
33610       REPAIR BY ENLARGEMENT        80                                 $260.42       20110801
33610       REPAIR BY ENLARGEMENT        81                                 $260.42       20110801
33610       REPAIR BY ENLARGEMENT        82                                 $260.42       20110801
33610       REPAIR BY ENLARGEMENT        AS                                 $260.42       20110801
33610       REPAIR BY ENLARGEMENT                                         $1,302.08       20110801
33611       REPAIR DOUBLE VENTRICLE      80                                 $290.89       20110801
33611       REPAIR DOUBLE VENTRICLE      81                                 $290.89       20110801
33611       REPAIR DOUBLE VENTRICLE      82                                 $290.89       20110801
33611       REPAIR DOUBLE VENTRICLE      AS                                 $290.89       20110801
33611       REPAIR DOUBLE VENTRICLE                                       $1,454.44       20110801
33612       REPAIR DOUBLE VENTRICLE      80                                 $292.81       20110801
33612       REPAIR DOUBLE VENTRICLE      81                                 $292.81       20110801
33612       REPAIR DOUBLE VENTRICLE      82                                 $292.81       20110801
33612       REPAIR DOUBLE VENTRICLE      AS                                 $292.81       20110801
33612       REPAIR DOUBLE VENTRICLE                                       $1,464.06       20110801
33615       REPAIR MODIFIED FONTAN       80                                 $296.56       20110801
33615       REPAIR MODIFIED FONTAN       81                                 $296.56       20110801
33615       REPAIR MODIFIED FONTAN       82                                 $296.56       20110801
33615       REPAIR MODIFIED FONTAN       AS                                 $296.56       20110801
33615       REPAIR MODIFIED FONTAN                                        $1,482.78       20110801



                                              Page 136
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
33617       REPAIR SINGLE VENTRICLE         80                                 $316.52       20110801
33617       REPAIR SINGLE VENTRICLE         81                                 $316.52       20110801
33617       REPAIR SINGLE VENTRICLE         82                                 $316.52       20110801
33617       REPAIR SINGLE VENTRICLE         AS                                 $316.52       20110801
33617       REPAIR SINGLE VENTRICLE                                          $1,582.62       20110801
33619       REPAIR SINGLE VENTRICLE         80                                 $392.13       20110801
33619       REPAIR SINGLE VENTRICLE         81                                 $392.13       20110801
33619       REPAIR SINGLE VENTRICLE         82                                 $392.13       20110801
33619       REPAIR SINGLE VENTRICLE         AS                                 $392.13       20110801
33619       REPAIR SINGLE VENTRICLE                                          $1,960.66       20110801
33620       APPLY RL PULM ART BANDS         80                                 $264.84       20110801
33620       APPLY RL PULM ART BANDS         81                                 $264.84       20110801
33620       APPLY RL PULM ART BANDS         82                                 $264.84       20110801
33620       APPLY RL PULM ART BANDS         AS                                 $264.84       20110801
33620       APPLY RL PULM ART BANDS                                          $1,324.18       20110801
33621       TRANSTHOR CATH FOR STENT        80                                 $142.22       20110801
33621       TRANSTHOR CATH FOR STENT        81                                 $142.22       20110801
33621       TRANSTHOR CATH FOR STENT        82                                 $142.22       20110801
33621       TRANSTHOR CATH FOR STENT        AS                                 $142.22       20110801
33621       TRANSTHOR CATH FOR STENT                                           $711.10       20110801
33622       REDO COMPL CARDIAC ANOMALY      80                                 $557.75       20110801
33622       REDO COMPL CARDIAC ANOMALY      81                                 $557.75       20110801
33622       REDO COMPL CARDIAC ANOMALY      82                                 $557.75       20110801
33622       REDO COMPL CARDIAC ANOMALY      AS                                 $557.75       20110801
33622       REDO COMPL CARDIAC ANOMALY                                       $2,788.76       20110801
33641       REPAIR HEART SEPTUM DEFECT      80                                 $241.33       20110801
33641       REPAIR HEART SEPTUM DEFECT      81                                 $241.33       20110801
33641       REPAIR HEART SEPTUM DEFECT      82                                 $241.33       20110801
33641       REPAIR HEART SEPTUM DEFECT      AS                                 $241.33       20110801
33641       REPAIR HEART SEPTUM DEFECT                                       $1,206.66       20110801
33645       REVISION OF HEART VEINS         80                                 $234.31       20110801
33645       REVISION OF HEART VEINS         81                                 $234.31       20110801
33645       REVISION OF HEART VEINS         82                                 $234.31       20110801
33645       REVISION OF HEART VEINS         AS                                 $234.31       20110801
33645       REVISION OF HEART VEINS                                          $1,171.56       20110801
33647       REPAIR HEART SEPTUM DEFECTS     80                                 $262.50       20110801
33647       REPAIR HEART SEPTUM DEFECTS     81                                 $262.50       20110801
33647       REPAIR HEART SEPTUM DEFECTS     82                                 $262.50       20110801
33647       REPAIR HEART SEPTUM DEFECTS     AS                                 $262.50       20110801
33647       REPAIR HEART SEPTUM DEFECTS                                      $1,312.48       20110801
33660       REPAIR OF HEART DEFECTS         80                                 $260.68       20110801
33660       REPAIR OF HEART DEFECTS         81                                 $260.68       20110801
33660       REPAIR OF HEART DEFECTS         82                                 $260.68       20110801
33660       REPAIR OF HEART DEFECTS         AS                                 $260.68       20110801
33660       REPAIR OF HEART DEFECTS                                          $1,303.38       20110801
33665       REPAIR OF HEART DEFECTS         80                                 $298.43       20110801
33665       REPAIR OF HEART DEFECTS         81                                 $298.43       20110801
33665       REPAIR OF HEART DEFECTS         82                                 $298.43       20110801
33665       REPAIR OF HEART DEFECTS         AS                                 $298.43       20110801
33665       REPAIR OF HEART DEFECTS                                          $1,492.14       20110801
33670       REPAIR OF HEART CHAMBERS        80                                 $294.79       20110801
33670       REPAIR OF HEART CHAMBERS        81                                 $294.79       20110801
33670       REPAIR OF HEART CHAMBERS        82                                 $294.79       20110801
33670       REPAIR OF HEART CHAMBERS        AS                                 $294.79       20110801
33670       REPAIR OF HEART CHAMBERS                                         $1,473.94       20110801
33675       CLOSE MULT VSD                  80                                 $292.76       20110801
33675       CLOSE MULT VSD                  81                                 $292.76       20110801
33675       CLOSE MULT VSD                  82                                 $292.76       20110801
33675       CLOSE MULT VSD                  AS                                 $292.76       20110801



                                                 Page 137
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
33675       CLOSE MULT VSD                                                  $1,463.80       20110801
33676       CLOSE MULT VSD W/RESECTION     80                                 $279.81       20110801
33676       CLOSE MULT VSD W/RESECTION     81                                 $279.81       20110801
33676       CLOSE MULT VSD W/RESECTION     82                                 $279.81       20110801
33676       CLOSE MULT VSD W/RESECTION     AS                                 $279.81       20110801
33676       CLOSE MULT VSD W/RESECTION                                      $1,399.06       20110801
33677       CL MULT VSD W/REM PUL BAND     80                                 $290.73       20110801
33677       CL MULT VSD W/REM PUL BAND     81                                 $290.73       20110801
33677       CL MULT VSD W/REM PUL BAND     82                                 $290.73       20110801
33677       CL MULT VSD W/REM PUL BAND     AS                                 $290.73       20110801
33677       CL MULT VSD W/REM PUL BAND                                      $1,453.66       20110801
33681       REPAIR HEART SEPTUM DEFECT     80                                 $271.18       20110801
33681       REPAIR HEART SEPTUM DEFECT     81                                 $271.18       20110801
33681       REPAIR HEART SEPTUM DEFECT     82                                 $271.18       20110801
33681       REPAIR HEART SEPTUM DEFECT     AS                                 $271.18       20110801
33681       REPAIR HEART SEPTUM DEFECT                                      $1,355.90       20110801
33684       REPAIR HEART SEPTUM DEFECT     80                                 $294.01       20110801
33684       REPAIR HEART SEPTUM DEFECT     81                                 $294.01       20110801
33684       REPAIR HEART SEPTUM DEFECT     82                                 $294.01       20110801
33684       REPAIR HEART SEPTUM DEFECT     AS                                 $294.01       20110801
33684       REPAIR HEART SEPTUM DEFECT                                      $1,470.04       20110801
33688       REPAIR HEART SEPTUM DEFECT     80                                 $278.77       20110801
33688       REPAIR HEART SEPTUM DEFECT     81                                 $278.77       20110801
33688       REPAIR HEART SEPTUM DEFECT     82                                 $278.77       20110801
33688       REPAIR HEART SEPTUM DEFECT     AS                                 $278.77       20110801
33688       REPAIR HEART SEPTUM DEFECT                                      $1,393.86       20110801
33690       REINFORCE PULMONARY ARTERY     80                                 $173.37       20110801
33690       REINFORCE PULMONARY ARTERY     81                                 $173.37       20110801
33690       REINFORCE PULMONARY ARTERY     82                                 $173.37       20110801
33690       REINFORCE PULMONARY ARTERY     AS                                 $173.37       20110801
33690       REINFORCE PULMONARY ARTERY                                        $866.84       20110801
33692       REPAIR OF HEART DEFECTS        80                                 $240.71       20110801
33692       REPAIR OF HEART DEFECTS        81                                 $240.71       20110801
33692       REPAIR OF HEART DEFECTS        82                                 $240.71       20110801
33692       REPAIR OF HEART DEFECTS        AS                                 $240.71       20110801
33692       REPAIR OF HEART DEFECTS                                         $1,203.54       20110801
33694       REPAIR OF HEART DEFECTS        80                                 $292.03       20110801
33694       REPAIR OF HEART DEFECTS        81                                 $292.03       20110801
33694       REPAIR OF HEART DEFECTS        82                                 $292.03       20110801
33694       REPAIR OF HEART DEFECTS        AS                                 $292.03       20110801
33694       REPAIR OF HEART DEFECTS                                         $1,460.16       20110801
33697       REPAIR OF HEART DEFECTS        80                                 $312.00       20110801
33697       REPAIR OF HEART DEFECTS        81                                 $312.00       20110801
33697       REPAIR OF HEART DEFECTS        82                                 $312.00       20110801
33697       REPAIR OF HEART DEFECTS        AS                                 $312.00       20110801
33697       REPAIR OF HEART DEFECTS                                         $1,560.00       20110801
33702       REPAIR OF HEART DEFECTS        80                                 $227.71       20110801
33702       REPAIR OF HEART DEFECTS        81                                 $227.71       20110801
33702       REPAIR OF HEART DEFECTS        82                                 $227.71       20110801
33702       REPAIR OF HEART DEFECTS        AS                                 $227.71       20110801
33702       REPAIR OF HEART DEFECTS                                         $1,138.54       20110801
33710       REPAIR OF HEART DEFECTS        80                                 $266.24       20110801
33710       REPAIR OF HEART DEFECTS        81                                 $266.24       20110801
33710       REPAIR OF HEART DEFECTS        82                                 $266.24       20110801
33710       REPAIR OF HEART DEFECTS        AS                                 $266.24       20110801
33710       REPAIR OF HEART DEFECTS                                         $1,331.20       20110801
33720       REPAIR OF HEART DEFECT         80                                 $227.60       20110801
33720       REPAIR OF HEART DEFECT         81                                 $227.60       20110801
33720       REPAIR OF HEART DEFECT         82                                 $227.60       20110801



                                                Page 138
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
33720       REPAIR OF HEART DEFECT          AS                                 $227.60       20110801
33720       REPAIR OF HEART DEFECT                                           $1,138.02       20110801
33722       REPAIR OF HEART DEFECT          80                                 $239.46       20110801
33722       REPAIR OF HEART DEFECT          81                                 $239.46       20110801
33722       REPAIR OF HEART DEFECT          82                                 $239.46       20110801
33722       REPAIR OF HEART DEFECT          AS                                 $239.46       20110801
33722       REPAIR OF HEART DEFECT                                           $1,197.30       20110801
33724       REPAIR VENOUS ANOMALY           80                                 $229.48       20110801
33724       REPAIR VENOUS ANOMALY           81                                 $229.48       20110801
33724       REPAIR VENOUS ANOMALY           82                                 $229.48       20110801
33724       REPAIR VENOUS ANOMALY           AS                                 $229.48       20110801
33724       REPAIR VENOUS ANOMALY                                            $1,147.38       20110801
33726       REPAIR PUL VENOUS STENOSIS      80                                 $304.36       20110801
33726       REPAIR PUL VENOUS STENOSIS      81                                 $304.36       20110801
33726       REPAIR PUL VENOUS STENOSIS      82                                 $304.36       20110801
33726       REPAIR PUL VENOUS STENOSIS      AS                                 $304.36       20110801
33726       REPAIR PUL VENOUS STENOSIS                                       $1,521.78       20110801
33730       REPAIR HEART-VEIN DEFECTS       80                                 $292.45       20110801
33730       REPAIR HEART-VEIN DEFECTS       81                                 $292.45       20110801
33730       REPAIR HEART-VEIN DEFECTS       82                                 $292.45       20110801
33730       REPAIR HEART-VEIN DEFECTS       AS                                 $292.45       20110801
33730       REPAIR HEART-VEIN DEFECTS                                        $1,462.24       20110801
33732       REPAIR HEART-VEIN DEFECT        80                                 $243.88       20110801
33732       REPAIR HEART-VEIN DEFECT        81                                 $243.88       20110801
33732       REPAIR HEART-VEIN DEFECT        82                                 $243.88       20110801
33732       REPAIR HEART-VEIN DEFECT        AS                                 $243.88       20110801
33732       REPAIR HEART-VEIN DEFECT                                         $1,219.40       20110801
33735       REVISION OF HEART CHAMBER       80                                 $189.54       20110801
33735       REVISION OF HEART CHAMBER       81                                 $189.54       20110801
33735       REVISION OF HEART CHAMBER       82                                 $189.54       20110801
33735       REVISION OF HEART CHAMBER       AS                                 $189.54       20110801
33735       REVISION OF HEART CHAMBER                                          $947.70       20110801
33736       REVISION OF HEART CHAMBER       80                                 $207.27       20110801
33736       REVISION OF HEART CHAMBER       81                                 $207.27       20110801
33736       REVISION OF HEART CHAMBER       82                                 $207.27       20110801
33736       REVISION OF HEART CHAMBER       AS                                 $207.27       20110801
33736       REVISION OF HEART CHAMBER                                        $1,036.36       20110801
33737       REVISION OF HEART CHAMBER       80                                 $190.11       20110801
33737       REVISION OF HEART CHAMBER       81                                 $190.11       20110801
33737       REVISION OF HEART CHAMBER       82                                 $190.11       20110801
33737       REVISION OF HEART CHAMBER       AS                                 $190.11       20110801
33737       REVISION OF HEART CHAMBER                                          $950.56       20110801
33750       MAJOR VESSEL SHUNT              80                                 $213.15       20110801
33750       MAJOR VESSEL SHUNT              81                                 $213.15       20110801
33750       MAJOR VESSEL SHUNT              82                                 $213.15       20110801
33750       MAJOR VESSEL SHUNT              AS                                 $213.15       20110801
33750       MAJOR VESSEL SHUNT                                               $1,065.74       20110801
33755       MAJOR VESSEL SHUNT              80                                 $187.72       20110801
33755       MAJOR VESSEL SHUNT              81                                 $187.72       20110801
33755       MAJOR VESSEL SHUNT              82                                 $187.72       20110801
33755       MAJOR VESSEL SHUNT              AS                                 $187.72       20110801
33755       MAJOR VESSEL SHUNT                                                 $938.60       20110801
33762       MAJOR VESSEL SHUNT              80                                 $176.18       20110801
33762       MAJOR VESSEL SHUNT              81                                 $176.18       20110801
33762       MAJOR VESSEL SHUNT              82                                 $176.18       20110801
33762       MAJOR VESSEL SHUNT              AS                                 $176.18       20110801
33762       MAJOR VESSEL SHUNT                                                 $880.88       20110801
33764       MAJOR VESSEL SHUNT GRAFT        80                                 $189.12       20110801
33764       MAJOR VESSEL SHUNT GRAFT        81                                 $189.12       20110801



                                                 Page 139
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
33764       MAJOR VESSEL SHUNT GRAFT        82                                 $189.12       20110801
33764       MAJOR VESSEL SHUNT GRAFT        AS                                 $189.12       20110801
33764       MAJOR VESSEL SHUNT GRAFT                                           $945.62       20110801
33766       MAJOR VESSEL SHUNT              80                                 $199.68       20110801
33766       MAJOR VESSEL SHUNT              81                                 $199.68       20110801
33766       MAJOR VESSEL SHUNT              82                                 $199.68       20110801
33766       MAJOR VESSEL SHUNT              AS                                 $199.68       20110801
33766       MAJOR VESSEL SHUNT                                                 $998.40       20110801
33767       MAJOR VESSEL SHUNT              80                                 $208.78       20110801
33767       MAJOR VESSEL SHUNT              81                                 $208.78       20110801
33767       MAJOR VESSEL SHUNT              82                                 $208.78       20110801
33767       MAJOR VESSEL SHUNT              AS                                 $208.78       20110801
33767       MAJOR VESSEL SHUNT                                               $1,043.90       20110801
33768       CAVOPULMONARY SHUNTING          80                                  $58.19       20110801
33768       CAVOPULMONARY SHUNTING          81                                  $58.19       20110801
33768       CAVOPULMONARY SHUNTING          82                                  $58.19       20110801
33768       CAVOPULMONARY SHUNTING          AS                                  $58.19       20110801
33768       CAVOPULMONARY SHUNTING                                             $290.94       20110801
33770       REPAIR GREAT VESSELS DEFECT     80                                 $317.10       20110801
33770       REPAIR GREAT VESSELS DEFECT     81                                 $317.10       20110801
33770       REPAIR GREAT VESSELS DEFECT     82                                 $317.10       20110801
33770       REPAIR GREAT VESSELS DEFECT     AS                                 $317.10       20110801
33770       REPAIR GREAT VESSELS DEFECT                                      $1,585.48       20110801
33771       REPAIR GREAT VESSELS DEFECT     80                                 $300.20       20110801
33771       REPAIR GREAT VESSELS DEFECT     81                                 $300.20       20110801
33771       REPAIR GREAT VESSELS DEFECT     82                                 $300.20       20110801
33771       REPAIR GREAT VESSELS DEFECT     AS                                 $300.20       20110801
33771       REPAIR GREAT VESSELS DEFECT                                      $1,500.98       20110801
33774       REPAIR GREAT VESSELS DEFECT     80                                 $266.81       20110801
33774       REPAIR GREAT VESSELS DEFECT     81                                 $266.81       20110801
33774       REPAIR GREAT VESSELS DEFECT     82                                 $266.81       20110801
33774       REPAIR GREAT VESSELS DEFECT     AS                                 $266.81       20110801
33774       REPAIR GREAT VESSELS DEFECT                                      $1,334.06       20110801
33775       REPAIR GREAT VESSELS DEFECT     80                                 $255.79       20110801
33775       REPAIR GREAT VESSELS DEFECT     81                                 $255.79       20110801
33775       REPAIR GREAT VESSELS DEFECT     82                                 $255.79       20110801
33775       REPAIR GREAT VESSELS DEFECT     AS                                 $255.79       20110801
33775       REPAIR GREAT VESSELS DEFECT                                      $1,278.94       20110801
33776       REPAIR GREAT VESSELS DEFECT     80                                 $270.04       20110801
33776       REPAIR GREAT VESSELS DEFECT     81                                 $270.04       20110801
33776       REPAIR GREAT VESSELS DEFECT     82                                 $270.04       20110801
33776       REPAIR GREAT VESSELS DEFECT     AS                                 $270.04       20110801
33776       REPAIR GREAT VESSELS DEFECT                                      $1,350.18       20110801
33777       REPAIR GREAT VESSELS DEFECT     80                                 $262.55       20110801
33777       REPAIR GREAT VESSELS DEFECT     81                                 $262.55       20110801
33777       REPAIR GREAT VESSELS DEFECT     82                                 $262.55       20110801
33777       REPAIR GREAT VESSELS DEFECT     AS                                 $262.55       20110801
33777       REPAIR GREAT VESSELS DEFECT                                      $1,312.74       20110801
33778       REPAIR GREAT VESSELS DEFECT     80                                 $324.58       20110801
33778       REPAIR GREAT VESSELS DEFECT     81                                 $324.58       20110801
33778       REPAIR GREAT VESSELS DEFECT     82                                 $324.58       20110801
33778       REPAIR GREAT VESSELS DEFECT     AS                                 $324.58       20110801
33778       REPAIR GREAT VESSELS DEFECT                                      $1,622.92       20110801
33779       REPAIR GREAT VESSELS DEFECT     80                                 $322.30       20110801
33779       REPAIR GREAT VESSELS DEFECT     81                                 $322.30       20110801
33779       REPAIR GREAT VESSELS DEFECT     82                                 $322.30       20110801
33779       REPAIR GREAT VESSELS DEFECT     AS                                 $322.30       20110801
33779       REPAIR GREAT VESSELS DEFECT                                      $1,611.48       20110801
33780       REPAIR GREAT VESSELS DEFECT     80                                 $345.18       20110801



                                                 Page 140
                                   DMAP Fee for Service Fee Schedule
                                             August 2012


Procedure   Description                     Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                     Date
33780       REPAIR GREAT VESSELS DEFECT     81                                 $345.18       20110801
33780       REPAIR GREAT VESSELS DEFECT     82                                 $345.18       20110801
33780       REPAIR GREAT VESSELS DEFECT     AS                                 $345.18       20110801
33780       REPAIR GREAT VESSELS DEFECT                                      $1,725.88       20110801
33781       REPAIR GREAT VESSELS DEFECT     80                                 $319.12       20110801
33781       REPAIR GREAT VESSELS DEFECT     81                                 $319.12       20110801
33781       REPAIR GREAT VESSELS DEFECT     82                                 $319.12       20110801
33781       REPAIR GREAT VESSELS DEFECT     AS                                 $319.12       20110801
33781       REPAIR GREAT VESSELS DEFECT                                      $1,595.62       20110801
33782       NIKAIDOH PROC                                                    $2,368.86       20110801
33783       NIKAIDOH PROC W/OSTIA IMPLT                                      $2,560.48       20110801
33786       REPAIR ARTERIAL TRUNK           80                                 $314.24       20110801
33786       REPAIR ARTERIAL TRUNK           81                                 $314.24       20110801
33786       REPAIR ARTERIAL TRUNK           82                                 $314.24       20110801
33786       REPAIR ARTERIAL TRUNK           AS                                 $314.24       20110801
33786       REPAIR ARTERIAL TRUNK                                            $1,571.18       20110801
33788       REVISION OF PULMONARY ARTERY    80                                 $211.38       20110801
33788       REVISION OF PULMONARY ARTERY    81                                 $211.38       20110801
33788       REVISION OF PULMONARY ARTERY    82                                 $211.38       20110801
33788       REVISION OF PULMONARY ARTERY    AS                                 $211.38       20110801
33788       REVISION OF PULMONARY ARTERY                                     $1,056.90       20110801
33800       AORTIC SUSPENSION               80                                 $144.40       20110801
33800       AORTIC SUSPENSION               81                                 $144.40       20110801
33800       AORTIC SUSPENSION               82                                 $144.40       20110801
33800       AORTIC SUSPENSION               AS                                 $144.40       20110801
33800       AORTIC SUSPENSION                                                  $722.02       20110801
33802       REPAIR VESSEL DEFECT            80                                 $157.04       20110801
33802       REPAIR VESSEL DEFECT            81                                 $157.04       20110801
33802       REPAIR VESSEL DEFECT            82                                 $157.04       20110801
33802       REPAIR VESSEL DEFECT            AS                                 $157.04       20110801
33802       REPAIR VESSEL DEFECT                                               $785.20       20110801
33803       REPAIR VESSEL DEFECT            80                                 $168.12       20110801
33803       REPAIR VESSEL DEFECT            81                                 $168.12       20110801
33803       REPAIR VESSEL DEFECT            82                                 $168.12       20110801
33803       REPAIR VESSEL DEFECT            AS                                 $168.12       20110801
33803       REPAIR VESSEL DEFECT                                               $840.58       20110801
33813       REPAIR SEPTAL DEFECT            80                                 $187.30       20110801
33813       REPAIR SEPTAL DEFECT            81                                 $187.30       20110801
33813       REPAIR SEPTAL DEFECT            82                                 $187.30       20110801
33813       REPAIR SEPTAL DEFECT            AS                                 $187.30       20110801
33813       REPAIR SEPTAL DEFECT                                               $936.52       20110801
33814       REPAIR SEPTAL DEFECT            80                                 $225.16       20110801
33814       REPAIR SEPTAL DEFECT            81                                 $225.16       20110801
33814       REPAIR SEPTAL DEFECT            82                                 $225.16       20110801
33814       REPAIR SEPTAL DEFECT            AS                                 $225.16       20110801
33814       REPAIR SEPTAL DEFECT                                             $1,125.80       20110801
33820       REVISE MAJOR VESSEL             80                                 $143.94       20110801
33820       REVISE MAJOR VESSEL             81                                 $143.94       20110801
33820       REVISE MAJOR VESSEL             82                                 $143.94       20110801
33820       REVISE MAJOR VESSEL             AS                                 $143.94       20110801
33820       REVISE MAJOR VESSEL                                                $719.68       20110801
33822       REVISE MAJOR VESSEL             80                                 $140.61       20110801
33822       REVISE MAJOR VESSEL             81                                 $140.61       20110801
33822       REVISE MAJOR VESSEL             82                                 $140.61       20110801
33822       REVISE MAJOR VESSEL             AS                                 $140.61       20110801
33822       REVISE MAJOR VESSEL                                                $703.04       20110801
33824       REVISE MAJOR VESSEL             80                                 $173.47       20110801
33824       REVISE MAJOR VESSEL             81                                 $173.47       20110801
33824       REVISE MAJOR VESSEL             82                                 $173.47       20110801



                                                 Page 141
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
33824       REVISE MAJOR VESSEL            AS                                 $173.47       20110801
33824       REVISE MAJOR VESSEL                                               $867.36       20110801
33840       REMOVE AORTA CONSTRICTION      80                                 $178.41       20110801
33840       REMOVE AORTA CONSTRICTION      81                                 $178.41       20110801
33840       REMOVE AORTA CONSTRICTION      82                                 $178.41       20110801
33840       REMOVE AORTA CONSTRICTION      AS                                 $178.41       20110801
33840       REMOVE AORTA CONSTRICTION                                         $892.06       20110801
33845       REMOVE AORTA CONSTRICTION      80                                 $200.88       20110801
33845       REMOVE AORTA CONSTRICTION      81                                 $200.88       20110801
33845       REMOVE AORTA CONSTRICTION      82                                 $200.88       20110801
33845       REMOVE AORTA CONSTRICTION      AS                                 $200.88       20110801
33845       REMOVE AORTA CONSTRICTION                                       $1,004.38       20110801
33851       REMOVE AORTA CONSTRICTION      80                                 $185.90       20110801
33851       REMOVE AORTA CONSTRICTION      81                                 $185.90       20110801
33851       REMOVE AORTA CONSTRICTION      82                                 $185.90       20110801
33851       REMOVE AORTA CONSTRICTION      AS                                 $185.90       20110801
33851       REMOVE AORTA CONSTRICTION                                         $929.50       20110801
33852       REPAIR SEPTAL DEFECT           80                                 $216.11       20110801
33852       REPAIR SEPTAL DEFECT           81                                 $216.11       20110801
33852       REPAIR SEPTAL DEFECT           82                                 $216.11       20110801
33852       REPAIR SEPTAL DEFECT           AS                                 $216.11       20110801
33852       REPAIR SEPTAL DEFECT                                            $1,080.56       20110801
33853       REPAIR SEPTAL DEFECT           80                                 $289.48       20110801
33853       REPAIR SEPTAL DEFECT           81                                 $289.48       20110801
33853       REPAIR SEPTAL DEFECT           82                                 $289.48       20110801
33853       REPAIR SEPTAL DEFECT           AS                                 $289.48       20110801
33853       REPAIR SEPTAL DEFECT                                            $1,447.42       20110801
33860       ASCENDING AORTIC GRAFT         80                                 $474.08       20110801
33860       ASCENDING AORTIC GRAFT         81                                 $474.08       20110801
33860       ASCENDING AORTIC GRAFT         82                                 $474.08       20110801
33860       ASCENDING AORTIC GRAFT         AS                                 $474.08       20110801
33860       ASCENDING AORTIC GRAFT                                          $2,370.42       20110801
33863       ASCENDING AORTIC GRAFT         80                                 $468.73       20110801
33863       ASCENDING AORTIC GRAFT         81                                 $468.73       20110801
33863       ASCENDING AORTIC GRAFT         82                                 $468.73       20110801
33863       ASCENDING AORTIC GRAFT         AS                                 $468.73       20110801
33863       ASCENDING AORTIC GRAFT                                          $2,343.64       20110801
33864       ASCENDING AORTIC GRAFT         80                                 $481.00       20110801
33864       ASCENDING AORTIC GRAFT                                          $2,405.00       20110801
33870       TRANSVERSE AORTIC ARCH GRAFT   80                                 $375.34       20110801
33870       TRANSVERSE AORTIC ARCH GRAFT   81                                 $375.34       20110801
33870       TRANSVERSE AORTIC ARCH GRAFT   82                                 $375.34       20110801
33870       TRANSVERSE AORTIC ARCH GRAFT   AS                                 $375.34       20110801
33870       TRANSVERSE AORTIC ARCH GRAFT                                    $1,876.68       20110801
33875       THORACIC AORTIC GRAFT          80                                 $292.19       20110801
33875       THORACIC AORTIC GRAFT          81                                 $292.19       20110801
33875       THORACIC AORTIC GRAFT          82                                 $292.19       20110801
33875       THORACIC AORTIC GRAFT          AS                                 $292.19       20110801
33875       THORACIC AORTIC GRAFT                                           $1,460.94       20110801
33877       THORACOABDOMINAL GRAFT         80                                 $535.70       20110801
33877       THORACOABDOMINAL GRAFT         81                                 $535.70       20110801
33877       THORACOABDOMINAL GRAFT         82                                 $535.70       20110801
33877       THORACOABDOMINAL GRAFT         AS                                 $535.70       20110801
33877       THORACOABDOMINAL GRAFT                                          $2,678.52       20110801
33880       ENDOVASC TAA REPR INCL SUBCL   80                                 $273.99       20110801
33880       ENDOVASC TAA REPR INCL SUBCL   81                                 $273.99       20110801
33880       ENDOVASC TAA REPR INCL SUBCL   82                                 $273.99       20110801
33880       ENDOVASC TAA REPR INCL SUBCL   AS                                 $273.99       20110801
33880       ENDOVASC TAA REPR INCL SUBCL                                    $1,369.94       20110801



                                                Page 142
                                  DMAP Fee for Service Fee Schedule
                                            August 2012


Procedure   Description                    Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                    Date
33881       ENDOVASC TAA REPR W/O SUBCL    80                                 $235.30       20110801
33881       ENDOVASC TAA REPR W/O SUBCL    81                                 $235.30       20110801
33881       ENDOVASC TAA REPR W/O SUBCL    82                                 $235.30       20110801
33881       ENDOVASC TAA REPR W/O SUBCL    AS                                 $235.30       20110801
33881       ENDOVASC TAA REPR W/O SUBCL                                     $1,176.50       20110801
33883       INSERT ENDOVASC PROSTH TAA     80                                 $170.25       20110801
33883       INSERT ENDOVASC PROSTH TAA     81                                 $170.25       20110801
33883       INSERT ENDOVASC PROSTH TAA     82                                 $170.25       20110801
33883       INSERT ENDOVASC PROSTH TAA     AS                                 $170.25       20110801
33883       INSERT ENDOVASC PROSTH TAA                                        $851.24       20110801
33884       ENDOVASC PROSTH TAA ADD-ON     80                                  $62.24       20110801
33884       ENDOVASC PROSTH TAA ADD-ON     81                                  $62.24       20110801
33884       ENDOVASC PROSTH TAA ADD-ON     82                                  $62.24       20110801
33884       ENDOVASC PROSTH TAA ADD-ON     AS                                  $62.24       20110801
33884       ENDOVASC PROSTH TAA ADD-ON                                        $311.22       20110801
33886       ENDOVASC PROSTH DELAYED        80                                 $146.74       20110801
33886       ENDOVASC PROSTH DELAYED        81                                 $146.74       20110801
33886       ENDOVASC PROSTH DELAYED        82                                 $146.74       20110801
33886       ENDOVASC PROSTH DELAYED        AS                                 $146.74       20110801
33886       ENDOVASC PROSTH DELAYED                                           $733.72       20110801
33889       ARTERY TRANSPOSE/ENDOVAS TAA   80                                 $120.80       20110801
33889       ARTERY TRANSPOSE/ENDOVAS TAA   81                                 $120.80       20110801
33889       ARTERY TRANSPOSE/ENDOVAS TAA   82                                 $120.80       20110801
33889       ARTERY TRANSPOSE/ENDOVAS TAA   AS                                 $120.80       20110801
33889       ARTERY TRANSPOSE/ENDOVAS TAA                                      $603.98       20110801
33891       CAR-CAR BP GRFT/ENDOVAS TAA    80                                 $151.27       20110801
33891       CAR-CAR BP GRFT/ENDOVAS TAA    81                                 $151.27       20110801
33891       CAR-CAR BP GRFT/ENDOVAS TAA    82                                 $151.27       20110801
33891       CAR-CAR BP GRFT/ENDOVAS TAA    AS                                 $151.27       20110801
33891       CAR-CAR BP GRFT/ENDOVAS TAA                                       $756.34       20110801
33910       REMOVE LUNG ARTERY EMBOLI      80                                 $247.68       20110801
33910       REMOVE LUNG ARTERY EMBOLI      81                                 $247.68       20110801
33910       REMOVE LUNG ARTERY EMBOLI      82                                 $247.68       20110801
33910       REMOVE LUNG ARTERY EMBOLI      AS                                 $247.68       20110801
33910       REMOVE LUNG ARTERY EMBOLI                                       $1,238.38       20110801
33915       REMOVE LUNG ARTERY EMBOLI      80                                 $200.93       20110801
33915       REMOVE LUNG ARTERY EMBOLI      81                                 $200.93       20110801
33915       REMOVE LUNG ARTERY EMBOLI      82                                 $200.93       20110801
33915       REMOVE LUNG ARTERY EMBOLI      AS                                 $200.93       20110801
33915       REMOVE LUNG ARTERY EMBOLI                                       $1,004.64       20110801
33916       SURGERY OF GREAT VESSEL        80                                 $244.04       20110801
33916       SURGERY OF GREAT VESSEL        81                                 $244.04       20110801
33916       SURGERY OF GREAT VESSEL        82                                 $244.04       20110801
33916       SURGERY OF GREAT VESSEL        AS                                 $244.04       20110801
33916       SURGERY OF GREAT VESSEL                                         $1,220.18       20110801
33917       REPAIR PULMONARY ARTERY        80                                 $218.50       20110801
33917       REPAIR PULMONARY ARTERY        81                                 $218.50       20110801
33917       REPAIR PULMONARY ARTERY        82                                 $218.50       20110801
33917       REPAIR PULMONARY ARTERY        AS                                 $218.50       20110801
33917       REPAIR PULMONARY ARTERY                                         $1,092.52       20110801
33920       REPAIR PULMONARY ATRESIA       80                                 $269.15       20110801
33920       REPAIR PULMONARY ATRESIA       81                                 $269.15       20110801
33920       REPAIR PULMONARY ATRESIA       82                                 $269.15       20110801
33920       REPAIR PULMONARY ATRESIA       AS                                 $269.15       20110801
33920       REPAIR PULMONARY ATRESIA                                        $1,345.76       20110801
33922       TRANSECT PULMONARY ARTERY      80                                 $204.67       20110801
33922       TRANSECT PULMONARY ARTERY      81                                 $204.67       20110801
33922       TRANSECT PULMONARY ARTERY      82                                 $204.67       20110801
33922       TRANSECT PULMONARY ARTERY      AS                                 $204.67       20110801



                                                Page 143
                                    DMAP Fee for Service Fee Schedule
                                              August 2012


Procedure   Description                      Mod 1     Mod 2   Rate Type   Price          Effective
Code                                                                                      Date
33922       TRANSECT PULMONARY ARTERY                                         $1,023.36       20110801
33924       REMOVE PULMONARY SHUNT           80                                  $42.38       20110801
33924       REMOVE PULMONARY SHUNT           81                                  $42.38       20110801
33924       REMOVE PULMONARY SHUNT           82                                  $42.38       20110801
33924       REMOVE PULMONARY SHUNT           AS                                  $42.38       20110801
33924       REMOVE PULMONARY SHUNT                                              $211.90       20110801
33925       RPR PUL ART UNIFOCAL W/O CPB     80                                 $256.88       20110801
33925       RPR PUL ART UNIFOCAL W/O CPB     81                                 $256.88       20110801
33925       RPR PUL ART UNIFOCAL W/O CPB     82                                 $256.88       20110801
33925       RPR PUL ART UNIFOCAL W/O CPB     AS                                 $256.88       20110801
33925       RPR PUL ART UNIFOCAL W/O CPB                                      $1,284.40       20110801
33926       REPR PUL ART UNIFOCAL W/CPB      80                                 $354.95       20110801
33926       REPR PUL ART UNIFOCAL W/CPB      81                                 $354.95       20110801
33926       REPR PUL ART UNIFOCAL W/CPB      82                                 $354.95       20110801
33926       REPR PUL ART UNIFOCAL W/CPB      AS                                 $354.95       20110801
33926       REPR PUL ART UNIFOCAL W/CPB                                       $1,774.76       20110801
33935       TRANSPLANTATION HEART/LUNG       80                                 $513.45       20110801
33935       TRANSPLANTATION HEART/LUNG       81                                 $513.45       20110801
33935       TRANSPLANTATION HEART/LUNG       82                                 $513.45       20110801
33935       TRANSPLANTATION HEART/LUNG       AS                                 $513.45       20110801
33935       TRANSPLANTATION HEART/LUNG                                        $2,567.24       20110801
33944       PREPARE DONOR HEART              80                                 $116.48       20110801
33944       PREPARE DONOR HEART              81                                 $116.48       20110801
33944       PREPARE DONOR HEART              82                                 $116.48       20110801
33944       PREPARE DONOR HEART              AS                                 $116.48       20110801
33944       PREPARE DONOR HEART                                                 $582.38       20110801
33945       TRANSPLANTATION OF HEART         80                                 $708.86       20110801
33945       TRANSPLANTATION OF HEART         81                                 $708.86       20110801
33945       TRANSPLANTATION OF HEART         82                                 $708.86       20110801
33945       TRANSPLANTATION OF HEART         AS                                 $708.86       20110801
33945       TRANSPLANTATION OF HEART                                          $3,544.32       20110801
33960       EXTERNAL CIRCULATION ASSIST      80                                 $145.96       20110801
33960       EXTERNAL CIRCULATION ASSIST      81                                 $145.96       20110801
33960       EXTERNAL CIRCULATION ASSIST      82                                 $145.96       20110801
33960       EXTERNAL CIRCULATION ASSIST      AS                                 $145.96       20110801
33960       EXTERNAL CIRCULATION ASSIST                                         $729.82       20110801
33961       EXTERNAL CIRCULATION ASSIST                                         $405.86       20110801
33967       INSERT IA PERCUT DEVICE          80                                  $40.51       20110801
33967       INSERT IA PERCUT DEVICE          81                                  $40.51       20110801
33967       INSERT IA PERCUT DEVICE          82                                  $40.51       20110801
33967       INSERT IA PERCUT DEVICE          AS                                  $40.51       20110801
33967       INSERT IA PERCUT DEVICE                                             $202.54       20110801
33968       REMOVE AORTIC ASSIST DEVICE                                          $25.74       20110801
33970       AORTIC CIRCULATION ASSIST        80                                  $54.29       20110801
33970       AORTIC CIRCULATION ASSIST        81                                  $54.29       20110801
33970       AORTIC CIRCULATION ASSIST        82                                  $54.29       20110801
33970       AORTIC CIRCULATION ASSIST        AS                                  $54.29       20110801
33970       AORTIC CIRCULATION ASSIST                                           $271.44       20110801
33971       AORTIC CIRCULATION ASSIST                                           $528.84       20110801
33973       INSERT BALLOON DEVICE            80                                  $78.68       20110801
33973       INSERT BALLOON DEVICE            81                                  $78.68       20110801
33973       INSERT BALLOON DEVICE            82                                  $78.68       20110801
33973       INSERT BALLOON DEVICE            AS                                  $78.68       20110801
33973       INSERT BALLOON DEVICE                                               $393.38       20110801
33974       REMOVE INTRA-AORTIC BALLOON                                         $673.40       20110801
33975       IMPLANT VENTRICULAR DEVICE       80                                 $164.06       20110801
33975       IMPLANT VENTRICULAR DEV